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Melamed N, Avnon T, Barrett J, Fox N, Rebarber A, Shah BR, Halperin I, Retnakaran R, Berger H, Kingdom J, Hiersch L. Gestational diabetes in twin pregnancies-a pathology requiring treatment or a benign physiological adaptation? Am J Obstet Gynecol 2024; 231:92-104.e4. [PMID: 38218511 DOI: 10.1016/j.ajog.2024.01.004] [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: 08/24/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
There is level-1 evidence that screening for and treating gestational diabetes in singleton pregnancies reduce maternal and neonatal morbidity. However, similar data for gestational diabetes in twin pregnancies are currently lacking. Consequently, the current approach for the diagnosis and management of gestational diabetes in twin pregnancies is based on the same diagnostic criteria and glycemic targets used in singleton pregnancies. However, twin pregnancies have unique physiological characteristics, and many of the typical gestational diabetes-related complications are less relevant for twin pregnancies. These differences raise the question of whether the greater increase in insulin resistance observed in twin pregnancies (which is often diagnosed as diet-treated gestational diabetes) should be considered physiological and potentially beneficial in which case alternative criteria should be used for the diagnosis of gestational diabetes in twin pregnancies. In this review, we summarize the most up-to-date evidence on the epidemiology, pathophysiology, and clinical consequences of gestational diabetes in twin pregnancies and review the available data on twin-specific screening and diagnostic criteria for gestational diabetes. Although twin pregnancies are associated with a higher incidence of diet-treated gestational diabetes, diet-treated gestational diabetes in twin pregnancies is less likely to be associated with adverse outcomes and accelerated fetal growth than in singleton pregnancies and may reduce the risk for intrauterine growth restriction. In addition, there is currently no evidence that treatment of diet-treated gestational diabetes in twin pregnancies improves outcomes, whereas preliminary data suggest that strict glycemic control in such cases might increase the risk for intrauterine growth restriction. Overall, these findings provide support to the hypothesis that the greater transient increase in insulin resistance observed in twin pregnancies is merely a physiological exaggeration of the normal increase in insulin resistance observed in singleton pregnancies (that is meant to support 2 fetuses) rather than a pathology that requires treatment. These data illustrate the need to develop twin-specific screening and diagnostic criteria for gestational diabetes to avoid overdiagnosis of gestational diabetes and to reduce the risks associated with overtreatment of diet-treated gestational diabetes in twin pregnancies. Although data on twin-specific screening and diagnostic criteria are presently scarce, preliminary data suggest that the optimal screening and diagnostic criteria in twin pregnancies are higher than those currently used in singleton pregnancies.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Ontario, Canada.
| | - Tomer Avnon
- Lis Maternity Hospital, Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nathan Fox
- Icahn School of Medicine at Mount Sinai, New York, NY; Maternal Fetal Medicine Associates, PLLC, New York, NY
| | - Andrei Rebarber
- Icahn School of Medicine at Mount Sinai, New York, NY; Maternal Fetal Medicine Associates, PLLC, New York, NY
| | - Baiju R Shah
- Institute for Clinical Evaluative Sciences, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Division of Endocrinology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Ilana Halperin
- Division of Endocrinology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Ravi Retnakaran
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology, University of Toronto, Toronto, ON, Canada
| | - Howard Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St Michael's Hospital, Toronto, Ontario, Canada
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Liran Hiersch
- Lis Maternity Hospital, Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ngene NC, Moodley J. Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102473. [PMID: 38513504 DOI: 10.1016/j.bpobgyn.2024.102473] [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: 11/14/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 03/23/2024]
Abstract
Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, Rahima Moosa Mother and Child Hospital, Johannesburg, Gauteng, South Africa; Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Gauteng, South Africa.
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, Department of Obstetrics and Gynecology, School of Clinical Medicine, Faculty of Health Sciences, University of Kwa Zulu-Natal, Durban, South Africa.
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Huang P, Wu R, Guo X, Gao X, Yan Y, Han C, Xue F. Clinical Features and Outcomes of Twin Pregnancies with Antiphospholipid Antibodies Positivity: A Retrospective Study. Risk Manag Healthc Policy 2024; 17:1165-1176. [PMID: 38737417 PMCID: PMC11088406 DOI: 10.2147/rmhp.s456226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
Objective This study aimed to evaluate the impact of twin pregnancies with antiphospholipid antibody (aPL) positivity, a rare and complex clinical condition that remains a huge challenge for management. Methods This study enrolled twin-pregnant women at our hospital between January 2018 and August 2023. Women with and without aPL positivity were selected using propensity score matching (PSM). Clinical features and pregnancy outcomes were compared between the two groups in the PSM cohort. To analyze the effect of aPL positivity on pregnancy outcomes, multivariate logistic models were used to obtain adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Among the 773 women with twin pregnancies, aPL positivity was found in 26 women (3.36%). In the PSM cohort, there were 24 twin-pregnant women with positive aPL, and 48 women without aPL were selected as controls. Twin-pregnant women with aPL positivity had a higher proportion of abortion (8.33% vs 0, P = 0.043), preterm birth < 34 weeks (33.33% vs 8.33%, P = 0.007) and very low birthweight (<1500 g) (20.83% vs 4.17%, P = 0.016) than the control group. In addition, stillbirth of one fetus was observed in one twin-pregnant woman with positive aPL. Multivariate logistic regression analysis revealed that twin pregnancy with aPL positivity was associated with preterm birth < 34 weeks (aOR = 2.76, 95% CI: 0.83-4.70, P = 0.005), very low birthweight (<1500 g) (OR = 2.40, 95% CI: 0.18-4.67, P = 0.034) and small for gestational age (SGA) (aOR = 1.66, 95% CI: 0.22-3.10, P =0.024). Conclusion Twin pregnancies with aPL positivity were correlated with obstetric complications, including abortion, preterm birth < 34 weeks and very low birthweight (<1500 g). The detection of aPL may be of clinical significance for women with twin pregnancies and should be considered in future studies.
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Affiliation(s)
- Pengzhu Huang
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Rongrong Wu
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xin Guo
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xiaoli Gao
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Ye Yan
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Cha Han
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Fengxia Xue
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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Barg M, Melamed B, Aviram A, Mei-Dan E, Barrett J, Melamed N. Risk of intrapartum cesarean delivery in twin pregnancies: A retrospective cohort study. Int J Gynaecol Obstet 2024. [PMID: 38654541 DOI: 10.1002/ijgo.15557] [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: 02/28/2024] [Revised: 04/04/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To compare the risk of intrapartum cesarean delivery (CD) between patients with twin and singleton pregnancies undergoing a trial of labor and identify risk factors for intrapartum CD in twin pregnancies. METHODS The present study was a retrospective cohort study of patients with a twin or singleton pregnancy who underwent a trial of labor at ≥340/7 weeks in a single center (2015-2022). The primary outcome was the rate of intrapartum CD. In twin pregnancies, this outcome was limited to CD of both twins. The association of plurality with intrapartum CD was estimated using multivariable Poisson regression. RESULTS A total of 20 754 patients met the study criteria, 669 of whom had a twin pregnancy. Patients with twins had a greater risk of intrapartum CD (of both twins) than those with singleton pregnancies (22.1% vs 15.9%, respectively; aRR 1.38 [95% CI: 1.15-1.66]), primarily due to a greater risk of failure to progress. In addition, 4.1% of the twin pregnancies had a CD for the second twin, resulting in an overall CD rate in twin pregnancies of 26.2%. Variables associated with intrapartum CD in twin pregnancies included nulliparity (aOR 3.50, 95% CI: 2.34-5.25), birthweight discordance >20% (aOR 2.47, 95% CI: 1.27-4.78), and labor induction (aOR 1.64, 95% CI: 1.07-2.53). The rate of intrapartum CD was highest when all three risk factors were present (67% [95% CI: 41%-87%]). CONCLUSION Twin pregnancies are associated with a greater risk of intrapartum CD than singleton pregnancies. Information on the individualized risk of intrapartum CD may be valuable when counseling patients with twins regarding mode of delivery.
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Affiliation(s)
- Moshe Barg
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Ben Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North York General Hospital, Toronto, Ontario, Canada
| | - Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North York General Hospital, Toronto, Ontario, Canada
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Raymond Y, Fernando S, Menezes M, Mol BW, McLennan A, da Silva Costa F, Hardy T, Rolnik DL. Placental, maternal, fetal, and technical origins of false-positive cell-free DNA screening results. Am J Obstet Gynecol 2024; 230:381-389. [PMID: 38008147 DOI: 10.1016/j.ajog.2023.11.1240] [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: 09/05/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 11/28/2023]
Abstract
The introduction of noninvasive prenatal testing has resulted in substantial reductions to previously accepted false-positive rates of prenatal screening. Despite this, the possibility of false-positive results remains a challenging consideration in clinical practice, particularly considering the increasing uptake of genome-wide noninvasive prenatal testing, and the subsequent increased proportion of high-risk results attributable to various biological events besides fetal aneuploidy. Confined placental mosaicism, whereby chromosome anomalies exclusively affect the placenta, is perhaps the most widely accepted cause of false-positive noninvasive prenatal testing. There remains, however, a substantial degree of ambiguity in the literature pertaining to the clinical ramifications of confined placental mosaicism and its potential association with placental insufficiency, and consequentially adverse pregnancy outcomes including fetal growth restriction. Other causes of false-positive noninvasive prenatal testing include vanishing twin syndrome, in which the cell-free DNA from a demised aneuploidy-affected twin triggers a high-risk result, technical failures, and maternal origins of abnormal cell-free DNA such as uterine fibroids or unrecognized mosaicisms. Most concerningly, maternal malignancies are also a documented cause of false-positive screening results. In this review, we compile what is currently known about the various causes of false-positive noninvasive prenatal testing.
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Affiliation(s)
- Yvette Raymond
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.
| | - Shavi Fernando
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia; Monash Women's, Monash Health, Melbourne, Australia; Monash Obstetrics, Melbourne, Australia
| | - Melody Menezes
- Monash Ultrasound for Women, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Monash IVF Group, Melbourne, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia; Monash Women's, Monash Health, Melbourne, Australia; Centre for Women's Health Research, The University of Aberdeen, Aberdeen, UK
| | - Andrew McLennan
- Sydney Ultrasound for Women, Sydney, Australia; Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Sydney, Australia
| | - Fabricio da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital, Queensland, Australia; School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Tristan Hardy
- Monash IVF Group, Melbourne, Australia; Repromed Adelaide, Dulwich, Australia
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia; Monash Women's, Monash Health, Melbourne, Australia; Monash Ultrasound for Women, Melbourne, Australia
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Wright A, Wright D, Chaveeva P, Molina FS, Akolekar R, Syngelaki A, Petersen OB, Kristensen SE, Nicolaides KH. Fetal Medicine Foundation charts for fetal growth in twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:181-188. [PMID: 37842873 DOI: 10.1002/uog.27514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE To derive reference distributions of estimated fetal weight (EFW) in twins relative to singletons. METHODS Gestational-age- and chorionicity-specific reference distributions for singleton percentiles and EFW were fitted to data on 4391 twin pregnancies with two liveborn fetuses from four European centers, including 3323 dichorionic (DC) and 1068 monochorionic diamniotic (MCDA) twin pregnancies. Gestational age was derived using the larger of the two crown-rump length measurements obtained during the first trimester of pregnancy. EFW was obtained from ultrasound measurements of head circumference, abdominal circumference and femur length using the Hadlock formula. Singleton percentiles were obtained using the Fetal Medicine Foundation population weight charts for singleton pregnancies. Hierarchical models were fitted to singleton Z-scores with autoregressive terms for serial correlations within the same fetus and between twins from the same pregnancy. Separate models were fitted for DC and MCDA twins. RESULTS Fetuses from twin pregnancies tended to be smaller than singletons at the earliest gestational ages (16 weeks for MCDA and 20 weeks for DC twins). This was followed by a period of catch-up growth until around 24 weeks. After that, both DC and MCDA twins showed reduced growth. In DC twins, the EFW corresponding to the 50th percentile was at the 50th percentile of singleton pregnancies at 23 weeks, the 43rd percentile at 28 weeks, the 32nd percentile at 32 weeks and the 22nd percentile at 36 weeks. In MCDA twins, the EFW corresponding to the 50th percentile was at the 36th percentile of singleton pregnancies at 24 weeks, the 29th percentile at 28 weeks, the 19th percentile at 32 weeks and the 12th percentile at 36 weeks. CONCLUSIONS In DC and, to a greater extent, MCDA twin pregnancies, fetal growth is reduced compared with that observed in singleton pregnancies. Furthermore, after 24 weeks, the divergence in growth trajectories between twin and singleton pregnancies becomes more pronounced as gestational age increases. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Wright
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - D Wright
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - P Chaveeva
- Fetal Medicine Unit, Shterev Hospital, Sofia, Bulgaria
| | - F S Molina
- Fetal Medicine Unit, Hospital Universitario San Cecilio, Granada, Spain
| | - R Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - A Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - O B Petersen
- Center for Fetal Medicine, Pregnancy and Ultrasound, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S E Kristensen
- Center for Fetal Medicine, Pregnancy and Ultrasound, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Abraham M, Ali N, Shivani Garapati SSL, Pandey P, Nair S, Swarna S, Chowdary DV, Aladeniyi F, Daing A, Abbas K. Delivery Methods in Twin Gestations: Evaluating Outcomes, Risk Factors, and the Paradigm Shift Towards Elective Cesarean Deliveries. Cureus 2023; 15:e46514. [PMID: 37927678 PMCID: PMC10625172 DOI: 10.7759/cureus.46514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
During the past decade, there has been a consistent rise in the number of twin births and the number of overall cesarean sections (CS) worldwide. This is owed to a variety of social, economic, educational, and scientific factors. More women are opting to advance their professional careers and gain financial stability before having children. Although this approach is understandable, a new set of challenges are faced as a result, the most important of which has been infertility due to advanced maternal age and the subsequent use of assisted fertility treatments, which have been noted to cause multiple gestations. Twin gestations are considered high-risk pregnancies and are associated with an amplitude of potential complications. Arguably, the biggest decision an obstetrician must make when dealing with this population is choosing the most appropriate mode of delivery. Given the lack of clear guidance pertaining to twin deliveries, CSs may often be perceived as safer and are often preferred over vaginal deliveries (VD). In this narrative review, we aimed to compare the outcomes of different delivery methods (CS versus VD) to investigate whether CS is truly superior to VD. Data were collected from the past two decades and analyzed based on the neonatal and maternal outcomes for each delivery mode. Our results indicate that planned VD is just as safe as CS, if not superior, in most uncomplicated twin pregnancies. Thus, it is best to advise and encourage healthy expecting twin carriers to undergo VD and explore any hesitations or fears they might have. Furthermore, a detailed guideline regarding twin delivery is essential to establish and better navigate twin deliveries, lower the rate of unnecessary CSs, and reduce overall twin gestation morbidity and mortality.
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Affiliation(s)
- Merin Abraham
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Noor Ali
- Obstetrics and Gynecology, Thumbay University Hospital, Ajman, ARE
- General Practice, Dubai Medical College, Dubai, ARE
| | | | - Priyanka Pandey
- Anatomical Sciences, Hind Institute of Medical Sciences, Sitapur, IND
| | - Shreya Nair
- Medicine, Krishna Institute of Medical Sciences, Karad, IND
| | - Sindhu Swarna
- Medicine, Kasturba Medical College, Mangalore, Mangalore, IND
| | | | | | | | - Kiran Abbas
- Community Health Sciences, Aga Khan University, Karachi, PAK
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