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Scott AK, Fodera DM, Yang P, Arter A, Hines AM, Kolluru SS, Zambuto SG, Myers KM, Kamilov US, Odibo AO, Oyen ML. Bioengineering approaches for patient-specific analysis of placenta structure and function. Placenta 2024:S0143-4004(24)00615-5. [PMID: 39153938 DOI: 10.1016/j.placenta.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 07/30/2024] [Accepted: 08/06/2024] [Indexed: 08/19/2024]
Abstract
The leading cause of perinatal mortality is fetal growth restriction (FGR), defined as in utero fetal growth below the 10th percentile. Insufficient exchange of oxygen and nutrients at the maternal-fetal interface is associated with FGR. This transport occurs through the vasculature of the placenta, particularly in the terminal villi, where the vascular membranes have a large surface area and are the thinnest. Altered structure of the placenta villi is thought to contribute to decreased oxygen exchange efficiency, however, understanding how the three-dimensional microstructure and properties decrease this efficiency remains a challenge. Here, a novel, multiscale workflow is presented to quantify patient-specific biophysical properties, 3D structural features, and blood flow of the villous tissue. Namely, nanoindentation, optical coherence tomography, and ultrasound imaging were employed to measure the time-dependent material properties of placenta tissue, the 3D structure of villous tissue, and blood flow through the villi to characterize the microvasculature of the placenta at increasing length scales. Quantifying the biophysical properties, the 3D architecture, and blood flow in the villous tissue can be used to infer changes in maternal-fetal oxygen transport at the villous membrane. Overall, this multiscale understanding will advance knowledge of how microvascular changes in the placenta ultimately lead to FGR, opening opportunities for diagnosis and intervention.
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Affiliation(s)
- Adrienne K Scott
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Women's Health Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Regenerative Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Daniella M Fodera
- Department of Biomedical Engineering, Columbia University, New York NY, USA
| | - Patrick Yang
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Women's Health Engineering, Washington University in St. Louis, St. Louis MO, USA
| | - Abigail Arter
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis MO, USA
| | - Amelia M Hines
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Women's Health Engineering, Washington University in St. Louis, St. Louis MO, USA
| | - Samyuktha S Kolluru
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Women's Health Engineering, Washington University in St. Louis, St. Louis MO, USA
| | - Samantha G Zambuto
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Women's Health Engineering, Washington University in St. Louis, St. Louis MO, USA; Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis MO, USA
| | - Kristin M Myers
- Department of Mechanical Engineering, Columbia University, New York NY, USA
| | - Ulugbek S Kamilov
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis MO, USA; Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis MO, USA
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis MO, USA
| | - Michelle L Oyen
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Women's Health Engineering, Washington University in St. Louis, St. Louis MO, USA; Center for Regenerative Medicine, Washington University in St. Louis, St. Louis MO, USA; Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis MO, USA.
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2
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de Ganzo Suárez T, de Paco Matallana C, Plasencia W. Spiral, uterine artery doppler and placental ultrasound in relation to preeclampsia. Best Pract Res Clin Obstet Gynaecol 2024; 92:102426. [PMID: 38039843 DOI: 10.1016/j.bpobgyn.2023.102426] [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] [Received: 05/02/2023] [Revised: 06/18/2023] [Accepted: 08/06/2023] [Indexed: 12/03/2023]
Abstract
Preeclampsia (PE) is a multiorgan disorder that complicates around 2-8% of pregnancies and is a major cause of perinatal and maternal morbidity and mortality. PE is a clinical syndrome characterized by hypertension secondary to systemic inflammation, endothelial dysfunction, and syncytiotrophoblast stress leading to hypertension and multiorgan dysfunction. The uterine arteries are the main blood vessels that supply blood to the uterus. They give off branches and plays an important role in maintaining blood supply during pregnancy. The arcuate artery originates from the uterine artery and runs medially through the myometrium. The arcuate arteries divide almost directly into anterior and posterior branches, from which the radial artery leads directly to the uterine cavity during their course. Near the endometrium-myometrium junction, the radial artery generates spiral arteries within the basal layer and functional endometrium. The walls of radial and spiral arteries are rich in smooth muscle, which is lost when trophoblast cells invade and become large-caliber vessels. This physiological transformation of uteroplacental spiral arteries is critical for successful placental implantation and normal placental function. In normal pregnancy, the luminal diameter of the spiral arteries is greatly increased, and the vascular smooth muscle is replaced by trophoblast cells. This process and changes in the spiral arteries are called spiral artery remodeling. In PE, this genetically and immunologically governed process is deficient and therefore there is decreased vascular capacitance and increased resistance in the uteroplacental circulation. Furthermore, this defect in uteroplacental spiral artery remodeling is not only associated with early onset PE, but also with fetal growth restriction, placental abruption, and spontaneous premature rupture of membranes. Doppler ultrasound allows non-invasive assessment of placentation, while the flow impedance decreases as the pregnancy progresses in normal pregnancies, in those destined to develop preeclampsia the impedance is increased.
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Affiliation(s)
- Tania de Ganzo Suárez
- Department of Obstetrics and Gynecology, Complejo Hospitalario Universitario Nuestra Señora de la Candelaria, Tenerife, Canary Islands, Spain.
| | - Catalina de Paco Matallana
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain; Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain; Faculty of Medicine, Universidad de Murcia, Murcia, Spain.
| | - Walter Plasencia
- Department of Obstetrics and Gynecology, Complejo Hospitalario Universitario de Canarias, Tenerife. Canary Islands, Spain.
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Waller JA, Saade G. Stillbirth and the placenta. Semin Perinatol 2024; 48:151871. [PMID: 38199875 DOI: 10.1016/j.semperi.2023.151871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Stillbirth affects a large proportion of pregnancies world-wide annually and continues to be a major public health concern. Several causes of stillbirth have been identified and include obstetrical complications, placental abnormalities, fetal malformations, infections, and medical complications in pregnancy. Placental abnormalities such as placental abruption, chorioangioma, vasa previa, and umbilical cord abnormalities have been identified as causes of death for a significant proportion of stillbirths. In the absence of placental abnormalities, the gross and histologic changes in the placenta in stillbirth are found when secondary to other etiologies. Here we describe both gross and histologic changes of the placenta that are associated with stillbirth.
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Affiliation(s)
- Jerri A Waller
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School.
| | - George Saade
- Department Chair of Obstetrics and Gynecology, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School
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Horgan R, Sinkovskaya E, Saade G, Kalafat E, Rice MM, Heeze A, Abuhamad A. Longitudinal assessment of spiral and uterine arteries in normal pregnancy using novel ultrasound tool. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:860-866. [PMID: 37470712 PMCID: PMC10801897 DOI: 10.1002/uog.26312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/09/2023] [Accepted: 06/22/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES To use superb microvascular imaging (SMI) to evaluate longitudinally spiral artery (SA) and uterine artery (UtA) vascular adaptation in normal human pregnancy, and to develop reference ranges for use at various gestational ages throughout pregnancy. METHODS The data for this study were obtained from the National Institutes of Health (NIH)-funded Human Placenta Project. Women aged 18-35 years, with a body mass index < 30 kg/m2 , without comorbidities, with a singleton gestation conceived spontaneously, and gestational age at or less than 13 + 6 weeks were eligible for inclusion. The current analysis was restricted to uncomplicated pregnancies carried to term. Exclusion criteria included maternal or neonatal complications, fetal or umbilical cord anomalies, abnormal placental implantation or delivery < 37 weeks. Women who fulfilled the inclusion criteria formed the reference population of the Human Placenta Project study. Each participant underwent eight ultrasound examinations during pregnancy. The pulsatility index (PI) of both the left and right UtA were obtained twice for each artery and the presence or absence of a notch was noted. Using SMI technology, the total number of SA imaged was recorded in a sagittal placental section at the level of cord insertion. The PI and peak systolic velocity (PSV) were also measured in a total of six SA, including two in the central portion of the placenta, two peripherally towards the uterine fundal portion, and two peripherally towards the lower uterine segment. RESULTS A total of 90 women fulfilled the study criteria. Maternal UtA-PI decreased throughout the first half of pregnancy from a mean ± SD of 1.39 ± 0.50 at 12-13 weeks' gestation to 0.88 ± 0.24 at 20-21 weeks' gestation. The mean number of SA visualized in a sagittal plane of the placenta increased from 8.83 ± 2.37 in the first trimester to 16.99 ± 3.31 in the late-third trimester. The mean SA-PI was 0.57 ± 0.12 in the first trimester and decreased progressively during the second trimester, reaching a nadir of 0.40 ± 0.10 at 24-25 weeks, and remaining constant until the end of pregnancy. SA-PSV was highest in early pregnancy with a mean of 57.16 ± 14.84 cm/s at 12-13 weeks' gestation, declined to a mean of 49.38 ± 17.88 cm/s at 20-21 weeks' gestation and continued to trend downward for the remainder of pregnancy, reaching a nadir of 34.50 ± 15.08 cm/s at 36-37 weeks' gestation. A statistically significant correlation was noted between SA-PI and UtA-PI (r = 0.5633; P < 0.001). Multilevel regression models with natural cubic splines were used to create reference ranges of SA-PSV and SA-PI for given gestational ages. CONCLUSION From early gestation, we have demonstrated the ability to image and quantify SA blood flow in normal pregnancy, and have developed reference ranges for use at various gestational ages throughout pregnancy. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - E Sinkovskaya
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - G Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - E Kalafat
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - M M Rice
- George Washington University Biostatistics Center, Milken Institute School of Public Health, Washington, DC, USA
| | - A Heeze
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - A Abuhamad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Herrera CL, Kim MJ, Do QN, Owen DM, Fei B, Twickler DM, Spong CY. The human placenta project: Funded studies, imaging technologies, and future directions. Placenta 2023; 142:27-35. [PMID: 37634371 PMCID: PMC11257151 DOI: 10.1016/j.placenta.2023.08.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Abstract
The placenta plays a critical role in fetal development. It serves as a multi-functional organ that protects and nurtures the fetus during pregnancy. However, despite its importance, the intricacies of placental structure and function in normal and diseased states have remained largely unexplored. Thus, in 2014, the National Institute of Child Health and Human Development launched the Human Placenta Project (HPP). As of May 2023, the HPP has awarded over $101 million in research funds, resulting in 41 funded studies and 459 publications. We conducted a comprehensive review of these studies and publications to identify areas of funded research, advances in those areas, limitations of current research, and continued areas of need. This paper will specifically review the funded studies by the HPP, followed by an in-depth discussion on advances and gaps within placental-focused imaging. We highlight the progress within magnetic reasonance imaging and ultrasound, including development of tools for the assessment of placental function and structure.
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Affiliation(s)
- Christina L Herrera
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, and Parkland Health Dallas, Texas, USA; Green Center for Reproductive Biology Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Meredith J Kim
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Quyen N Do
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - David M Owen
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, and Parkland Health Dallas, Texas, USA; Green Center for Reproductive Biology Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Baowei Fei
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA; Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Bioengineering, University of Texas at Dallas, Dallas, TX, USA
| | - Diane M Twickler
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, and Parkland Health Dallas, Texas, USA; Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, and Parkland Health Dallas, Texas, USA
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Espinoza J. Evolutionary perspective of uteroplacental malperfusion: subjacent insult common to most pregnancy complications. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:7-13. [PMID: 37391928 DOI: 10.1002/uog.26218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 07/02/2023]
Abstract
Linked article: There is a comment on this article by Yagel et al. Click here to view the Correspondence.
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Affiliation(s)
- J Espinoza
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Fetal Intervention, UTHealth, McGovern Medical School, University of Texas, Houston, TX, USA
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7
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Ji D, Pan Y, Qiu X, Gong J, Li X, Niu C, Yao J, Luo S, Zhang Z, Wang Q, Dai J, Wei Y. Unveiling Distribution of Per- and Polyfluoroalkyl Substances in Matched Placenta-Serum Tetrads: Novel Implications for Birth Outcome Mediated by Placental Vascular Disruption. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2023; 57:5782-5793. [PMID: 36988553 DOI: 10.1021/acs.est.2c09184] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The placenta is pivotal for fetal development and maternal-fetal transfer of many substances, including per- and polyfluoroalkyl substances (PFASs). However, the intraplacental distribution of PFASs and their effects on placental vascular function remain unclear. In this study, 302 tetrads of matched subchorionic placenta (fetal-side), parabasal placenta (maternal-side), cord serum, and maternal serum samples were collected from Guangzhou, China. Eighteen emerging and legacy PFASs and five placental vascular biomarkers were measured. Results showed that higher levels of perfluorooctanoic (PFOA), perfluorooctane sulfonic acid (PFOS), and chlorinated polyfluorinated ether sulfonic acids (Cl-PFESAs) were detected in subchorionic placenta compared to parabasal placenta. There were significant associations of PFASs in the subchorionic placenta, but not in the serum, with placental vascular biomarkers (up to 32.5%) and lower birth size. Birth weight was negatively associated with PFOA (β: -103.8, 95% CI: -186.3 and -21.32) and 6:2 Cl-PFESA (β: -80.04, 95% CI: -139.5 and -20.61), primarily in subchorionic placenta. Mediation effects of altered placental angiopoietin-2 and vascular endothelial growth factor receptor-2 were evidenced on associations of adverse birth outcomes with intraplacental PFOS and 8:2 Cl-PFESA, explaining 9.5%-32.5% of the total effect. To the best of our knowledge, this study is the first to report on differential intraplacental distribution of PFASs and placental vascular effects mediating adverse birth outcomes and provides novel insights into the placental plate-specific measurement in PFAS-associated health risk assessment.
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Affiliation(s)
- Di Ji
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Yitao Pan
- State Environmental Protection Key Laboratory of Environmental Health Impact Assessment of Emerging Contaminants, School of Environmental Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Xuelin Qiu
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Jingjin Gong
- Department of Obstetrics and Gynecology, He Xian Memorial Affiliated Hospital of Southern Medical University, Guangzhou 511402, China
| | - Xianjie Li
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Conying Niu
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Jingzhi Yao
- State Environmental Protection Key Laboratory of Environmental Health Impact Assessment of Emerging Contaminants, School of Environmental Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Shili Luo
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhuyi Zhang
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Qiong Wang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Jiayin Dai
- State Environmental Protection Key Laboratory of Environmental Health Impact Assessment of Emerging Contaminants, School of Environmental Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Yanhong Wei
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
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Hernandez-Andrade E, Huntley ES, Bartal MF, Soto-Torres EE, Tirosh D, Jaiman S, Johnson A. Doppler evaluation of normal and abnormal placenta. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:28-41. [PMID: 34806234 DOI: 10.1002/uog.24816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/12/2021] [Indexed: 06/13/2023]
Abstract
Doppler techniques are needed for the evaluation of the intraplacental circulation and can be of great value in the diagnosis of placental anomalies. Highly sensitive Doppler techniques can differentiate between the maternal (spiral arteries) and fetal (intraplacental branches of the umbilical artery) components of the placental circulation and assist in the evaluation of the placental functional units. A reduced number of placental functional units can be associated with obstetric complications, such as fetal growth restriction. Doppler techniques can also provide information on decidual vessels and blood movement. Abnormal decidual circulation increases the risk of placenta accreta. Doppler evaluation of the placenta greatly contributes to the diagnosis and clinical management of placenta accreta, vasa previa, placental infarcts, placental infarction hematoma, maternal floor infarction, massive perivillous fibrin deposition and placental tumors. However, it has a limited role in the diagnosis and clinical management of placental abruption, placental hematomas, placental mesenchymal dysplasia and mapping of placental anastomoses in monochorionic twin pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - M F Bartal
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E E Soto-Torres
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - D Tirosh
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - S Jaiman
- Department of Obstetrics and Gynecology Wayne State University, Detroit, MI, USA
| | - A Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
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