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Psenkova P, Tedla M, Minarcinova L, Zahumensky J. Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery. BMC Pregnancy Childbirth 2024; 24:292. [PMID: 38641800 PMCID: PMC11027349 DOI: 10.1186/s12884-024-06429-8] [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: 11/20/2023] [Accepted: 03/15/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group. METHODS This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 - December 2015) and after (January 2018 - December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit. RESULTS Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality. CONCLUSIONS This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.
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Affiliation(s)
- Petra Psenkova
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia
| | - Miroslav Tedla
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital Bratislava and Comenius University, Antolská 11, Bratislava, 851 07, Slovakia
| | - Lenka Minarcinova
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia.
| | - Jozef Zahumensky
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia
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Liu G, Zhou C, Wang S, Zhang H. Mid-trimester cervical length and prediction of vaginal birth after cesarean delivery in Chinese parturients: A retrospective study. J Gynecol Obstet Hum Reprod 2023; 52:102647. [PMID: 37611746 DOI: 10.1016/j.jogoh.2023.102647] [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: 01/27/2023] [Revised: 07/26/2023] [Accepted: 08/20/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND A successful trial of labor after cesarean (TOLAC) is linked with the best maternal/neonatal outcomes and is more cost-effective than elective repeat cesarean section (ERCS). Predictive models of vaginal birth after cesarean (VBAC) have been established worldwide to improve the success rate of TOLAC. OBJECTIVE To validate a VBAC prediction model (the updated Grobman's predictive model without ethnicity) and identify whether mid-trimester cervical lengths (MCL) improve the prediction of VBAC among Chinese women undergoing a TOLAC. METHODS In this retrospective cohort study, the inclusion criteria were a previous history of cesarean delivery (CD) as well as a singleton gestation in the vertex position with routine CL measurements between 20 and 24 weeks and the experience of a TOLAC. MCL as well as identifiable characteristics in early prenatal care that have been used in updated Grobman's predictive model (maternal age, height, pre-pregnancy weight, vaginal delivery history, VBAC history, arrest disorder in previous CD, and treated chronic hypertension) were obtained from the medical records. Associations of maternal characteristics and MCL with VBAC were evaluated using multivariate logistic regression. Two multivariable regression models with and without MCL as one of the risk factors were established and their predictive accuracy for VBAC was critically compared based on receiver-operating characteristic (ROC) curves. RESULTS This study involved 409 women, among which, 347 (84.8%) achieved a VBAC. The mean MCL was significantly shorter in women who had a successful VBAC than in those who required an intrapartum CD (4.16±0.49 cm vs. 4.35±0.46 cm, P=0.007). Multivariable logistic regression revealed that a longer MCL (cm) was significantly related to a lower success rate of TOLAC [adjusted odds ratio (aOR), 0.48; 95% confidence interval (CI), 0.26-0.88]. The areas under the ROCs of Grobman's model with and without MCL as one of the risk factors were 0.785 (95% CI, 0.725-0.844) and 0.774 (95% CI, 0.710-0.837), respectively, but not significantly different (Z = -0.968, P = 0.333). CONCLUSIONS We first evaluated the efficiency of the updated Grobman's model (without race and ethnicity) in the Chinese population. The area under the curve is relatively high, indicating that the model can be used efficiently in China. The shorter MCL was associated with a greater chance of VBAC and MCL was the independent factor from the factors of Grobman's model. However, the predictive capacity of the modified model by adding MCL as one of the risk factors did not improve significantly.
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Affiliation(s)
- Guangpu Liu
- Department of Obstetrics, The Forth Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Chaofan Zhou
- Department of neurology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Shengpu Wang
- Department of Obstetrics, The Forth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huixin Zhang
- Department of Obstetrics, The Forth Hospital of Hebei Medical University, Shijiazhuang, China
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Rottenstreich M, Rotem R, Samueloff A, Sela HY, Grisaru-Granovsky S. Trial of labor after cesarean delivery in grand multiparous women: maternal and neonatal outcomes. J Matern Fetal Neonatal Med 2020; 35:2629-2634. [PMID: 32664760 DOI: 10.1080/14767058.2020.1790518] [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: 10/23/2022]
Abstract
OBJECTIVE To evaluate success rates of vaginal birth after cesarean (VBAC) and maternal and neonatal outcomes associated with trial of labor after cesarean in grand multiparous women. STUDY DESIGN A retrospective computerized data base study was conducted at a single tertiary center, between 2005 and 2019. The study compared the maternal and neonatal outcomes of trial of labor after cesarean delivery in grand multiparous women (parity ≥ 6) as compared to multiparous women (parity: 3-5). Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. RESULTS During the study period we identified 2749 and 4294 cases of trial of labor after cesarean in grand multiparous and multiparas, respectively. VBAC was observed in 94.6% of the grand multiparous as compared to 96.5% in the multiparous group, p < .01. The grand multiparous group had a higher rate of postpartum hemorrhage (3 vs. 2.2%, p = .03) and prolonged postpartum hospitalization (1.4 vs. 0.7%, p < .01). The rates of uterine rupture (0.3 vs. 0.2%, p=.50), peripartum hysterectomy (0.1 vs. 0%, p = .33) and adverse neonatal outcomes were comparable between the groups. CONCLUSION Trial of labor after cesarean in grand multiparous women is associated with favorable maternal and neonatal outcomes. Consideration and awareness should be given for the increased risk for postpartum hemorrhage, not associated with uterine rupture.
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Affiliation(s)
- Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel.,Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Arnon Samueloff
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
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Kwong FL, Hamoodi I. Postnatal diagnosis of an occult uterine scar dehiscence after three uncomplicated vaginal births after Caesarean section: A case report. Case Rep Womens Health 2020; 27:e00203. [PMID: 32346520 PMCID: PMC7178318 DOI: 10.1016/j.crwh.2020.e00203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction The incidence of Caesarean sections has been increasing in the United Kingdom. Obstetricians have become more inclined to offer a trial of a vaginal birth to women following a single uncomplicated Caesarean section due to growing recognition of the high morbidity associated with repeat abdominal surgeries, and the relative rarity of a Caesarean scar defect causing complications at subsequent vaginal deliveries. The diagnosis of a Caesarean scar defect such as a uterine scar dehiscence in the postnatal period still remains elusive due to its vague presentation. An incorrect diagnosis or a delay in diagnosis can lead to unnecessary interventions or delay the management of patient symptoms. Case Presentation A 35-year-old woman with a single Caesarean section and three subsequent uncomplicated vaginal deliveries was diagnosed with an occult scar dehiscence two weeks postnatally. She initially complained of persistent vaginal bleeding and underwent a suction evacuation for suspected retained placental tissue. Her symptoms did not improve, and a CT scan was requested to rule out a uterine perforation following the surgical procedure. The CT scan suggested a uterine dehiscence at the level of the previous scar. As the patient remained clinically well, her symptoms were managed conservatively. She underwent a laparoscopic sterilisation six months later and was discharged as the scar defect had fully resolved. Conclusion Clinicians should remain vigilant about the possibility of an occult scar defect in women with a previous Caesarean section who present with persistent vaginal bleeding and pain in the postnatal period. Bladder flap haematomas over 5 cm raise the possibility of a Caesarean scar defect. Niche formation causes a spectrum of menstrual disorders. Contraception should be offered to all women with a Caesarean scar defect.
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Affiliation(s)
- Fong Lien Kwong
- Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington, Newcastle NE23 6NZ, United Kingdom
| | - Ibraheem Hamoodi
- Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington, Newcastle NE23 6NZ, United Kingdom
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Wu Y, Kataria Y, Wang Z, Ming WK, Ellervik C. Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2019; 19:360. [PMID: 31623587 PMCID: PMC6798397 DOI: 10.1186/s12884-019-2517-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
Background Evidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC. Methods A comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database’s inception to March 16, 2018. Observational studies, identifying women with a trial of labor after one previous low-transverse cesarean section were included. Two reviewers independently abstracted the data. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale. Results We included 94 eligible observational studies (239,006 pregnant women with 163,502 VBAC). Factors were associated with successful VBAC with the following odds ratios (OR;95%CI): age (0.92;0.86–0.98), obesity (0.50;0.39–0.64), diabetes (0.50;0.42–0.60), hypertensive disorders complicating pregnancy (HDCP) (0.54;0.44–0.67), Bishop score (3.77;2.17–6.53), labor induction (0.58;0.50–0.67), macrosomia (0.56;0.50–0.64), white race (1.39;1.26–1.54), previous vaginal birth before cesarean section (3.14;2.62–3.77), previous VBAC (4.71;4.33–5.12), the indications for the previous cesarean section (cephalopelvic disproportion (0.54;0.36–0.80), dystocia or failure to progress (0.54;0.41–0.70), failed induction (0.56;0.37–0.85), and fetal malpresentation (1.66;1.38–2.01)). Adjusted ORs were similar. Conclusions Diabetes, HDCP, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS should be considered as the factors affecting the success of VBAC.
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Affiliation(s)
- Yanxin Wu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, 510000, People's Republic of China.,Department of Laboratory Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02215, USA
| | - Yachana Kataria
- Department of Laboratory Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02215, USA
| | - Zilian Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, 510000, People's Republic of China.
| | - Wai-Kit Ming
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, 510000, People's Republic of China.
| | - Christina Ellervik
- Department of Laboratory Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02215, USA. .,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Zahumensky J, Psenkova P, Nemethova B, Halasova D, Kascak P, Korbel M. Evaluation of cesarean delivery rates at three university hospital labor units using the Robson classification system. Int J Gynaecol Obstet 2019; 146:118-125. [PMID: 31058314 DOI: 10.1002/ijgo.12842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/05/2019] [Accepted: 05/03/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To analyze the frequency of cesarean delivery using the Robson 10-group classification. METHODS A multicenter retrospective cohort study was conducted at three university hospital labor units in the Slovak Republic. The medical records of all women who gave birth at these centers from January 1 to December 31, 2017, were assessed. RESULTS In all, 1437 of 3361 (42.8%), 729 of 2795 (26.1%), and 303 of 2080 (14.6%) births recorded at the three centers during the current study period were by cesarean delivery. Among the nulliparous term singleton vertex deliveries (Robson group 1 and 2), the frequency of cesarean delivery at the three centers was 613 of 1653 (37.1%), 278 of 1389 (20.0%), and 91 of 898 (10.1%). Among term multiparas with one fetus in a cephalic position and at least one previous cesarean delivery (Robson group 5), the frequency of cesarean delivery at the three centers was 405 of 418 (96.9%), 261 of 343 (76.1%), and 55 of 115 (47.8%). CONCLUSION Analysis of the frequency of cesarean delivery by Robson classification could help to identify possibilities for safely decreasing cesarean delivery rates in the clinic. Robson groups 1, 2, and 5 were the most modifiable groups.
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Affiliation(s)
- Jozef Zahumensky
- 2nd Department of Obstetrics and Gynecology, University Hospital Bratislava and Comenius University, Bratislava, Slovak Republic
| | - Petra Psenkova
- 2nd Department of Obstetrics and Gynecology, University Hospital Bratislava and Comenius University, Bratislava, Slovak Republic
| | - Bianka Nemethova
- 1st Department of Obstetrics and Gynecology, University Hospital Bratislava and Comenius University, Bratislava, Slovak Republic
| | - Dominika Halasova
- Department of Obstetrics and Gynecology, Trencin University Hospital, Trencin, Slovak Republic
| | - Peter Kascak
- Department of Obstetrics and Gynecology, Trencin University Hospital, Trencin, Slovak Republic
| | - Miroslav Korbel
- 1st Department of Obstetrics and Gynecology, University Hospital Bratislava and Comenius University, Bratislava, Slovak Republic
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McLaren RA, Ndubizu C, Atallah F, Minkoff H. Association of uterine rupture with pregestational diabetes in women undergoing trial of labor after cesarean delivery. J Matern Fetal Neonatal Med 2019; 33:2697-2703. [PMID: 30522369 DOI: 10.1080/14767058.2018.1557143] [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: 10/27/2022]
Abstract
Objective: To evaluate the association of pregestational diabetes with uterine rupture during a trial of labor with one prior cesarean delivery.Study design: A retrospective study of women undergoing a trial of labor after cesarean. The study group consisted of women with pregestational diabetes and the control group was women without pregestational diabetes. Primary outcome was a uterine rupture. Data were extracted from the USA. Natality Database from 2012 to 2016. Maternal and neonatal outcomes were analyzed. Multivariable logistic regression analysis was used to estimate risks of uterine rupture and maternal and neonatal outcomes.Results: There were 359,504 women undergoing labor after cesarean, with 3508 women with pregestational diabetes and 355,996 without. The prevalence of uterine rupture among women with pregestational diabetes undergoing labor after cesarean was 0.5%, while among women without pregestational diabetes, it was 0.2% (adjusted odds ratio [OR] 2.03 [95% CI 1.18-3.51]; p = .01). There was an increased risk of unplanned hysterectomy among pregnancies complicated by pregestational diabetes (adjusted OR 3.06 [95% CI 1.41-6.66]).Conclusion: Women undergoing a trial of labor, who have pregestational diabetes had a higher rate of uterine rupture than women without a history of pregestational diabetes.
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Affiliation(s)
- Rodney A McLaren
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Chima Ndubizu
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Fouad Atallah
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, USA
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Wallstrom T, Bjorklund J, Frykman J, Jarnbert-Pettersson H, Akerud H, Darj E, Gemzell-Danielsson K, Wiberg-Itzel E. Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study. PLoS One 2018; 13:e0200024. [PMID: 29965989 PMCID: PMC6028115 DOI: 10.1371/journal.pone.0200024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/17/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin® and Cytotec®) for induction of labor in women with an unfavorable cervix and one previous Cesarean section. Material and methods Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 2012–2015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at ≥34 w, (n = 910). Results 3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec®, 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin® was used. Conclusions No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec® and balloon catheter were compared (p = 0.64). Orally administrated Cytotec® and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix.
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Affiliation(s)
- Tove Wallstrom
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
- * E-mail:
| | - Jenny Bjorklund
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
| | - Joanna Frykman
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
| | - Hans Jarnbert-Pettersson
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
| | - Helena Akerud
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Elisabeth Darj
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Oslo, Norway
| | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Wiberg-Itzel
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
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