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Study design and participants This study employed a prospective, nested casecontrol design embedded within four independent pregnancy cohorts: a discovery cohort from the University of Alabama at Birmingham (UAB), a longitudinal validation cohort from Stanford University (California), and two external validation cohorts in China (NCT06664554) to assess cross-population applicability: Hangzhou Womens Hospital (Asia 1) and Shenzhen Maternity and Child Health Hospital (Asia 2)

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