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Association of urinary misfolded protein quantification with preeclampsia and adverse pregnancy outcomes: a retrospective case study

  • Shuang Zhao , Mingju Zhang , Jingyuan Yang , Zhuoran Du , Guohui Wang and Shufan Shan EMAIL logo
Published/Copyright: April 17, 2025
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Journal of Perinatal Medicine
From the journal Journal of Perinatal Medicine Volume 53 Issue 5

Abstract

Objectives

This study aimed to explore the relationship between the detection of misfolded proteins in urine and preeclampsia (PE) as well as adverse pregnancy outcomes.

Methods

A retrospective analysis was conducted on 400 pregnant women who underwent prenatal care at our hospital from January 2022 to May 2023. Demographic and clinical data were collected. The study documented the incidence of PE, positive urine misfolded protein detection rate, and the occurrence of adverse pregnancy outcomes. Factors influencing the occurrence of adverse pregnancy outcomes were also analyzed.

Results

Out of the 400 pregnant women, 22 cases (5.50 %) developed PE. A total of 15 cases tested positive for misfolded proteins in urine, with 14 cases (63.64 %) of PE and 1 case (0.26 %) without PE. A history of smoking/secondhand smoke exposure (OR=3.592, 95 %CI: 3.217–4.012), oligohydramnios (OR=3.992, 95 %CI: 3.363–4.739), thyroid dysfunction (OR=2.164, 95 %CI: 1.835–2.552), the use of risky medications during pregnancy (OR=3.788, 95 %CI: 3.046–4.710), mild PE (OR=4.908, 95 %CI: 3.710–6.492), severe PE (OR=6.151, 95 %CI: 3.576–10.579), and a positive test for urinary misfolded proteins (OR=5.897, 95 %CI: 4.016–8.658) were all identified as risk factors for adverse pregnancy outcomes.

Conclusions

The rate of positive urinary misfolded protein detection was relatively high, but there was a certain rate of false positives. Furthermore, a positive test for urinary misfolded proteins and the severity of PE was associated with an increased incidence of adverse pregnancy outcomes.

Keywords: preeclampsia; urinary misfolded protein; adverse pregnancy outcomes; risk factor

Introduction

Preeclampsia (PE) is a hypertensive disorder in pregnancy that affects multiple maternal systems, with a global incidence of approximately 2–4 % and a high rate of severe complications ranging from 5–20 % [1], 2]. PE can result in maternal organ dysfunction, fetal growth restriction, fetal distress, and perinatal mortality, significantly impacting both maternal and child health and their subsequent quality of life [3].

The pathogenesis of PE is complex, and a comprehensive theory explaining its onset and progression is still lacking. The widely accepted “two-stage” hypothesis suggests that PE development occurs in two phases. In the first phase, placental hypoxia and ischemia result in the release of various placental factors. In the second, or clinical phase, these factors enter the maternal bloodstream, triggering inflammatory responses and endothelial cell damage, which lead to a cascade of clinical symptoms [4]. This model underscores PE as a multi-system, multi-organ disorder, indicating that treatments targeting a single pathway are unlikely to be fully effective. Currently, clinical management of PE focuses on slowing disease progression, alleviating symptoms, and preventing eclampsia, as no definitive cure exists. Therefore, early diagnosis and timely intervention are essential for optimal outcomes.

In clinical practice, the diagnosis of PE primarily relies on monitoring blood pressure, proteinuria, hepatic and renal function, platelet counts, and subjective symptoms reported by pregnant women. However, these markers often lack specificity, and assessments of disease progression are frequently untimely. Additionally, due to the variable clinical presentations of PE, many patients without obvious symptoms may miss the optimal window for treatment and intervention. As a result, researchers are increasingly focused on identifying more convenient, rapid, and non-invasive diagnostic methods. Recent studies have shown that urine and placental tissues of women with PE contain high levels of amyloid misfolded proteins and protein aggregates, which can be detected via their affinity for Congo red dye, offering potential as predictive and diagnostic biomarkers for PE [5]. Furthermore, growing evidence indicates a link between PE and adverse pregnancy outcomes [6], making the relationship between urinary misfolded proteins, PE, and adverse outcomes a promising area for further investigation.

Patients and methods

Study population

This retrospective study included 400 pregnant women who delivered at our hospital between January 2022 and May 2023, selected based on specific inclusion and exclusion criteria.

Inclusion criteria: (i) Met the diagnostic criteria for PE in the International Society for the Study of Hypertension in Pregnancy (ISSHP) [7]; (ii) knew the purpose of the study and voluntarily signed an informed consent form; and (iii) had no communication disorders and were conscious.

Exclusion criteria: (i) Fetal chromosomal and structural abnormalities; (ii) spontaneous abortions of unknown cause or intrauterine fetal demise before 28 weeks of gestation; (iii) premature rupture of membranes, preterm labor, and laboring women; (iv) other related hypertensive disorders of pregnancy: gestational hypertension and chronic hypertension with pregnancy; (v) adverse proteinuria due to severe renal disease or immune system disorders; (vi) adverse platelet counts caused by hematological or autoimmune diseases; (vii) concurrent neurological disorders (viii) Multiple pregnancies; (ix) incomplete clinical data.

The study complied with the Declaration of Helsinki and was reviewed by the Clinical Research Ethics Committee of our hospital, and informed consent was obtained from patients for all procedures.

Study protocol

General and clinical data were collected from participants, including age, pre-pregnancy body mass index (BMI), pregnancy and parity history, alcohol consumption, exposure to smoking/secondhand smoke, presence of oligohydramnios, thyroid dysfunction, sleep disorders, impaired glucose metabolism, pregnancy-related anemia, medication use during pregnancy, and prenatal supplement intake. Clean mid-stream urine samples were collected from each participant to test for misfolded proteins. The study recorded the incidence of PE, the detection rate of urinary misfolded proteins, and the occurrence of adverse pregnancy outcomes. Additionally, factors influencing adverse pregnancy outcomes were analyzed.

Diagnostic standards

Diagnostic criteria for PE

Blood pressure readings of systolic (≥140 mmHg) and/or diastolic (≥90 mmHg) taken after 20 weeks of gestation, in conjunction with any of the following: (i) proteinuria with a 24-h urine protein of ≥0.3 g, or a urine protein-to-creatinine ratio of ≥0.3, or a random urine protein level of ≥1+ (methods of examination when 24-h urine protein quantification cannot be performed); (ii) in the absence of proteinuria, any of the following organ or system involvements are present: significant organs such as the heart, lungs, liver, and kidneys, or abnormalities in the hematological, digestive, and nervous systems, as well as placental-fetal involvement [8].

Diagnosis of severe PE

Pregnant women diagnosed with PE and who also exhibit any of the following conditions can be diagnosed with severe PE: (i) systolic blood pressure≥160 mmHg and/or diastolic blood pressure≥110 mmHg, with persistently elevated and uncontrollable hypertension; (ii) persistent headache, visual disturbances, or other symptoms of central nervous system involvement; (iii) persistent upper abdominal pain, hepatic subcapsular hematoma, etc.; (iv) liver function damage: elevated levels of alanine aminotransferase (ALT) or aspartate aminotransferase (AST); (v) renal dysfunction: 24-h urine protein quantification>2.0 g, oliguria, or serum creatinine>106 μmol/L; (vi) persistent thrombocytopenia with platelet count<100×109/L, and microangiopathic hemolysis; (vii) heart failure; (viii) pulmonary edema; (ix) fetal growth restriction, placental abruption, and fetal distress in utero; (x) ascites, pleural effusion, pericardial effusion, etc.

Adverse perinatal pregnancy outcomes include adverse maternal pregnancy outcomes (abortion, premature rupture of membranes, placenta previa, postpartum hemorrhage, death, etc.) and adverse fetal pregnancy outcomes (premature, macrosomia, congenital abnormality, very low birth weight infant, fetal distress, fetal death, neonatal asphyxia, etc.) [9].

Urinary misfolded protein

Clean midstream urine samples were collected from patients for analysis and the levels of misfolded proteins were measured using a dot-blot method with Congo red staining at a fixed amount and concentration. A specific volume of urine sample was mixed with the reagent, then applied onto filter paper. After air drying, a semi-quantitative assessment was conducted using a kit from Zhejiang Suwen Biotechnology Co., Ltd. This method involved mixed staining with Congo red and Brilliant Blue, and the ratio of the radii of blue and red circles on the filter paper served as an auxiliary marker for detecting misfolded proteins. A ratio of ≥0.615 was considered a positive qualitative result for misfolded proteins in the urine [10].The interpretation of results requires two individuals to conduct the analysis simultaneously. Results are considered valid only if both interpretations agree; otherwise, retesting is required. All testing information should be accurately recorded, including the sample receipt time, sample characteristics, testing time, and test results, as well as any potential abnormalities, and stored independently using a coding system. Testing procedures and specimen reagent management are strictly carried out according to the instructions provided in the manual.

Statistical analysis

SPSS 25.0 statistical software was used for data analysis, and GraphPad Prism 9.5 software was used for plotting. Count data were expressed as percentage (%), and two test was used for comparison between groups. Multifactorial logistic regression analysis was used to explore the influencing factors of adverse pregnancy outcomes. The difference was considered statistically significant at p<0.05.

Results

Occurrence of PE and positive detection of urinary misfolded protein

Four hundred pregnant women who met the inclusion criteria were finally enrolled in this study and subsequently analyzed. A total of 22 (5.50 %) pregnant women were diagnosed with PE. Of these, a total of 14 had mild PE, and eight had severe PE. It was found that a total of 15 pregnant women were tested positive by detecting misfolded proteins in urine, of which 14 (63.64 %) had PE (Table 1, 7 (50.00 %) patients with mild PE and 7 (87.50 %) with severe PE, p>0.05). Notably one (0.26 %) other pregnant woman without PE was also tested positive.

Table 1:

Positive detection of urinary misfolded protein in patients with PE, n (%).

Urinary misfolded protein Mild PE (n=14) Severe PE (n=8) Statistic p-Value
Positive 7 (50.00 %) 7 (87.50 %) Fisher exact 0.079
Negative 7 (50.00 %) 1 (12.50 %)

  1. PE, preeclampsia.

Occurrence of adverse pregnancy outcomes

The results showed that the incidence of adverse pregnancy outcomes was significantly higher in urinary misfolded protein positive (86.67 %) than in negative (19.74 %) pregnancies (p<0.05). However, the incidence of adverse pregnancy outcomes was only numerically higher in mild PE pregnant women (87.50 %) than in severe PE (64.29 %) and was not statistically significant (p>0.05). The incidence of adverse pregnancy outcomes is shown in Table 2.

Table 2:

Occurrence of adverse pregnancy outcomes, n (%).

Urinary misfolded protein PE
Positive (n=15) Negative (n=385) Mild (n=14) Severe (n=8)
Adverse pregnancy 13 (86.67) 76 (19.74) 9 (64.29) 7 (87.50)
Normal pregnancy with risk factors 2 (13.33) 309 (80.26) 5 (35.71) 1 (12.50)
χ 2 37.381 1.383
p <0.001 0.240

  1. PE, preeclampsia.

Influential factors associated with adverse pregnancy outcomes

The 400 pregnant women in this study were finally adjudged to have adverse pregnancy outcomes (adverse pregnancy group) in 89 cases (22.25 %) and the remaining 311 cases (77.75 %) had normal pregnancy outcomes (normal pregnancy group). Demographic characteristics and clinical data of the two groups of patients are presented in Table 3. Pregnant women were considered to be of advanced maternal age if they were≥35 years of age [11], therefore age was separated here with a cut-off of 35 years. BMI≥30kg/m2 was considered to be obese and was again separated with a cut-off of 30kg/m2 [12].

Table 3:

Baseline characteristics of different pregnancy outcomes [n(%)].

Adverse pregnancy group (n=89) Normal pregnancy group (n=311) χ2 p-Value
Age, years 1.612 0.204
 <35 74 (83.15) 239 (76.85)
 ≥35 15 (16.85) 72 (23.15)
Pre-pregnancy BMI, kg/m2 2.318 0.128
 <30 57 (64.04) 171 (54.98)
 ≥30 32 (35.96) 140 (45.02)
Pregnancies (number) 0.244 0.621
 1 47 (52.81) 155 (49.84)
 ≥2 42 (47.19) 156 (50.16)
Parity 1.351 0.245
 Nulliparous 68 (76.40) 218 (70.10)
 Multipara 21 (23.60) 93 (29.90)
History of alcohol consumption 0.226 0.635
 Yes 18 (20.22) 56 (18.01)
 No 71 (79.78) 255 (81.99)
Exposure to smoking/secondhand smoke 19.432 <0.001
 Yes 31 (34.83) 44 (14.15)
 No 58 (65.17) 267 (85.85)
Oligohydramnios 12.378 <0.001
 Yes 13 (14.61) 13 (4.18)
 No 76 (85.39) 298 (95.82)
Thyroid dysfunction 12.192 <0.001
 Yes 15 (16.85) 17 (5.47)
 No 74 (83.15) 294 (94.53)
Sleep disorders 0.130 0.719
 Yes 24 (26.97) 78 (25.08)
 No 65 (73.03) 233 (74.92)
Adverse glucose metabolism 0.002 0.969
 Yes 22 (24.72) 59 (18.97)
 No 67 (75.28) 252 (81.03)
Anemia during pregnancy 0.854 0.355
 Yes 23 (25.84) 66 (21.22)
 No 66 (74.16) 245 (78.78)
Medication use during pregnancy 13.728 <0.001
 Yes 10 (11.24) 7 (2.25)
 No 79 (88.76) 304 (97.75)
Intake of prenatal supplements 0.220 0.639
 Yes 37 (41.57) 138 (44.37)
 No 52 (58.43) 173 (55.63)
Mild PE 14.819 <0.001
 Yes 9 (10.11) 5 (1.61)
 No 80 (89.89) 306 (98.49)
Severe PE 20.091 <0.001
 Yes 7 (7.87) 1 (0.32)
 No 82 (92.13) 310 (99.68)
Urinary misfolded protein 37.381 <0.001
 Positive 13 (14.61) 2 (0.64)
 Negative 76 (85.39) 309 (99.36)

  1. PE, preeclampsia; BMI, body mass index.

The results showed that an exposure to smoking/secondhand smoke (34.83 vs. 14.15 %), oligohydramnios (14.61 vs. 4.18 %), thyroid dysfunction (16.85 vs. 5.47 %), medication use during pregnancy (11.24 vs. 2.25 %), mild PE (10.11 vs. 1.61 %), severe PE (7.78 vs. 0.32 %), and urine misfolded protein positivity (14.61 vs. 0.64 %) were associated with the occurrence of adverse pregnancy outcomes in pregnant women (p<0.05).

Multifactorial analysis of adverse pregnancy outcomes

Influential factors that were statistically different in the univariate analysis were further tested by logistic regression analysis. The results showed (Table 4) that exposure to smoking/secondhand smoke (OR=3.592, 95%CI: 3.217–4.012), oligohydramnios (OR=3.992, 95 %CI: 3.363–4.739), thyroid dysfunction (OR=2.164, 95 %CI: 1.835–2.552), medication use during pregnancy (OR=3.788, 95 %CI: 3.046–4.710), mild PE (OR=4.908, 95 %CI: 3.710–6.492), severe PE (OR=6.151, 95 %CI: 3.576–10.579), and positive urinary misfolded protein (OR=5.897, 95 %CI: 4.016–8.658) were all independent risk factors for adverse pregnancy outcomes (p<0.05).

Table 4:

Multifactorial analysis of adverse pregnancy outcomes [n(%)].

Variables B SE Wald p-Value OR 95 %CI
Exposure to smoking/secondhand smoke 1.279 0.056 515.512 <0.001 3.592 3.217–4.012
Oligohydramnios 1.384 0.087 250.487 <0.001 3.992 3.363–4.739
Thyroid dysfunction 0.772 0.084 84.194 <0.001 2.164 1.835–2.552
Medication use during pregnancy 1.332 0.111 143.464 <0.001 3.788 3.046–4.710
Mild PE 1.591 0.143 124.249 <0.001 4.908 3.710–6.492
Severe PE 1.817 0.277 43.113 <0.001 6.151 3.576–10.579
Positive urinary misfolded protein 1.774 0.196 81.970 <0.001 5.897 4.016–8.658

  1. PE, preeclampsia; B, coefficient; SE, standard error; Wald, Wald statistic; OR, odds ratio; 95%CI, 95 % confidence interval.

Discussion

Hypertension is one of the most common conditions among pregnant women, posing significant risks to both fetal health and maternal well-being during the perinatal period [13]. PE represents the most severe form of hypertensive disorders in pregnancy. Its complex pathophysiology can lead to numerous adverse outcomes, including impaired maternal organ function, restricted fetal growth, preterm labor, and even mortality [14]. Consequently, early detection and diagnosis of PE are essential for ensuring a healthy pregnancy.

During pregnancy, abnormalities in the remodeling of the uterine placental vascular system can lead to imbalances in angiogenesis, oxidative stress, endoplasmic reticulum (ER) stress, and the release of inflammatory factors, all contributing to the pathogenesis of PE [15]. The ER plays a critical role in protein synthesis, and disruptions in this process can disturb ER homeostasis, leading to protein misfolding or incomplete folding and triggering pathological changes [16]. Studies have shown that the formation and aggregation of misfolded proteins are linked to PE [17]. While misfolded proteins are present at low levels in the urine of healthy pregnancies, they are significantly elevated in the urine of patients with PE [18]. Thus, urinary misfolded proteins serve as a promising marker for predicting PE.

In this study, 15 pregnant women tested positive for misfolded proteins in the urine, of whom 14 had PE, representing 63.64 % of the total PE cases. One positive case (0.26 %) was also identified in a non-PE patient. Li et al. reported a higher positive rate of around 74 % in women with late-pregnancy PE, with a 3 % false positive rate [19]. In contrast, the current study found both a lower positive rate and false positive rate for urinary misfolded protein testing in PE patients, which may be due to the smaller sample size and fewer PE cases. Regional differences may also account for the variance in results. Additionally, we observed a 50.00 % positive detection rate for mild PE and an 87.50 % rate for severe PE, suggesting that the positive rate may correlate with PE severity, though there was no statistical difference between groups.

This study identified both PE and positive urinary misfolded proteins as risk factors for adverse pregnancy outcomes. The odds ratio (OR) for adverse outcomes was higher in women with severe PE (6.151) compared to those with mild PE (4.908). The pathogenesis of PE is primarily linked to impaired placental development, including insufficient trophoblast invasion and abnormal remodeling of spiral arteries, resulting in reduced placental perfusion. Additionally, trophoblast apoptosis and necrosis release cellular debris that triggers an inflammatory response, causing systemic endothelial damage [20]. While timely intervention may prevent severe consequences in mild PE, it can still progress to a more severe form, necessitating close monitoring. As blood pressure, proteinuria, and misfolded protein levels rise, they may compromise organ function, such as in the liver and kidneys, leading to serious complications for both mother and fetus [6], ultimately contributing to adverse pregnancy outcomes.

Adverse pregnancy outcomes can arise from multiple risk factors, including smoking/secondhand smoke exposure, oligohydramnios, thyroid dysfunction, and the use of certain medications during pregnancy, each impacting maternal and fetal health through mechanisms such as uterine hypoxia [21], placental perfusion deficits [22], or altered fetal development [23], 24]. In this study, we observed that urinary misfolded proteins are associated with preeclampsia, a known risk factor for adverse outcomes. Misfolded proteins, as indicators of cellular stress and endothelial dysfunction, may reflect underlying pathophysiological processes contributing to these complications.

Finally, our study introduces the novel use of urinary misfolded proteins as a potential biomarker for predicting PE and adverse pregnancy outcomes. Unlike conventional biomarkers, urinary misfolded proteins offer a non-invasive and accessible means to assess PE risk, advantageous especially in resource-limited clinical settings. Moreover, the correlation between misfolded protein levels and PE severity adds valuable insights into the disease’s pathophysiology, presenting a promising direction for developing early diagnostic tools for high-risk pregnancies.

Limitation

The present study may have the following limitations: i) As a single-center retrospective study, the sample size is relatively small, particularly with respect to patients with preeclampsia (PE) and those who tested positive for misfolded proteins in urine, which is a limitation inherent to the actual epidemiological conditions. Nevertheless, this study provides timely insights into whether urinary misfolded proteins can serve as biomarkers for PE and adverse pregnancy outcomes. It may represent a valuable starting point, offering references for future larger-scale studies. ii) Despite the relatively high positive detection rate of urinary misfolded proteins, false positive results still exist, potentially leading to incorrect diagnoses of non-PE cases. To minimize this issue, results were interpreted by two independent researchers to reduce the risk of human error and false positives. However, despite this measure, false positive results cannot be entirely avoided, as they may be related to factors such as the sensitivity and specificity of the detection method, individual differences, and urine sample quality. Therefore, in clinical practice, positive results from urinary misfolded protein testing should be integrated with other clinical parameters and imaging studies for comprehensive evaluation, in order to avoid misdiagnosis and ensure effective intervention. iii) The statistical analysis may be limited by potential selection bias, incomplete control of confounding factors and ambiguity in establishing causality, which could collectively impact the reliability and generalizability of the findings.

Conclusions

In this study, we observed a high rate of positive urine misfolded protein detection, which shows strong potential as a predictive marker for PE, despite a certain false positive rate. The positive detection rate appears to correlate with the severity of PE, and the severity of PE is proportionally associated with the incidence of adverse pregnancy outcomes. Identified risk factors for adverse outcomes include PE, positive urinary misfolded proteins, exposure to smoking/secondhand smoke, oligohydramnios, thyroid dysfunction, and medication use during pregnancy.

Corresponding author: Shufan Shan, Obstetrical Department, Affiliated Hospital of ChiFeng University, 42 Wangfu Avenue, ChiFeng, 024000, China, E-mail:

Funding source: Scientific Research Project of Universities in Inner Mongolia Autonomous Region

Award Identifier / Grant number: NJZY2218

  1. Research ethics: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Affiliated hospital of ChiFeng University.

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

  3. Author contributions: Conceptualization, Shuang Zhao and Shufan Shan; methodology, Mingju Zhang; software, Zhuoran Du; validation, Shuang Zhao and Shufan Shan; formal analysis, Shuang Zhao, Shufan Shan and Jingyuan Yang; investigation, Zhuoran Du and Guohui Wang; data curation, Mingju Zhang and Guohui Wang; writing – original draft preparation, all authors; writing – review and editing, all authors; supervision, Shufan Shan; funding acquisition, Shuang Zhao. All authors have read and agreed to the published version of the manuscript.

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

  5. Conflict of interest: The authors state no conflict of interest.

  6. Research funding: This study was supported by Scientific research project of universities in Inner Mongolia Autonomous Region (NJZY2218).

  7. Data availability: Data supporting this study are available from the corresponding author upon reasonable request.

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Received: 2024-09-01
Accepted: 2025-02-21
Published Online: 2025-04-17
Published in Print: 2025-06-26

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

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

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  10. Upregulation of microRNA-3687 promotes gestational diabetes mellitus by inhibiting follistatin-like 3
  11. Placental elasticity in trisomy 21: prenatal assessment with shear-wave elastography
  12. Penicillin allergies and selection of intrapartum antibiotic prophylaxis against group B Streptococcus at a safety-net institution
  13. Assessing high-risk perinatal complications as risk factors for postpartum mood disorders
  14. Original Articles – Fetus
  15. Assessment of fetal thymus size in pregnancies of underweight women
  16. Normal fetal echocardiography ratios - a multicenter cross-sectional retrospective study
  17. Original Articles – Neonates
  18. Evaluation of the relationship of fetal lung elastography values with the development of postpartum respiratory distress in late preterm labor cases
  19. Short Communication
  20. Radiographic thoracic area in newborn infants with Down’s syndrome
  21. Letter to the Editor
  22. Teaching prospective parents basic newborn life support (BNLS) for unplanned out-of-hospital births
https://doi.org/10.1515/jpm-2024-0407
Keywords for this article
preeclampsia; urinary misfolded protein; adverse pregnancy outcomes; risk factor
Creative Commons
BY 4.0

Articles in the same Issue

  1. Frontmatter
  2. Reviews
  3. Pharmacologic thromboprophylaxis following cesarean delivery-what is the evidence? A critical reappraisal
  4. Fetal cardiac diagnostics in Indonesia: a study of screening and echocardiography
  5. Original Articles – Obstetrics
  6. Comparative analysis of antidiuretic effects of oxytocin and carbetocin in postpartum hemorrhage prophylaxis: a retrospective cohort study
  7. Severe thrombocytopenia in pregnancy: a cross-sectional analysis of perinatal and neonatal outcomes across different platelet count categories
  8. Association of urinary misfolded protein quantification with preeclampsia and adverse pregnancy outcomes: a retrospective case study
  9. Differentially expressed genes in the placentas with pre-eclampsia and fetal growth restriction using RNA sequencing and verification
  10. Upregulation of microRNA-3687 promotes gestational diabetes mellitus by inhibiting follistatin-like 3
  11. Placental elasticity in trisomy 21: prenatal assessment with shear-wave elastography
  12. Penicillin allergies and selection of intrapartum antibiotic prophylaxis against group B Streptococcus at a safety-net institution
  13. Assessing high-risk perinatal complications as risk factors for postpartum mood disorders
  14. Original Articles – Fetus
  15. Assessment of fetal thymus size in pregnancies of underweight women
  16. Normal fetal echocardiography ratios - a multicenter cross-sectional retrospective study
  17. Original Articles – Neonates
  18. Evaluation of the relationship of fetal lung elastography values with the development of postpartum respiratory distress in late preterm labor cases
  19. Short Communication
  20. Radiographic thoracic area in newborn infants with Down’s syndrome
  21. Letter to the Editor
  22. Teaching prospective parents basic newborn life support (BNLS) for unplanned out-of-hospital births
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