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Larsen ML, Krebs L, Hoei-Hansen CE, Kumar S. Assessment of fetal growth trajectory identifies infants at high risk of perinatal mortality. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:764-771. [PMID: 38339783 DOI: 10.1002/uog.27610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/14/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE To analyze perinatal risks associated with three distinct scenarios of fetal growth trajectory in the latter half of pregnancy compared with a reference group. METHODS This cohort study included women with a singleton pregnancy that delivered between 32 + 0 and 41 + 6 weeks' gestation and had two or more ultrasound scans, at least 4 weeks apart, from 18 + 0 weeks. We evaluated three different scenarios of fetal growth against a reference group, which comprised appropriate-for-gestational-age fetuses with appropriate forward-growth trajectory. The comparator growth trajectories were categorized as: Group 1, small-for-gestational-age (SGA) fetuses (estimated fetal weight (EFW) or abdominal circumference (AC) persistently < 10th centile) with appropriate forward growth; Group 2, fetuses with decreased growth trajectory (decrease of ≥ 50 centiles) and EFW or AC ≥ 10th centile (i.e. non-SGA) at their final ultrasound scan; and Group 3, fetuses with decreased growth trajectory and EFW or AC < 10th centile (i.e. SGA) at their final scan. The primary outcome was overall perinatal mortality (stillbirth or neonatal death). Secondary outcomes included stillbirth, delivery of a SGA infant, preterm birth, emergency Cesarean section for non-reassuring fetal status and composite severe neonatal morbidity. Associations were analyzed using logistic regression. RESULTS The final study cohort comprised 5319 pregnancies. Compared to the reference group, the adjusted odds of perinatal mortality were increased significantly in Group 2 (adjusted odds ratio (aOR), 4.00 (95% CI, 1.36-11.22)) and Group 3 (aOR, 7.71 (95% CI, 2.39-24.91)). Only Group 3 had increased odds of stillbirth (aOR, 5.69 (95% CI, 1.55-20.93)). In contrast, infants in Group 1 did not have significantly increased odds of demise. The odds of a SGA infant at birth were increased in all three groups compared with the reference group, but was highest in Group 1 (aOR, 111.86 (95% CI, 62.58-199.95)) and Group 3 (aOR, 40.63 (95% CI, 29.01-56.92)). In both groups, more than 80% of infants were born SGA and nearly half had a birth weight < 3rd centile. Likewise, the odds of preterm birth were increased in all three groups compared with the reference group, being highest in Group 3, with an aOR of 4.27 (95% CI, 3.23-5.64). Lastly, the odds of composite severe neonatal morbidity were increased in Groups 1 and 3, whereas the odds of emergency Cesarean section for non-reassuring fetal status were increased only in Group 3. CONCLUSION Assessing the fetal growth trajectory in the latter half of pregnancy can help identify infants at increased risk of perinatal mortality and birth weight < 3rd centile for gestation. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M L Larsen
- Center for Cerebral Palsy, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Copenhagen University Hospital - Amager-Hvidovre, Hvidovre, Denmark
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - L Krebs
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - C E Hoei-Hansen
- Center for Cerebral Palsy, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S Kumar
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
- Centre for Maternal and Fetal Medicine, Mater Mother's Hospital, Brisbane, Queensland, Australia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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Deter RL, Lee W, Dicker P, Breathnach F, Molphy Z, Malone FD. Can growth in dichorionic twins be monitored with individualized growth assessment? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:829-835. [PMID: 37488689 DOI: 10.1002/uog.26320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE To characterize fetal growth in dichorionic twins using individualized growth assessment (IGA), a method based on individual growth potential estimates. METHODS This secondary analysis included 286 fetuses/neonates from 143 dichorionic twin pregnancies that were part of the ESPRiT (Evaluation of Sonographic Predictors of Restricted Growth in Twins) study. The sample was subcategorized according to birth weight into appropriate-for-gestational-age (AGA) (n = 243) and small-for-gestational-age (SGA) (n = 43) cohorts. Serial biometric scans evaluating biparietal diameter, head circumference (HC), abdominal circumference, femur diaphysis length and estimated weight at 2-week intervals were used to evaluate fetal growth, while measurements of birth weight, crown-heel length and HC determined neonatal growth outcome. Six abnormalities (hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress, sepsis and death) constituted the evaluated adverse neonatal outcomes (ANO). IGA was used to: evaluate differences in second-trimester growth velocities between singletons (from a published dataset) and dichorionic twins (138 AGA twins with normal third-trimester growth); describe the degree to which actual third-trimester growth in twins followed expected growth (111 AGA twins, normal fetal growth and neonatal growth outcomes); determine if the fetal growth pathology score 1 (-FGPS1) could detect, quantify and classify twin growth pathology (224 AGA, 42 SGA); and assess the relationship between -FGPS1 and ANO (24 SGA twins with progressive growth restriction confirmed by abnormal neonatal growth outcome). RESULTS The differences in second-trimester growth velocity between singletons and twins (means and variances) were small and not statistically significant. Percent deviations from the expected third-trimester size trajectories were within the 95% reference ranges derived from singletons at 95.7% (1677/1752) of timepoints studied. Abnormal growth was detected in 37.9% of AGA twins and 85.7% of SGA twins. Growth restriction was more heterogeneous in AGA twins, while in SGA twins progressive growth restriction was the principal type (66.7%). -FGPS1 patterns previously defined in singletons classified 97.5% of pathological twin cases. In our most severe form of growth restriction (progressive), there were only three (12.5%) ANOs related to growth abnormalities, all in cases with -FGPS1 values more negative than -2.0%. Using these criteria, the frequency of ANO was 33%. CONCLUSIONS With respect to growth, dichorionic twins can be considered as two singletons in the same uterus. Normally growing dichorionic twins have the same growth potential as singletons with normal growth outcome. These twins also follow expected third-trimester growth trajectories with the same precision as do singletons. Third-trimester growth pathology can be detected, quantified and classified using -FGPS1 as in singletons. Limited evidence of a relationship between fetal growth abnormalities and adverse neonatal outcome was found. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - P Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F Breathnach
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Z Molphy
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Pereira SP, Diniz MS, Tavares LC, Cunha-Oliveira T, Li C, Cox LA, Nijland MJ, Nathanielsz PW, Oliveira PJ. Characterizing Early Cardiac Metabolic Programming via 30% Maternal Nutrient Reduction during Fetal Development in a Non-Human Primate Model. Int J Mol Sci 2023; 24:15192. [PMID: 37894873 PMCID: PMC10607248 DOI: 10.3390/ijms242015192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Intra-uterine growth restriction (IUGR) is a common cause of fetal/neonatal morbidity and mortality and is associated with increased offspring predisposition for cardiovascular disease (CVD) development. Mitochondria are essential organelles in maintaining cardiac function, and thus, fetal cardiac mitochondria could be responsive to the IUGR environment. In this study, we investigated whether in utero fetal cardiac mitochondrial programming can be detectable in an early stage of IUGR pregnancy. Using a well-established nonhuman IUGR primate model, we induced IUGR by reducing by 30% the maternal diet (MNR), both in males (MNR-M) and in female (MNR-F) fetuses. Fetal cardiac left ventricle (LV) tissue and blood were collected at 90 days of gestation (0.5 gestation, 0.5 G). Blood biochemical parameters were determined and heart LV mitochondrial biology assessed. MNR fetus biochemical blood parameters confirm an early fetal response to MNR. In addition, we show that in utero cardiac mitochondrial MNR adaptations are already detectable at this early stage, in a sex-divergent way. MNR induced alterations in the cardiac gene expression of oxidative phosphorylation (OXPHOS) subunits (mostly for complex-I, III, and ATP synthase), along with increased protein content for complex-I, -III, and -IV subunits only for MNR-M in comparison with male controls, highlight the fetal cardiac sex-divergent response to MNR. At this fetal stage, no major alterations were detected in mitochondrial DNA copy number nor markers for oxidative stress. This study shows that in 90-day nonhuman primate fetuses, a 30% decrease in maternal nutrition generated early in utero adaptations in fetal blood biochemical parameters and sex-specific alterations in cardiac left ventricle gene and protein expression profiles, affecting predominantly OXPHOS subunits. Since the OXPHOS system is determinant for energy production in mitochondria, our findings suggest that these early IUGR-induced mitochondrial adaptations play a role in offspring's mitochondrial dysfunction and can increase predisposition to CVD in a sex-specific way.
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Affiliation(s)
- Susana P. Pereira
- Laboratory of Metabolism and Exercise (LaMetEx), Research Centre in Physical Activity, Health and Leisure (CIAFEL), Laboratory for Integrative and Translational Research in Population Health (ITR), Faculty of Sports, University of Porto, 4200-450 Porto, Portugal
- CNC-UC, Center for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal; (M.S.D.); (T.C.-O.); (P.J.O.)
- CIBB—Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, 3004-504 Coimbra, Portugal
- Center for Pregnancy and Newborn Research, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA;
| | - Mariana S. Diniz
- CNC-UC, Center for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal; (M.S.D.); (T.C.-O.); (P.J.O.)
- PDBEB—Ph.D. Programme in Experimental Biology and Biomedicine, Institute for Interdisciplinary Research (IIIUC), University of Coimbra, 3030-789 Coimbra, Portugal
| | - Ludgero C. Tavares
- CNC-UC, Center for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal; (M.S.D.); (T.C.-O.); (P.J.O.)
- CIVG—Vasco da Gama Research Center, University School Vasco da Gama—EUVG, 3020-210 Coimbra, Portugal
| | - Teresa Cunha-Oliveira
- CNC-UC, Center for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal; (M.S.D.); (T.C.-O.); (P.J.O.)
| | - Cun Li
- Texas Pregnancy & Life-Course Health Research Center, Department of Animal Science, University of Wyoming, Laramie, WY 82071, USA;
| | - Laura A. Cox
- Center for Precision Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA; (L.A.C.); (P.W.N.)
- Section on Molecular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
- Section on Comparative Medicine, Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Mark J. Nijland
- Center for Pregnancy and Newborn Research, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA;
| | - Peter W. Nathanielsz
- Center for Precision Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA; (L.A.C.); (P.W.N.)
| | - Paulo J. Oliveira
- CNC-UC, Center for Neuroscience and Cell Biology, University of Coimbra, 3004-504 Coimbra, Portugal; (M.S.D.); (T.C.-O.); (P.J.O.)
- CIBB—Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, 3004-504 Coimbra, Portugal
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Shu X, Chen N, Zhang Y, Juan J, Zheng Y, Yang H. Fetal growth trajectories of small/large for gestational age infants in twin pregnancies. Am J Obstet Gynecol MFM 2023; 5:100999. [PMID: 37548246 DOI: 10.1016/j.ajogmf.2023.100999] [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: 02/13/2023] [Revised: 04/18/2023] [Accepted: 04/27/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Birthweight is the most common and accessible parameter in assessing neonatal perinatal outcomes and in evaluating the intrauterine environment globally. Infants born too large or too small not only may alter the maternal mode of delivery but also may face other long-term disorders, such as metabolic diseases and neurodevelopmental delay. Studies have revealed different growth profiles of large-for-gestational-age and small-for-gestational-age fetuses in singleton pregnancies. However, currently, no research is focused on the growth trajectories of these infants during twin pregnancies, even though they are at a much higher risk of being small for gestational age. OBJECTIVE This study aimed to explore fetal growth trajectories of large-for-gestational-age and small-for-gestational-age infants in twin pregnancies to provide strategies for fetal growth management. STUDY DESIGN This was a case-control study of all noncomplicated twin pregnancies delivered after 36 weeks of gestation at the Peking University First Hospital between 2012 and 2021. Ultrasound data were recorded every 2 to 4 weeks until delivery. All the infants were divided into large-for-gestational-age, small-for-gestational-age, and appropriate-for-gestational-age groups. Longitudinal fetal growth (estimated fetal weight, abdominal circumference, etc.) was compared among the 3 groups using a linear mixed model, and other maternal and neonatal perinatal outcomes were compared. Receiver operating characteristic curves were used to explore optimal biometric parameters and gestational weeks for predicting small-for-gestational-age infants. RESULTS Here, 797 pregnant patients with 1494 infants were recruited, with 59 small-for-gestational-age infants, 1335 appropriate-for-gestational-age infants, and 200 large-for-gestational-age infants. The mean birthweights were 1985.34±28.34 g in small-for-gestational-age infants, 2662.08±6.60 g in appropriate-for-gestational-age infants, and 3231.24±11.04 g in large-for-gestational-age infants. The estimated fetal weight of the 3 groups differed from each other from week 26, with the small-for-gestational-age fetuses weighing 51.946 g less and the large-for-gestational-age fetuses weighing 35.233 g more than the appropriate-for-gestational-age fetuses. This difference increased with gestation; at 39 weeks, the small-for-gestational-age fetuses weighed 707.438 g less and the large-for-gestational-age fetuses weighed 614.182 g more than the appropriate-for-gestational-age fetuses (all P<.05). The small-for-gestational-age group had a significantly higher rate of hospitalization (89.9 %) and jaundice (40.7 %) than the appropriate-for-gestational-age group, whereas the hospitalization rate in the large-for-gestational-age group was significantly lower than the appropriate-for-gestational-age group (7.5% and 2.5%; all P<.05). The fetal weight of the small-for-gestational-age infants with adverse outcomes remained near the 10th percentile of the reference and fell below the 3rd percentile at 34 weeks of gestation. The estimated fetal weight after 30 weeks of gestation had a satisfactory diagnostic value in predicting small-for-gestational-age infants. At 30, 32, 34, and 36 weeks of gestation, the areas under the curve were 0.829, 0.840, 0.929, and 0.889 respectively. CONCLUSION The growth patterns of small-for-gestational-age, appropriate-for-gestational-age, and large-for-gestational-age twin fetuses diverged from 26 weeks of gestation and continued to increase until delivery; therefore, closer monitoring is suggested from 26 weeks of gestation for those carrying small fetuses.
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Affiliation(s)
- Xinyu Shu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China (Drs Shu, Juan, and Yang)
| | - Na Chen
- Department of Obstetrics and Gynecology, The Hospital of Cang Town, Cangzhou, Hebei Province, China (Ms Chen)
| | - Yan Zhang
- Department of Pediatrics, People's Hospital of Daxing District, Beijing, China (Ms Zhang)
| | - Juan Juan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China (Drs Shu, Juan, and Yang)
| | - Yingdong Zheng
- Department of Epidemiology and Health Statistics, School of Public Health, Peking University Health Science Center, Beijing, China (Dr Zheng)
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China (Drs Shu, Juan, and Yang).
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Lees CC, Romero R, Stampalija T, Dall'Asta A, DeVore GA, Prefumo F, Frusca T, Visser GHA, Hobbins JC, Baschat AA, Bilardo CM, Galan HL, Campbell S, Maulik D, Figueras F, Lee W, Unterscheider J, Valensise H, Da Silva Costa F, Salomon LJ, Poon LC, Ferrazzi E, Mari G, Rizzo G, Kingdom JC, Kiserud T, Hecher K. Clinical Opinion: The diagnosis and management of suspected fetal growth restriction: an evidence-based approach. Am J Obstet Gynecol 2022; 226:366-378. [PMID: 35026129 PMCID: PMC9125563 DOI: 10.1016/j.ajog.2021.11.1357] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
This study reviewed the literature about the diagnosis, antepartum surveillance, and time of delivery of fetuses suspected to be small for gestational age or growth restricted. Several guidelines have been issued by major professional organizations, including the International Society of Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine. The differences in recommendations, in particular about Doppler velocimetry of the ductus venosus and middle cerebral artery, have created confusion among clinicians, and this review has intended to clarify and highlight the available evidence that is pertinent to clinical management. A fetus who is small for gestational age is frequently defined as one with an estimated fetal weight of <10th percentile. This condition has been considered syndromic and has been frequently attributed to fetal growth restriction, a constitutionally small fetus, congenital infections, chromosomal abnormalities, or genetic conditions. Small for gestational age is not synonymous with fetal growth restriction, which is defined by deceleration of fetal growth determined by a change in fetal growth velocity. An abnormal umbilical artery Doppler pulsatility index reflects an increased impedance to flow in the umbilical circulation and is considered to be an indicator of placental disease. The combined finding of an estimated fetal weight of <10th percentile and abnormal umbilical artery Doppler velocimetry has been widely accepted as indicative of fetal growth restriction. Clinical studies have shown that the gestational age at diagnosis can be used to subclassify suspected fetal growth restriction into early and late, depending on whether the condition is diagnosed before or after 32 weeks of gestation. The early type is associated with umbilical artery Doppler abnormalities, whereas the late type is often associated with a low pulsatility index in the middle cerebral artery. A large randomized clinical trial indicated that in the context of early suspected fetal growth restriction, the combination of computerized cardiotocography and fetal ductus venosus Doppler improves outcomes, such that 95% of surviving infants have a normal neurodevelopmental outcome at 2 years of age. A low middle cerebral artery pulsatility index is associated with an adverse perinatal outcome in late fetal growth restriction; however, there is no evidence supporting its use to determine the time of delivery. Nonetheless, an abnormality in middle cerebral artery Doppler could be valuable to increase the surveillance of the fetus at risk. We propose that fetal size, growth rate, uteroplacental Doppler indices, cardiotocography, and maternal conditions (ie, hypertension) according to gestational age are important factors in optimizing the outcome of suspected fetal growth restriction.
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Affiliation(s)
- Christoph C Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Tamara Stampalija
- Department of Obstetrics and Gynecology, Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, Scientific Institute for Research, Hospitalization and Healthcare Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Dall'Asta
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Greggory A DeVore
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - John C Hobbins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, John Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD
| | - Caterina M Bilardo
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands
| | - Henry L Galan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, CO
| | | | - Dev Maulik
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Francesc Figueras
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX
| | - Julia Unterscheider
- Department of Maternal-Fetal Medicine, Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Australia
| | - Herbert Valensise
- University of Rome Tor Vergata, Rome, Italy; Department of Surgery, Policlinico Casilino, Rome, Italy
| | - Fabricio Da Silva Costa
- Maternal-Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia; School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Laurent J Salomon
- Obstétrique et Plateforme LUMIERE, Hôpital Necker-Enfants Malades (AP-HP) et Université de Paris, Paris, France
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region of China
| | - Enrico Ferrazzi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Giuseppe Rizzo
- Università di Roma Tor Vergata, Department of Obstetrics and Gynecology, Fondazione Policinico Tor Vergata, Rome, Italy; The First I.M. Sechenov Moscow State Medical University, Department of Obstetrics and Gynaecology, Moscow, Russian Federation
| | - John C Kingdom
- Placenta Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Torvid Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, and Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Third-trimester growth diversity in small fetuses classified as appropriate-for-gestational age or small-for-gestational age at birth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:882-891. [PMID: 33998089 DOI: 10.1002/uog.23688] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/01/2021] [Accepted: 05/10/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE We have shown previously that third-trimester growth in small fetuses (estimated fetal weight (EFW) < 10th percentile) with birth weight (BW) < 10th percentile is heterogeneous using individualized growth assessment (IGA). We aimed to test our hypothesis that individual growth patterns in small fetuses with BW > 10th percentile are also variable but in different ways. METHODS This was a study of 191 cases with EFW < 10th percentile and BW > 10th percentile (appropriate-for-gestational-age (AGA) cohort), derived from the PORTO study. Composite size parameters were used to quantify growth pathology at individual third-trimester timepoints (individual composite prenatal growth assessment score (-icPGAS)). The fetal growth pathology score 1 (-FGPS1), calculated cumulatively from serial -icPGAS values, was used to characterize third-trimester growth patterns. Vascular-system evaluation included umbilical artery (UA) and middle cerebral artery (MCA) Doppler velocimetry. Outcome variables were birth age (preterm/term delivery) and BW (expressed as growth potential realization index for weight (GPRIWT ) and percentile). The findings from the AGA cohort were compared with those from small fetuses (EFW < 10th percentile) with BW < 10th percentile (small-for-gestational-age (SGA) cohort). RESULTS The AGA cohort was found to have 134 fetuses (70%) with normal growth pattern and 57 (30%) with growth restriction based on IGA criteria. Seven growth-restriction -FGPS1 patterns were observed, including the previously defined progressive, late, adaptive and recovering types. The recovering type was the most common growth pattern in the AGA cohort (50.9%). About one-third of fetuses without any evidence of growth restriction had significant unexplained abnormalities in the UA (34%) and MCA (31%) and elevated mean GPRIWT values (113 ± 12.5%). Comparison of the AGA and SGA cohorts indicated a significant difference in the distribution of -FGPS1 growth patterns (P = 0.0001). Compared with the SGA cohort, the AGA cohort had more fetuses with a normal growth pattern (70% vs 38%) and fewer cases with growth restriction (30% vs 62%). While the recovering type was the most common growth-restriction pattern in the AGA cohort (51%), the progressive type was the primary growth-restriction pattern in the SGA cohort (44%). No difference in the incidence of MCA or UA abnormality was found between the SGA and AGA cohorts when comparing subgroups of more than 10 fetuses. CONCLUSIONS Both normal-growth and growth-restriction patterns were observed in the AGA cohort using IGA, as seen previously in the SGA cohort. The seven types of growth restriction defined in the SGA cohort were also identified in AGA cases, but their distribution was significantly different. In one-third of cases without evidence of growth pathology in the AGA cohort, Doppler abnormalities in the UA and MCA were seen. This heterogeneity underscores the difficulty of accurate classification of fetal and neonatal growth status using conventional population-based methods. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - P Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - E C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - K M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Kanagawa T, Ishii K, Yamamoto R, Sasahara J, Mitsuda N. Fetal Outcomes Associated with the Sequence of Doppler Deterioration in Severely Growth-Restricted Fetuses. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2307-2315. [PMID: 33438784 DOI: 10.1002/jum.15614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/01/2020] [Accepted: 12/19/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Various patterns of Doppler deterioration exist in fetal growth restriction (FGR). However, the factors that differentiate these patterns are still unknown. The purpose of this study was to clarify the perinatal outcomes and factors to determine the pattern of Doppler deterioration in severe FGR. MATERIALS AND METHODS We conducted a retrospective cohort study of preterm severe FGR with Doppler abnormality, wherein the clinical features, including maternal characteristics, medical history, and sonographic findings, were compared between the patterns of Doppler deterioration. We used the multivariable logistic regression analyses to identify the factors associated with the pattern of Doppler deterioration. RESULTS Of 322 eligible fetuses, 143 had Doppler abnormalities. Fetuses with Doppler deterioration from ductus venosus uniquely featured fetal and placental-umbilical abnormalities detected after birth. Gestational age (GA) at diagnosis of FGR and at the first diagnosis of Doppler abnormality in fetuses with Doppler deterioration from middle cerebral artery (MCA) were later than those from umbilical artery. In addition, the factor associated with Doppler deterioration from MCA was 31-week GA at the first diagnosis of Doppler abnormality (adjusted odds ratio [aOR]: 26.7; 95% CI: 8.35-103), not GA at diagnosis of FGR (aOR: 1.82; 95% CI: 0.50-5.96). CONCLUSIONS Characteristics of each Doppler deterioration pattern might reflect FGR etiology. Undetectable anomalies and umbilical-placental abnormalities were found in fetuses with Doppler deterioration from the ductus venosus. Doppler deterioration from the MCA was observed after 31 weeks of gestation not only in the late-onset FGR but also in the early-onset FGR with normal umbilical artery Doppler findings.
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Affiliation(s)
- Takeshi Kanagawa
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Keisuke Ishii
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Ryo Yamamoto
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Jun Sasahara
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Nobuaki Mitsuda
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
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Sherwin E, Deter R, Joudi N, Trepman P, Lee W, El-Sayed YY, Girsen AI, Datoc I, Hintz SR, Blumenfeld YJ. Individualized growth assessment in pregnancies complicated by fetal gastroschisis. J Matern Fetal Neonatal Med 2021; 35:6842-6852. [PMID: 34098833 DOI: 10.1080/14767058.2021.1926976] [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: 10/21/2022]
Abstract
OBJECTIVE Prenatal ultrasound (US) has been shown to overestimate the incidence of suspected fetal growth restriction (FGR) in gastroschisis cases. This is largely because of altered sonographic abdominal circumference (AC) measurements when comparing gastroschisis cases with population nomograms. Individualized Growth Assessment (IGA) evaluates fetal growth using serial US measurements that allow consideration of the growth potential for a given case. Our goal was to assess the utility of IGA for distinguishing normal and pathological fetal growth in gastroschisis cases. STUDY DESIGN Pregnancies with prenatally diagnosed fetal gastroschisis were managed and delivered at a single academic medical center. US fetal biometry including head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FDL), and neonatal measurements including birthweight and HC were collected and analyzed for 32 consecutive fetal gastroschisis cases with at least two 2nd and two 3rd trimester measurements. Second trimester growth velocities were compared to a group of 118 non-anomalous fetuses with normal neonatal growth outcomes. Gastroschisis cases were classified into groups based on fetal growth pathology score (FGPS9) patterns. Agreement between IGA (FGPS9) and serial conventional estimated fetal weight (EFW) measurements for determining growth pathology was evaluated. Neonatal size outcomes were compared between conventional birthweight classifications for determining small for gestational age (SGA) and IGA Growth Potential Realization Index (GPRI) for weight and head circumference measurements. RESULTS Fetal growth pathology score (FGPS9) measurements identified three in-utero growth patterns: no growth pathology, growth restriction and recovery, and progressive growth restriction. In the no growth pathology group (n = 19), there was 84% agreement between IGA and conventional methods in determining pathological growth in both the 3rd trimester and at birth. In the growth restriction and recovery group (n = 7), there was 71% agreement both in the 3rd trimester and at birth between IGA and conventional methods. In the progressive growth restriction group (n = 5), there was 100% agreement in the 3rd trimester and 60% agreement at birth between IGA and conventional methods. CONCLUSION We present the first study using IGA to evaluate normal and pathological fetal growth in prenatally diagnosed gastroschisis cases. IGA was able to delineate two 3rd trimester growth pathology patterns - one with persistent growth restriction and another with in-utero growth recovery. Further validation of these initial findings with larger cohorts is warranted.
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Affiliation(s)
- Elizabeth Sherwin
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Russell Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Noor Joudi
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Paula Trepman
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Yasser Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna I Girsen
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Imee Datoc
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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9
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in SGA fetuses: 3. Late, adaptive and recovering growth restriction. J Matern Fetal Neonatal Med 2020; 35:2808-2817. [PMID: 32938245 DOI: 10.1080/14767058.2020.1803262] [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 characterize abnormal growth processes and their associated cardiovascular abnormalities in SGA fetuses using Individualized Growth Assessment (IGA). METHODS This longitudinal investigation utilized a SGA cohort [EFW and BW <10th percentile] derived from the PORTO study. Fetuses categorized by their Fetal Growth Pathology Score [FGPS1] patterns [Pattern 2 {n = 12}, Pattern 3 {n = 11}, Pattern 5 {n = 13}] were evaluated. Growth pathology was measured using the -FGPS1 and the individual composite Prenatal Growth Assessment Score {-icPGAS]. Paired cardiovascular assessments utilized measurements of the Pulsatility Index [umbilical artery {UA}, middle cerebral artery {MCA}, ductus venosus {DV}] and the myocardial performance index [MPI; heart]. Outcome variables were birth age [preterm or, term] and birth weight [small or normal (IGA criteria)]. RESULTS Pattern 2 was usually characterized by a single, growth abnormality (67% of cases) of variable magnitude that occurred within two weeks of delivery {median onset age: 37.6 weeks}. The incidence of UA abnormalities was low (25%) while those of MCA and DV/MPI were high {60%, 42%}. Most neonates were of normal size (67%) and delivered at term (67%). Pattern 3 had an initial progressive growth restriction phase, followed by constant but abnormally low growth. Growth pathology had an early onset (median age: 31.6 weeks), was moderate but persistently abnormal. The incidences of cardiovascular abnormalities were moderate [30-50%]. Most neonates were abnormally small (80%) but delivered at term (90%). Pattern 5 had an initial progressive phase with an early onset [onset age {median}: 31.6 weeks]. However, this process was arrested and returned toward normal. Growth pathology magnitudes were minor as were the incidences of cardiovascular abnormalities. Neonatal size was usually normal and all fetuses delivered at term. CONCLUSIONS Characteristics of SGA Growth Restricted, Patterns 2, 3 and 5 are clearly different from those found in SGA Normal or SGA Growth Restricted Pattern 1 groups. They also differed from one another, indicating that growth restriction can manifest itself in several different ways. Pattern 2 is similar to "late" growth restriction reported previously. Patterns 3 and 5 are novel and have been designated as "adaptive" and "recovering" types of growth restriction.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth C Tully
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Deter RL, Dicker P, Lee W, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in SGA fetuses: 2. Normal growth and progressive growth restriction. J Matern Fetal Neonatal Med 2020; 35:2818-2827. [PMID: 32924675 DOI: 10.1080/14767058.2020.1807506] [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
OBJECTIVES To characterize growth processes and their associated cardiovascular abnormalities in SGA fetuses with normal growth and progressive growth restriction patterns as defined by Individualized Growth Assessment (IGA). METHODS A SGA cohort (EFW and BW < 10th percentile) was derived from the PORTO study that included 47 fetuses with normal growth outcome (SGA Normal) and 34 fetuses with progressive growth restriction (SGA Growth Restricted, Pattern 1). Composite fetal size parameters were used to quantify growth pathology at individual third trimester time points (individual composite Prenatal Growth Assessment Score {icPGAS}) and calculated cumulatively during the third trimester (Fetal Growth Pathology Score 1{FGPS1}). Paired Doppler evaluations of the umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and myocardial performance index (MPI) were used to detect cardiovascular anomalies. Outcome variables were birth age and birth weight. RESULTS Ranking fetuses with respect to the severity of the 3rd trimester growth pathology (-FGPS1) revealed three subgroups in each of these two groups. In SGA Normal, no (51%), minimal (19%) or minor (30%) growth abnormalities were present. Although vascular flow abnormalities occurred without growth abnormalities (UA: 38%; MCA: 35%), they increased with minor growth disturbances (UA: 64%; MCA: 50%). All fetuses delivered at term and in only 7 cases (minor growth abnormalities subgroup) were the neonates abnormally small based on IGA criteria. In SGA Growth Restricted, Pattern 1, the progression of growth restriction was slow (47%), moderate (21%) and rapid (32%). Corresponding median -FGPS1 values were -1.34%, -2.67% and -4.88%, respectively. The median age of onset was 33.6, 29.7 and 29.7 weeks in these three subgroups. UA abnormalities occurred infrequently in the first two subgroups but were found in all cases of rapidly progressing pathology. Similar results were found for the MCA and DV + MPI Doppler parameters (rapid progression: MCA = 50%; DV + MPI = 50%). Premature delivery occurred less frequently with slow progression but was nearly 100% in the moderately and rapidly progressive subgroups. CONCLUSIONS Negative FGPS1 growth restriction patterns can be used to classify SGA fetuses. Subgroups, based on ranked -FGPS1 values in both SGA Normal and SGA Growth Restricted Pattern 1 groups had marked differences in cardiovascular abnormalities and neonatal outcomes. The characteristics of these two groups are consistent with small, normally growing fetuses and fetuses with "early" growth restriction, respectively.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Elizabeth C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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