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Hong J, Crawford K, Cavanagh E, da Silva Costa F, Kumar S. Prediction of preterm birth in growth-restricted and appropriate-for-gestational-age infants using maternal PlGF and the sFlt-1/PlGF ratio-A prospective study. BJOG 2024; 131:1089-1101. [PMID: 38196326 DOI: 10.1111/1471-0528.17752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE To assess the utility of placental growth factor (PlGF) levels and the soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio to predict preterm birth (PTB) for infants with fetal growth restriction (FGR) and those appropriate for gestational age (AGA). DESIGN Prospective, observational cohort study. SETTING Tertiary maternity hospital in Australia. POPULATION There were 320 singleton pregnancies: 141 (44.1%) AGA, 83 (25.9%) early FGR (<32+0 weeks) and 109 (30.0%) late FGR (≥32+0 weeks). METHODS Maternal serum PlGF and sFlt-1/PlGF ratio were measured at 4-weekly intervals from recruitment to delivery. Low maternal PlGF levels and elevated sFlt-1/PlGF ratio were defined as <100 ng/L and >5.78 if <28 weeks and >38 if ≥28 weeks respectively. Cox proportional hazards models were used. The analysis period was defined as the time from the first measurement of PlGF and sFlt-1/PlGF ratio to the time of birth or censoring. MAIN OUTCOME MEASURES The primary study outcome was overall PTB. The relative risks (RR) of birth within 1, 2 and 3 weeks and for medically indicated and spontaneous PTB were also ascertained. RESULTS The early FGR cohort had lower median PlGF levels (54 versus 229 ng/L, p < 0.001) and higher median sFlt-1 levels (2774 ng/L versus 2096 ng/L, p < 0.001) and sFlt-1/PlGF ratio higher (35 versus 10, p < 0.001). Both PlGF <100 ng/L and elevated sFlt-1/PlGF ratio were strongly predictive for PTB as well as PTB within 1, 2 and 3 weeks of diagnosis. For both FGR and AGA groups, PlGF <100 ng/L or raised sFlt-1/PlGF ratio were strongly associated with increased risk for medically indicated PTB. The highest RR was seen in the FGR cohort when PlGF was <100 ng/L (RR 35.20, 95% CI 11.48-175.46). CONCLUSIONS Low maternal PlGF levels and elevated sFlt-1/PlGF ratio are potentially useful to predict PTB in both FGR and AGA pregnancies.
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Affiliation(s)
- Jesrine Hong
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Kylie Crawford
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Erika Cavanagh
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Fabricio da Silva Costa
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Maternal Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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Yusrika MU, Al Fattah AN, Kusuma RA, Widjaja FF, Marizni S, Putri VP. Incidence and first trimester risk factors of stillbirth in Indonesia. J Perinat Med 2024; 52:392-398. [PMID: 38407221 DOI: 10.1515/jpm-2023-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/28/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To determine the incidence and the risk factors of stillbirth from maternal biophysical, ultrasound, and biochemical markers at 11-13 weeks of gestation in the Indonesian population. METHODS This was a retrospective cohort study of pregnant women for first-trimester preeclampsia screening at 11-13 weeks of gestation in some clinics and hospital in Jakarta. Maternal characteristics and history, mean arterial pressure (MAP) measurement, uterine artery pulsatility index (UtA-PI) ultrasound, maternal ophthalmic peak ratio (Oph-PR) Doppler, and placental growth factor (PlGF) serum were collected during the visit. Stillbirth was classified into placental dysfunction-related when it occurred with preeclampsia or birth weight <10th percentile and non-placental dysfunction-related. Bivariate and multivariate logistic regression analyses were employed to determine the risk factors associated with stillbirth. RESULTS Of 1,643 eligible participants, 13 (0.79 %) stillbirth cases were reported. More than half of the stillbirths (7) were placental dysfunction-related. After adjusted with maternal age, body mass index (BMI), and parity status, chronic hypertension (aOR (adjusted odds ratio)) 24.41, 95 % CI {confidence interval} 5.93-100.43), previous pregnancy with preeclampsia (aOR 15.79, 95 % CI 4.42-56.41), MAP >101.85 (aOR 26.67, 95 % CI 8.26-86.06), UtA-PI >1.90 (aOR 10.68, 95 % CI 2.34-48.58, and PlGF <28.77 pg/mL (aOR 18.60, 95 % CI 5.59-61.92) were associated with stillbirth. CONCLUSIONS The incidence of stillbirth in the population is comparable to studies conducted in developed countries. Most routine variables assessed at the 11-13 weeks combined screening for preeclampsia are associated with the risk of stillbirth.
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Affiliation(s)
| | - Adly Nanda Al Fattah
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
- Kosambi Maternal and Children Center, Jakarta, Indonesia
| | - Raden Aditya Kusuma
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
- Harapan Kita National Women and Children Hospital, Jakarta, Indonesia
| | | | - Shinda Marizni
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
| | - Vania Permata Putri
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
- Kosambi Maternal and Children Center, Jakarta, Indonesia
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Magee LA, Syngelaki A, Akolekar R, von Dadelszen P, Nicolaides KH. Placental growth factor testing at 19-23 weeks of gestation as a guide to subsequent care in pregnancy: A prospective observational study. BJOG 2024; 131:803-810. [PMID: 37873570 DOI: 10.1111/1471-0528.17684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/19/2023] [Accepted: 09/18/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To determine whether serum placental growth factor (PlGF) at 19-23 weeks of gestation can improve the identification of risk for adverse outcomes. DESIGN Prospective observational cohort study. SETTING Two English maternity units. POPULATION Unselected singleton pregnancies attending routine ultrasound at 19-23 weeks of gestation. METHODS Outcomes ascertained by health record review. Diagnostic test properties evaluated clinical risk factors for pre-eclampsia (according to National Institute of Care Excellence) or fetal growth restriction (according to Royal College of Obstetricians and Gynaecologists), low PlGF at 19-23 weeks of gestation (<5th percentile) or both. MAIN OUTCOME MEASURES Pre-eclampsia, gestational hypertension, stillbirth, birthweight below third percentile or neonatal intensive care unit (NICU) admission for ≥48 h. RESULTS In 30 013 pregnancies, risk factors were present in 9941 (33.1%), low PlGF was present in 1501 (5.0%) and both ('two-stage' screening) were present in 547 (1.8%) pregnancies. Risk factors detected 41.7%-54.7% of adverse outcomes, and could not meaningfully revise the risk (all positive likelihood ratios, +LR, <5.0; all negative likelihood ratios, -LR, ≥0.2). Low PlGF detected 8.5%-17.4% of adverse outcomes, but meaningfully increased risks (other than NICU admission) associated with delivery <37 weeks of gestation (+LR = 5.03-15.55); all -LRs were ≥0.2. 'Two-stage' screening detected 4.2%-8.9% of adverse outcomes, with meaningful +LRs (6.28-18.61) at <37 weeks of gestation, except for NICU admission of ≥48 h, which had an +LR of 7.56 at <34 weeks of gestation; all -LRs were ≥0.2. No screening strategy meaningfully increased or decreased the detection of adverse outcome risk at term. CONCLUSIONS Clinical risk factor screening has a high screen-positive rate and a poor detection of adverse outcomes. False positives cannot be reduced by PlGF testing at 19-23 weeks of gestation; therefore, this cannot be recommended as a useful strategy on its own.
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Affiliation(s)
- Laura A Magee
- Institute of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Argyro Syngelaki
- Institute of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Ranjit Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
- Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
| | - Peter von Dadelszen
- Institute of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
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Hong J, Crawford K, Cavanagh E, da Silva Costa F, Kumar S. Placental growth factor and fetoplacental Doppler indices in combination predict preterm birth reliably in pregnancies complicated by fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:635-643. [PMID: 37820083 DOI: 10.1002/uog.27513] [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: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE To assess the association between placental biomarkers (placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1)/PlGF ratio) and fetoplacental Doppler indices (umbilical artery (UA) pulsatility index (PI) and uterine artery (UtA) PI) in various combinations for predicting preterm birth (PTB) in pregnancies complicated by fetal growth restriction (FGR). METHODS This was a prospective observational cohort study, performed at Mater Mother's Hospital in Brisbane, Queensland, Australia, from May 2022 to June 2023, of pregnancies complicated by FGR and appropriate-for-gestational-age (AGA) pregnancies. Maternal serum PlGF levels, sFlt-1/PlGF ratio, UA-PI and UtA-PI were measured at 2-4-weekly intervals from recruitment until delivery. Harrell's concordance statistic (Harrell's C) was used to evaluate multivariable Cox proportional hazards regression models featuring various combinations of placental biomarkers and fetoplacental Doppler indices to ascertain the best combination to predict PTB (< 37 weeks). Multivariable Cox regression models were used with biomarkers as time-varying covariates. RESULTS The study cohort included 320 singleton pregnancies, comprising 179 (55.9%) affected by FGR, defined according to a Delphi consensus, and 141 (44.1%) with an AGA fetus. In the FGR cohort, both low PlGF levels and elevated sFlt-1/PlGF ratio were associated with significantly shorter time to PTB. Low PlGF was a better predictor of PTB than was either sFlt-1/PlGF ratio or a combination of PlGF and sFlt-1/PlGF ratio (Harrell's C, 0.81, 0.78 and 0.79, respectively). Although both Doppler indices were significantly associated with time to PTB, in combination they were better predictors of PTB than was either UA-PI > 95th centile or UtA-PI > 95th centile alone (Harrell's C, 0.82, 0.75 and 0.76, respectively). Predictive utility for PTB was best when PlGF < 100 ng/L, UA-PI > 95th centile and UtA-PI > 95th centile were combined (Harrell's C, 0.88) (hazard ratio, 32.99; 95% CI, 10.74-101.32). CONCLUSIONS Low maternal serum PlGF level (< 100 ng/L) and abnormal fetoplacental Doppler indices (UA-PI > 95th centile and UtA-PI > 95th centile) in combination have the greatest predictive utility for PTB in pregnancies complicated by FGR. Their assessment may help guide clinical management of these complex pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Hong
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - K Crawford
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - E Cavanagh
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - F da Silva Costa
- School of Medicine and Dentistry, Griffith University and Maternal Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - S Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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Balyan K, Humtso BY, Meena B, Sapna S, Rana A, Kumar M. Materno-fetal outcome with PlGF above or below cutoff during second half of pregnancy in high-risk women. Int J Gynaecol Obstet 2024; 165:211-219. [PMID: 37814586 DOI: 10.1002/ijgo.15143] [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: 03/31/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVE To evaluate the materno-fetal outcome of high-risk women using placental growth factor (PlGF). METHODS This prospective cohort study was performed at a tertiary care hospital from September 2019 to April 2022. Women having clinically major or minor high risk factors of pre-eclampsia were included after consent. The placental growth factor (PlGF) was evaluated among high-risk women at 20-22, 28-30, and 34-36 weeks of gestation. They were followed throughout pregnancy until delivery. Materno-fetal outcome was evaluated based on PlGF levels at three different time points. The gestational age specific cutoff was derived. Those with levels below cutoff were taken as cases and those with values above cutoff were considered as controls. The odds of having complications if the PlGF was below cutoff were determined. RESULTS Out of 287 high-risk women, 46 (16%) had pre-eclampsia (PE). The derived cutoff of PlGF was 224, 211, and 176 pg/mL at 20-22, 28-30, and 34-36 weeks, respectively. With PlGF below the cutoff at 20-22 weeks the odds of having HELLP syndrome was 15.8, with low PlGF at 28-30 weeks the odds for developing early onset PE was 11.3. Low PlGF was also significantly associated with preterm delivery (P < 0.001) and early onset FGR (P < 0.001). The sensitivity (91.7%) and specificity (78.5%) of PlGF for PE prediction was highest at 28-30 weeks. CONCLUSION Low PlGF at 28-30 weeks was associated with high likelihood of developing early onset PE, and the PlGF cutoff should be gestational age specific.
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Affiliation(s)
- Kirti Balyan
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | | | - Bhawana Meena
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Surbhi Sapna
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Anjali Rana
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Manisha Kumar
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
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Young RE, Nelson KM, Hofbauer SI, Vijayakumar T, Alameh MG, Weissman D, Papachristou C, Gleghorn JP, Riley RS. Systematic development of ionizable lipid nanoparticles for placental mRNA delivery using a design of experiments approach. Bioact Mater 2024; 34:125-137. [PMID: 38223537 PMCID: PMC10784148 DOI: 10.1016/j.bioactmat.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 01/16/2024] Open
Abstract
Ionizable lipid nanoparticles (LNPs) have gained attention as mRNA delivery platforms for vaccination against COVID-19 and for protein replacement therapies. LNPs enhance mRNA stability, circulation time, cellular uptake, and preferential delivery to specific tissues compared to mRNA with no carrier platform. However, LNPs are only in the beginning stages of development for safe and effective mRNA delivery to the placenta to treat placental dysfunction. Here, we develop LNPs that enable high levels of mRNA delivery to trophoblasts in vitro and to the placenta in vivo with no toxicity. We conducted a Design of Experiments to explore how LNP composition, including the type and molar ratio of each lipid component, drives trophoblast and placental delivery. Our data revealed that utilizing C12-200 as the ionizable lipid and 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE) as the phospholipid in the LNP design yields high transfection efficiency in vitro. Analysis of lipid molar composition as a design parameter in LNPs displayed a strong correlation between apparent pKa and poly (ethylene) glycol (PEG) content, as a reduction in PEG molar amount increases apparent pKa. Further, we present one LNP platform that exhibits the highest delivery of placental growth factor mRNA to the placenta in pregnant mice, resulting in synthesis and secretion of a potentially therapeutic protein. Lastly, our high-performing LNPs have no toxicity to both the pregnant mice and fetuses. Our results demonstrate the feasibility of LNPs as a platform for mRNA delivery to the placenta, and our top LNP formulations may provide a therapeutic platform to treat diseases that originate from placental dysfunction during pregnancy.
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Affiliation(s)
- Rachel E. Young
- Department of Biomedical Engineering, Henry M. Rowan College of Engineering, Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
- School of Translational Biomedical Engineering & Sciences, Virtua College of Medicine & Life Sciences of Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
| | - Katherine M. Nelson
- Department of Chemical and Biomolecular Engineering, College of Engineering, University of Delaware, 150 Academy Street, Newark, DE 19716, United States
| | - Samuel I. Hofbauer
- Department of Biomedical Engineering, Henry M. Rowan College of Engineering, Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
- School of Translational Biomedical Engineering & Sciences, Virtua College of Medicine & Life Sciences of Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
- Cooper Medical School of Rowan University, Rowan University, 401 Broadway, Camden, NJ 08103, United States
| | - Tara Vijayakumar
- Department of Biomedical Engineering, Henry M. Rowan College of Engineering, Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
- School of Translational Biomedical Engineering & Sciences, Virtua College of Medicine & Life Sciences of Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
| | - Mohamad-Gabriel Alameh
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Drew Weissman
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Charalampos Papachristou
- Department of Mathematics, College of Science & Mathematics, Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
| | - Jason P. Gleghorn
- Department of Biomedical Engineering, College of Engineering, University of Delaware, 590 Avenue 1743, Newark, DE 19713, United States
| | - Rachel S. Riley
- Department of Biomedical Engineering, Henry M. Rowan College of Engineering, Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
- School of Translational Biomedical Engineering & Sciences, Virtua College of Medicine & Life Sciences of Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, United States
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Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Directive clinique n o 442 : Retard de croissance intra-utérin : Dépistage, diagnostic et prise en charge en contexte de grossesse monofœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102155. [PMID: 37730301 DOI: 10.1016/j.jogc.2023.05.023] [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: 09/22/2023]
Abstract
OBJECTIF Le retard de croissance intra-utérin est une complication obstétricale fréquente qui touche jusqu'à 10 % des grossesses dans la population générale et qui est le plus souvent due à une pathologie placentaire sous-jacente. L'objectif de la présente directive clinique est de fournir des déclarations sommaires et des recommandations pour appuyer un protocole clinique de dépistage, diagnostic et prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. POPULATION CIBLE Toutes les patientes enceintes menant une grossesse monofœtale. BéNéFICES, RISQUES ET COûTS: La mise en application des recommandations de la présente directive devrait améliorer la compétence des cliniciens quant à la détection du retard de croissance intra-utérin et à la réalisation des interventions indiquées. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches effectuées jusqu'en septembre 2022 dans les bases de données PubMed, Medline, CINAHL et Cochrane Library en utilisant un vocabulaire contrôlé au moyen de termes MeSH pertinents (fetal growth retardation and small for gestational age) et de mots-clés (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. La littérature grise a été obtenue par des recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle, radiologistes et autres professionnels de la santé qui prodiguent des soins aux patientes enceintes. RéSUMé POUR TWITTER: Mise à jour de la directive sur le dépistage, le diagnostic et la prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS: Prédiction du retard de croissance intra-utérin Prévention du retard de croissance intra-utérin Détection du retard de croissance intra-utérin Examens en cas de retard de croissance intra-utérin soupçonné Prise en charge du retard de croissance intra-utérin précoce Prise en charge du retard de croissance intra-utérin tardif Prise en charge du post-partum et consultations préconception.
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Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Guideline No. 442: Fetal Growth Restriction: Screening, Diagnosis, and Management in Singleton Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102154. [PMID: 37730302 DOI: 10.1016/j.jogc.2023.05.022] [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] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Fetal growth restriction is a common obstetrical complication that affects up to 10% of pregnancies in the general population and is most commonly due to underlying placental diseases. The purpose of this guideline is to provide summary statements and recommendations to support a clinical framework for effective screening, diagnosis, and management of pregnancies that are either at risk of or affected by fetal growth restriction. TARGET POPULATION All pregnant patients with a singleton pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase clinician competency to detect fetal growth restriction and provide appropriate interventions. EVIDENCE Published literature in English was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library through to September 2022 using appropriate controlled vocabulary via MeSH terms (fetal growth retardation and small for gestational age) and key words (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Grey literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for pregnant patients. TWEETABLE ABSTRACT Updated guidelines on screening, diagnosis, and management of pregnancies at risk of or affected by FGR. SUMMARY STATEMENTS RECOMMENDATIONS: Prediction of FGR Prevention of FGR Detection of FGR Investigations in Pregnancies with Suspected Fetal Growth Restriction Management of Early-Onset Fetal Growth Restriction Management of Late-Onset FGR Postpartum management and preconception counselling.
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Stapleton D, Darmonkow A, Ravi Chandran A, Milligan N, Saghian R, Shinar S, Whitehead CL, Hobson SR, Serghides L, Macgowan CK, Sled JG, Kingdom JC, Baschat AA, Parks WT, Cahill LS. Peripheral cord insertion is associated with adverse pregnancy outcome only when accompanied by clinically significant placental pathology. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:248-254. [PMID: 36971026 DOI: 10.1002/uog.26206] [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: 12/20/2022] [Revised: 02/17/2023] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. METHODS Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre-eclampsia, preterm birth, small-for-gestational age) were examined. RESULTS A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA-PI was normal. CONCLUSIONS This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Stapleton
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
| | - A Darmonkow
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
| | - A Ravi Chandran
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - N Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - R Saghian
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Shinar
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - C L Whitehead
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | - S R Hobson
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - L Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology and Institutes of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - C K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - J G Sled
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - J C Kingdom
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - A A Baschat
- Center for Fetal Therapy, Johns Hopkins Medicine, Baltimore, MD, USA
| | - W T Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - L S Cahill
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
- Discipline of Radiology, Memorial University of Newfoundland, St John's, NL, Canada
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10
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Tsompanidis A, Blanken L, Broere-Brown ZA, van Rijn BB, Baron-Cohen S, Tiemeier H. Sex differences in placenta-derived markers and later autistic traits in children. Transl Psychiatry 2023; 13:256. [PMID: 37443170 DOI: 10.1038/s41398-023-02552-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Autism is more prevalent in males and males on average score higher on measures of autistic traits. Placental function is affected significantly by the sex of the fetus. It is unclear if sex differences in placental function are associated with sex differences in the occurrence of autistic traits postnatally. To assess this, concentrations of angiogenesis-related markers, placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1) were assessed in maternal plasma of expectant women in the late 1st (mean= 13.5 [SD = 2.0] weeks gestation) and 2nd trimesters (mean=20.6 [SD = 1.2] weeks gestation), as part of the Generation R Study, Rotterdam, the Netherlands. Subsequent assessment of autistic traits in the offspring at age 6 was performed with the 18-item version of the Social Responsiveness Scale (SRS). Associations of placental protein concentrations with autistic traits were tested in sex-stratified and cohort-wide regression models. Cases with pregnancy complications or a later autism diagnosis (n = 64) were also assessed for differences in placenta-derived markers. sFlt-1 levels were significantly lower in males in both trimesters but showed no association with autistic traits. PlGF was significantly lower in male pregnancies in the 1st trimester, and significantly higher in the 2nd trimester, compared to female pregnancies. Higher PlGF levels in the 2nd trimester and the rate of PlGF increase were both associated with the occurrence of higher autistic traits (PlGF-2nd: n = 3469,b = 0.24 [SE = 0.11], p = 0.03) in both unadjusted and adjusted linear regression models that controlled for age, sex, placental weight and maternal characteristics. Mediation analyses showed that higher autistic traits in males compared to females were partly explained by higher PlGF or a faster rate of PlGF increase in the second trimester (PlGF-2nd: n = 3469, ACME: b = 0.005, [SE = 0.002], p = 0.004). In conclusion, higher PlGF levels in the 2nd trimester and a higher rate of PlGF increase are associated with both being male, and with a higher number of autistic traits in the general population.
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Affiliation(s)
- A Tsompanidis
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK.
| | - L Blanken
- The Generation R Study Group, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Z A Broere-Brown
- The Generation R Study Group, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - B B van Rijn
- The Generation R Study Group, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - S Baron-Cohen
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - H Tiemeier
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, USA
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11
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Wu P, Green M, Myers JE. Hypertensive disorders of pregnancy. BMJ 2023; 381:e071653. [PMID: 37391211 DOI: 10.1136/bmj-2022-071653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.
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Affiliation(s)
- Pensée Wu
- School of Medicine, Keele University, Newcastle-under-Lyme, UK
- Academic Department of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, UK
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Jenny E Myers
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK
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12
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Lin Y, Mallia D, Clark-Sevilla A, Catto A, Leshchenko A, Yan Q, Haas D, Wapner R, Pe'er I, Raja A, Salleb-Aouissi A. A Comprehensive and Bias-Free Machine Learning Approach for Risk Prediction of Preeclampsia with Severe Features in a Nulliparous Study Cohort. RESEARCH SQUARE 2023:rs.3.rs-2635419. [PMID: 37090627 PMCID: PMC10120773 DOI: 10.21203/rs.3.rs-2635419/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Objective Preeclampsia is one of the leading causes of maternal morbidity, with consequences during and after pregnancy. Because of its diverse clinical presentation, preeclampsia is an adverse pregnancy outcome that is uniquely challenging to predict and manage. In this paper, we developed machine learning models that predict the onset of preeclampsia with severe features or eclampsia at discrete time points in a nulliparous pregnant study cohort. Materials and Methods The prospective study cohort to which we applied machine learning is the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) study, which contains information from eight clinical sites across the US. Maternal serum samples were collected for 1,857 individuals between the first and second trimesters. These patients with serum samples collected are selected as the final cohort. Results Our prediction models achieved an AUROC of 0.72 (95% CI, 0.69-0.76), 0.75 (95% CI, 0.71-0.79), and 0.77 (95% CI, 0.74-0.80), respectively, for the three visits. Our initial models were biased toward non-Hispanic black participants with a high predictive equality ratio of 1.31. We corrected this bias and reduced this ratio to 1.14. The top features stress the importance of using several tests, particularly for biomarkers and ultrasound measurements. Placental analytes were strong predictors for screening for the early onset of preeclampsia with severe features in the first two trimesters. Conclusion Experiments suggest that it is possible to create racial bias-free early screening models to predict the patients at risk of developing preeclampsia with severe features or eclampsia nulliparous pregnant study cohort.
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13
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Agrawal S, Parks WT, Kingdom JC. Uterine and umbilical artery Doppler combined with placental growth factor assay for placental function expertise in the assessment of fetal growth restriction: a response. Am J Obstet Gynecol 2023; 228:108-109. [PMID: 36108730 DOI: 10.1016/j.ajog.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/06/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Swati Agrawal
- Division of Maternal-Fetal Medicine (Placenta Program), Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - W Tony Parks
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - John C Kingdom
- Division of Maternal-Fetal Medicine (Placenta Program), Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 600 University Ave., Ontario, Canada M5G 1X5.
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14
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Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol 2023; 141:85-108. [PMID: 36455925 DOI: 10.1097/aog.0000000000005024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 12/05/2022]
Abstract
The most common thrombotic microangiopathy (TMA) of pregnancy is the well-recognized syndrome of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, rare TMAs, including thrombotic thrombocytopenic purpura, complement-mediated hemolytic-uremic syndrome, and catastrophic antiphospholipid syndrome, may occur during pregnancy or postpartum and present with features similar to those of preeclampsia with severe features. Early recognition and treatment of these infrequently encountered conditions are key for avoiding serious maternal morbidities with long-term sequelae and possible maternal or fetal death. Differentiating between preeclampsia with severe features and these rare TMAs is diagnostically challenging as there is significant overlap in their clinical and laboratory presentation. Given the rarity of these TMAs, high-quality evidence-based recommendations on diagnosis and management during pregnancy are lacking. Using current objective information and recommendations from working groups, this report provides practical clinical approaches to diagnose and manage these rare TMAs. This report also discusses how to manage individuals with a history of these rare TMAs who are planning to conceive. To optimize favorable outcomes, a multidisciplinary approach including obstetricians, maternal-fetal medicine specialists, hematologists, and nephrologists alongside close clinical and laboratory monitoring is vital.
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15
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Young RE, Nelson KM, Hofbauer SI, Vijayakumar T, Alameh MG, Weissman D, Papachristou C, Gleghorn JP, Riley RS. Lipid Nanoparticle Composition Drives mRNA Delivery to the Placenta. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2022:2022.12.22.521490. [PMID: 36597546 PMCID: PMC9810215 DOI: 10.1101/2022.12.22.521490] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ionizable lipid nanoparticles (LNPs) have gained attention as mRNA delivery platforms for vaccination against COVID-19 and for protein replacement therapies. LNPs enhance mRNA stability, circulation time, cellular uptake, and preferential delivery to specific tissues compared to mRNA with no carrier platform. However, LNPs have yet to be developed for safe and effective mRNA delivery to the placenta as a method to treat placental dysfunction. Here, we develop LNPs that enable high levels of mRNA delivery to trophoblasts in vitro and to the placenta in vivo with no toxicity. We conducted a Design of Experiments to explore how LNP composition, including the type and molar ratio of each lipid component, drives trophoblast and placental delivery. Our data revealed that a specific combination of ionizable lipid and phospholipid in the LNP design yields high transfection efficiency in vitro . Further, we present one LNP platform that exhibits highest delivery of placental growth factor mRNA to the placenta in pregnant mice, which demonstrates induced protein synthesis and secretion of a therapeutic protein. Lastly, our high-performing LNPs have no toxicity to both the pregnant mice and fetuses. Our results demonstrate the feasibility of LNPs as a platform for mRNA delivery to the placenta. Our top LNPs may provide a therapeutic platform to treat diseases that originate from placental dysfunction during pregnancy.
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16
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Contribution of Second Trimester Sonographic Placental Morphology to Uterine Artery Doppler in the Prediction of Placenta-Mediated Pregnancy Complications. J Clin Med 2022; 11:jcm11226759. [PMID: 36431236 PMCID: PMC9697802 DOI: 10.3390/jcm11226759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Second-trimester uterine artery Doppler is a well-established tool for the prediction of preeclampsia and fetal growth restriction. At delivery, placentas from affected pregnancies may have gross pathologic findings. Some of these features are detectable by ultrasound, but the relative importance of placental morphologic assessment and uterine artery Doppler in mid-pregnancy is presently unclear. Objective: To characterize the association of second-trimester sonographic placental morphology markers with placenta-mediated complications and determine whether these markers are predictive of placental dysfunction independent of uterine artery Doppler. Methods: This was a retrospective cohort study of patients with a singleton pregnancy at high risk of placental complications who underwent a sonographic placental study at mid-gestation (160/7−246/7 weeks’ gestation) in a single tertiary referral center between 2016−2019. The sonographic placental study included assessment of placental dimensions (length, width, and thickness), placental texture appearance, umbilical cord anatomy, and uterine artery Doppler (mean pulsatility index and early diastolic notching). Placental area and volume were calculated based on placental length, width, and thickness. Continuous placental markers were converted to multiples on medians (MoM). The primary outcome was a composite of early-onset preeclampsia and birthweight < 3rd centile. Results: A total of 429 eligible patients were identified during the study period, of whom 45 (10.5%) experienced the primary outcome. The rate of the primary outcome increased progressively with decreasing placental length, width, and area, and increased progressively with increasing mean uterine artery pulsatility index (PI). By contrast, placental thickness followed a U-shaped relationship with the primary outcome. Placental length, width, and area, mean uterine artery PI and bilateral uterine artery notching were all associated with the primary outcome. However, in the adjusted analysis, the association persisted only for placenta area (adjusted odds ratio [aOR] 0.21, 95%-confidence interval [CI] 0.06−0.73) and mean uterine artery PI (aOR 11.71, 95%-CI 3.84−35.72). The area under the ROC curve was highest for mean uterine artery PI (0.80, 95%-CI 0.71−0.89) and was significantly higher than that of placental area (0.67, 95%-CI 0.57−0.76, p = 0.44). A model that included both mean uterine artery PI and placental area did not significantly increase the area under the curve (0.82, 95%-CI 0.74−0.90, p = 0.255), and was associated with a relatively minor increase in specificity for the primary outcome compared with mean uterine artery PI alone (63% [95%-CI 58−68%] vs. 52% [95%-CI 47−57%]). Conclusion: Placental area is independently associated with the risk of placenta-mediated complications yet, when combined with uterine artery Doppler, did not further improve the prediction of such complications compared with uterine artery Doppler alone.
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17
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Grimaldi B, Kohan-Ghadr HR, Drewlo S. The Potential for Placental Activation of PPARγ to Improve the Angiogenic Profile in Preeclampsia. Cells 2022; 11:cells11213514. [PMID: 36359910 PMCID: PMC9659243 DOI: 10.3390/cells11213514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022] Open
Abstract
Preeclampsia (PE) is one of the most common causes of maternal-fetal morbidity and mortality world-wide. While the underlying causes of PE remain elusive, aberrant trophoblast differentiation and function are thought to cause an imbalance of secreted angiogenic proteins resulting in systemic endothelial dysfunction and organ damage in the mother. The placental dysfunction is also characterized by a reduction of the transcription factor, peroxisome proliferator activated receptor γ (PPARγ) which normally promotes trophoblast differentiation and healthy placental function. This study aimed to understand how placental activation of PPARγ effects the secretion of angiogenic proteins and subsequently endothelial function. To study this, healthy and PE placental tissues were cultured with or without the PPARγ agonist, Rosiglitazone, and a Luminex assay was performed to measure secreted proteins from the placenta. To assess the angiogenic effects of placental activation of PPARγ, human umbilical vein endothelial cells (HUVECs) were cultured with the placental conditioned media and the net angiogenic potential of these cells was measured by a tube formation assay. This is the first study to show PPARγ's beneficial effect on the angiogenic profile in the human preeclamptic placenta through the reduction of anti-angiogenic angiopoietin-2 and soluble endoglin and the upregulation of pro-angiogenic placental growth factor, fibroblast growth factor-2, heparin-binding epidermal growth factor, and follistatin. The changes in the angiogenic profile were supported by the increased angiogenic potential observed in the HUVECs when cultured with conditioned media from rosiglitazone-treated preeclamptic placentas. The restoration of these disrupted pathways by activation of PPARγ in the preeclamptic placenta offers potential to improve placental and endothelial function in PE.
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Affiliation(s)
- Brooke Grimaldi
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
| | - Hamid-Reza Kohan-Ghadr
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
| | - Sascha Drewlo
- Biological Sciences Platform, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto M4N 3M5, Canada
- Department of Obstetrics and Gynecology, Temerty Faculty of Medicine, University of Toronto, Toronto M5G 1E2, Canada
- Correspondence:
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18
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The Update of Fetal Growth Restriction Associated with Biomarkers. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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19
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Kadoura S, Alhalabi M, Nattouf AH. Follicular fluid PlGF and IVF/ICSI outcomes among PCOS and normo-ovulatory women using different controlled hyperstimulation protocols: A prospective case-control study. Ann Med Surg (Lond) 2022; 79:104096. [PMID: 35860057 PMCID: PMC9289487 DOI: 10.1016/j.amsu.2022.104096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/24/2022] [Accepted: 06/24/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sally Kadoura
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syrian Arab Republic
- Corresponding author.
| | - Marwan Alhalabi
- Department of Embryology and Reproductive Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
- Assisted Reproduction Unit, Orient Hospital, Damascus, Syrian Arab Republic
| | - Abdul Hakim Nattouf
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syrian Arab Republic
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20
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Diagnostic utility of serial circulating placental growth factor levels and uterine artery Doppler waveforms in diagnosing underlying placental diseases in pregnancies at high risk of placental dysfunction. Am J Obstet Gynecol 2022; 227:618.e1-618.e16. [PMID: 35644246 DOI: 10.1016/j.ajog.2022.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Placental pathology assessment following delivery in pregnancies complicated by preeclampsia, fetal growth restriction, abruption, and stillbirth reveals a range of underlying diseases. The most common pathology is maternal vascular malperfusion, characterized by high-resistance uterine artery Doppler waveforms and abnormal expression of circulating maternal angiogenic growth factors. Rare placental diseases (massive perivillous fibrinoid deposition and chronic histiocytic intervillositis) are reported to have high recurrence risks, but their associations with uterine artery Doppler waveforms and angiogenic growth factors are presently ill-defined. OBJECTIVE To characterize the patterns of serial placental growth factor measurements and uterine artery Doppler waveform assessments in pregnancies that develop specific types of placental pathology to gain insight into their relationships with the timing of disease onset and pregnancy outcomes. STUDY DESIGN A retrospective cohort study conducted between January 2017 and November 2021 included all singleton pregnancies with at least 1 measurement of maternal circulating placental growth factor between 16 and 36 weeks' gestation, delivery at our institution, and placental pathology analysis demonstrating diagnostic features of maternal vascular malperfusion, fetal vascular malperfusion, villitis of unknown etiology, chronic histiocytic intervillositis, or massive perivillous fibrinoid deposition. Profiles of circulating placental growth factor as gestational age advanced were compared between these placental pathologies. Maternal and perinatal outcomes were recorded. RESULTS A total of 337 pregnancies from 329 individuals met our inclusion criteria. These comprised placental pathology diagnoses of maternal vascular malperfusion (n=109), fetal vascular malperfusion (n=87), villitis of unknown etiology (n=96), chronic histiocytic intervillositis (n=16), and massive perivillous fibrinoid deposition (n=29). Among patients who developed maternal vascular malperfusion, placental growth factor levels gradually declined as pregnancy progressed (placental growth factor <10th percentile at 16-20 weeks' gestation in 42.9%; 20-24 weeks in 61.9%; 24-28 weeks in 77%; and 28-32 weeks in 81.4%) accompanied by mean uterine artery Doppler pulsatility index >95th percentile in 71.6% cases. Patients who developed either fetal vascular malperfusion or villitis of unknown etiology mostly exhibited normal circulating placental growth factor values in association with normal uterine artery Doppler waveforms (mean [standard deviation] pulsatility index values: fetal vascular malperfusion, 1.14 [0.49]; villitis of unknown etiology, 1.13 [0.45]). Patients who developed either chronic histiocytic intervillositis or massive perivillous fibrinoid deposition exhibited persistently low placental growth factor levels from the early second trimester (placental growth factor <10th centile at 16-20 weeks' gestation in 80% and 77.8%, respectively; 20-24 weeks in 88.9% and 63.6%; 24-28 weeks in 85.7% and 75%), all in combination with normal uterine artery Doppler waveforms (mean pulsatility index >95th centile: chronic histiocytic intervillositis, 25%; massive perivillous fibrinoid deposition, 37.9%). Preeclampsia developed in 83 of 337 (24.6%) patients and was most common in those developing maternal vascular malperfusion (54/109, 49.5%) followed by chronic histiocytic intervillositis (7/16, 43.8%). There were 29 stillbirths in the cohort (maternal vascular malperfusion, n=10 [9.2%]; fetal vascular malperfusion, n=5 [5.7%]; villitis of unknown etiology, n=1 [1.0%]; chronic histiocytic intervillositis, n=7 [43.8%]; massive perivillous fibrinoid deposition, n=6 [20.7%]). Most patients experiencing stillbirth exhibited normal uterine artery Doppler waveforms (21/29, 72.4%) and had nonmaternal vascular malperfusion pathologies (19/29, 65.5%). By contrast, 28 of 29 (96.5%) patients experiencing stillbirth had ≥1 low placental growth factor values before fetal death. CONCLUSION Serial circulating maternal placental growth factor tests, in combination with uterine artery Doppler waveform assessments in the second trimester, may indicate the likely underlying type of placental pathology mediating severe adverse perinatal events. This approach has the potential to test disease-specific therapeutic strategies to improve clinical outcomes. Serial placental growth factor testing, compared with uterine artery Doppler studies, identifies a greater proportion of patients destined to have a poor perinatal outcome because diseases other than maternal vascular malperfusion are characterized by normal uteroplacental circulation.
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McLaughlin K, Snelgrove JW, Sienas LE, Easterling TR, Kingdom JC, Albright CM. Phenotype‐Directed Management of Hypertension in Pregnancy. J Am Heart Assoc 2022; 11:e023694. [PMID: 35285667 PMCID: PMC9075436 DOI: 10.1161/jaha.121.023694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypertensive disorders of pregnancy are among the most serious conditions that pregnancy care providers face; however, little attention has been paid to the concept of tailoring clinical care to reduce associated adverse maternal and perinatal outcomes based on the underlying disease pathogenesis. This narrative review discusses the integration of phenotype‐based clinical strategies in the management of high‐risk pregnant patients that are currently not common clinical practice: real‐time placental growth factor testing at Mount Sinai Hospital, Toronto and noninvasive hemodynamic monitoring to guide antihypertensive therapy at the University of Washington Medical Center, Seattle. Future work should focus on promoting more widespread integration of these novel strategies into obstetric care to improve outcomes of pregnancies at high risk of adverse maternal‐fetal outcomes from these complications of pregnancy.
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Affiliation(s)
- Kelsey McLaughlin
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - John W. Snelgrove
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - Laura E. Sienas
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
| | - Thomas R. Easterling
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
| | - John C. Kingdom
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - Catherine M. Albright
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
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22
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Ashwal E, Ferreira F, Mei-Dan E, Aviram A, Sherman C, Zaltz A, Kingdom J, Melamed N. The accuracy of Fetoplacental Doppler in distinguishing between growth restricted and constitutionally small fetuses. Placenta 2022; 120:40-48. [DOI: 10.1016/j.placenta.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/17/2021] [Accepted: 02/07/2022] [Indexed: 01/05/2023]
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23
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McLaughlin K, Hobson SR, Chandran AR, Agrawal S, Windrim RC, Parks WT, Bowman AW, Sovio U, Smith GC, Kingdom JC. Circulating maternal placental growth factor responses to low-molecular-weight heparin in pregnant patients at risk of placental dysfunction. Am J Obstet Gynecol 2022; 226:S1145-S1156.e1. [PMID: 34461078 DOI: 10.1016/j.ajog.2021.08.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients at high risk of severe preeclampsia and fetal growth restriction have low circulating levels of placental growth factor and features of maternal vascular malperfusion placental pathology at delivery. Multimodal screening and commencement of aspirin prophylaxis at 11 to 13 weeks' gestation markedly reduces the risk of preterm delivery with preeclampsia. However, the additional role of low-molecular-weight heparin and mechanisms of action remain uncertain. Because low-molecular-weight heparin augments the production and release of placental growth factor in vitro by both placental villi and vascular endothelium, it may be effective to suppress the risk of severe preeclampsia in a niche group of high-risk patients with low circulating placental growth factor in the early second trimester. OBJECTIVE This study aimed to define a gestational age-specific reference range for placental growth factor and to test the hypothesis that prophylactic low-molecular-weight heparin administered in the early second trimester may restore deficient circulating placental growth factor levels and thereby prolong pregnancy. STUDY DESIGN Centile curves for circulating placental growth factor levels from 12 to 36 weeks' gestation were derived using quantile regression of combined data from a published cohort of 4207 unselected nulliparous patients in Cambridge, United Kingdom, at 4 sampling time points (12, 20, 28, and 36 weeks' gestation) and the White majority (n=531) of a healthy nulliparous cohort in Toronto, Canada, at 16 weeks' gestation using the same test platform. Within a specialty high-risk clinic in Toronto, a niche group of 7 patients with a circulating placental growth factor at the <10th centile in the early second trimester received daily prophylactic low-molecular-weight heparin (enoxaparin; 40 mg subcutaneously) and were followed up until delivery (group 1). Their baseline characteristics, delivery details, and placental pathologies were compared with 5 similar patients who did not receive low-molecular-weight heparin during the observation period (group 2) and further with 21 patients who delivered with severe preeclampsia (group 3) in the same institution. RESULTS A gestational age-specific reference range for placental growth factor levels at weekly intervals between 12 and 36 weeks was established for White women with singleton pregnancies. Within group 1, 5 of 7 patients demonstrated a sustained increase in circulating placental growth factor levels, whereas placental growth factor levels did not increase in group 2 or group 3 patients who did not receive low-molecular-weight heparin. Group 1 patients receiving low-molecular-weight heparin therapy exhibited a later gestation at delivery, relative to groups 2 and 3 (36 weeks [33-37] vs 23 weeks [22-26] and 28 weeks [27-31], respectively), and consequently had higher birthweights (1.93 kg [1.1-2.7] vs 0.32 kg [0.19-0.39] and 0.73 kg [0.52-1.03], respectively). The incidence of stillbirth was lowest in group 1 (14% [1 of 7]), relative to groups 2 and 3 (80% [4 of 5] and 29% [6 of 21], respectively). Maternal vascular malperfusion was the most common placental pathology found in association with abnormal uterine artery Doppler. CONCLUSION In patients at high risk of a serious adverse pregnancy outcome owing to placental disease, the addition of low-molecular-weight heparin to aspirin prophylaxis in the early second trimester may restore deficient circulating placental growth factor to mediate an improved perinatal outcome. These data support the implementation of a multicenter pilot randomized control trial where patients are recruited primarily based on the assessment of placental function in the early second trimester.
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Bujold E. Optimal Screening for Preeclampsia in the First Trimester of Pregnancy. Hypertension 2022; 79:323-324. [PMID: 35020460 DOI: 10.1161/hypertensionaha.121.18421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emmanuel Bujold
- Research Center of CHU de Québec-Université Laval, Canada. Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, Canada
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Lausman A, Kingdom J. How and when to recommend delivery of a growth-restricted fetus: A review. Best Pract Res Clin Obstet Gynaecol 2021; 77:119-128. [PMID: 34657786 DOI: 10.1016/j.bpobgyn.2021.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
Clinicians consider a range of variables when formulating decisions regarding the diagnosis, monitoring plan, and ultimately the decision to recommend the delivery of a growth-restricted fetus. The differential diagnosis of a pathological fetal growth pattern is initially considered via the history, a physical and laboratory examination of the pregnant person, as well as a comprehensive fetal ultrasound examination. These factors allow a broad distinction between pre-existing disease in the pregnant person, constitutionally small normal growth, placenta-mediated Fetal Growth Restriction (FGR), and intrinsic fetal disease. Most commonly, pathological growth restriction is mediated by underlying placental diseases, of which maternal vascular malperfusion is the most common, and often results in co-existent hypertension. A program of combined monitoring of the pregnant person and fetus, comprising hypertension assessment, and serial fetal ultrasound, including Doppler studies is then instituted, and may be combined with biochemical markers, such as Placental Growth Factor, for greater clinical precision. Recommendations on timing to deliver the growth-restricted fetus worldwide are converging, with similar guidance from clinical practice guidelines informed by high-quality Randomized Controlled Trials (RCTs) and large cohort studies. In most instances, it is reasonable to recommend delivery of all growth-restricted fetuses by approximately 38 weeks. Timing of delivery should take into consideration both short-term neonatal outcomes and long-term outcomes at school age. Mode of delivery is based on many factors, and induction of labor is a safe approach, especially after 34 weeks. Mechanical methods of induction may be preferred to pharmacologic methods, although both have a role and the choice of method is based on individualized assessment. Elective Cesarean birth thereby bypassing fetal stress during labor, is recommended in preterm growth-restricted fetuses with signs of adaptive fetal compromise, especially when ductus venosus flow is abnormal, or a contraction stress test is positive.
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Affiliation(s)
- Andrea Lausman
- Department of Obstetrics and Gynecology, University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | - John Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.
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Bujold E. Relying on the Metabolic Clock of Gestation for a Better Understanding of Preeclampsia. Hypertension 2021; 78:1411-1413. [PMID: 34644167 DOI: 10.1161/hypertensionaha.121.17819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emmanuel Bujold
- Research Center of CHU de Québec-Université Laval, Québec, Canada. Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, Canada
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Chandran AR, Agrawal S, Hobson SR, Windrim RC, Parks T, Kingdom JC. Stillbirth Following Normal Ultrasound Findings and Maternal Placental Growth Factor Levels. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:1426-1428. [PMID: 34411727 DOI: 10.1016/j.jogc.2021.07.019] [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: 04/27/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Attempts to reduce the current rate of antepartum stillbirth in the late third trimester have largely focused on the accurate identification of fetal growth restriction. Universal ultrasound significantly increases detection, especially when combined with maternal angiogenic growth factors, but this screening strategy is not well suited to identify umbilical cord pathology. While this poses unique challenges to pregnancy care, the recurrence risk of cord obstruction is low in comparison with many intrinsic placental diseases. CASE A 30-year-old woman with normal uterine artery Doppler waveforms, fetal growth ultrasounds, and circulating placental growth factor experienced an unexpected third-trimester stillbirth. Placental pathology demonstrated fetal vascular malperfusion and cord hyper-coiling. CONCLUSION Despite normal placental function, the otherwise healthy fetus is at risk of antepartum stillbirth due to cord-related pathology.
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Affiliation(s)
| | - Swati Agrawal
- Maternal Fetal Medicine, Sinai Health System, Toronto, ON
| | | | - Rory C Windrim
- Maternal Fetal Medicine, Sinai Health System, Toronto, ON
| | - Tony Parks
- Department of Pathology, Sinai Health System, Toronto, ON
| | - John C Kingdom
- Maternal Fetal Medicine, Sinai Health System, Toronto, ON
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Armistead B, Kadam L, Siegwald E, McCarthy FP, Kingdom JC, Kohan-Ghadr HR, Drewlo S. Induction of the PPARγ (Peroxisome Proliferator-Activated Receptor γ)-GCM1 (Glial Cell Missing 1) Syncytialization Axis Reduces sFLT1 (Soluble fms-Like Tyrosine Kinase 1) in the Preeclamptic Placenta. Hypertension 2021; 78:230-240. [PMID: 34024123 DOI: 10.1161/hypertensionaha.121.17267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Brooke Armistead
- From the Michigan State University, Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Grand Rapids (B.A., H.-R.K.-G., S.D.)
| | - Leena Kadam
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland (L.K.)
| | - Emily Siegwald
- Spectrum Health SHARE Biorepository and Office of Research and Education, Spectrum Health, Grand Rapids, MI (E.S.)
| | - Fergus P McCarthy
- Department of Obstetrics and Gynaecology, Infant Research Centre, University College Cork, Ireland (F.P.M.)
| | - John C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, ON, Canada (J.C.K.).,Department of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada (J.C.K.)
| | - Hamid-Reza Kohan-Ghadr
- From the Michigan State University, Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Grand Rapids (B.A., H.-R.K.-G., S.D.)
| | - Sascha Drewlo
- From the Michigan State University, Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Grand Rapids (B.A., H.-R.K.-G., S.D.)
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