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Moiz B, Salman M, Rasheed S, Qudus R, Millard G, Hyland CA, Flower RL, Wilson B, Turner R, Lopez GH, Liew YW. Recurrent pregnancy loss in a patient with anti-Rh17. Transfus Med 2024; 34:66-70. [PMID: 37941301 DOI: 10.1111/tme.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Rh is one of the most important blood group systems in transfusion medicine. The two homologous genes RHD and RHCE are located on chromosome 1p36.11 and encode for RhD and RhCE proteins, respectively. Complex genetic polymorphisms result in a variety of antigenic expression of D, C, E, c, and e. Here, we describe a case of a young female with D-- who developed anti-Rh17 secondary to blood transfusion and had signs of haemolytic disease of the fetus and fetal death in five consecutive pregnancies. CASE DESCRIPTION EDTA-whole blood samples were collected from the patient, husband and eight siblings for blood grouping, phenotyping, and red cell antibody screening. Extracted DNA was genotyped by SNP-microarray and massively parallel sequencing (MPS) with targeted blood group exome sequencing. Copy number variation analysis was performed to identify structural variants in the RHD and RHCE. Routine phenotyping showed all family members were D+. The patient's red blood cells were C-E-c-e-, Rh17- and Rh46- and had anti-Rh17 and anti-e antibodies. MPS showed the patient carried a wildtype RHD sequence and homozygous for RHCE (1)-D (2-9)-CE (10) hybrid gene predicted to express a D-- phenotype. CONCLUSIONS Our patient had a rare D-- phenotype and confirmed to have RHCE/RHD hybrid gene with replacement of 2-9 exons of RHCE by RHD sequences. Unfortunately, our patient developed anti-Rh17 and anti-e antibodies due to blood transfusion and suffered fetal demise in her very first pregnancy. The adverse outcomes could have been prevented by active prenatal management.
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Affiliation(s)
- Bushra Moiz
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Muhammed Salman
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Seher Rasheed
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Ruhul Qudus
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Glenda Millard
- Red Cell Reference Laboratory, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
- Research and Development, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Catherine A Hyland
- Research and Development, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
- School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robert L Flower
- Research and Development, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
- School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Brett Wilson
- Red Cell Reference Laboratory, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Robyn Turner
- Red Cell Reference Laboratory, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Genghis H Lopez
- Research and Development, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Yew-Wah Liew
- Red Cell Reference Laboratory, Clinical Services and Research, Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
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Ernstsen SL, Ahlen MT, Johansen T, Bertelsen EL, Kjeldsen-Kragh J, Tiller H. Antenatal intravenous immunoglobulins in pregnancies at risk of fetal and neonatal alloimmune thrombocytopenia: comparison of neonatal outcome in treated and nontreated pregnancies. Am J Obstet Gynecol 2022; 227:506.e1-506.e12. [PMID: 35500612 DOI: 10.1016/j.ajog.2022.04.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/01/2022] [Accepted: 04/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Maternal alloantibodies to human platelet antigen-1a can cause severe intracranial hemorrhage in a fetus or newborn. Although never evaluated in placebo-controlled clinical trials, most Western countries use off-label weekly administration of high-dosage intravenous immunoglobulin in all pregnant women with an obstetrical history of fetal and neonatal alloimmune thrombocytopenia. In Norway, antenatal intravenous immunoglobulin is only recommended in pregnancies wherein a previous child had intracranial hemorrhage (high-risk) and is generally not given in other human platelet antigen-1a alloimmunized pregnancies (low-risk). OBJECTIVE To compare the frequency of anti-human platelet antigen-1a-induced intracranial hemorrhage in pregnancies at risk treated with intravenous immunoglobulin vs pregnancies not receiving this treatment as a part of a different management program. STUDY DESIGN This was a retrospective comparative study where the neonatal outcomes of 71 untreated human platelet antigen-1a-alloimmunized pregnancies in Norway during a 20-year period was compared with 403 intravenous-immunoglobulin-treated pregnancies identified through a recent systematic review. We stratified analyses on the basis of whether the mothers belonged to high- or low-risk pregnancies. Therefore, only women who previously had a child with fetal and neonatal alloimmune thrombocytopenia were included. RESULTS Two neonates with brain bleeds were identified from 313 treated low-risk pregnancies (0.6%; 95% confidence interval, 0.2-2.3). There were no neonates born with intracranial hemorrhage of 64 nontreated, low-risk mothers (0.0%; 95% confidence interval, 0.0-5.7). Thus, no significant difference was observed in the neonatal outcome between immunoglobulin-treated and untreated low-risk pregnancies. Among high-risk mothers, 5 of 90 neonates from treated pregnancies were diagnosed with intracranial hemorrhage (5.6%; 95% confidence interval, 2.4-12.4) compared with 2 of 7 neonates from nontreated pregnancies (29%; 95% confidence interval, 8.2-64.1; P=.08). CONCLUSION The most reliable data hitherto for the evaluation of intravenous immunoglobulins treatment in low-risk pregnancies is shown herein. We did not find evidence that omitting antenatal intravenous immunoglobulin treatment in low-risk pregnancies increases the risk of neonatal intracranial hemorrhage.
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Lorthe E, Letouzey M, Torchin H, Foix L'helias L, Gras-Le Guen C, Benhammou V, Boileau P, Charlier C, Kayem G. Antibiotic prophylaxis in preterm premature rupture of membranes at 24-31 weeks' gestation: perinatal and 2-year outcomes in the EPIPAGE-2 cohort. BJOG 2021; 129:1560-1573. [PMID: 34954867 PMCID: PMC9546066 DOI: 10.1111/1471-0528.17081] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/05/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022]
Abstract
Objective To compare different antibiotic prophylaxis administered after preterm premature rupture of membranes to determine whether any were associated with differences in obstetric and/or neonatal outcomes and/or neurodevelopmental outcomes at 2 years of corrected age. Design Prospective, nationwide, population‐based EPIPAGE‐2 cohort study of preterm infants. Setting France, 2011. Sample We included 492 women with a singleton pregnancy and a diagnosis of preterm premature rupture of membranes at 24–31 weeks. Exclusion criteria were contraindication to expectant management or indication for antibiotic therapy other than preterm premature rupture of membranes. Antibiotic prophylaxis was categorised as amoxicillin (n = 345), macrolide (n = 30), third‐generation cephalosporin (n = 45) or any combinations covering Streptococcus agalactiae and >90% of Escherichia coli (n = 72), initiated within 24 hours after preterm premature rupture of membranes. Methods Population‐averaged robust Poisson models. Main Outcome Measures Survival at discharge without severe neonatal morbidity, 2‐year neurodevelopment. Results With amoxicillin, macrolide, third‐generation cephalosporin and combinations, 78.5%, 83.9%, 93.6% and 86.0% of neonates were discharged alive without severe morbidity. The administration of third‐generation cephalosporin or any E. coli‐targeting combinations was associated with improved survival without severe morbidity (adjusted risk ratio 1.25 [95% confidence interval 1.08–1.45] and 1.10 [95 % confidence interval 1.01–1.20], respectively) compared with amoxicillin. We evidenced no increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen. Conclusion In preterm premature rupture of membranes at 24–31 weeks, antibiotic prophylaxis based on third‐generation cephalosporin may be associated with improved survival without severe neonatal morbidity when compared with amoxicillin, with no evidence of increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen. Tweetable Abstract Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes. Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes.
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Affiliation(s)
- Elsa Lorthe
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathilde Letouzey
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Versailles Saint Quentin en Yvelines University, France
| | - Héloïse Torchin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Neonatal Pediatrics, Cochin Port Royal Hospital, APHP, Paris, France
| | - Laurence Foix L'helias
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Neonatal Pediatrics, Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Christèle Gras-Le Guen
- Department of pediatrics, pediatrics emergency unit and general pediatrics, Nantes University Hospital, hôpital Mère-Enfant, CHU de Nantes, 7, quai Moncousu, 44000, Nantes, France
| | - Valérie Benhammou
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France
| | - Pascal Boileau
- Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Versailles Saint Quentin en Yvelines University, France.,UFR des sciences de la Santé Simone Veil, Versailles St Quentin en Yvelines University, Montigny le Bretonneux, France
| | - Caroline Charlier
- Université de Paris, Hôpital Universitaire Necker-Enfants Malades, Division of Infectious Diseases and Tropical Medicine, Assistance Publique-Hôpitaux de Paris, Institut Pasteur, Biology of Infection Unit, French National Reference Center and WHO Collaborating Center for Listeria, Inserm U1117, Paris, France
| | - Gilles Kayem
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France.,Department of Gynecology and Obstetrics, Trousseau Hospital, APHP, Sorbonne University, Paris, France
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Newman RA, Makhoul J, Chang J, Senderoff D, Bosse B, Crosland BA, Seet E, Chan K. Antepartum vaginal bleeding: characteristics associated with delivery within seven days. J Matern Fetal Neonatal Med 2021; 35:8580-8585. [PMID: 34645356 DOI: 10.1080/14767058.2021.1989402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To identify maternal and/or fetal characteristics associated with delivery within seven days for patients who present with vaginal bleeding in the antepartum period.Methods: This is a retrospective chart review performed at a community-academic tertiary care center. Three hundred and twenty-two consecutive charts associated with admission for vaginal bleeding during pregnancy between January 2015 and May 2020 were reviewed. One hundred and twenty-six women were included based on singleton gestation, gestational age 24 0/7 - 36 6/7 weeks, self-limited vaginal bleeding, vital sign stability (blood pressure >100/60 mmHg, heart rate >60 beats per minute, respiratory rate <20 breaths per minute), absence of signs of labor, no known placenta previa/accreta, recent vaginal intercourse, or trauma. Patient demographic and clinical characteristics were compared using Fisher's exact and two-sample t-tests tests when appropriate. Univariate and multivariate logistic regression models were fitted to predict delivery within 7 days.Results: Thirty-four percent of women who presented with light vaginal bleeding delivered within seven days, with a mean of 2.6 days (n = 44/126). Patients without evidence of labor but with sterile vaginal exam (SVE) >2 cm on admission were 14 times more likely to deliver within 7 days than SVE ≤ 2 cm (AOR 14.49, 95% CI 3.33-63.03); however, 35.2% of women with SVE ≤ 2 cm still delivered in this timeframe (n = 12/34). Of the 59 patients who had cervical lengths (CL) performed, those with CL ≤2.5 cm were 4.22 times more likely to deliver within 7 days (OR 4.22, 95% CI 1.10-16.20). Seventy-eight percent of the patients who had CL >2.5 cm and SVE 0-1 cm went on to deliver >14 days from their initial bleeds (n = 18/23).Conclusion: Patients who present with self-limited vaginal bleeding and SVE > 2 cm should be admitted for antenatal steroids. Prolonged inpatient observation beyond the typical steroid window of 48-72 h should be dependent on the individual patient. Given that CL ≤2.5 cm and regular contractions are known risk factors for preterm delivery, these characteristics alone may also warrant extended inpatient observation, though even in conjunction with vaginal bleeding, neither was a significant predictor for delivery in our study. In contrast, the majority of patients with vaginal bleeding and SVE <2 cm delivered >14 days after their initial bleeds and are likely eligible for shorter periods of observation.
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Affiliation(s)
- Rachel A Newman
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joshua Makhoul
- Department of Obstetrics and Gynecology, University of California, Irvine, CA, USA
| | - Jenny Chang
- Department of Obstetrics and Gynecology, University of California, Irvine, CA, USA
| | - Dana Senderoff
- Department of Obstetrics and Gynecology, University of California, Irvine, CA, USA
| | - Bradley Bosse
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - B Adam Crosland
- Department of Obstetrics and Gynecology, University of California, Irvine, CA, USA
| | - Emily Seet
- Department of Obstetrics and Gynecology, Memorial Care Miller Children's & Women's Hospital Long Beach, Long Beach, CA, USA
| | - Kenneth Chan
- Department of Obstetrics and Gynecology, Memorial Care Miller Children's & Women's Hospital Long Beach, Long Beach, CA, USA
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Atallah A, Butin M, Moret S, Claris O, Gaucherand P, Doret-Dion M. Fetal growth restriction: underdiagnosed condition with non-optimal screening. J Matern Fetal Neonatal Med 2021; 35:8237-8244. [PMID: 34420493 DOI: 10.1080/14767058.2021.1967924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Fetal Growth restriction (FGR) is the pathological failure of a fetus to reach its biologically determined growth potential. Detection of FGR fetuses is a universally agreed key objective of antenatal care. Antenatal detection of FGR has undeniable benefits, juggling between intensive fetal surveillance and optimized timing of delivery; it reduces adverse perinatal outcomes by up to four-fold. However, FGR is still widely underdiagnosed. We aimed to identify the prevalence of FGR diagnosis in our wards and study the impact of the 2013 published French guidelines on the detection rate of FGR. The secondary objective aimed to highlight the factors of suboptimal screening in the population of non-diagnosed FGR fetuses and emphasize the screening method that led to antenatal diagnosis of FGR. MATERIALS AND METHODS We conducted a retrospective study at a single tertiary maternity center in Lyon-France, the Femme Mère Enfant Hospital, including the exhaustive population of FGR born after 24 + 0 weeks of gestation from 1 January 2011 to 31 December 2017. FGR was defined combining the neonatal and antenatal consensus-based definitions for early and late FGR in absence of congenital anomalies, excluding small for gestational age fetuses. For all FGR fetuses, we compared the antenatal detection rate of FGR during 2011-2013 to 2015-2017, since the French guidelines were published in December 2013. When FGR fetuses underwent an antenatal diagnosis of FGR, we retrospectively collected the characteristics that led to the diagnosis. When fetuses were not diagnosed as FGR, we retrospectively reviewed the implementation of the recommended screening method, enabling to evaluate whether screening was optimal or not. Statistical analysis was performed in July 2018, and statistical significance was regarded as a p-value <.05. RESULTS Over the seven-year period, and among 31,052 newborns, 1020 (3.3%) infants were identified as FGR and met the inclusion criteria. The detection rate of FGR was similar before and after publication of the French Guidelines related to FGR in 2013. Indeed, 50.8% (201/395) FGR were diagnosed between 2011 and 2013 versus 52.6% (245/465) between 2015 and 2017 (p = .59). In the population of non-diagnosed FGR infants, screening was suboptimal in 80%. Symphysis-fundal height (SFH) was not measured in 10.7%, with no difference before and after 2014 (7.3 versus 11.8% p = .11). Ultrasound examination for fetal biometry had not been prescribed in spite of abnormal SFH in 47.7% of undiagnosed FGR infants. Diagnosis has been missed in 11.5% of infants because of misinterpretation of the estimated fetal weight's centile. CONCLUSION FGR is widely underdiagnosed. However, the limited performances can partially be explained by the regular misuse of screening method in clinical practice. Despite the systematic third trimester ultrasound screening, the detection rate of FGR was similar to the one reported in the medical literature. The timing of routine third trimester ultrasound in low-risk women may be rethought.
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Affiliation(s)
- Anthony Atallah
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, Saint-Etienne, France.,University Hospital Centre Sainte Justine, Department of Maternal Fetal Medicine, University of Montreal, Canada
| | - Marine Butin
- Department of Neonatalogy, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,International Center for Research in Infectiology, INSERM U1111, CNRS UMR5308, University of Lyon 1, Lyon, France
| | - Stéphanie Moret
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France
| | - Olivier Claris
- University Hospital Centre Sainte Justine, Department of Maternal Fetal Medicine, University of Montreal, Canada.,University of Lyon, Lyon, EA, France
| | - Pascal Gaucherand
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, Saint-Etienne, France
| | - Muriel Doret-Dion
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, Saint-Etienne, France
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Abstract
Background Although it is well established that systemic lupus erythematosus (SLE) negatively affects pregnancy outcomes, there is insufficient evidence on the effect of lupus nephritis (LN) on antenatal management and pregnancy outcomes. We performed a systematic review and meta-analysis to determine the association of LN with management and pregnancy outcomes in SLE patients. Methods Embase, Medline, Cochrane, and ClinicalTrials.gov were carefully searched for relevant English and Chinese language studies. A total of 2,987 articles were reviewed. Data were extracted that compared management and pregnancy outcomes in SLE pregnant women with LN vs without LN. Risk of bias was assessed by a modified version of the Newcastle-Ottawa Scale and the STROBE checklist. Combined odds ratios (OR) and 95% confidence intervals (CI) were obtained and sensitivity analysis was performed using RevMan 5.3 software. Results Sixteen studies, including 1,760 pregnant patients with SLE, were included. Gestational hypertension (OR=5.65, 95% CI=2.94–10.84), preeclampsia (OR=2.84, 95% CI=1.87–4.30), SLE flare (OR=2.66, 95% CI=1.51–4.70), renal flare (OR=15.18, 95% CI=5.89–39.14), proteinuria (OR=8.86, 95% CI=4.75–16.52), and hypocomplementemia (OR=2.86, 95% CI=1.68–4.87) were significantly affected in pregnant women with LN. Anti-Sjögren’s syndrome-related antigen A/Ro autoantibodies were negatively associated with pregnant women with LN (OR=0.57, 95% CI=0.33–0.98). Pregnant women with LN presented a significant decrease in live births (OR=0.62, 95% CI=0.49–0.80) and a significant increase in preterm births (OR=1.92, 95% CI=1.49–2.49) and fetal growth restriction (OR=1.43, 95% CI=1.08–1.91). Regarding antenatal management, steroids (OR=2.48, 95% CI=1.59–3.87) and immunosuppressant treatment (OR=6.77, 95% CI=3.30–13.89) were more frequently used in women with LN. Conclusion This review identified a significant association between the aforementioned outcomes and SLE pregnant patients with LN. In patients with SLE, LN increased the risks for adverse pregnancy outcomes and the use of medication. Therefore, special treatment and close monitoring should be allocated to pregnant women with LN.
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Affiliation(s)
- Jiayue Wu
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Jinghang Ma
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Wei-Hong Zhang
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Wen Di
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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