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Lee N, Shi L, Colon Caraballo M, Nallasamy S, Mahendroo M, Iozzo RV, Myers K. Mechanical Response of Mouse Cervices Lacking Decorin and Biglycan During Pregnancy. J Biomech Eng 2022; 144:061009. [PMID: 35348624 PMCID: PMC9125869 DOI: 10.1115/1.4054199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/23/2022] [Indexed: 11/08/2022]
Abstract
Cervical remodeling is critical for a healthy pregnancy. The proper regulation of extracellular matrix (ECM) turnover leads to remodeling throughout gestation, transforming the tissue from a stiff material to a compliant, extensible, viscoelastic tissue prepared for delivery. Small leucine-rich proteoglycans (SLRPs) regulate structural fiber assembly in the cervical ECM and overall tissue material properties. To quantify the SLRPs' mechanical role in the cervix, whole cervix specimens from nonpregnant and late pregnant knockout mice of SLRPs, decorin and biglycan, were subjected to cyclic load-unload, ramp-hold, and load-to-failure mechanical tests. Further, a fiber composite material model, accounting for collagen fiber bundle waviness, was developed to describe the cervix's three-dimensional large deformation equilibrium behavior. In nonpregnant tissue, SLRP knockout cervices have the same equilibrium material properties as wild-type tissue. In contrast, the load-to-failure and ramp-hold tests reveal SLRPs impact rupture and time-dependent relaxation behavior. Loss of decorin in nonpregnant (NP) cervices results in inferior rupture properties. After extensive remodeling, cervical strength is similar between all genotypes, but the SLRP-deficient tissue has a diminished ability to dissipate stress during a ramp-hold. In mice with a combined loss of decorin and biglycan, the pregnant cervix loses its extensibility, compliance, and viscoelasticity. These results suggest that decorin and biglycan are necessary for crucial extensibility and viscoelastic material properties of a healthy, remodeled pregnant cervix.
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Affiliation(s)
- Nicole Lee
- Department of Mechanical Engineering, Columbia University, New York, NY 10027
| | - Lei Shi
- Department of Mechanical Engineering, Columbia University, New York, NY 10027
| | - Mariano Colon Caraballo
- Department of Obstetrics and Gynecology, Cecil H. and Ida Green Center for Reproductive Biological Science, The University of Texas, Southwestern Medical Center, Dallas, TX 75390
| | - Shanmugasundaram Nallasamy
- Department of Obstetrics and Gynecology, Cecil H. and Ida Green Center for Reproductive Biological Science, The University of Texas, Southwestern Medical Center, Dallas, TX 75390
| | - Mala Mahendroo
- Department of Obstetrics and Gynecology, Cecil H. and Ida Green Center for Reproductive Biological Science, The University of Texas, Southwestern Medical Center, Dallas, TX 75390
| | - Renato V. Iozzo
- Department of Pathology, Anatomy and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Cancer Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107
| | - Kristin Myers
- Department of Mechanical Engineering, Columbia University, New York, NY 10027
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Colon-Caraballo M, Lee N, Nallasamy S, Myers K, Hudson D, Iozzo RV, Mahendroo M. Novel regulatory roles of small leucine-rich proteoglycans in remodeling of the uterine cervix in pregnancy. Matrix Biol 2022; 105:53-71. [PMID: 34863915 PMCID: PMC9446484 DOI: 10.1016/j.matbio.2021.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 01/03/2023]
Abstract
The cervix undergoes rapid and dramatic shifts in collagen and elastic fiber structure to achieve its disparate physiological roles of competence during pregnancy and compliance during birth. An understanding of the structure-function relationships of collagen and elastic fibers to maintain extracellular matrix (ECM) homeostasis requires an understanding of the mechanisms executed by non-structural ECM molecules. Small-leucine rich proteoglycans (SLRPs) play key functions in biology by affecting collagen fibrillogenesis and regulating enzyme and growth factor bioactivities. In the current study, we evaluated collagen and elastic fiber structure-function relationships in mouse cervices using mice with genetic ablation of decorin and/or biglycan genes as representative of Class I SLRPs, and lumican gene representative of Class II SLRP. We identified structural defects in collagen fibril and elastic fiber organization in nonpregnant mice lacking decorin, or biglycan or lumican with variable resolution of defects noted during pregnancy. The severity of collagen and elastic fiber defects was greater in nonpregnant mice lacking both decorin and biglycan and defects were maintained throughout pregnancy. Loss of biglycan alone reduced tissue extensibility in nonpregnant mice while loss of both decorin and biglycan manifested in decreased rupture stretch in late pregnancy. Collagen cross-link density was similar in the Class I SLRP null mice as compared to wild-type nonpregnant and pregnant controls. A broader range in collagen fibril diameter along with an increase in mean fibril spacing was observed in the mutant mice compared to wild-type controls. Collectively, these findings uncover functional redundancy and hierarchical roles of Class I and Class II SLRPs as key regulators of cervical ECM remodeling in pregnancy. These results expand our understating of the critical role SLRPs play to maintain ECM homeostasis in the cervix.
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Affiliation(s)
- Mariano Colon-Caraballo
- Department of Ob/Gyn and Cecil H. and Ida Green Center for Reproductive Biological Science, The University of Texas Southwestern Medical Center, Dallas, Texas 75390
| | - Nicole Lee
- Department of Mechanical Engineering, Columbia University New York, New York 10027
| | - Shanmugasundaram Nallasamy
- Department of Ob/Gyn and Cecil H. and Ida Green Center for Reproductive Biological Science, The University of Texas Southwestern Medical Center, Dallas, Texas 75390,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont Burlington, Vermont 05405
| | - Kristin Myers
- Department of Mechanical Engineering, Columbia University New York, New York 10027
| | - David Hudson
- Department of Orthopaedics and Sports Medicine, University of Washington Seattle, Washington 98165
| | - Renato V. Iozzo
- Department of Pathology, Anatomy, and Cell Biology and the Translational Cellular Oncology Program, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania 19107
| | - Mala Mahendroo
- Department of Ob/Gyn and Cecil H. and Ida Green Center for Reproductive Biological Science, The University of Texas Southwestern Medical Center, Dallas, Texas 75390,Correspondence to: Mala Mahendroo, Ph.D, Department of Ob/Gyn and Cecil H. and Ida Green Center for Reproductive Biological Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas 75390.
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Roles of Two Small Leucine-Rich Proteoglycans Decorin and Biglycan in Pregnancy and Pregnancy-Associated Diseases. Int J Mol Sci 2021; 22:ijms221910584. [PMID: 34638928 PMCID: PMC8509074 DOI: 10.3390/ijms221910584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/18/2022] Open
Abstract
Two small leucine-rich proteoglycans (SLRP), decorin and biglycan, play important roles in structural–functional integrity of the placenta and fetal membranes, and their alterations can result in several pregnancy-associated diseases. In this review, we briefly discuss normal placental structure and functions, define and classify SLRPs, and then focus on two SLRPs, decorin (DCN) and biglycan (BGN). We discuss the consequences of deletions/mutations of DCN and BGN. We then summarize DCN and BGN expression in the pregnant uterus, myometrium, decidua, placenta, and fetal membranes. Actions of these SLRPs as ligands are then discussed in the context of multiple binding partners in the extracellular matrix and cell surface (receptors), as well as their alterations in pathological pregnancies, such as preeclampsia, fetal growth restriction, and preterm premature rupture of membranes. Lastly, we raise some unanswered questions as food for thought.
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Abstract
Preterm birth is a leading cause of neonatal mortality in the US and globally, with preterm premature rupture of fetal membranes (PPROM) accounting for one third of preterm births. Currently no predictive diagnostics are available to precisely assess risk and potentially reduce the incidence of PPROM. Bigycan and decorin, the main proteoglycans present in human fetal membranes, are involved in the physiological maturation of fetal membranes as well as in the pathophysiology of preterm birth. The serum protein sex hormone-binding globulin (SHBG) has recently been identified as a predictor of spontaneous preterm birth. We hypothesize that the balance between serum decorin and biglycan on one hand and SHBG on the other hand may provide insight into the status of the fetal membranes in early pregnancy, thereby predicting PPROM prior to symptoms. Using chart review, 18 patients with confirmed cases of PPROM were identified from 2013-2016. Second trimester residual serum was retreived from freezer storage for these cases along with 5 matched controls for each case. The biomarkers biglycan, decorin and SHBG were analyzed first separately, then in combination to determine their ability to predict PPROM. The predictive score for the combined model displays an AUC = 0.774. The ROC curve of the predicted score has an optimal threshold of 0.238 and a sensitivity and specificity of 0.72 and 0.84 respectively. This prenatal serum panel is a promising serum screening-based biochemical model to predict PPROM in asymptomatic women.
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Pantham P, Armstrong DL, Bodnariuc J, Haupt O, Johnson AW, Underhill L, Iozzo RV, Lechner BE, Wildman DE. Transcriptomic profiling of fetal membranes of mice deficient in biglycan and decorin as a model of preterm birth†. Biol Reprod 2020; 104:611-623. [PMID: 33165521 DOI: 10.1093/biolre/ioaa205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 08/09/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022] Open
Abstract
Approximately, 25% of all preterm births are due to preterm premature rupture of membranes. Mice deficient in proteoglycans biglycan (Bgn) and decorin (Dcn) display abnormal fetal membranes and increased incidence of preterm birth. We conducted RNA-Seq to profile fetal membranes and identify molecular pathways that may lead to preterm birth in double knockout (DKO) mice (Bgn-/-; Dcn-/-) compared to wild-type (WT) at two different gestational stages, E12 and E18 (n = 3 in each group). 3264 transcripts were differentially regulated in E18 DKO vs. WT fetal membranes, and 96 transcripts differentially regulated in E12 DKO vs. WT fetal membranes (FDR < 0.05, log 2 FC ≥ 1). Differentially regulated transcripts in E18 DKO fetal membranes were significantly enriched for genes involved in cell cycle regulation, extracellular matrix-receptor interaction, and the complement cascade. Fifty transcripts involved in the cell cycle were altered in E18 DKO fetal membranes (40↓, 10↑, FDR < 0.05), including p21 and p57 (↑), and Tgfb2, Smad3, CycA, Cdk1, and Cdk2(↓). Thirty-one transcripts involved in the complement cascade were altered (11↓, 20↑, FDR < 0.05) in E18 DKO fetal membranes, including C1q, C2, and C3 (↑). Differentially expressed genes in the top three molecular pathways (1) showed evidence of negative or purifying selection, and (2) were significantly enriched (Z-score > 10) for transcription factor binding sites for Nr2f1 at E18. We propose that in DKO mice, cell cycle arrest results in lack of cell proliferation in fetal membranes, inability to contain the growing fetus, and preterm birth.
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Affiliation(s)
- Priyadarshini Pantham
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA.,Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Don L Armstrong
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Jonathan Bodnariuc
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Owen Haupt
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Amy Wagoner Johnson
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Department of Mechanical Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Lori Underhill
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Renato V Iozzo
- Department of Pathology, Anatomy and Cell Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Beatrice E Lechner
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Derek E Wildman
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Genomics Program, College of Public Health, University of South Florida, Tampa, FL, USA
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Serum Decorin, Biglycan, and Extracellular Matrix Component Expression in Preterm Birth. Reprod Sci 2020; 28:228-236. [PMID: 32804350 PMCID: PMC7782456 DOI: 10.1007/s43032-020-00251-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 11/24/2022]
Abstract
Preterm birth is a leading cause of infant morbidity and mortality. Decorin and biglycan are proteoglycans that play key roles in maintaining the connective tissue matrix and tensile strength of human fetal membranes and have been previously linked to PPROM. Extracellular matrix proteins, such as matrix metalloproteinase 2 (MMP-2), matrix metalloproteinase 9 (MMP-9), TIMP metallopeptidase inhibitor 1 (TIMP-1), TIMP metallopeptidase inhibitor 2 (TIMP-2), and collagen VI (COL-6), have also been linked to PPROM and may have utility in a serum-based screening model for this condition. To define the natural course of serum decorin and biglycan expression throughout the duration of healthy pregnancy, to explore patterns of serum decorin and biglycan expression in serum of asymptomatic women who go on to develop spontaneous preterm labor, and to investigate the potential role for matrix metalloproteinases, their inhibitors, and collagen VI in a serum-based screening model to predict PPROM. Serum decorin level decreases less than 1% per week, and serum biglycan decreases by 2.9% per week over the duration of healthy pregnancy. Serum decorin and biglycan concentrations do not differ in spontaneous preterm labor cases compared with those in controls. Mean concentrations of MMP-2, MMP-9, TIMP-1, TIMP-2, and COL-6 do not differ in PPROM cases compared with those in controls. We have demonstrated that serum decorin and biglycan concentrations remain stable throughout the duration of normal pregnancy and are not early indicators of preterm labor, while common MMPs, TIMPs, and collagen VI are not early indicators of PPROM.
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Kram V, Shainer R, Jani P, Meester JAN, Loeys B, Young MF. Biglycan in the Skeleton. J Histochem Cytochem 2020; 68:747-762. [PMID: 32623936 DOI: 10.1369/0022155420937371] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Small leucine rich proteoglycans (SLRPs), including Biglycan, have key roles in many organ and tissue systems. The goal of this article is to review the function of Biglycan and other related SLRPs in mineralizing tissues of the skeleton. The review is divided into sections that include Biglycan's role in structural biology, signaling, craniofacial and long bone homeostasis, remodeled skeletal tissues, and in human genetics. While many cell types in the skeleton are now known to be affected by Biglycan, there are still unanswered questions about its mechanism of action(s).
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Affiliation(s)
- Vardit Kram
- Molecular Biology of Bones and Teeth Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, U.S. Department of Health & Human Services, Bethesda, Maryland
| | - Reut Shainer
- Molecular Biology of Bones and Teeth Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, U.S. Department of Health & Human Services, Bethesda, Maryland
| | - Priyam Jani
- Molecular Biology of Bones and Teeth Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, U.S. Department of Health & Human Services, Bethesda, Maryland
| | - Josephina A N Meester
- Laboratory of Cardiogenetics, Center of Medical Genetics, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | - Bart Loeys
- Laboratory of Cardiogenetics, Center of Medical Genetics, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | - Marian F Young
- Molecular Biology of Bones and Teeth Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, U.S. Department of Health & Human Services, Bethesda, Maryland
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McCoy AM, Arrington J, Yau PM. Effect of Preparation Method on the Protein Profile of Equine Amnion Dressings. J Proteome Res 2019; 18:2676-2685. [PMID: 31117638 DOI: 10.1021/acs.jproteome.9b00240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The protein content of amnion is thought to be the primary contributor to its efficacy as a biological dressing for wounds. Protein elution into antibiotic processing media has been reported, but the effect of antiseptic-based processing methods is unknown. Amniotic membranes were collected from eight healthy mares. Samples were collected after removal of gross debris. Tissues were subsequently divided and processed with either 0.05% chlorhexidine or 2% iodine/0.25% acetic acid. After protein extraction and trypsin digestion, the proteins were labeled with 8-plex iTRAQ tags, combined, and analyzed by high-resolution liquid chromatography-mass spectrometry. The MaxQuant-Perseus software suite was used to identify and quantify sample proteins, with functional annotation performed in PANTHER. There were 220 unique proteins identified, of which 144 were found in all individuals and across all conditions, several with a known role in wound healing. Contrary to expectations, processing did not significantly alter the protein content of the amnion tissue. Limitations include the small sample size and single time point. These results suggest that either processing method is acceptable for use in the preparation of equine amnion dressings. The role of expressed proteins in the biological activity of amnion dressings remains to be elucidated.
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Affiliation(s)
- Annette M McCoy
- Department of Veterinary Clinical Medicine , University of Illinois Urbana-Champaign , 1008 West Hazelwood Drive , Urbana , Illinois 61802 , United States
| | - Justine Arrington
- Protein Sciences Facility, Roy J. Carver Biotechnology Center , University of Illinois Urbana-Champaign , 505 South Matthews Avenue , Urbana , Illinois 61801 , United States
| | - Peter M Yau
- Protein Sciences Facility, Roy J. Carver Biotechnology Center , University of Illinois Urbana-Champaign , 505 South Matthews Avenue , Urbana , Illinois 61801 , United States
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9
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Underhill LA, Avalos N, Tucker R, Zhang Z, Messerlian G, Lechner B. Serum Decorin and Biglycan as Potential Biomarkers to Predict PPROM in Early Gestation. Reprod Sci 2019:1933719119831790. [PMID: 30895897 DOI: 10.1177/1933719119831790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Preterm birth is a leading cause of neonatal mortality in the US and globally, with preterm premature rupture of fetal membranes (PPROM) accounting for one third of preterm births. Currently no predictive diagnostics are available to precisely assess risk and potentially reduce the incidence of PPROM. Bigycan and decorin, the main proteoglycans present in human fetal membranes, are involved in the physiological maturation of fetal membranes as well as in the pathophysiology of preterm birth. The serum protein sex hormone-binding globulin (SHBG) has recently been identified as a predictor of spontaneous preterm birth. We hypothesize that the balance between serum decorin and biglycan on one hand and SHBG on the other hand may provide insight into the status of the fetal membranes in early pregnancy, thereby predicting PPROM prior to symptoms. Using chart review, 18 patients with confirmed cases of PPROM were identified from 2013-2016. Second trimester residual serum was retreived from freezer storage for these cases along with 5 matched controls for each case. The biomarkers biglycan, decorin and SHBG were analyzed first separately, then in combination to determine their ability to predict PPROM. The predictive score for the combined model displays an AUC = 0.774. The ROC curve of the predicted score has an optimal threshold of 0.238 and a sensitivity and specificity of 0.72 and 0.84 respectively. This prenatal serum panel is a promising serum screening-based biochemical model to predict PPROM in asymptomatic women.
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Affiliation(s)
- Lori A Underhill
- 1 Warren Alpert Medical School at Brown University, Providence, RI ,USA
- 2 Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Nora Avalos
- 2 Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Richard Tucker
- 2 Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Zheng Zhang
- 3 School of Public Health, Brown University, Providence, RI, USA
| | - Geralyn Messerlian
- 2 Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Beatrice Lechner
- 1 Warren Alpert Medical School at Brown University, Providence, RI ,USA
- 2 Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
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Atalay MA, Ozmen T, Demir BC, Kasapoglu I, Ozkaya G. Serum decorin measurement in prediction of the risk for preterm birth. Taiwan J Obstet Gynecol 2018; 57:23-27. [PMID: 29458898 DOI: 10.1016/j.tjog.2017.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To define serum decorin (sDEC) levels in healthy pregnants and in patients with preterm labor (PTL), and to introduce possible role of sDEC in predicting the risk for preterm birth (PTB). MATERIALS AND METHODS Thirty-one women with diagnosis of PTL between 24th to 32nd weeks of pregnancy were compared with 44 healthy pregnants in this prospective case-control study. Maternal blood sDEC and uterine cervical length (CL) measurements were conducted at referral. RESULTS Median sDEC level was significantly decreased in PTL group (p = 0.013). Median CL was significantly shorter in PTL group (p < 0.001). There was not any correlation between sDEC level and maternal age, BMI, and gestational age at blood sampling time within PTL (p = 0.955, p = 0.609, p = 0.079, respectively) and control groups (p = 0.652, p = 0.131, and p = 0.921, respectively). There was not any association between sDEC level and PTB within 7 days, before 34th weeks, but before 37th weeks there was (p = 0.206, 0.091, and p = 0.026, respectively). There was not any correlation between sDEC level and the CL in PTL group (p = 0.056). CONCLUSIONS sDEC has a limited effect in prediction of PTB within a week or before 34th weeks. Combination of sDEC with CL measurements predicted PTB before 37th weeks. CONCLUSION
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Affiliation(s)
- Mehmet Aral Atalay
- Department of Obstetrics and Gynecology of Uludag University School of Medicine, Bursa, Turkey
| | - Turan Ozmen
- Van State Hospital, Department of Obstetrics and Gynecology, Van, Turkey
| | - Bilge Cetinkaya Demir
- Department of Obstetrics and Gynecology of Uludag University School of Medicine, Bursa, Turkey; Division of Perinatal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Isil Kasapoglu
- Department of Obstetrics and Gynecology of Uludag University School of Medicine, Bursa, Turkey.
| | - Guven Ozkaya
- Department of Biostatistics, Uludag University School of Medicine, Bursa, Turkey
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