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Cassidy AG, Li L, Golan Y, Gay C, Lin CY, Jigmeddagva U, Chidboy MA, Ilala M, Buarpung S, Gonzalez VJ, Basilio E, Duck M, Murtha AP, Wu AHB, Lynch KL, Asiodu IV, Prahl MK, Gaw SL. Assessment of Adverse Reactions, Antibody Patterns, and 12-month Outcomes in the Mother-Infant Dyad After COVID-19 mRNA Vaccination in Pregnancy. JAMA Netw Open 2023; 6:e2323405. [PMID: 37450302 PMCID: PMC10349345 DOI: 10.1001/jamanetworkopen.2023.23405] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/28/2023] [Indexed: 07/18/2023] Open
Abstract
Importance Longitudinal data on COVID-19 messenger RNA (mRNA) vaccine reactogenicity and immunogenicity in pregnancy and for the mother-infant dyad are needed. Objective To examine COVID-19 mRNA vaccine reactogenicity and immunogenicity in pregnancy and observe longitudinal maternal and infant outcomes. Design, Setting, and Participants This prospective cohort study of pregnant individuals enrolled in the COVID-19 Vaccination in Pregnancy and Lactation study from December 1, 2020, through December 31, 2021, with follow-up through March 31, 2022, was conducted at a large academic medical center in an urban metropolitan area in California. Pregnant individuals receiving COVID-19 mRNA vaccines (mRNA-1273 [Moderna] and BNT162b2 [Pfizer-BioNTech]) were eligible. Of 81 participants enrolled, 5 were excluded after enrollment: 1 terminated pregnancy, 1 received the third vaccine dose prior to delivery, and 3 delivered prior to completing the initial vaccine series. Exposure COVID-19 mRNA vaccination at any time during pregnancy. Main Outcomes and Measures The primary outcomes were vaccine response as measured by blood Immunoglobulin G (IgG) titers after each vaccine dose and self-reported postvaccination symptoms. Patients' IgG titers were measured in cord blood and in infant blood at intervals up to 1 year of life; IgG and IgA titers were measured in maternal milk. Clinical outcomes were collected from medical records. Results Of 76 pregnant individuals included in final analyses (median [IQR] maternal age, 35 [29-41] years; 51 [67.1%] White; 28 [36.8%] primigravid; 37 [48.7%] nulliparous), 42 (55.3%) received BNT162b2 and 34 (44.7%) received mRNA-1237. There were no significant differences in maternal characteristics between the 2 vaccine groups. Systemic symptoms were more common after receipt of the second vaccine dose than after the first dose (42 of 59 [71.2%] vs 26 of 59 [44.1%]; P = .007) and after mRNA-1237 than after BNT162b2 (25 of 27 [92.6%] vs 17 of 32 53.1%; P = .001). Systemic symptoms were associated with 65.6% higher median IgG titers than no symptoms after the second vaccine dose (median [IQR], 2596 [1840-4455] vs 1568 [1114-4518] RFU; P = .007); mean cord titers in individuals with local or systemic symptoms were 6.3-fold higher than in individuals without symptoms. Vaccination in all trimesters elicited a robust maternal IgG response. The IgG transfer ratio was highest among individuals vaccinated in the second trimester. Anti-SARS-CoV-2 IgG was detectable in cord blood regardless of vaccination trimester. In milk, IgG and IgA titers remained above the positive cutoff for at least 5-6 months after birth, and infants of mothers vaccinated in the second and third trimesters had positive IgG titers for at least 5 to 6 months of life. There were no vaccine-attributable adverse perinatal outcomes. Conclusions and Relevance The findings of this cohort study suggest that mRNA COVID-19 vaccination in pregnancy provokes a robust IgG response for the mother-infant dyad for approximately 6 months after birth. Postvaccination symptoms may indicate a more robust immune response, without adverse maternal, fetal, or neonatal outcomes.
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Affiliation(s)
- Arianna G. Cassidy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Lin Li
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Yarden Golan
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco
- Institute for Human Genetics, University of California, San Francisco
| | - Caryl Gay
- Department of Family Health Care Nursing, University of California, San Francisco
| | - Christine Y. Lin
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Unurzul Jigmeddagva
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Megan A. Chidboy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Mikias Ilala
- Division of Experimental Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
- Division of Pediatric Infectious Diseases and Global Health, Department of Pediatrics, University of California, San Francisco
| | - Sirirak Buarpung
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Veronica J. Gonzalez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Emilia Basilio
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Meghan Duck
- UCSF Benioff Children’s Hospital, University of California, San Francisco
| | - Amy P. Murtha
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Alan H. B. Wu
- Department of Laboratory Medicine, University of California, San Francisco
| | - Kara L. Lynch
- Department of Laboratory Medicine, University of California, San Francisco
| | - Ifeyinwa V. Asiodu
- Department of Family Health Care Nursing, University of California, San Francisco
| | - Mary K. Prahl
- Division of Pediatric Infectious Diseases and Global Health, Department of Pediatrics, University of California, San Francisco
| | - Stephanie L. Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
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Matsui Y, Li L, Prahl M, Cassidy AG, Ozarslan N, Golan Y, Gonzalez VJ, Lin CY, Jigmeddagva U, Chidboy MA, Montano M, Taha TY, Khalid MM, Sreekumar B, Hayashi JM, Chen PY, Kumar GR, Warrier L, Wu AH, Song D, Jegatheesan P, Rai DS, Govindaswami B, Needens J, Rincon M, Myatt L, Asiodu IV, Flaherman VJ, Afshar Y, Jacoby VL, Murtha AP, Robinson JF, Ott M, Greene WC, Gaw SL. Neutralizing antibody activity against SARS-CoV-2 variants in gestational age-matched mother-infant dyads after infection or vaccination. JCI Insight 2022; 7:e157354. [PMID: 35579965 PMCID: PMC9309042 DOI: 10.1172/jci.insight.157354] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
Pregnancy confers unique immune responses to infection and vaccination across gestation. To date, there are limited data comparing vaccine- and infection-induced neutralizing Abs (nAbs) against COVID-19 variants in mothers during pregnancy. We analyzed paired maternal and cord plasma samples from 60 pregnant individuals. Thirty women vaccinated with mRNA vaccines (from December 2020 through August 2021) were matched with 30 naturally infected women (from March 2020 through January 2021) by gestational age of exposure. Neutralization activity against the 5 SARS-CoV-2 spike sequences was measured by a SARS-CoV-2-pseudotyped spike virion assay. Effective nAbs against SARS-CoV-2 were present in maternal and cord plasma after both infection and vaccination. Compared with WT spike protein, these nAbs were less effective against the Delta and Mu spike variants. Vaccination during the third trimester induced higher cord-nAb levels at delivery than did infection during the third trimester. In contrast, vaccine-induced nAb levels were lower at the time of delivery compared with infection during the first trimester. The transfer ratio (cord nAb level divided by maternal nAb level) was greatest in mothers vaccinated in the second trimester. SARS-CoV-2 vaccination or infection in pregnancy elicits effective nAbs with differing neutralization kinetics that are influenced by gestational time of exposure.
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Affiliation(s)
- Yusuke Matsui
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
- Michael Hulton Center for HIV Cure Research at Gladstone, San Francisco, California, USA
| | - Lin Li
- Division of Maternal-Fetal Medicine and
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
| | - Mary Prahl
- Department of Pediatrics
- Division of Pediatric Infectious Diseases and Global Health
| | | | - Nida Ozarslan
- Division of Maternal-Fetal Medicine and
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
| | - Yarden Golan
- Department of Bioengineering and Therapeutic Sciences
| | | | | | - Unurzul Jigmeddagva
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
| | - Megan A. Chidboy
- Division of Maternal-Fetal Medicine and
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
| | - Mauricio Montano
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
- Michael Hulton Center for HIV Cure Research at Gladstone, San Francisco, California, USA
| | - Taha Y. Taha
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
| | - Mir M. Khalid
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
| | - Bharath Sreekumar
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
| | - Jennifer M. Hayashi
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
| | - Pei-Yi Chen
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
| | - G. Renuka Kumar
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
| | | | - Alan H.B. Wu
- Department of Laboratory Medicine, UCSF, San Francisco, California, USA
| | - Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Daljeet S. Rai
- Stanford-O’Connor Family Medicine Residency Program, Division of Family Medicine, Stanford University, Palo Alto, California, USA
| | | | - Jordan Needens
- Department of Obstetrics and Gynecology, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Yalda Afshar
- Department of Obstetrics and Gynecology, UCLA, Los Angeles, California, USA
| | | | | | - Joshua F. Robinson
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
| | - Melanie Ott
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
- Michael Hulton Center for HIV Cure Research at Gladstone, San Francisco, California, USA
- Department of Medicine, and
| | - Warner C. Greene
- Gladstone Institute of Virology, Gladstone Institutes, San Francisco, California, USA
- Michael Hulton Center for HIV Cure Research at Gladstone, San Francisco, California, USA
- Department of Medicine, and
- Department of Microbiology and Immunology, UCSF, San Francisco, California, USA
| | - Stephanie L. Gaw
- Division of Maternal-Fetal Medicine and
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
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Prahl M, Golan Y, Cassidy AG, Matsui Y, Li L, Alvarenga B, Chen H, Jigmeddagva U, Lin CY, Gonzalez VJ, Chidboy MA, Warrier L, Buarpung S, Murtha AP, Flaherman VJ, Greene WC, Wu AHB, Lynch KL, Rajan J, Gaw SL. Evaluation of transplacental transfer of mRNA vaccine products and functional antibodies during pregnancy and early infancy. Res Sq 2021:rs.3.rs-1150427. [PMID: 34931183 PMCID: PMC8687466 DOI: 10.21203/rs.3.rs-1150427/v1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Studies are needed to evaluate the safety and effectiveness of mRNA SARS-CoV-2 vaccination during pregnancy, and the levels of protection provided to their newborns through placental transfer of antibodies. We evaluated the transplacental transfer of mRNA vaccine products and functional anti-SARS-CoV-2 antibodies during pregnancy and early infancy in a cohort of 20 individuals vaccinated during pregnancy. We found no evidence of mRNA vaccine products in maternal blood, placenta tissue, or cord blood at delivery. However, we found time-dependent efficient transfer of IgG and neutralizing antibodies to the neonate that persisted during early infancy. Additionally, using phage immunoprecipitation sequencing, we found a vaccine-specific signature of SARS-CoV-2 Spike protein epitope binding that is transplacentally transferred during pregnancy. In conclusion, products of mRNA vaccines are not transferred to the fetus during pregnancy, however timing of vaccination during pregnancy is critical to ensure transplacental transfer of protective antibodies during early infancy.
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Affiliation(s)
- Mary Prahl
- Department of Pediatrics, University of California, San Francisco
| | - Yarden Golan
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco
| | - Arianna G Cassidy
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Yusuke Matsui
- Gladstone Center for HIV Cure Research, Gladstone Institute, San Francisco, CA
| | - Lin Li
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Bonny Alvarenga
- Department of Medicine, University of California, San Francisco
| | - Hao Chen
- Weill Institute for Neurosciences, Division of Neurology, University of California, San Francisco, CA
| | - Unurzul Jigmeddagva
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Christine Y Lin
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Veronica J Gonzalez
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Megan A Chidboy
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Lakshmi Warrier
- Department of Medicine, University of California, San Francisco
| | - Sirirak Buarpung
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | - Amy P Murtha
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
| | | | - Warner C Greene
- Gladstone Center for HIV Cure Research, Gladstone Institute, San Francisco, CA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California, San Francisco
| | - Kara L Lynch
- Department of Laboratory Medicine, University of California, San Francisco
| | - Jayant Rajan
- Department of Medicine, University of California, San Francisco
| | - Stephanie L Gaw
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco
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Prahl M, Golan Y, Cassidy AG, Matsui Y, Li L, Alvarenga B, Chen H, Jigmeddagva U, Lin CY, Gonzalez VJ, Chidboy MA, Warrier L, Buarpung S, Murtha AP, Flaherman VJ, Greene WC, Wu AHB, Lynch KL, Rajan J, Gaw SL. Evaluation of transplacental transfer of mRNA vaccine products and functional antibodies during pregnancy and early infancy. medRxiv 2021. [PMID: 34931197 DOI: 10.1101/2021.12.09.21267423] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Studies are needed to evaluate the safety and effectiveness of mRNA SARS-CoV-2 vaccination during pregnancy, and the levels of protection provided to their newborns through placental transfer of antibodies. We evaluated the transplacental transfer of mRNA vaccine products and functional anti-SARS-CoV-2 antibodies during pregnancy and early infancy in a cohort of 20 individuals vaccinated during pregnancy. We found no evidence of mRNA vaccine products in maternal blood, placenta tissue, or cord blood at delivery. However, we found time-dependent efficient transfer of IgG and neutralizing antibodies to the neonate that persisted during early infancy. Additionally, using phage immunoprecipitation sequencing, we found a vaccine-specific signature of SARS-CoV-2 Spike protein epitope binding that is transplacentally transferred during pregnancy. In conclusion, products of mRNA vaccines are not transferred to the fetus during pregnancy, however timing of vaccination during pregnancy is critical to ensure transplacental transfer of protective antibodies during early infancy.
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Golan Y, Prahl M, Cassidy AG, Gay C, Wu AHB, Jigmeddagva U, Lin CY, Gonzalez VJ, Basilio E, Chidboy MA, Warrier L, Buarpung S, Li L, Murtha AP, Asiodu IV, Ahituv N, Flaherman VJ, Gaw SL. COVID-19 mRNA Vaccination in Lactation: Assessment of Adverse Events and Vaccine Related Antibodies in Mother-Infant Dyads. Front Immunol 2021; 12:777103. [PMID: 34804068 PMCID: PMC8595828 DOI: 10.3389/fimmu.2021.777103] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/15/2021] [Indexed: 01/17/2023] Open
Abstract
Background Data regarding symptoms in the lactating mother-infant dyad and their immune response to COVID-19 mRNA vaccination during lactation are needed to inform vaccination guidelines. Methods From a prospective cohort of 50 lactating individuals who received mRNA-based vaccines for COVID-19 (mRNA-1273 and BNT162b2), blood and milk samples were collected prior to first vaccination dose, immediately prior to 2nd dose, and 4-10 weeks after 2nd dose. Symptoms in mother and infant were assessed by detailed questionnaires. Anti-SARS-CoV-2 antibody levels in blood and milk were measured by Pylon 3D automated immunoassay and ELISA. In addition, vaccine-related PEGylated proteins in milk were measured by ELISA. Blood samples were collected from a subset of infants whose mothers received the vaccine during lactation (4-15 weeks after mothers' 2nd dose). Results No severe maternal or infant adverse events were reported in this cohort. Two mothers and two infants were diagnosed with COVID-19 during the study period before achieving full immune response. PEGylated proteins were not found at significant levels in milk after vaccination. After vaccination, levels of anti-SARS-CoV-2 IgG and IgM significantly increased in maternal plasma and there was significant transfer of anti-SARS-CoV-2-Receptor Binding Domain (anti-RBD) IgA and IgG antibodies to milk. Milk IgA levels after the 2nd dose were negatively associated with infant age. Anti-SARS-CoV-2 IgG antibodies were not detected in the plasma of infants whose mothers were vaccinated during lactation. Conclusions COVID-19 mRNA vaccines generate robust immune responses in plasma and milk of lactating individuals without severe adverse events reported.
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Affiliation(s)
- Yarden Golan
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, United States
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, United States
| | - Mary Prahl
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- Division of Pediatric Infectious Diseases and Global Health, University of California, San Francisco, San Francisco, CA, United States
| | - Arianna G. Cassidy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Caryl Gay
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA, United States
| | - Alan H. B. Wu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Unurzul Jigmeddagva
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Christine Y. Lin
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Veronica J. Gonzalez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Emilia Basilio
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Megan A. Chidboy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Lakshmi Warrier
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Sirirak Buarpung
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Lin Li
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Amy P. Murtha
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Ifeyinwa V. Asiodu
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA, United States
| | - Nadav Ahituv
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, United States
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, United States
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Stephanie L. Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
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