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Anastasio MK, Anastasio AT, Kuller JA. Peripartum Pubic Symphysis Diastasis. Obstet Gynecol Surv 2023; 78:369-375. [PMID: 37322998 DOI: 10.1097/ogx.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Importance Peripartum separation of the pubic symphysis is a rare but potentially severe complication of childbirth, which may lead to prolonged immobilization. Thus, prompt diagnosis and treatment are paramount. Objective The purpose of this review is to define peripartum separation of the pubic symphysis and provide a thorough review of its etiology, clinical manifestations, diagnostic imaging techniques, management, and prognosis. Evidence Acquisition This was a literature review using PubMed and Google Scholar. Results Peripartum pubic symphysis separation is defined as disruption of the pubic symphysis joint and ligamentous structures with greater than 1 cm of separation during delivery. Risk factors include fetal macrosomia, nulliparity, and precipitous labor. Patients often present with a sensation of something "giving way" in the pubic symphysis area at the time of delivery, or with severe pain in the pubic symphysis region with attempted mobilization postpartum. In severe cases, associated hematomas, pelvic fractures, sacroiliac joint disruption, and urinary tract injury may be seen. Imaging such as x-ray or ultrasound may be used to confirm the diagnosis. Although most patients recover well with conservative management, orthopedic surgical intervention may be indicated in more severe or unresolved cases. Conclusions and Relevance Pubic symphysis separation is increasingly identified peripartum due enhanced accessibility and utilization of imaging modalities. It can be debilitating and lead to prolonged immobility postpartum. Therefore, early recognition and diagnosis are important, as this can guide decision-making for management. A multidisciplinary team approach, including coordination with obstetrics, orthopedic surgery, physical therapy, and occupational therapy should be used for early detection and treatment to ensure optimal patient outcomes.
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Affiliation(s)
| | | | - Jeffrey A Kuller
- Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Nyrhi L, Ponkilainen V, Kekki M, Mattila VM, Kuitunen I. Incidence of vaginal birth-related rupture of the pubic symphysis: A nationwide register study in Finland from 1998 to 2018. Scand J Surg 2022; 111:14574969221103161. [PMID: 35722784 DOI: 10.1177/14574969221103161] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To assess the incidence of vaginal birth -related rupture of the pubic symphysis in Finland from 1998 to 2018. METHODS A retrospective cohort study using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register. As participants we included all ≥ 22-week pregnancies of women aged between 15 and 49 years from January 1, 1998 to December 31, 2017. Pubic symphysis rupture was classified based on the ICD-10 code S33.4 and operations were gathered with pelvis-specific operation codes of the Nordic NOMESCO-classification. Incidence per 100 000 deliveries with 95% confidence intervals (CI) was calculated for symphysis rupture and surgery using Poisson's exact test. RESULTS For a total 1 175 326 deliveries, a total of 9 pubic symphysis ruptures occurred during the intrapartum and puerperal periods. All ruptures occurred after vaginal delivery. Of these, 4 ruptures were treated operatively. The incidence of rupture for vaginal delivery was 0.9 per 100 000 deliveries (CI 0.1 to 1.0). No perinatal mortality was observed. CONCLUSIONS Birth -related ruptures of the pubic symphysis are rate events and are mostly associated with vaginal delivery with most ruptures being treated conservatively.
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Affiliation(s)
- Lauri Nyrhi
- Faculty of Medicine and Health Technology, Tampere University, Arvo Building PB 100, 33014 Tampere Finland.,Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - Ville Ponkilainen
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - Maiju Kekki
- Department of Gynecology and Obstetrics, Tampere University Hospital, Tampere, Finland.,Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Ilari Kuitunen
- School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Pediatrics, Mikkeli Central Hospital, Mikkeli, Finland
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Deng L, Xiong LY, Zeng JH, Xiao Q, Xiong YH. Perinatal pubic symphysis separation combined with pubic fracture: a case report and literature review. J OBSTET GYNAECOL 2021; 42:1553-1555. [PMID: 34907841 DOI: 10.1080/01443615.2021.1981272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Liang Deng
- Department of Orthopedics, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Liang-Yu Xiong
- Department of Orthopedics, Zhangshu Municipal People's Hospital, Yichun, China
| | - Ji-Huan Zeng
- Department of Orthopedics, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Qiang Xiao
- Department of Orthopedics, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Yuan-Huan Xiong
- Department of Obstetrics and Gynecology, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
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Heim JA, Vang S, Lips E, Asche SE, Ly T, Das K. Pubic Symphysis Separation and Regression in Vaginal versus Cesarean Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:42-47. [PMID: 34416357 DOI: 10.1016/j.jogc.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To quantify the association of pubic symphysis separation with mode of delivery and follow the resolution of this physiologic separation in the postpartum period. METHODS Prospective observational cohort study that recruited two cohorts of primiparous women: those undergoing vaginal and cesarean delivery (45 and 46 patients, respectively). Chart review collected intrapartum factors. Patients were followed with serial anterior-posterior radiographs within 48 hours of delivery and at 6, 12, and 24 weeks postpartum, to evaluate the extent of pubic symphysis separation. Differences between the two cohorts in intrapartum factors were assesses as was pubic symphysis separation at each time point. RESULTS Mean age of women was 25.8 (SD 5.1) years, and 56% were White. Mean birth weight was 3.5 (SD 0.52) kg. Mean immediate postpartum pubic symphysis separation was 7.6 (SD 2.2) mm and did not differ between groups, at 7.18 mm for vaginal delivery versus 8.04 mm for cesarean delivery (CD; P = 0.08). Pubic symphysis separation was not significantly different for CD with and without labour. Black race and obesity were associated with increased pubic symphysis separation. No intrapartum events were related to extent of separation. Normalization of pregnancy pubic symphysis separation to 4-5 mm occurred by 6 weeks postpartum. Separation of >10mm and <15mm occurred in 10 of the 91 women and occurred after vaginal and cesarean delivery. The widest pubic symphysis separation was observed in 3 patients after vaginal delivery. CONCLUSION Physiological pubic symphysis separation occurs during pregnancy and regresses postpartum with minimal effects from labour and delivery. Cesarean delivery does not prevent physiological pubic symphysis separation.
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Affiliation(s)
- Jennifer A Heim
- Department of Obstetrics & Gynecology, Kaiser Permanente (TPMG), Santa Clara, CA
| | - Sandy Vang
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN; Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Erin Lips
- Department of Obstetrics & Gynecology, Women and Infants Hospital of Rhode Island, Providence, RI
| | | | - Thuan Ly
- Department of Orthopaedic Trauma, Massachusetts General Hospital, Boston, MA
| | - Kamalini Das
- Department of Obstetrics, Gynecology and Women's Health, Regions Hospital, St. Paul, MN.
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Musculoskeletal Considerations for Exercise and Sport: Before, During, and After Pregnancy. J Am Acad Orthop Surg 2021; 29:e805-e814. [PMID: 34043597 DOI: 10.5435/jaaos-d-21-00044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/03/2021] [Indexed: 02/01/2023] Open
Abstract
There is little written in the orthopaedic literature regarding common musculoskeletal problems that women encounter in relation to pregnancy and their clinical and surgical management. Exercise and other physical activity are generally recommended for most women before, during, and after pregnancy. Unfortunately, a variety of musculoskeletal issues may keep women from starting, continuing, or resuming a healthy exercise regimen throughout a notable portion of their reproductive years. Untreated and undertreated orthopaedic conditions in female athletes may therefore have further unintended negative effects on maternal and fetal health. This article reviews the existing literature on musculoskeletal health considerations before, during, and after pregnancy to provide practical information to orthopaedic surgeons who treat women of all ages and athletic abilities.
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Pascarella R, Sangiovanni P, Fantasia R, Cerbasi S. Chronic Pelvic Diastasis 22 Years After Twin Natural Delivery: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00107. [PMID: 34111042 DOI: 10.2106/jbjs.cc.20.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present here a case of chronic pelvic separation 22 years after twin natural delivery in a 49-year-old woman surgically treated with anterior and posterior stabilization. The functional and radiological recovery after a 4-year follow-up was extremely good. CONCLUSION Postpartum pubic symphysis diastasis is a rare but dreaded complication of natural delivery. Nonoperative treatment is still considered the gold standard. However, when pain persists despite nonoperative treatment and when a pelvic radiograph reveals a pubic diastasis greater than 2 cm, surgery is recommended. In the case of low back pain because of sacroiliac joint lesions, posterior fixation is indicated.
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Peripartum Pubic Symphysis Diastasis-Practical Guidelines. J Clin Med 2021; 10:jcm10112443. [PMID: 34072828 PMCID: PMC8198205 DOI: 10.3390/jcm10112443] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/10/2021] [Accepted: 05/28/2021] [Indexed: 12/29/2022] Open
Abstract
Optimal development of a fetus is made possible due to a lot of adaptive changes in the woman’s body. Some of the most important modifications occur in the musculoskeletal system. At the time of childbirth, natural widening of the pubic symphysis and the sacroiliac joints occur. Those changes are often reversible after childbirth. Peripartum pubic symphysis separation is a relatively rare disease and there is no homogeneous approach to treatment. The paper presents the current standards of diagnosis and treatment of pubic diastasis based on orthopedic and gynecological indications.
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Wang Y, Li YQ, Tian MR, Wang N, Zheng ZC. Role of relaxin in diastasis of the pubic symphysis peripartum. World J Clin Cases 2021; 9:91-101. [PMID: 33511175 PMCID: PMC7809669 DOI: 10.12998/wjcc.v9.i1.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/10/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Separation of the pubic symphysis can occur during the peripartum period. Relaxin (RLX) is a hormone primarily secreted by the corpus luteum that can mediate hemodynamic changes during pregnancy as well as loosen the pelvic ligaments. However, it is unknown whether RLX is associated with peripartum pubic symphysis separation and if the association is affected by other factors.
AIM To study the association between RLX and peripartum pubic symphysis separation and evaluate other factors that might affect this association.
METHODS We performed a cross-sectional study of pregnant women between April 2019 and January 2020. Baseline demographic characteristics, including gestational age, weight, neonatal weight, delivery mode and duration of the first and second stages of labor, were recorded. The clinical symptoms were used as a screening index during pregnancy, and the patients with pubic symphysis and inguinal pain were examined by color Doppler ultrasonography to determine whether there was pubic symphysis separation. Serum RLX concentrations were evaluated 1 d after delivery using an enzyme-linked immunosorbent assay, and pubic symphysis separation was diagnosed based on postpartum X-ray examination. We used an independent-sample t test to analyze the association between serum RLX levels and peripartum pubic symphysis separation. Multivariate regression analysis was used to evaluate whether the association between RLX and peripartum pubic symphysis separation was confounded by other factors, and the association between RLX and the severity of pubic symphysis separation was also assessed. We used Pearson correlation analysis to determine the factors related to RLX levels as well as the correlation between the degree of pubic symphysis separation and activities of daily living (ADL) and pain.
RESULTS A total of 54 women were enrolled in the study, with 15 exhibiting (observational group) and 39 not exhibiting (control group) peripartum pubic symphysis separation. There were no statistically significant differences in terms of maternal age, gestational age, pre-pregnancy weight, weight gain during pregnancy, delivery modes, or duration of the first or second stages of labor between the 2 groups. We did, however, note a statistically significant difference in serum RLX concentrations and neonatal weight between the observational and control groups (122.3 ± 0.7 µg/mL vs 170.4 ± 42.3 µg/mL, P < 0.05; 3676.000 ± 521.725 g vs 3379.487 ± 402.420 g, P < 0.05, respectively). Multivariate regression analyses showed that serum RLX level [odds ratio (OR): 1.022) and neonatal weight (OR: 1.002) were associated with pubic symphysis separation peripartum. The degree of separation of the pubic symphysis was negatively correlated with ADL and positively correlated with pain. There was no statistically significant association between serum RLX levels and the severity of pubic symphysis separation after adjusting for confounding factors.
CONCLUSION Serum RLX levels and neonatal weight were associated with the occurrence, but not the severity, of peripartum pubic symphysis separation.
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Affiliation(s)
- Yan Wang
- Rehabilitation Medicine, Taian City Central Hospital, Taian 271000, Shandong Province, China
| | - Yong-Qiang Li
- Department of Otolaryngology, Taian City Central Hospital, Taian 271000, Shandong Province, China
| | - Mei-Rong Tian
- Department of Obstetrics, Taian City Central Hospital, Taian 271000, Shandong Province, China
| | - Nan Wang
- Rehabilitation Centre, Qingdao Fuwai Cardiovascular Hospital, Qingdao 266034, Shandong Province, China
| | - Zun-Cheng Zheng
- Department of Rehabilitation, Taian City Central Hospital, Taian 271000, Shandong Province, China
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Müller M, Greve F, Zyskowski M, Wurm M, Biberthaler P, Kirchhoff C. [External fixation for treatment of peripartum pubic symphysis separation : Clinical case and discussion]. Unfallchirurg 2020; 124:673-677. [PMID: 33336261 PMCID: PMC8370944 DOI: 10.1007/s00113-020-00936-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 11/30/2022]
Abstract
A complete peripartum pubic symphysis separation is a rare but severe complication of natural birth. Its incidence is estimated to be 0.03-3 ‰. Minor partial separations with a small width can be treated with a pelvic binder. Separations with major dehiscence should be treated by surgical reduction and fixation. This article presents the case of a 30-year-old woman who suffered a complete rupture of the pubic symphysis during the birth of her second child. Radiographic dehiscence was 39 mm. The operative treatment was carried out using a supra-acetabular external fixator for 12 weeks with a good result.
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Affiliation(s)
- M Müller
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland.
| | - F Greve
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - M Zyskowski
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - M Wurm
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - P Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - C Kirchhoff
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland
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The effects of pelvic belt use on pelvic alignment during and after pregnancy: a prospective longitudinal cohort study. BMC Pregnancy Childbirth 2019; 19:305. [PMID: 31438891 PMCID: PMC6704663 DOI: 10.1186/s12884-019-2457-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 08/13/2019] [Indexed: 11/27/2022] Open
Abstract
Background Pelvic alignment changes during pregnancy and post-childbirth. Pelvic belts exert external forces that compress and stabilize the joints, and therefore, could influence pelvic alignment. However, limited information is available regarding this potential effect. Therefore, the purpose of this study is to investigate the influence of pelvic belt use on pelvic alignment during and after pregnancy. Methods Data of 201 pregnant women in late pregnancy and 1 month after childbirth were used. Pelvic alignment measurements, including anterior and posterior pelvic width, pelvic asymmetry, and pelvic belt use during and after pregnancy were investigated. Participants were divided into four groups according to pelvic belt use: before and after childbirth (BAC), before childbirth only (BC), after childbirth only (AC), and non-use (NU). Then, an initial one-way ANOVA was conducted to compare the amount of change in pelvic alignment from late pregnancy to post-childbirth between the groups. After the initial analysis, a multivariate regression analysis was performed to determine the statistically significant differences between the groups to consider other factors that influenced pelvic alignment such as age, BMI, number of previous childbirths, vaginal delivery and pelvic asymmetry in late pregnancy. Next, a cutoff point for subgroup stratification based on the weekly duration of pelvic belt use and inter-group changes in pelvic alignment were compared. Results As the result of the initial one-way ANOVA, the decrease in pelvic asymmetry from during pregnancy to postpartum for BAC was greater than that for AC. Moreover, multiple regression analysis showed that the effect of pelvic belt that was revealed in the initial analysis was statistical significance even after adjustment for other factors. Moreover, pelvic asymmetry in the BAC group decreased, compared to being increased or unchanged in the NU and AC groups when the group cutoff time was 7 h per week. Conclusions Continuous and extended use of pelvic belts during and after pregnancy might be related to modifications of pelvic asymmetry in the perinatal period. Therefore, the instruction of correct and comfortable usage and the recommendation of continuous use of pelvic belt especially during pregnancy are required for prevention of some discomforts related to pelvic malalignment. Electronic supplementary material The online version of this article (10.1186/s12884-019-2457-6) contains supplementary material, which is available to authorized users.
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Buitendyk M, Brennan B, Vora P, Smith P, Winsor S. Acute Intrapartum Rupture of the Pubic Symphysis Requiring Resuscitation and Surgical Intervention: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 40:68-71. [PMID: 28822629 DOI: 10.1016/j.jogc.2017.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/21/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pubic symphysis rupture significant enough to cause serious complications or require surgical intervention is exceedingly rare. Here we review the literature and examine the details of a unique presentation. CASE A 27-year-old woman presented in labour at 34+6 weeks gestation after an uncomplicated monochorionic-diamniotic twin pregnancy. After vaginal delivery, she developed a substantial labial hematoma. Hours later, she became hemodynamically unstable. Imaging revealed a 4.7-cm pubic diastasis and a small arterial tear. One week later, the diastasis had expanded to 6 cm on X-ray. As a result, the patient underwent surgical intervention. She was discharged home on postpartum day 21 and remained non-weight-bearing for 8 weeks. CONCLUSION Pubic symphysis rupture is a potentially life-threatening obstetrical complication that requires early recognition and effective multidisciplinary care.
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Affiliation(s)
- Marie Buitendyk
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON.
| | - Barbara Brennan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University Medical Centre, Hamilton, ON
| | - Parag Vora
- Department of Radiology, McMaster University Medical Centre, Hamilton, ON
| | - Patricia Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University Medical Centre, Hamilton, ON
| | - Stephanie Winsor
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University Medical Centre, Hamilton, ON
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