Abstract
Objectives
To explore the ultrasound findings, treatment strategies, and reproductive outcomes in patients with recurrent cesarean scar pregnancy (CSP), providing evidence for clinical management.
Methods
We identified 1371 confirmed CSP from 1517 initially screened cases (2012–2022) through blinded image review. From 159 subsequent live births in this cohort, 27 recurrent CSP cases were matched 1:1 with CSP patients having normal subsequent pregnancies. Baseline characteristics and reproductive outcomes were collected via medical records and structured interviews.
Results
This study revealed the recurrent CSP group showed significantly higher rates of exogenous implantation pattern (33.3% versus 7.4%, OR = 1.96), rich vascularity on color Doppler (81.5% versus 40.7%, OR = 2.80), and embryonic cardiac activity detection (51.9% versus 18.5%, OR = 1.98) than the normal intrauterine pregnancy group after CSP (p < .05) during initial diagnosis. The most commonly used treatment at our hospital is trans‐abdominal ultrasound‐guided suction curettage, which effectively controls the condition and preserves fertility. However, during long‐term follow‐up, some patients still face the risks of recurrence infertility.
Conclusions
Recurrent CSP presents characteristic sonographic features at initial diagnosis, among which an exogenous implantation pattern, rich vascular flow signals, and embryonic cardiac activity serve as relevant and significant indicators. Although transabdominal ultrasound‐guided suction curettage is effective in managing the condition and preserving fertility, some patients still face long‐term risks of recurrence and infertility.
Keywords: recurrent cesarean scar pregnancy, reproductive outcomes, ultrasound
Abbreviations
- CSP
cesarean scar pregnancy
- MTX
methotrexate
- OR
odds ratio
- PSM
propensity score matching
- UAE
uterine artery embolization
Cesarean scar pregnancy (CSP) is a rare but increasingly recognized form of ectopic pregnancy, characterized by implantation within the scar tissue from a prior cesarean section. 1 The exact incidence of CSP remains difficult to determine due to variations in study populations and diagnostic criteria. However, a clear upward trend has been widely observed in the literature, with reported estimates evolving from approximately 1:2000 2 in earlier studies to more recent figures nearing 1:1500. 3 , 4 This apparent increase corresponds strongly with the global rise in cesarean delivery rates and reflects both improved diagnostic sensitivity and a genuine growth in cases. 5 , 6 CSP poses substantial clinical risks, including a high likelihood of uterine rupture and severe hemorrhage, which can result in the need for hysterectomy and a significant reduction in fertility potential. 7 Therefore, early diagnosis and timely management, including prompt termination of the pregnancy, are crucial for optimizing maternal outcomes. 8 , 9 , 10 While most cases of CSP are primary events, an increasing number of recurrent CSP cases have been reported in recent years. 11 However, there remains a paucity of data on the reproductive outcomes of women with recurrent CSP. A comprehensive understanding of the prognosis and reproductive potential in this population is critical for informing clinical decision‐making, particularly for those desiring future pregnancies. This study aims to assess the management strategies and reproductive outcomes of recurrent CSP in our institution, providing additional evidence to guide clinical practice.
Materials and Methods
Patients
We identified potential CSP cases through a 2‐stage process. First, we screened the electronic medical records using ICD‐9/10 codes, identifying 1517 potential cases between January 2012 and December 2022. The final confirmation was then based on an independent, blinded review of the original PACS ultrasound images by 2 senior sonographers using predetermined diagnostic criteria. This rigorous review process confirmed 1371 eligible cases, with the remaining cases excluded due to inadequate image quality, diagnostic uncertainty (eg, suspected low implantation), or incomplete clinical data. During follow‐up of the initial cohort of 1371 CSP patients, 159 subsequent pregnancies resulting in live births were observed (excluding spontaneous abortions, induced abortions, and stillbirths). From this group, 27 patients diagnosed with recurrent CSP were enrolled in the case group; subsequently, propensity score matching (PSM) was performed in a 1:1 ratio to select 27 comparable patients with normal intrauterine pregnancies following CSP as the control group. This study systematically collected and compared baseline clinical characteristics between the 2 groups, including demographic features, clinical symptoms (vaginal bleeding and/or abdominal pain), parity, history of cesarean delivery, number of induced abortions, ultrasonographic findings, and serum β‐human chorionic gonadotropin levels at diagnosis.
Prognostic data and reproductive outcomes for the 27 patients with recurrent CSP were collected through a combination of medical record review and structured telephone interviews. Data collection was conducted centrally between December 2024 and January 2025. Given that initial treatments spanned from January 2012 to December 2022, the follow‐up interval ranged from approximately 23 months to 12 years. The reproductive outcome analysis was restricted to completed pregnancies with definitive outcomes (eg, live birth, miscarriage), excluding ongoing pregnancies at the time of follow‐up. Written informed consent was obtained from each patient, and the study was approved by the Institutional Review Board of the hospital.
Ultrasound Examinations
Ultrasound examinations were performed using Philips iU 22, Philips iU Elite, Philips EPIQ5, and GE Voluson E8 color Doppler diagnostic ultrasound systems, equipped with transvaginal probes operating at frequencies of 5 to 9 MHz. Transvaginal sonography was employed to evaluate the relationship between the gestational sac and the cesarean scar, cervix, and uterine cavity, as well as to assess the implantation pattern of CSP. Parameters measured included the myometrial thickness between the gestational sac and the bladder wall, the dimensions of the gestational sac, and the assessment of blood flow signals surrounding the gestational sac and the anterior isthmus myometrium, using color Doppler imaging. The diagnostic criteria for CSP include 1 : a history of lower segment cesarean section; positive serum β‐hCG levels; and the following ultrasound criteria: no embryonic implantation in the uterine cavity or cervix; the presence of a gestational sac on the anterior wall of the lower uterine segment; a thin myometrial layer between the gestational sac and the bladder; and a rich vascular pattern around the cesarean scar and placenta (Figures 1 and 2).
Figure 1.
Ultrasound images of cesarean scar implantation. UC, uterine cavity; CX, cervix; GS, gestational sac; BL, bladder. Arrow indicating myometrium between bladder and gestational sac.
Figure 2.
A, Greyscale ultrasound showing the “endogenous” implantation pattern. B, Magnified color Doppler view of the anterior wall of the uterine isthmus corresponding to A. C, Greyscale ultrasound showing an “exogenous” implantation pattern. D, Magnified color Doppler view of the anterior wall of the uterine isthmus corresponding to C. UC, uterine cavity; CX, cervix; GS, gestational sac; BL, bladder. Arrow indicating gestational sac.
Treatment
The primary management for all 1371 patients adhered to institutional guidelines. Treatment strategies encompassed: (1)Transabdominal ultrasound‐guided uterine suction curettage (alone or combined with uterine artery embolization [UAE]); (2) UAE combined with methotrexate (MTX) arterial infusion, followed by transabdominal ultrasound‐guided suction curettage; (3) UAE followed by laparoscopic surgery; and (4) hysteroscopic excision of CSP.
A total of 27 patients with recurrent CSP underwent one of the following treatment regimens: (A) transabdominal ultrasound‐guided uterine suction curettage; (B) UAE followed by laparoscopic surgery; (C) UAE combined with MTX arterial infusion, followed by transabdominal ultrasound‐guided suction curettage; or (D) conservative management without intervention. Postoperative active uterine bleeding was managed using intrauterine balloon tamponade. All patients expressed a desire for fertility preservation. Follow‐up evaluations were conducted approximately 1 month after the intervention, including serum β‐hCG measurements and ultrasound imaging. Treatment success was defined by the normalization of serum β‐hCG levels and the resolution of the CSP‐related mass.
Statistical Analysis
All statistical analyses were performed using SPSS version 27.0 (IBM, USA). First, to balance the baseline characteristics between the treatment and control groups, propensity score matching was conducted using the PSM plugin, with nearest‐neighbor matching and a caliper of 0.05. After matching, the standardized differences of all baseline covariates were significantly reduced. Subsequent statistical inferences were based on the successfully matched sample. Normally distributed variables are presented as mean ± standard deviation and were compared using independent samples t‐tests; non‐normally distributed variables are presented as median (interquartile range) and were compared using the Mann–Whitney U test. Categorical variables are expressed as number (percentage) and were compared using Chi‐square tests or Fisher's exact test. In the statistical analysis results, an odds ratio (OR) greater than 1 indicates a positive association of the factor with the case group.
Results
Clinical Characteristics
Table 1 summarizes baseline characteristics before and after propensity score matching between recurrent CSP cases (n = 27) and post‐CSP normal pregnancy controls (n = 159 initially). Before matching, significant differences were observed between the case group (n = 27) and control group (n = 159) in clinical symptoms, parity distribution, and history of induced abortions (p < .05), with significantly different propensity scores (0.24 versus 0.05, p < .001).
Table 1.
Comparison of Baseline Characteristics Between Case and Control Groups Before and After Matching
| Variable | Unmatched Sample | Matched Sample | ||||
|---|---|---|---|---|---|---|
| Case | Control | p | Case | Control | p | |
| N | 27 | 159 | 27 | 27 | ||
| Age (years) | 33.0 (5.0) | 33.0 (4.0) | .901 | 33.0 (5.0) | 33.0 (5.0) | .520 |
| Symptom at diagnosis | <.001 | 1.000 | ||||
| Vaginal bleeding or/and Abdominal pain | 24 (88.9) | 76 (47.8) | 24 (88.9) | 24 (88.9) | ||
| Asymptomatic | 3 (11.1) | 83 (52.2) | 3 (11.1) | 3 (11.1) | ||
| Parity | .018 | .526 | ||||
| 1 | 19 (70.4) | 139 (87.4) | 19 (70.4) | 21 (77.8) | ||
| 2 | 8 (29.6) | 15 (9.4) | 8 (29.6) | 5 (18.5) | ||
| 3 | 0 (0.0) | 5 (3.1) | 0 (0.0) | 1 (3.7) | ||
| Number of cesarean sections | .136 | .250 | ||||
| 1 | 21 (77.8) | 142 (89.3) | 21 (77.8) | 24 (88.9) | ||
| 2 | 6 (22.2) | 14 (8.8) | 6 (22.2) | 2 (7.4) | ||
| 3 | 0 (0.0) | 3 (1.9) | 0 (0.0) | 1 (3.7) | ||
| Number of induced abortions | .037 | .642 | ||||
| 1 | 8 (29.6) | 42 (26.4) | 8 (29.6) | 7 (25.9) | ||
| 2 | 6 (22.2) | 62 (39.0) | 6 (22.2) | 7 (25.9) | ||
| 3 | 8 (29.6) | 39 (24.5) | 8 (29.6) | 7 (25.9) | ||
| 4 | 3 (11.1) | 16 (10.1) | 3 (11.1) | 6 (22.2) | ||
| 5 | 2 (7.4) | 0 (0.0) | 2 (7.4) | 0 (0.0) | ||
| Propensity score | 0.24 (0.12) | 0.05 (0.19) | <.001 | 0.24 ± 0.11 | 0.23 ± 0.11 | .943 |
Data are median (IQR), or n (%).
After 1:1 matching, all 27 cases were successfully paired. No significant differences remained in any baseline characteristics between the matched groups (p > .05), and propensity scores were well balanced (0.24 ± 0.11 versus 0.23 ± 0.11, p = .943), indicating effective control of confounding factors.
Ultrasound Findings in the First CSP
Table 2 compares the sonographic characteristics in the first diagnosis between recurrent and post‐CSP normal intrauterine pregnancies. No significant intergroup differences were observed in gestational sac diameter (27.0 [13.0] mm versus 27.0 [11.0] mm; p = .883) or myometrial thickness between the gestational sac and bladder wall (3.0 [2.0] mm versus 3.2 [1.8] mm; p = .493).
Table 2.
Comparative Analysis of Sonographic Characteristics During the First CSP Diagnosis Between Recurrent CSP and Post‐CSP Normal Intrauterine Pregnancy
| Parameters | Recurrent CSP | Post‐CSP Normal Intrauterine Pregnancy | OR (95% CI) | p |
|---|---|---|---|---|
| (n = 27) | (n = 27) | |||
| Maximum diameter of the gestational sac (mm) | 27.0 (13.0) | 27.0 (11.0) | ‐ | .883 |
| Myometrial thickness between the gestational sac and bladder wall (mm) | 3.0 (2.0) | 3.2 (1.8) | ‐ | .493 |
| implantation model | .018* | |||
| Endogenous | 18 (66.7) | 25 (92.6) | 1.00 | |
| Exogenous | 9 (33.3) | 2 (7.4) | 1.96 (1.25–3.06) | |
| CDFI | .002* | |||
| Sparse vascularity | 5 (18.5) | 16 (59.3) | 1.00 | |
| Rich vascularity | 22 (81.5) | 11 (40.7) | 2.80 (1.26–5.25) | |
| embryonic cardiac activity | .010* | |||
| ‐ | 13 (48.1) | 22 (81.5) | 1.00 | |
| + | 14 (51.9) | 5 (18.5) | 1.98 (1.19–3.30) |
Data are median (IQR), or n (%). CSP, cesarean scar pregnancy; OR, odds ratio; 95% CI, 95% confidence interval.
A statistically significant difference.
Significant differences were identified in 3 key sonographic markers. The recurrent CSP group showed a higher prevalence of the exogenous implantation pattern (33.3% [9/27] versus 7.4% [2/27]; p = .018), with an OR of 1.96 (95% CI: 1.25–3.06). Rich vascularity on color Doppler was more common in recurrent CSP (81.5% [22/27] versus 40.7% [11/27]; p = .002), corresponding to an OR of 2.80 (95% CI: 1.26–5.25). Embryonic cardiac activity was also detected more frequently in recurrent CSP cases (51.9% [14/27] versus 18.5% [5/27]; p = .010), with an OR of 1.98 (95% CI: 1.19–3.30).
Treatment and Reproductive Outcomes
Among the 1371 patients, the distribution of these primary treatments was as follows: 80.0% underwent transabdominal ultrasound‐guided suction curettage (±UAE), 8.5% received UAE with methotrexate infusion followed by transabdominal ultrasound‐guided suction curettage, 5.9% were treated with UAE followed by laparoscopic surgery, and 5.0% underwent hysteroscopic excision.
All the 27 patients with recurrent CSP had favorable clinical outcomes, with no cases requiring hysterectomy. Fertility was preserved in all patients. Postoperatively, 8 patients experienced active uterine hemorrhage; the median intraoperative blood loss was 150 mL, with a range of 100–300 mL, which was successfully managed using intrauterine balloon tamponade. Two patients required repeat treatment (suction curettage) due to incomplete evacuation following incomplete therapeutic abortion. One patient with incomplete spontaneous abortion received intervention with suction curettage after abnormal ultrasound findings and menstrual irregularities were detected. The detailed treatment outcomes are presented in Table 3.
Table 3.
Outcomes and Reproductive Results of Different Treatment Methods for Recurrent CSP Patients
| Treatment Method | Sample Size (n = 27) | 1‐Month Post‐Treatment Outcome | Reproductive Outcome |
|---|---|---|---|
| A | 17 |
|
|
| B | 2 |
|
/ |
| C | 7 |
|
|
| D | 1 |
|
/ |
A, transabdominal ultrasound‐guided uterine suction curettage; B, uterine artery embolization (UAE) followed by laparoscopic surgery; C, UAE combined with methotrexate (MTX) arterial infusion, followed by transabdominal ultrasound‐guided suction curettage; D, conservative management without intervention; CSP, cesarean scar pregnancy; β‐hCG, β‐human chorionic gonadotropin.
Among the 27 patients with recurrent CSP, 6 women were lost to follow‐up regarding reproductive outcomes. Among the 21 women successfully contacted, 13 chose contraception, of which 2 experienced contraceptive failure. Of these 2, 1 underwent an abortion after early pregnancy detection, while the other was diagnosed with recurrent CSP and underwent surgical treatment. Among the 8 women who desired future pregnancies 4 patients were diagnosed with secondary infertility during attempted subsequent conception, while the other 4 successfully conceived. Of the 4 women who achieved pregnancy, 2 had live births, while the other 2 experienced recurrent CSP and underwent surgical treatment. Following surgical treatment for recurrent CSP in these 2 patients, 1 woman chose contraception after surgery, while another conceived twice in 2022 and 2023 but experienced 2 miscarriages. However, the patient subsequently achieved a new pregnancy in 2024, which had progressed to 17 weeks of gestation by mid‐December 2024. As this was an ongoing pregnancy at the conclusion of the follow‐up period, the final outcome was not included in the formal reproductive outcomes analysis. The long follow‐up data flow chart for the 27 patients with recurrent CSP is shown in Figure 3, and their short follow‐up data for different treatment modalities are summarized in Table 3.
Figure 3.
Flowchart of follow‐up data for study population.
Discussion
In an 11‐year follow‐up study conducted at our institution, a total of 1371 cases of CSP were treated, of which 27 cases were diagnosed as recurrent CSP. Due to incomplete follow‐up data in some cases, accurately determining the recurrence rate of CSP remains challenging. Regarding ultrasonographic findings, this study identified that both an exogenous CSP implantation pattern (OR = 1.96, p = .018) was significantly associated with an increased risk of CSP recurrence. This finding is consistent with the report by Qian et al, 12 suggesting that the risk of scar pregnancy may be proportional to the size of the anterior uterine wall defect. 13 The underlying mechanism may involve the deep myometrial infiltration characteristic of exogenous‐type embryos, leading to persistent myometrial thinning and defect formation. Furthermore, when decidualization in the lower uterine segment is compromised due to prior myometrial injury, the attachment and invasion of trophoblastic cells become enhanced. 12 Recently, Timor‐Tritsch et al 14 proposed classifying CSP as either “on‐the‐scar” (oCSP) or “ectopic” (CSeP). This distinction explains differential recurrence risks: CSeP implants deep within the scar niche with a thin residual myometrium (<3 mm), demonstrating greater trophoblast invasiveness that often leads to incomplete treatment and subsequent recurrence. This study also found a significant association between embryonic cardiac activity and recurrent CSP (OR = 1.98, p = .010), aligning with previous research. 15 This association can be explained by the fact that viable CSP, due to its enhanced trophoblastic invasiveness, is more likely to cause irreversible scar damage. This study observed that patients with recurrent CSP exhibited richer blood flow signals around the lesion on color Doppler ultrasound (OR = 2.80, p = .002) during initial diagnosis. This finding is highly consistent with the results of the recent systematic review and network meta‐analysis by Fu et al, 16 which provides strong evidence for understanding the relationship between treatment response for CSP and the vascular characteristics of the lesion.
The optimal management of CSP remains a topic of debate, and data regarding reproductive outcomes following CSP treatment remain limited. Transabdominal ultrasound‐guided suction curettage is frequently utilized, especially in cases with sufficient myometrial thickness between the gestational sac and bladder. Some authors have raised concerns regarding the elevated risk of hemorrhage and uterine rupture associated with this method. 17 , 18 However, other studies have supported its use, reporting lower complication rates. 19 , 20 Myometrial thickness is a pivotal parameter in determining the feasibility of this approach, with thresholds of 2, 21 3, 22 or 4.5 mm 23 commonly cited. Recent study reports prevention of recurrent CSP requires individualized surgical strategies based on classification. For high‐risk patients with residual myometrial thickness ≤3 mm, excisional surgery reduces recurrence risk (5.0% versus 31.5%) and improves subsequent pregnancy rates through complete lesion removal and scar reinforcement. 24 Sun et al 25 recommend type Ia for ultrasound‐guided curettage, type IIa for hysteroscopy, and types IIb/III for laparoscopic/laparotomic surgery. Notably, surgical technique selection shows no significant impact on recurrence in unselected populations, suggesting initial scar condition is more prognostic than surgical method. 26 Although this study reveals the predominant role of transabdominal ultrasound‐guided suction curettage (with or without UAE) in the management of recurrent CSP (80.0%), this treatment distribution suggests that the high concentration of therapeutic approaches may be influenced by single‐center clinical pathway preferences or resource availability, indicating significant selection bias that limits the generalizability of the conclusions. In our study, 17 of the 27 patients with recurrent CSP underwent transabdominal ultrasound‐guided suction curettage, with 15 achieving successful outcomes. Two patients with myometrial thicknesses of 1.7 and 1.9 mm required repeat procedures due to incomplete evacuation, likely resulting from cautious surgical approaches to avoid uterine perforation and hemorrhage. UAE has been widely adopted in gynecology and obstetrics as an effective strategy to control hemorrhage by reducing uterine blood flow 4 , 27 , 28 . Lu et al 29 demonstrated that UAE combined with MTX arterial infusion, followed by transabdominal ultrasound‐guided suction curettage was associated with faster recovery, fewer complications, lower recurrence rates, and shorter hospital stays, particularly in patients desiring future pregnancies. More previous studies 30 , 31 , 32 have consistently reported that UAE combined with MTX arterial infusion, followed by transabdominal ultrasound‐guided suction curettage significantly reduces the incidence of complications. In our study, 6 patients underwent UAE combined with MTX arterial infusion followed by suction curettage, while 2 received UAE combined with MTX arterial infusion followed by laparoscopic surgery. All patients had a myometrial thickness ≥2 mm. Postoperative follow‐ups revealed favorable outcomes, with a significantly lower rate of active bleeding (22.2%) compared to patients who did not undergo UAE (35.3%). These findings emphasize the superior efficacy of UAE in managing hemorrhage and preserving fertility. Evidence regarding the impact of different treatment modalities on reproductive outcomes following CSP is limited. Li et al 27 reported a 38.1% pregnancy rate among 42 women who attempted conception after UAE and suction curettage. Similarly, Sun et al 33 observed an 84% pregnancy rate in a 5‐year follow‐up study of 53 women treated for CSP. In our follow‐up of 27 recurrent CSP cases, 6 patients were lost to contact. Among the 21 patients successfully reached, 13 opted for contraception, while only 8 expressed a desire for future pregnancies. Due to the small sample size and the presence of selection bias, we were unable to determine an accurate pregnancy rate.
In this study, reproductive outcomes were assessed for women with recurrent CSP. Six women were lost to follow‐up, which underscores a common challenge in long‐term reproductive studies where patient compliance can be a limiting factor. Among the 21 women successfully contacted, contraception was chosen by 13 participants. Notably, 2 women experienced contraceptive failure, highlighting the potential for unintended pregnancies despite contraception use, which is an important consideration when counseling women after recurrent CSP. The outcomes in women who desired future pregnancies varied significantly. Of the 8 women who expressed a desire for subsequent pregnancies, half were diagnosed with secondary infertility during attempted subsequent conception This rate of secondary infertility is concerning, especially when compared to the general population, and may reflect underlying issues related to prior CSP, including uterine scarring, tubal factor infertility, or other gynecological complications resulting from the initial CSP or treatment methods used. On the other hand, the 4 women who successfully conceived had mixed outcomes. Two of these pregnancies resulted in live births, which indicates that successful pregnancies after recurrent CSP are possible, but their occurrence may depend on individual patient factors, such as the extent of uterine damage, the treatment approach used for CSP, and overall reproductive health. However, the other 2 women experienced recurrent CSP, which required further medical intervention, indicating that repeat CSP may be a risk for some women, even after successful initial treatment. These recurrent cases underscore the need for ongoing monitoring and management in women who have had a history of CSP. Of particular interest is 1 patient's reproductive journey. This woman experienced miscarriages in both 2022 and 2023 but successfully conceived again in 2024. As of mid‐December 2024, she had reached 17 weeks of gestation. This case highlights the possibility of successful pregnancies after recurrent CSP, even after previous pregnancy losses. It also emphasizes the importance of individualized care and follow‐up, as this patient appears to have overcome previous challenges to reach the second trimester in her current pregnancy.
This study has several limitations. First, the wide range of follow‐up intervals may have introduced bias in outcome reporting. Second, due to sample size constraints, we could not perform a stratified analysis based on the time since treatment. These factors highlight the need for future research with long‐term, prospective designs to better delineate outcome trajectories. Secondly, the reliance on patient‐reported outcomes via telephone interviews introduces the potential for recall bias, particularly for historical events. Although a structured questionnaire was used and key outcomes were cross‐verified with medical records where feasible, this inherent limitation remains. Third, the retrospective design led to an uneven distribution of primary treatments, with most patients (84.3%) receiving ultrasound‐guided curettage. This precluded meaningful comparison of other treatment strategies due to small sample sizes in alternative groups.
Conclusions
The characteristic sonographic features of recurrent CSP, including an exogenous implantation pattern, rich vascularity, and embryonic cardiac activity, serve as early indicators for its identification. Although transabdominal ultrasound‐guided suction curettage effectively manages the condition and preserves fertility, long‐term follow‐up reveals persistent risks of recurrence and infertility in some patients.
We would like to express our gratitude to all those who helped us during the writing of this manuscript. Thanks to all the peer reviewers for their opinions and suggestions. The authors declare no conflict of interest.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
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Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.