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Vinnars MT, Bixo M, Damdimopoulou P. Pregnancy-related maternal physiological adaptations and fetal chemical exposure. Mol Cell Endocrinol 2023; 578:112064. [PMID: 37683908 DOI: 10.1016/j.mce.2023.112064] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/15/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023]
Abstract
Prenatal life represents a susceptible window of development during which chemical exposures can permanently alter fetal development, leading to an increased likelihood of disease later in life. Therefore, it is essential to assess exposure in the fetus. However, direct assessment in human fetuses is challenging, so most research measures maternal exposure. Pregnancy induces a range of significant physiological changes in women that may affect chemical metabolism and responses. Moreover, placental function, fetal sex, and pregnancy complications may further modify these exposures. The purpose of this narrative review is to give an overview of major pregnancy-related physiological changes, including placental function and impacts of pregnancy complications, to summarize existing studies assessing chemical exposure in human fetal organs, and to discuss possible interactions between physiological changes and exposures. Our review reveals major knowledge gaps in factors affecting fetal chemical exposure, highlighting the need to develop more sophisticated tools for chemical health risk assessment in fetuses.
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Affiliation(s)
- Marie-Therese Vinnars
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Marie Bixo
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Pauliina Damdimopoulou
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Magnetic resonance spectroscopy and liquid chromatography-mass spectrometry metabolomics study may differentiate pre-eclampsia from gestational hypertension. Eur Radiol 2023:10.1007/s00330-023-09454-x. [PMID: 36809432 DOI: 10.1007/s00330-023-09454-x] [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: 04/27/2022] [Revised: 01/12/2023] [Accepted: 02/05/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE To investigate the findings of magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and serum metabolomics for differentiating pre-eclampsia (PE) from gestational hypertension (GH). METHODS This prospective study enrolled 176 subjects including a primary cohort with healthy non-pregnant women (HN, n = 35), healthy pregnant women (HP, n = 20), GH (n = 27), and PE (n = 39) and a validation cohort with HP (n = 22), GH (n = 22), and PE (n = 11). T1 signal intensity index (T1SI), apparent diffusion coefficient (ADC) value, and the metabolites on MRS were compared. The differentiating performances of single and combined MRI and MRS parameters for PE were evaluated. Serum liquid chromatography-mass spectrometry (LC-MS) metabolomics was investigated by sparse projection to latent structures discriminant analysis. RESULTS Increased T1SI, lactate/creatine (Lac/Cr), and glutamine and glutamate (Glx)/Cr and decreased ADC value and myo-inositol (mI)/Cr in basal ganglia were found in PE patients. T1SI, ADC, Lac/Cr, Glx/Cr, and mI/Cr yielded an area under the curves (AUC) of 0.90, 0.80, 0.94, 0.96, and 0.94 in the primary cohort, and of 0.87, 0.81, 0.91, 0.84, and 0.83 in the validation cohort, respectively. A combination of Lac/Cr, Glx/Cr, and mI/Cr yielded the highest AUC of 0.98 in the primary cohort and 0.97 in the validation cohort. Serum metabolomics analysis showed 12 differential metabolites, which are involved in pyruvate metabolism, alanine metabolism, glycolysis, gluconeogenesis, and glutamate metabolism. CONCLUSIONS MRS is expected to be a noninvasive and effective tool for monitoring GH patients to avoid the development of PE. KEY POINTS • Increased T1SI and decreased ADC value in the basal ganglia were found in PE patients than in GH patients. • Increased Lac/Cr and Glx/Cr, and decreased mI/Cr in the basal ganglia were found in PE patients than in GH patients. • LC-MS metabolomics showed that the major differential metabolic pathways between PE and GH were pyruvate metabolism, alanine metabolism, glycolysis, gluconeogenesis, and glutamate metabolism.
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Yarlagadda RD, Johnson J, Vårtun Å, Flo K, Acharya G. Maternal plasma pro-atrial and C-type natriuretic peptide levels and their associations with cardiovascular and renal function in the second half of normal pregnancy: a longitudinal study. BMC Pregnancy Childbirth 2021; 21:358. [PMID: 33952207 PMCID: PMC8097896 DOI: 10.1186/s12884-021-03824-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/21/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Physiological adaptation in pregnancy is characterized by remodeling of endocrine, cardiovascular and renal functions leading to fluid retention, volume expansion, altered cardiac loading conditions and hyperdynamic circulation. Natriuretic peptides have been used as biomarkers of cardiovascular function, but their associations with gestational age-related changes in maternal cardiac, endothelial and renal function have not been elucidated. The aim of this study was to establish longitudinal reference values for maternal plasma atrial natriuretic peptide (proANP) and C-type natriuretic peptide (CNP) and investigate their temporal association with cardiovascular and renal function in the second half of pregnancy. METHODS This study was a prospective longitudinal study of 53 low-risk pregnancies. Women were examined every 3-5 weeks during 22-40 weeks of gestation (252 observations). Fasting maternal blood samples were obtained to measure proANP, CNP, creatinine, cystatin C, uric acid, and fibrinogen levels. Cardiac function and systemic hemodynamics were assessed noninvasively by impedance cardiography (ICG) and vascular endothelial function by flow-mediated vasodilation of brachial artery (FMD). RESULTS The plasma proANP (R2adj = 0.79; P = 0.007), CNP (R2adj = 0.54; P = 0.005) decreased between 22 and 40 weeks. The creatinine (R2adj = 0.90; P < 0.001), cystatin C (R2adj = 0.93; P = < 0.001) and uric acid (R2adj = 0.83; P < 0.001) increased significantly, whereas the estimated glomerular filtration rate (R2adj = 0.93; P < 0.001) decreased with gestational age. The FMD did not change significantly but fibrinogen (R2adj = 0.79; P < 0.001) increased with advancing gestation. The maternal systemic vascular resistance index (R2adj = 0.50; P < 0.001) increased, stroke index (R2adj = 0.62; P < 0.001) decreased, whereas the cardiac index (R2adj = 0.62; P = 0.438) and thoracic fluid content (R2adj = 0.72; P = 0.132) did not change significantly with gestation. The proANP was associated with thoracic fluid content (R2adj = 0.74; P < 0.001) and fibrinogen (R2adj = 0.78; P = 0.034) but not with other variables of systemic hemodynamics, endothelial function, or renal function. The CNP was not associated significantly with parameters of cardiovascular or renal function. CONCLUSION Longitudinal reference values for maternal plasma proANP and CNP were established. These natriuretic peptides decreased slightly with advancing gestation, but they did not reflect the temporal physiological changes in maternal systemic hemodynamics, vascular endothelial function and renal function during the second half of pregnancy. The proANP correlated with the thoracic fluid content reflecting volume load in pregnancy.
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Affiliation(s)
- Rima D Yarlagadda
- Department of Clinical Medicine, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway
- The University of Virginia, College of Arts and Science, Charlottesville, VA, USA
| | - Jonas Johnson
- Division of Obstetrics and Gynecology, CLINTEC, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Åse Vårtun
- Department of Clinical Medicine, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Kari Flo
- Department of Clinical Medicine, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway
- University Hospital of North Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Ganesh Acharya
- Department of Clinical Medicine, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway.
- Division of Obstetrics and Gynecology, CLINTEC, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
- University Hospital of North Norway, Tromsø, Norway.
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Mallucci G, Beneventi F, Bergamaschi R, Bizzotto C, Cavagnoli C, De Maggio I, Bellingeri C, Monti C, Viarengo G, Spinillo A. Circulating endothelial progenitor cells during pregnancy in multiple sclerosis. Neurol Sci 2020; 42:1443-1451. [PMID: 32804349 PMCID: PMC7956006 DOI: 10.1007/s10072-020-04648-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/01/2020] [Indexed: 11/30/2022]
Abstract
Background Endothelial progenitor cells (EPCs) have been shown to increase during physiological pregnancy and are believed to play a fundamental role in the process of placentation. Reduced levels of EPCs during pregnancy have been associated with preeclampsia and miscarriage. Women with multiple sclerosis (MS) are not at increased risk of preeclampsia nor of general adverse obstetric outcome, in contrast with some other autoimmune diseases. Objective The aim of this study was to evaluate circulating EPCs levels in pregnant patients with MS. Methods CD34+ and CD133+ were longitudinally detected by flow cytometry in the maternal plasma of 29 healthy controls and 9 MS patients and in the cord blood of their newborns. Results EPCs were affected by pregnancy with the same trend in both groups (CD34+ p = 0.0342; CD133+ p = 0.0347). EPCs during pregnancy were increased in MS (mean ± SD: CD34+ cells 0.038 ± 0.010; CD133+ 0.024 ± 0.009) with respect to healthy controls (mean ± SD: CD34+ cells 0.022 ± 0.006; CD133+ 0.016 ± 0.004), CD34+ p = 0.0004; CD133+ p = 0.0109. EPCs levels of the cord blood of MS patients' newborns mild correlated with maternal EPC levels at delivery (CD34+: spearman’s Rho 0.658, p = 0.054; CD133+: spearman’s Rho 0.758, p = 0.018). Conclusions This work identified increased circulating EPC levels during pregnancy, following the same trend both in MS patients and healthy controls. Despite the similar trend, the levels of circulating EPCs were significantly higher in MS patients with respect to the control population. A correlation was also found in MS patients between cord blood EPCs and circulating EPCs at delivery. Electronic supplementary material The online version of this article (10.1007/s10072-020-04648-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giulia Mallucci
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
- Multiple Sclerosis Center, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
| | - Fausta Beneventi
- Department of Obstetrics and Gynaecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Roberto Bergamaschi
- Multiple Sclerosis Center, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Cristina Bizzotto
- Multiple Sclerosis Center, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Chiara Cavagnoli
- Department of Obstetrics and Gynaecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Irene De Maggio
- Department of Obstetrics and Gynaecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Camilla Bellingeri
- Department of Obstetrics and Gynaecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Cristina Monti
- Department of Public Health Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Gianluca Viarengo
- Immunohaematology and Transfusion Service, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Arsenio Spinillo
- Department of Obstetrics and Gynaecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy
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Tolunay HE, Elci E. Importance of haemogram parameters for prediction of the time of birth in women diagnosed with threatened preterm labour. J Int Med Res 2020; 48:300060520918432. [PMID: 32295437 PMCID: PMC7163240 DOI: 10.1177/0300060520918432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/08/2020] [Indexed: 12/12/2022] Open
Abstract
Objective This study aimed to estimate the importance of complete blood count parameters for predicting the timing of birth in threatened preterm labour cases. Methods We performed a retrospective study of 92 patients who were diagnosed with threatened preterm labour (24–34 gestational weeks). The patients were divided into two groups according to the time of birth (group 1: delivered within the first week after diagnosis; group 2: delivered later than 1 week). We compared characteristics and complete blood count parameters between these two groups. Results There were no significant differences in maternal age, body mass index, gravida, parity, haemoglobin levels, and gestational weeks between the two groups. The mean cervical length was 24.24 ± 3.60 mm in group 1 and 30.70 ± 5.32 mm in group 2. There were significant differences in the neutrophil to lymphocyte ratio, white blood cell count, red cell distribution width (RDW), absolute lymphocyte cell count, and absolute neutrophil cell count between the two groups. Conclusion Maternal serum RDW, the neutrophil to lymphocyte ratio, white blood cell count, absolute lymphocyte cell count, and the absolute neutrophil cell count profile could guide clinicians in predicting the time of birth in threatened preterm labour cases.
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Affiliation(s)
- Harun Egemen Tolunay
- Department of Perinatology, Etlik Zübeyde Hanım Maternity and
Women’s Health Teaching and Research Hospital, Ankara, Turkey
| | - Erkan Elci
- Van Training and Research Hospital, Department of Obstetrics and
Gynecology, Van, Turkey
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Zhang J, Li J. Efficacy and safety of combination of magnesium sulfate, phentolamine and nifedipine in treatment of patients with hypertensive disorder complicating pregnancy. Exp Ther Med 2019; 18:3341-3346. [PMID: 31602207 PMCID: PMC6777338 DOI: 10.3892/etm.2019.7965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/01/2019] [Indexed: 12/22/2022] Open
Abstract
Efficacy and safety of the combination of magnesium sulfate, phentolamine and nifedipine in the treatment of patients with hypertensive disorder complicating pregnancy (HDCP) and its effect on hemodynamics and urinary protein level were investigated. One hundred and six patients with HDCP diagnosed at the Affiliated Hospital of Beihua University from February 5, 2016 to May 9, 2017 were retrospectively analyzed. Patients were divided into the magnesium sulfate group and the combination group, according to the therapeutic schemes. The efficacy 1 week later was observed. The general clinical data of the patients were recorded, and data were acquired with respect to hemodynamic indexes before and after treatment [changes of S/D ratio of umbilical artery flow, and cardiac index and total peripheral resistance (TPR)], the 24-h urinary protein level, clinical efficacy and safety [adverse drug reactions (ADR) and maternal and neonatal outcomes]. Before treatment, there was no statistically significant difference between the two groups in terms of S/D ratio of umbilical artery flow (P>0.05), while after treatment the S/D ratio was significantly lower than that before treatment in both groups (P<0.05). Before treatment, there was no statistically significant difference between the two groups in terms of cardiac index (P>0.05). TPR after treatment was significantly lower than that before treatment in both groups (P<0.001). Compared with the magnesium sulfate group, patients in the combination group had significantly lower 24-h urinary protein level after treatment (P<0.001), significantly higher total effective rate (P<0.05), significantly lower incidence rate of ADR (P<0.001), and significantly lower incidence rate of adverse maternal and neonatal outcomes (P<0.001). In conclusion, the combination of magnesium sulfate, phentolamine and nifedipine can significantly improve the hemodynamic indexes, the 24-h urinary protein level, the clinical efficacy, ADR and maternal and neonatal outcomes of patients with HDCP, therefore it is worthy of use in the clinic.
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Affiliation(s)
- Jinggui Zhang
- Department of Cardiovascular Medicine, Affiliated Hospital of Beihua University, Jilin 132001, P.R. China
| | - Jun Li
- Screening Laboratory, Jilin Hospital for Gynecology and Obstetrics, Jilin 132011, P.R. China
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Garg P, Jaryal AK, Kachhawa G, Kriplani A, Deepak KK. Sequential profile of endothelial functions and arterial stiffness in preeclampsia during the course of pregnancy. Pregnancy Hypertens 2019; 18:88-95. [DOI: 10.1016/j.preghy.2019.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/31/2019] [Accepted: 09/22/2019] [Indexed: 11/15/2022]
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8
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Can E, Can C. The value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) parameters in analysis with fetal malnutrition neonates. J Perinat Med 2019; 47:775-779. [PMID: 31318695 DOI: 10.1515/jpm-2019-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/25/2019] [Indexed: 11/15/2022]
Abstract
Objective To assess the association between fetal malnutrition (FM) and the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) in singleton term appropriate for gestational age (AGA) neonates. Methods This cross-sectional observational study was performed with 4340 singleton, term AGA neonates without perinatal disease over a two-year period. Results A total of 4320 neonates were evaluated in this study. Those diagnosed with fetal malnutrition, 284 (6%) neonates, were compared with 150 healthy term AGA neonates. Gestational week, birth weight, birth height, head circumference, maternal age, last pregnancy weight, and status of income of the FM group were found to be lower when compared to the control group (P = 0.011). Low last pregnancy weight (P = 0.017) and low level of income (P = 0.042) were found to be factors that affect the presence of FM. The NLR and PLR were found to be significantly higher in the FM group compared with term AGA healthy controls. In correlation analyses, there was a negative correlation between the NLR and PLR with fetal nutritional status (P = 0.011 and P < 0.001, respectively). When the NLR level was taken as 4.51, the sensitivity and specificity of the test for FM were calculated as 81.2% and 80.8%, respectively [area under the receiver-operating characteristic curve (AUROC): 0.81]; when the PLR level was taken as 155.4, the sensitivity and specificity of the test for FM were calculated as 87.0% and 85.4%, respectively (AUROC: 0.94). Conclusion Cord-blood NLR and PLR negatively correlate with term FM AGA neonates.
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Affiliation(s)
- Emrah Can
- Associate Professor, Department of Pediatrics, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Ceren Can
- Department of Pediatric Immunology and Allergy, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Mannaerts D, Faes E, Cornette J, Gyselaers W, Spaanderman M, Goovaerts I, Stoop T, Roelant E, Jacquemyn Y, Van Craenenbroeck EM. Low-flow mediated constriction as a marker of endothelial function in healthy pregnancy and preeclampsia: A pilot study. Pregnancy Hypertens 2019; 17:75-81. [PMID: 31487661 DOI: 10.1016/j.preghy.2019.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 01/27/2019] [Accepted: 02/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Overwhelming clinical evidence exists on disturbed vascular and endothelial function in the pathophysiology of preeclampsia (PE). In a non-pregnant (NP) population, L-FMC (low-flow mediated constriction) provides insight in the 'resting' endothelial capacity in contrast to the gold standard of flow mediated dilatation (FMD), reflecting endothelial nitric oxide bioavailability. STUDY DESIGN Longitudinal follow-up of 100 healthy pregnant (HP) women, 33 PE women and 16 NP controls with non-invasive vascular assessments. HP women were evaluated at 12 and 35 weeks of gestation and at 6 months postpartum. PE patients were assessed at diagnosis (mean 30 weeks) and 6 months postpartum. MAIN OUTCOME MEASURES Endothelial function (L-FMC, FMD, peripheral arterial tonometry (PAT)) and arterial stiffness (pulse wave velocity (PWV) and analysis (PWA)) were measured at the different visits and compared between groups. RESULTS Overall endothelial dysfunction is present in PE (FMD HP 9.09 ± 4.20 vs PE 5.21 ± 4.47, p = 0.0004; L-FMC HP -1.90 ± 2.66 vs PE -0.40 ± 2.09, p = 0.03). L-FMC gradually elevates during the course of a HP (1st trim -0.31 ± 1.75 vs 3rd trim -1.97 ± 3.02, p < 0.0001) and is present in 85% of women in the third trimester. In NP, only 27% of women has L-FMC. In PE, L-FMC is present in 50% of cases. Arterial stiffness is increased in PE (all p < 0.0001). There is no correlation between L-FMC and other markers of vascular function (p > 0.05). CONCLUSION PE is characterized by dysfunction of both resting and recruitable endothelial capacity. This study offers new insights in different aspects of endothelial function in pregnancy, since L-FMC reflects an adaptation in HP that is absent in PE.
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Affiliation(s)
- Dominique Mannaerts
- Research Group ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Belgium; Department of Obstetrics and Gynaecology, Antwerp University Hospital, Belgium.
| | - Ellen Faes
- Research Group ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Belgium; Department of Obstetrics and Gynaecology, Antwerp University Hospital, Belgium
| | - Jerome Cornette
- Department of Obstetrics and Gynaecology, Erasmus M.C. Rotterdam, The Netherlands
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynaecology, Ziekenhuis-Oost Limburg, Genk, Belgium
| | - Marc Spaanderman
- Department of Obstetrics and Gynaecology, MUMC Maastricht University, The Netherlands
| | - Inge Goovaerts
- Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Tibor Stoop
- Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Yves Jacquemyn
- Research Group ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Belgium; Department of Obstetrics and Gynaecology, Antwerp University Hospital, Belgium
| | - Emeline M Van Craenenbroeck
- Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium; Research Group Cardiovascular Diseases, Translational Pathophysiological Research, University of Antwerp, Edegem, Belgium
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Mannaerts D, Faes E, Gielis J, Van Craenenbroeck E, Cos P, Spaanderman M, Gyselaers W, Cornette J, Jacquemyn Y. Oxidative stress and endothelial function in normal pregnancy versus pre-eclampsia, a combined longitudinal and case control study. BMC Pregnancy Childbirth 2018; 18:60. [PMID: 29482567 PMCID: PMC5827979 DOI: 10.1186/s12884-018-1685-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Pre-eclampsia (PE) is related to an impaired endothelial function. Endothelial dysfunction accounts for altered vascular reactivity, activation of the coagulation cascade and loss of vascular integrity. Impaired endothelial function originates from production of inflammatory and cytotoxic factors by the ischemic placenta and results in systemic oxidative stress (OS) and an altered bioavailability of nitric oxide (•NO). The free radical •NO, is an endogenous endothelium-derived relaxing factor influencing endothelial function. In placental circulation, endothelial release of •NO dilates the fetal placental vascular bed, ensuring feto-maternal exchange. The Endopreg study was designed to evaluate in vivo endothelial function and to quantify in vitro OS in normal and pre-eclamptic pregnancies. Methods/design The study is divided into two arms, a prospective longitudinal study and a matched case control study. In the longitudinal study, pregnant patients ≥18 years old with a singleton pregnancy will be followed throughout pregnancy and until 6 months post-partum. In the case control study, cases with PE will be compared to matched normotensive pregnant women. Maternal blood concentration of superoxide (O2•) and placental concentration of •NO will be determined using EPR (electron paramagnetic resonance). Endothelial function and arterial stiffness will be evaluated using respectively Peripheral Arterial Tonometry (PAT), Flow-Mediated Dilatation (FMD) and applanation tonometry. Placental expression of eNOS (endothelial NOS) will be determined using immune-histochemical staining. Target recruitment will be 110 patients for the longitudinal study and 90 patients in the case-control study. Discussion The results of Endopreg will provide longitudinal information on in vivo endothelial function and in vitro OS during normal pregnancy and PE. Adoption of these vascular tests in clinical practice potentially predicts patients at risk to develop cardiovascular events later in life after PE pregnancies. •NO, O2•− and eNOS measurements provide further inside in the pathophysiology of PE. Trial registration This trial has been registered on clinicaltrials.gov. ClinicalTrials.gov Identifier: NCT02603913. Registered October 2015.
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Affiliation(s)
- Dominique Mannaerts
- Departement of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium.,ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Antwerp, Belgium
| | - Ellen Faes
- Departement of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium.,ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Antwerp, Belgium
| | - Jan Gielis
- ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Antwerp, Belgium
| | - Emeline Van Craenenbroeck
- Laboratory for Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.,Research Group Cardiovascular Diseases, Translational Pathophysiological Research, University of Antwerp, Antwerp, Belgium
| | - Paul Cos
- Laboratory for Microbiology, Parasitology and Hygiene (LMPH), University of Antwerp, Antwerp, Belgium
| | - Marc Spaanderman
- Departement of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wilfried Gyselaers
- Departement of Obstetrics and Gynecology, Ziekenhuis-Oost-Limburg (ZOL), Genk, Belgium
| | - Jerome Cornette
- Departement of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Yves Jacquemyn
- Departement of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium. .,ASTARC, Antwerp Surgical Training, Anatomy and Research Centre, University of Antwerp, Antwerp, Belgium. .,Department of Obstetrics and Gynaecology, Antwerp Surgical Training and Anatomy Research Centre (ASTARC), Antwerp University/Antwerp University Hospital, Antwerp, Belgium.
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Mannaerts D, Heyvaert S, De Cordt C, Macken C, Loos C, Jacquemyn Y. Are neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and/or mean platelet volume (MPV) clinically useful as predictive parameters for preeclampsia? J Matern Fetal Neonatal Med 2017; 32:1412-1419. [PMID: 29179639 DOI: 10.1080/14767058.2017.1410701] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Preeclampsia (PE) is a severe pregnancy complication with significant maternal and neonatal morbi-mortality resulting in high health care costs. Prevention, mainly based on the administration of acetylsalicylic acid, is only possible if timely identification of high-risk patients can be realized in an easy, nonexpensive, and widely available method. This paper explores the clinical usability of neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and/or mean platelet volume (MPV) in discriminating between women that will and those that will not develop PE. STUDY DESIGN Demographic data and laboratory results were retrospectively collected and compared in 2050 pregnant women (164 PE and 1886 controls) between 1 January 2014 and 31 January 2016. RESULTS In the PE group, gravidity, parity, gestational age, and birth weight were significantly lower compared to the control group. Before the 20th pregnancy week, MPV was significantly elevated in the PE group compared to the controls (p = .006), hence analysis revealed an optimal cut-off point of 8.15 (sensitivity 66.7%, specificity 56.3%) for predicting PE. At the end of pregnancy, NLR and MPV appeared to be higher and PLR lower in the PE group compared to the controls, which strengthens the current knowledge on the pathogenesis of PE. CONCLUSIONS MPV is significantly elevated in the first half of pregnancy in women who later develop PE and might therefore be implemented in combination with other parameters in a PE prediction model.
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Affiliation(s)
- Dominique Mannaerts
- a Department of Obstetrics and Gynecology , Antwerp University Hospital , Antwerp , Belgium.,b Anatomy and Research Centre, Research Group ASTARC, Antwerp Surgical Training, University of Antwerp , Antwerp , Belgium
| | - Suzanne Heyvaert
- a Department of Obstetrics and Gynecology , Antwerp University Hospital , Antwerp , Belgium
| | - Chania De Cordt
- a Department of Obstetrics and Gynecology , Antwerp University Hospital , Antwerp , Belgium
| | - Claartje Macken
- a Department of Obstetrics and Gynecology , Antwerp University Hospital , Antwerp , Belgium
| | - Charlotte Loos
- a Department of Obstetrics and Gynecology , Antwerp University Hospital , Antwerp , Belgium
| | - Yves Jacquemyn
- a Department of Obstetrics and Gynecology , Antwerp University Hospital , Antwerp , Belgium.,b Anatomy and Research Centre, Research Group ASTARC, Antwerp Surgical Training, University of Antwerp , Antwerp , Belgium
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12
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Lopes van Balen VA, van Gansewinkel TAG, de Haas S, van Kuijk SMJ, van Drongelen J, Ghossein-Doha C, Spaanderman MEA. Physiological adaptation of endothelial function to pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:697-708. [PMID: 28170124 DOI: 10.1002/uog.17431] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/30/2016] [Accepted: 01/30/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To establish reference values for flow-mediated dilatation (FMD) and brachial artery diameter (BAD) in pregnancy and to provide insight into the physiological and pathological course of endothelial adaptation throughout human singleton pregnancy. METHODS A meta-analysis was performed following a systematic review of current literature on FMD, as a derivative for endothelial function, and BAD, throughout uncomplicated and complicated pregnancy. PubMed (NCBI) and EMBASE (Ovid) electronic databases were used for the literature search, which was performed from inception to 9 June 2016. To allow judgment of changes in comparison with the non-pregnant state, studies were required to report both non-pregnant mean reference of FMD (matched control group, prepregnancy or postpartum measurement) and mean FMD at a predetermined and reported gestational age. Pooled mean differences between the reference and pregnant FMD values were calculated for predefined intervals of gestational age. RESULTS Fourteen studies that enrolled 1231 participants met the inclusion criteria. Publication dates ranged from 1999 to 2014. In uncomplicated pregnancy, FMD was increased in the second and third trimesters. Between 15 and 21 weeks of gestation, absolute FMD increased the most, by a mean (95% CI) of 1.89% (0.25-3.53%). This was a relative increase of 22.5% (3.0-42.0%) compared with the non-pregnant reference. BAD increased progressively, in a steady manner, by the second trimester but not significantly in the first half of the second trimester. We could not discern differences in FMD and BAD between complicated and uncomplicated pregnancies at 29-35 weeks' gestation, reported in the three studies that met our inclusion criteria. Despite the increase in FMD and BAD throughout gestation, both reference curves were characterized by wide 95% CIs. CONCLUSION During healthy pregnancy, endothelium-dependent vasodilatation and BAD increase. Women with a complicated pregnancy had FMD values within the lower range when compared with those with uncomplicated pregnancy but, as a group, did not differ from each other. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- V A Lopes van Balen
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - T A G van Gansewinkel
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S de Haas
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - C Ghossein-Doha
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M E A Spaanderman
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Dong X, Bai C, Nao J. Clinical and radiological features of posterior reversible encephalopathy syndrome in patients with pre-eclampsia and eclampsia. Clin Radiol 2017; 72:887-895. [DOI: 10.1016/j.crad.2017.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/26/2017] [Accepted: 06/06/2017] [Indexed: 12/19/2022]
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14
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Mannaerts D, Faes E, Goovaerts I, Stoop T, Cornette J, Gyselaers W, Spaanderman M, Van Craenenbroeck EM, Jacquemyn Y. Flow-mediated dilation and peripheral arterial tonometry are disturbed in preeclampsia and reflect different aspects of endothelial function. Am J Physiol Regul Integr Comp Physiol 2017; 313:R518-R525. [PMID: 28794106 DOI: 10.1152/ajpregu.00514.2016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 12/26/2022]
Abstract
Endothelial function and arterial stiffness are known to be altered in preeclamptic pregnancies. Previous studies have shown conflicting results regarding the best technique for assessing vascular function in pregnancy. In this study, we made a comprehensive evaluation of in vivo vascular function [including flow-mediated dilatation (FMD), peripheral arterial tonometry (PAT), and arterial stiffness] in preeclamptic patients and compared them with normal pregnancies. In addition, we assessed the relation between vascular function and systemic inflammation. Fourteen patients with preeclampsia (PE) and 14 healthy pregnant controls were included. Endothelial function was determined by FMD and PAT and arterial stiffness by carotid-femoral pulse-wave velocity and augmentation index. Systemic inflammation was assessed using mean platelet volume (MPV) and neutrophil-lymphocyte ratio (NLR). The reactive hyperemia index, assessed using PAT, is decreased at the third trimester compared with the first trimester in a normal, uncomplicated pregnancy (P = 0.001). Arterial stiffness is significantly higher in PE versus normal pregnancy (P < 0.001). Endothelial function, obtained by FMD, is deteriorated in PE versus normal pregnancy (P = 0.015), whereas endothelial function assessment by PAT is improved in PE versus normal pregnancy (P = 0.001). Systemic inflammation (MPV and NLR) increases during normal pregnancy. FMD and PAT are disturbed in PE. Endothelial function, assessed by FMD and PAT, shows distinct results. This may indicate that measurements with FMD and PAT reflect different aspects of endothelial function and that PAT should not be used as a substitute for FMD as a measure of endothelial function in pregnancy.
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Affiliation(s)
- Dominique Mannaerts
- Research Group, Antwerp Surgical Training, Anatomy & Research Center, University of Antwerp, Antwerp, Belgium; .,Department of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium
| | - Ellen Faes
- Research Group, Antwerp Surgical Training, Anatomy & Research Center, University of Antwerp, Antwerp, Belgium.,Department of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium
| | - Inge Goovaerts
- Laboratory of Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Tibor Stoop
- Laboratory of Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Jerome Cornette
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynaecology, Ziekenhuis-Oost Limburg, Genk, Belgium
| | - Marc Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands; and
| | - Emeline M Van Craenenbroeck
- Laboratory of Cellular and Molecular Cardiology and Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.,Research Group Cardiovascular Diseases, Translational Pathophysiological Research, University of Antwerp, Antwerp, Belgium
| | - Yves Jacquemyn
- Research Group, Antwerp Surgical Training, Anatomy & Research Center, University of Antwerp, Antwerp, Belgium.,Department of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium
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16
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Akgun N, Namli Kalem M, Yuce E, Kalem Z, Aktas H. Correlations of maternal neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) with birth weight. J Matern Fetal Neonatal Med 2017; 30:2086-2091. [PMID: 27678153 DOI: 10.1080/14767058.2016.1237497] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study is to investigate the possible correlation of hemogram parameters including neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) with birth weight and gestational week. MATERIALS AND METHODS This prospective study has been conducted with 783 patients. The maternal age, parity, gestational age, type of delivery, values of complete blood count (CBC) variables and the weight of newborn were recorded. We analyzed the statistical differences between the NLR, PLR, hemoglobin (HGB), platelet distribution width (PDW), red cell distribution width (RDW), mean platelet volume (MPV), platelet, neutrophil, lymphocyte and white blood cells (WBC) in terms of the birth weight. RESULTS There was no statistically significant difference in the NLR in terms of the birth weight (p = 0.097), whereas there was a statistically significant difference in the PLR (p < 0.001). In correlation analyses, a linear, negative, weak and statistically significant correlation was detected between NLR and PLR with the birth weight of infant and gestational week (p = 0.011 and p < 0.001, respectively). CONCLUSION This prospective study is the first in the literature which investigates the correlation of NLR and PLR with the week of birth and birth weight of the infant. Our study suggested that the maternal NLR and PLR are negatively correlated with the week of birth and birth weight of the infant.
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Affiliation(s)
- Nilufer Akgun
- a Department of Gynecology and Obstetrics, Turgut Ozal University , Ankara , Turkey
| | - Muberra Namli Kalem
- a Department of Gynecology and Obstetrics, Turgut Ozal University , Ankara , Turkey
| | - Ebru Yuce
- a Department of Gynecology and Obstetrics, Turgut Ozal University , Ankara , Turkey
| | - Ziya Kalem
- b Department of Gynecology and Obstetrics, Gurgan Clinic and İVF Center , Ankara , Turkey
| | - Hatice Aktas
- c Department of Biostatistics, Yıldırım Beyazıt University , Ankara , Turkey
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Bugatto F, Quintero-Prado R, Visiedo FM, Vilar-Sánchez JM, Figueroa-Quiñones A, López-Tinoco C, Torrejón R, Bartha JL. The Influence of Lipid and Proinflammatory Status on Maternal Uterine Blood Flow in Women With Late Onset Gestational Diabetes. Reprod Sci 2017; 25:837-843. [DOI: 10.1177/1933719117698576] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Fernando Bugatto
- Division of Fetal-Maternal Medicine, Department of Obstetrics and Gynecology, “Puerta del Mar” University Hospital, Cadiz, Spain
| | - Rocío Quintero-Prado
- Clinicas Ginemed, Sevilla, Spain
- Department of Obstetrics and Gynecology, “Hospital de Jerez” University Hospital, Jerez de la Frontera, Cádiz, Spain
| | | | - José M. Vilar-Sánchez
- Division of Fetal-Maternal Medicine, Department of Obstetrics and Gynecology, “Puerta del Mar” University Hospital, Cadiz, Spain
| | - Alejandro Figueroa-Quiñones
- Division of Fetal-Maternal Medicine, Department of Obstetrics and Gynecology, “Puerta del Mar” University Hospital, Cadiz, Spain
| | - Cristina López-Tinoco
- Department of Endocrinology and Nutrition, “Puerta del Mar” University Hospital, Cadiz, Spain
| | - Rafael Torrejón
- Division of Fetal-Maternal Medicine, Department of Obstetrics and Gynecology, “Puerta del Mar” University Hospital, Cadiz, Spain
| | - José L. Bartha
- Division of Fetal-Maternal Medicine, Department of Obstetrics, “La Paz” University Hospital, Madrid, Spain
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Circulating progenitor and angiogenic cell frequencies are abnormally static over pregnancy in women with preconception diabetes: A pilot study. PLoS One 2017; 12:e0172988. [PMID: 28278173 PMCID: PMC5344347 DOI: 10.1371/journal.pone.0172988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/13/2017] [Indexed: 11/30/2022] Open
Abstract
Type 1 and 2 diabetes decrease the frequencies and functional capacities of circulating angiogenic cells (CAC). Diabetes also elevates gestational complications. These observations may be interrelated. We undertook pilot studies to address the hypothesis that preconception diabetes deviates known gestational increases in CACs. Cross-sectional study of type 1 diabetic, type 2 diabetic and normoglycemic pregnant women was conducted at 1st, 2nd, and 3rd trimester and compared to a 6mo postpartum surrogate baseline. Circulating progenitor cells (CPC; CD34+CD45dimSSlow) and CACs (CD34+CD45dimSSlow expressing CD133 without or with KDR) were quantified by flow cytometry and by colony assay (CFU-Hill). In pregnant normoglycemic women, CD34+CD45dimSSlow cell frequency was greater in 1st and 3rd trimester than postpartum but frequency of these cells was static over type 1 or 2 diabetic pregnancies. Type 1 and type 2 diabetic women showed CACs variance versus normal controls. Type 1 diabetic women had more total CD34+KDR+ CACs in 1st trimester and a higher ratio of CD133+KDR+ to total CD133+ cells in 1st and 2nd trimesters than control women, demonstrating an unbalance in CD133+KDR+ CACs. Type 2 diabetic women had more CD133+KDR+ CACs in 1st trimester and fewer CD133+KDR- CACs at mid-late pregnancy than normal pregnant women. Thus, pregnancy stage-specific physiological fluctuation in CPCs (CD34+) and CACs (CD133+KDR+ and CD133+KDR-) did not occur in type 1 and type 2 diabetic women. Early outgrowth colonies were stable across normal and diabetic pregnancies. Therefore, preconception diabetes blocks the normal dynamic pattern of CAC frequencies across gestation but does not alter colony growth. The differences between diabetic and typical women were seen at specific gestational stages that may be critical for initiation of the uterine vascular pathologies characterizing diabetic gestations.
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Garg P, Badhwar S, Jaryal AK, Kachhawa G, Deepak KK, Kriplani A. The temporal trend of vascular function in women with gestational diabetes. Vasc Med 2017; 22:96-102. [DOI: 10.1177/1358863x16678479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Priyanka Garg
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Smriti Badhwar
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok Kumar Jaryal
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Garima Kachhawa
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Kishore Kumar Deepak
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Alka Kriplani
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
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