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Comparison of cord blood alarin levels of full-term infants according to birth weight

  • Melek Buyukeren ORCID logo EMAIL logo , Beyza Ozcan ORCID logo , Ummugulsum Can ORCID logo , Aytac Kenar ORCID logo , Ramazan Kececi ORCID logo , Melike Geyik Bayman ORCID logo and Oguzhan Gunenc ORCID logo
Published/Copyright: October 28, 2024
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Journal of Perinatal Medicine
From the journal Journal of Perinatal Medicine Volume 53 Issue 1

Abstract

Objectives

To compare the cord blood alarin levels of infants in different birth weight groups with those of infants born to mothers diagnosed with gestational diabetes mellitus (GDM) who were not subgrouped according to birth weight.

Methods

This prospective study was conducted between September 2023 and January 2024. Healthy term babies whose families agreed to participate in the study were divided into four groups according to their birth weight (small for gestational age (SGA), appropriate for gestational age (AGA) and large for gestational age (LGA)) and whether their mothers had GDM.

Results

There was a significant difference between the cord blood alarin levels of the AGA and SGA groups (p=0.014). There was also a significant difference between the cord blood alarin levels of the AGA and GDM groups (p=0.012). However, the cord blood alarin levels of the LGA group (whose mothers did not have GDM) were similar to those of the AGA group (p=0.394).

Conclusions

We found evidence that alarin levels in umbilical cord blood are associated with low birth weight and GDM.

Keywords: alarin; small for gestational age; newborn; gestational diabetes mellitus

Introduction

Birth weight and gestational age are determinants of mortality and morbidity for newborns. Birth weight by gestational age is a factor in diseases that may occur later in life [1], 2]. Newborns with a birth weight below the 10th percentile for their gestational age are defined as small for gestational age (SGA), newborns with a birth weight above the 90th percentile for their gestational age are defined as large for gestational age (LGA), and newborns between the 10th and 90th percentiles are defined as appropriate for gestational age (AGA) [3]. LGA and SGA infants may experience problems such as hypoglycemia, hypoxia, and polycythemia and may need respiratory support in the neonatal period. At later ages, they may also face diseases that affect life quality and duration, such as metabolic syndrome, obesity, cardiovascular diseases, and diabetes mellitus (DM) [2]. Gestational DM (GDM) refers to abnormal glucose tolerance that starts or is first recognized during pregnancy. GDM has long been associated with obstetric and neonatal complications, is particularly related to large birth weight, and is increasingly recognized as a risk factor for future cardiometabolic disease in infants [4]. The causes of serious health problems may be traced back to maternal illnesses or variances in birth weight. Therefore, these illnesses and weight variances are the subjects of ongoing research.

Alarin, the most recently discovered of the four members of the galanin peptide family, is a peptide consisting of 25 amino acids that can be detected in serum and has been shown to have orexigenic effects [5], 6]. An animal study confirmed that the intracerebroventricular injection of alarin caused increased food intake and body weight among the subjects, and there are also studies showing that it has an effect on energy homeostasis [7], 8]. It has also been determined that centrally administered alarin increases the glucose uptake of skeletal muscles and induces beneficial effects on glucose uptake and insulin sensitivity in the adipocytes of animal subjects with type 2 DM [9], 10]. Other studies revealed that alarin plays an important role in the onset of diabetes and obesity [6], 11]. One of those studies found that circulating alarin levels were significantly higher in patients with both impaired glucose tolerance and type 2 DM than in healthy individuals [6].

Bili et al. [12] have shown the relationship between the levels of galanin in amniotic fluid during the second trimester and birth weight. Additionally, in the human placenta, galanin is secreted by trophoblastic cells to regulate placental function [13]. Galanin was found in the decidual cells of the human placenta, particularly at the interface between the mother and fetus, suggesting that the galanin system may regulate placental blood flow for fetal growth and development [14]. Levels of galanin in the umbilical cord blood originating from the fetus were significantly higher than those in the maternal circulation [15], 16]. Based on all this, we planned to evaluate the role of alarin, a member of the same family, in fetal growth.

Furthermore, animal studies have shown that alarin is an antioxidant, made evident by the fact that alarin levels increase in cases of myocardial injury or heart failure for the purpose of reducing oxidative damage [17], 18].

Considering the results of the aforementioned studies, we planned to compare the cord blood alarin levels of infants in different birth weight groups (SGA, AGA, and LGA) with those of infants born to mothers diagnosed with GDM who were not subgrouped according to birth weight.

Materials and methods

This prospective study was approved by the Karatay University Ethics Committee (Ethics Committee Decision No. 2023/008) and Konya City Hospital. The study was conducted between September 2023 and January 2024 in the Department of Obstetrics and Gynecology, Neonatal Intensive Care Unit, and the Medical Biochemistry Department of Konya City Hospital (Clinical Trials ID: NCT06333548).

Study group

Infants who had suspected sepsis, were in need of intensive care, were ill or premature, or were born to mothers with premature rupture of membranes, chorioamnionitis, or preeclampsia were excluded from the study. Infants whose mothers had any disease other than DM were also excluded. Healthy full-term infants (born between 370/7 and 426/7 weeks) delivered by cesarean section were included in the study. Four different groups were established:

  1. Infants with appropriate weight for gestational age (AGA): Of the 27 infants classified as AGA whose mothers consented to participation in the study, 2 whose laboratory data were insufficient were excluded from the study, while the other 25 were included in this group.

  2. Infants small for gestational age (SGA): Of the 22 infants classified as SGA whose mothers consented to participation in the study, 2 whose laboratory data were insufficient or who were admitted to the Neonatal Intensive Care Unit (NICU) were excluded from the study, while the other 20 were included in this group.

  3. Infants large for gestational age (LGA): Of the 25 infants classified as LGA whose mothers consented to participation in the study, 3 whose laboratory data were insufficient, who were admitted to the NICU, or who had suspected sepsis were excluded from the study, while the other 22 were included in this group.

  4. Infants whose mothers had GDM: Of the 23 infants in this group whose mothers consented to participation in the study, 2 who were admitted to the NICU or who had suspected sepsis and 1 whose mother’s Hemoglobin A1c (HbA1c) results could not be accessed were excluded from the study, while the other 20 were included in this group.

Demographic and neonatal data and the alarin levels of the patients included in the study were recorded. Blood HbA1c levels of mothers with GDM and their methods for blood glucose regulation (insulin or diet) in the last 1 month before delivery were also recorded. In addition, the body mass index (BMI) values of all pregnant women before pregnancy and at delivery were calculated by dividing their weight (kg) at the respective times by the square of their height (m2).

According to power analysis performed taking the alarin levels reported in animal studies as a reference, with a margin of error of 0.05, actual power of 0.8749157, and effect size of 0.90, a minimum of 20 infants per group was appropriate for each pairwise comparison.

Biochemical analysis

Blood samples were taken from all participants. Serum samples were separated from blood samples. Serum alarin levels were evaluated using a commercially available enzyme-linked immunosorbent assay (ELISA) kit (ELK Biotechnology Co., Ltd., Denver, USA) following the manufacturer’s instructions.

Statistical analysis

IBM SPSS Statistics 22 was used for statistical analysis. Normally distributed variables were evaluated by independent t-test and non-normally distributed variables were evaluated with the nonparametric Mann-Whitney U test. Categorical variables were analyzed with Fisher’s exact test and Pearson’s chi-square test. Values of p<0.05 were considered statistically significant. Numerical results were expressed as mean values (±standard deviation) and categorical results were expressed as median values (25th–75th percentile). A multivariable regression analysis was performed to exclude factors affecting birth weight. A receiver operating characteristic (ROC) curve analysis was conducted between the GDM and LGA groups.

Results

The demographic data of 87 patients in the four groups included in the study and comparisons of the groups according to demographic data are given in Table 1.

Table 1:

Demographic data of the patients and group comparisons.

AGA babies, n=25, % SGA babies, n=20, % LGA babies, n=22, % Baby of mother diagnosed with GDM, n=20, % p-Value
Newborn’s sex (male/female) 16/9 (64/36) 10/10 (50/50) 15/7 (68/32) 11/9 (55/45) 0.611
Maternal ages, yearsa 30.0 (26.0–34.5) 26.5 (24.3–32.8) 27.0 (22.5–34.3) 28.0 (23.5–34.0) 0.461
Number of pregnanciesa 2.0 (1.5–3.5) 2.0 (1.0–3.8) 2.0 (2.0–3.3) 3.0 (1.0–3.0) 0.991
Gestational ages, weeksa 38.6 (38.1–39.1) 39.4 (38.0–40.2) 39.0 (38.3–39.8) 38.6 (38.0–39.7) 0.333
Birth weight, ga 3,360 (3,113–3,605) 2,400 (2,178–2,449) 4,325 (4,210–4,455) 3,440 (3,258–3,738) <0.001
Birth length, cma 51.0 (50.0–51.5) 48.0 (46.0–49.0) 53.0 (53.0–55.0) 51.0 (50.0–52.0) <0.001
Cephalic perimeter , cma 36.0 (35.0–36.0) 34.0 (33.0–34.0) 37.0 (36.0–38.0) 35.0 (34.3–36.0) <0.001
Apgar 1. min scorea 8.0 (8.0–9.0) 8.0 (7.3–8.0) 8.0 (8.0–9.0) 8.0 (8.0–8.0) 0.589
Apgar 5. min scorea 9.0 (9.0–9.0) 9.0 (9.0–9.0) 9.0 (9.0–9.0) 9.0 (9.0–9.0) 0.878
The mother’s BMI before pregnancy, kg/m2a 22.3 (19.2–29.0) 23.5 (22.0–28.7) 26.4 (22.8–31.1) 27.3 (23.1–29.1) 0.168
The mother’s BMI at delivery, kg/m2a 26.1 (22.9–30.1) 26.3 (23.3–31.0) 29.8 (26.1–33.7) 30.2 (27.2–31.2) 0.098

  1. aMedian (quartile range).

There was no significant difference between the groups in terms of sex, APGAR scores at 1 and 5 minutes after birth, or the mother’s age and number of pregnancies (p=0.611, p=0.878, p=0.461, p=0.991, and p=0.589, respectively). Since all patients were delivered by cesarean section, no comparison was made according to mode of delivery. In addition, all patients were full-term and there was no significant difference between the groups in terms of gestational age (p=0.333). Since infants with different birth weights by gestational age were included in our study, there were significant differences in terms of birth weight, length, and head circumference between the groups (p<0.001, p<0.001, and p<0.001, respectively). There was no significant difference between the groups in terms of the mother’s BMI before pregnancy or at delivery (p=0.168 and p=0.098, respectively).

The distribution of cord blood alarin levels measured during the study according to groups is given in Table 2.

Table 2:

Blood alarin levels according to groups.

AGA babies SGA babies p1 LGA babies p2 Baby of mother diagnosed with GDM p3 ps
Alarin levels, pg/mL 186.6 (153.4–259.3) 286.1 (191.3–533.6) 0.014 204.3 (167.5–282.9) 0.394 258.5 (211.0–309.0) 0.012 0.025

  1. p1, comparison of AGA and SGA babies; p2, comparison of AGA and LGA babies; p3, comparison of AGA and GDM; ps, comparison of all babies.

Cord blood alarin levels were compared between the four groups. The median (25–75th percentile) alarin values were 186.6 (153.4–259.3) pg/mL in the AGA group, 286.1 (191.3–533.6) pg/mL in the SGA group, 204.3 (167.5–282.9) pg/mL in the LGA group, and 258.5 (211.0–309.0) pg/mL in the GDM group. There was a significant difference between the alarin levels of the groups (p=0.025). Pairwise comparisons were made between the groups to identify the groups causing the significant difference. There was a significant difference between the cord blood alarin levels of the AGA and SGA groups (p=0.014). There was also a significant difference between the cord blood alarin levels of the AGA and GDM groups (p=0.012). However, the cord blood alarin levels of the LGA group (whose mothers did not have GDM) were similar to those of the AGA group (p=0.394).

Table 3 shows the treatment modalities used by the mothers with GDM and comparisons of their blood HbA1c levels in the last 1 month and alarin levels according to treatment modalities. Of the 20 mothers diagnosed with GDM, 13 regulated their blood glucose through diet, while 7 were prescribed insulin during follow-up.

Table 3:

Comparison of HbA1c and alarin levels of mothers with GDM according to treatment modality.

Median (quartile range) Treatment modality p-Value
Diet n=13 Insulin n=7
HbA1c levels 5.8 (5.2–6.1) 6.1 (5.6–6.3) 0.135
Alarin levels, pg/mL 268.7 (239.2–308.7) 184.0 (165.7–932.6) 0.211
The mother’s BMI before pregnancy, kg/m2 26.8 (24.2–28.8) 27.7 (23.1–30.0) 0.877
The mother’s BMI at delivery, kg/m2 30.2 (27.5–31.2) 30.3 (26.9–32.0) 0.938

Among the mothers who were followed with a diagnosis of GDM, the HbA1c levels of those who regulated their blood glucose through diet were lower than those of the mothers who needed insulin, although the difference was not significant (p=0.135). No significant difference was found between the alarin levels of mothers diagnosed with GDM according to treatment modality (p=0.211). In addition, no significant difference was found between pre-pregnancy and at-delivery BMI values according to treatment modality (p=0.877 and p=0.938, respectively).

An ROC curve analysis was conducted between the GDM and LGA groups. According to the ROC analysis, in the GDM group, the level of alarin in umbilical cord blood was determined to be 219.2 pg/mL with a sensitivity of 75.0 % and a specificity of 59.1 % compared to the LGA group. The ROC curve analysis graph for the GDM and LGA groups is shown in Figure 1.

Figure 1: Receiver operating characteristic curves of the cord blood alarin level.
Figure 1:

Receiver operating characteristic curves of the cord blood alarin level.

A multivariable regression analysis was performed to exclude factors affecting birth weight. Birth weight was considered as the dependent variable. Mother’s age, the number of pregnancies, gestational age, mother’s BMI before pregnancy and at delivery, weight gained during pregnancy were considered as independent variables. According to Table 4, birth weight was not affected by these variables. The model created as a result of the regression analysis was not statistically significant (model significance: F=0.632; p=0.704; R2=0.045).

Table 4:

The multivariable regression analysis for birth weight.

Coefficientsa
Model Unstandardized coefficients Standard coefficients t p-Value 95.0 % confidence interval for B
B Std. error Beta Lower bound Upper bound
1 (Constant) 1,851.625 2,917.702 0.635 0.527 −3,954.788 7,658.038
Mother’s age −11.457 16.404 −0.093 −0.698 0.487 −44.101 21.187
Number of pregnancies 60.596 71.595 0.109 0.846 0.400 −81.882 203.074
Gestational age 30.164 72.695 0.046 0.415 0.679 −114.504 174.833
Mother’s BMI before pregnancy −9.815 20.930 −0.069 −0.469 0.640 −51.467 31.837
Mother’s BMI at delivery 23.862 17.646 0.201 1.352 0.180 −11.255 58.978
Weight gain during pregnancy 8.165 12.747 0.072 0.641 0.524 −17.202 33.531

  1. aDependant variable: birth weight.

Discussion

Low or high birth weight by gestational age may cause serious health problems that can lead to morbidity and mortality both in the neonatal period and later in life.

Alarin is a member of the galanin neuropeptide family, and it has orexigenic and glucose-regulating effects similar to those of galanin [5], 6]. Since there are few existing studies on alarin, the discussion below compares some of our results to those of similar studies on galanin rather than alarin.

Fang et al. found that pregnant women with GDM had significantly higher galanin levels compared to those with normal glucose tolerance [19]. Zhang et al. reported similar results [20]. Both research teams interpreted elevated circulating galanin levels as a physiological adaptation to increases in glucose associated with GDM [19], 20]. Li et al. also demonstrated that children with obesity and insulin resistance had higher blood alarin levels compared to children of normal weight [11]. The effects of the galanin family of peptides, including alarin, on glucose homeostasis is clear. We also considered the higher cord blood alarin levels of infants born to mothers with GDM as a physiological response to high blood glucose levels during pregnancy.

Zamłyński et al. found a significant correlation between birth weight and cord blood galanin levels [15]. In their study, Bili et al. determined a strong linear correlation between second-trimester amniotic fluid galanin levels and newborn birth weight, reporting that galanin levels could explain 72.1 % of the variance in birth weight [12]. However, both of those studies included only full-term infants weighing over 2,500 g, meaning that there were no SGA groups. In addition, their analyses did not take into account the percentiles to which the infants belonged. In other words, they did not categorize infants into separate LGA and AGA groups. In another study, Bili et al. found that fetal circulating galanin levels were not correlated with neonatal fat mass [21]. We found that the blood alarin levels of the LGA and AGA groups were statistically similar, with those of the LGA group being insignificantly higher. This may have been due to either the limited number of patients in our study groups or to blood alarin levels not being associated with neonatal fat mass. Further studies with larger numbers of patients are needed to clarify this issue.

In our study, the model created from the multiple regression analysis for independent variables that could potentially affect birth weight was statistically insignificant. This result increased the reliability of the findings related to alarin levels in umbilical cord blood.

Zamłyński et al. found a relationship between maternal BMI and plasma galanin levels [15]. Zhang et al. determined a significant relationship between pre-pregnancy BMI and galanin levels in mothers with GDM [20]. In our study, although both pre-pregnancy and at-delivery BMIs of the mothers with GDM were higher, the differences were not significant. This result can be attributed to the small numbers of patients in each group. In addition, the belief held in Turkey that infants need to be “fattened up” during pregnancy often leads to excessive increases in the calorie intake of mothers. This may be the reason for the insignificant differences in BMI values, especially at birth.

Guo et al. reported that food intake and body weight are regulated by orexigenic and anorexigenic neuropeptides expressed in the hypothalamic arcuate nucleus [10]. In their animal study, Boughton et al. showed that alarin has orexigenic effects via neuropeptide Y [8]. When body weight is considered, SGA infants would be expected to have lower alarin levels due to lower birth weights, but we found that the SGA group had higher alarin levels compared to the AGA group. According to the “small-baby syndrome” hypothesis of Barker et al., children with low birth weight are at high risk of developing metabolic disorders such as impaired glucose tolerance and dyslipidemia later in life as a result of prenatal undernutrition [22]. In their animal study comparing the hypothalamic expressions of mRNA for the galanin and galanin 2 receptors of rats fed with different amounts of protein during pregnancy, Bellinger et al. demonstrated that feeding behavior is programmed prenatally [23]. In a study investigating the increased risk of SGA-born rats for adulthood diabetes, Schellong et al. found that hypothalamic misprogramming leading to reduced anorexigenic activity in the SGA rats underlay their later diseases [24]. Based on the results of these studies, we think that increased alarin levels, known to have orexigenic effects on the hypothalamic arcuate nucleus, serve to decrease the anorexigenic activity of SGA infants. However, additional animal studies are needed to support this claim.

Looking at the results of our study, we found that umbilical cord blood alarin levels were higher in the SGA and GDM mother-infant group, which has a higher risk of neonatal hypoglycemia compared to other groups. This suggests that elevated alarin levels might be protective against hypoglycemia complications, such as secondary seizures, irreversible damage to the nervous system, and neurodevelopmental abnormalities, which are major concerns for newborns. However, to make such a definitive statement, studies should include a larger number of patients, particularly those requiring intensive hypoglycemia treatments. Additionally, future research should explore when the protective effects of alarin begin, how long they last, and what they specifically protect against.

In addition, the antioxidant effects of alarin have been shown in animal studies [25]. The antioxidant effects alone may explain the variance in blood alarin levels of infants from the SGA and GDM groups. Alarin’s antioxidant effects should be investigated in further studies.

Conclusions

Regardless of birth weight, alarin levels in umbilical cord blood were found to be higher in SGA babies and in babies born to mothers with GDM compared to AGA and LGA babies. No difference was observed in alarin levels in relation to the type of diabetes treatment administered to mothers with GDM. According to the ROC analysis between the GDM and LGA groups, in the GDM group, the alarin level in umbilical cord blood was determined to be 219.2 pg/mL with a sensitivity of 75.0 % and a specificity of 59.1 % compared to the LGA group.

Corresponding author: Dr. Melek Buyukeren, MD, Department of Pediatrics, Division of Neonatology, Konya City Hospital, Konya, Türkiye, E-mail:

  1. Research ethics: The study was approved by the Karatay University Ethics Committee (Ethics Committee Decision No. 2023/008) and Konya City Hospital (Clinical Trials ID: NCT06333548). The families of the babies gave written informed consent. Afterwards, they were included in the study. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

  2. Informed consent: Informed consent was obtained from all individuals included in this study.

  3. Author contributions: MB: conceptualization/design and supervision/oversight, methology, investigation, data curation, resurces. BO: conceptualization/design and supervision/oversight, methology, investigation. UC: conceptualization/design and supervision/oversight, methology, investigation. AK: methodology, investigation, formal analysis. RK: methology, investigation, formal analysis. MGB: methodology, investigation, data curation. OG: methodology, investigation, data curation. The authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Use of Large Language Models, AI and Machine Learning Tools: None declared.

  5. Conflict of interests: The authors state no conflicts of interest to declare.

  6. Research funding: None declared.

  7. Data availability: Not applicable.

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Received: 2024-05-27
Accepted: 2024-10-10
Published Online: 2024-10-28
Published in Print: 2025-01-29

© 2025 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. The Journal of Perinatal Medicine is switching its publication model to open access
  4. Original Articles – Obstetrics
  5. The early COVID-19 pandemic period and associated gestational weight gain
  6. Evaluation of fetal growth and birth weight in pregnancies with placenta previa with and without placenta accreta spectrum
  7. Nutritional guidance through digital media for glycemic control of women with gestational diabetes mellitus: a randomized clinical trial
  8. Adverse perinatal outcomes related to pregestational obesity or excessive weight gain in pregnancy
  9. Maternal and fetal outcomes among pregnant women with endometriosis
  10. The role of the lower uterine segment thickness in predicting preterm birth in twin pregnancies presenting with threatened preterm labor
  11. Effect of combination of uterine artery doppler and vitamin D level on perinatal outcomes in second trimester pregnant women
  12. Contemporary prenatal diagnosis of congenital heart disease in a regional perinatal center lacking onsite pediatric cardiac surgery: obstetrical and neonatal outcomes
  13. How time influences episiotomy utilization and obstetric anal sphincter injuries (OASIS)
  14. The first 2-year prospective audit of prenatal cell-free deoxyribonucleic screening using single nucleotide polymorphisms approach in a single academic laboratory
  15. Original Articles – Fetus
  16. Evaluating fetal pulmonary vascular development in congenital heart disease: a comparative study using the McGoon index and multiple parameters of fetal echocardiography
  17. Antenatal corticosteroids for late small-for-gestational-age fetuses
  18. A systematic catalog of studies on fetal heart rate pattern and neonatal outcome variables
  19. Original Articles – Neonates
  20. Comparison of cord blood alarin levels of full-term infants according to birth weight
  21. Reviewer Acknowledgment
  22. Reviewer Acknowledgment
https://doi.org/10.1515/jpm-2024-0236
Keywords for this article
alarin; small for gestational age; newborn; gestational diabetes mellitus
Creative Commons
BY 4.0

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. The Journal of Perinatal Medicine is switching its publication model to open access
  4. Original Articles – Obstetrics
  5. The early COVID-19 pandemic period and associated gestational weight gain
  6. Evaluation of fetal growth and birth weight in pregnancies with placenta previa with and without placenta accreta spectrum
  7. Nutritional guidance through digital media for glycemic control of women with gestational diabetes mellitus: a randomized clinical trial
  8. Adverse perinatal outcomes related to pregestational obesity or excessive weight gain in pregnancy
  9. Maternal and fetal outcomes among pregnant women with endometriosis
  10. The role of the lower uterine segment thickness in predicting preterm birth in twin pregnancies presenting with threatened preterm labor
  11. Effect of combination of uterine artery doppler and vitamin D level on perinatal outcomes in second trimester pregnant women
  12. Contemporary prenatal diagnosis of congenital heart disease in a regional perinatal center lacking onsite pediatric cardiac surgery: obstetrical and neonatal outcomes
  13. How time influences episiotomy utilization and obstetric anal sphincter injuries (OASIS)
  14. The first 2-year prospective audit of prenatal cell-free deoxyribonucleic screening using single nucleotide polymorphisms approach in a single academic laboratory
  15. Original Articles – Fetus
  16. Evaluating fetal pulmonary vascular development in congenital heart disease: a comparative study using the McGoon index and multiple parameters of fetal echocardiography
  17. Antenatal corticosteroids for late small-for-gestational-age fetuses
  18. A systematic catalog of studies on fetal heart rate pattern and neonatal outcome variables
  19. Original Articles – Neonates
  20. Comparison of cord blood alarin levels of full-term infants according to birth weight
  21. Reviewer Acknowledgment
  22. Reviewer Acknowledgment
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