1
|
Liu Y, Zhang Q, Zhang F, Liu M, Zhang J, Cao X, Yin W. Is three-dimensional ultrasonography a valuable diagnostic tool for patients with ovarian cancer? Systematic review and meta-analysis. Front Oncol 2024; 14:1404426. [PMID: 39040447 PMCID: PMC11260635 DOI: 10.3389/fonc.2024.1404426] [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: 03/21/2024] [Accepted: 06/18/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction This paper was to assess the diagnostic performance and clinical value of three-dimensional ultrasonography (3DUS), three-dimensional ultrasonography power Doppler (3DPD), and 3DUS combined with 3DPD in ovarian cancer (OC). Methods The study was registered with PROSPERO (CRD 42023405765). PubMed and Web of Science were searched from inception to 25 January 2022, and reference lists of potentially eligible studies were also manually searched. Patient and study characteristics were extracted by two independent reviewers. Any discrepancies were addressed through discussion. The sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR, respectively), and the area under the receiver operating characteristic curve (AUC) were pooled separately. Results We retrieved 2,566 studies, of which 18 were finally enrolled, with 2,548 cases. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DUS were 0.89 (95% CI: 0.85-0.93), 0.93 (95% CI: 0.88-0.96), 13.1 (95% CI: 7.3-23.4), 0.11 (95% CI: 0.08-0.16), and 0.90 (95% CI: 0.87-0.93), respectively. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DPD were 0.90 (95% CI: 0.80-0.95), 0.85 (95% CI: 0.71-0.92), 5.8 (95% CI: 3.0-11.2), 0.12 (95% CI: 0.06-0.24), and 0.94 (95% CI: 0.91-0.96), respectively. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DUS combined with 3DPD were 0.99 (95% CI: 0.73-1.00), 0.95 (95% CI: 0.85-0.99), 21.9 (95% CI: 6.1-78.9), 0.01 (95% CI: 0.00-0.37), and 0.99 (95% CI: 0.98-1.00), respectively. Conclusions 3DUS, 3DPD, and 3DUS combined with 3DPD are promising diagnostic tools for OC, alongside elevated sensitivity and specificity. However, the combination of 3DUS and 3DPD techniques has higher diagnostic efficiency. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD 42023405765.
Collapse
Affiliation(s)
- Yuan Liu
- School of Medical Imaging, Binzhou Medical University, Yantai, Shandong, China
| | - Qingdong Zhang
- Department of Ultrasonography, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Fang Zhang
- Department of Ultrasonography, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
| | - Meiyan Liu
- Department of Ultrasonography, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
| | - Jun Zhang
- Department of Scientific Research and Teaching, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
| | - Xiaoli Cao
- Department of Ultrasonography, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Weihong Yin
- Department of Ultrasonography, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
| |
Collapse
|
2
|
Guerriero S, Pascual M, Ajossa S, Neri M, Pilloni M, Graupera B, Rodriguez I, Alcazar JL. The Reproducibility of Ultrasonographic Findings of Rectosigmoid Endometriosis Among Examiners With Different Level of Expertise. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:403-408. [PMID: 33837976 PMCID: PMC9290985 DOI: 10.1002/jum.15717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/15/2021] [Accepted: 03/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To analyze the reproducibility of ultrasonographic (US) findings of rectosigmoid endometriosis among examiners with different level of expertise using stored three-dimensional (3D) volumes of the posterior compartment of the pelvis as a part of SANABA (Sardinia-Navarra-Barcelona) collaborative study. MATERIALS AND METHODS Six examiners in 3 academic Department of Obstetrics and Gynecology, with different levels of experience and blinded to each other, evaluated 60 stored 3D volumes from the posterior compartment of the pelvis and looked for the presence or absence of features of rectosigmoid endometriotic lesions defined as an irregular hypoechoic nodule with or without hypoechoic foci at the level of the muscularis propria of the anterior wall rectum sigma. Multiplanar view and virtual navigation were used. All examiners had to assess the 3D volume of posterior compartment of the pelvis and classify it as present or absent disease. To analyze intra-observer and the inter-observer agreements, each examiner performed the assessment twice with a 2-week interval between the first and second assessments. Reproducibility was assessed by calculating the weighted Kappa index. RESULTS Intra-observer reproducibility was moderate to very good for all observers (Kappa index ranging from 0.49 to 0.96) associated with a good diagnostic accuracy of each reader. Inter-observer reproducibility was fair to very good (Kappa index range: 0.21-0.87). CONCLUSIONS The typical US sign of rectosigmoid endometriosis is reasonably recognizable to observers with different level of expertise when assessed in stored 3D volumes.
Collapse
Affiliation(s)
- Stefano Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico‐GinecologicaPoliclinico Universitario Duilio Casula, University of CagliariCagliari
| | - MariaAngela Pascual
- Department of Obstetrics, Gynecology, and ReproductionHospital Universitari DexeusBarcelonaSpain
| | - Silvia Ajossa
- Department of Obstetrics and GynecologyUniversity of Cagliari, Policlinico Universitario Duilio CasulaCagliariItaly
| | - Manuela Neri
- Department of Obstetrics and GynecologyUniversity of Cagliari, Policlinico Universitario Duilio CasulaCagliariItaly
| | - Monica Pilloni
- Department of Obstetrics and GynecologyUniversity of Cagliari, Policlinico Universitario Duilio CasulaCagliariItaly
| | - Betlem Graupera
- Department of Obstetrics, Gynecology, and ReproductionHospital Universitari DexeusBarcelonaSpain
| | - Ignacio Rodriguez
- Departamento de Obstetricia, Ginecología y ReproducciónHospital Universitario Quirón Dexeus, Unidad Epidemiología y EstadísticaBarcelonaSpain
| | - Juan Luis Alcazar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of MedicineUniversity of NavarraPamplonaSpain
| |
Collapse
|
3
|
Guerriero S, Saba L, Alcazar JL, Pascual MA, Ajossa S, Perniciano M, Piras A, Sedda F, Peddes C, Fabbri P, Pilla F, Zajicek M, Giuseppina P, Melis GB. Past, present and future ultrasonographic techniques for analyzing ovarian masses. ACTA ACUST UNITED AC 2016; 11:369-83. [PMID: 26102474 DOI: 10.2217/whe.15.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.
Collapse
Affiliation(s)
- Stefano Guerriero
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Luca Saba
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Juan Luis Alcazar
- Department of Obstetrics & Gynecology, University of Navarra, Pamplona, Spain
| | | | - Silvia Ajossa
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Maura Perniciano
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Alba Piras
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Federica Sedda
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Cristina Peddes
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Paola Fabbri
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Federica Pilla
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Michal Zajicek
- Department of Obstetrics & Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Parodo Giuseppina
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | | |
Collapse
|
4
|
Dueholm M, Christensen JW, Rydbjerg S, Hansen ES, Ørtoft G. Two- and three-dimensional transvaginal ultrasound with power Doppler angiography and gel infusion sonography for diagnosis of endometrial malignancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:734-743. [PMID: 24862861 DOI: 10.1002/uog.13421] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 05/14/2014] [Accepted: 05/16/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate the diagnostic efficiency of two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography, power Doppler angiography (PDA) and gel infusion sonography (GIS) at offline analysis for recognition of malignant endometrium compared with real-time evaluation during scanning, and to determine optimal image parameters at 3D analysis. METHODS One hundred and sixty-nine consecutive women with postmenopausal bleeding and endometrial thickness ≥ 5 mm underwent systematic evaluation of endometrial pattern on 2D imaging, and 2D videoclips and 3D volumes were later analyzed offline. Histopathological findings at hysteroscopy or hysterectomy were used as the reference standard. The efficiency of the different techniques for diagnosis of malignancy was calculated and compared. 3D image parameters, endometrial volume and 3D vascular indices were assessed. Optimal 3D image parameters were transformed by logistic regression into a risk of endometrial cancer (REC) score, including scores for body mass index, endometrial thickness and endometrial morphology at gray-scale and PDA and GIS. RESULTS Offline 2D and 3D analysis were equivalent, but had lower diagnostic performance compared with real-time evaluation during scanning. Their diagnostic performance was not markedly improved by the addition of PDA or GIS, but their efficiency was comparable with that of real-time 2D-GIS in offline examinations of good image quality. On logistic regression, the 3D parameters from the REC-score system had the highest diagnostic efficiency. The area under the curve of the REC-score system at 3D-GIS (0.89) was not improved by inclusion of vascular indices or endometrial volume calculations. CONCLUSION Real-time evaluation during scanning is most efficient, but offline 2D and 3D analysis is useful for prediction of endometrial cancer when good image quality can be obtained. The diagnostic efficiency at 3D analysis may be improved by use of REC-scoring systems, without the need for calculation of vascular indices or endometrial volume. The optimal imaging modality appears to be real-time 2D-GIS.
Collapse
Affiliation(s)
- M Dueholm
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - J W Christensen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - S Rydbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - E S Hansen
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - G Ørtoft
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
5
|
Turkgeldi E, Urman B, Ata B. Role of Three-Dimensional Ultrasound in Gynecology. J Obstet Gynaecol India 2014; 65:146-54. [PMID: 26085733 DOI: 10.1007/s13224-014-0635-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/07/2014] [Indexed: 01/17/2023] Open
Abstract
Three-dimensional ultrasound (3D USG) is a fast-evolving imaging technique that holds a great potential for use in gynecology. Its sensitivity and specificity is reported to be close to 100 % for diagnosing congenital uterine anomalies, comparable with those of magnetic resonance imaging (MRI) and laparoscopy. With 3D USG, a coronal view of the uterus can be obtained, clearly outlining the external contour of the uterus and providing accurate information about the shape of the cavity. Although 3D USG may not perform well in thin endometria, combining it with saline infusion sonography (SIS) overcomes this problem. Research shows that 3D USG is more sensitive and specific than two-dimensional ultrasound (2D USG) in defining and mapping uterine lesions, such as fibroids, adenomyosis, and intrauterine synechia. In cases of suspected malignancy, 3D USG is mainly used in the initial evaluation of patients. Measuring various indices and mapping vascular architecture with 3D power Doppler have been proposed for evaluating adnexal masses. Although some studies raised hope, no consensus is reached about its use, success, and limitations. In urogynecology, translabial 3D USG is proved to be a valuable tool, as it provides instant access to the axial plane, which clearly depicts the relationship of the vagina, urethra, rectum, and the muscular pelvic floor. Studies report no significant differences between translabial 3D USG and MRI measurements for evaluation of the pelvic floor. In conclusion, adding 3D USG to routine gynecological workup can be beneficial for clinicians, as it provides fast and accurate results in a relatively cost-effective setting.
Collapse
Affiliation(s)
- Engin Turkgeldi
- Department of Obstetrics and Gynecology, Amerikan Hospital, Koc University School of Medicine, Rumelifeneri Yolu Sarıyer, 34450 Istanbul, Turkey
| | - Bulent Urman
- Department of Obstetrics and Gynecology, Amerikan Hospital, Koc University School of Medicine, Rumelifeneri Yolu Sarıyer, 34450 Istanbul, Turkey
| | - Baris Ata
- Department of Obstetrics and Gynecology, Amerikan Hospital, Koc University School of Medicine, Rumelifeneri Yolu Sarıyer, 34450 Istanbul, Turkey
| |
Collapse
|
6
|
Guerriero S, Saba L, Ajossa S, Peddes C, Angiolucci M, Perniciano M, Melis GB, Alcazar JL. Three-dimensional ultrasonography in the diagnosis of deep endometriosis. Hum Reprod 2014; 29:1189-98. [DOI: 10.1093/humrep/deu054] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
7
|
Alcázar JL, Aubá M, Ruiz-Zambrana Á, Olartecoechea B, Diaz D, Hidalgo JJ, Pineda L, Utrilla-Layna J. Ultrasound assessment in adnexal masses: an update. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.12.49] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
8
|
Guerriero S, Saba L, Ajossa S, Peddes C, Sedda F, Piras A, Olartecoechea B, Aubá M, Alcázar JL. Assessing the reproducibility of the IOTA simple ultrasound rules for classifying adnexal masses as benign or malignant using stored 3D volumes. Eur J Obstet Gynecol Reprod Biol 2013; 171:157-60. [DOI: 10.1016/j.ejogrb.2013.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 06/17/2013] [Accepted: 08/14/2013] [Indexed: 11/30/2022]
|
9
|
Armstrong L, Fleischer A, Andreotti R. Three-dimensional volumetric sonography in gynecology: an overview of clinical applications. Radiol Clin North Am 2013; 51:1035-47. [PMID: 24210443 DOI: 10.1016/j.rcl.2013.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Three-dimensional (3D) sonography can significantly improve on the diagnostic ability of two-dimensional sonography of the pelvic organs. 3D sonography has become a problem-solving technique in the evaluation of a variety of gynecologic disorders involving the uterus, adnexa, and pelvic floor. It allows an accurate depiction of the uterine cavity and outline of the uterus in the coronal plane. 3D sonography is less expensive than other modalities, is convenient, and does not have the risk of radiation or potential nephrotoxicity from contrast that other imaging modalities have. It is a cost-effective tool to assess the pelvic organs.
Collapse
Affiliation(s)
- Linda Armstrong
- Department of Radiology, Vanderbilt University Medical Center, 1161 Medical Center Drive, Medical Center North, Suite CCC-1121, Nashville, TN 37232, USA
| | | | | |
Collapse
|
10
|
Alcázar JL, Díaz L, Flórez P, Guerriero S, Jurado M. Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:218-223. [PMID: 23420783 DOI: 10.1002/uog.12440] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 12/28/2012] [Accepted: 01/04/2013] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To assess the feasibility of a specific training program for ultrasound diagnosis of adnexal masses. METHODS A 2-month intensive training program was developed. The program protocol consisted of a 1-day intensive theoretical course focused on clinical and sonographic issues related to adnexal masses and ovarian cancer, followed by a 4-week real-time ultrasound training program in a tertiary center (25-30 adnexal masses evaluated per month) and a final 4-week period for offline assessment of three-dimensional (3D) volumes from adnexal masses. In this final period, each trainee evaluated five sets of 100 3D volumes. 3D volumes contained gray-scale and power Doppler information, and the trainee was provided with clinical data for each case (patient age, menopausal status and reported symptoms). 3D volumes were obtained from surgically removed masses that had undergone histological diagnosis or from masses that had been followed up until resolution. After assessment of each set, the trainee's diagnostic performance was calculated (sensitivity and specificity) and each incorrectly classified mass was evaluated with the trainer. The objective was to achieve a sensitivity of > 95% and a specificity of > 90%. Learning curve cumulative summation (LC-CUSUM) graphs were plotted to assess the learning curve for the trainees. RESULTS One trainer and two trainees with little experience in gynecological ultrasound (one gynecologist and one radiologist) participated in this study. LC-CUSUM graphs showed that competence was achieved after 170 or 185 examinations. The objectives for diagnostic performance were achieved after assessment of the second set of 3D volumes (200 cases) for each trainee. CONCLUSIONS The proposed training program appears to be feasible. High diagnostic performance can be achieved after analysis of 200 cases and maintained thereafter.
Collapse
Affiliation(s)
- J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.
| | | | | | | | | |
Collapse
|
11
|
Sladkevicius P, Valentin L. Intra- and interobserver agreement when describing adnexal masses using the International Ovarian Tumor Analysis terms and definitions: a study on three-dimensional ultrasound volumes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:318-327. [PMID: 22915506 DOI: 10.1002/uog.12289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/01/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To estimate intraobserver repeatability and interobserver agreement in: (1) describing adnexal masses using the International Ovarian Tumor Analysis (IOTA) terms and definitions; (2) the risk of malignancy calculated using IOTA logistic regression model 1 (LR1) and model 2 (LR2); and (3) the diagnosis made on the basis of subjective assessment of ultrasound images. METHODS One-hundred and three adnexal masses were examined by transvaginal gray-scale and power Doppler ultrasound. Three-dimensional ultrasound volumes of the mass were saved. After 12-18 months the volumes were analyzed twice, 1-6 months apart, by each of two independent experienced sonologists who used the IOTA terms and definitions to describe the masses. The risk of malignancy was calculated using LR1 and LR2. The sonologists also classified the masses as benign or malignant using subjective assessment. RESULTS Eighty-four masses were benign, eight were borderline and 11 were invasively malignant. There was substantial variability within and between observers in the results of measurements included in LR1 and LR2 and some variability also when assessing categorical variables included in the models (agreement = 51-100% and kappa = 0.42-1.00). This resulted in substantial variability in the calculated risk of malignancy, the limits of agreement indicating that the calculated risk of malignancy could vary by a factor of 5-20 within and between observers. The reliability of the calculated risk of malignancy was moderate (LR1) or poor (LR2) when the calculated risk of malignancy was > 10% (intraclass correlation coefficients varied from 0.21 to 0.73). Interobserver agreement when classifying tumors as benign or malignant using the predetermined risk of malignancy cut-off of 10% was fair to good (agreement = 85% and kappa = 0.61 for LR1; agreement = 81% and kappa = 0.52 for LR2). Intra- and interobserver agreements for subjective assessment were 96%, 96% and 96% with kappa values of 0.89, 0.87 and 0.88, respectively. CONCLUSIONS Intra- and interobserver agreement in classifying tumors as benign or malignant using the risk of malignancy cut-off of 10% for LR1 and LR2 was fair or good, whilst the reproducibility of subjective assessment was excellent. The reliability of calculated risks > 10% was poor, and calculated risk > 10% cannot be used to discriminate between individuals at different risk. These results cannot be extrapolated to real-time ultrasound examinations.
Collapse
Affiliation(s)
- P Sladkevicius
- Department of Obstetrics and Gynecology, Skåne University Hospital Malmö, Lund University, Malmö, Sweden.
| | | |
Collapse
|