1
|
Soundararajan R, Khan T, Dadelszen PV. Pre-eclampsia challenges and care in low and middle-income countries: Understanding diagnosis, management, and health impacts in remote and developing regions. Best Pract Res Clin Obstet Gynaecol 2024:102525. [PMID: 38964990 DOI: 10.1016/j.bpobgyn.2024.102525] [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: 11/21/2023] [Revised: 01/20/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024]
Abstract
As an example of a low- and middle-income country (LMIC), India ranks pre-eclampsia among the top three causes of maternal mortality, following haemorrhage and infections. It is one of the primary concerns for maternal and perinatal health in LMICs. Many LMICs lack clear consensus and guidelines for the prevention, diagnosis, and management of hypertensive disorders in pregnancy, including pre-eclampsia. The International Society for the Study of Hypertension in Pregnancy 2021 guidelines address LMIC applications, offering customisable solutions. Atypical presentations of pre-eclampsia contribute to diagnostic delays, resulting in additional adverse maternal and perinatal outcomes. Implementing management strategies faces challenges in both urban and rural settings. Adapting global research involving local populations is imperative, with the potential for cost-effective adoption of international guidelines. Prevention, early diagnosis, and education dissemination are essential, involving healthcare providers and advocacy initiatives. Encouraging government investment in pre-eclampsia management as a public health initiative is important. This article explores socio-economic, cultural, and legislative factors influencing the management of pre-eclampsia in LMICs, addressing emerging challenges and potential partnerships for healthcare provision.
Collapse
Affiliation(s)
- Revathi Soundararajan
- Chief Consultant [Maternal Fetal Medicine], Managing Director, Mirror Health, Secretary, SMFM (I), Co-Chair, PEN (I), Bengaluru, India.
| | - Tamkin Khan
- Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India.
| | | |
Collapse
|
2
|
Niles KM, Jain V, Chan C, Choo S, Dore S, Kiely DJ, Lim K, Roy Lacroix ME, Sharma S, Waterman E. Guideline No. 441: Antenatal Fetal Health Surveillance. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:665-677.e3. [PMID: 37661122 DOI: 10.1016/j.jogc.2023.05.020] [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] [Indexed: 09/05/2023]
Abstract
OBJECTIVE To summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality. TARGET POPULATION Pregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation. OPTIONS To use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation. OUTCOMES Early identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery. BENEFITS, HARMS, AND COSTS Antenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm. EVIDENCE Medline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE All health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists. SUMMARY STATEMENTS RECOMMENDATIONS.
Collapse
|
3
|
Niles KM, Jain V, Chan C, Choo S, Dore S, Kiely DJ, Lim K, Roy-Lacroix MÈ, Sharma S, Waterman E. Directive clinique n o 441 : Surveillance prénatale du bien-être fœtal. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:678-693.e3. [PMID: 37661123 DOI: 10.1016/j.jogc.2023.05.021] [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] [Indexed: 09/05/2023]
Abstract
OBJECTIF Résumer les données probantes actuelles et formuler des recommandations pour la surveillance prénatale du bien-être fœtal afin de détecter les facteurs de risque périnatal et toute potentielle décompensation fœtale et de permettre une intervention rapide en prévention de la morbidité et la mortalité périnatales. POPULATION CIBLE Personnes enceintes avec ou sans facteurs maternels, fœtaux ou gravidiques associés à des risques périnataux et à la décompensation fœtale. OPTIONS Utiliser des examens prénataux par technologie de base et/ou avancée en fonction des facteurs de risque de décompensation fœtale. RéSULTATS: La reconnaissance précoce de toute décompensation fœtale potentielle permet d'intervenir de façon à favoriser l'adaptation fœtale pour maintenir le bien-être ou à accélérer l'accouchement. BéNéFICES, RISQUES ET COûTS: Chez les personnes enceintes ayant des facteurs de risque périnatal confirmés, la surveillance du bien-être fœtal contribue à réduire le risque d'issue défavorable. Compte tenu du taux élevé de faux positifs, la surveillance du bien-être fœtal peut augmenter le risque d'interventions inutiles, ce qui peut avoir des effets nuisibles, dont l'anxiété parentale, l'accouchement prématuré ou assisté et l'utilisation accrue des ressources de soins de santé. L'optimisation des protocoles de surveillance d'après des pratiques fondées sur des données probantes peut améliorer les issues périnatales et réduire les effets nuisibles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à janvier 2022, à partir de termes MeSH et de mots clés liés à la grossesse, à la surveillance fœtale, aux mouvements fœtaux, à la mortinaissance, aux complications de grossesse et à l'échographie fœtale. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les membres de l'équipe de soins qui prodiguent des soins ou donnent de l'information aux patientes en obstétrique, notamment les spécialistes en médecine fœto-maternelle, les obstétriciens, les médecins de famille, les sages-femmes, les infirmières, les infirmières praticiennes et les radiologistes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
Collapse
|
4
|
Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Directive clinique n o 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:572-597.e1. [PMID: 35577427 DOI: 10.1016/j.jogc.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIF La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse. POPULATION CIBLE Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ». Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. PROFESSIONNELS CIBLES Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse. RECOMMANDATIONS
Collapse
|
5
|
Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:547-571.e1. [PMID: 35577426 DOI: 10.1016/j.jogc.2022.03.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP. TARGET POPULATION Pregnant women. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes. EVIDENCE A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies. VALIDATION METHODS The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication. INTENDED USERS All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy. RECOMMENDATIONS
Collapse
|
6
|
Jones CA, Hawkins L, Friedman C, Hitkari J, McMahon E, Born KB. Choosing Wisely Canada: Canadian fertility and andrology society’s list of top items physicians and patients should question in fertility medicine. Arch Gynecol Obstet 2022; 306:267-275. [PMID: 35278119 PMCID: PMC8917376 DOI: 10.1007/s00404-022-06453-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
Abstract
Purpose To create a Choosing Wisely Canada list of the top 5 diagnostic and therapeutic interventions that should be questioned in Reproductive Endocrinology and Infertility in Canada. Methods The Canadian Fertility and Andrology Society (CFAS) National Working Group developed an initial list of recommendations of diagnostic and therapeutic interventions that are commonly used, but are not supported by evidence, and could expose patients to unnecessary harm. These were chosen based on their prevalence, cost, potential for harm, and quality of supporting evidence. A modified Delphi consensus was used over 5 rounds to generate ideas, review supporting evidence, assess clinical relevance, estimate recommendation impact and narrow the recommendations list to 5 items. Results Fifty unique ideas were first proposed by the working group, and after 5 rounds including a survey of Canadian Fertility and Andrology Society (CFAS) members, the final list of recommendations was created, including topics related to unnecessary investigations and interventions for patients with infertility and recurrent pregnancy loss, and those undergoing IVF. In this article, we describe not only the Delphi process used to determine the list, but also provide a summary of the evidence behind each of the final recommendations. Conclusions The list of five recommendations highlights opportunities to initiate conversations between clinicians and patients about the risks, benefits, harms and costs of unnecessary fertility treatments and procedures in a Canadian context.
Collapse
Affiliation(s)
- C A Jones
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, Toronto, ON, M5G 1E2, Canada
- Mount Sinai Fertility, Sinai Health System, 700-250 Dundas Street West, Toronto, ON, M5T 2Z5, Canada
| | - L Hawkins
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, Toronto, ON, M5G 1E2, Canada
- Department of Obstetrics and Gynaecology, Humber River Hospital, 1235 Wilson Ave, North York, ON, M3M 0B2, Canada
| | - Catherine Friedman
- Department of Obstetrics and Gynaecology, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada.
| | - J Hitkari
- Department of Obstetrics and Gynaecology, University of British Columbia, 930-1125 Howe Street, Vancouver, BC, V6Z 2K8, Canada
- Olive Fertility Centre, 300-East Tower, 555 West 12th Avenue, Vancouver, BC, V5Z 3X7, Canada
| | - E McMahon
- Mount Sinai Fertility, Sinai Health System, 700-250 Dundas Street West, Toronto, ON, M5T 2Z5, Canada
- Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - K B Born
- Institute of Health Policy, Management and Evaluation, Dalla School of Public Health, University of Toronto, 155 College St. 4th Floor, Toronto, ON, M5T 3M6, Canada
| |
Collapse
|
7
|
Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
|
8
|
von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
9
|
Magee LA, Sharma S, Sevene E, Qureshi RN, Mallapur A, Macuácua SE, Goudar S, Bellad MB, Adetoro OO, Payne BA, Sotunsa J, Valá A, Bone J, Shennan AH, Vidler M, Bhutta ZA, von Dadelszen P. Population-level data on antenatal screening for proteinuria; India, Mozambique, Nigeria, Pakistan. Bull World Health Organ 2020; 98:661-670. [PMID: 33177756 PMCID: PMC7652559 DOI: 10.2471/blt.19.248898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023] Open
Abstract
Objective To estimate the prevalence and prognosis of proteinuria at enrolment in the 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia cluster randomized trials. Methods We identified pregnant women eligible for inclusion in the trials in their communities in four countries (2013–2017). We included women who delivered by trial end and received an intervention antenatal care visit. The intervention was a community health worker providing supplementary hypertension-oriented care, including proteinuria assessment by visual assessment of urinary dipstick at the first visit and all subsequent visits when hypertension was detected. In a multilevel regression model, we compared baseline prevalence of proteinuria (≥ 1+ or ≥ 2+) across countries. We compared the incidence of subsequent complications by baseline proteinuria. Findings Baseline proteinuria was detected in less than 5% of eligible pregnancies in each country (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004; Pakistan: 315/10 885), almost always with normotension (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). There was no consistent relationship between baseline proteinuria (either ≥ 1+ or ≥ 2+) and progression to hypertension, maternal mortality or morbidity, birth at < 37 weeks, caesarean section delivery or perinatal mortality or morbidity. If proteinuria testing were restricted to women with hypertension, we projected annual cost savings of 153 223 981 United States dollars (US$) in India, US$ 9 055 286 in Mozambique, US$ 53 181 933 in Nigeria and US$ 38 828 746 in Pakistan. Conclusion Our findings question the recommendations to routinely evaluate proteinuria at first assessment in pregnancy. Restricting proteinuria testing to pregnant women with hypertension has the potential to save resources.
Collapse
Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, King's College London, Becket House, 1 Lambeth Palace Road, SE1 7EU, London, England
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Esperança Sevene
- Centro de Investigação em Saúde da Manhiça, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Rahat N Qureshi
- Centre of Excellence, Aga Khan University, Karachi, Pakistan
| | - Ashalata Mallapur
- S Nijalingappa Medical College and HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Bagalkote, India
| | - Salésio E Macuácua
- Centro de Investigação em Saúde da Manhiça, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Shivaprasad Goudar
- KLE Academy of Higher Education and Research's J N Medical College Belagavi, Karnataka, India
| | - Mrutunjaya B Bellad
- KLE Academy of Higher Education and Research's J N Medical College Belagavi, Karnataka, India
| | - Olalekan O Adetoro
- Department of Obstetrics and Gynaecology, Olabisi Onabanjo University, Ago Iwoye, Nigeria
| | - Beth A Payne
- Centre for International Child Health, University of British Columbia, Vancouver, Canada
| | - John Sotunsa
- Babcock University Teaching Hospital, Ilishan-Remo, Nigeria
| | - Anifa Valá
- Centro de Investigação em Saúde da Manhiça, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Andrew H Shennan
- Department of Women and Children's Health, King's College London, Becket House, 1 Lambeth Palace Road, SE1 7EU, London, England
| | - Marianne Vidler
- Centre for International Child Health, University of British Columbia, Vancouver, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, Becket House, 1 Lambeth Palace Road, SE1 7EU, London, England
| | | |
Collapse
|
10
|
Tourigny C, Rey E, Moreau J, Guimond MO, Ouellet A, Dubé J, Côté AM. Albumin/Creatinine Ratio for the Detection of Significant Proteinuria of Preeclampsia in Hospitalized Hypertensive Women. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:S1701-2163(20)30687-3. [PMID: 34756405 DOI: 10.1016/j.jogc.2020.08.019] [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: 06/02/2020] [Revised: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Preeclampsia is a hypertensive disorder of pregnancy associated with proteinuria detected by 24-hour urine collection (≥0.3 g/24 h) or protein/creatinine ratio (≥30 mg/mmol). The albumin/creatinine ratio (ACR) is used outside pregnancy to detect abnormal amounts of albumin in the urine, but there is little data on its value in pregnancy. Our objective was to determine the diagnostic threshold for ACR to detect significant proteinuria in women investigated for preeclampsia. METHODS A prospective observational study involving 99 hypertensive women (≥140/90 mm Hg) over 20 weeks gestation who were hospitalized at 2 Canadian tertiary centres. A 24-hour urine collection and a morning urine sample were collected. The optimal ACR threshold was determined by a receiver operating characteristic (ROC) curve using the 24-hour collection as the reference test; sensitivity and specificity analyses were performed. Maternal and perinatal characteristics were extracted from medical records. RESULTS Of the 87 women who had completed urine collection, 74 (85%) had an initial diagnosis of preeclampsia and 63 (72%) had significant proteinuria confirmed by 24-hour collection. The area under the morning ROC curve was 0.92 (95% CI 0.86-0.98) and the optimal threshold obtained for the ACR was 9 mg/mmol, with a sensitivity and specificity of 84% (95% CI 73-92) and 88% (95% CI 68-97), respectively. CONCLUSION Our results suggest that an ACR threshold of 9 mg/mmol on a morning urine sample can be used to detect significant proteinuria of preeclampsia in hospitalized hypertensive women.
Collapse
Affiliation(s)
- Camille Tourigny
- Département de médecine, Université de Sherbrooke, Sherbrooke, QC
| | - Evelyne Rey
- Département d'obstétrique-gynécologie and Centre de Recherche, CHU Sainte-Justine, Montréal, QC
| | | | | | - Annie Ouellet
- Département d'obstétrique-gynécologie, CHUS, Sherbrooke, QC
| | - Jean Dubé
- Département de biochimie, CHUS, Sherbrooke, QC
| | - Anne-Marie Côté
- Département de médecine, Université de Sherbrooke, Sherbrooke, QC; Centre de recherche du CHUS, Sherbrooke, QC.
| |
Collapse
|