Mark Evans

• MD
• Director at Icahn School of Medicine at Mount Sinai

Publications on artificial intelligence (AI) applications have dramatically increased for most medical specialties, including obstetrics. Here, we review the most recent pertinent publications on AI programs in obstetrics, describe trends in AI applications for specific obstetric problems, and assess AI's possible effects on obstetric care. Searche...

Purpose: The United States has the highest maternal and neonatal mortality rates among the 45 high-income countries demonstrating enormous discrepancies between white and black mothers and infants. These outcome discrepancies have worsened over the last decade despite the availability of insurance coverage from the Affordable Care Act (ACA) to over...

Objective: Intrauterine resuscitation (IR) may be employed during labor to reduce emergency deliveries with concerns for fetal wellbeing emanating mostly from increased uterine contraction frequency and/or intensity. However, there is no standard definition of what constitutes IR, and how its impact is assessed. Here, we have created two measures o...

Sixty years ago, the purpose of introducing electronic fetal heart rate monitoring (EFM) was to reduce the incidence of intrapartum stillbirth. However, by the early 1980s, with falling stillbirth rates, fetal blood sampling had been widely abandoned, as many considered that EFM was sufficient on its own. Unfortunately, while the sensitivity of EFM...

Objective: Intrauterine resuscitation (IR) may be employed during labor to reduce emergency deliveries with concerns for fetal wellbeing emanating mostly from increased uterine contraction frequency and/or intensity. However, there is no standard definition of what constitutes IR and how its impact is assessed. Here, we have created two measures of...

Importance: American maternal and neonatal mortality rates are the worst of the world's high-income countries. These rates are particularly low among patients of color, who have higher Cesarean delivery rates (CDR), higher healthcare costs, and poorer outcomes than White patients. However, common economic analyses do not address interlinked issues...

Early detection of intrapartum risk enables interventions to potentially prevent or mitigate adverse labor outcomes such as cerebral palsy. Currently, there is no accurate automated system to predict such events to assist with clinical decision-making. To fill this gap, we propose "Artificial Intelligence (AI) for Modeling and Explaining Neonatal H...

Introduction: The USA has the poorest health statistics of any high-income country. Political polarization has risen dramatically; newer safety net programs (the Affordable Care Act [ACA]) are unevenly provided because many Republican-leaning states refused expanded Federal coverage. Democratic programs have reduced physician leadership of medicin...

Background Antenatal steroid therapy for fetal lung maturation is routinely administered to women at risk of preterm delivery. There is strong evidence to demonstrate benefit from antenatal steroids in terms of survival and respiratory disease, notably in infants delivered at or below 32 weeks’ gestation. However, dosing remains unoptimized and lun...

We are developing a non-invasive neonatal monitoring device to continue monitoring of the fetus during the first 30–60 minutes postpartum. We monitor critical physiological parameters such as oxygenation, heart rate, and skin pH. These are crucial for the early identification of potential health issues in newborns, including hypoxia and acidosis wh...

Cerebral palsy (CP) has been recognized as a group of neurologic disorders with varying etiologies and ontogenies. While a percentage of CP cases arises during labor, the expanded use of electronic fetal monitoring (EFM) to include prevention of CP has resulted in decades of vastly increased interventions that have not significantly reduced the inc...

Electronic fetal monitoring (EFM) is designed for the early detection of fetal risks and the prevention of serious neurological impairment but suffers from high false positive rates. The Fetal Reserve Index (FRI) is an expert-based system that combines EFM with maternal, obstetrical, and fetal risk factors and displays superior performance in risk...

To evaluate obstetrical outcomes for women having late amniocentesis (on or after 24 weeks). Electronic databases were searched from inception to January 1st, 2023. The obstetrical outcomes evaluated were gestational age at delivery, preterm birth (PTB) < 37 weeks, PTB within 1 week from amniocentesis, premature prelabor rupture of membranes (pPROM...

A fundamental tenet of modern genetics is to provide nondirective counseling to patients so that they can make whatever informed decision they feel is most appropriate for them [1]. In our own counseling of patients, we often state that in a complex situation if 100% of patients go “left” or 100% of patients go “right,” then we clearly have not don...

Over the past 50 years, there have been dramatic advances in both ultrasound and genetic laboratory technologies. The combination of these, not either one alone, has led to an explosion of capabilities to diagnose fetal status earlier in pregnancy. The pace of change is accelerating faster and faster. The major shift in screening from second-trimes...

Fetal reduction (FR) for higher-order multiples accounted for 103.6 per 100,00 births across the United States in 2015, and the need for this service has expanded over the last 30 years. Despite improvements in neonatal care, triplet pregnancies are more likely to experience adverse outcomes, including infant mortality and morbidity, than twin or s...

Electronic fetal monitoring, particularly in the form of cardiotocography, forms the centerpiece of labor management. Initially successfully designed for stillbirth prevention, there was hope to also include prediction and prevention of fetal acidosis and its sequelae. With the routine use of electronic fetal monitoring, the cesarean delivery rate...

Advances in medical technology do not follow a smooth process and are highly variable. Implementation can occasionally be rapid, but often faces varying degrees of resistance resulting at the very least in delayed implementation. Using qualitative comparative analysis, we have evaluated numerous technological advances from the perspective of how th...

Since the 1970s, electronic fetal monitoring (EFM) also known as cardiotocography (CTG) has been used extensively in labor around the world, despite its known failure to help prevent many babies from developing neonatal encephalopathy and cerebral palsy. Part of EFM's poor performance with respect to these outcomes arises from a fundamental misunde...

Infertility treatments have benefited millions of couples to have their own children; however, the complication of multiple pregnancies with their increased morbidity and mortality has created significant problems. Fetal reduction (FR) was developed to ameliorate these issues. Over 30 years of publications show that FR has been highly successful in...

Objective This systematic review and meta-analysis aims to compare the fetal survival rate and perinatal outcomes of triplet pregnancies after selective reduction to twins (RTT) vs singletons (RTS). Data sources PubMed, Web of Science, Scopus, and Embase were systematically searched from inception of the databases until 16 January 2022. Study eli...

Objective Increased frequency of uterine contractions is a component in the cluster of causal conditions that can lead to fetal hypoxia and acidosis and increase the risk for neonatal neurologic injury. For most international obstetrical societies, 5 contractions per 10 min averaged over 30 min is considered as the upper limit of normal uterine act...

The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, eve...

Infertility treatments have benefited millions of couples to have their own children, but resultant multiple pregnancies with their increased morbidity and mortality have been a significant complication. Fetal reduction (FR) was developed to ameliorate those. Over 30 years of publications show that FR has been highly successful in substantially red...

Epithelial ovarian cancer (EOC) is a leading cause of cancer mortality among women but unfortunately is usually not diagnosed until advanced stage. Early detection of EOC is of paramount importance to improve outcomes. Liquid biopsy of circulating tumor cells (CTCs) is emerging as one of the promising biomarkers for early detection of solid tumors....

A false negative can happen in many kinds of medical tests, regardless of whether they are screening or diagnostic in nature. However, it inevitably poses serious concerns especially in a prenatal setting because its sequelae can mark the birth of an affected child beyond expectation. False negatives are not a new thing because of emerging new test...

Objective Over 5 decades, Cesarean Delivery rates (CDR) have risen 6-fold while vaginal operative deliveries [VODs] decreased from >20% to ∼3%. Poor outcomes (HIE and cerebral palsy) haven’t improved. Potentiating the virtual abandonment of forceps (F), particularly midforceps (Mid), were allegations about various poor neonatal outcomes. Here, we e...

Over the past 50 years, the scope and extent of prenatal diagnosis and screening for genetic disorders have improved geometrically. There has been a pendulum like swing from testing to screening back and forth as new technologies emerge. The concurrent developments of cell free fetal DNA analysis of maternal blood has dramatically changed patient's...

Objective: The use of pH and base excess (FSSPHBE) from fetal scalp sampling (FSS) was abandoned when cardiotocography (CTG) was believed to be sufficiently accurate to direct patient management. We sought to understand the fetus' tolerance to stress in the 1st stage of labor and to develop a better and earlier screening test for its risk for deve...

Objective: Electronic fetal monitoring/ cardiotocography (EFM) is nearly ubiquitous, but nearly everyone acknowledges there is room for improvement. We have contextualized monitoring by breaking it down into quantifiable components and adding to that, other factors that have not been formally used: ie the assessment of uterine contractions, and the...

Objective:: Electronic fetal monitoring (EFM) has been used extensively for almost 50 years but performs poorly in predicting and preventing adverse neonatal outcome. In recent years, the current "enhanced" classification of patterns (category I-III system [CAT]) were introduced into routine practice without corroborative studies, which has result...

Electronic fetal monitoring (EFM) is a poor predictor of outcomes attributable to delivery problems. Contextualizing EFM by adding maternal, obstetrical, and fetal risk-related information to create an index called the Fetal Reserve Index (FRI) improves the predictive capacity and facilitates the timing of interventions. Here, we test critical assu...

Objective: The cardiotocograph (CTG) or electronic fetal monitoring (EFM) was developed to prevent fetal asphyxia and subsequent neurological injury. From a public health perspective, it has failed these objectives while increasing emergency operative deliveries (emergency operative deliveries (EODs) – emergency cesarean delivery or operative vagin...

Objective: To assess the implications of increasing utilization of noninvasive prenatal screening (NIPS), which may reach 50% with the concomitant decrease in diagnostic procedures (DPs) for its impact on detection of chromosomal abnormalities. Methods: We studied our program's statistics over 5 years for DPs and utilization of array comparative...

Some medical practices have been ingrained in custom for decades, long after "proof" that they were effective was established. It is necessary to periodically reevaluate these practices, as newer theories and research may challenge the evidence upon which they were based. An example is the decades' old practice of recommending a 4-mg (4,000-µg) sup...

Objective: To evaluate the impact of genetic counseling (GC) during the third trimester by analyzing changes in pregnancy management and the correlation with postnatal findings. Methods: This was a retrospective study. Pregnancy course and neonatal follow-up were analyzed according to the reason for referral and implementation of recommendations...

Background: Even Key Opinion leaders now concede that electronic fetal monitoring (EFM) cannot reliably identify fetal acidemia which many vouch as the only labor mediated pathophysiologic precursor for cerebral palsy (CP). We have developed the “Fetal Reserve Index” – an algorithm combining five dynamic components of EFM (1. Rate, 2. Variability,...

Objective: The near-ubiquitous use of electronic fetal monitoring has failed to lower the rates of both cerebral palsy and emergency operative deliveries (EODs). Its performance metrics have low sensitivity, specificity, and predictive values for both. There are many EODs, but the vast majority have normal outcomes. The EODs, however, cause seriou...

Non-invasive prenatal screening (NIPS) has revolutionized the approach to prenatal fetal aneuploidy screening. Many commercial providers now offer analyses for sub-chromosomal copy number variations (CNVs). Here, we review the use of NIPS in the context of screening for microdeletions and microduplications, issues surrounding the choice of disorder...

Objective: Electronic fetal monitoring (EFM) correlates poorly with neonatal outcome. We present a new metric: the "Fetal Reserve Index" (FRI), formally incorporating EFM with maternal, obstetrical, fetal risk factors, and excessive uterine activity for assessment of risk for cerebral palsy (CP). Methods: We performed a retrospective, case-contr...

More than 3 decades ago, a small group of physicians and other practitioners active in what they called "fetal treatment" authored an opinion piece outlining the current status and future challenges anticipated in the field. Many advances in maternal, neonatal, and perinatal care and diagnostic and therapeutic modalities have been made in the inter...

Background/objectives: Multiple pregnancies have tripled in the United States over the past 3 decades. Attributed to increasing maternal age at delivery but more so assisted reproductive technological advances, an effort has been made to decrease twinning through elective single embryo transfer. We sought to review and evaluate risks of monochorio...

Establishing what constitutes an appropriate standard of care with respect to risk communication and support is a complex task with different roots. For this examination of how physician-patient and physician-physician communication about risk and options for dealing with risk is shaped by the conservatism of the context within which they take plac...

What is already known about this topic: • Innovation and technological development have commonalities across all disciplines in terms of process, evaluation, and incorporation into use. • Many technologies have evolved through traditional methods such as research grant funding, individual and multicenter trials, followed by eventual introduction i...

The choice of screening or invasive procedure in twin pregnancies is a personal choice of whether the patient wishes to take a small risk of having a baby with a serious disorder versus a small risk of having a complication because she wishes to avoid that. How to interpret such risks has profound effects on the perceived value of techniques, eithe...

The past few years have seen extraordinary advances in prenatal genetic practice led by 2 major technological advances; next-generation sequencing of cell-free DNA in the maternal plasma to noninvasively identify fetal chromosome abnormalities, and microarray analysis of chorionic villus sampling and amniotic fluid samples, resulting in increased c...

Objectives: The explosion in genetic technologies, including array comparative genomic hybridization (aCGH), has increased the complexity of genetic counseling. We now offer chorionic villus sampling (CVS) and aCGH to all first-trimester patients, as this allows the prenatal diagnosis of an additional 1% of anomalies not otherwise detectable and c...

Over the past few decades there have been dramatic advances in both ultrasound and genetic laboratory technologies. The combination of these, not either one by itself, has led to an explosion of capabilities to diagnose fetal status earlier and earlier in pregnancy. The major shift in screening from second trimester ultrasounds and multiple marker...

Several isolated reports of fetal goiter treatment have shown limited generalizability of approaches and provide no real guidance for optimal timing, dosages, and treatment strategies. Graves' disease accounts for >60% of these cases. Maternal treatments of hyperthyroidism include antithyroid medications such as methimazole and more commonly propyl...

There have been tremendous advances in the ability to screen for the "odds" of having a genetic disorder (both mendelian and chromosomal). With microarray analyses on fetal tissue now showing a minimum risk for any pregnancy being at least 1 in 150 and ultimately greater than 1%, it is thought that all patients, regardless of age, should be offered...

Objectives To determine whether implementation of primary cell-free fetal DNA (cffDNA) screening would be cost-effective in the USA and to evaluate potential lower-cost alternatives. Methods Three strategies to screen for trisomy 21 were evaluated using decision tree analysis: 1) a primary strategy in which cffDNA screening was offered to all patie...

The procedure of fetal reduction (FR) was begun 30 years ago to salvage pregnancies of couples who, following fertility therapy, were “too successful,” i.e., pregnant with too many fetuses. FR has gone from a rarity performed in only the highest risk situations to now an integral fail-safe of infertility practice. Our understanding of the problems...

Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. Published studies assessing long-term neurological outcomes after comm...

Fetal reduction (FR) began in the 1980s to salvage the pregnancies of couples needing fertility therapy who were finally successful but with too many fetuses. Since then, it has gone from a rarity performed in only the highest risk situations to an integral fail-safe of infertility practice. Our understanding of the problems of multiple and prematu...

Fetal reduction (FR) began in the 1980’s to salvage the pregnancies of couples needing fertility therapy who were finally successful but with too many fetuses. Over 25+ years, it has gone from a rarity performed in only the highest risk situations to an integral fail-safe of infertility practice. Our understanding of the problems of multiple and pr...

Background: Gestational carriers and egg donors have been used by 'traditional' and now increasingly, gay couples. Three gay male couples, all using egg donors and gestational carriers with semen from both partners, had triplets. All desired reductions to twins for the standard medical indications, but requested, if reasonably possible, to have tw...

To examine using CVS and FISH to detect aneuploidy before first trimester fetal reduction (FR) in sonographically normal-appearing fetuses. A retrospective review of 470 patients referred to our unit for FR from January 2007 - March 2011. Prenatal diagnosis was offered to all. FR was performed after next-day FISH results. Abnormalities were categor...

Objective: Fetal reduction (FR) in multiples dramatically improves outcomes. We prioritize FR decisions for health and historically declined to factor gender. As male preferences apparently diminished, our bioethicist encouraged a re-evaluation. Methods: Three hundred ninety-six patients reducing triplets or twins were categorized as 3➔2, 3➔1, a...

Introduction: To determine if nuchal translucency (NT) quality correlates with the extent to which clinics vary in rigor and quality control. Methods: We correlated NT performance quality (bias and precision) of 246,000 patients with two alternative measures of clinic culture - % of cases for whom nasal bone (NB) measurements were performed and...

This study aimed to assess the efficacy of first-trimester aneuploidy screening in a single clinical setting. Maternal age, nuchal translucency, and maternal serum levels of pregnancy-associated plasma protein A and free beta human chorionic gonadotrophin comprised first-trimester risk assessment for Down syndrome and trisomies 13/18. Means, screen...

To determine the feasibility of digital PCR analysis for noninvasive prenatal diagnosis of trisomy 21. Through power equations, we modeled the number of wells necessary to determine the feasibility of digital PCR as a practical method for trisomy 21 risk assessment. The number of wells needed is a direct correlate of the ability to isolate free fet...

In the USA, both The Fetal Medicine Foundation (FMF) and the Nuchal Translucency Quality Review Program (NTQR) have operated education, review and credentialing for physicians and sonographers for the measurement of nuchal translucency (NT). We sought to assess differences in the distribution of NT measurements based upon the system from which the...

The purpose of this study was to determine the performance of Down syndrome screening in triplet pregnancy. Nuchal translucency (NT; n = 794), nasal bone (n = 219), and biochemistry (n = 198) were evaluated in triplet pregnancy. Screening performance was evaluated with the use of delta and Gaussian models. The median multiples of the median values...

Differences in quality among ultrasound nuchal translucency providers or laboratories can profoundly affect Down syndrome screening results. A new method, performance adjusted risks (PAR), is developed to allow for such differences and improve performance. Individual provider and laboratory marker distribution parameters are compared with national...