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Morris RK, Johnstone E, Lees C, Morton V, Smith G. Investigation and Care of a Small-for-Gestational-Age Fetus and a Growth Restricted Fetus (Green-top Guideline No. 31). BJOG 2024. [PMID: 38740546 DOI: 10.1111/1471-0528.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Key recommendations
All women should be assessed at booking (by 14 weeks) for risk factors for fetal growth restriction (FGR) to identify those who require increased surveillance using an agreed pathway [Grade GPP]. Findings at the midtrimester anomaly scan should be incorporated into the fetal growth risk assessment and the risk assessment updated throughout pregnancy. [Grade GPP]
Reduce smoking in pregnancy by identifying women who smoke with the assistance of carbon monoxide (CO) testing and ensuring in‐house treatment from a trained tobacco dependence advisor is offered to all pregnant women who smoke, using an opt‐out referral process. [Grade GPP]
Women at risk of pre‐eclampsia and/or placental dysfunction should take aspirin 150 mg once daily at night from 12+0–36+0 weeks of pregnancy to reduce their chance of small‐for‐gestational‐age (SGA) and FGR. [Grade A]
Uterine artery Dopplers should be carried out between 18+0 and 23+6 weeks for women at high risk of fetal growth disorders [Grade B]. In a woman with normal uterine artery Doppler and normal fetal biometry at the midtrimester scan, serial ultrasound scans for fetal biometry can commence at 32 weeks. Women with an abnormal uterine artery Doppler (mean pulsatility index > 95th centile) should commence ultrasound scans at 24+0–28+6 weeks based on individual history. [Grade B]
Women who are at low risk of FGR should have serial measurement of symphysis fundal height (SFH) at each antenatal appointment after 24+0 weeks of pregnancy (no more frequently than every 2 weeks). The first measurement should be carried out by 28+6 weeks. [Grade C]
Women in the moderate risk category are at risk of late onset FGR so require serial ultrasound scan assessment of fetal growth commencing at 32+0 weeks. For the majority of women, a scan interval of four weeks until birth is appropriate. [Grade B]
Maternity providers should ensure that they clearly identify the reference charts to plot SFH, individual biometry and estimated fetal weight (EFW) measurements to calculate centiles. For individual biometry measurements the method used for measurement should be the same as those used in the development of the individual biometry and fetal growth chart [Grade GPP]. For EFW the Hadlock three parameter model should be used. [Grade C]
Maternity providers should ensure that they have guidance that promotes the use of standard planes of acquisition and calliper placement when performing ultrasound scanning for fetal growth assessment. Quality control of images and measurements should be undertaken. [Grade C]
Ultrasound biometry should be carried out every 2 weeks in fetuses identified to be SGA [Grade C]. Umbilical artery Doppler is the primary surveillance tool and should be carried out at the point of diagnosis of SGA and during follow‐up as a minimum every 2 weeks. [Grade B]
In fetuses with an EFW between the 3rd and 10th centile, other features must be present for birth to be recommended prior to 39+0 weeks, either maternal (maternal medical conditions or concerns regarding fetal movements) or fetal compromise (a diagnosis of FGR based on Doppler assessment, fetal growth velocity or a concern on cardiotocography [CTG]) [Grade C]. For fetuses with an EFW or abdominal circumference less than the 10th centile where FGR has been excluded, birth or the initiation of induction of labour should be considered at 39+0 weeks after discussion with the woman and her partner/family/support network. Birth should occur by 39+6 weeks. [Grade B]
Pregnancies with early FGR (prior to 32+0 weeks) should be monitored and managed with input from tertiary level units with the highest level neonatal care. Care should be multidisciplinary by neonatology and obstetricians with fetal medicine expertise, particularly when extremely preterm (before 28 weeks) [Grade GPP]. Fetal biometry in FGR should be repeated every 2 weeks [Grade B]. Assessment of fetal wellbeing can include multiple modalities but must include computerised CTG and/or ductus venous. [Grade B]
In pregnancies with late FGR, birth should be initiated from 37+0 weeks to be completed by 37+6 weeks [Grade A]. Decisions for birth should be based on fetal wellbeing assessments or maternal indication. [Grade GPP]
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Mitta K, Tsakiridis I, Giougi E, Mamopoulos A, Kalogiannidis I, Dagklis T, Athanasiadis A. Comparison of Fetal Crown-Rump Length Measurements between Thawed and Fresh Embryo Transfer. J Clin Med 2024; 13:2575. [PMID: 38731104 PMCID: PMC11084813 DOI: 10.3390/jcm13092575] [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: 03/12/2024] [Revised: 04/08/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background and Objectives: Neonates born from thawed embryo transfers tend to have a significantly higher birthweight compared to those from fresh embryo transfers. The aim of this study was to compare the crown-rump length (CRL) between thawed and fresh embryos to investigate the potential causes of different growth patterns between them. Materials and Methods: This was a retrospective study (July 2010-December 2023) conducted at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece. In total, 3082 assisted reproductive technology (ART) pregnancies (4044 embryos) underwent a routine scan at 11+0-13+6 gestational weeks and were included in the study. Maternal age, the type of embryo transfer (thawed vs. fresh, donor vs. their own oocytes), CRL, twin and singleton gestations were analyzed. Results: The mean maternal age in thawed was significantly higher than in fresh embryos (39.8 vs. 35.8 years, p-value < 0.001). The mean CRL z-score was significantly higher in thawed compared to fresh embryo transfers (0.309 vs. 0.199, p-value < 0.001). A subgroup analysis on singleton gestations showed that the mean CRL z-score was higher in thawed blastocysts compared to fresh (0.327 vs. 0.215, p-value < 0.001). Accordingly, an analysis on twins revealed that the mean CRL z-score was higher in thawed blastocysts (0.285 vs. 0.184, p-value: 0.015) and in oocytes' recipients compared to own oocytes' cases (0.431 vs. 0.191, p-value: 0.002). Conclusions: The difference in CRL measurements between thawed and fresh embryos may be a first indication of the subsequent difference in sonographically estimated fetal weight and birthweight. This finding highlights the need for additional research into the underlying causes, including maternal factors and the culture media used.
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Affiliation(s)
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (K.M.); (E.G.); (A.M.); (I.K.); (T.D.); (A.A.)
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3
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Movahedi M, Khanjani S, Shahshahan Z, Hajihashemi M, Farahbod F, Shahsavandi E. Evaluation of the Relationship between Pregnancy-Associated Plasma Protein A (PAPP-A) and Pregnancy Outcomes. Adv Biomed Res 2023; 12:91. [PMID: 37288030 PMCID: PMC10241634 DOI: 10.4103/abr.abr_344_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 06/09/2023] Open
Abstract
Background In the current study, we aimed to evaluate the association between pregnancy-related plasma protein-A (PAPP-A) levels measured in the first trimester and pregnancy outcomes. Materials and Methods This is a descriptive-analytical study that was performed in 2019--2021 on 1061 pregnant women in their first trimester. Demographic and basic information of all women were collected. These data included age, weight, parity, and date of delivery. Then the quantity of PAPP-A was recorded in three groups including less than 0.5 MOM, 0.5 to 2.5 MOM, and more than 2.5 MOM. Results Data of 1061 women were analyzed. 900 women (84.8%) had term delivery and 155 women (14.6%) had pre-term deliveries. PAPP-A levels were normal in 83.4% of women. BMI and number of pregnancies had significant relationships with PAPP-A (p < 0.001, P = 0.03 respectively). The mean BMI in mothers with PAPP-A higher than 2.5 was significantly more than mothers with normal or lower PAPP-A levels (26.2 ± 31, P = 0.04). The frequency of term labor in mothers with normal PAPP-A was higher than other mothers (86.3%, P = 0.04). The frequency of preeclampsia in recent pregnancies in mothers with normal PAPP-A was significantly lower than other mothers (p < 0.001) and the frequency of abortions in recent pregnancies in mothers with PAPP-A less than 0.5 was significantly higher than mothers with normal or elevated PAPP-A (p < 0.001). Conclusion Mothers with low PAPP-A levels are more likely to have poor pregnancy outcomes such as abortion, pre-term labor, and preeclampsia.
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Affiliation(s)
- Minoo Movahedi
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Khanjani
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Shahshahan
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Hajihashemi
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farinaz Farahbod
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elaheh Shahsavandi
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Asoglu MR, Bahceci M. Does endometrial thickness affect birth weight and serum levels of pregnancy-associated plasma protein-A in frozen cycles? Eur J Obstet Gynecol Reprod Biol 2023; 284:24-29. [PMID: 36924659 DOI: 10.1016/j.ejogrb.2023.03.007] [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: 10/10/2022] [Revised: 01/14/2023] [Accepted: 03/09/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE To investigate whether endometrial thickness (EMT) affects birth weight and maternal serum pregnancy-associated plasma protein-A (PAPP-A) level in singleton pregnancies following frozen-thawed blastocyst transfer (FET). METHODS This retrospective study included women who underwent first-trimester combined screening for aneuploidy after FET, and subsequently delivered a singleton live birth after 24 weeks of gestation at a private in-vitro fertilization centre. The subjects were stratified into three groups based on EMT percentiles: <7.7 mm (<10th percentile), 7.7-12 mm (10-90th percentile), and > 12 mm (>90th percentile). Multi-variable linear regression analysis was undertaken to identify the association between birth weight and EMT after adjusting for variables with p < 0.1 on univariate analysis. RESULTS In total, 560 women met the inclusion criteria. Mean (±standard deviation) birth weight was 3127 ± 783 g in those with EMT < 7.7 mm, 3225 ± 644 g in those with EMT 7.7-12 mm, and 3256 ± 599 g in those with EMT > 12 mm (p = 0.577). Mean PAPP-A and PAPP-A < 0.5 rates were similar in the three groups. On multi-variate analysis, maternal serum PAPP-A was found to be a significant predictor of birth weight (p = 0.013), but EMT was not found to be predictive of birth weight on univariate or multi-variate analysis. CONCLUSION This study provided a new angle to evaluate the association between EMT and neonatal birth weight by analysing this association along with maternal serum PAPP-A as a marker for placental function, suggesting that EMT is not an independent factor for neonatal birth weight.
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Affiliation(s)
| | - Mustafa Bahceci
- Bahceci Fulya Assisted Reproduction Centre, Istanbul, Turkey
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Elmas B, Laleli Koç B, Tuğrul Ersak D, Zorlu U, Aydoğdu E, Yılmaz G, Üreyen Özdemir E, Hançerlioğulları N, Moraloğlu Tekin Ö. The relationship between the first trimester maternal serum PAPP-A and β-hCG values and newborn intensive care needs in low-risk pregnancies. Turk J Obstet Gynecol 2022; 19:287-294. [DOI: 10.4274/tjod.galenos.2022.48861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Muacevic A, Adler JR, Daskalakis G, Theodora M, Rodolakis A, Antsaklis P. Importance of Low Pregnancy Associated Plasma Protein-A (PAPP-A) Levels During the First Trimester as a Predicting Factor for Adverse Pregnancy Outcomes: A Prospective Cohort Study of 2636 Pregnant Women. Cureus 2022; 14:e31256. [PMID: 36505175 PMCID: PMC9731607 DOI: 10.7759/cureus.31256] [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] [Accepted: 11/01/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES The aim of this study is to investigate the predictive value of low levels of pregnancy associated plasma protein-A (PAPP-A) during the first trimester on adverse pregnancy outcomes, namely pregnancy induced hypertension (PIH), preeclampsia (PE), intrauterine growth restriction (IUGR), and fetal loss. METHODS This is a prospective cohort study including 2636 women with singleton pregnancies that attended the Prenatal Diagnosis Unit of the First Department of Obstetrics and Gynecology of National and Kapodistrian University of Athens in "Alexandra Hospital" between 2017 and 2019 for the first trimester combined screening routine scan. The study population was divided into two groups according to their PAPP-A levels. The cut-off value of the PAPP-A level was defined as the 0.4 multiple of median (MoM) which is in correspondence with the fifth centile. The women were followed-up prospectively until delivery and the primary outcome measures were the incidence of PIH, PE, IUGR (<10th centile), and fetal loss. Results: PAPP-A levels of ≤0.4 MoM were associated with increased maternal body mass index (BMI), increased uterine arteries pulsatility index (PI), and lower birth weight. Women with PAPP-A levels ≤0.4 MoM were more likely to develop PE (2.3% vs. 0.2%, p<0.001), PE or PIH (2.3% vs. 0.4%, p=0.003), IUGR (2.3% vs. 0.4%, p=0.003), and combined adverse outcome (25.5% vs. 1.9%, p<0.001) compared to women with PAPP-A>0.4 MoM. CONCLUSIONS This study confirms that among women with PAPP-A levels ≤0.4 MoM in the first trimester, there are increased odds for PE or PIH, IUGR, and combined composite pregnancy outcome.
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Arabi Belaghi R, Beyene J, McDonald SD. Prediction of preterm birth in nulliparous women using logistic regression and machine learning. PLoS One 2021; 16:e0252025. [PMID: 34191801 PMCID: PMC8244906 DOI: 10.1371/journal.pone.0252025] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/10/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To predict preterm birth in nulliparous women using logistic regression and machine learning. DESIGN Population-based retrospective cohort. PARTICIPANTS Nulliparous women (N = 112,963) with a singleton gestation who gave birth between 20-42 weeks gestation in Ontario hospitals from April 1, 2012 to March 31, 2014. METHODS We used data during the first and second trimesters to build logistic regression and machine learning models in a "training" sample to predict overall and spontaneous preterm birth. We assessed model performance using various measures of accuracy including sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC) in an independent "validation" sample. RESULTS During the first trimester, logistic regression identified 13 variables associated with preterm birth, of which the strongest predictors were diabetes (Type I: adjusted odds ratio (AOR): 4.21; 95% confidence interval (CI): 3.23-5.42; Type II: AOR: 2.68; 95% CI: 2.05-3.46) and abnormal pregnancy-associated plasma protein A concentration (AOR: 2.04; 95% CI: 1.80-2.30). During the first trimester, the maximum AUC was 60% (95% CI: 58-62%) with artificial neural networks in the validation sample. During the second trimester, 17 variables were significantly associated with preterm birth, among which complications during pregnancy had the highest AOR (13.03; 95% CI: 12.21-13.90). During the second trimester, the AUC increased to 65% (95% CI: 63-66%) with artificial neural networks in the validation sample. Including complications during the pregnancy yielded an AUC of 80% (95% CI: 79-81%) with artificial neural networks. All models yielded 94-97% negative predictive values for spontaneous PTB during the first and second trimesters. CONCLUSION Although artificial neural networks provided slightly higher AUC than logistic regression, prediction of preterm birth in the first trimester remained elusive. However, including data from the second trimester improved prediction to a moderate level by both logistic regression and machine learning approaches.
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Affiliation(s)
- Reza Arabi Belaghi
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Statistics, University of Tabriz, Tabriz, Iran
| | - Joseph Beyene
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Mathematics and Statistics, McMaster University, Hamilton, Ontario, Canada
| | - Sarah D. McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology (Division of Maternal-Fetal Medicine), McMaster University, Hamilton, Ontario, Canada
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
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Cavoretto PI, Farina A, Girardelli S, Gaeta G, Spinillo S, Morano D, Amodeo S, Galdini A, Viganò P, Candiani M. Greater fetal crown-rump length growth with the use of in vitro fertilization or intracytoplasmic sperm injection conceptions after thawed versus fresh blastocyst transfers: secondary analysis of a prospective cohort study. Fertil Steril 2021; 116:147-156. [PMID: 33500139 DOI: 10.1016/j.fertnstert.2020.11.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 11/14/2020] [Accepted: 11/23/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To compare first-trimester fetal crown-rump length (CRL) measurements in pregnancies obtained after thawed blastocyst transfer versus fresh blastocyst transfer after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). DESIGN Prospective longitudinal cohort study of CRL Z scores with adjustment for major confounders. SETTING University-affiliated obstetrics, fetal medicine, and fertility units. PATIENT(S) Singleton gestations conceived via IVF/ICSI and fresh or thawed blastocyst transfer with ultrasound performed at 6-14 weeks of gestational age. INTEVENTION None. MAIN OUTCOME MEASURE(S) CRL Z scores. RESULT(S) A total of 365 IVF/ICSI pregnancies were recruited (fresh: 161; thawed: 204). The mean CRL Z score at 6-14 weeks was significantly greater in thawed versus fresh transfers. Different growth trajectories between thawed and fresh transfers were detected: Mean CRL Z score was 0 at 65 days in fresh versus 80 days in frozen. Comparisons of both fresh and thawed transfers with reference values from the general population confirmed significantly lower CRL Z scores in both IVF/ICSI groups (P<.001). The risks of CRL <5th percentile in fresh versus thawed were, respectively 68% vs. 40% at 6 weeks and 2% vs. 1% at 14 weeks. A significant positive correlation between CRL Z scores and birth weight Z scores was found only for fresh transfers, not for thawed. CONCLUSION(S) At 6-14 weeks, thawed blastocyst transfers after IVF/ICSI conceptions present greater CRLs compared with fresh, and both IVF/ICSI groups show smaller CRLs than the general population. This effect is particularly evident before 9 weeks and it may favor birth weight difference of thawed versus fresh BT pregnancies.
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Affiliation(s)
- Paolo Ivo Cavoretto
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy.
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Serena Girardelli
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy
| | - Gerarda Gaeta
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy
| | - Silvia Spinillo
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy
| | - Danila Morano
- Department of Obstetrics and Gynecology, Sant'Anna University Hospital, Cona, Ferrara, Italy
| | - Silvia Amodeo
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Galdini
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy
| | - Paola Viganò
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, Scientific Institute for Research, Hospitalization and Healthcare, San Raffaele Hospital, University Vita e Salute, Milan, Italy
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Boutin A, Gasse C, Demers S, Blanchet G, Giguère Y, Bujold E. Does Low PAPP-A Predict Adverse Placenta-Mediated Outcomes in a Low-Risk Nulliparous Population? the Great Obstetrical Syndromes (GOS) Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:663-668. [DOI: 10.1016/j.jogc.2017.08.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 01/30/2023]
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