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Kalk E, Heekes A, Lavies D, Jacobs L, Spencer C, Boutall A, Osman A, Stewart C, Davies MA, van Niekerk A, Fieggen K, Boulle A, Mehta U. Population-based prevalence of congenital defects in a routine sentinel site-based surveillance system in the Western Cape, South Africa. Birth Defects Res 2024; 116:e2388. [PMID: 39118354 DOI: 10.1002/bdr2.2388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/18/2024] [Accepted: 07/15/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Lack of data on the burden and scope of congenital disorders (CDs) in South Africa undermines resource allocation and limits the ability to detect signals from potentially teratogenic pregnancy exposures. METHODS We used routine electronic data in the Western Cape Pregnancy Exposure Registry (PER) to determine the overall and individual prevalence of CD identified on neonatal surface examination at birth in the Western Cape, South Africa, 2016-2022. CD was confirmed by record review. The contribution of late (≤24 months) and antenatal diagnoses was assessed. We compared demographic and obstetric characteristics between women with/without pregnancies affected by CD. RESULTS Women with a viable pregnancy (>22 weeks gestation; birth weight ≥ 500 g) (n = 32,494) were included. Of 1106 potential CD identified, 56.1% were confirmed on folder review. When internal and minor CD were excluded the prevalence of major CD identified on surface examination at birth was 7.2/1000 births. When missed/late diagnoses on examination (16.8%) and ultrasound (6.8%) were included, the prevalence was 9.2/1000 births: 8.9/1000 livebirths and 21.5/1000 stillbirths. The PER did not detect 21.5% of major CD visible at birth. Older maternal age and diabetes mellitus were associated with an increased prevalence of CD. Women living with/without HIV (or the timing of antiretroviral therapy, before/after conception), hypertension or obesity did not significantly affect prevalence of CD. CONCLUSIONS A surveillance system based on routine data successfully determined the prevalence of major CD identified on surface examination at birth at rates slightly higher than in equivalent studies. Overall rates, modeled at ~2%, are likely underestimated. Strengthening routine neonatal examination and clinical record-keeping could improve CD ascertainment.
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Affiliation(s)
- Emma Kalk
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Sub-Saharan African Congenital Anomalies Network, University of Cape Town, Cape Town, South Africa
| | - Alexa Heekes
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Government Department of Health & Wellness, Cape Town, South Africa
| | - Diane Lavies
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Sub-Saharan African Congenital Anomalies Network, University of Cape Town, Cape Town, South Africa
| | - Lizel Jacobs
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Sub-Saharan African Congenital Anomalies Network, University of Cape Town, Cape Town, South Africa
| | - Careni Spencer
- Division of Human Genetics, Department of Medicine, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Alison Boutall
- Department of Obstetrics & Gynaecology, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Ayesha Osman
- Department of Obstetrics & Gynaecology, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Chantal Stewart
- Department of Obstetrics & Gynaecology, University of Cape Town & Mowbray Maternity Hospital, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Government Department of Health & Wellness, Cape Town, South Africa
| | - Anika van Niekerk
- Sub-Saharan African Congenital Anomalies Network, University of Cape Town, Cape Town, South Africa
- Department of Paediatrics & Child Health, University of Cape Town & Mowbray Maternity Hospital, Cape Town, South Africa
| | - Karen Fieggen
- Sub-Saharan African Congenital Anomalies Network, University of Cape Town, Cape Town, South Africa
- Division of Human Genetics, Department of Medicine, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Government Department of Health & Wellness, Cape Town, South Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Sub-Saharan African Congenital Anomalies Network, University of Cape Town, Cape Town, South Africa
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Robles Espinoza K, López Uriarte GA, García Castañeda GB, Torres Muñoz I, Lugo Trampe JDJ, Elizondo Riojas G, Barboza Quintana O, Ponce Camacho M, Guzmán López A, Martínez de Villareal L. Multidisciplinary Workup for Stillbirth at a Tertiary-Care Hospital in Northeast Mexico: Findings, Challenges and Perspectives. Matern Child Health J 2024; 28:1072-1079. [PMID: 38184497 DOI: 10.1007/s10995-023-03874-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVES Stillbirth is an important health problem, and in Mexico, only half of the stillbirths have an explainable cause. The aim of this study was to implement a multidisciplinary workup to identify the etiology and potential risk factors for stillbirth at the Hospital Universitario "Dr. José Eleuterio González". METHODS This is a prospective, descriptive, observational study that included stillbirths from the Obstetrics Service from October 1st, 2019 to May 25, 2020. Evaluation strategies included a complete maternal medical history, physical examination of the fetus, and a photographic medical record. For every stillbirth either a prenatal ultrasound, a postnatal x-ray, or a fetal autopsy, were needed. Multiplex Ligation Probe Amplification (MLPA) was performed with an umbilical cord sample. RESULTS Thirty-three stillbirths were reported; 21 were included in the analysis. Eleven women (52.3%) had known risk factors for stillbirth, mainly elevated body mass index and diabetes. On physical examination, external birth defects were found in 8 fetuses (38%). X-ray was performed in 14 cases (66%), alterations were detected as a probable etiologic cause just in one. All cases underwent MLPA, which were reported negative. Three cases had criteria for autopsy. Findings were inconclusive to determine etiology. CONCLUSIONS The best tools for evaluation of stillbirth were the elaboration of clinical history, physical examination, and prenatal ultrasound. Diabetes and obesity were the most frequent risk factors found in our population. These factors are preventable by implementing strategies that lead to better prenatal care.
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Affiliation(s)
- Kiabeth Robles Espinoza
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico.
| | - Graciela Arelí López Uriarte
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico.
| | - Gloria Beatriz García Castañeda
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Iris Torres Muñoz
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - José de Jesús Lugo Trampe
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Guillermo Elizondo Riojas
- Department of Radiology and Imaging, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Oralia Barboza Quintana
- Department of Pathologic Anatomy, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Marco Ponce Camacho
- Department of Pathologic Anatomy, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Abel Guzmán López
- Gynecology and Obstetrics Service, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Laura Martínez de Villareal
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
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3
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Gergely L, Repiská V, Böhmer D, Korbeľ M, Václavová Z, McCullough L, Melišová K, Priščáková P. Post-mortem rapid aneuploidy testing for holoprosencephaly. Birth Defects Res 2024; 116:e2342. [PMID: 38632851 DOI: 10.1002/bdr2.2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Abortion and fetal death are common in fetuses with holoprosencephaly, so genetic examinations often have to be made in a post-mortem setting. The efficiency of the conventional karyotyping using cultured fibroblasts in these situations is limited due to frequent culture failure. In the current study, archived cases of holoprosencephaly, where post-mortem genetic evaluation was requested and sufficient frozen material was available, were reevaluated using the quantitative fluorescence polymerase chain reaction (QF-PCR) technique. METHODS Testing for aneuploidies of chromosomes 13, 15, 16, 18, 21, 22, X, and Y with the QF-PCR technique was carried out on DNA isolated from archived frozen chorionic villi in seven cases of holoprosencephaly. RESULTS QF-PCR was successful in all seven cases. Two cases of trisomy 13, two cases of triploidy, and one case of trisomy 18 was found meaning a 71% diagnostic yield. The success rate of QF-PCR (100%, 7/7) was superior compared to conventional karyotyping (43%, 3/7). CONCLUSIONS Rapid aneuploidy testing using the QF-PCR technique is a simple, reliable, time- and cost-effective method sufficient to conclude the etiologic investigation in the majority of holoprosencephaly cases post-mortem.
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Affiliation(s)
- Lajos Gergely
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Vanda Repiská
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Daniel Böhmer
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Miroslav Korbeľ
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Zuzana Václavová
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Liam McCullough
- 1st Department of Gynaecology and Obstetrics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Katarína Melišová
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
| | - Petra Priščáková
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University Bratislava, Bratislava, Slovakia
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Holmes LB, Quinn M, Conant S, Lyons A, Hauser WA, Yerby M, Hernandez-Diaz S. Ascertainment of malformations in pregnancy registries: Lessons learned in the North American AED Pregnancy Registry. Birth Defects Res 2023; 115:1274-1283. [PMID: 37387678 DOI: 10.1002/bdr2.2188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Pregnancy registries, designed to assess the safety of medications and vaccines for the exposed mother and fetus, have been developed since the 1990s. Malformations present in the exposed liveborn or stillborn infant or fetuses in elective terminations are the outcome of greatest concern. The experiences of the North American AED (antiepileptic drug) Pregnancy Registry (NAAPR) can be used to identify the challenges and limitations of a pregnancy registry in identifying congenital malformations. METHODS The NAAPR enrolls pregnant women who are taking one or more AEDs for any medical condition, but primarily to prevent seizures, and an unexposed comparison group. Participants are interviewed by clinical research coordinators (CRCs) at enrollment, later in pregnancy and postpartum. Malformations are identified in the mother's reports and her infant's medical records through age 12 weeks. A teratologist, blinded to exposure status, evaluates each potential malformation identified. RESULTS Among 10,982 pregnancies enrolled between 1997 and 2022, 282 malformations were identified in the 9677 AED-exposed and 15 among the 1305 unexposed infants. Isolated malformations, such as cleft palate, accounted for 84% of the malformations identified. Increased frequencies of oral clefts and myelomeningocele were associated with exposure to several different AEDs. Copies of reports from many diagnostic studies were not obtained and very few pregnancy losses had autopsies. CONCLUSIONS The evaluation of the AED-exposed infants in a pregnancy registry is indirect. Improvements rely on the rapport established with the mothers by the CRCs and the mothers' willingness to assist in obtaining information from her infants' physicians.
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Affiliation(s)
- Lewis B Holmes
- North American AED (Antiepileptic Drug) Pregnancy Registry, Boston, Massachusetts, USA
- Medical Genetics and Metabolism Unit, Mass General for Children, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Moira Quinn
- North American AED (Antiepileptic Drug) Pregnancy Registry, Boston, Massachusetts, USA
| | - Susan Conant
- North American AED (Antiepileptic Drug) Pregnancy Registry, Boston, Massachusetts, USA
| | - Amy Lyons
- North American AED (Antiepileptic Drug) Pregnancy Registry, Boston, Massachusetts, USA
| | - W Allen Hauser
- Department of Neurology and Epidemiology, G. H. Sergievsky Center, Columbia University, New York, New York, USA
| | - Mark Yerby
- North American AED (Antiepileptic Drug) Pregnancy Registry, Boston, Massachusetts, USA
| | - Sonia Hernandez-Diaz
- North American AED (Antiepileptic Drug) Pregnancy Registry, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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5
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Holmes LB, Nasri HZ, Hunt AT, Zash R, Shapiro RL. Limited surface examination to evaluate potential teratogens in a resource-limited setting. Birth Defects Res 2021; 113:702-707. [PMID: 33779067 PMCID: PMC8148051 DOI: 10.1002/bdr2.1887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND To determine the frequency of malformations that would be identified in the limited surface examination of a newborn by the delivering nurse midwife in a resource-limited setting. METHODS The limited surface examination will identify visible external anomalies, but not abnormalities inside the mouth, most heart defects, undescended testes, inguinal hernias, hip dysplasia, peripheral vascular anomalies, and some internal anomalies. The findings in a malformations surveillance program, involving 289,365 births in Boston, have been used to establish the prevalence rate of malformations that would be identified and not identified. In African countries, the number of anomalies to be identified should also be reduced by excluding polydactyly, postaxial, type B, a common minor finding, from the list of potential malformations. RESULTS Of note, 2.05% (n = 5,941) of the 289,365 births surveyed had one or more malformations. The abnormalities that would have been missed, using surface exam alone, accounted for 0.5% of all of malformations identified and reduced the overall prevalence rate of malformations to 1.5%. In addition, excluding all infants with isolated postaxial polydactyly, type B reduced the expected prevalence rate of malformations to 1.3% in unexposed newborn infants. CONCLUSION A limited surface examination can detect the majority of malformations among newborn infants.
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Affiliation(s)
- Lewis B Holmes
- Medical Genetics and Metabolism Unit, MassGeneral Hospital for Children, Boston, MA, USA
| | - Hanah Z Nasri
- Medical Genetics and Metabolism Unit, MassGeneral Hospital for Children, Boston, MA, USA
| | | | - Rebecca Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Roger L Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Abstract
OBJECTIVES To provide an investigation protocol to help health care providers determine the cause of a fetal death. OPTIONS Consideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries. OUTCOMES Identification of possible causes of stillbirth and their relationship to future pregnancies. EVIDENCE Articles related to the etiology of fetal death were identified in a search of PubMed (June 2006 to September 2018), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the International Stillbirth Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and the Reproductive Care Program of Nova Scotia. BENEFITS To provide better advice for women regarding possible causes of fetal death and implications for future pregnancies. VALIDATION The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS
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Wojcik MH, Agrawal PB. Deciphering congenital anomalies for the next generation. Cold Spring Harb Mol Case Stud 2020; 6:mcs.a005504. [PMID: 32826208 PMCID: PMC7552931 DOI: 10.1101/mcs.a005504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Congenital anomalies are common, with 2%-3% of infants estimated to have at least one major congenital malformation and countless others with minor malformations of lesser cosmetic or medical importance. As congenital malformations are major drivers of morbidity and mortality, representing the leading cause of infant mortality in the United States, there is substantial interest in understanding the underlying etiologies-particularly if modifiable causes may be identified or pre- or postnatal treatments can be offered. Recent research has begun to reveal the spectrum of monogenic disorders that commonly result in birth defects, and newer approaches have revealed non-Mendelian genetic contributions including gene-environment interactions. Our experience suggests that increased efforts to sequence and analyze cases of perinatal death, as well as continued global collaboration, will be essential in understanding the genomic landscape of structural anomalies.
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Affiliation(s)
- Monica H Wojcik
- Divisions of Newborn Medicine and Genetics and Genomics, Department of Pediatrics, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Pankaj B Agrawal
- Divisions of Newborn Medicine and Genetics and Genomics, Department of Pediatrics, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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Lisonkova S, Razaz N, Sabr Y, Muraca GM, Boutin A, Mayer C, Joseph KS, Kramer MS. Maternal risk factors and adverse birth outcomes associated with HELLP syndrome: a population-based study. BJOG 2020; 127:1189-1198. [PMID: 32189413 DOI: 10.1111/1471-0528.16225] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome. DESIGN A retrospective population-based cohort study. SETTING Canada (excluding Quebec), 2012/2013-2015/2016. POPULATION Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks' gestation (n = 1 078 323). METHODS HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalisation data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes. MAIN OUTCOME MEASURES Adverse maternal (e.g. eclampsia) and fetal/neonatal outcomes (e.g. intraventricular haemorrhage, perinatal death). RESULTS The incidence of HELLP syndrome was 2.5 per 1000 singleton deliveries (n = 2663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g. fetomaternal transfusion) and congenital anomalies. PROM and age <25 years were inversely associated with HELLP syndrome (P-values <0.05). Women with the syndrome had a 10-fold higher maternal mortality (95% CI 1.6-84.3) and elevated severe maternal morbidity (9.6 versus 121.7 per 1000; AOR 12.5, 95% CI 11.1-14.1); and higher perinatal mortality (4.3 versus 21.0 per 1000; AOR 4.5, 95% CI 3.5-5.9) and perinatal mortality/severe neonatal morbidity (21.2 versus 202.4 per 1000; AOR 10.7, 95% CI 9.7-11.8). CONCLUSION HELLP syndrome is associated with specific pre-pregnancy and pregnancy risk factors, higher rates of maternal death, and substantially higher severe maternal morbidity, perinatal mortality and severe neonatal morbidity. TWEETABLE ABSTRACT HELLP syndrome is associated with higher maternal death rate, and substantially higher severe maternal and neonatal morbidity, and perinatal mortality.
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Affiliation(s)
- S Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - N Razaz
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Y Sabr
- Department of Obstetrics and Gynaecology, King Saud University, Riyadh, Saudi Arabia
| | - G M Muraca
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - A Boutin
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - C Mayer
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M S Kramer
- Departments of Paediatrics and of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine, Montreal, QC, Canada
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Directive clinique No 394 - Investigation sur la mortinaissance. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:100-108. [DOI: 10.1016/j.jogc.2019.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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