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Abdulrahman N, Burger NB, van den Broek S, Kaaijk EM, Oudijk MA, de Boer MA, Huirne JAF. Patient perspectives and preferences on cerclage and preterm birth: a focus group study. Qual Life Res 2024:10.1007/s11136-024-03637-9. [PMID: 38888673 DOI: 10.1007/s11136-024-03637-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 06/20/2024]
Abstract
AIM This qualitative focus group study aims to asses cerclage-related symptoms, the impact of a cerclage on daily functioning and patient perspectives of their healthcare experience. This study extends beyond the current focus on surgical and obstetric outcomes of a cerclage, thereby contributing to a more comprehensive understanding of the challenges faced by individuals in the context of extreme preterm birth and fetal loss and the impact of a cerclage on multiple facets in life. METHODS Participants were recruited from the Amsterdam University Medical Center, Amsterdam, the Netherlands or via the website of a Dutch patient organization for (extreme) preterm birth. Eligible participants were ≥ 18 years old with a previous vaginal and/or abdominal cerclage with a subsequent delivery at ≥ 34 weeks of gestation with neonatal survival. Two focus group discussions (FGD) were performed. A predefined format was used, which was identical for both the vaginal and abdominal cerclage group. The International Classification of Functioning, Disability and Health (ICF-DH) was used to provide structure. Outcomes were a broad range of participants reported perspectives on physical, emotional, and social-related quality of life. RESULTS In the Vaginal Cerclage Group (VCG) and Abdominal Cerclage Group (ACG), respectively, 11 and 8 participants were included. Fear for a subsequent pregnancy loss was the most limiting factor to perform daily activities during pregnancy in all participants with a cerclage. Fear to conceive again because of prior second-trimester fetal loss was experienced by 27% in the VCG and 13% in the ACG. The majority of participants experienced a reduction in anxiety after placement of their cerclage (VCG = 64%, ACG = 75%). Decreased mobility/bedrest (VCG = 100%, ACG = 75%) and blood loss (VCG = 55%, ACG = 13%) were frequently mentioned complaints during pregnancy with cerclage. Other aspects mentioned in both groups were social isolation, the lack of societal participation, and the perceived need to quit work and sports. All participants in the abdominal cerclage group reported a lack of comprehensible and unambiguous information about obstetric management and expectations during pregnancy in secondary care hospitals. Clear communication between secondary and tertiary care hospitals about obstetric management following an abdominal cerclage, for example, about the need for cervical length measurements by ultrasound, the need for bedrest or advice concerning sexual activity was missing (63%). Psychologic support was desired in half of all participants, but was not offered to them. CONCLUSIONS The fear of a subsequent pregnancy loss was reported as the most limiting factor in daily life by all participants. Cerclage placement resulted in the reduction of anxiety. Participants mentioned a significant impact of bedrest and activity restriction during pregnancy with cerclage on social participation and daily activities. Unfortunately, no high level evidence is available on this matter. Patients might even benefit from appropriate levels of physical activity throughout their pregnancy to promote their overall well-being. More evidence is needed to determine the optimal level of physical activity. There is a need for clear and unambiguous patient information about obstetric management.
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Affiliation(s)
- Nour Abdulrahman
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands.
- Department of Obstetrics and Gynaecology, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
| | - Nicole B Burger
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Susan van den Broek
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Eugenie M Kaaijk
- Department of Obstetrics and Gynaecology, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
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Saroyo YB, Madjid OA, Santawi VPA, Scovani L, Purbadi S. Cerclage in complete placenta previa preventing preterm labor: A rare case report. SAGE Open Med Case Rep 2023; 11:2050313X231200121. [PMID: 37791065 PMCID: PMC10542318 DOI: 10.1177/2050313x231200121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/22/2023] [Indexed: 10/05/2023] Open
Abstract
Placenta previa often leads to antepartum hemorrhage, which warrants the patient for emergency room admission. The bleeding occurs mainly due to cervical dilation, which could be caused by cervical incompetence. Cervical cerclage has been considered as the primary treatment for cervical incompetence. However, evidence is lacking for its application in placenta previa. Here, we present a case of a 30-year-old pregnant woman diagnosed with complete placenta previa where a good obstetrical outcome could be achieved. The patient had antepartum hemorrhage during the 21st week of gestational age due to cervical dilation in a complete placenta previa case. An emergency cerclage using McDonald's technique was then performed, which prolonged the pregnancy to the 34th week of gestation. The patient had cesarean section and delivered a healthy baby girl weighing 2190 g. The mother and the baby had an uneventful recovery and were discharged after 2 days of hospitalization.
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Affiliation(s)
- Yudianto Budi Saroyo
- Fetomaternal Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Omo Abdul Madjid
- Social Obstetrics and Gynecology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Victor Prana Andika Santawi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Laurensia Scovani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Sigit Purbadi
- Gynecology-Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, DKI Jakarta, Indonesia
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Cai B, Xia Y, Na X. Correlation Between Clinical Factors and Pregnancy Outcome Following Repeat Cerclage: A Retrospective Analysis of a Chinese Population. Front Med (Lausanne) 2022; 9:846755. [PMID: 35445034 PMCID: PMC9013839 DOI: 10.3389/fmed.2022.846755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background The role of repeat cerclage (RC) among patients with prolapsed membranes remains controversial. We aimed to investigate the effectiveness of RC and assess the correlation between clinical factors and pregnancy outcome following RC. Methods The clinical data of patients who underwent RC for prolapsed membranes after prior cerclage were retrospectively investigated. The clinical characteristics of patients were compared between singleton and twin pregnancies. The clinical characteristics of singleton pregnancies were compared between the gestational age (GA) at delivery <28 weeks' and ≥28 weeks' groups. Receiver operating characteristic (ROC) curve analysis was performed to determine predictive factors. Singleton patients were divided into two groups according to GA at RC as follows: GA <22.3 weeks and GA ≥22.3 weeks. Pregnancy outcomes were compared between groups. Results The mean GA at delivery of singleton pregnancies was significantly higher than that of twin pregnancies. The mean latency between RC and delivery of singleton pregnancies was significantly longer than their twin counterparts. There were significant differences in the pregnancy outcomes between the GA <22.3 weeks group and GA ≥22.3 weeks group. Kaplan–Meier survival curves showed a lower incidence of neonatal death in the GA ≥22.3 weeks group compared with that in the GA <22.3 weeks group. Conclusions RC may be an effective method to prolong the duration of pregnancy among patients with singleton pregnancy. However, the selection of RC for patients with twin pregnancies remains controversial. GA at RC appears to be fair for predicting pregnancy outcomes following RC.
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Affiliation(s)
- Benshuo Cai
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yajun Xia
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xinni Na
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
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Stephens AJ, Chen HY, Chauhan SP, Sibai BM. Body mass index and adverse outcomes among singletons with cerclage. Eur J Obstet Gynecol Reprod Biol 2021; 262:129-133. [PMID: 34020116 DOI: 10.1016/j.ejogrb.2021.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/27/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the neonatal and maternal adverse outcomes among women with cerclage and prepregnancy body mass index (BMI) < versus > 30 kg/m2 STUDY DESIGN: This retrospective cohort study utilized the U.S. Vital Statistics Datasets from 2011-2013. Inclusion criteria were women with non-anomalous singletons, with cerclage placement, without diabetes or hypertensive disorders, and who delivered at 20-41 weeks. The primary outcome was the composite neonatal adverse outcome (Apgar score below 5 at 5 min, birth injury, assisted ventilation for more than 6 h, neonatal seizure, or neonatal death). The secondary outcomes included the composite maternal adverse outcome (admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure), chorioamnionitis, and cesarean delivery. Multivariable Poisson regression models with robust error variance were used, while adjusting for confounders. Adjusted relative risk with 95 % confidence intervals were calculated. RESULTS Of the 22,466 live births that met the inclusion criteria during the study period, 6427 (28.6 %) had cerclage and prepregnancy BMI ≥ 30 kg/m2. The composite neonatal adverse outcome was significantly increased (aRR 1.45; 95 % CI 1.33-1.60) among women with cerclage and BMI ≥ 30 kg/m2 when compared to those with BMI < 30 kg/m2. The composite maternal adverse outcome was similar (aRR 0.93; 95 % CI 0.72-1.20) among the two groups. Chorioamnionitis (aRR 1.46; 95 % CI 1.24-1.72) and cesarean delivery (aRR 1.24; 95 % CI 1.19-1.29) were higher in women with cerclage and BMI ≥ 30 kg/m2. CONCLUSION Among pregnancies with cerclage and delivery at 20-41 weeks, the risk of the composite neonatal adverse outcome was modestly increased in newborns delivered by women with BMI ≥ 30 kg/m2 than those delivered by women with BMI < 30 kg/m2. No significant difference was found in the risk of the composite maternal adverse outcome.
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Affiliation(s)
- Angela J Stephens
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States.
| | - Han-Yang Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Baha M Sibai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Battarbee AN, Ellis JS, Manuck TA. Beyond Cervical Length: Association between Postcerclage Transvaginal Ultrasound Parameters and Preterm Birth. Am J Perinatol 2019; 36:1317-1324. [PMID: 31039598 PMCID: PMC7008975 DOI: 10.1055/s-0039-1688480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the value of transvaginal ultrasound parameters after cerclage placement in estimating the risk of spontaneous preterm birth. STUDY DESIGN This is a retrospective cohort at a single tertiary care center from 2013 to 2016. Women carrying a singleton, nonanomalous fetus with cerclage in situ and at least one postcerclage transvaginal ultrasound from 160/7 to 256/7 weeks' gestation were included. In addition to abstracting maternal demographic and obstetric characteristics, two study investigators separately reviewed each of the images from the first transvaginal ultrasound after cerclage placement, masked to pregnancy outcomes. We measured the angle between the anterior uterine wall and cervical canal at the internal os and external os, closed canal length above and below the stitch, width of the anterior and posterior cervix at the level of the cerclage, and stitch distance from the cervical canal. The presence of additional ultrasound findings such as sludge and cervical funneling was also noted. The main outcomes were preterm birth < 34 weeks and preterm birth < 37 weeks. Transvaginal ultrasound parameters were compared between women with preterm birth and those without preterm birth using chi-square, Fisher's exact, and Wilcoxon's rank-sum tests, as appropriate. Log binomial regression was used to estimate the relative risk of preterm birth for all significant obstetric and ultrasound characteristics. RESULTS A total of 102 women met inclusion criteria: 58% had history-indicated, 20% ultrasound-indicated, and 23% exam-indicated cerclages. Of these, 28 (27.5%) women delivered at < 34 weeks' gestation, and 48 (47.0%) women delivered at < 37 weeks' gestation. Preterm birth did not vary by race, maternal age, insurance, smoking, or gestational age of the earliest prior preterm birth (for multiparous women), but women who had preterm birth were more likely to have exam-indicated cerclage. There were several transvaginal ultrasound parameters associated with preterm birth < 34 weeks and preterm birth < 37 weeks. Of these, cervical length below the stitch, stitch distance from the cervical canal, straight cervical canal, funneling to or past the stitch, and presence of sludge had the greatest effect sizes. CONCLUSION Rates of preterm birth are high postcerclage. In addition to measuring cervical length, utilization of postcerclage transvaginal ultrasound to evaluate the location of the cerclage within the cervix, the curvature of the cervical canal, and the presence of funneling and sludge may help identify women who are at the highest risk for preterm birth.
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Affiliation(s)
- Ashley N. Battarbee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Joshua S. Ellis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Tracy A. Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Wang YY, Duan H, Zhang XN, Wang S, Gao L. A Novel Cerclage Insertion: Modified Laparoscopic Transabdominal Cervical Cerclage with Transvaginal Removing (MLTCC-TR). J Minim Invasive Gynecol 2019; 27:1300-1307. [PMID: 31586476 DOI: 10.1016/j.jmig.2019.09.774] [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] [Received: 06/24/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE To report on our center's experience of a novel modified approach for laparoscopic cervical cerclage and to evaluate its safety and efficacy preliminarily. DESIGN Retrospective descriptive study. SETTING Single academic institution. PATIENTS Pregnant and nonpregnant women who underwent the modified laparoscopic transabdominal cervical cerclage with transvaginal removing (MLTCC-TR) from June 2016 to April 2019. Eligible participants had multiple adverse obstetric histories or the short cervix and were not suitable for a second transvaginal cerclage. INTERVENTIONS Preconceptional or postconceptional MLTCC-TR. MEASUREMENTS AND MAIN RESULTS A total of 24 participants (including 3 first-trimester singleton pregnant women) underwent the MLTCC-TR, giving birth to 27 infants. Among 21 women who underwent preconceptional cerclage, 26 cases of postoperational pregnancies were noted, and the incidence of term labor was 73.07%, which was significantly higher than that in the precerclage group (p <.001). Their mean gestational age at delivery was 37.21 ± 5.05 weeks. Among 3 cases of postconceptional cerclage, the mean gestational age at cerclage was 10.90 ± 2.61 weeks, and all of them had term delivery. The overall neonatal survival rate was 100% (27/27), of which 81.48% (22/27) were term infants. There were no severe perioperative complications directly related to the insertion of cerclage. CONCLUSION Our new approach of MLTCC-TR may be a relatively effective, feasible, and safe treatment for cervical insufficiency. It may be considered as an acceptable alternative to the traditional laparoscopic cervical cerclage with its superiority of transvaginal removing.
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Affiliation(s)
- Yi-Yi Wang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University (Drs. Y. Wang, Duan, and S. Wang)
| | - Hua Duan
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University (Drs. Y. Wang, Duan, and S. Wang).
| | - Xiang-Ning Zhang
- Beijing, and the Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University (Drs. Zhang and Gao), Jinan, Shandong Province, China
| | - Sha Wang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University (Drs. Y. Wang, Duan, and S. Wang)
| | - Lei Gao
- Beijing, and the Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University (Drs. Zhang and Gao), Jinan, Shandong Province, China
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Eke AC, Sheffield J, Graham EM. Adjuvant 17-hydroxyprogesterone caproate in women with history-indicated cerclage: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2018; 98:139-153. [PMID: 30339274 DOI: 10.1111/aogs.13488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/14/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate whether there are additional benefits of 17-hydroxyprogesterone caproate (17-OHPC) supplementation in preventing recurrent spontaneous preterm birth in women with a prophylactic cerclage. MATERIAL AND METHODS Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) were searched for studies published before June 2018. Keywords included "preterm birth", "prophylactic cerclage", "history-indicated cerclage", "pregnancy" and "17-hydroxyprogesterone caproate". Studies comparing history-indicated cerclage alone with cerclage+17-OHPC were included. The primary outcome measure was preterm birth at <24 weeks of gestation. Secondary outcome measures include preterm birth at <28 weeks, <32 weeks and <37 weeks of gestation, respiratory distress syndrome, necrotizing enterocolitis, fetal birthweight, neonatal intensive care unit stay, mean gestational age at delivery, fetal/neonatal death, neurological morbidity (intraventricular hemorrhage plus periventricular leukomalacia), neonatal sepsis and a composite of severe neonatal morbidity. Severe neonatal morbidity was defined as a composite measure of periventricular leukomalacia, intraventricular hemorrhage (grades III and IV), necrotizing enterocolitis or respiratory distress syndrome. Meta-analysis was performed using the random-effects model of DerSimonian and Laird. Risk of bias and quality assessment were performed using the ROBINS-I and GRADE tools, respectively. PROSPERO Registration Number: CRD42018094559. RESULTS Five studies met the inclusion criteria and were included in the final analysis. Of the 546 women, 357 (75%) received history-indicated cerclage alone and 189 (35%) received adjuvant 17-OHPC. The composite endpoint, severe neonatal morbidity, was present in 84 of 1515 neonates. Though there was a trend toward a reduced risk of preterm birth, the summary estimate of effect was not statistically significant when comparing cerclage alone with cerclage+17-OHPC at <24 weeks (relative risk [RR] .86, 95% confidence interval [CI] .45-1.65). Similarly, we found no differences in preterm birth at <37 weeks (RR .90, 95% CI .70-1.17) and <28 weeks (RR .85, 95% CI .54-1.32) when comparing cerclage alone with cerclage+17-OHPC. There were no differences in fetal birthweight, respiratory distress syndrome or necrotizing enterocolitis comparing cerclage alone with cerclage+17-OHPC. CONCLUSIONS Intramuscular 17-OHPC in combination with prophylactic cerclage in women with prior preterm birth had no synergistic effect in reducing spontaneous recurrent preterm birth or improving perinatal outcomes.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Jeanne Sheffield
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M Graham
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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