Authors often compare publishing a book to birthing a baby – a metaphor that is even more apt when the book in question is THE medical textbook on high-risk pregnancy, delivery, and fetal health.

At 1,494 pages, the 9^th edition of Creasy & Resnick’s Maternal-Fetal Medicine: Principles and Practice weighs in at 9.79 pounds – a good two pounds heftier than the average newborn baby. Clad in a glossy purple cover, it is a book that demands attention on any shelf.

“I should have warned you guys to bring a wheelbarrow for your books,” joked Dr. Judette Louis, professor and chair of Obstetrics and Gynecology (OB/GYN) at the USF Health Morsani College of Medicine and one of seven co-editors of the newest edition.

The department celebrated the publication of the new edition with a book-signing breakfast Wednesday for its trainees: 24 OB/GYN residents and four fellows in Maternal-Fetal Medicine (MFM). Both Dr. Louis and Dr. Charles J. Lockwood, dean of the Morsani College of Medicine and executive vice president of USF Health, were on hand to sign each copy. The publisher describes the book as “the definitive reference in the field for more than 35 years.”

“I am incredibly honored that Drs. Creasy and Resnik honored me as the new chief editor,” said Dr. Lockwood. He noted that the book would be 400 or so pages longer if it included all the references, which are only listed online.

“It’s definitely a great weight-bearing exercise,” joked Dr. Lockwood about the textbook’s heft.

Jokes aside, the residents said the book signing was a nice recognition that the physicians they are learning from are among the nation’s top experts.

“Knowing that we have some of the best mentors in the field as we go on to our careers – I think it’s inspiring,” said resident Dr. Rachelle Price, who will start her MFM fellowship next year.

“It’s amazing,” said Dr. Danielle Hardman. “I went to medical school here, so Dr. Lockwood’s been here during all my time here. It’s an honor” to have her textbook signed by him.

Resident Dr. Brittany Manobianco said one of her friends, who is going into MFM, was especially excited to get her copy.

“This is her Taylor Swift tour,” she proclaimed.

Perhaps fortunately, Ticketmaster did not work on the books – but the editors definitely did. Each editor was assigned a different section of the book, which includes chapters by a variety of authors who are experts on a variety of maternal and fetal high-risk conditions, such as premature labor and pregnancy-related hypertension. Editors conducted multiple levels of review and fact checks to ensure that each chapter reflects the latest science, evidence and best practices.

And then they proofed it all over again.

“I read every word in this book,” Dr. Lockwood said. “Every. Single. Word.”

Just how familiar is Dr. Lockwood with Creasy & Resnick?

Back when he was an MFM fellow himself, Dr. Lockwood studied the textbook’s first edition.

Photos by Allison Long, USF Health Communications.

A USF Health-Tampa General Hospital study suggests different management protocols may be needed for obese vs. nonobese patients to improve maternal outcomes

TAMPA, Fla (Dec. 21, 2020) — Postpartum hemorrhage, or excessive bleeding after delivery, is still one of the leading causes of severe maternal injury and death in the United States. And the rise in obesity among pregnant women has been linked to increased rates of this potentially serious, largely preventable obstetric complication.

As part of an academic medical center initiative to improve maternal health, researchers at the University of South Florida Health (USF Health) and Tampa General Hospital (TGH) examined how obesity affected the management and outcomes of postpartum hemorrhage at a tertiary care center. Their findings were published Oct. 14 in the American Journal of Perinatology.

“This study showed that we managed postpartum hemorrhage the same way for women who were obese and those who were not. That’s good overall – but the same medical treatment is not always equitable because the obese women still experienced worse outcomes,” said study senior author Judette Louis, MD, MPH, the James Ingram Endowed Professor and chair of Obstetrics and Gynecology at the USF Health Morsani College of Medicine and co-medical director of Women’s and Children’s Services at TGH. “It highlights that certain groups of high-risk obstetric patients, such as obese women, may need some additional support or a different treatment protocol for postpartum hemorrhage.”

The researchers conducted a retrospective analysis of all deliveries complicated by postpartum hemorrhage from February 2013 through January 2014 – about 2.6% of the hospital’s 9,890 deliveries during that period (a rate consistent with the national average). Controlling for confounding variables, they compared two groups of patients treated for postpartum hemorrhage: obese women (a body mass index of 30 or higher) and nonobese women (BMI characteristic of normal weight or overweight). Both groups were similar in age, race, insurance status, and alcohol and tobacco use.

Judette Louis, MD, MPH, is a USF Health maternal-fetal medicine specialist at Tampa General Hospital.

Among the study’s key findings:

• Obese patients were more likely to have had cesarean deliveries, a risk factor for hemorrhage complications, than nonobese patients.
• Both groups were equally likely to receive the same medications (carboprost, methylergonovine and misoprostol) to treat excessive blood loss, but obese women tended to receive more than one of these uterotonic agents. The medications are administered to induce contractions when the uterus does not contract enough to shrink to normal size after childbirth. This condition, known as uterine atony, is a primary cause of postpartum hemorrhage.
• Despite similar management, obese women experienced more of any severe hemorrhage-related complications (including shock, renal failure, transfusion-related lung injury, and cardiac arrest), and they were more apt to sustain more than one of the serious complications.
• While the need for blood transfusion was similar for both groups, obese women were more likely to have greater blood loss and require more units of transfused blood. “Hemorrhage-related complications are largely driven by blood loss and the number of units of blood transfused,” said Dr. Louis, a USF Health maternal-fetal medicine specialist at TGH.
• Although obese women were more often transferred to the operating room, the rates of intrauterine pressure balloon tamponade (a device used to promote uterine contraction), interventional radiology procedures, or hysterectomy were no different for obese and nonobese women.

Some basic science and clinical studies investigating uterine contractions during labor indicate obesity can impair uterine tone, so that the reproductive organ may not react as quickly or well to contraction-inducing medications. The underlying reasons for this are undefined, but a disruption of the hormonal balance in obese women may contribute to the impaired uterine response to control bleeding, Dr. Louis said. “Perhaps they need a higher dose of uterotonic agents, or the order in which the medications are administered should be changed to work more effectively for them.”

The USF Health-TGH study points to the need for larger, multisite studies to better understand the different responses to treatment protocols for postpartum hemorrhage in obese women, she added. That includes looking into the possible physiological connections between obesity, pharmacokinetics of the treatment (how the body processes medications) and the impact on uterine atony.

“With higher rates of obesity affecting higher numbers of pregnant women each year, it is important to evaluate how this is affecting the management of obstetric complications,” the study authors conclude. “This study shows that despite similar (postpartum hemorrhage) management, key differences do exist in outcomes based on obesity status. There are numerous directions for future research… many of which have the potential for significant clinical implications and improvement of maternal outcomes.”

ABOUT USF HEALTH
USF Health’s mission is to envision and implement the future of health. It is the partnership of the USF Health Morsani College of Medicine, the College of Nursing, the College of Public Health, the Taneja College of Pharmacy, the School of Physical Therapy and Rehabilitation Sciences, the Biomedical Sciences Graduate and Postdoctoral Programs, and USF Health’s multispecialty physicians group. The University of South Florida is a high-impact global research university dedicated to student success. Over the past 10 years, no other public university in the country has risen faster in U.S. News & World Report’s national university rankings than USF. For more information, visit health.usf.edu

ABOUT TAMPA GENERAL HOSPITAL
Tampa General Hospital, a 1006-bed non-profit academic medical center, is one of the largest hospitals in America and delivers world-class care as the region’s only center for Level l trauma and comprehensive burn care. It is one of the nation’s busiest adult solid organ transplant centers and is the primary teaching hospital for the USF Health Morsani College of Medicine. With five medical helicopters, Tampa General Hospital transports critically injured or ill patients from 23 surrounding counties to receive the advanced care they need. Tampa General houses a nationally accredited comprehensive stroke center and its 32-bed Neuroscience Intensive Care Unit is the largest on the West Coast of Florida. It also is home to the Jennifer Leigh Muma 82-bed Level IV neonatal intensive care unit, and a nationally accredited rehabilitation center. Tampa General Hospital’s footprint includes 17 Tampa General Medical Group Primary Care offices, TGH Family Care Center Kennedy, TGH Brandon Healthplex, TGH Virtual Health and 19 outpatient Radiology Centers. Tampa Bay residents also receive world-class care from the TGH Urgent Care powered by Fast Track network of clinics, and they can even receive home visits in select areas through TGH Urgent Care at Home, powered by Fast Track.  As one of the largest hospitals in Florida, Tampa General Hospital is first in the state to partner with GE Healthcare and open a clinical command center that uses artificial intelligence and predictive analytics to improve and better coordinate patient care at a lower cost.  For more information, go to www.tgh.org.

The common sleep disorder was also associated with uncommon medical conditions leading to pregnancy-related deaths, large-scale analysis by the University of South Florida indicated

Tampa, FL (May 1, 2014) — Pregnant women with obstructive sleep apnea are more than five times as likely to die in the hospital than those without the sleep disorder, a comprehensive national study by University of South Florida researchers found.

Among delivery-related hospital discharges, sleep apnea was also associated with an increase in severe medical conditions that are top causes of maternal death, including preeclampsia, eclampsia, an enlarged heart and pulmonary blood clots, reported the study published online today in the journal SLEEP.

Dr. Judette Louis, assistant professor of obstetrics and gynecology at the USF Health Morsani College of Medicine, led the large-scale national study appearing in the journal SLEEP. She specializes in maternal-fetal medicine, working out of Tampa General Hospital.

Sleep apnea causes repeated awakenings and pauses in breathing during the night.  Previous smaller studies have found that the condition increases the risk for poor pregnancy outcomes, including preeclampsia (high blood pressure in pregnancy associated with loss of protein in the urine), restricted growth of the fetus, preterm delivery and gestational diabetes.  Obesity appears to contribute to the adverse effects.

However, the USF study provided the first large-scale U.S. analysis of the association between sleep apnea and maternal deaths.

“The astounding association with maternal death was surprising,” said lead author Judette Louis, MD, MPH, assistant professor of obstetrics and gynecology at the USF Health Morsani College of Medicine who works out of Tampa General Hospital.  “I did not expect to find such a difference in mortality between pregnant women who had sleep apnea and those who did not, especially when we controlled for obesity and other complicating factors.

While more study is needed, the increased likelihood of death for those with sleep apnea may be explained in part by the physiological demands of pregnancy, she said. “Underlying damage or chronic disease caused by sleep apnea may be exacerbated by the stresses of pregnancy.”

Maternal death rates have increased slightly in recent years, and obesity is one suspected reason.

“Our study indicates that sleep apnea may also play a role, whether a woman is obese or not,” said Dr. Louis, who holds a joint appointment in the USF College of Public Health’s Department of Community and Family Health. “It’s important for obstetricians and primary care practitioners to identify sleep apnea in younger women of reproductive age, convey its risk, and treat the condition before pregnancy.”

The researchers drew upon a nationally representative sample of 55 million maternal-related hospital discharges from 1998 to 2009 – women who were pregnant or gave birth while in the hospital.  They identified those with sleep apnea diagnoses and examined the links between this sleep-disordered breathing and poor pregnancy health outcomes, including in-hospital deaths.

Jamillet Flores, 34, diagnosed with sleep apnea during pregnancy, wears a CPAP device every night to help keep her upper airways open and reduce symptoms such as snoring and daytime drowsiness. While she did not experience pregancy-related complications from the sleep disorder, Flores only found out about the condition when it was diagnosed during an unrelated treatment at the hospital. “Sleep apnea is largely underdiagnosed in reproductive-age women,” Dr. Louis said.

Flores with her newborn son in the neonatal intensive care unit at Tampa General.

Among the retrospective study’s findings:

–          Women with sleep apnea during pregnancy were more likely to experience serious medical conditions and pregnancy-related complications than women without sleep apnea diagnoses.

–          The strongest associations were with the following medical conditions:  cardiomyopathy (an enlarged heart), heart failure and pulmonary edema (fluid build-up in the lungs).

–          Among pregnancy-related complications, sleep apnea was associated with a greater likelihood of eclampsia and preeclampsia as well as gestational diabetes and gestational high blood pressure, even after controlling for obesity.

–          Even after adjusting for potentially life-threatening cardiovascular and metabolic conditions, women with sleep apnea were five times more likely to die before discharge from the hospital than their counterparts without sleep apnea.

–          The increase in the rate of sleep apnea among pregnancy-related discharges over the study period coincided with a rise in obesity rates.

–          With the exception of cesarean delivery, gestational hypertension and stillbirth, the likelihood of potentially life-threatening illnesses and maternal death were higher for women with sleep apnea – irrespective of obesity.

–          The presence of obesity appeared to intensify the effects of risks of cardiovascular disease in pregnant women with sleep apnea.

Article citation:
Louis JM, Mogos MF, Salemi JL, Redline S, Salihu HM. “Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009.” SLEEP, 2014;37(5):843-849.

                                                                                                                -USF Health-
USF Health’s mission is to envision and implement the future of health. It is the partnership of the USF Health Morsani College of Medicine, the College of Nursing, the College of Public Health, the College of Pharmacy, the School of Biomedical Sciences and the School of Physical Therapy and Rehabilitation Sciences; and the USF Physician’s Group. The University of South Florida is a Top 50 research university in total research expenditures among both public and private institutions nationwide, according to the National Science Foundation. For more information, visit www.health.usf.edu

RELATED STORY:
Sleep apnea in obese preganant women linked to poor maternal health and neonatal outcomes  

Photos by Eric Younghans, USF Health Communications

Media contact:
Anne DeLotto Baier, USF Health Communications
abaier@health.usf.edu or (813) 974-3303