Cross-sectional study of gestational weight gain andperinatal outcomes in pregnant women at a tertiary carecenter in southern India

Usha Radhakrishnan1, Geeta Kolar1 and Praveen K. Nirmalan2

1Department of Fetal Medicine and Ultrasonography and 2Clinical Research Unit, Fernandez Hospital, Hyderabad, India

Abstract

Aim: The aim of this study was to determine maternal and neonatal outcomes of less than recommended orexcess gestational weight gain (GWG) based on the recommended Institute of Medicine (IOM) guidelines.Material and Methods: Using a cross-sectional study design, GWG was assessed for 1462 pregnant womenpresenting to a tertiary care perinatal institute in India. Body mass index at baseline, co-existing morbidities,fetal growth, details of delivery, and maternal and fetal outcomes were determined and documented. Appro-priate GWG for each woman was determined based on the revised IOM guidelines. Outcome measuresincluded the proportion of pregnant women compliant with IOM guidelines for GWG and associations of lessthan recommended or excess GWG with maternal and neonatal outcomes.Results: A total of 547 (37.41%, 95% confidence interval [CI]: 34.96–39.92) pregnant women gained less thanrecommended and 313 (21.41%, 95%CI: 19.36–23.57) pregnant women gained more than the recommendedweight. Preterm deliveries were associated with less than optimal weight gain (adjusted odds ratio 3.58,95%CI: 1.75–7.32) after adjusting for gestational age at delivery. GWG was not associated with neonataloutcomes in this population.Conclusions: The lack of associations with perinatal outcomes indicates that the IOM guidelines may not bethe appropriate standard for monitoring GWG in this population.Key words: body mass index, gestational weight gain, Institute of Medicine guidelines, perinatal outcome,pregnancy.

Introduction

The Institute of Medicine (IOM) guidelines developedin 1990 recommended a maternal weight gain of 25–35pounds for women with normal weight for height tooptimize fetal growth and maternal/infant outcomes.1

Many key aspects of the reproductive health of womenof child-bearing age have since changed, especiallyincreasing advanced maternal age, a rising prevalenceof obesity, diabetes, hypertension and other chronicnon-communicable diseases, prompting a revision of

the IOM guidelines in 2009.2 The revised recommenda-tions provide a specific range of weight gain for over-weight and obese women that was previously lacking.The wide acceptance and adoption of the IOM guide-lines has not, however, translated into optimal gesta-tional weight gain (GWG) with studies reporting that37% of normal-weight women and 64% of over-weight women gain more than IOM recommenda-tions.3,4 GWG that exceeds the IOM recommendedlevels is associated with complications in delivery(cesarean section deliveries), large-for-gestational-age

Received: September 24 2012.Accepted: February 27 2013.Reprint request to: Dr Geeta Kolar, Department of Fetal Medicine and Ultrasonography, Fernandez Hospital, Hyderabad 500001,India. Email: geetkolar@gmail.com; drgeeta@fernandezhospital.com

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doi:10.1111/jog.12115 J. Obstet. Gynaecol. Res. Vol. 40, No. 1: 25–31, January 2014

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(macrosomic) babies, obesity in offspring by age 3years, greater postpartum weight retention and anincreased risk of being overweight in the future, andmay co-exist with other maternal lifestyle diseases likehypertension and diabetes.5–15

The National Family Health Survey-III from India,which includes the health of women of child-bearingage, reports that 33% of women have a body massindex (BMI) below normal, 14.8% of women are over-weight or obese and 57.9% of pregnant women areanemic.16 Appropriate GWG may help optimizematernal and fetal outcomes in pregnant women whomay be undernourished at conception. To the best ofour knowledge, there is little or no information fromIndia on GWG, the adherence to or usefulness of theIOM recommendations for GWG in this populationand the effects of GWG on fetal outcomes and mater-nal health. The current study was designed to deter-mine the distribution of adherence of GWG to theIOM recommendations and its appropriateness in apopulation of pregnant women booked for antenatalcare at a tertiary care perinatal institute in southernIndia.

Methods

The study was initiated after the study protocol wasapproved by the Institutional Review Board of thestudy institute, which is an advanced tertiary care peri-natal teaching institute that carries out approximately5000 deliveries each year. Pregnant women aged 18years or older, booked for antenatal care at the studyinstitute prior to 22 gestational weeks with the gesta-tional age confirmed by ultrasound dating and with asingleton fetus were considered as eligible for inclu-sion in the study. Pregnant women who did not meetthe inclusion criteria and pregnant women whosematernal health necessitated termination of pregnancyprior to 25 gestational weeks or did not provideinformed consent were excluded from the study.Written informed consent was obtained from each par-ticipant prior to recruitment.

Details of antenatal care at the study institute, basedon standardized clinical care protocols, were initiallyentered into a medical case record and subsequentlytransferred into an electronic database. Maternal andneonatal morbidity were identified and documentedusing standard clinical definitions and categories.Every pregnant woman was assessed for height using ameasuring tape, weight using a calibrated electronic

weighing machine, blood pressures in the seated posi-tion, medical, surgical and obstetric history, personalrisk behavior and nutrition assessments. Baselineinvestigations included, but were not limited to, hemo-globin, blood sugar levels (including a 2-h 75-g oralglucose tolerance test between 24 and 28 weeks of ges-tation based on the International Association of the Dia-betes and Pregnancy Study Groups [IADPSG] criteria),screening for thyroid disorders and trimester-specificultrasound exams. The BMI for each woman was esti-mated as the weight in kg divided by height in m2. Theweight gain during each trimester was assessed at20–24 weeks and at 30–35 weeks using the same weigh-ing machine. The presence of medical co-morbidities,gestational age at delivery, details of delivery (includ-ing mode of delivery and complications associatedwith delivery) and neonatal outcomes were routinelyrecorded. Consistent with the IOM guidelines, aBMI < 18.5 kg/m2 was considered as lean, 18.5–24.9 kg/m2 as normal, 25–29.9 kg/m2 as overweightand 30 kg/m2 or above as obese. The IOM guidelines(revised in 2009) developed for the US population rec-ommends a GWG of 12.5–18, 11.5–16, 7–11.5 and5–9 kg as appropriate for women with pre-pregnancyBMI considered as lean, normal, overweight and obese,respectively.2 Overweight and obese pregnant womenand women with gestational diabetes or diabetes mel-litus were referred for nutritional counseling as part ofroutine antenatal care. However, pregnant womenwith a lean pre-pregnancy BMI were sent for nutri-tional counseling based on the discretion of the treatingclinician.

Fetal growth was assessed through serial ultrasoundmeasurements by trained sonologists. The Volusonwith curved array transabdominal transducer AB2–7 MHz with multihertz and harmonic capability andHP machine with transabdominal probe was used forthe ultrasound exams with images stored in digitalimaging media. These images were available for retro-spective assessment and re-measurement of all fetalparameters as needed. The first-trimester scan wasdone at 11–13+6 weeks of gestation for nuchal translu-cency and dating of gestational age by measuringcrown–rump length. The second-trimester targetedimaging for fetal anomalies scan was done at 19–24weeks of gestation. Dating of pregnancy was doneduring this period if it was not done earlier. The third-trimester scan (fetal well-being scan) was done at 30–35weeks of gestation and the growth of the fetus wasplotted on the population-based growth curves. Thebiparietal diameter, head circumference, abdominal

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circumference, and femur length taken using standardplanes of ultrasound were considered and used as acombination of these variables to derive an estimatedfetal weight and growth pattern of the given fetus.Population-based growth curves (from Sonocare soft-ware developed by Mediscan systems at Chennai) for asouth Indian population were used to determine thetype of fetal growth. Fetuses whose growth parameterswere in between the 5th and 95th centiles were consid-ered as average for gestational age, fetuses whosegrowth parameters were on the 95th centile or abovewere considered as large for gestational age and fetuseswhose growth parameters were on the 5th centileor lower were considered as small for gestationalage.

The Open Epi-Epidemiologic Calculator was used toestimate a sample size of 1015 pregnant women basedon a two-sided significance level (1-alpha) of 95% anda hypothesized frequency of inappropriate GWG(greater than or lower than recommended weight gainguidelines) of 70 � 5% in an estimated 5000 annualdeliveries at Fernandez Hospital.17 A potential dropoutrate of 30% was considered to further revise the esti-mated sample size to 1320 pregnant women.

Statistical analysis was performed using stata statis-tical software (version 9.0). The distribution and the95% confidence intervals (95%CI) around the pointestimates for women who had optimal, less than rec-ommended or more than recommended GWG basedon the IOM guidelines were determined. The distribu-tion of gestational medical co-morbidities, mode ofdelivery and complications, and neonatal outcomeswere compared between the three groups. The c2-testor Fisher’s exact test were used to compare categoricalvariables and a one-way anova test was used tocompare continuous variables. A multivariate logisticregression model (that adjusted for factors found sig-nificant in a bivariate analysis) was used to exploreassociations of the different GWG categories withmaternal and neonatal outcomes. A P-value < 0.05 wasconsidered as statistically significant.

Results

The study included 1462 pregnant women booked atFernandez Hospital for antenatal care from June 2010to April 2011. The mean (standard deviation) age ofstudy participants was 27.30 (4.27) years (range 18–44years). The mean (standard deviation) weight gainduring pregnancy was 10.51 (4.46) kg (range 1–28 kg).An optimal weight gain based on the IOM recommen-

dations was present for 602 (41.18%, 95%CI: 38.67–43.72) of the pregnant women. A total of 547 (37.41%,95%CI: 34.96–39.92) pregnant women gained less thanrecommended and 313 (21.41%, 95%CI: 19.36, 23.57%)pregnant women gained more than the recommendedweight. Table 1 presents the characteristics of the 1462pregnant women in the study stratified by GWG.

The distribution of maternal and neonatal outcomeswith GWG is presented in Tables 2 and 3, respectively.Preterm deliveries (<37 weeks of gestation) were sig-nificantly more common in women with less thanoptimal weight gain (see Table 2). Gestational hyper-tension was less common in women with less thanoptimal weight gain; however, this difference was notstatistically significant (see Table 2). Babies born tomothers with less than optimal weight gain had sig-nificantly lower mean birthweights (see Table 3) andwere more likely to be low birthweight (<1.5 kg)although this association was not statistically signifi-cant. Babies born to mothers with more than optimalweight gain were significantly more likely to be largefor gestational age (see Table 3). In a multivariateregression model that adjusted for age of mother,parity, gestational age at delivery and BMI, pretermdeliveries were significantly associated (adjusted oddsratio 3.58, 95%CI: 1.75–7.32) with less than optimalweight gain in pregnancy (see Table 4). Gestationalweight gain, categorized as per the revised IOM guide-lines, was not significantly associated with other mater-nal or neonatal outcomes.

Discussion

The results of the study indicate a lower than optimaladherence in this population to the IOM recommen-dations for appropriate GWG. Overall, more than onein three pregnant women gained less than the recom-mended weight and one in five pregnant womengained more than the recommended weight duringpregnancy. In this study, 59.07% of pregnant womenwith a lean BMI at baseline gained less than recom-mended weight and 36.24% and 29.27% of over-weight and obese pregnant women gained morethan the recommended weight during pregnancy.Lower than optimal weight gain was associated withincreased preterm births and lower mean birth-weights, even after adjusting for gestational age atdelivery. However, it is possible that the less-than-optimal weight gain and lower birthweights were aneffect rather than cause of prematurity.

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Consistent with previous studies, it was found thatwomen with gestational diabetes gained less than rec-ommended weight during pregnancy.18,19 It is possiblethat the lower-than-recommended weight gain isattributable to stricter nutritional counseling when weconsider that the majority (86.03%) of pregnant womenwith gestational diabetes in this study were on a com-bination of diet control and exercise. The association ofhypertensive disorders in pregnancy with more-than-recommended weight gain is consistent with available

knowledge, although our study design does not allowus to comment on a cause-and-effect correlation.18,20

The influence of edema and fluid retention on mea-sured weight in hypertensive disorders of pregnancyneeds further study. Similar to other studies, more-than-recommended weight gain during pregnancy wasassociated with an increased incidence of operativedeliveries through a cesarean section.2,6

Maternal weight gain more than the IOM recom-mendations has been reported with an increased risk of

Table 1 Characteristics of the 1462 pregnant women included in the study

Characteristics Optimal weight gain(n = 602)

Less-than-optimalweight gain (n = 547)

Excess weight gain(n = 313)

Total(n = 1462)

Lean BMI at baseline 35 (33.33%) 62 (59.05%) 8 (7.62%) 105 (7.18%)Optimal BMI at baseline 277 (40.26%) 337 (48.98%) 74 (10.76%) 688 (47.06%)Overweight BMI at

baseline217 (42.97%) 105 (20.79%) 183 (36.24%) 505 (34.54%)

Obese BMI at baseline 73 (44.51%) 43 (26.22%) 48 (29.27%) 164 (11.22%)Previous cesarean

section128 (21.26%) 134 (24.50%) 56 (17.89%) 318 (21.75%)

Chronic hypertension 13 (2.16%) 18 (3.29%) 5 (1.60%) 36 (2.46%)Diabetes mellitus 8 (1.33%) 18 (3.29%) 11 (3.51%) 37 (2.53%)Prior hypothyroid 53 (8.80%) 42 (7.68%) 28 (8.95%) 123 (8.41%)Prior renal disease 12 (1.99%) 8 (1.46%) 8 (2.56%) 28 (1.92%)Prior CVS disease 2 (0.33%) 9 (1.65%) 2 (0.64%) 13 (0.89%)Primigravida 266 (44.19%) 170 (31.08%) 147 (46.96%) 583 (39.88%)Nulliparous 333 (55.32%) 223 (40.77%) 202 (64.54%) 758 (51.85%)Pre-eclampsia 21 (3.49%) 17 (3.11%) 13 (4.15%) 51 (3.49%)Eclampsia 4 (0.66%) 2 (0.37%) 1 (0.32%) 7 (0.48%)Gestational hypertension 17 (2.82%) 9 (1.65%) 14 (4.47%) 40 (2.74)Gestational diabetes 137 (22.76%) 143 (26.14%) 78 (24.92%) 358 (24.49%)Screen hypothyroid

(detected duringantenatal care)

25 (4.15%) 30 (5.48%) 13 (4.15%) (4.65%)

BMI, body mass index; CVS, cardiovascular system.

Table 2 Maternal outcomes and gestational weight gain

Maternal outcomes Optimal weightgain (n = 602)

Less-than-optimalweight gain(n = 547)

Excess weightgain (n = 313)

P-value*

Preterm (<37 weeks) 54 (8.97%) 96 (17.55%) 25 (7.99%) <0.001Postpartum hemorrhage 11 (1.83%) 3 (0.55%) 5 (1.60%) 0.14Cesarean section† 255 (48.76%) 221 (45.38%) 155 (54.96%) 0.04Assisted vaginal delivery† 79 (22.77%) 59 (18.15%) 29 (18.59%) 0.28Preterm premature rupture of membranes† 16 (2.89%) 13 (2.57%) 6 (2.17%) 0.83Premature rupture of membranes† 48 (8.19%) 41 (7.69%) 37 (12.05%) 0.08Pre-eclampsia† 21 (3.70%) 17 (3.28%) 13 (4.44%) 0.70Eclampsia† 4 (0.73%) 2 (0.40%) 1 (0.36%) 0.69Gestational hypertension† 17 (3.01%) 9 (1.76%) 14 (4.76%) 0.05Gestational diabetes mellitus† 137 (23.06%) 143 (27.03%) 78 (25.83%) 0.29Screen-detected hypothyroid† 25 (4.58%) 30 (5.94%) 13 (4.58%) 0.54

*P-values determined using the c2-test and Fisher’s exact test. Fisher’s exact test was used where category counts were <5. A P-value < 0.05was considered as significant. †Denominator includes those categorized as normal for that category.

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neonatal complications like macrosomia, hypoglyce-mia and hyperbilirubinemia (jaundice).21 Jaundice andhypoglycemia in neonates were more common inwomen with excess weight gain; however, neonatal

outcomes did not vary significantly across BMI catego-ries after stratification by pre-pregnancy BMI. Thenumber of stillbirths and perinatal deaths was notsufficiently large enough to explore for any statistical

Table 3 Neonatal outcomes and gestational weight gain categories

Neonatal outcomes Optimal weightgain (n = 602)

Less-than-optimalweight gain (n = 547)

Excess weightgain (n = 313)

P-value*

Mean birthweight in kg 2.99 (0.49) 2.79 (0.56) 3.07 (0.51) <0.001Low Apgar at 5 min 5 (0.84%) 2 (0.37%) 1 (0.32%) 0.47Stillborn 5 (0.83%) 6 (1.1%) 2 (0.64%) 0.77Neonatal death 2 (0.33%) 2 (0.37%) 2 (0.64%) 0.77Small for gestational age† 30 (5.44%) 31 (6.05%) 11 (4.09%) 0.51Large for gestational age† 51 (8.92%) 35 (6.78%) 44 (14.57%) 0.001Birthweight < 1.5 kg 7 (1.16%) 17 (3.11%) 5 (1.60%) 0.05Jaundice 286 (47.51%) 254 (46.44%) 163 (52.08%) 0.26Sepsis 27 (4.49%) 31 (5.67%) 9 (2.88%) 0.17Congenital anomalies 18 (2.99%) 22 (4.02%) 9 (2.88%) 0.54Hypoglycemia 9 (1.50%) 10 (1.83%) 10 (3.19%) 0.21Respiratory distress 18 (2.99%) 27 (4.94%) 9 (2.88%) 0.15Birth asphyxia 5 (0.83%) 3 (0.55%) 0 (0.00%) 0.27

*P-values were determined using the c2-test and Fisher’s exact test for categorical variables and one-way anova test for continuous variables.Fisher’s exact test was used where category counts were <5. A P-value < 0.05 was considered significant. †Denominator includes thosecategorized as normal for that category.

Table 4 Multivariate logistic regression model† for associations of gestationalweight gain with maternal and neonatal outcomes

Maternal outcomes Less-than-optimalweight gainAdjusted OR(95%CI)

Excess weight gainAdjusted OR(95%CI)

Preterm (<37 weeks) 3.58 (1.75–7.32) 0.42 (0.14–1.25)Cesarean section 0.82 (0.47–1.44) 1.56 (0.86–2.82)Assisted vaginal delivery 0.75 (0.42–1.31) 1.03 (0.44–2.36)Preterm premature rupture of

membranes0.5 (0.13–1.87) 2.25 (0.42–12.08)

Premature rupture of membranes 1.15 (0.57–2.31) 2.52 (1.20–5.28)Pre-eclampsia 0.89 (0.40–1.96) 1.88 (0.72–4.90)Eclampsia 0.09 (0.001–6.06) 0.58 (0.01–22.69)Gestational hypertension 0.63 (0.26–1.52) 0.71 (0.25–2.00)Low Apgar at 5 min 0.20 (0.02–1.60) —Stillborn 2.00 (0.18–22.05) —Neonatal death 0.59 (0.09–3.87) 1.00Small for gestational age 0.99 (0.51–1.95) 0.52 (0.20–1.36)Large for gestational age 0.64 (0.33–1.25) 1.49 (0.86–2.60)Birthweight < 1.5 kg 3.00 (0.59–15.01) 0.33 (0.01–5.96)Jaundice 0.95 (0.70–1.30) 1.39 (0.96–1.99)Sepsis 1.02 (0.42–2.45) 1.24 (0.40–3.84)Congenital anomalies 1.04 (0.47–2.30) 0.79 (0.23–2.63)Hypoglycemia 0.95 (0.23–3.78) 3.90 (0.97–15.62)Respiratory distress 1.07 (0.42–2.75) 0.98 (0.30–3.16)Birth asphyxia 0.34 (0.05–2.23) —

†Adjusted for age of mother, parity, gestational age at delivery and body mass index,reference category is optimal weight gain and normal for each category of morbidity. CI,confidence interval; OR, odds ratio.

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significance. Stillbirths were more common in womenwith less-than-optimal weight gain although this maybe associated with preterm deliveries.

Consistent with several other studies, less-than-optimal weight gain was associated with pretermdeliveries and lower birthweights.2,6,22,23 However, it isnot possible to suitably comment on causation attribut-able to less-than-optimal weight gain as data on GWGby gestational age in weeks was not collected. A strati-fied analysis of weight gain by gestational age mayprovide more information that can support a possiblecausal mechanism.

Nearly two-thirds of pregnant women with leanBMI at baseline had a less-than-optimal weight gainin this tertiary care center. This statistic is importantwhen one considers that approximately one in threewomen of childbearing age in India has a lean BMI.16

The study design does not allow us to attributereasons for the less-than-optimal weight gain in thesubgroup of women with lean BMI. An explorationof any potential beliefs or practices pertaining toreduced obstetrical complications (if GWG was not inexcess) was not performed.24 The subgroup of preg-nant women with lean BMI is not prioritized fornutritional counseling, thus, possibly affecting appro-priate weight gain.

The study highlights several areas of concern. Froma clinical perspective, it is necessary to develop andevaluate appropriate GWG criteria in this populationbased on associations with maternal and fetal out-comes. This study shows that the IOM guidelines maynot be appropriate for use in this population as theywere developed on a different population. Addition-ally, the IOM guidelines are not based on associationswith improved clinical outcomes. The proportion ofwomen with lean BMI and less-than-optimal weightgain is a matter of concern in India. Any impact ofappropriate nutritional counseling and adherence torecommended GWG guidelines on women with leanBMI and preterm births in this population needsfurther study.

The representativeness of the study population tothe general population of southern India is a limita-tion of the study. The proportion of pregnant womenwith lean BMI at baseline in this study is much lowerthan the general population and the proportion ofpregnant women that were overweight or obese atbaseline is much higher than the distribution inthe general population.16 India has recently revisedthe BMI cut-offs for Asian Indians25 with aBMI > 25 kg/m2 considered as obese leading to a sub-

stantial increase in the proportion of pregnant womencategorized as obese. A previous study from the studyinstitute has shown an increase in the prevalence ofobesity from 19.49% to 54.63% when the revisedguidelines are used as the upper limits of what waspreviously considered a normal BMI (BMI of 23.0–24.9 kg/m2) is now considered as overweight.25,26

However, there has been no revision of limits for leanBMI.25 Obstetricians caring for pregnant Asian Indianwomen may need to consider the revised BMI catego-ries to determine overweight/obese pregnant womenin their clinical practice, although these revised BMIcategories did not consider obstetric outcomes duringtheir development. The ‘re-categorization’ necessitatesa change in the appropriate BMI-based GWG guide-lines that can be applied for Asian Indian women.A larger study is necessary to develop appropriateguidelines for GWG by gestational weeks and trimes-ter. It is possible that the associations we find mightchange in direction and/or strength if we use therevised BMI categories for India. We could not,however, test for shifts in associations, as weight gainguidelines based on the revised BMI categories forAsian Indians are not available.

The higher incidence of gestational diabetes mellituscan be attributed to the use of the IADPSG criteria forthe detection of gestational diabetes. The lack of repre-sentativeness may be attributed to the tertiary carereferral nature of the study institute with nearly 60% ofpregnant women presenting at the institute referredfrom other practices. The results of this study may notbe generalizable to the larger community of pregnantwomen in southern India.

In conclusion, there is a lower-than-optimal adher-ence to recommended IOM guidelines for GWG inthis population. Less-than-optimal GWG is associatedwith preterm births, even if the pregnant womenare overweight or obese at baseline. The lack ofsignificant associations of less than or more thanoptimal weight gain with clinical perinatal outcomesindicates that the IOM standards for GWG may not beappropriate for this population. Further studiesare required to determine appropriate GWG criteriafor this population based on clinical perinataloutcomes.

Acknowledgments

Dr U.R. was involved with all aspects of the studyincluding data collection and writing of the manu-script, Authors G.K. and P.K.N. were involved with the

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design, analysis, interpretation of results and writing ofthe manuscript. The manuscript has been read andapproved by all the authors; the requirements forauthorship have been met by all authors; and eachauthor believes that the manuscript represents honestwork. The study protocol was approved by the Institu-tional Review Board of Fernandez Hospital, Hydera-bad through the protocol number EC Ref # 18_2010 R1and approved on 31 May 2010.

Disclosure

None of the authors have any conflict of interest orfinancial disclosures pertaining to this manuscript toreport.

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