Abstract
Purpose
To describe labor induction outcomes and short-term maternal and neonatal adverse events following controlled-release vaginal dinoprostone use in women beyond 36 weeks of gestation at a provincial obstetric hospital in Vietnam.
Methods
This prospective, single-center observational study included 102 women who received controlled-release vaginal dinoprostone during routine inpatient care at Thai Binh Obstetrics and Gynecology Hospital from January to June 2025. Eligible women had singleton, live, cephalic pregnancies beyond 36 weeks of gestation, a Bishop score ≤4, and no contraindication to vaginal delivery. The primary outcome was successful induction within 24 hours. Secondary outcomes included vaginal and cesarean delivery, time-to-event outcomes, short-term maternal and neonatal adverse events, and factors associated with induction success. No concurrent comparison group was included.
Results
The mean maternal age was 28.5 ± 5.5 years, the mean gestational age was 39.8 ± 1.3 weeks, and the mean baseline Bishop score was 3.37 ± 0.82. Successful induction occurred in 84 women (82.4%; 95% CI: 73.8–88.5), and 81 women delivered vaginally (79.4%; 95% CI: 70.6–86.1). The mean interval from insertion to successful induction was 8.0 ± 5.3 hours, and the mean interval to vaginal delivery was 10.6 ± 5.8 hours. Uterine tachysystole/hyperstimulation occurred in 4 women (3.9%) and fetal distress in 3 (2.9%). No uterine rupture, postpartum hemorrhage, birth asphyxia, or 5-minute Apgar score <7 was recorded. Higher baseline Bishop score was strongly associated with successful induction (p<0.001).
Conclusion
In this prospective observational cohort, high proportions of women achieved successful induction and vaginal delivery, and few short-term maternal or neonatal adverse events were recorded. Baseline Bishop score was associated with induction success. Because the study had no comparison group, the findings describe outcomes after dinoprostone use rather than comparative efficacy. Larger multicenter comparative studies are needed before the results are generalized to other populations and care settings.
Keywords: dinoprostone, labor induction, cervical ripening, Bishop score, vaginal delivery, Vietnam
Plain Language Summary
Why was the Study done?
Some pregnant women need labor to be started when continuing pregnancy may be less safe for the mother or baby. Dinoprostone is placed in the vagina to help soften the cervix and start contractions.
What did the Researchers do and find?
We followed 102 women beyond 36 weeks of gestation who had an unfavorable cervix and received controlled-release vaginal dinoprostone at a provincial obstetric hospital in Vietnam. Within 24 hours, 82.4% met the study definition of successful induction, and 79.4% delivered vaginally. Few short-term complications were recorded, and all newborns had a 5-minute Apgar score of at least 7.
What do the Results mean?
Most women in this cohort entered labor and delivered vaginally after receiving the insert. The Bishop score before induction helped identify women who were more likely to meet the study definition of successful induction. The study did not compare dinoprostone with another induction method, so it cannot show that the insert is better than other options. Larger comparative studies in several hospitals are needed to determine how these findings apply to a wider range of women.
Introduction
Induction of labor is used when the expected maternal or fetal benefit of delivery outweighs the risk of continuing pregnancy. International guidance emphasizes assessment of the indication for delivery, maternal and fetal status, cervical favorability, patient preferences, and the availability of fetal monitoring and emergency obstetric care.1 Women should also receive balanced information about the expected benefits, limitations, and adverse effects of the available induction methods.2
For women with an unfavorable cervix, cervical ripening can be performed with pharmacological agents, including misoprostol and dinoprostone, or with mechanical methods such as a balloon catheter. A network meta-analysis found no single method to be superior across vaginal delivery within 24 hours, uterine hyperstimulation with fetal heart rate changes, and cesarean delivery; the balance of benefits and risks differed among methods.3 Controlled-release vaginal dinoprostone provides a retrievable 10-mg prostaglandin E2 preparation, allowing the insert to be removed when labor is established or if tachysystole or a non-reassuring fetal heart rate pattern occurs.4 A randomized trial in women with Bishop score ≤4 also reported different delivery outcomes between the controlled-release insert and vaginal dinoprostone gel.5
Prospective Vietnamese data have described maternal and neonatal outcomes after use of a 10-mg slow-release dinoprostone insert in low-risk term pregnancies.6 A Japanese single-center study also reported outcomes after the introduction of controlled-release dinoprostone for women with unfavorable cervices.7 However, evidence from Vietnamese provincial maternity hospitals remains limited, particularly for women beyond 36 weeks of gestation with a Bishop score ≤4.
This study therefore aimed to describe labor induction outcomes and short-term maternal and neonatal adverse events following controlled-release vaginal dinoprostone use in women beyond 36 weeks of gestation at Thai Binh Obstetrics and Gynecology Hospital, Vietnam. A secondary aim was to explore clinical factors associated with successful induction, with particular attention to baseline Bishop score. Because the cohort had no concurrent comparator, the study was not designed to estimate comparative efficacy.
Materials and Methods
Study Design and Setting
This prospective, single-center observational cohort was conducted at the Delivery Department of Thai Binh Obstetrics and Gynecology Hospital, Vietnam, from January 1 to June 30, 2025. Consecutive eligible women who received controlled-release vaginal dinoprostone during the study period were enrolled and followed from insertion to delivery and early postpartum/neonatal assessment. No concurrent comparison group was included. The manuscript was prepared in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations.8
Participants
Eligible participants were pregnant women with singleton, live, cephalic pregnancies beyond 36 weeks of gestation, an indication for labor induction, no established spontaneous labor at admission, Bishop score ≤4, no contraindication to vaginal delivery, and agreement to undergo dinoprostone induction.
Exclusion criteria included previous uterine scar, uterine malformation, more than three previous term deliveries, severe systemic maternal disease, hypersensitivity to dinoprostone, previous use of another induction method, suspected fetal compromise before induction, fetal anomaly, cephalopelvic disproportion, placenta previa, or vasa previa.
Intervention and Monitoring Protocol
All participants received a controlled-release vaginal dinoprostone insert placed in the posterior vaginal fornix. Dinoprostone was used as the generic drug name throughout the manuscript; the commercial preparation was Propess 10 mg (Ferring Pharmaceuticals, Saint-Prex, Switzerland).
After insertion, women were monitored clinically and by cardiotocography according to the hospital protocol. Maternal vital signs, uterine contractions, cervical changes, fetal heart rate, and adverse effects were followed regularly for up to 24 hours. The insert was removed when labor induction was successful, when 24 hours elapsed without successful induction, or earlier if complications such as tachysystole, fetal heart rate abnormality, significant bleeding, or serious maternal adverse effects occurred. Oxytocin augmentation, cervical softening medication, and labor analgesia were used after clinical assessment rather than by random allocation.
Outcomes
The primary outcome was successful labor induction, defined as effective uterine contractions with cervical dilation reaching 3 cm within 24 hours after dinoprostone insertion. Secondary outcomes included full cervical dilation, vaginal delivery, cesarean delivery, time from insertion to successful induction, time from insertion to full cervical dilation, time from insertion to vaginal delivery, indications for insert removal, causes of induction failure, indications for cesarean delivery, neonatal Apgar scores, maternal and neonatal complications, and adverse drug reactions.
Statistical Analysis
Data were analyzed using SPSS version 26.0 (IBM Corp, Armonk, NY, USA). Continuous variables were summarized as mean ± standard deviation or median and range, as appropriate. Categorical variables were summarized as frequencies and percentages. Wilson 95% confidence intervals were calculated for key proportions. Chi-square or Fisher exact tests were used for categorical comparisons, and crude odds ratios with 95% confidence intervals were calculated where appropriate. A two-sided p-value <0.05 was considered statistically significant. Because the number of failed inductions was limited, no large multivariable model was fitted; inferential results were treated as exploratory associations rather than causal effects.
Ethics Approval and Informed Consent
The study was conducted following approval of the Scientific Committee of Thai Binh University of Medicine and Pharmacy (Decision No. 412/GCN-IRB-TBUMP, January 11, 2025) and permission from Thai Binh Obstetrics and Gynecology Hospital. The study complied with the Declaration of Helsinki. All participants provided written informed consent for dinoprostone use and study participation before enrollment. Personal information was coded and used only for research purposes.
Results
Participant Characteristics
A total of 102 women were included. The mean maternal age was 28.5 ± 5.5 years (range, 17–43), and 65 women (63.7%) were undergoing their first delivery. The mean gestational age was 39.8 ± 1.3 weeks. Before induction, 72 women (70.6%) had intact membranes and 30 (29.4%) had prelabor rupture of membranes. The mean baseline Bishop score was 3.37 ± 0.82. Baseline maternal and obstetric characteristics are summarized in Table 1.
Table 1.
Baseline Maternal and Obstetric Characteristics
| Characteristic | Overall, n = 102 |
|---|---|
| Maternal age, years | 28.5 ± 5.5 |
| Height, cm | 157.5 ± 4.8 |
| Weight, kg | 65.4 ± 8.5 |
| BMI, kg/m2 | 26.3 ± 3.0 |
| Gestational age, weeks | 39.8 ± 1.3 |
| Baseline Bishop score | 3.37 ± 0.82 |
| Birth weight, g | 3095.1 ± 345.4 |
| Age group | |
| <25 years | 22 (21.6%) |
| 25–29 years | 41 (40.2%) |
| 30–34 years | 21 (20.6%) |
| >34 years | 18 (17.6%) |
| Number of births | |
| First delivery | 65 (63.7%) |
| Second delivery | 17 (16.7%) |
| Third delivery | 20 (19.6%) |
| Gestational age | |
| 37 weeks | 11 (10.8%) |
| 38 weeks | 6 (5.9%) |
| 39 weeks | 14 (13.7%) |
| 40 weeks | 30 (29.4%) |
| 41 weeks | 41 (40.2%) |
| Membranes | |
| Intact | 72 (70.6%) |
| Ruptured | 30 (29.4%) |
| Amniotic fluid index | |
| <50 mm | 40 (39.2%) |
| 50–250 mm | 58 (56.9%) |
| >250 mm | 4 (3.9%) |
| Post-date pregnancy | 69 (67.6%) |
| Prelabor rupture of membranes | 30 (29.4%) |
| Oligohydramnios | 31 (30.4%) |
| Fetal growth restriction | 1 (1.0%) |
Notes: Values are presented as mean ± SD or n (%). Indications for induction were clinician-assigned and could overlap.
Abbreviations: BMI, body mass index; SD, standard deviation.
Induction and Delivery Outcomes
Successful induction within 24 hours occurred in 84 women (82.4%; 95% CI: 73.8–88.5). Of these women, 81 delivered vaginally and 3 underwent cesarean delivery after meeting the induction-success criterion. All 18 women with failed induction underwent cesarean delivery, giving an overall vaginal delivery rate of 79.4% (81/102; 95% CI: 70.6–86.1) and an overall cesarean delivery rate of 20.6% (21/102). The study flow is shown in Figure 1. Outcome proportions and mean time intervals are summarized in Table 2 and Figure 2A and B. The distribution of time intervals is shown in Supplementary Figure 1, and reasons for insert removal, failed induction, and cesarean delivery are provided in Supplementary Table 1.
Figure 1.
Study flow and main delivery outcomes. Of the 84 women who met the study definition of successful induction within 24 hours, 81 delivered vaginally and 3 underwent cesarean delivery. All 18 women with failed induction underwent cesarean delivery.
Table 2.
Labor Induction and Delivery Outcomes
| Outcome | Result | 95% CI or Range |
|---|---|---|
| Successful induction within 24 hours | 84/102 (82.4%) | 73.8–88.5 |
| Full cervical dilation | 84/102 (82.4%) | 73.8–88.5 |
| Vaginal delivery | 81/102 (79.4%) | 70.6–86.1 |
| Cesarean delivery | 21/102 (20.6%) | 13.9–29.4 |
| Insertion to successful induction, hours | 8.0 ± 5.3 | Median 6.0; min-max 1–22 |
| Insertion to full cervical dilation, hours | 10.6 ± 5.7 | Median 8.75; min-max 2–24 |
| Insertion to vaginal delivery, hours | 10.6 ± 5.8 | Median 8.5; min-max 2–24 |
Notes: Values are presented as n/N (%) or mean ± SD. Confidence intervals for proportions were calculated using the Wilson method.
Abbreviations: CI, confidence interval; SD, standard deviation.
Figure 2.
Labor induction outcomes and time intervals after controlled-release vaginal dinoprostone. (A) Proportions with successful induction, vaginal delivery, and cesarean delivery. (B) Mean time from insert placement to successful induction, full cervical dilation, and vaginal delivery; error bars indicate standard deviation.
Safety Outcomes
Overall, 95 women (93.1%) had no recorded maternal or fetal complication. Fetal distress occurred in 3 cases (2.9%), and uterine tachysystole/hyperstimulation occurred in 4 (3.9%). No threatened uterine rupture, uterine rupture, birth asphyxia, or postpartum hemorrhage was recorded. All newborns had Apgar scores ≥7 at 1 and 5 minutes. Safety outcomes are summarized in Table 3 and Figure 3. Reported adverse drug reactions were nausea in 3 women (2.9%), fever in 3 (2.9%), and diarrhea in 1 (1.0%); these events are shown in Supplementary Figure 2.
Table 3.
Short-Term Maternal and Neonatal Safety Outcomes
| Safety Outcome | Result |
|---|---|
| No maternal/fetal complication | 95/102 (93.1%) |
| Fetal distress | 3/102 (2.9%) |
| Uterine tachysystole/hyperstimulation | 4/102 (3.9%) |
| Threatened uterine rupture | 0/102 (0.0%) |
| Uterine rupture | 0/102 (0.0%) |
| Birth asphyxia | 0/102 (0.0%) |
| Postpartum hemorrhage | 0/102 (0.0%) |
| Birth weight, g | 3095.1 ± 345.4 |
| Birth weight <3500 g | 84/102 (82.4%) |
| Birth weight ≥3500 g | 18/102 (17.6%) |
| 1-minute Apgar score | 7.98 ± 0.14 |
| 5-minute Apgar score | 9.98 ± 0.14 |
| 1-minute Apgar ≥7 | 102/102 (100.0%) |
| 5-minute Apgar ≥7 | 102/102 (100.0%) |
| No adverse drug reaction | 96/102 (94.1%) |
| Nausea | 3/102 (2.9%) |
| Diarrhea | 1/102 (1.0%) |
| Fever | 3/102 (2.9%) |
| Vomiting | 0/102 (0.0%) |
| Tachycardia | 0/102 (0.0%) |
| Hypotension | 0/102 (0.0%) |
Notes: Values are presented as n/N (%) or mean ± SD.
Abbreviation: SD, standard deviation.
Figure 3.
Short-term maternal and neonatal safety outcomes after controlled-release vaginal dinoprostone. Bars show the percentage of the full cohort (n=102) with each recorded outcome.
Factors Associated with Successful Induction
Maternal age, parity, gestational age, and the main induction indications were not significantly associated with successful induction. Baseline Bishop score showed a strong graded association: successful induction occurred in 0/4 women with score 1, 1/10 with score 2, 28/32 with score 3, and 55/56 with score 4 (p<0.001). Women with Bishop score ≥3 had higher crude odds of successful induction than those with score ≤2 (OR 215.8; 95% CI: 23.3–1997.3), although the estimate was imprecise because of sparse cells (Table 4; Figure 4). Among the 84 women with successful induction, vaginal delivery occurred in 72/73 women who received labor analgesia and 9/11 who did not (98.6% vs 81.8%; Fisher exact p=0.044). Oxytocin augmentation and cervical-softening medication were not associated with delivery mode in this subgroup (Supplementary Table 2). These post-induction associations are exploratory and should not be interpreted causally.
Table 4.
Clinical Factors Associated with Successful Induction
| Factor | Successful Induction | Failed Induction | p-value |
|---|---|---|---|
| Age group | 0.577 | ||
| <25 years | 19/22 (86.4%) | 3/22 (13.6%) | |
| 25–29 years | 32/41 (78.0%) | 9/41 (22.0%) | |
| 30–34 years | 19/21 (90.5%) | 2/21 (9.5%) | |
| >34 years | 14/18 (77.8%) | 4/18 (22.2%) | |
| Parity | 0.688 | ||
| First delivery | 52/65 (80.0%) | 13/65 (20.0%) | |
| Second delivery | 15/17 (88.2%) | 2/17 (11.8%) | |
| Third delivery | 17/20 (85.0%) | 3/20 (15.0%) | |
| Gestational age | 0.126 | ||
| 37 weeks | 6/11 (54.5%) | 5/11 (45.5%) | |
| 38 weeks | 5/6 (83.3%) | 1/6 (16.7%) | |
| 39 weeks | 13/14 (92.9%) | 1/14 (7.1%) | |
| 40 weeks | 25/30 (83.3%) | 5/30 (16.7%) | |
| 41 weeks | 35/41 (85.4%) | 6/41 (14.6%) | |
| Baseline Bishop score | <0.001 | ||
| 1 point | 0/4 (0.0%) | 4/4 (100.0%) | |
| 2 points | 1/10 (10.0%) | 9/10 (90.0%) | |
| 3 points | 28/32 (87.5%) | 4/32 (12.5%) | |
| 4 points | 55/56 (98.2%) | 1/56 (1.8%) | |
| Post-date pregnancy | 58/69 (84.1%) | 11/69 (15.9%) | 0.514 |
| Prelabor rupture of membranes | 25/30 (83.3%) | 5/30 (16.7%) | 0.867 |
| Oligohydramnios | 26/31 (83.9%) | 5/31 (16.1%) | 0.790 |
| Fetal growth restriction | 0/1 (0.0%) | 1/1 (100.0%) | 0.176 |
| Bishop ≤2 | 1/14 (7.1%) | 13/14 (92.9%) | Reference |
| Bishop ≥3 | 83/88 (94.3%) | 5/88 (5.7%) | <0.001 |
Notes: p-values were calculated using the chi-square test or Fisher exact test, as appropriate. For Bishop score ≥3 vs ≤2, the crude OR was 215.8 (95% CI: 23.3–1997.3). This estimate should be interpreted cautiously because of sparse cells.
Abbreviations: CI, confidence interval; OR, odds ratio.
Figure 4.
Successful induction according to baseline Bishop score. Percentages are shown with the number of women in each Bishop score category.
Discussion
This prospective, single-center observational study described labor induction and short-term safety outcomes after controlled-release vaginal dinoprostone use in women beyond 36 weeks of gestation with a Bishop score ≤4. Successful induction occurred in 82.4% of participants, and 79.4% delivered vaginally. Uterine tachysystole/hyperstimulation and fetal distress were recorded in 3.9% and 2.9%, respectively; no uterine rupture, postpartum hemorrhage, birth asphyxia, or 5-minute Apgar score <7 was recorded. Because the study lacked a comparison group, these proportions should not be interpreted as evidence of superiority or comparative efficacy.
The observed vaginal delivery rate was higher than the 67.6% reported in a prospective Vietnamese study of low-risk term pregnancies, although direct comparison is limited by differences in eligibility criteria, cervical status, induction protocols, and clinical thresholds for cesarean delivery.6 A Japanese single-center study also reported favorable delivery outcomes after controlled-release dinoprostone was introduced as an induction option for women with unfavorable cervices.7 The present cohort adds data from a provincial Vietnamese maternity hospital, but differences between studies should be interpreted descriptively rather than as evidence that one protocol is more effective than another.
Baseline Bishop score was the clearest clinical factor associated with induction success. The marked separation between scores 1–2 and 3–4 supports the use of Bishop score for counseling and planning, while the wide confidence interval indicates that the magnitude of the association is uncertain in this small cohort. A recent dinoprostone study similarly identified Bishop score together with fetal head position, amniotic fluid index, and maternal characteristics as variables associated with induction outcomes.9
The controlled-release formulation has practical features that may be relevant in monitored inpatient care. It combines cervical-ripening and uterotonic effects and can be removed when labor is established or when excessive uterine activity or fetal heart rate abnormalities occur. In a randomized trial of women with Bishop score ≤4, the 24-hour insert produced a higher spontaneous vaginal delivery rate than repeated dinoprostone gel, although cesarean rates were not significantly different.5 These comparative findings do not establish the performance of the present single-arm protocol but provide context for the choice of formulation.
Among women with successful induction, labor analgesia was associated with vaginal delivery. This exploratory result is susceptible to time-order bias and confounding by indication because analgesia was administered after labor progress had begun and was influenced by maternal preference and clinical judgment. Hasegawa et al also showed that the timing of epidural analgesia in relation to cervical ripening and labor onset requires careful interpretation when dinoprostone inserts are used.10 The present finding should therefore be regarded as hypothesis-generating rather than causal.
The findings should also be considered alongside alternative ripening methods. In a randomized trial, the Foley catheter and controlled-release dinoprostone insert differed in time-to-delivery outcomes, while cesarean rates were not significantly different.11 A network meta-analysis found that no ripening method was uniformly superior across delivery, cesarean, and hyperstimulation outcomes,3 and a systematic review comparing misoprostol with dinoprostone found broadly similar maternal and neonatal safety outcomes across trials.12 A multicenter cohort of 1687 women receiving dinoprostone gel or insert identified tachysystole as the principal adverse event but reported no uterine rupture, maternal death, or fetal death.13 These data support individualized selection based on cervical status, membrane status, monitoring capacity, contraindications, and patient preferences rather than assuming that one method is preferable in all settings.
Strengths and Limitations
The study has several strengths. Data were collected prospectively under a defined hospital protocol, eligibility criteria were explicit, and participants were followed from dinoprostone insertion through delivery and early maternal/neonatal assessment. Reporting both induction and adverse-event outcomes provides a clinically interpretable description of routine inpatient use in an underrepresented Vietnamese setting.
Several limitations should be acknowledged. First, the single-center, single-arm design precludes comparative efficacy estimates and is vulnerable to selection, management, and referral patterns specific to the hospital. Second, the sample size was modest and only 18 inductions failed, limiting statistical power, producing sparse cells, and preventing stable multivariable adjustment. Third, induction indications overlapped and were assigned in routine practice, which limited comparisons among mutually exclusive indication groups. Fourth, the study was not powered to estimate rare events such as uterine rupture, severe neonatal morbidity, or postpartum hemorrhage, and no long-term neonatal outcomes were assessed. Generalizability is therefore greatest to similarly selected women with singleton cephalic pregnancies, an unscarred uterus, Bishop score ≤4, and access to inpatient fetal and uterine monitoring. The results may not apply to women with previous cesarean delivery, severe maternal or fetal disease, outpatient ripening, or settings with different monitoring and cesarean thresholds.
Conclusion
In this prospective observational cohort, most selected women beyond 36 weeks of gestation achieved successful induction and vaginal delivery after controlled-release vaginal dinoprostone, and few short-term adverse events were recorded. Baseline Bishop score was associated with induction success. The absence of a comparison group and the modest sample size prevent conclusions about comparative efficacy or rare-event safety. These findings are most applicable to monitored inpatient care in women with singleton cephalic pregnancies, an unscarred uterus, and Bishop score ≤4. Larger multicenter comparative studies are needed before broader generalization.
Acknowledgments
The authors thank the staff of the Delivery Department and the Department of Planning and General Affairs, Thai Binh Obstetrics and Gynecology Hospital, for their support during data collection and clinical monitoring.
Funding Statement
The authors received no external funding for this work.
Abbreviations
BMI, body mass index; CI, confidence interval; CTG, cardiotocography; FGR, fetal growth restriction; IOL, induction of labor; OR, odds ratio; PROM, prelabor rupture of membranes; SD, standard deviation; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology.
Data Sharing Statement
The data supporting the findings of this study are not publicly available because they contain clinical information and are subject to institutional privacy restrictions. De-identified data may be available from the corresponding author upon reasonable request and with permission from Thai Binh Obstetrics and Gynecology Hospital and Thai Binh University of Medicine and Pharmacy.
Consent for Publication
This manuscript contains no identifiable individual images, videos, or personal details. Therefore, specific consent for publication of identifiable material was not required.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Specifically, Kien Trung Nguyen and Tien Minh Bui conceived and designed the study. Trang Thao Duong and Tuyen Thi Thanh Bui contributed to data acquisition and clinical data collection. Kien Trung Nguyen and Tuyen Thi Thanh Bui performed the statistical analysis and interpreted the data. Tien Minh Bui and Kien Trung Nguyen drafted the manuscript, and all authors revised it critically for important intellectual content. Tien Minh Bui supervised the study. All authors read and approved the final manuscript.
Disclosure
The authors declare no conflicts of interest in this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are not publicly available because they contain clinical information and are subject to institutional privacy restrictions. De-identified data may be available from the corresponding author upon reasonable request and with permission from Thai Binh Obstetrics and Gynecology Hospital and Thai Binh University of Medicine and Pharmacy.