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Biomedical subjects

Anthony M Vintzileos

Publications and source records attributed to Anthony M Vintzileos.

At least 19 recordsLinked to original sources

Maternal-fetal conditions necessitating a medical intervention resulting in preterm birth.

OBJECTIVE: The objective of the study was to evaluate the extent to which maternal and fetal conditions necessitate medically indicated preterm birth. STUDY DESIGN: A population-based, retrospective, cohort study of women who delivered a singleton live birth at 20 weeks or longer in Missouri, 1989 to 1997 was performed (n = 684,711). Maternal-fetal conditions that necessitated iatrogenic preterm birth included preeclampsia, small-for-gestational-age birth, fetal distress, placental abruption, placenta previa, unexplained vaginal bleeding, pregestational and gestational diabetes, renal disease, Rh sensitization, and congenital malformations. We examined the association between each of the aforementioned conditions and risk of medically indicated preterm birth at less than 35 weeks. Medically indicated preterm birth was defined as a labor induction or a prelabor cesarean in the absence of premature rupture of membranes at preterm gestations. Adjusted relative risk with 95% confidence interval for preterm birth was derived from multivariable logistic regression models, and population attributable fractions were calculated. RESULTS: The preterm birth rate (less than 35 weeks) was 4.6% (n = 31,238), with 23.5% (n = 7,347) of such births being medically indicated. Preeclampsia, fetal distress, small-for-gestational-age, and placental abruption were the most common indications for a medical intervention resulting in preterm birth, with at least 1 of these conditions present in 53.2% of medically indicated preterm births and in 17.7% of term births (relative risk 4.9, 95% confidence interval 4.7, 5.2). CONCLUSION: Preeclampsia, fetal distress, small-for-gestational-age, and placental abruption, conditions that are associated with ischemic placental disease, are implicated in well over half of all medically indicated preterm births. Although the etiology of preterm birth is heterogeneous, it is reasonable that ischemic placental disease may serve as an important pathway to preterm birth.

Abruptio Placentae↗

Fetal transcerebellar diameter measurement for prediction of gestational age in twins.

OBJECTIVE: This study was undertaken to determine the accuracy of our previously published and prospectively validated institution-specific singleton transcerebellar diameter (TCD) nomogram in the prediction of gestational age (GA) in twin pregnancies. We further evaluated whether the prediction of GA in twin gestations using the singleton TCD nomogram differs between monochorionic and dichorionic twins. STUDY DESIGN: In our previously published studies, we retrospectively constructed a cross-sectional nomogram using TCD measurements in 24,026 well-dated, singleton fetuses, and prospectively validated the nomogram using 2,597 singleton fetuses. The current study comprised of 1,278 well-dated twins (19.6% monochorionic) seen in our ultrasound unit between August 1994 and May 2003, and the singleton TCD nomogram was validated in these twin gestations. The actual GA was subtracted from the GA predicted by the TCD nomogram and the concordance between actual and predicted GAs was assessed on the basis of the Pearson's correlation coefficient (r). This was performed separately for monochorionic and dichorionic twins. RESULTS: Concordance between the actual and predicted twin TCD measurements based on our previously published singleton TCD nomogram was high (Pearson's correlation, r = 0.95, P < .0001). Between 16 and 23 weeks' gestation, the predicted mean GA was within 6 days of actual GA. Between 24 and 30 weeks, the predicted mean GA was within 3 days, and at 32 weeks or more, the predicted mean GA was within 5 days of the actual GA. Prediction of GA based on the singleton TCD nomogram was equally accurate in both monochorionic and dichorionic twin gestations (P = .686). CONCLUSION: This study demonstrates that our previously validated singleton TCD nomogram is reliable and accurate in twins irrespective of placental chorionicity.

Adult↗

Uteroplacental bleeding disorders during pregnancy: do missing paternal characteristics influence risk?

BACKGROUND: Several studies have assessed the risks of uteroplacental bleeding disorders in relation to maternal characteristics. The association between uteroplacental bleeding disorders and paternal characteristics, however, has received considerably less attention. Data on paternal demographics, notably race and age, from birth certificate data are becoming increasingly incomplete in recent years. This pattern of increasingly underreporting of paternal demographic data led us to speculate that pregnancies for which paternal characteristics are partially or completely missing may be associated with increased risk for uteroplacental bleeding disorders. The objective of this study is to examine the association between placenta previa and placental abruption and missing paternal age and race. METHODS: A retrospective cohort study using U.S. linked birth/infant death data from 1995 through 2001 (n = 26,336,549) was performed. Risks of placenta previa and placental abruption among: (i) pregnancies with complete paternal age and race data; (ii) paternal age only missing; (iii) paternal race only missing; and (iv) both paternal age and race missing, were evaluated. Relative risk (RR) with 95% confidence interval (CI) for placenta previa and placental abruption by missing paternal characteristics were derived after adjusting for confounders. RESULTS: Adjusted RR for placental abruption were 1.30 (95% CI 1.24, 1.37), 1.00 (95% CI 0.95, 1.05), and 1.08 (95% CI 1.06, 1.10) among pregnancies with "paternal age only", "paternal race only", and "both paternal age and race" missing, respectively. The increased risk of placental abruption among the "paternal age only missing" category is partly explained by increased risks among whites aged 20-29 years, and among blacks aged >or=30 years. However, no clear patterns in the associations between missing paternal characteristics and placenta previa were evident. CONCLUSION: Missing paternal characteristics are associated with increased risk of placental abruption, likely mediated through low socio-economic conditions.

Journal Article↗

Recurrence of spontaneous versus medically indicated preterm birth.

OBJECTIVE: Despite the increased tendency of preterm birth to recur, little is known with regard to recurrence risks for spontaneous and medically indicated preterm birth as well as recurrence risks in relation to severity of preterm birth. We examined the recurrence of spontaneous and medically indicated preterm birth. STUDY DESIGN: A population-based, retrospective cohort study of births in Missouri (1989 to 1997) was carried out with analyses restricted to women who delivered their first 2 consecutive singleton live births (n = 154,809). Women who experienced spontaneous onset of labor and subsequently delivered preterm (less than 35 weeks) were classified as spontaneous preterm birth. Medically indicated preterm birth included women who delivered preterm through a labor induction or a prelabor cesarean delivery. Risk and odds ratio of preterm birth recurrence were derived from fitting multivariate conditional logistic regression models after adjusting for potential confounders. RESULTS: If the first pregnancy resulted in a spontaneous preterm birth, then affected women were more likely to deliver preterm spontaneously (adjusted odds ratio 3.6, 95% confidence interval 3.2, 4.0) and also as a medically indicated preterm birth (odds ratio 2.5, 95% confidence interval 2.1, 3.0) in the second birth. Similarly, if the first pregnancy resulted in a medically indicated preterm birth, affected women were 10.6-fold (95% confidence interval 10.1, 12.4) more likely to deliver preterm because of medical indications in the second pregnancy as well as preterm spontaneously (odds ratio 1.6, 95% confidence interval 1.3, 2.1). The greatest risk of recurrence of preterm birth in the second pregnancy tended to occur around the same gestational age as preterm birth in the first pregnancy, regardless of the clinical subtype. CONCLUSION: The observation that spontaneous preterm birth is not only associated with increased recurrence of spontaneous but also medically indicated preterm birth and vice versa, suggests that the 2 clinical subtypes may share common etiologies.

Adult↗

Acute and chronic respiratory diseases in pregnancy: associations with placental abruption.

OBJECTIVE: This study was undertaken to examine the associations between maternal respiratory diseases and placental abruption. STUDY DESIGN: A population-based, retrospective cohort study was conducted to examine the associations between maternal respiratory diseases and abruption in the United States. Data on women who delivered singleton births (n = 37,314,022) were derived from the National Hospital Discharge Survey for the years 1993 to 2003. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify pregnant women hospitalized for acute upper respiratory diseases, viral and bacterial pneumonia, acute bronchitis, and acute bronchiolitis, chronic bronchitis, asthma, and abruption. Relative risk (RR) and 95% CI were derived from multivariable logistic regression models to evaluate the associations after adjusting for maternal age, race, marital status, smoking, cocaine use, adequacy of prenatal care, maternal insurance status, geographic location, and year of birth (although data on smoking and cocaine use are likely underreported). RESULTS: The rate of abruption was 9.7 per 1,000 singleton births. The overall rate for acute respiratory conditions was 2.2 per 1000 pregnancies. Acute upper respiratory diseases (RR 3.2, 95% CI 3.0-3.4) and viral/bacterial pneumonia (RR 2.2, 95% CI 1.9-2.4) were associated with abruption. The rate of chronic respiratory conditions was 9.0 per 1,000 pregnancies. Chronic bronchitis was strongly associated with abruption (RR 31.8, 95% CI 29.6-34.3), but the association between asthma and abruption was modest (RR 1.1, 95% CI 1.0-1.2). Stratified analysis by maternal race showed that asthma was associated with abruption among black women but not white women. CONCLUSION: Pregnancies complicated by acute and chronic respiratory diseases requiring hospitalization are associated with placental abruption.

Abruptio Placentae↗

Epidemiology of preterm birth and its clinical subtypes.

Preterm birth (<37 weeks) complicates 12.5% of all deliveries in the USA, and remains the leading cause of perinatal mortality and morbidity, accounting for as many as 75% of perinatal deaths. Despite the recent temporal increase in preterm birth, efforts to understand the problem of prematurity have met with little success. This may be attributable to the under-appreciation of the etiologic heterogeneity of preterm birth as well as the heterogeneity in its underlying clinical presentations--spontaneous onset of labor, preterm premature rupture of membranes, and medically indicated preterm birth. In this paper, we review data regarding preterm births with particular focus on its incidence, temporal trends, and recurrence. Studies of births from the USA indicate that the recent temporal increase in the overall preterm birth rate is driven by an impressive concomitant increase in medically indicated preterm birth. However, the largest temporal decline in perinatal mortality has also occurred among medically indicated preterm births (relative to other clinical subtypes), suggesting that these obstetric interventions at preterm gestational ages are associated with a reduction in perinatal mortality. Recent data indicate that spontaneous preterm birth is not only associated with increased recurrence of spontaneous, but also medically indicated, preterm birth, and vice versa. This suggests that the clinical subtypes may share common underlying etiologies. Since medically indicated preterm birth accounts for as many as 40% of all preterm births, efforts to understand the reasons for such interventions and their impact on short- and long-term morbidity in newborns is compelling. Further research is necessary in order to understand the mechanisms and etiology of preterm birth, thus leading to the possibility of effective preventive or therapeutic strategies.

Black or African American↗

The influence of mode of delivery on twin neonatal mortality in the US: variance by birth weight discordance.

OBJECTIVE: The purpose of this study was to examine if neonatal mortality rates (NMR) based on birth weight discordance (BWD) differ based on mode of delivery. STUDY DESIGN: The population-based US "matched multiple birth" database (1995 to 1998) was used to examine the effect of vaginal/vaginal (VV) and cesarean/cesarean (CC) modes of delivery (MOD) on neonatal mortality (<28 days after birth). Births at <32 weeks, congenital malformations, chromosomal anomalies, and discordant MOD (vaginal/cesarean) were excluded. The association between MOD (with CC as the reference) and neonatal mortality was expressed as relative risks (RR) with 95% CI, derived from logistic regression models. RESULTS: The NMR increased with increasing degrees of BWD regardless of mode of delivery. CC was associated with decreased NMR when BWD was between 20% and 40%, but this reached significance at BWD > or =40%; VV pairs had a 1.6-fold (95% CI 1.1-2.2) increased NMR compared with CC. CONCLUSION: In twins with BWD <40%, MOD has no effect on NMR. Beyond or equal to 40% discordance, there was lower NMR with cesarean-cesarean delivery.

Adult↗

Placental abruption in the United States, 1979 through 2001: temporal trends and potential determinants.

OBJECTIVE: The purpose of this study was to evaluate temporal trends in abruption risk and to assess how much underlying changes in the clinical determinants may have affected these trends. STUDY DESIGN: We used the National Hospital Discharge Summary data (1979-2001), an annual survey of sampled non-federal, short stay, general, and specialty hospitals in the United States. Trends in abruption were assessed for the periods 1979 through 1981 and 1999 through 2001. Clinical determinants of abruption that were evaluated included hypertensive diseases, anemia, gestational diabetes mellitus, preterm labor, preterm premature rupture of membranes, chorioamnionitis, oligohydramnios, obstetric shock/trauma, uterine tumors, short umbilical cord, and velamentous cord insertion. Temporal trends in abruption were examined before and after adjustment for determinants through multivariable logistic regression. RESULTS: The rate of abruption increased 92% (95% CI, 88, 96) among black women between 1979-1981 (0.76%; n = 13,584 women) and 1999-2001 (1.43%; n = 18,960 women). Among white women, the rate increased by 15% (95% CI, 14,16) over the same period, from 0.82% (n = 66,186 women) in 1979-1981 to 0.94% (n = 59,284 women) in 1999-2001. The determinants that were associated with trends in abruption included anemia, gestational diabetes mellitus, preterm labor, short umbilical cord, and velamentous cord insertion, although their effects varied substantially by maternal race. CONCLUSION: The temporal increase in rates of abruption may reflect a true increase in risk or may be the result of improved diagnosis of both abruption and its determinants. Although the cause of abruption is still speculative, the trend is of concern and deserves scrutiny.

Abruptio Placentae↗

Transabdominal fetal pulse oximetry with near-infrared spectroscopy.

OBJECTIVE: The purpose of this study was to determine the feasibility of noninvasive fetal pulse oximetry in the human fetus with transabdominal continuous-wave near-infrared spectroscopy. STUDY DESIGN: The instrument has 3 wavelength light-emitting diodes (735, 805, and 850 nm) as light sources and a photomultiplier tube as a detector. This instrument was used in 6 pregnant women (>36 weeks of gestation). First, a fetal heart rate was obtained with a fetal heart rate monitor. Then, the depth of fetal tissue (head) from the maternal abdomen was determined by ultrasound examination; the distance between the optodes (light source and the detector) was set to be approximately twice the depth of the fetus (7-11 cm). The data analysis was based on the modified Beer-Lambert law and the use of optical densities at 735 and 850 nm to obtain the concentration changes of the oxyhemoglobin and deoxyhemoglobin. The saturation was expressed as the percent of oxygen saturation equal to 100 x oxyhemoglobin/(oxyhemoglobin + deoxyhemoglobin). We recorded the spectroscopy data and the fetal heart rate for approximately 3 to 10 minutes in each patient. RESULTS: The mean oxygen saturation values of each of the 6 individual fetuses ranged from 50% to 74% (overall mean saturation, 61% +/- 14.8% [SD]). CONCLUSION: This preliminary data indicate that transabdominal fetal pulse oximetry is feasible for human patient application. The measured values were similar to those that are obtained with transvaginal pulse oximetry. Future studies should correlate transabdominally obtained measurements with those measurements that are obtained by transvaginal fetal pulse oximetry.

Abdomen↗

Delayed interval delivery in twin pregnancies in the United States: Impact on perinatal mortality and morbidity.

OBJECTIVE: To estimate the incidence of delayed interval delivery in twin pregnancies in the United States and evaluate the impact of delayed delivery on perinatal outcomes. STUDY DESIGN: A population-based retrospective cohort study was performed using the U.S. "matched multiple birth" file (1995 to 1998), restricting our analysis to twin sets in which the first twin was delivered vaginally at 22 to 28 weeks (n = 4257). Outcomes examined included perinatal and infant mortality and small-for-gestational-age births. Outcomes of second twins in pregnancies that underwent delayed interval delivery of 1, 2, 3, and >/=4 weeks were compared with those in which both twins were delivered contemporaneously. RESULTS: In this cohort, 6.1% (n = 258) of twins had delayed delivery (>/=1 week) of the second twin. Decreases in perinatal and infant mortality were observed only when the first twin was delivered at 22 to 23 weeks and when the delivery interval was </=3weeks. However, for intervals >/=4 weeks or when the first twin was delivered at 24 to 28 weeks (regardless of delivery interval), there was no benefit in perinatal or infant mortality. Delayed delivery of >/=4 weeks was associated with increased risk of small-for-gestational-age birth in the second twin, regardless of gestational age at delivery of the first. CONCLUSION: When a first twin was delivered at 22 to 23 weeks, delayed delivery of the second twin was associated with reduced perinatal and infant mortality of the second twin if the interval was less than 3 weeks. Delayed delivery of the second twin when the first was delivered at >/=24 weeks had no benefit on mortality.

Adult↗

Mode of delivery and risk of stillbirth and infant mortality in triplet gestations: United States, 1995 through 1998.

OBJECTIVE: The purpose of this study was to estimate the risks of stillbirth and neonatal and infant deaths in triplets, according to mode of delivery. STUDY DESIGN: We used the "matched multiple birth" data file that was comprised of triple births that were delivered in the United States in the years 1995 through 1998. Analyses were restricted to fetuses that were delivered at >/=24 weeks of gestation. Based on the order of the birth of the fetuses within the triplet set, the mode of delivery of triplets was assigned as cesarean-cesarean-cesarean (all cesarean), vaginal-vaginal-vaginal (all vaginal), and vaginal-cesarean-cesarean or vaginal-vaginal-cesarean (other). Associations between mode of delivery and stillbirth, neonatal deaths (within 28 days), and infant deaths (up to 1 year) were expressed as relative risks with 95% confidence intervals and population attributable risks, which were derived from multivariate logistic regression models that were based on the method of generalized estimated equations (with all cesarean deliveries serving as the reference). All analyses were adjusted for several confounding factors. RESULTS: Ninety-five percent of all triplets were delivered by cesarean delivery. Vaginal delivery (all vaginal) was associated with an increased risk for stillbirth (relative risk, 5.70; 95% CI, 3.83, 8.49) and neonatal (relative risk, 2.83; 95% CI, 1.91, 4.19) and infant (relative risk, 2.29; 95% CI, 1.61, 3.25) deaths. The population-attributable risks were 15.9% for neonatal and 12.4% for infant deaths, which implied that these proportions of deaths were potentially avoidable had these triplet fetuses all been delivered by cesarean delivery rather than all fetuses being delivered vaginally. CONCLUSION: Cesarean delivery of all 3 triplet fetuses is associated with the lowest neonatal and infant mortality rate. Vaginal delivery among triplet gestations should be avoided.

Cesarean Section↗

Trends in twin preterm birth subtypes in the United States, 1989 through 2000: impact on perinatal mortality.

OBJECTIVE: We examined trends in twin preterm birth <37 weeks following ruptured membranes (ROM), medically indicated preterm birth, and preterm birth following spontaneous onset of labor (PTL). We further examined whether the changes in preterm birth subtypes were associated with trends in twin perinatal mortality. STUDY DESIGN: We carried out a retrospective cohort study of 1,172,405 twin live births and stillbirths delivered in the US between 1989 and 2000. Trends in preterm birth subtypes and perinatal mortality (stillbirths at > or = 22 weeks plus neonatal deaths within 28 days) were examined through ecological logistic regression models after adjusting for confounders. RESULTS: Twin preterm birth among whites increased from 46.6% in 1989 to 1990 to 56.7% in 1999 to 2000, and from 56.1% to 61.0% among blacks over the same period. Medically indicated preterm birth increased by 50% (95% CI 49-52) among whites, and by 33% (95% CI 29-36) among blacks. PTL increased by 24% among whites, but remained fairly unchanged among blacks between the two periods. Preterm birth following ROM also did not change between the 2 periods among whites, but declined by 7% among blacks. Perinatal mortality among twin births declined by 41% (95% CI 38-44) among whites, and by 37% (95% CI 32-42) among blacks between 1989 and 1990 and 1999 and 2000. This mortality decline was most closely associated with the increase in medically indicated preterm birth among whites, and with the decrease in preterm birth following ROM among blacks. CONCLUSION: Temporal trends in twin preterm birth varied substantially based on underlying subtypes and race. The increase in medically indicated preterm birth is associated with a large reduction in perinatal mortality.

Adult↗

Maternal anterior sacral meningocele in pregnancy.

Anterior sacral meningocele is a rare condition resulting from herniation of the meninges through a sacral defect. Women with this condition may undergo inappropriate surgery because the correct diagnosis is missed, resulting in serious complications. In labor, the cyst may rupture, with consequent meningitis and high maternal mortality. We report the case of a 31 year-old pregnant woman with an anterior sacral meningocele. We describe the role of magnetic resonance imaging in the evaluation and management planning in this condition. She was delivered by cesarean section at 34 weeks without complications. Accurate diagnosis and delivery by cesarean prior to labor are important in assuring good outcomes in women with anterior sacral meningoceles.

Adult↗

Trends in preterm birth and perinatal mortality among singletons: United States, 1989 through 2000.

OBJECTIVE: Despite the recent increase in preterm birth in the United States, trends in preterm birth subtypes have not been adequately examined. We examined trends in preterm birth among singletons following ruptured membranes, medical indications, and spontaneous preterm birth and evaluated the impact of these trends on perinatal mortality. METHODS: A population-based, retrospective cohort study comprising 46,375,578 women (16% blacks) who delivered singleton births in the United States, 1989 through 2000, was performed. Rates of preterm birth (< 37 weeks), their subtypes, and associated perinatal mortality (stillbirths at >/= 22 weeks plus neonatal deaths within 28 days), before and after adjustment for potential confounders, were derived from ecological logistic regression models. RESULTS: Preterm birth rates increased by 14% (95% confidence interval 13-15%) among whites from 8.3% to 9.4% and decreased by 15% (95% confidence interval 14-16%) among blacks from 18.5% to 16.2% between 1989 and 2000. Among whites, preterm birth following ruptured membranes declined by 23%, medically indicated preterm birth increased by 55%, and spontaneous preterm birth increased by 3%. Among blacks, preterm birth following ruptured membranes declined by 37%, medically indicated preterm birth increased by 32%, and spontaneous preterm birth decreased by 27%. The largest decline in perinatal mortality among whites was associated with increases in medically indicated preterm birth, whereas the largest decline in perinatal mortality among blacks was associated with declines in preterm birth following ruptured membranes and spontaneous preterm birth. CONCLUSION: Temporal trends in preterm birth varied substantially based on underlying subtype and maternal race. The recent increase in medically indicated preterm birth was associated with a favorable reduction in perinatal mortality.

Adolescent↗

Design, execution, interpretation, and reporting of economic evaluation studies in obstetrics.

OBJECTIVE: The purpose of this article was to propose guidelines for the design, execution, interpretation, and reporting of economic evaluation studies in obstetrics. Study design We performed a PubMed search of economic evaluation articles to identify those articles that deal with the quality of published economic evaluation studies, the development of guidelines, and the development of checklists/guidelines for the reporting of economic evaluation studies. All other articles were excluded from the review. RESULTS: We identified 160 articles. We included 8 articles in our review that reported on the quality of published economic analyses, 12 articles that reported on guidelines, and 3 articles that reported on checklists/guidelines that are used by journals. There were 2 articles that dealt with the quality of published economic evaluations in obstetrics and gynecology, both of which showed less than optimal quality. There were only 4 articles that provided some general guidelines for the reporting of economic evaluations in obstetrics and gynecology. We found no articles on any checklist/guidelines for the reporting of economic evaluation studies in obstetrics and gynecology. CONCLUSION: There is a need to improve the design, execution, interpretation, and reporting of economic evaluation studies in obstetrics.

Cost-Benefit Analysis↗

Fetal transcerebellar diameter measurement with particular emphasis in the third trimester: a reliable predictor of gestational age.

OBJECTIVE: The purpose of this study was to validate prospectively a previous retrospectively established nomogram for the prediction of gestational age using transcerebellar diameter, especially in the third trimester. STUDY DESIGN: In a previous study, we retrospectively constructed a cross-sectional nomogram using transcerebellar diameter measurements in 24,026 well-dated singleton fetuses. In the present study, this nomogram was validated prospectively on the basis of patients who were seen between August 2002 and May 2003 and who were carrying non-anomalous and non-malformed singleton gestations between 14 and 42 weeks (n = 2597 gestations). The actual gestational age was then subtracted from the predicted gestational age, and the concordance between actual and predicted gestational ages was assessed based on the Pearson correlation (r). RESULTS: Concordance between the actual and predicted gestational age was high (r = 0.92; P < .0001). This agreement was superior in the second trimester (r = 0.93; P < .0001) than in the third trimester (r = 0.81; P < .001). Between 17 and 21 weeks, and between 22 and 28 weeks of gestation, the predicted gestational age ranged between 0 and 4 days, and between 0 and 2 days, respectively, of actual gestational age. Between 29 and 36 weeks of gestation, predicted gestational age was within 5 days of actual gestational age; at 37 weeks of gestation, the predicted gestational age was discrepant by 9 days. CONCLUSION: This prospective study demonstrates that transcerebellar diameter measurement is an accurate predictor of gestational age, even in the third trimester of pregnancy.

Cerebellum↗