David M Stamilio

University of North Carolina at Chapel Hill, North Carolina, United States

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Publications (236)998.92 Total impact


  • No preview · Article · Jan 2016 · American Journal of Obstetrics and Gynecology

  • No preview · Article · Jan 2016 · American Journal of Obstetrics and Gynecology
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    ABSTRACT: Objective This study aims to determine preferences of a nationally representative sample of obstetrician/gynecologists (OB/GYNs) regarding cesarean delivery (CD) incision practices for women with morbid obesity (body mass index ≥ 40 kg/m(2)). Study Design We conducted an online survey using the American College of Obstetricians and Gynecologists database. We compared physician demographics, practice characteristics, and CD incision type preference. Results After exclusion of ineligible participants, 247 OB/GYNs completed the survey (42% response rate). In nonemergency CD of morbidly obese women, 84% of physicians preferred a Pfannenstiel skin incision (67% preferring taping the pannus; 17% without taping the pannus). In emergency CD, 66% preferred a Pfannenstiel incision (46% without taping the pannus; 20% with taping the pannus) and 20% a vertical incision. For both emergency and nonemergency CD, there was no difference in incision type preferences by provider years in practice, practice scope, or number of CD performed each year. Conclusion Given the preference of a Pfannenstiel incision with taping the pannus during CD of morbidly obese women, further investigation is needed to assess the risks and benefits of this incision and the practice of elevating the pannus.
    No preview · Article · Oct 2015 · American Journal of Perinatology
  • Marcela C Smid · Morgan S Kearney · David M Stamilio
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    ABSTRACT: Objective The objective of this study was to estimate the association between obesity and wound complications after cesarean delivery. Methods A secondary cohort analysis of the Maternal-Fetal Medicine Unit Cesarean Registry. We stratified the exposure, maternal body mass index (BMI) at delivery, as not obese (BMI < 30), obese (BMI 30-45), and extremely obese (BMI > 45). Our primary outcome was wound complication composite of wound infection, endometritis, wound opening, seroma/hematoma, and hospital readmission. Our secondary outcomes included infection composite (wound infection and endometritis) and each individual outcome included in the primary composite. We performed unadjusted and multivariable logistic regression analyses. Results We included 38,229 women who underwent cesarean; 39% were not obese, 55% were obese, and 6% were extremely obese. In our cohort, 40% of women underwent repeat cesarean and 57% underwent cesarean after labor. Extremely obese women had increased risk for any wound complication (14%, adjusted odds ratio [AOR], 1.65; 95% confidence interval [CI], 1.44-1.89), endometritis (8.3%, AOR, 1.26; 95% CI, 1.07-1.49), wound infection (2.0%, AOR, 3.77; 95% CI, 2.60-5.46), wound opening (0.8%, AOR, 5.47; 95% CI, 2.79-10.71), and wound infection-related hospital readmission (3.6%, AOR, 2.97; 95% CI, 2.26-3.91) compared with nonobese women. Obese women had increased risk for any wound complication (9.6%, AOR, 1.14; 95% CI, 1.06-1.23) and postcesarean infection (7.7%, AOR, 1.12; 95% CI, 1.03-1.22) but not other outcomes. Conclusion In a large multicenter cohort study, we found that extreme obesity was associated with substantial increase in maternal postcesarean complications, and the association between obesity and postcesarean complications appears dose related. These findings validate associations found in single-center studies.
    No preview · Article · Oct 2015 · American Journal of Perinatology
  • Jessica A McPherson · Sarah Smiley · David M Stamilio
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    ABSTRACT: Given the association between risk of cerebral palsy and children born to obese women, the study aim was to estimate if maternal obesity is associated with reduced effectiveness of conventional antenatal magnesium sulfate dosing for the prevention of cerebral palsy and death. This is a secondary cohort analysis of a multi-center randomized clinical trial completed by the Maternal-Fetal Medicine Units Network. Women were included in the original trial if deemed high risk for preterm delivery in the subsequent 24 hours. The present study included singleton, non-anomalous fetuses that were randomized to and received magnesium sulfate with complete data available. Outcomes between obese (body mass index ≥ 30 kg/m(2)) and non-obese women were compared. A secondary analysis of outcomes between morbidly obese (body mass index ≥ 40 kg/m(2)) and non-morbidly obese women was performed. The primary outcome was a composite of cerebral palsy or perinatal death before 15 months corrected age. Secondary outcomes included moderate to severe cerebral palsy or death, any cerebral palsy, moderate to severe cerebral palsy, and death. Logistic regression analysis was used to estimate the odds ratio of each outcome. Based on sample size, exposure rate (obesity) and an outcome rate of 10%, assuming an 80% power and a 0.05 alpha error, this study had sufficient power to detect a 2-fold increase in the primary outcome. Of 1188 women randomized to receive magnesium sulfate, 806 were included in this analysis. After adjusting for gestational age at delivery, maternal obesity was not associated with an increased risk of cerebral palsy or death in children born to women who received magnesium sulfate. Women with morbid obesity had higher rates of the primary outcome and cerebral palsy in unadjusted analysis but did not have increased risks after adjusting for gestational age at delivery. In analyses stratified on gestational age, morbidly obese women who delivered after 28 weeks had increased risks of children with cerebral palsy or death and cerebral palsy although case numbers were small. Among women receiving antenatal neuroprotective magnesium sulfate, maternal obesity is not associated with an increased risk of having a child with cerebral palsy or death. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jun 2015 · American journal of obstetrics and gynecology
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    ABSTRACT: Objective This study aims to evaluate whether magnesium sulfate (MgSO4) infusion at the time of delivery or magnesium cord blood concentration is associated with cerebral palsy (CP) or death diagnosed by the age of 2 years. Methods Secondary analysis of data from a randomized trial of MgSO4 versus placebo for prevention of CP or death among offspring of women with anticipated preterm delivery. This study cohort included singleton, nonanomalous fetuses, whose mothers received MgSO4 as neuroprophylaxis. The primary outcomes were CP or death diagnosed by the age of 2 years. Results A total of 936 neonates (93 with CP or death, 843 controls) were included in the analysis. Infants in the group with CP or death had MgSO4 infusing at delivery at a similar frequency to that of controls (49 [52.7%] vs. 463 [54.9%], p = 0.68). Mean concentrations of cord blood magnesium, available for 596 neonates, also were not different between the two groups (2.7 ± 0.9 vs. 2.6 ± 0.9 mEq/L, p = 0.66, respectively). Multivariable analyses did not alter these findings. Conclusion Among the offspring of women exposed to MgSO4, in utero, neither MgSO4 infusion at the time of delivery nor magnesium cord blood concentration is associated with CP or death. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
    No preview · Article · Jun 2015 · American Journal of Obstetrics and Gynecology
  • Alison Stuebe · Jorge Tolosa · Cindy McEvoy · David Stamilio

    No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology
  • Jessica McPherson · Sarah Smiley · David Stamilio

    No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology
  • Morgan Kearney · Marcela Smid · David Stamilio

    No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology
  • Marcela Smid · Morgan Kearney · David Stamilio

    No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology
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    ABSTRACT: OBJECTIVE: To evaluate the association of duration of magnesium sulfate infusion with stillbirth or death, cerebral palsy, and select adverse maternal and neonatal outcomes. METHODS: This is a secondary cohort analysis of women randomized to receive magnesium sulfate within a previously reported Maternal-Fetal Medicine Units Network prospective clinical trial. The association of antenatal infusion of magnesium sulfate for less than 12 hours, 12-18 hours, and greater than 18 hours on maternal and perinatal outcomes was compared. The primary outcome was cerebral palsy of any severity or death. Secondary outcomes included cerebral palsy, death, and select maternal and neonatal outcomes. Stratified and logistic regression analyses were used. The models were adjusted for race, gestational age at birth, time since last magnesium sulfate, any magnesium sulfate at delivery, and eligibility criteria as appropriate. RESULTS: Of 933 women available for analysis, 356, 341, and 236 received antenatal magnesium sulfate infusion for a total of less than 12 hours, 12-18 hours, or greater than 18 hours, respectively. Any cerebral palsy or death occurred in 39 women (11.7%) who received magnesium sulfate less than 12 hours, 34 women (10.3%) who received 12-18 hours of magnesium sulfate, and 20 women (8.8%) who received greater than 18 hours of magnesium sulfate. There was no difference in death or cerebral palsy among groups (less than 12 hours as reference; adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 0.60-1.77 for 12-18 hours; adjusted OR 1.08, 95% CI 0.57-2.03 for greater than 18 hours). Select maternal adverse drug affects and neonatal morbidities were also similar across groups. CONCLUSION: The duration of antenatal magnesium sulfate infusion is not associated with risk of death or cerebral palsy. The optimal treatment duration needed for maximal neuroprotection remains unknown.
    No preview · Article · Sep 2014 · Obstetrics and Gynecology
  • David M Stamilio · Christina M Scifres
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    ABSTRACT: OBJECTIVE: To estimate the association of obesity and extreme obesity with maternal complications after cesarean delivery. METHODS: This was a secondary cohort analysis of a randomized controlled trial. The parent study was designed to estimate the effect of supplemental oxygen on postcesarean infectious morbidity. Because the study intervention had no effect, study groups were combined as a cohort. For this secondary analysis, the exposure was obesity, stratified as normal or overweight (body mass index [BMI] less than 30), obese (BMI 30-45), or extremely obese (BMI higher than 45). The primary outcome was a composite of wound infection and endometritis. Secondary outcomes included wound infection, endometritis, wound opening, hematoma or seroma, and emergency department visit. We performed unadjusted and multivariable logistic regression analyses. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: We included 585 women in the analysis. Eighty-five patients (14.5%) had BMIs higher than 45. Rates of black race, chronic hypertension, diabetes, and gestational diabetes increased and operative duration increased with increasing obesity severity. Obese patients were more likely to have a cesarean delivery after labor and have a vertical skin incision or classical uterine incision. After controlling for confounders, extremely obese patients had a twofold to fourfold increase in postoperative complications, including the primary infectious outcome (18.8%, adjusted OR 2.7, CI 1.2-6.1), wound infection (18.8%, adjusted OR 3.4, CI 1.4-8.0), and emergency department visit (23.1%, adjusted OR 2.2, CI 1.03-4.9). CONCLUSION: Maternal extreme obesity is associated with a considerable increase in postcesarean wound complications.
    No preview · Article · Jul 2014 · Obstetrics and Gynecology
  • Jessica A McPherson · Robert A Strauss · David M Stamilio
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    ABSTRACT: Objective: Concern for uterine rupture has led to the decline in vaginal births after cesarean. Nonreassuring fetal status (NRFS) may precede uterine rupture. The objective of this study was to estimate the risks of uterine rupture, uterine dehiscence, and adverse fetal outcomes associated with NRFS during trial of labor after cesarean (TOLAC). Study design: In a retrospective cohort study of the previously reported Maternal-Fetal Medicine Units Network prospective cohort cesarean registry, we compared women undergoing repeat cesarean for NRFS after TOLAC to those requiring repeat cesarean for other intrapartum indications. Exclusion criteria included women with a prior cesarean who underwent elective or indicated repeat cesarean or women with a multiple gestation. Primary outcomes included uterine rupture or dehiscence. Secondary outcomes included 5-minute Apgar score <7 and neonatal intensive care unit admission. Planned subanalyses for term and preterm deliveries were performed. Stratified and logistic regression analyses were used. Results: Of 17,740 women undergoing TOLAC, 4754 (26.8%) had a failed vaginal birth after cesarean. Of those, NRFS was the primary indication for cesarean in 1516 (31.9%). Women with NRFS as the primary indication for repeat cesarean were at increased risk of uterine rupture (adjusted odds ratio, 3.32; 95% confidence interval, 2.21-5.00), uterine dehiscence (adjusted odds ratio, 1.70; 95% confidence interval, 1.09-2.65), 5-minute Apgar score <7, and neonatal intensive care unit admission compared to women with other primary indications. Conclusion: Women attempting TOLAC who require repeat cesarean for NRFS are at increased risk of uterine rupture and uterine dehiscence.
    No preview · Article · Jun 2014 · American Journal of Obstetrics and Gynecology
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    ABSTRACT: Previous studies have shown mixed results for pregnancy outcomes after loop electrosurgical excision procedure (LEEP); however, evidence is lacking regarding the pregnancy outcome of spontaneous abortion with respect to time elapsed from LEEP to pregnancy. We investigated risks of spontaneous abortion and preterm birth as they relate to time elapsed from LEEP to pregnancy. A 10-year, multicenter cohort study of women who underwent LEEP was performed between 1996 and 2006. Trained research nurses conducted telephone interviews with all patients to complete data extraction unavailable in charts. Median time from LEEP to pregnancy for spontaneous abortion compared with no spontaneous abortion and preterm birth before 34 and before 37 weeks of gestation compared with term birth were estimated. Patients with time intervals less than 12 months compared with 12 months or more from LEEP to pregnancy were then compared with identify adjusted odds ratios for spontaneous abortion and preterm birth. Five hundred ninety-six patients met inclusion criteria. Median time from LEEP to pregnancy was significantly shorter for women with a spontaneous abortion (20 months [interquartile range 11.2-40.9] compared with 31 months [interquartile range 18.7-51.2]; P=.01) but did not differ for women with a term birth compared with preterm birth. Women with a time interval less than 12 months compared with 12 months or more were at significantly increased risk for spontaneous abortion (17.9% compared with 4.6%; adjusted odds ratio 5.6; 95% confidence interval 2.5-12.7). No increased risk was identified for preterm birth before 34 weeks of gestation or before 37 weeks of gestation. Women with a shorter time interval from LEEP to pregnancy are at increased risk for spontaneous abortion but not preterm birth. LEVEL OF EVIDENCE:: II.
    No preview · Article · Nov 2013 · Obstetrics and Gynecology
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    ABSTRACT: To estimate the utility of the fetal-pelvic index (FPI) in predicting cesarean among nulliparous and women undergoing trial of labor after cesarean (TOLAC). This prospective cohort study included subjects at 2 hospitals from the University of Pennsylvania Health system. The study sample included nulliparous women and TOLAC women, with non-anomalous pregnancies at ≥ 37 weeks of gestation in vertex presentation (n=221 and 207 respectively). FPI score was calculated using ultrasound based fetal biometric measures performed within 2 weeks of delivery and x-ray pelvimetry performed within 48 hours of delivery. Multivariable logistic regression was used to develop a clinical predictive index for cesarean delivery, including FPI and clinical factors, in nulliparous women or women attempting TOLAC. The prediction models were tested for accuracy with the area under the receiver operating characteristics (ROC) curve. Higher FPI scores was associated with greater odds of cesarean. A unit increase in FPI score increased the odds of cesarean by 15% [adjusted odds ratio (aOR): 1.15, 95% confidence interval (CI): 1.09, 1.21] for nulliparous women and 15% for TOLAC women (aOR: 1.15, 95% CI: 1.10, 1.20) after adjusting for maternal age, race, medical risk factors, and labor method. Among nulliparous women, the ROC curve analysis estimated an area under the curve of 0.88, with positive and negative predictive values of 76% and 87%, respectively. Similar findings were observed in the subgroup of TOLAC women. The FPI can accurately identify women at high risk for cesarean when combined with clinical risk factors.
    No preview · Article · Jun 2013 · American journal of obstetrics and gynecology
  • George A. Macones · Alison Cahill · David M. Stamilio · Anthony O. Odibo
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    ABSTRACT: Induction of labor remains a significant risk factor for cesarean delivery (CD). Amniotomy is generally thought to be inexpensive and safe, but studies have not investigated the efficacy of the procedure in nulliparous women. This unblinded, randomized controlled trial was undertaken to determine whether early amniotomy, defined as artificial rupture of the membranes (AROM) at 4-cm dilation or less, would reduce the duration of labor or increase the proportion of women delivered within 24 hours. The safety of early amniotomy was assessed for adverse obstetric outcomes and maternal and neonatal infectious morbidities. Inclusion criteria were nulliparity, singleton, term gestation, and a need for labor induction as determined by the treating physician. Patients were randomly assigned to early amniotomy or to standard management, which was amniotomy at greater than 4-cm dilation. In the early amniotomy group, amniotomy was performed as early as could be done safely. No specific instructions were given regarding the timing of amniotomy in the standard treatment group. This decision and decisions for the primary method of induction and other intrapartum/postpartum factors were made at the physician’s discretion. The primary outcomes were time from initiation of induction, defined as time at delivery of the first induction method to delivery, and the proportion of women delivered within 24 hours from the initiation of induction. Secondary end points included rates of and indications for CD, chorioamnionitis, postpartum fever, wound infection, endomyometritis, neonatal intensive care unit (NICU) admission, and suspected neonatal sepsis. Statistical analyses were performed with the intent-to-treat principle. Continuous outcomes were compared with the use of the Student t test or Mann-Whitney U dependent on their distributions; dichotomous outcomes were assessed with χ2 or Fisher exact tests. Time to delivery was not normally distributed and was compared with the use of the Mann-Whitney U test. Of 749 women screened for eligibility, 84 women (11.2%) were ineligible by exclusion criteria. Of the 635 eligible nulliparous women, 585 women (92%) consented and were assigned randomly, with 292 women in the early amniotomy group, and 293 women in the standard treatment group. The groups were similar in demographics and maternal medical conditions; the mean gestational age at induction was 22.7 ± 5.8 years and 23.3 ± 6.2 years in the early amniotomy and standard groups, respectively. The admission cervical dilations were 1.1 ± 1.03 and 1.1 ± 0.97 cm, respectively. The indications for labor induction were similar between the groups, with the most common indications being more than 40-week gestations and gestational hypertension/preeclampsia. Most women received misoprostol, and about 30% of the women received a Foley bulb; 73% of women in both groups received more than 1 agent for induction. The average time from the start of induction to delivery was 19.0 hours in the early amniotomy group compared with 21.3 hours in the standard group (P = 0.04). This difference in length of labor occurred mainly in the first stage, which was defined as time from randomization assignment to complete cervical dilation. In the early amniotomy group, 68% of women were delivered within 24 hours of the start of induction compared with 56% in the standard treatment group (P = 0.002). However, rates of CD did not differ between the groups. The rate of chorioamnionitis was 11.5% in the early amniotomy group and 8.5% in the standard group, not a statistically significant difference. Two cord prolapses occurred in the early amniotomy group (both infants did well), but none in the standard group. The groups did not differ in the rate of confirmed or suspected neonatal sepsis or admission to the NICU. These results indicate that early amniotomy shortens labor by about 2 hours and increases the proportion of women delivered within 24 hours, but does not increase the rate of CDs. The shorter duration of labor must be weighed against both maternal and neonatal safety concerns. Although chorioamnionitis did not lead to an increase in the rate of suspected neonatal sepsis or NICU admission, and no serious maternal consequences developed, future studies should focus on the occurrence of chorioamnionitis with early amniotomy. Based on data from this study, early amniotomy may be a useful adjunct in nulliparous labor inductions and may be incorporated into induction algorithms.
    No preview · Article · Mar 2013 · Obstetrical and Gynecological Survey
  • Lorie M Harper · Anthony O Odibo · David M Stamilio · George A Macones
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    ABSTRACT: Objective: The purpose of this study was to determine whether x-ray measures of the mid pelvis can be used to predict cesarean delivery. Study design: Women were enrolled prospectively; x-ray pelvimetry was performed after delivery; the readers were blinded to the outcome. Groups were determined by mid pelvis measures (transverse diameter, anteroposterior diameter, and circumference ≤ 10th percentile. The primary outcome was cesarean delivery. Univariable, stratified, and multivariable analyses were performed to estimate the effect of mid pelvis measures on cesarean delivery. Receiver operator characteristics curves were created to estimate the predictive value of mid pelvis measures of cesarean delivery. Results: Four hundred twenty-six women were included. Subjects with anteroposterior diameter or circumference ≤ 10th percentile were at greater risk of cesarean delivery (risk ratio for anteroposterior diameter, 4.8; 95% confidence interval, 3.9-5.8; risk ratio for circumference ≤ 10th percentile, 3.8; 95% confidence interval, 3.1-4.8). Transverse diameter ≤ 10th percentile was not associated with an increased risk of cesarean delivery. The area under the receiver operator characteristics curves for anteroposterior diameter, circumference ≤ 10th percentile, and transverse diameter were 0.88, 0.85, and 0.69, respectively (P < .01). Conclusion: Simple radiographic measures of the mid pelvis on x-ray can provide a useful adjunct to clinical information in the determination of who should attempt a vaginal delivery.
    No preview · Article · Mar 2013 · American journal of obstetrics and gynecology

  • No preview · Article · Jan 2013 · American Journal of Obstetrics and Gynecology
  • David Stamilio · Molly Stout · George Macones · Christina Scifres

    No preview · Article · Jan 2013 · American Journal of Obstetrics and Gynecology

  • No preview · Article · Jan 2013 · American Journal of Obstetrics and Gynecology

Publication Stats

2k Citations
998.92 Total Impact Points

Institutions

  • 2014-2016
    • University of North Carolina at Chapel Hill
      • Department of Obstetrics and Gynecology
      North Carolina, United States
  • 2007-2013
    • Washington University in St. Louis
      • Department of Obstetrics and Gynecology
      San Luis, Missouri, United States
    • Duke University
      Durham, North Carolina, United States
  • 2012
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
  • 2010
    • Saint Louis University
      Saint Louis, Michigan, United States
  • 2008
    • University of California, San Francisco
      San Francisco, California, United States
    • University of Kentucky
      • Department of Obstetrics and Gynecology
      Lexington, Kentucky, United States
  • 2004-2007
    • The Philadelphia Center
      Filadelfia, Pennsylvania, United States
    • Leiden University Medical Centre
      • Department of Obstetrics
      Leyden, South Holland, Netherlands
    • University of Connecticut
      • Department of Obstetrics and Gynecology
      Storrs, Connecticut, United States
  • 2005-2006
    • Brown University
      Providence, Rhode Island, United States
    • William Penn University
      Filadelfia, Pennsylvania, United States
    • Ben-Gurion University of the Negev
      Be'er Sheva`, Southern District, Israel
    • Columbia University
      • Department of Obstetrics and Gynecology
      New York, New York, United States
    • Johns Hopkins University
      • Department of Gynecology & Obstetrics
      Baltimore, Maryland, United States
    • Canadian Society for Epidemiology and Biostatistics 
      Canada
  • 2001-2006
    • University of Pennsylvania
      • • Department of Obstetrics and Gynecology
      • • Center for Clinical Epidemiology and Biostatistics
      Filadelfia, Pennsylvania, United States
  • 1998-2005
    • Society for Maternal-Fetal Medicine
      Filadelfia, Pennsylvania, United States
  • 1997-2004
    • Hospital of the University of Pennsylvania
      • Department of Obstetrics and Gynecology
      Filadelfia, Pennsylvania, United States
  • 2003
    • Tel Aviv University
      • Department of Obstetrics and Gynecology
      Tell Afif, Tel Aviv, Israel
  • 2000
    • Cooper University Hospital
      Cooper, Texas, United States