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Dhombres F, Massoud M. [A pragmatic comparison of fetal biometry curves]. Gynecol Obstet Fertil Senol 2023; 51:524-530. [PMID: 37739067 DOI: 10.1016/j.gofs.2023.09.003] [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] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
INTRODUCTION The fetal biometrics charts recommended in France for ultrasound screening include measurements of head circumference (HC), biparietal diameter (BIP), abdominal circumference (AC) and femur length (FL). New international growth standards have been recommended since 2022. The aim of this work is to quantitatively describe the differences between these biometric curves. METHODS The biometry curves from the French College for Fetal Ultrasound, OMS and INTERGROWTH-21 are pragmatically compared based on their original quantile regression equations (superposition and quantification of differences in millimeters and in proportion) for different percentiles of clinical interest. RESULTS Compared with the new charts, CFEF underestimates HC<-3DS and AC<10eP. The proportions of differences between the CFEF and INTERGROWTH-21 or WHO curves always remained <5%. The proportions of difference of the 3rd percentile of HC and FL, 10th and 90th percentile of AC were always lower than 2%, 2%, 5% and 4% respectively, between OMS and INTERGROWTH-21. CONCLUSION The switch to prescriptive standards suggests an improvement in the detection of fetuses with AC<10th percentile, an improvement in the detection of prenatal onset microcephaly, with no argument for a decrease in the detection rate of severe constitutional bone disease or modification of obstetrical guidelines.
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Affiliation(s)
- Ferdinand Dhombres
- Sorbonne université, AP-HP, hôpital Trousseau, service de médecine fœtale, GRC26 et inserm LIMICS, Paris, France.
| | - Mona Massoud
- Université Claude-Bernard Lyon I, hospices civils de Lyon, service obstétrique et médecine fœtale, centre hospitalier Lyon Sud, Lyon, France
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2
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Monier I, Hocquette A, Zeitlin J. [Review of the literature on intrauterine and birthweight charts]. Gynecol Obstet Fertil Senol 2023; 51:256-269. [PMID: 36302475 DOI: 10.1016/j.gofs.2022.09.014] [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] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/29/2022] [Indexed: 05/05/2023]
Abstract
OBJECTIVES To describe the main intrauterine and birthweight charts and review the studies comparing their performance for the identification of infants at risk of adverse perinatal outcomes. METHODS We carried out a literature search using Medline and selected the charts most frequently cited in the literature, French charts and those recently published. RESULTS Current knowledge on the association between mortality and morbidity and growth anomalies (small and large for gestational age) mostly relies on the use of descriptive charts which describe the weight distribution in unselected populations. Prescriptive charts, which describe ideal growth in low risk populations, have been constructed more recently. Few studies have evaluated whether the thresholds used to identify infants at risk with descriptive charts (such as the 3rd or the 10th percentile) are applicable to prescriptive charts. There is a large variability in the percentage of fetuses or newborns identified as being at risk by each chart, with from 3 to 25% having with a weight under the 10th percentile, regardless of whether descriptive or prescriptive charts are used. The sensitivity and specificity of antenatal screening for small or large for gestational age newborns depends on the chart used to derive estimated fetal weight percentiles. CONCLUSION There is marked variability between intrauterine growth charts that can influence the percentage of infants identified as having abnormal growth. These results show that before the adoption of a growth chart, it is essential to evaluate whether it adequately describes the population and its performance for identifying of infants at risk because of growth anomalies.
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Affiliation(s)
- I Monier
- Université Paris Cité, CRESS, Équipe de recherche en épidémiologie obstétricale périnatale et pédiatrique (EPOPé), INSERM, INRA, Paris, France; Service d'obstétrique et de gynécologie, Hôpital Antoine-Béclère, AP-HP, Université Paris Saclay, Clamart, France.
| | - A Hocquette
- Université Paris Cité, CRESS, Équipe de recherche en épidémiologie obstétricale périnatale et pédiatrique (EPOPé), INSERM, INRA, Paris, France
| | - J Zeitlin
- Université Paris Cité, CRESS, Équipe de recherche en épidémiologie obstétricale périnatale et pédiatrique (EPOPé), INSERM, INRA, Paris, France
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3
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Papastefanou I, Nicolaides KH, Salomon LJ. Audit of fetal biometry: understanding sources of error to improve our practice. Ultrasound Obstet Gynecol 2023; 61:431-435. [PMID: 36647209 DOI: 10.1002/uog.26156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 06/17/2023]
Affiliation(s)
- I Papastefanou
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Women and Children's Health, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - L J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, AP-HP, Paris, France
- URP FETUS 7328 and LUMIERE Platform, University of Paris Cité, Institut Imagine, Paris, France
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4
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Conférence nationale de l’échographie obstétricale et fœtale. [The French National Committee on Obstetrical and Fetal Ultrasound guidelines 2022 (CNEOF)]. Gynecol Obstet Fertil Senol 2023:S2468-7189(23)00010-7. [PMID: 36649816 DOI: 10.1016/j.gofs.2023.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Indexed: 01/15/2023]
Abstract
The 2022 CNEOF guidelines (Conférence nationale d'échographie obstétricale et fœtale) report has been recently issued. It presents the necessary evolutions for the years to come, in a philosophy of optimal security for patients and caregivers, through a homogenization of ultrasound screening practices. As a source of changes in practices, this new version raises concerns, and even reticence, which must be heard and addressed, by reminding that this report is not fixed and can be adapted to the realities of practice over time and their feedback. This short text presents the CNEOF, the novelties of the 2022 report and details some important parts of the report that have been a source of questioning in the month following its publication. The aim of this text is to present a summary (in addition to the full report) to reassure, through education, all the parties involved in this medical practice which is so exciting and of major importance for perinatal health. Thus, the types of ultrasound examinations (screening, diagnostic, expertise…), the conditions of their realization, dating, biometries and the items part of the ultrasound reports are presented with elements of precision useful for their implementation.
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Verspyck E, Gascoin G, Senat MV, Ego A, Simon L, Guellec I, Monier I, Zeitlin J, Subtil D, Vayssiere C. [Ante- and postnatal growth charts in France - guidelines for clinical practice from the Collège national des gynécologues et obstétriciens français (CNGOF) and from the Société française de néonatologie (SFN)]. Gynecol Obstet Fertil Senol 2022; 50:570-584. [PMID: 35781088 DOI: 10.1016/j.gofs.2022.06.008] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To recommend the most appropriate biometric charts for the detection of antenatal growth abnormalities and postnatal growth surveillance. METHODS Elaboration of specific questions and selection of experts by the organizing committee to answer these questions; analysis of the literature by experts and drafting conclusions by assigning a recommendation (strong or weak) and a quality of evidence (high, moderate, low, very low) and for each question; all these recommendations have been subject to multidisciplinary external review (obstetrician gynecologists, pediatricians). The objective for the reviewers was to verify the completeness of the literature review, to verify the levels of evidence established and the consistency and applicability of the resulting recommendations. The overall review of the literature, quality of evidence and recommendations were revised to take into consideration comments from external reviewers. RESULTS Antenatally, it is recommended to use all WHO fetal growth charts for EFW and common ultrasound biometric measurements (strong recommendation; low quality of evidence). Indeed, in comparison with other prescriptive curves and descriptive curves, the WHO prescriptive charts show better performance for the screening of SGA (Small for Gestational Age) and LGA (Large for Gestational Age) with adequate proportions of fetuses screened at extreme percentiles in the French population. It also has the advantages of having EFW charts by sex and biometric parameters obtained from the same perspective cohort of women screened by qualified sonographers who measured the biometric parameters according to international standards. Postnatally, it is recommended to use the updated Fenton charts for the assessment of birth measurements and for growth monitoring in preterm infants (strong recommendation; moderate quality of evidence) and for the assessment of birth measurements in term newborn (expert opinion). CONCLUSION It is recommended to use WHO fetal growth charts for antenatal growth monitoring and Fenton charts for the newborn.
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Affiliation(s)
- E Verspyck
- Service de gynécologie-obstétrique, CHU de Rouen, université de Rouen, Rouen, France.
| | - G Gascoin
- Service de néonatologie, CHU de Toulouse, université de Toulouse, hôpital des enfants, Toulouse, France
| | - M-V Senat
- Service de gynécologie-obstétrique, CHU du Kremlin-Bicêtre, université du Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
| | - A Ego
- Pôle santé publique, CHU de Grenoble-Alpes, Grenoble, France
| | - L Simon
- Service de néonatologie, CHU de Nantes, université de Nantes, Nantes, France
| | - I Guellec
- Service de néonatologie, CHU de Nice, université de Nice, Nice, France
| | - I Monier
- Inserm UMR1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), CRESS, Sorbonne Paris-Cité, Paris, France; Service de gynécologie-obstétrique, université Paris Saclay, hôpital Antoine-Béclère, AP-HP, Clamart, France
| | - J Zeitlin
- Inserm UMR1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), CRESS, Sorbonne Paris-Cité, Paris, France
| | - D Subtil
- Service de gynécologie-obstétrique, CHU de Lille, université de Lille, Lille, France
| | - C Vayssiere
- Service de gynécologie-obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, Toulouse, France; Team SPHERE (Study of Perinatal, pediatric and adolescent Health: Epidemiological Research and Evaluation), CERPOP, UMR 1295, Toulouse III University, Toulouse, France
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6
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Bessis R, Dhombres F, Dumont C, Fries N, Haddad G, Massoud M, Stirnemann J, Salomon LJ. Assessing the performance of growth charts: A difficult endeavour. BJOG 2022; 129:1234-1235. [PMID: 35301797 DOI: 10.1111/1471-0528.17143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/25/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Roger Bessis
- College Français d'Echographie Foetale, CFEF, Paris, France
| | - Ferdinand Dhombres
- College Français d'Echographie Foetale, CFEF, Paris, France.,Sorbonne University, Armand Trousseau University hospital, Fetal Medicine department, GRC-26, APHP, Paris, France.,INSERM, Laboratory in Medical Informatics and Knowledge Engineering in e-Health (LIMICS), Sorbonne University, Paris, France
| | - Coralie Dumont
- College Français d'Echographie Foetale, CFEF, Paris, France.,Fetal Medicine department, University Hospital of South Reunion Island, BP 350 - 97448 Saint Pierre Cedex, Saint Pierre, Reunion
| | - Nicolas Fries
- College Français d'Echographie Foetale, CFEF, Paris, France
| | - Georges Haddad
- College Français d'Echographie Foetale, CFEF, Paris, France.,Simone VEIL Hospital, Blois, France
| | - Mona Massoud
- College Français d'Echographie Foetale, CFEF, Paris, France.,Fetal Medecine unit, Hôpital Femme Mère Enfants, Hospices Civils de Lyon, Lyon, France.,FLUID Team, Lyon Neurosciences Research Center, INSERM U1028, CNRS UMR5292, Lyon-1 University, Bron, France
| | - Julien Stirnemann
- College Français d'Echographie Foetale, CFEF, Paris, France.,Obstetrics and Gynecology Department, APHP, Hôpital Necker - Enfants Malades, Paris, France.,EA FETUS 7328 and LUMIERE Platform, Université de Paris Cité, Paris, France
| | - Laurent Julien Salomon
- College Français d'Echographie Foetale, CFEF, Paris, France.,Obstetrics and Gynecology Department, APHP, Hôpital Necker - Enfants Malades, Paris, France.,EA FETUS 7328 and LUMIERE Platform, Université de Paris Cité, Paris, France
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Jasper EA, Oltman SP, Rogers EE, Dagle JM, Murray JC, Kamya M, Kakuru A, Kajubi R, Ochieng T, Adrama H, Okitwi M, Olwoch P, Jagannathan P, Clark TD, Dorsey G, Ruel T, Jelliffe-Pawlowski LL, Ryckman KK. Targeted newborn metabolomics: prediction of gestational age from cord blood. J Perinatol 2022; 42:181-186. [PMID: 35067676 PMCID: PMC8830770 DOI: 10.1038/s41372-021-01253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Our study sought to determine whether metabolites from a retrospective collection of banked cord blood specimens could accurately estimate gestational age and to validate these findings in cord blood samples from Busia, Uganda. STUDY DESIGN Forty-seven metabolites were measured by tandem mass spectrometry or enzymatic assays from 942 banked cord blood samples. Multiple linear regression was performed, and the best model was used to predict gestational age, in weeks, for 150 newborns from Busia, Uganda. RESULTS The model including metabolites and birthweight, predicted the gestational ages within 2 weeks for 76.7% of the Ugandan cohort. Importantly, this model estimated the prevalence of preterm birth <34 weeks closer to the actual prevalence (4.67% and 4.00%, respectively) than a model with only birthweight which overestimates the prevalence by 283%. CONCLUSION Models that include cord blood metabolites and birth weight appear to offer improvement in gestational age estimation over birth weight alone.
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Affiliation(s)
| | - Scott P Oltman
- University of California, San Francisco, Department of Epidemiology & Biostatistics, Kampala, Uganda.,UCSF California Preterm Birth Initiative, Kampala, Uganda
| | - Elizabeth E Rogers
- University of California San Francisco, Department of Pediatrics, Kampala, Uganda
| | - John M Dagle
- University of Iowa, Department of Pediatrics, Kampala, Uganda
| | | | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Richard Kajubi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Teddy Ochieng
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Harriet Adrama
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Martin Okitwi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Peter Olwoch
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Tamara D. Clark
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Theodore Ruel
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Laura L Jelliffe-Pawlowski
- University of California, San Francisco, Department of Epidemiology & Biostatistics, Kampala, Uganda.,UCSF California Preterm Birth Initiative, Kampala, Uganda
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa, Iowa, IA, USA.
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Stirnemann J, Massoud M, Fries N, Dumont C, Haddad G, Bessis R, Dhombres F, Salomon LJ. Crown-rump length measurement: a new age for first-trimester ultrasound? Ultrasound Obstet Gynecol 2021; 58:345-346. [PMID: 34131973 DOI: 10.1002/uog.23692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 06/12/2023]
Affiliation(s)
- J Stirnemann
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
- EA FETUS, 7328, Université Paris-Descartes, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - M Massoud
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
- Hôpital Femme Mère Enfant et Université Claude Bernard Lyon 1, Bron, France
| | - N Fries
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
| | - C Dumont
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
- CHU de la Réunion, Saint Pierre, France
| | - G Haddad
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
| | - R Bessis
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
| | - F Dhombres
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Trousseau, Sorbonne Université, Paris, France
| | - L J Salomon
- Collège Français d'Echographie Fœtale (CFEF), Paris, France
- EA FETUS, 7328, Université Paris-Descartes, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
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Gadsbøll K, Wright A, Kristensen SE, Verfaille V, Nicolaides KH, Wright D, Petersen OB. Crown-rump length measurement error: impact on assessment of growth. Ultrasound Obstet Gynecol 2021; 58:354-359. [PMID: 33998101 DOI: 10.1002/uog.23690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/21/2021] [Accepted: 05/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To examine the impact of first-trimester crown-rump length (CRL) measurement error on the interpretation of estimated fetal weight (EFW) and classification of fetuses as small-, large- or appropriate-for-gestational age on subsequent growth scans. METHODS We examined the effects of errors of ± 2, ± 3 and ± 4 mm in the measurement of fetal CRL on percentiles of EFW at 20, 32 and 36 weeks' gestation and classification as small-, large- or appropriate-for-gestational age. Published data on CRL measurement error were used to determine variation present in practice. RESULTS A measurement error of -2 mm in first-trimester CRL shifts an EFW on the 10th percentile at the 20-week scan to around the 20th percentile, and the effect of a CRL measurement error of + 2 mm would shift an EFW on the 10th percentile to around the 5th percentile. At 32 weeks, a first-trimester CRL measurement error would shift an EFW on the 10th percentile to the 7th (+ 2 mm) or 14th (-2 mm) percentile; at 36 weeks, the EFW would shift from the 10th percentile to the 8th (+ 2 mm) or 12th (-2 mm) percentile. Published data suggest that measurement errors of 2 mm or more are common in practice. CONCLUSION Because of the widespread and potentially severe consequences of CRL measurement errors as small as 2 mm on clinical assessment, patient management and research results, there is a need to increase awareness of the impact of CRL measurement error and to reduce measurement error variation through standardization and quality control. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K Gadsbøll
- Center for Fetal Medicine, Pregnancy and Ultrasound, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - S E Kristensen
- Center for Fetal Medicine, Pregnancy and Ultrasound, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - V Verfaille
- Ultrasound Clinic BovenMaas, Rotterdam, The Netherlands
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - O B Petersen
- Center for Fetal Medicine, Pregnancy and Ultrasound, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Bessis R. [R. Bessis et al. in response to the editorial by E. Verspyck et al.: Which fetal growth curve reference should be now chosen for our country? Gynécologie Obstétrique Fertilité & Sénologie 2021; 49 (10à:S246871892100129X. https://doi.org/10.1016/j.gofs.2021.05.001]. ACTA ACUST UNITED AC 2021; 49:874-876. [PMID: 34146756 DOI: 10.1016/j.gofs.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Roger Bessis
- 122 boulevard Saint Germain 75008 Paris, France.
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11
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Verspyck E, Senat MV, Subtil D, Vayssiere C. [Which fetal growth curve reference should be now chosen for our country?]. ACTA ACUST UNITED AC 2021; 49:801-802. [PMID: 33989829 DOI: 10.1016/j.gofs.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/09/2021] [Indexed: 10/21/2022]
Affiliation(s)
- E Verspyck
- Service de gynécologie-obstétrique, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France.
| | - M V Senat
- Service de gynécologie-obstétrique, université du Kremlin-Bicêtre, CHU du Kremlin-Bicêtre, Kremlin-Bicêtre, France
| | - D Subtil
- Service de gynécologie-obstétrique, université de Lille, CHU de Lille, Lille, France
| | - C Vayssiere
- Service de gynécologie-obstétrique, université de Toulouse, CHU de Toulouse, Toulouse, France
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