1
|
Basavaraj C, Grant AD, Aras SG, Erickson EN. Deep Learning Model Using Continuous Skin Temperature Data Predicts Labor Onset. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.25.24303344. [PMID: 38464102 PMCID: PMC10925356 DOI: 10.1101/2024.02.25.24303344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Changes in body temperature anticipate labor onset in numerous mammals, yet this concept has not been explored in humans. Methods We evaluated patterns in continuous skin temperature data in 91 pregnant women using a wearable smart ring. Additionally, we collected daily steroid hormone samples leading up to labor in a subset of 28 pregnancies and analyzed relationships among hormones and body temperature trajectory. Finally, we developed a novel autoencoder long-short-term-memory (AE-LSTM) deep learning model to provide a daily estimation of days until labor onset. Results Features of temperature change leading up to labor were associated with urinary hormones and labor type. Spontaneous labors exhibited greater estriol to α-pregnanediol ratio, as well as lower body temperature and more stable circadian rhythms compared to pregnancies that did not undergo spontaneous labor. Skin temperature data from 54 pregnancies that underwent spontaneous labor between 34 and 42 weeks of gestation were included in training the AE-LSTM model, and an additional 40 pregnancies that underwent artificial induction of labor or Cesarean without labor were used for further testing. The model was trained only on aggregate 5-minute skin temperature data starting at a gestational age of 240 until labor onset. During cross-validation AE-LSTM average error (true - predicted) dropped below 2 days at 8 days before labor, independent of gestational age. Labor onset windows were calculated from the AE-LSTM output using a probabilistic distribution of model error. For these windows AE-LSTM correctly predicted labor start for 79% of the spontaneous labors within a 4.6-day window at 7 days before true labor, and 7.4-day window at 10 days before true labor. Conclusion Continuous skin temperature reflects progression toward labor and hormonal status during pregnancy. Deep learning using continuous temperature may provide clinically valuable tools for pregnancy care.
Collapse
Affiliation(s)
- Chinmai Basavaraj
- Department of Computer Science, The University of Arizona, Tucson, AZ, USA
| | | | - Shravan G Aras
- Center for Biomedical Informatics and Biostatistics, The University of Arizona Health Sciences, Tucson, AZ, USA
| | | |
Collapse
|
2
|
Pappa C, Gkrozou F, Dimitriou E, Tsonis O, Kitsouli A, Varvarousis D, Xydis V, Paschopoulos M, Kitsoulis P. Can maternal hormones play a significant role in delivery mode? J OBSTET GYNAECOL 2022; 42:2779-2786. [PMID: 35962554 DOI: 10.1080/01443615.2022.2109139] [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: 01/06/2023]
Abstract
The aim of this study was primarily to evaluate the levels of progesterone, oestradiol and relaxin during different delivery modes and secondarily to assess specific traits and changes in maternal pelvic dimensions during pregnancy and childbirth, in correlation with foetal size and maternal hormonal profile. Nulliparous women (n = 448) were evaluated at three different stages, during first trimester, at the time of admission for childbirth and finally just before childbirth. Each examination included clinical internal pelvimetry, blood sample collection for defining the hormones levels in peripheral maternal circulation and ultrasonographic measurements of specific variables of the pubic symphysis and the foetus. We included 304 nulliparous women divided in three groups. According to our results, there was statistically significant difference at the mean progesterone, oestradiol and relaxin range during different modes of childbirth (p-value < .01). We also found significant correlation between the newborn's weight and the changes in pubic symphysis dimensions. However, no significant association was noted between maternal hormones studied and the changes in pelvic dimensions.IMPACT STATEMENTWhat is already known on this subject? Mode of childbirth can be affected by various aspects, like maternal pelvic anatomy, foetal size and hormonal status at the time of labour. Hormonal fluctuations along with mechanical forces caused by the foetus are believed to lead to morphological alterations to promote natural vaginal childbirth.What do the results of this study add? Our results clearly showed that successful vaginal delivery is characterised by the prevalence of a hyperoestrogenic environment with higher values of intrapartum oestradiol range and significant increase in maternal serum relaxin levels. We also proved that progesterone levels do not decrease during vaginal childbirth, and we concluded that foetal size seems to be the most crucial factor causing alterations in maternal pelvis during parturition.What are the implications of these findings for clinical practice and further research? Our findings could form part of a set of key factors included in future algorithms or computerised biomechanical models for predicting potential childbirth mode. Larger multicenter studies should confirm our results and evaluate their clinical significance in the decision making to ensure safe childbirth and optimal maternal and perinatal outcomes.
Collapse
Affiliation(s)
- Christina Pappa
- Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Fani Gkrozou
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Orestis Tsonis
- St. Bartholomew's Hospital, Barts Health NHS, City of London, UK
| | - Aikaterini Kitsouli
- Anatomy-Histology-Embryology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Vasileios Xydis
- Department of Radiology, University Hospital of Ioannina, Ioannina, Greece
| | - Minas Paschopoulos
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | - Panagiotis Kitsoulis
- Anatomy-Histology-Embryology, University Hospital of Ioannina, Ioannina, Greece.,Orthopedic Surgeon, Medical School, University of Ioannina, Ioannina, Greece
| |
Collapse
|
3
|
Peer V, Muhsen K, Betser M, Green MS. Antibody Response to Pertussis Vaccination in Pregnant and Non-Pregnant Women-The Role of Sex Hormones. Vaccines (Basel) 2021; 9:vaccines9060637. [PMID: 34200795 PMCID: PMC8230440 DOI: 10.3390/vaccines9060637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/05/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022] Open
Abstract
Pertussis containing vaccine is recommended for pregnant women to protect neonates prior to being fully immunized against the disease. The immune response during pregnancy may be impacted by changes in the hormonal status. The aim of this study was to evaluate the immune response to pertussis immunization in pregnancy and to assess the role of sex hormones. In a cross-sectional study, blood samples were drawn from 174 pregnant and 74 non-pregnant women 45-60 days following immunization. Anti-pertussis toxin (Anti-PT) IgG antibody levels, estrogen, and progestogen concentrations were compared between the two groups. Multiple logistic regression analysis was used to examine the association between serum antibody and sex hormone concentrations in each group, controlling for age, body mass index (BMI), and smoking status. The geometric mean concentration (GMC) of anti-PT IgG antibody was significantly higher in non-pregnant women compared with pregnant women (median of 2.09 and 1.86, interquartile range = 2.36-1.8 and 2.11-1.16 respectively, p < 0.0001). Among pregnant women, the anti-PT IgG antibody GMC was negatively associated with both progesterone (odds ratio = 0.300, 95% CI = 0.116, 0.772, p = 0.013) and estrogen (odds ratio = 0.071, 95% CI = 0.017, 0.292, p < 0.0001), after controlling for age, BMI, and smoking. Pregnancy was associated with lower anti-PT IgG antibody levels (odds ratio = 0.413, 95% CI = -0.190, 0.899, p = 0.026). This appears to be at least partially explained by the higher levels of hormones during pregnancy. These findings demonstrate the important role of sex hormones in the response to pertussis vaccine during pregnancy and can help to evaluate the optimum vaccination schedule.
Collapse
Affiliation(s)
- Victoria Peer
- School of Public Health, University of Haifa, Abba Khoushy 199, Mount Carmel, Haifa 3498838, Israel;
- Correspondence:
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University Ramat Aviv, Ramat Aviv, Tel Aviv 6139001, Israel;
| | - Moshe Betser
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Zerifin 70300, Israel;
| | - Manfred S Green
- School of Public Health, University of Haifa, Abba Khoushy 199, Mount Carmel, Haifa 3498838, Israel;
| |
Collapse
|
4
|
Karakoc G, Turgal M, Eroglu H, Cakir C, Yavuz A, Yucel A. Relations between second-trimester aneuploidy screening results and prediction of labour induction success in term pregnancies. J OBSTET GYNAECOL 2020; 41:527-531. [PMID: 32496936 DOI: 10.1080/01443615.2020.1755619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We aimed to assess whether the second-trimester maternal serum markers could be used for the prediction of labour induction success. This prospective study enrolled women planned labour induction at term. Women were assigned to one of two groups: vaginal prostaglandin or balloon dilatation. All patients were evaluated for Bishop score, maternal serum oestriol, human chorionic gonadotropin and progesterone at the time of second-aneuploidy screening. The total successful rate for induction of labour was 63.9% in both groups. Maternal serum oestriol multiple of median (MoM) values were significantly lower among the caesarean section group compared to the vaginal delivery group (p < .001). A MoM value of 0.74 for oestriol was associated with a sensitivity of 75.9%, specificity of 41.0%, a positive predictive value of 76.6% and a negative predictive value of 58.0% for a successful induction of labour. Oestriol had a good performance in the prediction of successful induction of labour at term.IMPACT STATEMENTWhat is already known on this subject? Induction of labour is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management. Previous studies have reported that a decreased progesterone/oestradiol ratio and increased maternal plasma oestriol levels are associated with successful labour. What the results of this study add? The results of this study showed that second-trimester oestriol multiple of median (MoM) value provide a significant contribution to the efforts of the prediction of successful induction of labour in term pregnancy, having a sensitivity of 69.8%, specificity of 92.4%, positive predictive value of 83.3% and negative predictive value of 82.5%.What the implications are of these findings for clinical practice and/or further research? This finding can be used as an additional method for prediction of labour induction as well as multiparity and Bishop score. This adds new valuable data to the literature which could be used for systematic reviews and for implementing guidelines and protocols on labour induction.
Collapse
Affiliation(s)
- Gokhan Karakoc
- Department of Maternal Fetal Medicine, Health Sciences University, Etlik Zubeyde Hanim Maternity and Research Hospital, Ankara, Turkey
| | - Mert Turgal
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - Hasan Eroglu
- Department of Maternal Fetal Medicine, Health Sciences University, Etlik Zubeyde Hanim Maternity and Research Hospital, Ankara, Turkey
| | - Caner Cakir
- Department of Maternal Fetal Medicine, Health Sciences University, Etlik Zubeyde Hanim Maternity and Research Hospital, Ankara, Turkey
| | - And Yavuz
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Women And Children's Diseases Training And Research Hospital, Istanbul, Turkey
| | - Aykan Yucel
- Department of Maternal Fetal Medicine, Health Sciences University, Etlik Zubeyde Hanim Maternity and Research Hospital, Ankara, Turkey
| |
Collapse
|
5
|
Lai PF, Georgiou EX, Tribe RM, Johnson MR. The impact of progesterone and RU-486 on classic pro-labour proteins & contractility in human myometrial tissues during 24-hour exposure to tension & interleukin-1β. Mol Cell Endocrinol 2020; 500:110633. [PMID: 31678609 DOI: 10.1016/j.mce.2019.110633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/19/2019] [Accepted: 10/26/2019] [Indexed: 01/16/2023]
Abstract
Increased expression of pro-labour genes that encode cyclooxygenase-2 (COX-2), oxytocin receptor (OTR) and connexin-43 (Cx43) at parturition is often attributed to P4 functional withdrawal, based on findings from animal models and human primary myometrial cells. However, the cause of reduced myometrial P4 responsiveness that promotes contractions at labour is not fully determined. Uterine stretch occurs with advancing gestation but most in vitro experimental models do not take this into consideration. We aimed to examine whether tissue-level myometrial stretch influences the ability of P4 to regulate pro-labour protein abundance by using myometrial biopsies from term gestation pregnant women to assess the impact of 24 h exposure to combinations of (i) stretch-mediated tension, (ii) P4 (100 nM) and (iii) an anti-progestin, RU-486 (1 μM). Firstly, we observed baseline COX-2 and Cx43 protein levels increased, whereas P4 content along with calponin-1 and progesterone receptor (PR) protein abundance decreased, in vehicle-treated tissues. P4 supplementation subtly reduced COX-2 levels in un-stretched tissues. Spontaneous and oxytocin-augmented contractility were unchanged by tissue culture exposure to P4 and/or RU-486. Interleukin-1β (IL-1β; 1 ng/ml) enhanced COX-2 protein and PGE2 content in un-stretched tissues. Overall, tissue stretch may, in part, regulate P4-sensitive pro-labour protein levels, but this is likely to be reliant on interaction with other in utero factors that were absent in our tissue cultures. More complex culture conditions should be evaluated in future to aid further development of a physiologically relevant model to improve our understanding of in utero myometrial P4 responsiveness.
Collapse
Affiliation(s)
- Pei F Lai
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, SW10 9NH, UK
| | - Ektoras X Georgiou
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, SW10 9NH, UK
| | - Rachel M Tribe
- Department of Women and Children's Health, Kings College London, London, SE1 7EH, UK
| | - Mark R Johnson
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, SW10 9NH, UK.
| |
Collapse
|
6
|
ElDeeb AM, Osman DM, Atta HK, Hamada HA. Effect of reproductive hormones variation during menstrual cycle on hip abductor and adductor muscles performance in college students. BULLETIN OF FACULTY OF PHYSICAL THERAPY 2019. [DOI: 10.4103/bfpt.bfpt_28_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
7
|
The role of prostaglandins E1 and E2, dinoprostone, and misoprostol in cervical ripening and the induction of labor: a mechanistic approach. Arch Gynecol Obstet 2017; 296:167-179. [DOI: 10.1007/s00404-017-4418-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/30/2017] [Indexed: 12/23/2022]
|
8
|
李 雪, 郭 跃, 许 燕, 朱 斌, 邬 雪, 陈 翊, 王 晓, 陈 敦, 陈 慧, 张 建, 王 志, 安 胜. [Clinical efficacy and safety of controlled-release dinoprostone insert: a multicenter retrospective study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:18-23. [PMID: 28109093 PMCID: PMC6765749 DOI: 10.3969/j.issn.1673-4254.2017.01.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To analyze the effectiveness and safety of controlled-release dinoprostone insert for term labor induction in the Pearl River Delta of Guangdong province. METHODS Twenty hospitals using controlled-release dinoprostone insert for term labor induction in the Pearl River Delta of Guangdong province were stratified into provincial hospitals and municipal hospitals, and three hospitals of each level were selected as research units. According to the inclusion and exclusion criteria, 1390 pregnant women receiving term labor induction using controlled-release dinoprostone insert were retrospectively analyzed to evaluate the the effectiveness and safety with another 957 pregnant women with induced abortion using oxytocin as the control group. RESULTS Compared with the control group, the controlled-release dinoprostone insert group showed a significantly longer length of the latent phase of labor (4.06∓2.65 vs 3.20∓2.08 h, P=0.003, 95%CI [0.182, 0.920]) and shorter lengths of the active phase (1.73∓1.32 vs 2.22∓1.75 h, P=0.000, 95%CI [-0.795, -0.363]) and the second stage of labor (0.49∓0.37 vs 0.54∓0.43 h, P=0.003, 95%CI [-0.137, -0.028]). No significant differences were found in the length of the first stage of labor, the vaginal delivery rate, adverse reactions, or fetal outcomes between the two groups. CONCLUSION Controlled-release dinoprostone insert is effective and safe for labor induction at term.
Collapse
Affiliation(s)
- 雪媛 李
- 南方医科大学南方医院妇产科, 广东 广州 510515Department of Gynecology and Obstetrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 跃文 郭
- 顺德第一人民医院妇产科, 广东 佛山 528300Department of Gynecology and Obstetrics, Shunde First People's Hospital, Foshan 528300, China
| | - 燕文 许
- 番禺何贤纪念医院妇产科, 广东 广州 511400Department of Gynecology and Obstetrics, Hexian Memorial Hospital, Guangzhou 511400, China
| | - 斌 朱
- 番禺何贤纪念医院妇产科, 广东 广州 511400Department of Gynecology and Obstetrics, Hexian Memorial Hospital, Guangzhou 511400, China
| | - 雪雪 邬
- 番禺中心医院妇产科, 广东 广州 511400Department of Gynecology and Obstetrics, Panyu Central Hospital, Guangzhou 511400, China
| | - 翊 陈
- 番禺中心医院妇产科, 广东 广州 511400Department of Gynecology and Obstetrics, Panyu Central Hospital, Guangzhou 511400, China
| | - 晓怡 王
- 广州医科大学附属第三医院 妇产科, 广东 广州 510000Department of Gynecology and Obstetrics, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - 敦金 陈
- 广州医科大学附属第三医院 妇产科, 广东 广州 510000Department of Gynecology and Obstetrics, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - 慧 陈
- 中山大学孙逸仙纪念医院妇产科, 广东 广州 510000Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - 建平 张
- 中山大学孙逸仙纪念医院妇产科, 广东 广州 510000Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - 志坚 王
- 南方医科大学南方医院妇产科, 广东 广州 510515Department of Gynecology and Obstetrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 胜利 安
- 顺德第一人民医院妇产科, 广东 佛山 528300Department of Gynecology and Obstetrics, Shunde First People's Hospital, Foshan 528300, China
| |
Collapse
|
9
|
Gao Q, Lv J, Li W, Zhang P, Tao J, Xu Z. Disrupting the circadian photo-period alters the release of follicle-stimulating hormone, luteinizing hormone, progesterone, and estradiol in maternal and fetal sheep. J Reprod Dev 2016; 62:487-493. [PMID: 27319751 PMCID: PMC5081736 DOI: 10.1262/jrd.2016-009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although a large number of studies show that photo-period disruption potentially affects hormone secretion in mammals, information about the effects of
circadian photo-period disruption during pregnancy on fetal blood reproductive hormone levels is scarce. This study used ewes and their fetuses to determine the
effects of circadian photo-period disruption (deprivation of darkness) on follicle-stimulating hormone, luteinizing hormone, estradiol, and progesterone in
maternal and fetal circulation at late gestation. Pregnant ewes (gestational age: 135 ± 3 days) were randomly placed into control and dark deprivation groups.
The control (N = 5) and dark deprivation (N = 5) groups were exposed to a fixed 12 h light/12 h dark cycle and a 24 h constant light cycle, respectively, for 2
days. Dark deprivation up-regulated follicle-stimulating hormone and estradiol levels and down-regulated progesterone levels in both maternal and fetal
circulation, and up-regulated luteinizing hormone levels in fetal but not maternal circulation. These results provide new information about how circadian
photo-period disruption during pregnancy could alter the release of certain reproductive hormones into fetal blood, which may influence the development of fetal
organs in utero, as well as long-term health.
Collapse
Affiliation(s)
- Qinqin Gao
- Institute for Fetology, the First Affiliated Hospital of Soochow University, Jiangsu 215006, China
| | | | | | | | | | | |
Collapse
|
10
|
Carlson NS, Hernandez TL, Hurt KJ. Parturition dysfunction in obesity: time to target the pathobiology. Reprod Biol Endocrinol 2015; 13:135. [PMID: 26684329 PMCID: PMC4683915 DOI: 10.1186/s12958-015-0129-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 11/24/2015] [Indexed: 12/23/2022] Open
Abstract
Over a third of women of childbearing age in the United States are obese, and during pregnancy they are at increased risk for delayed labor onset and slow labor progress that often results in unplanned cesarean delivery. The biology behind this dysfunctional parturition is not well understood. Studies of obesity-induced changes in parturition physiology may facilitate approaches to optimize labor in obese women. In this review, we summarize known and proposed biologic effects of obesity on labor preparation, contraction/synchronization, and endurance, drawing on both clinical observation and experimental data. We present evidence from human and animal studies of interactions between obesity and parturition signaling in all elements of the birth process, including: delayed cervical ripening, prostaglandin insensitivity, amniotic membrane strengthening, decreased myometrial oxytocin receptor expression, decreased myocyte action potential initiation and contractility, decreased myocyte gap junction formation, and impaired myocyte neutralization of reactive oxygen species. We found convincing clinical data on the effect of obesity on labor initiation and successful delivery, but few studies on the underlying pathobiology. We suggest research opportunities and therapeutic interventions based on plausible biologic mechanisms.
Collapse
Affiliation(s)
- Nicole S Carlson
- Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Teri L Hernandez
- Department of Medicine, Division of Endocrinology, Metabolism, & Diabetes, College of Nursing, University of Colorado School of Medicine, 12801 E. 17th Ave, MS 8106, Aurora, CO, 80045, USA.
| | - K Joseph Hurt
- Department of Obstetrics & Gynecology, Divisions of Maternal-Fetal Medicine & Reproductive Sciences, University of Colorado School of Medicine, 12700 East 19th Ave, MS 8613, Aurora, CO, 80045, USA.
| |
Collapse
|