1
|
Helbig M, Schaal NK, Drumm J, Fürst F, Reinhart L, Fehm T, Beyer I. Correlation between pain and depressive symptoms in patients with confirmed endometriosis during COVID-19 pandemic. Arch Gynecol Obstet 2024; 309:631-637. [PMID: 38103055 PMCID: PMC10808472 DOI: 10.1007/s00404-023-07295-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 11/07/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Endometriosis is a chronic, estrogen-dependent, inflammatory condition which affects women of reproductive age physically and psychologically in their everyday life. The most common symptom is chronic lower abdominal pain. Apart from physical pain, endometriosis often also leads to an unfulfilled desire to give birth. In general, these two main aspects alone lead to emotional stress for patients and often initiate depressive symptoms. To what extent endometriosis patients are additionally affected by the COVID pandemic and its effects is to be determined in this study. METHODS Patients who presented at our endometriosis center and met the study criteria were offered participation in the study. A link to an online questionnaire (SoSci-Survey) was sent by email. The online questionnaire evaluated depressive symptoms before and during the pandemic as well as the pain perception and perceived support during the pandemic. The data of 167 fully completed questionnaires were evaluated and analyzed using SPSS. RESULTS The analysis of the questionnaires revealed a significant association between pain levels and depressive symptomatology in endometriosis patients during the pandemic. Patients with more severe pain showed significantly higher depressive symptoms than patients with little or no pain. During the pandemic, patients showed higher depressive symptoms than before. In addition, it was found that those endometriosis patients who felt left alone with their pain due to the consequences of the COVID pandemic, or who felt they had to endure the pain alone, also had higher depressive symptoms. CONCLUSION In summary, it can be observed that endometriosis patients with a high pain burden had significantly higher depressive symptoms during the COVID pandemic. The consequences of the pandemic often led to the feeling of having to cope with the symptoms alone or having to endure pain alone, which in turn increased the depressive symptoms. As treating physicians, we should be aware of these connections and try to counteract them with targeted offers and support.
Collapse
Affiliation(s)
- Martina Helbig
- Clinic for Gynecology and Obstetrics, University Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Nora K Schaal
- Department of Experimental Psychology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Johannes Drumm
- Clinic for Gynecology and Obstetrics, University Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Flurina Fürst
- Clinic for Gynecology and Obstetrics, University Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Lisa Reinhart
- Clinic for Gynecology and Obstetrics, University Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Tanja Fehm
- Clinic for Gynecology and Obstetrics, University Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Ines Beyer
- Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Academic Teaching Hospital Leverkusen, University of Cologne, Cologne, Germany
| |
Collapse
|
2
|
Arena A, Degli Esposti E, Pazzaglia E, Orsini B, Cau I, Govoni F, Raimondo D, Palermo R, Lenzi J, Casadio P, Seracchioli R. Not All Bad Comes to Harm: Enhanced Recovery After Surgery for Rectosigmoid Endometriosis. J Minim Invasive Gynecol 2024; 31:49-56. [PMID: 37839779 DOI: 10.1016/j.jmig.2023.10.011] [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: 07/10/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
STUDY OBJECTIVE To assess the impact of implementing an enhanced recovery after surgery (ERAS) protocol on the length of hospitalization in women undergoing laparoscopy for rectosigmoid deep infiltrating endometriosis (DIE). DESIGN A retrospective cohort study. SETTING An academic referral center for endometriosis and minimally invasive gynecologic surgery. PATIENTS Women aged between 18 and 50 years scheduled for laparoscopic excision (shaving, full-thickness anterior wall resection, segmental resection) of rectosigmoid endometriosis between February 2017 and February 2023. INTERVENTIONS We divided patients into 2 groups (non-ERAS and ERAS) based on the timing of surgery (before or after March 5, 2020). Starting from this day, restrictions were issued to limit the spread of the coronavirus disease 2019 pandemic, inducing our group to implement an ERAS protocol for patients hospitalized after surgery for posterior DIE. MEASUREMENTS AND MAIN RESULTS We included 579 patients in the analysis, 316 (54.6%) in the non-ERAS group and 263 (45.4%) in the ERAS group. In the ERAS group, we observed a shorter length of hospital stay (5.8 ± 3.1 days vs 4.8 ± 2.9 days; p <.001) and lower complications rates (33, 12.5% vs 60, 19.0%; p = .04), despite a decreased frequency of conservative surgical approaches (shaving procedures 121 vs 196; p <.001). Repeated surgery or hospital readmissions owing to postdischarge complications were infrequent, with no significant differences between the 2 groups. The multiple linear regression analysis strengthened our results given the higher prevalence of bowel resection surgeries (both full-thickness anterior wall or segmental), showing that patients managed with a multimodal protocol had an overall reduction of hospital stay by 1.5 days. CONCLUSION The implementation of an ERAS program in patients undergoing laparoscopic surgery for DIE is associated with a significant reduction in hospital stay, without an increase in perioperative or postoperative complication rates.
Collapse
Affiliation(s)
- Alessandro Arena
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Eugenia Degli Esposti
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Enrico Pazzaglia
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli).
| | - Benedetta Orsini
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Irene Cau
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Francesca Govoni
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Roberto Palermo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Jacopo Lenzi
- Department of biomedical and neuromotor sciences, Alma mater Studiorum, University of Bologna, Bologna, Italy (Dr. Lenzi)
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| |
Collapse
|
3
|
Lami A, Giacomelli G, Lenzi J, Alvisi S, Seracchioli R, Meriggiola MC. The COVID-19 Pandemic Impact on the Psychophysical Health of Post-Menopausal Women: A Cross-Sectional Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1154. [PMID: 37374358 DOI: 10.3390/medicina59061154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/30/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: The aim of this study was to investigate lifestyle, menopausal symptoms, depression, post-traumatic stress disorder (PTSD) and sleep disorders in post-menopausal women throughout the first wave of the COVID-19 pandemic, including the impact of menopause hormonal therapy (HT). Materials and Methods: Post-menopausal women were given the following questionnaires: socio-demographic characteristics; lifestyle; history of COVID-19; menopause-specific quality of life (MENQOL), the first part of which refers to the pre-pandemic period ("pre COVID-19") and the second refers to the current period ("during COVID-19"); Beck's depression inventory (BDI); the impact of event scale-revised (IES-R); and the Pittsburgh sleep quality index (PSQI). Results: One hundred and twenty-six women completed all questionnaires, with a mean age of 55.5 ± 6.0 years. The mean menopause duration was 5.7 ± 5.6 years. Twenty-four women were taking HT. A significant mean weight gain, a reduction in physical activity (respectively p < 0.001) and worsened quality of romantic relationships (p = 0.001) were reported during the pandemic. Menopausal symptoms did not vary significantly throughout the pandemic; however, women taking menopausal HT had lower physical (p = 0.003) and sexual (p = 0.049) MENQOL domain scores, lower depressive symptoms (p = 0.039) and better romantic relationships (p = 0.008). Conclusions: The COVID-19 pandemic caused reduced physical activity, worsened food habits and weight gain in post-menopausal women. They also reported a high rate of severe-moderate PTSD and a negative influence on their romantic relationships. Menopausal HT seems to be a potential protective factor for sexual and physical status and for symptoms of depression.
Collapse
Affiliation(s)
- Alessandra Lami
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Giulia Giacomelli
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Maria Cristina Meriggiola
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| |
Collapse
|
4
|
Endometriosis and COVID-19: A Systematic Review and Meta-Analysis. Int J Mol Sci 2022; 23:ijms232112951. [PMID: 36361745 PMCID: PMC9657778 DOI: 10.3390/ijms232112951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/13/2022] [Accepted: 10/22/2022] [Indexed: 11/22/2022] Open
Abstract
Endometriosis is defined as ectopic endometrial tissues dispersed outside the endometrium. This can cause disruption in hormonal and immunological processes, which may increase susceptibility to SARS-CoV-2 infection. Worsening of endometriosis symptoms may occur as a result of this infection. The aim of our review was to estimate the pooled prevalence of SARS-CoV-2 infection and the health impacts of the COVID-19 pandemic in endometriosis patients. We conducted a systematic review and meta-analysis. MEDLINE, Science Direct, Scopus, and Google Scholar databases were searched, using the keywords: (endometriosis) AND (COVID-19 OR SARS-CoV-2). Forest plots and pooled estimates were created using the Open Meta Analyst software. After screening 474 articles, 19 studies met the eligibility criteria for the systematic review, and 15 studies were included in the meta-analyses. A total of 17,799 patients were analyzed. The pooled prevalence of SARS-CoV-2 infection in endometriosis patients was 7.5%. Pooled estimates for the health impacts were 47.2% for decreased access to medical care, 49.3% increase in dysmenorrhea, 75% increase in anxiety, 59.4% increase in depression, and 68.9% increase in fatigue. Endometriosis patients were undeniably impacted by the COVID-19 pandemic, which caused the worsening of symptoms such as dysmenorrhea, pelvic pain, anxiety, depression, and fatigue.
Collapse
|
6
|
Determinants of Pain-Induced Disability in German Women with Endometriosis during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148277. [PMID: 35886130 PMCID: PMC9320034 DOI: 10.3390/ijerph19148277] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 02/01/2023]
Abstract
(1) Background: The main aim of this research was to examine the factors leading to pain-induced disability by assessing the impact of demographic, endometriosis-specific, pandemic-specific, and mental health factors. (2) Methods: Women with endometriosis who attended online support groups were invited to respond to an online survey during the first wave of the COVID-19 pandemic in Germany. The Pain Disability Index (PDI) was employed to assess disability-related daily functioning. Independent predictors of pain-induced disability were determined using univariate and multivariate logistic regression analyses. (3) Results: The mean PDI score of the study population was 31.61 (SD = 15.82), which was significantly higher (p < 0.001) than that reported in a previously published normative study of the German population. In the present study, a high level of pain-induced disability, as defined by scores equal to or higher than the median of the study population, older age (OR 1.063, 95% CI 1.010−1.120, p = 0.020), dysmenorrhea (OR 1.015, 95% CI 1.005−1.026, p = 0.005), dysuria (OR 1.014; 95% CI 1.001−1.027, p = 0.029), lower back pain (OR 1.018, 95% CI 1.007−1.029, p = 0.001), and impaired mental health (OR 1.271, 95% CI 1.134−1.425, p < 0.001) were found to be independent risk factors. Pandemic-specific factors did not significantly influence the pain-induced disability of the participants in this study. (4) Conclusions: The level of pain-induced disability was significantly higher among the women with endometriosis than among women in the normative German validation study. Our findings identified risk factors for experiencing a high level of pain-induced disability, such as demographic and specific pain characteristics. Pandemic-specific factors did not significantly and independently influence the pain-induced disability during the first wave of the COVID-19 pandemic in Germany. Impaired mental health negatively influenced functioning during daily activities. Thus, women with endometriosis should be managed by a multidisciplinary team of healthcare professionals to prevent negative effects of pain-induced disability on their quality of life.
Collapse
|
7
|
Schwab R, Stewen K, Ost L, Kottmann T, Theis S, Elger T, Schmidt MW, Anic K, Kalb SR, Brenner W, Hasenburg A. Predictors of Psychological Distress in Women with Endometriosis during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084927. [PMID: 35457794 PMCID: PMC9024970 DOI: 10.3390/ijerph19084927] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 12/14/2022]
Abstract
Background: Endometriosis is a multifaceted chronic pain condition that can have a negative impact on mental health. Patients suffering from chronic pain may face an additional psychological burden during adversity, such as the COVID-19 pandemic. The main aim of this research was to evaluate the prevalence of self-reported depression and anxiety, the influence of demographic, endometriosis-specific, pandemic-specific factors, and resilience on mental health outcomes of patients with endometriosis. Methods: An online survey was conducted through patient support groups of women suffering from endometriosis during the first wave of the COVID-19 pandemic. The PHQ-4 questionnaire, which combines two items of the Patient Health Questionnaire for Depression (PHQ-2) and two items from the Generalized Anxiety Disorder Scale (GAD-2) was used to assess self-reported mental health. The Brief Resilience Score (BRS) was employed to evaluate resilience. Independent risk and protective factors for mental health were investigated by multivariate logistic regression analyses. Results: The PHQ-4 questionnaire was completed by 274 respondents. More than 40% reached depression (PHQ-2) and anxiety (GAD-2) scores of ≥3, and more than 20% achieved PHQ-2 and GAD-2 scores of ≥5. High resilience was found to be a reliable and strong independent protector for the probability of developing adverse psychological outcomes: OR 0.295, p < 0.001 for developing generalized anxiety disorder (GAD-2 ≥ 3), and OR 0.467, p < 0.001 for having major depression (PHQ-2 ≥ 3). Conclusions: Pain-induced disability is an independent risk factor for developing major depression and anxiety, while resilience was identified as a potential protective parameter in terms of positive psychological outcomes in women with endometriosis. The results of this study may help to identify women at risk for adverse mental health outcomes and should encourage healthcare practitioners to establish strategies for the reduction of negative psychological and psychiatric impacts on patients with endometriosis.
Collapse
Affiliation(s)
- Roxana Schwab
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
- Correspondence: ; Tel.: +49-6131-17-0
| | - Kathrin Stewen
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Laura Ost
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Tanja Kottmann
- CRO Dr. Med. Kottmann GmbH & Co. KG, 59077 Hamm, Germany;
| | - Susanne Theis
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Tania Elger
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Mona Wanda Schmidt
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Katharina Anic
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Stefanie Roxana Kalb
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Walburgis Brenner
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| | - Annette Hasenburg
- Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (K.S.); (L.O.); (S.T.); (T.E.); (M.W.S.); (K.A.); (S.R.K.); (W.B.); (A.H.)
| |
Collapse
|