Prenatal Ultrasound and Genetic Analysis of PIK3CA-Related Fetal Overgrowth: A Case Report

Prenatal Ultrasound and Genetic Analysis of PIK3CA-Related Fetal Overgrowth: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Prenatal Ultrasound and Genetic Analysis of PIK3CA-Related Fetal Overgrowth: A Case Report Tingting Ge, xiyuan Deng, Xiaoyu Song, Yafei Wang, Xiaozhuan Wang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6477397/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective To analyze the ultrasonographic features and genetic etiology of fetal overgrowth caused by PIK3CA variant, and to provide references for prenatal diagnosis and genetic counseling. Method Whole exome sequencing was performed on the fetus and her parents. Sanger sequencing was used to verify the candidate pathogenic genes. Result At 27 +6 weeks of gestation, the fetus showed an enlarged biparietal diameter (85.8mm) and head circumference (313.4mm), along with other abnormalities such as a widened Wechsler's lumen, a thinner corpus callosum, a widened third ventricle, a right choroid plexus cyst, and a single umbilical artery. MRI revealed an enlarged right lateral ventricle and bilateral subependymal cysts. By 30 +0 weeks, these measurements continued to increase, and the forehead and hindbrain were notably prominent. Invasive prenatal diagnosis, including routine karyotype analysis and whole exome sequencing (WES), identified a de novel PIK3CA variant, c.1133G>A(p.Cys378Tyr), according to the ACMG guidelines, this variant was classified as likely pathogenic(PS2+PP2+PM2_Supportong+PP3). The condition was diagnosed as PIK3CA -related overgrowth spectrum, leading the family to terminate the pregnancy after ethical consultation. Conclusions Fetal overgrowth with macroencephaly is caused by a missense variant in PIK3CA . The discovery of this variant expands the phenotypic spectrum of PIK3CA and provides a new direction and basis for genetic counseling and prenatal diagnosis of fetal overgrowth. PIK3CA-related Overgrowth Spectrum (PROS) Prenatal diagnosis Fetal Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction A 21-year-old pregnant woman who conceived naturally. Both partners were in good health and were not related by blood. There was no reported history of exposure to toxic substances or radiation prior to or during the pregnancy, and the patient reported no genetic history. At 25 +2 weeks of gestation, ultrasound examination indicated that the fetal growth parameters exceeded the expected values for the gestational age, biparietal diameter (BPD) measured 72.5mm, head circumference (HC) measured 265.5mm, although the oral glucose tolerance test (OGTT) results were normal. By 27 weeks of gestation, Referral to our hospital. Ultrasound findings at 27 +6 weeks revealed a BPD of 85.8 mm (＞5+SD), HC of 313.4 mm (＞5+SD). Besides, widening of the Wechsler lumen, thinning of the corpus callosum, enlargement of the third ventricle, a right choroid plexus cyst, and a single umbilical artery. Magnetic resonance imaging (MRI) further identified dilatation of the right lateral ventricle and the presence of subependymal cysts in the anterior aspect of the bilateral ventricles. At 30 weeks of gestation, the fetus exhibited continued growth in biparietal diameter and head circumference, with notable prominence of the forehead and hindbrain (Figure 1)，the BPD of 95.2mm, the HC of 363.1mm. the growth curve is obviously abnormal (Figure 2). Consequently, an invasive prenatal diagnostic procedure was conducted. Routine karyotype analysis and chromosomal copy number variation examination yielded normal results, prompting the performance of WES on the amniotic fluid. By using WES, the fetus identified a de novel heterzygous variant c.1133G>A (p.Cys378Tyr)in the PIK3CA , (Figure 3), in, while both parents were confirmed to be wild-type. According to the American College of Medical Genetics and Genomics (ACMG) guidelines [1] , this variant was classified as likely pathogenic, with the following evidence: PS2 (a de novo variant in the patient with no family history, verified by parental testing), PP2 (a novel missense variant in a gene where missense variants are known to cause disease and the proportion of benign variants is low), and PM2_Supporting (variants not present in the normal control population or at very low frequency in recessive genetic diseases, as per the ESP, 1000 Genomes, and the ExAC) and PP3(multiple software predict it as a harmful variant). The condition associated with PIK3CA variants is currently defined within the PIK3CA -related overgrowth spectrum. Currently, there is no definitive treatment for postnatal overgrowth, and the success rate of existing interventions remains low. Consequently, following deliberations by the ethics committee, the family opted for termination of the pregnancy. The aborted fetus weighed 4130 grams (Figure 4). The clinical diagnosis included fetal megalencephaly, a missense variant in the PIK3CA , and a fetal monogenic disorder. This study received approval from the hospital's Ethics Committee, with the approval number: (2024) GSFY Ethics Review [07]. Informed consent was obtained from the family members, who agreed to the collection of blood samples and clinical data. Discussion The primary characteristic of PIK3CA -Related Overgrowth Spectrum (PROS) is segmental or focal overgrowth, which may occur with or without dysplasia from birth or early childhood. The principal regions affected by overgrowth include the brain, limbs, trunk, and face, typically exhibiting an asymmetric distribution. This is evident in conditions such as megalencephaly capillary malformation syndrome (MCAP), hemihyperplastic polylipomatosis (HHML), CLOVES syndrome, and a range of associated rare syndromes [ 2 ] . The PIK3CA encodes the p110α subunit of phosphatidylinositol 3-kinase (PI3K), which has been recognized as an oncogene. Currently, there are limited prenatal cases of PROS documented. In this context, we present a case of PROS characterized by progressive enlargement of head circumference and biparietal diameter, attributed to a PIK3CA variant identified through amniotic fluid whole exome sequencing. In this study, ultrasound examinations revealed a progressive increase in fetal biparietal diameter and head circumference during the second and third trimesters. Whole-exome sequencing identified a missense variant in the PIK3CA , which is infrequently detected prenatally. The PIK3CA encodes a component of the PI3K protein complex, a lipid kinase involved in the PI3K-Akt-mTOR signaling pathway. This pathway is critical for regulating cell proliferation, metabolism, survival, and angiogenesis. Variants in the PIK3CA can lead to aberrant PI3K activity, resulting in uncontrolled cell division and fetal overgrowth. When variants occur in the PIK3CA , they are linked to various abnormalities, including fibrofatty hyperplasia or overgrowth, HHML, CLOVES syndrome, macrodactyly, hemihypertrophy, associated megalencephaly, megalencephaly-capillary malformation and hypertrichosis, hemimegalencephaly syndrome, and dermatological manifestations such as benign lichen keratosis (BLK), epidermal nevus (EN), and seborrheic keratosis (SK). The overlapping yet distinct clinical presentations of these disorders contribute to terminological confusion. In 2013, the National Institutes of Health (NIH) convened a comprehensive discussion on recent advancements in clinical and molecular research, culminating in the consensus to adopt the term " PIK3CA -Related Overgrowth Spectrum (PROS)" to encompass these conditions. The core features of this disease are the presence of somatic PIK3CA variant, congenital or early childhood onset /focal overgrowth with or without cellular dysplasia, feature as descriped in either A or B, A.spectrum(two or more feature)1. Overgrowth of any multiple tissues, brain, fat, blood vessels, muscle, bone, nerve; 2. Vascular malformation: capillary, venous, arteriovenous, malformation, lymphatic; 3. spidermal nevus. B: single feature.1. Large Isolated Lymphatic Malformation; 2. Isolated Macrodactyly OR Overgrown Splayed Feet/ Hands, Overgrown Limbs; 3. Truncal Adipose Overgrowth; 4. Hemimegalencephaly (bilateral)/ Dysplastic Megalencephaly/ Focal Cortical Dysplasia; 5. Epidermal nevus; 6. Seborrheic Keratoses; 7. Benign Lichenoid Keratoses [ 3 ] . In the academic literature, prenatal ultrasound findings indicative of fetal overgrowth and progressive megalencephaly, along with additional manifestations such as ventriculomegaly, pleural effusion, polyhydramnios, limb asymmetry, and frontal bulging [ 4 – 6 ] , have been associated with MCAP syndrome. Scharf et al. [ 7 ] documented the prenatal identification of fetal cystic cavernous lymphangioma characterized by significant blood flow and progressive enlargement; however, the pregnant woman declined amniocentesis. Following delivery by cesarean section at term, a missense variant c.1633G > A (p.Glu545Lys) was identified to confirm the diagnosis. All cases were classified under the PROS in accordance with the latest guidelines. The predominant cause of fetal macrosomia is gestational diabetes mellitus. In this study, pregnant women who tested negative for glucose tolerance and experienced natural pregnancies exhibited normal fetal size during the first trimester. However, in the second trimester, the biparietal diameter and head circumference of the fetuses increased progressively, significantly exceeding the measurements expected for the corresponding gestational weeks, indicating a state of overgrowth. WES of amniotic fluid identified a missense variant in the PIK3CA , c.1133G > A (p.Cys378Tyr), with both parents exhibiting the wild-type allele. The fetus was clinically diagnosed with PROS. Unfortunately, the diagnosis was made at 34 weeks of gestation. In accordance with the wishes of the pregnant woman and her family, and following approval from the ethics committee, labor was induced. Currently, there is no effective treatment for PROS, highlighting the importance of prenatal diagnosis. For the prenatal detection of conditions such as fetal overgrowth and vascular abnormalities, it is essential to conduct not only CNV-seq to exclude micro-duplications and micro-deletions but also more comprehensive WES analysis. Di et al. [ 8 ] reported a case involving a 6-year-old boy who exhibited mild macrosomia at birth (birth weight + 2.44 SD, body length + 1.8 SD, and HC + 3.3 SD). At the age of 5 years, brain MRI revealed an enlarged cerebellar vermis and mild polymicrogyria, with a head circumference of + 3.1 SD at age 6. Sanger sequencing identified a novel heterozygous missense variant in the PIK3CA , c.335 T > A(p.Ile112Asn). Zeng Ting et al. [ 9 ] documented a case involving a 4-year-old female patient presenting with intellectual disability, an unstable gait, a head circumference of 56.9 cm (> 2.0 SD), and Chiari malformation type I accompanied by obstructive hydrocephalus. The developmental quotient, as assessed by the Gesell Developmental Scale, was 32. WES revealed a de novo variant, c.1133G > A,p.Cys378Tyr, in the PIK3CA , while both parents exhibited the wild-type. This study identified a PIK3CA missense variant and megalencephaly prenatally, which not only contributes to reducing the incidence of birth defects but also mitigates potential adverse effects on pregnant women and their families. Furthermore, this research has broadened the prenatal phenotypic spectrum of PROS and suggests that the PIK3CA missense variant may be a potential genetic factor for macrosomia and macrocephaly. Consequently, ongoing prenatal ultrasound monitoring is essential. In instances where abnormal fetal growth parameters are detected, comprehensive structural screening and invasive prenatal diagnostic procedures become imperative, particularly in cases of progressive asymmetric enlargement. This study identifies that PIK3CA -related overgrowth spectrum (PROS), attributed to variants in the PIK3CA , manifests as a progressive increase in fetal head circumference and biparietal diameter, accompanied by abnormal fetal brain structures. These findings were elucidated through whole-exome sequencing of amniotic fluid, thereby enhancing prenatal understanding of the condition and broadening the prenatal phenotypic spectrum associated with PIK3CA variants. This research offers novel insights and a foundational basis for genetic counseling and prenatal diagnosis in cases of fetal overgrowth. Abbreviation WES whole exome sequencing BPD biparietal diameter HC head circumference ACMG American College of Medical Genetics and Genomics PROS PIK3CA -Related Overgrowth Spectrum Declarations Ethics approval and consent to participate The present study was approved by the Medical Ethics Committee of Gansu Provincial Maternity and Child-care Hospital (No. (2024) GSFY Ethics Review [07]), and written informed consent for treatment was obtained from study participants. Consent for publication Written informed consent for publication of case report was obtained from study participants. Competing interests The authors declare no competing interests. Acknowledgements We thank the patients for their cooperation for this study. Author Contributions Tingting Ge, DengxiYuan wrote the main manuscript text. Xiaoyu Song performed ultrasound examination. Chunying Li,Yafei Wang prepared figures 1-3. Xiaozhuan Wang prepared figures 4. Chuan Zhang performed the genetic analysis. Xiaojuan Lin conceptualizing and supervising the study design. All authors reviewed the manuscript. Funding Science and Technology Project of Gansu Province (Youth Science and Technology Fund) (23JRRA1752), Lanzhou Science and Technology Plan Project (2022-3-15), Gansu Provincial Science and Technology Plan Project (21JR11RA171、22YF7FA094), Hospital Research Fund Project Support Project (GMCCH2024-2-2, GMCCH2025-2-3-08). Availability of data and materials The data used to support the findings of this study are available from the corresponding author upon request (Xiaojuan Lin, email: [email protected] ). The variant have been submitted to the Clinvar (https://www.ncbi.nlm.nih.gov/ clinvar/) and the accession numbers was SCV006080933. References Richards S, Aziz N, Bale S, et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology [J]. Genet Med, 2015, 17(5): 405-424. Mirzaa G, Graham JM, Jr., Keppler-Noreuil K. PIK3CA-Related Overgrowth Spectrum [J][A]. In: GeneReviews(®) (Adam MP, Feldman J, Mirzaa GM et al., eds). Seattle (WA): University of Washington, Seattle Copyright © 1993-2024, University of Washington, Seattle. GeneReviews is a registered trademark of the University of Washington, Seattle. All rights reserved., 1993. Keppler-Noreuil KM, Rios JJ, Parker VE, et al. PIK3CA-related overgrowth spectrum (PROS): diagnostic and testing eligibility criteria, differential diagnosis, and evaluation [J]. Am J Med Genet A, 2015, 167a(2): 287-295. Nyberg RH, Uotila J, Kirkinen P, et al. Macrocephaly-cutis marmorata telangiectatica congenita syndrome--prenatal signs in ultrasonography [J]. Prenat Diagn, 2005, 25(2): 129-132. Swarr DT, Khalek N, Treat J, et al. Expanding the differential diagnosis of fetal hydrops: an unusual prenatal presentation of megalencephaly-capillary malformation syndrome [J]. Prenat Diagn, 2013, 33(10): 1010-1012. Emrick LT, Murphy L, Shamshirsaz AA, et al. Prenatal diagnosis of CLOVES syndrome confirmed by detection of a mosaic PIK3CA mutation in cultured amniocytes [J]. Am J Med Genet A, 2014, 164a(10): 2633-2637. Scharf JL, Gembicki M, Dracopoulos C, et al. Lymphangioma of the fetal neck within the PIK3CA‐related‐overgrowth spectrum (PROS): A case report [J]. Clinical Case Reports, 2021, 9(7). Di Donato N, Rump A, Mirzaa GM, et al. Identification and Characterization of a Novel Constitutional PIK3CA Mutation in a Child Lacking the Typical Segmental Overgrowth of "PIK3CA-Related Overgrowth Spectrum" [J]. Hum Mutat, 2016, 37(3): 242-245. Zeng T, Zeng P P, Guo Y, et al. Megalencephaly-capillary malformation-polymicrogyria syndrome caused by PIK3CA gene mutation: a case report and literature review [J] Clin Pediatr, 2019, 37(07): 549-552. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 29 Jul, 2025 Reviewers agreed at journal 04 Jul, 2025 Reviewers invited by journal 25 Jun, 2025 Editor assigned by journal 18 Jun, 2025 Editor invited by journal 29 May, 2025 Submission checks completed at journal 28 May, 2025 First submitted to journal 28 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6477397","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":477386840,"identity":"ca66db3e-9fbe-44c1-a256-9553238d4822","order_by":0,"name":"Tingting Ge","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tingting","middleName":"","lastName":"Ge","suffix":""},{"id":477386843,"identity":"f4545a1e-039a-4349-9039-ba8b07063d21","order_by":1,"name":"xiyuan Deng","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":false,"prefix":"","firstName":"xiyuan","middleName":"","lastName":"Deng","suffix":""},{"id":477386844,"identity":"ba7fbdc9-dba9-43de-9f6d-14f27d6e072b","order_by":2,"name":"Xiaoyu Song","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyu","middleName":"","lastName":"Song","suffix":""},{"id":477386845,"identity":"eba50394-bbaf-48bc-83e2-a86bfb5bfef7","order_by":3,"name":"Yafei Wang","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yafei","middleName":"","lastName":"Wang","suffix":""},{"id":477386846,"identity":"8d38c431-145e-4d1d-a688-54d91c92d910","order_by":4,"name":"Xiaozhuan Wang","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaozhuan","middleName":"","lastName":"Wang","suffix":""},{"id":477386847,"identity":"c6ef224b-8b2f-4757-8262-1a130a25fe0f","order_by":5,"name":"Chunying Li","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chunying","middleName":"","lastName":"Li","suffix":""},{"id":477386848,"identity":"34fd0e74-3683-45b8-b8b7-1baf9f49dff9","order_by":6,"name":"Chuan Zhang","email":"","orcid":"","institution":"Gansu Provincial Maternity and Child Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chuan","middleName":"","lastName":"Zhang","suffix":""},{"id":477386849,"identity":"eb1e29fa-a9a3-4c0a-834c-6c8207d03c2d","order_by":7,"name":"Xiaojuan Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACxgbmhgNAmoePvbHx4QfitDBCtLDxHG42liDWHjDFJpHeJsBDjAbmGYmNhwtz7GTYJB+2MUgw2MnpNhCyo+dgw+GZ25J52KQT2x4UMCQbmx0gpKW9seEw7zZmkJZ2AwmGA4nbCGppZgRpqedhkzzYJsFDlBaILYd52CQYidUC8gvvtuPAQE4EBrIBEX4xnJF8+DPvtmp7fvbjDx9+qLCTI6ylAYVrQEA5CMgToWYUjIJRMApGOgAAI+Y/eucXy+wAAAAASUVORK5CYII=","orcid":"","institution":"Gansu Provincial Maternity and Child-care Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiaojuan","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2025-04-18 08:23:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6477397/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6477397/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85819487,"identity":"3a5ee1f4-26c3-44b5-b587-e692b3300daf","added_by":"auto","created_at":"2025-07-02 06:19:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160976,"visible":true,"origin":"","legend":"\u003cp\u003ePrenatal ultrasound images. a widening of the Wechsler lumen, enlargement of the third ventricle; b notable prominence of the forehead and hindbrain; c ultrasound in 3-D mode showed the face of the fetus.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6477397/v1/7a67bc469767a7802564a807.png"},{"id":85819005,"identity":"51eaf99d-5bea-4479-a86c-9210aa762037","added_by":"auto","created_at":"2025-07-02 06:11:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":95216,"visible":true,"origin":"","legend":"\u003cp\u003eFetal growth and development curve，a BPD of the fetal；b HC of the fetal\u003c/p\u003e\n\u003cp\u003eBPD: Biparietal diameter; HC: head circumference\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6477397/v1/62fb11b5f4817cb8d551efcf.png"},{"id":85819007,"identity":"56aba8f1-b95c-4147-bbc1-b0a9e6efbfef","added_by":"auto","created_at":"2025-07-02 06:11:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":49363,"visible":true,"origin":"","legend":"\u003cp\u003eSanger sequencing identified a novel heterozygous missense variant in the PIK3CA gene, c.335 T\u0026gt;A(p.Ile112Asn). The top chromatograms are from the fetus, the middle two are from the father, and the bottom two are from the mother.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6477397/v1/9bae6b6443f2fcf850ce54dd.png"},{"id":85819008,"identity":"7cf22895-7d5b-4040-b2ef-4a7923378b2f","added_by":"auto","created_at":"2025-07-02 06:11:09","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":232966,"visible":true,"origin":"","legend":"\u003cp\u003eGross anatomy of the aborted fetus, showing the fetal head was markedly enlarged\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6477397/v1/c6f71ddce4963204a9aa09b7.png"},{"id":85820500,"identity":"613ac5d2-07dd-4ba7-8610-050b135f4978","added_by":"auto","created_at":"2025-07-02 06:27:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":960764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6477397/v1/f06830ee-a64e-45ca-97f4-f4590ef21b9c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prenatal Ultrasound and Genetic Analysis of PIK3CA-Related Fetal Overgrowth: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA 21-year-old pregnant woman who conceived naturally. Both partners were in good health and were not related by blood. There was no reported history of exposure to toxic substances or radiation prior to or during the pregnancy, and the patient reported no genetic history. At 25\u003csup\u003e+2\u003c/sup\u003eweeks of gestation, ultrasound examination indicated that the fetal growth parameters exceeded the expected values for the gestational age, biparietal diameter (BPD) measured 72.5mm, head circumference (HC) measured 265.5mm, although the oral glucose tolerance test (OGTT) results were normal. By 27 weeks of gestation, Referral to our hospital. Ultrasound findings at 27\u003csup\u003e+6\u003c/sup\u003eweeks revealed a BPD of 85.8 mm (＞5+SD), HC of 313.4 mm (＞5+SD). Besides, widening of the Wechsler lumen, thinning of the corpus callosum, enlargement of the third ventricle, a right choroid plexus cyst, and a single umbilical artery. Magnetic resonance imaging (MRI) further identified dilatation of the right lateral ventricle and the presence of subependymal cysts in the anterior aspect of the bilateral ventricles. At 30 weeks of gestation, the fetus exhibited continued growth in biparietal diameter and head circumference, with notable prominence of the forehead and hindbrain (Figure 1)，the BPD of 95.2mm, the HC of 363.1mm. the growth curve is obviously abnormal (Figure 2). Consequently, an invasive prenatal diagnostic procedure was conducted. Routine karyotype analysis and chromosomal copy number variation examination yielded normal results, prompting the performance of WES on the amniotic fluid. By using WES, the fetus identified a de novel heterzygous variant c.1133G\u0026gt;A (p.Cys378Tyr)in the \u003cem\u003ePIK3CA\u003c/em\u003e, (Figure 3), in, while both parents were confirmed to be wild-type. According to\u0026nbsp;the\u0026nbsp;American College of Medical Genetics and Genomics\u0026nbsp;(ACMG)\u0026nbsp;guidelines\u003csup\u003e[1]\u003c/sup\u003e, this variant was classified as likely pathogenic, with the following evidence: PS2 (a de novo variant in the patient with no family history, verified by parental testing), PP2 (a novel missense variant in a gene where missense variants are known to cause disease and the proportion of benign variants is low), and PM2_Supporting (variants not present in the normal control population or at very low frequency in recessive genetic diseases, as per the ESP, 1000 Genomes, and the ExAC) and PP3(multiple software predict it as a harmful variant). The condition associated with\u003cem\u003e\u0026nbsp;PIK3CA\u003c/em\u003e variants is currently defined within the \u003cem\u003ePIK3CA\u003c/em\u003e-related overgrowth spectrum. Currently, there is no definitive treatment for postnatal overgrowth, and the success rate of existing interventions remains low. Consequently, following deliberations by the ethics committee, the family opted for termination of the pregnancy. The aborted fetus weighed 4130 grams (Figure 4). The clinical diagnosis included fetal megalencephaly, a missense variant in the \u003cem\u003ePIK3CA\u003c/em\u003e, and a fetal monogenic disorder. This study received approval from the hospital\u0026apos;s Ethics Committee, with the approval number: (2024) GSFY Ethics Review [07]. Informed consent was obtained from the family members, who agreed to the collection of blood samples and clinical data.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary characteristic of \u003cem\u003ePIK3CA\u003c/em\u003e-Related Overgrowth Spectrum (PROS) is segmental or focal overgrowth, which may occur with or without dysplasia from birth or early childhood. The principal regions affected by overgrowth include the brain, limbs, trunk, and face, typically exhibiting an asymmetric distribution. This is evident in conditions such as megalencephaly capillary malformation syndrome (MCAP), hemihyperplastic polylipomatosis (HHML), CLOVES syndrome, and a range of associated rare syndromes\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The \u003cem\u003ePIK3CA\u003c/em\u003e encodes the p110\u0026alpha; subunit of phosphatidylinositol 3-kinase (PI3K), which has been recognized as an oncogene. Currently, there are limited prenatal cases of PROS documented. In this context, we present a case of PROS characterized by progressive enlargement of head circumference and biparietal diameter, attributed to a \u003cem\u003ePIK3CA\u003c/em\u003e variant identified through amniotic fluid whole exome sequencing.\u003c/p\u003e\n\u003cp\u003eIn this study, ultrasound examinations revealed a progressive increase in fetal biparietal diameter and head circumference during the second and third trimesters. Whole-exome sequencing identified a missense variant in the \u003cem\u003ePIK3CA\u003c/em\u003e, which is infrequently detected prenatally. The \u003cem\u003ePIK3CA\u003c/em\u003e encodes a component of the PI3K protein complex, a lipid kinase involved in the PI3K-Akt-mTOR signaling pathway. This pathway is critical for regulating cell proliferation, metabolism, survival, and angiogenesis. Variants in the \u003cem\u003ePIK3CA\u003c/em\u003e can lead to aberrant PI3K activity, resulting in uncontrolled cell division and fetal overgrowth.\u003c/p\u003e\n\u003cp\u003eWhen variants occur in the \u003cem\u003ePIK3CA\u003c/em\u003e, they are linked to various abnormalities, including fibrofatty hyperplasia or overgrowth, HHML, CLOVES syndrome, macrodactyly, hemihypertrophy, associated megalencephaly, megalencephaly-capillary malformation and hypertrichosis, hemimegalencephaly syndrome, and dermatological manifestations such as benign lichen keratosis (BLK), epidermal nevus (EN), and seborrheic keratosis (SK). The overlapping yet distinct clinical presentations of these disorders contribute to terminological confusion. In 2013, the National Institutes of Health (NIH) convened a comprehensive discussion on recent advancements in clinical and molecular research, culminating in the consensus to adopt the term \u0026quot;\u003cem\u003ePIK3CA\u003c/em\u003e-Related Overgrowth Spectrum (PROS)\u0026quot; to encompass these conditions. The core features of this disease are the presence of somatic \u003cem\u003ePIK3CA\u003c/em\u003e variant, congenital or early childhood onset /focal overgrowth with or without cellular dysplasia, feature as descriped in either A or B, A.spectrum(two or more feature)1. Overgrowth of any multiple tissues, brain, fat, blood vessels, muscle, bone, nerve; 2. Vascular malformation: capillary, venous, arteriovenous, malformation, lymphatic; 3. spidermal nevus. B: single feature.1. Large Isolated Lymphatic Malformation; 2. Isolated Macrodactyly OR Overgrown Splayed Feet/ Hands, Overgrown Limbs; 3. Truncal Adipose Overgrowth; 4. Hemimegalencephaly (bilateral)/ Dysplastic Megalencephaly/ Focal Cortical Dysplasia; 5. Epidermal nevus; 6. Seborrheic Keratoses; 7. Benign Lichenoid Keratoses\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn the academic literature, prenatal ultrasound findings indicative of fetal overgrowth and progressive megalencephaly, along with additional manifestations such as ventriculomegaly, pleural effusion, polyhydramnios, limb asymmetry, and frontal bulging\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, have been associated with MCAP syndrome. Scharf et al.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003edocumented the prenatal identification of fetal cystic cavernous lymphangioma characterized by significant blood flow and progressive enlargement; however, the pregnant woman declined amniocentesis. Following delivery by cesarean section at term, a missense variant c.1633G\u0026thinsp;\u0026gt;\u0026thinsp;A (p.Glu545Lys) was identified to confirm the diagnosis. All cases were classified under the PROS in accordance with the latest guidelines.\u003c/p\u003e\n\u003cp\u003eThe predominant cause of fetal macrosomia is gestational diabetes mellitus. In this study, pregnant women who tested negative for glucose tolerance and experienced natural pregnancies exhibited normal fetal size during the first trimester. However, in the second trimester, the biparietal diameter and head circumference of the fetuses increased progressively, significantly exceeding the measurements expected for the corresponding gestational weeks, indicating a state of overgrowth. WES of amniotic fluid identified a missense variant in the \u003cem\u003ePIK3CA\u003c/em\u003e, c.1133G\u0026thinsp;\u0026gt;\u0026thinsp;A (p.Cys378Tyr), with both parents exhibiting the wild-type allele. The fetus was clinically diagnosed with PROS. Unfortunately, the diagnosis was made at 34 weeks of gestation. In accordance with the wishes of the pregnant woman and her family, and following approval from the ethics committee, labor was induced. Currently, there is no effective treatment for PROS, highlighting the importance of prenatal diagnosis. For the prenatal detection of conditions such as fetal overgrowth and vascular abnormalities, it is essential to conduct not only CNV-seq to exclude micro-duplications and micro-deletions but also more comprehensive WES analysis.\u003c/p\u003e\n\u003cp\u003eDi et al.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e reported a case involving a 6-year-old boy who exhibited mild macrosomia at birth (birth weight\u0026thinsp;+\u0026thinsp;2.44 SD, body length\u0026thinsp;+\u0026thinsp;1.8 SD, and HC\u0026thinsp;+\u0026thinsp;3.3 SD). At the age of 5 years, brain MRI revealed an enlarged cerebellar vermis and mild polymicrogyria, with a head circumference of +\u0026thinsp;3.1 SD at age 6. Sanger sequencing identified a novel heterozygous missense variant in the \u003cem\u003ePIK3CA\u003c/em\u003e, c.335 T\u0026thinsp;\u0026gt;\u0026thinsp;A(p.Ile112Asn). Zeng Ting et al.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e documented a case involving a 4-year-old female patient presenting with intellectual disability, an unstable gait, a head circumference of 56.9 cm (\u0026gt;\u0026thinsp;2.0 SD), and Chiari malformation type I accompanied by obstructive hydrocephalus. The developmental quotient, as assessed by the Gesell Developmental Scale, was 32. WES revealed a de novo variant, c.1133G\u0026thinsp;\u0026gt;\u0026thinsp;A,p.Cys378Tyr, in the \u003cem\u003ePIK3CA\u003c/em\u003e, while both parents exhibited the wild-type. This study identified a \u003cem\u003ePIK3CA\u003c/em\u003e missense variant and megalencephaly prenatally, which not only contributes to reducing the incidence of birth defects but also mitigates potential adverse effects on pregnant women and their families. Furthermore, this research has broadened the prenatal phenotypic spectrum of PROS and suggests that the \u003cem\u003ePIK3CA\u003c/em\u003e missense variant may be a potential genetic factor for macrosomia and macrocephaly.\u003c/p\u003e\n\u003cp\u003eConsequently, ongoing prenatal ultrasound monitoring is essential. In instances where abnormal fetal growth parameters are detected, comprehensive structural screening and invasive prenatal diagnostic procedures become imperative, particularly in cases of progressive asymmetric enlargement. This study identifies that \u003cem\u003ePIK3CA\u003c/em\u003e-related overgrowth spectrum (PROS), attributed to variants in the \u003cem\u003ePIK3CA\u003c/em\u003e, manifests as a progressive increase in fetal head circumference and biparietal diameter, accompanied by abnormal fetal brain structures. These findings were elucidated through whole-exome sequencing of amniotic fluid, thereby enhancing prenatal understanding of the condition and broadening the prenatal phenotypic spectrum associated with \u003cem\u003ePIK3CA\u003c/em\u003e variants. This research offers novel insights and a foundational basis for genetic counseling and prenatal diagnosis in cases of fetal overgrowth.\u003c/p\u003e"},{"header":"Abbreviation","content":"\u003cp\u003eWES whole exome sequencing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBPD biparietal diameter\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHC head circumference \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eACMG American College of Medical Genetics and Genomics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePROS\u003cem\u003e\u0026nbsp;PIK3CA\u003c/em\u003e-Related Overgrowth Spectrum\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was approved by the Medical Ethics Committee of \u0026nbsp;Gansu Provincial Maternity and Child-care Hospital (No. (2024) GSFY Ethics Review [07]), and written informed consent for treatment was obtained from study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of case report was obtained from study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patients for their cooperation for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTingting Ge, DengxiYuan wrote the main manuscript text. Xiaoyu Song performed ultrasound examination. Chunying Li,Yafei Wang prepared figures 1-3. Xiaozhuan Wang prepared figures 4. Chuan Zhang performed the genetic analysis. Xiaojuan Lin conceptualizing and supervising the study design. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eScience and Technology Project of Gansu Province (Youth Science and Technology Fund) (23JRRA1752), Lanzhou Science and Technology Plan Project (2022-3-15), Gansu Provincial Science and Technology Plan Project (21JR11RA171、22YF7FA094), Hospital Research Fund Project Support Project (GMCCH2024-2-2, GMCCH2025-2-3-08).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author upon request (Xiaojuan Lin, email: [email protected]). The variant have been submitted to the Clinvar (https://www.ncbi.nlm.nih.gov/ clinvar/) and the accession numbers was SCV006080933.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRichards S, Aziz N, Bale S, et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology [J]. Genet Med, 2015, 17(5): 405-424.\u003c/li\u003e\n \u003cli\u003eMirzaa G, Graham JM, Jr., Keppler-Noreuil K. PIK3CA-Related Overgrowth Spectrum [J][A]. In: \u003cem\u003eGeneReviews(\u0026reg;)\u003c/em\u003e (Adam MP, Feldman J, Mirzaa GM et al., eds). Seattle (WA): University of Washington, Seattle Copyright \u0026copy; 1993-2024, University of Washington, Seattle. GeneReviews is a registered trademark of the University of Washington, Seattle. All rights reserved., 1993.\u003c/li\u003e\n \u003cli\u003eKeppler-Noreuil KM, Rios JJ, Parker VE, et al. PIK3CA-related overgrowth spectrum (PROS): diagnostic and testing eligibility criteria, differential diagnosis, and evaluation [J]. Am J Med Genet A, 2015, 167a(2): 287-295.\u003c/li\u003e\n \u003cli\u003eNyberg RH, Uotila J, Kirkinen P, et al. Macrocephaly-cutis marmorata telangiectatica congenita syndrome--prenatal signs in ultrasonography [J]. Prenat Diagn, 2005, 25(2): 129-132.\u003c/li\u003e\n \u003cli\u003eSwarr DT, Khalek N, Treat J, et al. Expanding the differential diagnosis of fetal hydrops: an unusual prenatal presentation of megalencephaly-capillary malformation syndrome [J]. Prenat Diagn, 2013, 33(10): 1010-1012.\u003c/li\u003e\n \u003cli\u003eEmrick LT, Murphy L, Shamshirsaz AA, et al. Prenatal diagnosis of CLOVES syndrome confirmed by detection of a mosaic PIK3CA mutation in cultured amniocytes [J]. Am J Med Genet A, 2014, 164a(10): 2633-2637.\u003c/li\u003e\n \u003cli\u003eScharf JL, Gembicki M, Dracopoulos C, et al. Lymphangioma of the fetal neck within the PIK3CA‐related‐overgrowth spectrum (PROS): A case report [J]. Clinical Case Reports, 2021, 9(7).\u003c/li\u003e\n \u003cli\u003eDi Donato N, Rump A, Mirzaa GM, et al. Identification and Characterization of a Novel Constitutional PIK3CA Mutation in a Child Lacking the Typical Segmental Overgrowth of \u0026quot;PIK3CA-Related Overgrowth Spectrum\u0026quot; [J]. Hum Mutat, 2016, 37(3): 242-245.\u003c/li\u003e\n \u003cli\u003eZeng T, Zeng P P, Guo Y, et al. Megalencephaly-capillary malformation-polymicrogyria syndrome caused by PIK3CA gene mutation: a case report and literature review [J] Clin Pediatr, 2019, 37(07): 549-552.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-genomics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mgnm","sideBox":"Learn more about [BMC Medical Genomics](http://bmcmedgenomics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mgnm/default.aspx","title":"BMC Medical Genomics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"PIK3CA-related Overgrowth Spectrum (PROS), Prenatal diagnosis, Fetal","lastPublishedDoi":"10.21203/rs.3.rs-6477397/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6477397/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e To analyze the ultrasonographic features and genetic etiology of fetal overgrowth caused by PIK3CA variant, and to provide references for prenatal diagnosis and genetic counseling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e Whole exome sequencing was performed on the fetus and her parents. Sanger sequencing was used to verify the candidate pathogenic genes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e At 27\u003csup\u003e+6\u003c/sup\u003eweeks of gestation, the fetus showed an enlarged biparietal diameter (85.8mm) and head circumference (313.4mm), along with other abnormalities such as a widened Wechsler's lumen, a thinner corpus callosum, a widened third ventricle, a right choroid plexus cyst, and a single umbilical artery. MRI revealed an enlarged right lateral ventricle and bilateral subependymal cysts. By 30\u003csup\u003e+0 \u003c/sup\u003eweeks, these measurements continued to increase, and the forehead and hindbrain were notably prominent. Invasive prenatal diagnosis, including routine karyotype analysis and whole exome sequencing (WES), identified a de novel \u003cem\u003ePIK3CA\u003c/em\u003e variant, c.1133G\u0026gt;A(p.Cys378Tyr), according to the ACMG guidelines, this variant was classified as likely pathogenic(PS2+PP2+PM2_Supportong+PP3). The condition was diagnosed as \u003cem\u003ePIK3CA\u003c/em\u003e-related overgrowth spectrum, leading the family to terminate the pregnancy after ethical consultation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e Fetal overgrowth with macroencephaly is caused by a missense variant in \u003cem\u003ePIK3CA\u003c/em\u003e. The discovery of this variant expands the phenotypic spectrum of PIK3CA and provides a new direction and basis for genetic counseling and prenatal diagnosis of fetal overgrowth.\u003c/p\u003e","manuscriptTitle":"Prenatal Ultrasound and Genetic Analysis of PIK3CA-Related Fetal Overgrowth: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 06:11:04","doi":"10.21203/rs.3.rs-6477397/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-29T07:28:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315339293591465353814970987397987395849","date":"2025-07-04T06:08:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-25T11:22:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T09:53:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-29T09:38:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T05:21:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Genomics","date":"2025-05-28T05:20:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-genomics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mgnm","sideBox":"Learn more about [BMC Medical Genomics](http://bmcmedgenomics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mgnm/default.aspx","title":"BMC Medical Genomics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9dc0ff87-f839-4b38-a9b8-75b1ecdb8065","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-02T06:11:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 06:11:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6477397","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6477397","identity":"rs-6477397","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}