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Tomruk C, Şirin Tomruk C, Denizlioğlu B, Olukman M, Ercan G, Duman S, Köse T, Çetin Uyanıkgil EÖ, Uyanıkgil Y, Uysal A. Effects of apelin on neonatal brain neurogenesis in L-NAME-induced maternal preeclampsia. Sci Rep 2024; 14:19347. [PMID: 39164321 DOI: 10.1038/s41598-024-69326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 08/02/2024] [Indexed: 08/22/2024] Open
Abstract
The aim of this study was to investigate the possible protective effects of apelin, which is known to have antioxidant and anti-inflammatory effects, on changes in neurogenesis in newborns of pregnant rats with L-NAME-induced preeclampsia. Wistar albino female rats were divided into four experimental groups: Control, Apelin, Preeclampsia and Preeclampsia + Apelin. Blood pressure was measured on the 5th, 11th and 17th days of gestation, urine protein was analyzed from urine samples collected for 24 h on the 6th, 12th and 18th days and serum creatinine was analyzed from serum samples. Maternal kidney and placenta tissues were obtained to establish the preeclampsia model, and neonatal brain tissues including the cortex, hippocampus and cerebellum regions were obtained to investigate neurogenesis and examined by histological and immunohistochemical methods. The number of newborns, body weight and brain weight of the newborns were measured. eNOS, IL-10, nNOS and NO levels in the brain analyzed via ELISA. Mean arterial pressure, urine protein and serum creatinine increased in the preeclampsia. Newborn weight decreased in the Preeclampsia group, the values in the Preeclampsia + Apelin group were closer to the Control and Apelin groups. In the Preeclampsia group, edema and dilatation in the proximal and distal tubules of kidneys, perivillous fibrin deposition and increase in syncytial nodules of placenta were observed. VEGF immunoreactivity decreased and iNOS immunoreactivity increased in both kidney and placenta. In neonatal brain tissue examinations, cytotoxic edema accompanied by thinning of cortex, delayed migration and lower cell counts in the hippocampus, and increase in intercellular spaces and EGL thickening in the cerebellum were observed in the preeclampsia. Expression of NeuN, GFAP, MBP, IL-10, eNOS, nNOS and NO levels decreased, whereas expression of Iba-1 increased in the preeclampsia. In the Preeclampsia + Apelin group, these findings were similar to the Control and Apelin groups. Apelin administration was found to be beneficial for preventing the adverse consequences of preeclampsia, but further experimental and clinical studies are needed to better understand these effects.
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Affiliation(s)
- Canberk Tomruk
- Department of Histology and Embryology, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
- Histology and Embryology, Samsun Training and Research Hospital, İlkadim, Samsun, Türkiye
| | - Cansın Şirin Tomruk
- Department of Histology and Embryology, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
| | - Burcu Denizlioğlu
- Department of Medical Biochemistry, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
- Emergency Medicine, Aydın State Hospital, Efeler, Aydın, Türkiye
| | - Murat Olukman
- Department of Medical Pharmacology, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
| | - Gülinnaz Ercan
- Department of Medical Biochemistry, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
| | - Soner Duman
- Department of Internal Medicine, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
| | - Timur Köse
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
| | - Emel Öykü Çetin Uyanıkgil
- Department of Pharmaceutical Technology, Department of Biopharmaceutics and Pharmacokinetics, Faculty of Pharmacy, Ege University, Bornova, İzmir, Türkiye
| | - Yiğit Uyanıkgil
- Department of Histology and Embryology, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye.
| | - Ayşegül Uysal
- Department of Histology and Embryology, Faculty of Medicine, Ege University, Bornova, İzmir, Türkiye
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Wat JM, Baczyk D, Kingdom JC. The antithrombin binding regions of heparin mediate fetal growth and reduced placental damage in the RUPP model of preeclampsia†. Biol Reprod 2021; 102:1102-1110. [PMID: 31950133 PMCID: PMC7186778 DOI: 10.1093/biolre/ioaa006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/08/2019] [Accepted: 01/14/2020] [Indexed: 12/15/2022] Open
Abstract
Preeclampsia is a serious hypertensive disorder of pregnancy, which is only cured with delivery of the placenta, thereby commonly necessitating preterm birth of the fetus. Low-molecular-weight heparin (LMWH) has demonstrated potential to reduce the incidence of preeclampsia in high-risk pregnant women, although the underlying mechanism by which LMWH protects against preeclampsia is unknown. Given the complex structure and biologic actions of heparin, we tested the hypothesis that heparin can mediate preeclampsia prevention via nonanticoagulant pathways. We compared the effects of a nonanticoagulant, glycol-split LMWH (gsHep)—rendered nonanticoagulant through disruption of the antithrombin binding regions—with the LMWH dalteparin in the rat reduced uterine perfusion pressure (RUPP) surgical model of preeclampsia. Although RUPP animals exhibit significantly elevated blood pressure and reduced plasma levels of placental growth factor (PGF) compared to sham, neither dalteparin nor gsHep treatment significantly impacted these parameters. However, the observed positive correlation between PGF levels and number of viable fetuses in RUPP-induced animals suggests that reduced PGF levels were predominately due to placental loss. Daily subcutaneous injections of low-dose dalteparin but not gsHep significantly restored fetal growth that was impaired by RUPP surgery. Placentas from RUPP animals exhibited an abnormal labyrinth structure, characterized by expanded sinusoidal blood spaces, relative to sham-operated animals. Morphometric analysis demonstrated that dalteparin but not gsHep treatment normalized development of the labyrinth in RUPP-exposed conceptuses. These data suggest that the antithrombin-binding regions of LMWH are required to confer its protective effects on fetal growth and placental development.
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Affiliation(s)
- Jovian M Wat
- Research Centre for Women's and Infant's Health, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Dora Baczyk
- Research Centre for Women's and Infant's Health, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - John C Kingdom
- Research Centre for Women's and Infant's Health, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
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Gatford KL, Andraweera PH, Roberts CT, Care AS. Animal Models of Preeclampsia: Causes, Consequences, and Interventions. Hypertension 2020; 75:1363-1381. [PMID: 32248704 DOI: 10.1161/hypertensionaha.119.14598] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Preeclampsia is a common pregnancy complication, affecting 2% to 8% of pregnancies worldwide, and is an important cause of both maternal and fetal morbidity and mortality. Importantly, although aspirin and calcium are able to prevent preeclampsia in some women, there is no cure apart from delivery of the placenta and fetus, often necessitating iatrogenic preterm birth. Preclinical models of preeclampsia are widely used to investigate the causes and consequences of preeclampsia and to evaluate safety and efficacy of potential preventative and therapeutic interventions. In this review, we provide a summary of the published preclinical models of preeclampsia that meet human diagnostic criteria, including the development of maternal hypertension, together with new-onset proteinuria, maternal organ dysfunction, and uteroplacental dysfunction. We then discuss evidence from preclinical models for multiple causal factors of preeclampsia, including those implicated in early-onset and late-onset preeclampsia. Next, we discuss the impact of exposure to a preeclampsia-like environment for later maternal and progeny health. The presence of long-term impairment, particularly cardiovascular outcomes, in mothers and progeny after an experimentally induced preeclampsia-like pregnancy, implies that later onset or reduced severity of preeclampsia will improve later maternal and progeny health. Finally, we summarize published intervention studies in preclinical models and identify gaps in knowledge that we consider should be targets for future research.
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Affiliation(s)
- Kathryn L Gatford
- From the Adelaide Medical School and Robinson Research Institute, The University of Adelaide, Australia
| | - Prabha H Andraweera
- From the Adelaide Medical School and Robinson Research Institute, The University of Adelaide, Australia
| | - Claire T Roberts
- From the Adelaide Medical School and Robinson Research Institute, The University of Adelaide, Australia
| | - Alison S Care
- From the Adelaide Medical School and Robinson Research Institute, The University of Adelaide, Australia
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McLaughlin K, Nadeem L, Wat J, Baczyk D, Lye SJ, Kingdom JC. Low molecular weight heparin promotes transcription and release of placental growth factor from endothelial cells. Am J Physiol Heart Circ Physiol 2020; 318:H1008-H1017. [PMID: 32196359 DOI: 10.1152/ajpheart.00109.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Circulating levels of placental growth factor (PlGF) are significantly reduced in women who develop preeclampsia. Low molecular weight heparin (LMWH) has been shown to acutely elevate circulating PlGF levels in pregnant women at increased risk of preeclampsia. The objective of the current investigation was to determine the mechanisms by which LMWH mediates the extracellular release of PlGF from endothelial cells. Cultured human aortic endothelial cells (HAECs) and human umbilical vein endothelial cells (HUVECs) were exposed to LMWH; PlGF transcription, translation, mobilization, and secretion were then assessed. LMWH significantly increased the release of PlGF from both HAECs and HUVECs. LMWH treatment promoted a significant increase of PlGF-1 mRNA expression in HAECs, accompanied by the intracellular transport and release of PlGF into the conditioned media. LMWH-mediated release of PlGF from HAECs was not directly mediated by extracellular mobilization, synthesis, or stability of PlGF mRNA/protein. LMWH exposure promotes the release of PlGF from endothelial cells through the upregulation of PlGF-1 mRNA expression. Stimulation of circulating PlGF levels by LMWH may be an important mechanism by which LMWH could reduce the risk of preeclampsia or minimize disease severity.NEW & NOTEWORTHY There are few therapeutic options available for the prevention of preeclampsia, a serious hypertensive disorder of pregnancy. Women who subsequently develop preeclampsia exhibit significantly reduced circulating levels of the proangiogenic placental growth factor protein. Low molecular weight heparin (LMWH) has previously been investigated as a preventative therapy against the development of preeclampsia; however, its mechanism of action is not known. The current study determined that LMWH promotes the transcription and release of placental growth factor protein from endothelial cells, providing a mechanistic basis by which LMWH could reduce the risk of preeclampsia or minimize disease severity.
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Affiliation(s)
- Kelsey McLaughlin
- Division of Cardiology, Department of Medicine, Sinai Health System, University of Toronto, Toronto, Canada.,The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Lubna Nadeem
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Jovian Wat
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Dora Baczyk
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Stephen J Lye
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
| | - John C Kingdom
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System, University of Toronto, Toronto, Canada
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Xu X, Pan JR, Zhang YZ. CoQ10 alleviate preeclampsia symptoms by enhancing the function of mitochondria in the placenta of pregnant rats with preeclampsia. Hypertens Pregnancy 2019; 38:217-222. [PMID: 31366258 DOI: 10.1080/10641955.2019.1649420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: To assess whether supplementation with Coenzyme Q10 (CoQ10) during pregnancy alleviate preeclampsia symptoms and the underlying mechanism in the rats with preeclampsia. Methods: Forty-five pregnant Wistar rats were equally divided into three groups randomly and received subcutaneous saline injection (control group, n = 15) or 200 mg/kg L-NAME injection to induce preeclampsia symptoms (PE group, n = 30). The PE rats were treated by distilled water (PE+DW group, n = 15) and CoQ10 (PE+CoQ10 group, n = 15) on day 15 to 21 of gestation randomly. Physiological characteristics such as urine volume, total urine protein, blood pressure, number and weight of pups were recorded. Fluorescent dye was used to detect mitochondrial membrane potential in placenta. Real-time fluorescent quantitative PCR was used to detect the expression of mitochondrial DNA(mtDNA) in placenta. Results: There was no statistic difference among all the three groups on day 10 of gestation in SBP and 24-h proteinuria (P > 0.05). Whereas, SBP and 24-h proteinuria were significantly higher in PE group than control group on day 15 and 21 of gestation (P < 0.05). SBP and 24-h proteinuria were significantly lower in PE+CoQ10 group than PE+DW group on day 21 of gestation (P < 0.05). The number and weight of normal pups were significantly lower in PE group than the control group (P < 0.05), which were most notably in distilled water group, and the number and weight of normal pups were markedly bigger in PE+CoQ10 group rats compared to PE+DW (P < 0.05). The PE+CoQ10 group showed a significantly higher in level of mitochondrial membrane potential than PE+DW group. The expression of mtDNA was significantly higher in the PE+CoQ10 group compared with PE+DW group (P < 0.05). Conclusions: CoQ10 can alleviate preeclampsia symptoms and enhance the function of mitochondria in the placenta.
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Affiliation(s)
- Xia Xu
- Department of Obstetrics and Gynecology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University , Fuzhou , China
| | - Jian-Rong Pan
- Department of Obstetrics and Gynecology, Fujian Medical University Union Hospital , Fuzhou , China
| | - Yan-Zhen Zhang
- Department of Obstetrics and Gynecology, Fujian Medical University Union Hospital , Fuzhou , China
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Tian M, Zhang Y, Liu Z, Sun G, Mor G, Liao A. The PD-1/PD-L1 inhibitory pathway is altered in pre-eclampsia and regulates T cell responses in pre-eclamptic rats. Sci Rep 2016; 6:27683. [PMID: 27277012 PMCID: PMC4899740 DOI: 10.1038/srep27683] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/24/2016] [Indexed: 12/20/2022] Open
Abstract
The programmed cell death-1(PD-1)/PD-ligand 1 (PD-L1) pathway is critical to immune homeostasis by promoting regulatory T (Treg) development and inhibiting effector T (such as Th17) cell responses. However, the association between the PD-1/PD-L1 pathway and the Treg/Th17 imbalance has not been fully investigated in pre-eclampsia (PE). In this study, we observed an inverse correlation between the percentages of Treg and Th17 cells, and the expression of PD-1 and PD-L1 on the two subsets also changed in PE compared with normal pregnancy. We further explored their relationship in vivo using the L-NG-Nitroarginine Methyl Ester (L-NAME) induced PE-like rat models, also characterized by Treg/Th17 imbalance. Administration of PD-L1-Fc protein provides a protective effects on the pre-eclamptic models, both to the mother and the fetuses, by reversing Treg/Th17 imbalance through inhibiting PI3K/AKT/m-TOR signaling and enhancing PTEN expression. In addition, we also observed a protective effect of PD-L1-Fc on the placenta by reversing placental damages. These results suggested that altered PD-1/PD-L1 pathway contributed to Treg/Th17 imbalance in PE. Treatment with PD-L1-Fc posed protective effects on pre-eclamptic models, indicating that the use of PD-L1-Fc might be a potential therapeutic target in PE treatment.
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Affiliation(s)
- Mei Tian
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Yonghong Zhang
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Zhaozhao Liu
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Guoqiang Sun
- Department of Obstetrics and Gynecology, Maternal and Child Health Hospital of Hubei province, Wuhan, P.R. China
| | - Gil Mor
- Department of Obstetrics, Gynecology &Reproductive Sciences, Division of Reproductive Sciences, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Aihua Liao
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
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Kell DB, Kenny LC. A Dormant Microbial Component in the Development of Preeclampsia. Front Med (Lausanne) 2016; 3:60. [PMID: 27965958 PMCID: PMC5126693 DOI: 10.3389/fmed.2016.00060] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022] Open
Abstract
Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.
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Affiliation(s)
- Douglas B. Kell
- School of Chemistry, The University of Manchester, Manchester, UK
- The Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK
- Centre for Synthetic Biology of Fine and Speciality Chemicals, The University of Manchester, Manchester, UK
- *Correspondence: Douglas B. Kell,
| | - Louise C. Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynecology, University College Cork, Cork, Ireland
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McLaughlin K, Drewlo S, Parker JD, Kingdom JC. Current Theories on the Prevention of Severe Preeclampsia With Low-Molecular Weight Heparin. Hypertension 2015; 66:1098-103. [DOI: 10.1161/hypertensionaha.115.05770] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/02/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Kelsey McLaughlin
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
| | - Sascha Drewlo
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
| | - John D. Parker
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
| | - John C.P. Kingdom
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
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