Mary E D'Alton

Columbia University, New York, New York, United States

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Publications (221)1155.7 Total impact


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

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

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

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

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

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

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

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

  • No preview · Article · Jan 2016 · American Journal of Obstetrics and Gynecology
  • Leslie Moroz · Mary D'Alton

    No preview · Article · Nov 2015 · Journal of Perinatal Medicine
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    ABSTRACT: The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.
    Full-text · Article · Oct 2015 · American journal of obstetrics and gynecology
  • K L Palmerola · M E D'Alton · C O Brock · A M Friedman
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    ABSTRACT: Guidelines for pharmacologic obstetric venous thromboembolism (VTE) prophylaxis from the American Congress of Obstetricians (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), and the American College of Chest Physicians (Chest) vary significantly. The objective of this study was to determine the practical implications of these recommendations in terms of prophylaxis rates for a tertiary obstetric population. Cross-sectional. Tertiary referral hospital. Patients post-operative day 1 after caesarean delivery. This cross-sectional study evaluated rates of pharmacologic prophylaxis for women based on RCOG, ACOG, and Chest recommendations. Medical, obstetric, and demographic risk factors for thromboembolism were reviewed for individual patients. Rates of prophylaxis based on each of the guidelines with 95% confidence intervals were calculated. Recommended pharmacologic prophylaxis. About 293 patients were included in the analysis. Under RCOG guidelines, 85.0% of patients would receive post-caesarean pharmacologic prophylaxis [95% confidence interval (CI) 80.5–88.6%] compared with 1.0% of patients under ACOG guidelines (95% CI 0.3–3.0%) and 34.8% of patients under Chest guidelines (95% CI 29.6–40.4%). Caesarean during labour, obesity, advanced maternal age, pre-eclampsia, and multiple gestation were among the most commonrisk factors. Recommended prophylaxis differed significantly. Under ACOG recommendations a small minority of patients would receive prophylaxis, whereas under RCOG recommendations a large majority of patients would receive low-molecular-weight heparin. Given the large differences in prophylaxis rates for post-caesarean thromboprophylaxis based on different guidelines, further research is urgently needed to compare the risks and benefits of recommendations. Recommendations from major society guidelines for post-caesarean thromboprophylaxis differ greatly.
    No preview · Article · Oct 2015 · BJOG An International Journal of Obstetrics & Gynaecology
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    ABSTRACT: Fetomaternal hemorrhage (FMH) can be associated with significant perinatal mortality. Our review of the literature did not identify any cases of FMH following placement of an intrauterine pressure catheter (IUPC). In our case, an IUPC was inserted in a patient undergoing induction of labor at term. Fetal bradycardia ensued shortly after placement, warranting an emergent cesarean delivery. Severe neonatal anemia was identified, and evaluation of maternal blood was consistent with massive FMH. This is the first reported association between FMH and IUPC placement. If this relationship is validated in future reports, appropriate changes in clinical practice may be warranted.
    Preview · Article · Sep 2015
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    ABSTRACT: Objective: Fetal growth is associated with long-term health yet no appropriate standards exist for the early identification of undergrown or overgrown fetuses. We sought to develop contemporary fetal growth standards for 4 self-identified US racial/ethnic groups. Study design: We recruited for prospective follow-up 2334 healthy women with low-risk, singleton pregnancies from 12 community and perinatal centers from July 2009 through January 2013. The cohort comprised: 614 (26%) non-Hispanic whites, 611 (26%) non-Hispanic blacks, 649 (28%) Hispanics, and 460 (20%) Asians. Women were screened at 8w0d to 13w6d for maternal health status associated with presumably normal fetal growth (aged 18-40 years; body mass index 19.0-29.9 kg/m(2); healthy lifestyles and living conditions; low-risk medical and obstetrical history); 92% of recruited women completed the protocol. Women were randomized among 4 ultrasonography schedules for longitudinal fetal measurement using the Voluson E8 (GE Healthcare, Milwaukee, WI). In-person interviews and anthropometric assessments were conducted at each visit; medical records were abstracted. The fetuses of 1737 (74%) women continued to be low risk (uncomplicated pregnancy, absent anomalies) at birth, and their measurements were included in the standards. Racial/ethnic-specific fetal growth curves were estimated using linear mixed models with cubic splines. Estimated fetal weight (EFW) and biometric parameter percentiles (5th, 50th, 95th) were determined for each gestational week and comparisons made by race/ethnicity, with and without adjustment for maternal and sociodemographic factors. Results: EFW differed significantly by race/ethnicity >20 weeks. Specifically at 39 weeks, the 5th, 50th, and 95th percentiles were 2790, 3505, and 4402 g for white; 2633, 3336, and 4226 g for Hispanic; 2621, 3270, and 4078 g for Asian; and 2622, 3260, and 4053 g for black women (adjusted global P < .001). For individual parameters, racial/ethnic differences by order of detection were: humerus and femur lengths (10 weeks), abdominal circumference (16 weeks), head circumference (21 weeks), and biparietal diameter (27 weeks). The study-derived standard based solely on the white group erroneously classifies as much as 15% of non-white fetuses as growth restricted (EFW <5th percentile). Conclusion: Significant differences in fetal growth were found among the 4 groups. Racial/ethnic-specific standards improve the precision in evaluating fetal growth.
    Full-text · Article · Sep 2015 · American journal of obstetrics and gynecology
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    ABSTRACT: OBJECT The Management of Myelomeningocele Study (MOMS) was a multicenter randomized trial comparing the safety and efficacy of prenatal and postnatal closure of myelomeningocele. The trial was stopped early because of the demonstrated efficacy of prenatal surgery, and outcomes on 158 of 183 pregnancies were reported. Here, the authors update the 1-year outcomes for the complete trial, analyze the primary and related outcomes, and evaluate whether specific prerandomization risk factors are associated with prenatal surgery benefit. METHODS The primary outcome was a composite of fetal loss or any of the following: infant death, CSF shunt placement, or meeting the prespecified criteria for shunt placement. Primary outcome, actual shunt placement, and shunt revision rates for prenatal versus postnatal repair were compared. The shunt criteria were reassessed to determine which were most concordant with practice, and a new composite outcome was created from the primary outcome by replacing the original criteria for CSF shunt placement with the revised criteria. The authors used logistic regression to estimate whether there were interactions between the type of surgery and known prenatal risk factors (lesion level, gestational age, degree of hindbrain herniation, and ventricle size) for shunt placement, and to determine which factors were associated with shunting among those infants who underwent prenatal surgery. RESULTS Ninety-one women were randomized to prenatal surgery and 92 to postnatal repair. The primary outcome occurred in 73% of infants in the prenatal surgery group and in 98% in the postnatal group (p < 0.0001). Actual rates of shunt placement were only 44% and 84% in the 2 groups, respectively (p < 0.0001). The authors revised the most commonly met criterion to require overt clinical signs of increased intracranial pressure, defined as split sutures, bulging fontanelle, or sunsetting eyes, in addition to increasing head circumference or hydrocephalus. Using these modified criteria, only 3 patients in each group met criteria but did not receive a shunt. For the revised composite outcome, there was a difference between the prenatal and postnatal surgery groups: 49.5% versus 87.0% (p < 0.0001). There was also a significant reduction in the number of children who had a shunt placed and then required a revision by 1 year of age in the prenatal group (15.4% vs 40.2%, relative risk 0.38 [95% CI 0.22-0.66]). In the prenatal surgery group, 20% of those with ventricle size < 10 mm at initial screening, 45.2% with ventricle size of 10 up to 15 mm, and 79.0% with ventricle size ≥ 15 mm received a shunt, whereas in the postnatal group, 79.4%, 86.0%, and 87.5%, respectively, received a shunt (p = 0.02). Lesion level and degree of hind-brain herniation appeared to have no effect on the eventual need for shunting (p = 0.19 and p = 0.13, respectively). Similar results were obtained for the revised outcome. CONCLUSIONS Larger ventricles at initial screening are associated with an increased need for shunting among those undergoing fetal surgery for myelomeningocele. During prenatal counseling, care should be exercised in recommending prenatal surgery when the ventricles are 15 mm or larger because prenatal surgery does not appear to improve outcome in this group. The revised criteria may be useful as guidelines for treating hydrocephalus in this group.
    Preview · Article · Sep 2015 · Journal of Neurosurgery Pediatrics
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    ABSTRACT: To determine whether surgical speed is associated with maternal outcomes in women who have a history of prior cesarean (CD) and require emergent delivery. This is a secondary analysis of a multicenter, prospective observational study of women with a history of prior CD. Women attempting a vaginal birth after CD and requiring emergent CD were dichotomized into those with a skin incision to fetal delivery time of ≤2min (I-D≤2) or >2min (I-D>2), based on the mode I-D. Rates of composite maternal complications and specific surgical complications were compared. 793 women had an emergency repeat CD: 108 (13.6%) had I-D≤2, and 685 (86.4%) had I-D>2. The composite of maternal morbidity occurred in 36% of women with I-D≤2 and 23% with I-D>2 (p<0.01). Women with I-D≤2 had higher odds of intraoperative transfusion, uterine artery ligation, and broad ligament hematoma. In a multivariable regression model, the only variable that remained associated with maternal outcome was I-D (RR 1.66, 95% CI 1.23-2.23). There was no difference in the incidence of neonatal acidemia between groups. Among women undergoing emergent repeat cesarean delivery, surgical speed is associated with an increased risk for maternal complications. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jul 2015 · American journal of obstetrics and gynecology
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    ABSTRACT: Following treatment sufficient to normalize thyrotropin (TSH), non-pregnant hypothyroid adults display higher free thyroxine (fT4) concentrations than a reference population. Our aim is to determine whether fT4 concentrations are higher during pregnancy among women treated for hypothyroidism and whether their weight is associated with fT4 levels. Weight/fT4 relationships have not previously been reported in treated hypothyroid adults (either pregnant or non-pregnant). Thyroid-related measurements were available from over 10,000 women at two early pregnancy time periods; FaSTER (First and Second Trimester Evaluation of Risk for Fetal aneuploidy) trial (1999 through 2002). All women were receiving routine prenatal care. Present analyses were restricted to 9,257 reference women and 306 treated, hypothyroid women with TSH between the 2nd and 98th reference centiles. We compared fT4 values between those groups at 11-14 and 15-18 weeks' gestation, using linear regression to estimate fT4/maternal weight relationships, after accounting for treatment and other potential covariates. In comparison to reference women, median fT4 values and percent of fT4 values ≥95th reference centile are significantly higher in treated women at both 11-14 and 15-18 weeks' gestation (p<0.001), overall, and after stratification by weight into tertiles. Among both treated and reference women, median fT4 decreases monotonically with increasing weight, regardless of thyroperoxidase antibody status. Maternal age, maternal weight, and treatment status are important predictors of fT4 levels (p<0.001, defined by partial r2 values of 1% or higher). TPO antibody status, TSH values (after logarithmic transformation), and all interaction terms are well below r2 of 1%. fT4 levels are 1.45 pmol/L higher in treated than referent women, independent of other factors. Maternal age and weight reduce fT4 levels by 0.0694 pmol/L/year and 0.0208 pmol/L/Kg, respectively. fT4 concentrations are higher among treated hypothyroid pregnant women than among referent women, and higher maternal weight is associated with lower fT4 levels, regardless of treatment status. This inverse relationship is not associated with higher TSH levels. While no immediate clinical implications are attached to the current observations, increased peripheral deiodinase activity in the presence of higher weight might explain these findings. Further investigation appears worthy of attention.
    No preview · Article · May 2015 · Thyroid: official journal of the American Thyroid Association
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    ABSTRACT: Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD). A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model. A total of 485 247 women were identified, including 365 596 (75.3%) cesarean deliveries without labor, 41 988 (8.6%) successful and 77 663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities. TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors.
    Full-text · Article · Apr 2015 · The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians

  • No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology

  • No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology

Publication Stats

6k Citations
1,155.70 Total Impact Points

Institutions

  • 2001-2016
    • Columbia University
      • Department of Obstetrics and Gynecology
      New York, New York, United States
  • 2015
    • Cornell University
      Итак, New York, United States
  • 2005-2015
    • Society for Maternal-Fetal Medicine
      New York, New York, United States
  • 2001-2015
    • CUNY Graduate Center
      New York, New York, United States
  • 2003-2012
    • New York Presbyterian Hospital
      • Department of Obstetrics and Gynecology
      New York, New York, United States
  • 2011
    • Alpert Medical School - Brown University
      • Department of Pathology and Laboratory Medicine
      Providence, Rhode Island, United States
  • 1999-2009
    • Mid-Columbia Medical Center
      DLS, Oregon, United States
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
    • Tufts Medical Center
      Boston, Massachusetts, United States
  • 1993-2009
    • Tufts University
      • Department of Obstetrics and Gynecology
      Medford, MA, United States
  • 2008
    • University of Cambridge
      • Department of Obstetrics & Gynaecology
      Cambridge, England, United Kingdom
  • 2007
    • Texas A&M University - Galveston
      Galveston, Texas, United States
    • University of Washington Seattle
      • Department of Obstetrics and Gynecology
      Seattle, Washington, United States
  • 2006-2007
    • Boston University
      • Department of Biostatistics
      Boston, Massachusetts, United States
    • Rotunda Hospital
      Dublin, Leinster, Ireland
  • 2004
    • CARDIO MD
      Newark, New Jersey, United States
  • 1995-2000
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 1997
    • The Children's Hospital of Philadelphia
      • Center for Fetal Diagnosis and Treatment
      Filadelfia, Pennsylvania, United States
    • Dartmouth–Hitchcock Medical Center
      Lebanon, New Hampshire, United States
  • 1996
    • National Maternity Hospital
      Dublin, Leinster, Ireland
    • Boston Children's Hospital
      • Department of Pediatrics
      Boston, MA, United States