1
|
Siqueira TS, Silva JRS, Silva IMO, Menezes DR, Santos PE, Gurgel RQ, Martins-Filho PR, Santos VS. Temporal trends and spatial clusters of high risk for maternal death due to COVID-19 pre and during COVID-19 vaccination in Brazil: a national population-based ecological study. Public Health 2024; 231:15-22. [PMID: 38593681 DOI: 10.1016/j.puhe.2024.03.009] [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] [Received: 10/23/2023] [Revised: 02/21/2024] [Accepted: 03/06/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE This study comprehensively analyzed the temporal and spatial dynamics of COVID-19 cases and deaths within the obstetric population in Brazil, comparing the periods before and during mass COVID-19 vaccination. We explored the trends and geographical patterns of COVID-19 cases and maternal deaths over time. We also examined their correlation with the SARS-CoV-2 variant circulating and the social determinants of health. STUDY DESIGN This is a nationwide population-based ecological study. METHODS We obtained data on COVID-19 cases, deaths, socioeconomic status, and vulnerability information for Brazil's 5570 municipalities for both the pre-COVID-19 vaccination and COVID-19 vaccination periods. A Bayesian model was used to mitigate indicator fluctuations. The spatial correlation of maternal cases and fatalities with socioeconomic and vulnerability indicators was assessed using bivariate Moran. RESULTS From March 2020 to June 2023, a total of 23,823 cases and 1991 maternal fatalities were recorded among pregnant and postpartum women. The temporal trends in maternal incidence and mortality rates fluctuated over the study period, largely influenced by widespread COVID-19 vaccination and the dominant SARS-CoV-2 variant. There was a significant reduction in maternal mortality due to COVID-19 following the introduction of vaccination. The geographical distribution of COVID-19 cases and maternal deaths exhibited marked heterogeneity in both periods, with distinct spatial clusters predominantly observed in the North, Northeast, and Central West regions. Municipalities with the highest Human Development Index reported the highest incidence rates, while those with the highest levels of social vulnerability exhibited elevated mortality and fatality rates. CONCLUSION Despite the circulation of highly transmissible variants of concern, maternal mortality due to COVID-19 was significantly reduced following the mass vaccination. There was a heterogeneous distribution of cases and fatalities in both periods (before and during mass vaccination). Smaller municipalities and those grappling with social vulnerability issues experienced the highest rates of maternal mortality and fatalities.
Collapse
Affiliation(s)
- T S Siqueira
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Brazil
| | - J R S Silva
- Department of Statistics and Actuarial Science, Federal University of Sergipe, Aracaju, Brazil
| | - I M O Silva
- Department of Medicine, Federal University of Sergipe, Lagarto, Brazil
| | - D R Menezes
- Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
| | - P E Santos
- Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
| | - R Q Gurgel
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Brazil; Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
| | - P R Martins-Filho
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Brazil; Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Brazil; Applied Health Sciences Graduate Program, Federal University of Sergipe, Lagarto, Brazil
| | - V S Santos
- Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Brazil; Department of Medicine, Federal University of Sergipe, Lagarto, Brazil; Applied Health Sciences Graduate Program, Federal University of Sergipe, Lagarto, Brazil.
| |
Collapse
|
2
|
Razai MS, Mansour R, Goldsmith L, Freeman S, Mason-Apps C, Ravindran P, Kooner P, Berendes S, Morris J, Majeed A, Ussher M, Hargreaves S, Oakeshott P. Interventions to increase vaccination against COVID-19, influenza and pertussis during pregnancy: a systematic review and meta-analysis. J Travel Med 2023; 30:taad138. [PMID: 37934788 PMCID: PMC10755181 DOI: 10.1093/jtm/taad138] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Pregnant women and their babies face significant risks from three vaccine-preventable diseases: COVID-19, influenza and pertussis. However, despite these vaccines' proven safety and effectiveness, uptake during pregnancy remains low. METHODS We conducted a systematic review (PROSPERO CRD42023399488; January 2012-December 2022 following PRISMA guidelines) of interventions to increase COVID-19/influenza/pertussis vaccination in pregnancy. We searched nine databases, including grey literature. Two independent investigators extracted data; discrepancies were resolved by consensus. Meta-analyses were conducted using random-effects models to estimate pooled effect sizes. Heterogeneity was assessed using the I2 statistics. RESULTS From 2681 articles, we identified 39 relevant studies (n = 168 262 participants) across nine countries. Fifteen studies (39%) were randomized controlled trials (RCTs); the remainder were observational cohort, quality-improvement or cross-sectional studies. The quality of 18% (7/39) was strong. Pooled results of interventions to increase influenza vaccine uptake (18 effect estimates from 12 RCTs) showed the interventions were effective but had a small effect (risk ratio = 1.07, 95% CI 1.03, 1.13). However, pooled results of interventions to increase pertussis vaccine uptake (10 effect estimates from six RCTs) showed no clear benefit (risk ratio = 0.98, 95% CI 0.94, 1.03). There were no relevant RCTs for COVID-19. Interventions addressed the 'three Ps': patient-, provider- and policy-level strategies. At the patient level, clear recommendations from healthcare professionals backed by text reminders/written information were strongly associated with increased vaccine uptake, especially tailored face-to-face interventions, which addressed women's concerns, dispelled myths and highlighted benefits. Provider-level interventions included educating healthcare professionals about vaccines' safety and effectiveness and reminders to offer vaccinations routinely. Policy-level interventions included financial incentives, mandatory vaccination data fields in electronic health records and ensuring easy availability of vaccinations. CONCLUSIONS Interventions had a small effect on increasing influenza vaccination. Training healthcare providers to promote vaccinations during pregnancy is crucial and could be enhanced by utilizing mobile health technologies.
Collapse
Affiliation(s)
- Mohammad S Razai
- Population Health Research Institute, St George’s University of London, London, UK
| | - Rania Mansour
- Population Health Research Institute, St George’s University of London, London, UK
| | - Lucy Goldsmith
- Population Health Research Institute, St George’s University of London, London, UK
| | - Samuel Freeman
- Primary Care Unit, University Hospitals Sussex NHS Foundation Trust, Sussex, UK
| | - Charlotte Mason-Apps
- Population Health Research Institute, St George’s University of London, London, UK
| | - Pahalavi Ravindran
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | | | - Sima Berendes
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joan Morris
- Population Health Research Institute, St George’s University of London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Michael Ussher
- Population Health Research Institute, St George’s University of London, London, UK
- Institute of Social Marketing and Health, University of Stirling, Stirling, UK
| | - Sally Hargreaves
- Population Health Research Institute, St George’s University of London, London, UK
- The Migrant Health Research Unit, Institute for Infection and Immunity, St George’s, University of London, London, UK
| | - Pippa Oakeshott
- Population Health Research Institute, St George’s University of London, London, UK
| |
Collapse
|
3
|
Ribeiro HF, de Barros Carvalho MD, Pelloso FC, Santos LD, de Andrade Pereira Silva M, Stevanato KP, Borghesan DHP, Romani I, Marques VD, de Freitas KMS, Jacinto Alarcão AC, Pujals C, Bocchi Pedroso R, Cardelli AAM, Pelloso SM. Maternal Risk Factors Associated with Negative COVID-19 Outcomes and Their Relation to Socioeconomic Indicators in Brazil. Healthcare (Basel) 2023; 11:2072. [PMID: 37510513 PMCID: PMC10379003 DOI: 10.3390/healthcare11142072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/30/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND This study aimed to analyze maternal risk factors associated with negative outcomes of COVID-19 and association with socioeconomic indicators in Brazil. METHODS A cross-sectional study, with data from the Influenza Epidemiological Surveillance Information System (SIVEP-Flu) of pregnant women with COVID-19 and cases of hospitalization and death. For the analysis of risk factors and outcomes, the multiple logistic regression method was used. RESULTS Pregnant women who had some risk factor represented 47.04%. The chance of death was 2.48 times greater when there was a risk factor, 1.55 for ICU admission and 1.43 for use of ventilatory support. The percentage of cure was 79.64%, 15.46% without any negative outcome, 4.65% death and 0.26% death from other causes. Pregnant women who did not take the vaccine represented 30.08%, 16.74% took it and 53.18% were not specified. The variables HDI, illiteracy, per capita income and urbanization did not influence the cases of COVID-19. CONCLUSIONS Factors such as age, obesity, asthma and pregnancy were responsible for the increase in hospitalizations, respiratory complications and death. Vaccination reduced the risk of negative outcomes by 50%. There were no correlations between socioeconomic indicators and the negative outcomes of COVID-19 in pregnant women.
Collapse
Affiliation(s)
- Helena Fiats Ribeiro
- Health Sciences Center, State University of Maringá-UEM, Maringá 87020-900, Brazil
| | | | | | - Lander Dos Santos
- Health Sciences Center, State University of Maringá-UEM, Maringá 87020-900, Brazil
| | | | | | | | - Isaac Romani
- University Center UNINGÁ, Maringá 87035-510, Brazil
| | | | | | | | - Constanza Pujals
- Health Sciences Center, State University of Maringá-UEM, Maringá 87020-900, Brazil
| | | | | | | |
Collapse
|
4
|
Attini R, Laudani ME, Versino E, Massaro A, Pagano A, Petey F, Revelli A, Masturzo B. COVID-19 in Pregnancy: Influence of Body Weight and Nutritional Status on Maternal and Pregnancy Outcomes-A Review of Literature and Meta-Analysis. Nutrients 2023; 15:nu15041052. [PMID: 36839410 PMCID: PMC9962478 DOI: 10.3390/nu15041052] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
In the last two and a half years, COVID-19 has been one of the most challenging public health issues worldwide. Based on the available evidence, pregnant women do not appear to be more susceptible to infection than the general population but having COVID-19 during pregnancy may increase the risk of major complications for both the mother and the fetus. The aim of this study is to identify the correlation between BMI and nutritional status and the likelihood of contracting COVID-19 infection in pregnancy, its severity, and maternal pregnancy outcomes. We carry out a systematic literature search and a meta-analysis using three databases following the guidelines of the Cochrane Collaboration. We include 45 studies about COVID-19-positive pregnant women. Compared with normal-weight pregnant women with COVID-19, obesity is associated with a more severe infection (OR = 2.32 [1.65-3.25]), increased maternal death (OR = 2.84 [2.01-4.02]), and a higher rate of hospital admission (OR = 2.11 [1.37-3.26]). Obesity may be associated with adverse maternal and pregnancy outcomes by increasing symptom severity and, consequently, hospital and Intensive Care Unit (ICU) admission, and, finally, death rates. For micronutrients, the results are less definite, even if there seems to be a lower level of micronutrients, in particular Vitamin D, in COVID-19-positive pregnant women.
Collapse
Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza, Sant’Anna Hospital, 10126 Turin, Italy
- Correspondence:
| | - Maria Elena Laudani
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza, Sant’Anna Hospital, 10126 Turin, Italy
| | - Elisabetta Versino
- Department of Clinical and Biological Sciences, University of Turin, 10100 Turin, Italy
- Centre for Biostatistics, Epidemiology and Public Health (C-BEPH), 10100 Turin, Italy
| | - Alessio Massaro
- Department of Obstetrics and Gynecology SC1U, Città della Salute e della Scienza, Sant’Anna Hospital, 10126 Turin, Italy
| | - Arianna Pagano
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza, Sant’Anna Hospital, 10126 Turin, Italy
| | - Francesca Petey
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza, Sant’Anna Hospital, 10126 Turin, Italy
| | - Alberto Revelli
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza, Sant’Anna Hospital, 10126 Turin, Italy
| | - Bianca Masturzo
- Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy
| |
Collapse
|
5
|
Moza A, Bernad ES, Lungeanu D, Craina M, Bernad BC, Hogea L, Paul C, Muresan C, Nitu R, Iacob D. Pregnancy Outcomes in SARS-CoV-2-Positive Patients: A 20-Month Retrospective Analysis of Delivery Cases. Medicina (Kaunas) 2023; 59. [PMID: 36837541 DOI: 10.3390/medicina59020341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/15/2023]
Abstract
Background and Objectives: The SARS-CoV-2 infection brings supplemental risks for pregnant women. Due to controversial hesitancy, their vaccination rate was lower in 2021 compared to the general population. In addition, access to maternal care was reduced during the pandemic. We conducted a retrospective cross-sectional analysis of the health records data over 20 months (1 April 2020 to 20 November 2021) aiming to explore the outcomes in SARS-CoV-2-positive cases referred for delivery to a tertiary public hospital in Western Romania. Materials and Methods: Women with SARS-CoV-2 infection diagnosed for the first time at the moment of birth who delivered singletons after 24 weeks of gestation, and had a clear immunization status were included in the analysis. Results: Out of the 97 patients included in the study, 35 (36%) had undergone ARN-based vaccination. Five cases of maternal death were recorded (all unvaccinated). Our retrospective exploratory analysis showed that the presence of COVID-19 symptoms in the SARS-CoV-2-positive patients made a significant impact on the delivery hospitalization, with a median hospital stay increase from 5 to 9 days (Mann-Whitney test, p = 0.014): longer hospitalization was recorded in the symptomatic cases irrespective of their vaccination status. No other adverse outcomes, such as gestational age at delivery, C-section rate, 5 min Apgar index, or birth weight were associated with the presence of symptoms. Conclusions: Our clinic maintained safe maternal care for the COVID-19 patients during the analyzed period. Vaccination of the expectant women was beneficial in SARS-CoV-2-positive patients by lowering the risk of COVID-19 symptoms, with subsequent implications on the newborns' health and maternal attachment.
Collapse
|
6
|
Orellana J, Jacques N, Leventhal DGP, Marrero L, Morón-Duarte LS. Excess maternal mortality in Brazil: Regional inequalities and trajectories during the COVID-19 epidemic. PLoS One 2022; 17:e0275333. [PMID: 36264994 PMCID: PMC9584504 DOI: 10.1371/journal.pone.0275333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has exceeded 6 million known disease-related deaths and there is evidence of an increase in maternal deaths, especially in low- and middle-income countries. We aimed to estimate excess maternal deaths in Brazil and its macroregions as well as their trajectories in the first 15 months of the COVID-19 epidemic. METHODS This study evaluated maternal deaths from the Mortality Information System of the Ministry of Health, with excess deaths being assessed between March 2020 and May 2021 by quasi-Poisson generalized additive models adjusted for overdispersion. Observed deaths were compared to deaths expected without the pandemic, accompanied by 95% confidence intervals according to region, age group, and trimester of occurrence. Analyses were conducted in R version 3.6.1 and RStudio version 1.2.1335. RESULTS There were 3,291 notified maternal deaths during the study period, resulting in a 70% excess of deaths regardless of region, while in the North, Northeast, South and Southeast regions, excess deaths occurred regardless of age group. Excess deaths occurred in the March-May 2021 trimester regardless of region and age group. Excess deaths were observed in the Southeast region for the 25-36-year-old age group regardless of the trimester assessed, and in the North, Central-West and South regions, the only period in which excess deaths were not observed was September-November 2020. Excess deaths regardless of trimester were observed in the 37-49-year-old age group in the North region, and the South region displayed explosive behavior from March-May 2021, with a 375% excess of deaths. CONCLUSIONS Excess maternal deaths, with geographically heterogenous trajectories and consistently high patterns at the time of the epidemic's greatest impact, reflect not only the previous effect of socioeconomic inequalities and of limited access to maternal health services, but most of all the precarious management of Brazil's health crisis.
Collapse
Affiliation(s)
- Jesem Orellana
- Leônidas and Maria Deane Institute, Oswaldo Cruz Foundation, Manaus, Amazonas, Brazil
- * E-mail:
| | - Nadège Jacques
- Postgraduate Program in Epidemiology, Department of Social Medicine, Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | | | - Lihsieh Marrero
- Department of Nursing, Amazonas State University, Manaus, Amazonas, Brazil
| | - Lina Sofía Morón-Duarte
- Global Institute of Clinical Excellence, Keralty, Bogotá, Distrito Capital, Colombia
- Translational Research Group, Sanitas University Foundation, Bogotá, Distrito Capital, Colombia
| |
Collapse
|
7
|
Martins-Filho PR, Santos VS. Relationship between living conditions in neighborhoods in the Northeast Brazil and COVID-19 estimates during the third wave associated with the Omicron variant. Biodemography Soc Biol 2022; 67:224-228. [PMID: 36417277 DOI: 10.1080/19485565.2022.2149464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Brazil experienced a critical increase in COVID-19 cases during the first weeks of 2022 due to community transmission of the SARS-CoV-2 Omicron variant. Furthermore, there has been a significant increase in the country's demand for hospital beds, especially among those unvaccinated or partially vaccinated. Despite this scenario, the number of deaths was considerably lower than in previous COVID-19 waves. However, evidence is limited regarding the disease burden at this stage of the pandemic in more vulnerable regions. In this ecological study, we investigated the impacts of the third wave of COVID-19 caused by the Omicron on cases and deaths in a region of Northeast Brazil, and their relationship with the living conditions of the population in a neighborhood-level analysis. We found that neighborhoods with worse living conditions had a lower COVID-19 incidence (median 193.4 cases per 10 000) than those with better living conditions (median 335.1 cases per 10 000) (p < .001), but no differences were found regarding mortality. Despite advances in vaccination coverage against the disease in Brazil and the significant reduction in the number of deaths during the third wave, our findings may suggest differences in access to diagnostic resources for COVID-19 in the poorest communities.
Collapse
|
8
|
Tekin AB, Yassa M, Birol İlter P, Yavuz E, Önden B, Usta C, Budak D, Günkaya OS, Çavuşoğlu G, Taymur BD, Tuğ N. COVID-19 related maternal mortality cases in associated with Delta and Omicron waves and the role of lung ultrasound. Turk J Obstet Gynecol 2022; 19:88-97. [PMID: 35770508 PMCID: PMC9249361 DOI: 10.4274/tjod.galenos.2022.36937] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Indexed: 12/21/2022] Open
Abstract
Objective: To present coronavirus disease-2019 (COVID-19) related maternal mortality in relation to Delta and Omicron waves and to investigate the role of lung ultrasound (LUS) in estimating mortality. Materials and Methods: This retrospective cohort study was conducted in the obstetrics and gynecology clinic of a tertiary pandemic hospital between March 2020 and January 2022. The hospitalized pregnant women with COVID-19 diagnosis and maternal deaths were studied in relation with Delta and Omicron waves. The relationship between LUS scores of hospitalized patients and maternal mortality was explored. Results: Thousand and sixty-five pregnant women were hospitalized because of COVID-19 infection. Fifty-one (4.79%) of these patients had critical sickness, 96 (9.01%) of them had severe illness, 62 (5.82%) of them were admitted to the intensive care unit and 28 (2.63%) of all hospitalized pregnant women had died. Of the 1.065 patients, 783 (73.5%) were hospitalized before the Delta wave and the maternal mortality rate was 1.28% (10/783), 243 (22.8%) were hospitalized during the Delta wave and the maternal mortality rate was 7% (17/243) [relative risk (RR)=5.478, 95% confidence interval (CI) (2.54-11.8), z=4.342, p<0.001]. During the Omicron wave 39 (3.66%) patients were hospitalized and the maternal mortality rate was 2.56% (1/39). Maternal mortality rates, according to LUS scores, were 0.37% (1/273) for LUS 0, 0.72% (2/277) for LUS 1, 2.58% (10/387) for LUS 2 and 11.72% (15/128) for LUS 3 respectively (LUS 3 vs. others; maternal mortality: RR=8.447, 95% CI (4.11-17.34), z=5.814, p<0.0001). There were no vaccinated patients in the study cohort. Conclusion: The maternal mortality rate was relatively high, particularly during the Delta wave at our referral center. The Delta wave, delayed vaccination and vaccine hesitancy of pregnant women might have important roles in maternal mortality. Higher LUS scores should warn clinicians of an increased risk of maternal death.
Collapse
Affiliation(s)
- Arzu Bilge Tekin
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Murat Yassa
- Bahçeşehir University, VM Medical Park Maltepe Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Pınar Birol İlter
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Emre Yavuz
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Betül Önden
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Canberk Usta
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Doğuş Budak
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Osman Samet Günkaya
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Gül Çavuşoğlu
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Bilge Doğan Taymur
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Niyazi Tuğ
- University of Health Sciences Turkey, Şehit Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| |
Collapse
|