Emergency Peripartum Hysterectomy Research Articles

Emergency peripartum hysterectomy: a 9-year review

To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy. A retrospective study of the patients requiring an emergency peripartum hysterectomy of a 9-year period was conducted. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 h after delivery. Demographic and clinical variables were obtained from the maternal records. There were 34 emergency peripartum hysterectomies out of 117,095 deliveries for a rate of 0.29 per 1,000. Of the 16 cases that were delivered by cesarean section, seven had a previous cesarean section and 18 cases were delivered vaginally, including two using vacuum extraction. Total hysterectomy was performed in 24 patients, and subtotal hysterectomy in ten patients. The indications for hysterectomy were uterine rupture (n=12), placenta accreta (n=10), uterine atony (n=7), and hemorrhage (n=5). There were two maternal deaths, six stillbirths, and two early neonatal deaths. This study identified surgical deliveries, uterine rupture, placenta accreta, and uterine atony as risk factors for emergency peripartum hysterectomy. The most common reason for abnormal placental adherence was a previous cesarean section. Multiparity and oxytocin use for uterine stimulation were among the risk factors for uterine atony that necessitated emergency peripartum hysterectomy.

Emergency peripartum hysterectomy in a teaching hospital in Eastern Taiwan

SummaryThis study aims to review the incidence, indications, risk factors and complications associated with emergency peripartum hysterectomy in a teaching hospital. We reviewed records of patients undertaking emergency peripartum hysterectomy performed at our institution from 1998 to 2004. Emergency peripartum hysterectomy was defined as one performed for haemorrhage unresponsive to other treatments <24 h after delivery. Eight cases of emergency peripartum hysterectomy were performed. The rate of peripartum hysterectomy was 0.25%. The main indications for hysterectomy were uterine atony and abnormal placentation. No maternal death occurred. Use of peripartum hysterectomy may become necessary in managing obstetrical haemorrhage refractory to other measures.

Prise en charge chirurgicale des hémorragies sévères du post-partum

Surgical management of an intractable postpartum haemorrhage after failure of medical and obstetric measures is not limited to the emergency peripartum hysterectomy. Uterine atony and abnormal placental insertions are the major causes of primary postpartum haemorrhages. Involving mostly young women, having few or no child, before with a healthy uterus, in first intention conservative option is recommended. The simplest methods must be known and be applied. It will be essentially progressive uterine arteries' ligation, which can be adapted to the majority of situations. Internal iliac arteries' ligation is a little less effective and technically more difficult to carry out. It remains interesting in obstetrical traumatic hurts, which do not concern the uterus. New and easier surgical methods, such as uterine compression or hemostatic suturing techniques have been described for which we lack experience. The quality of the result depends of the length of intervention and the cause of the bleeding. Nevertheless the main cause of failure with conservative treatments is placenta accreta. In case of failure of a conservative treatment, it would be dangerous to multiply techniques. Emergency peripartum hysterectomy then should remain the choice procedure.

Emergency peripartum hysterectomy: A prospective study in The Netherlands

Objective To determine the incidence, indication, association with caesarean section (CS) and outcome of emergency peripartum hysterectomy (EPH) in The Netherlands. Study design All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of EPH between 1 April 2002 and 1 April 2003. For every case, a form with questions about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed. Results Eighty-nine (89%) hospitals participated and registered in total 48 EPH. The estimated incidence of EPH is 0.33/1000 births. The main indication for EPH was placenta accreta (50%), followed by uterine atony (27%). There were two maternal deaths (4%). Severe maternal morbidity included: urinary tract injury 15%, relaparotomy 25%, transfusion >10 units red blood cells 67%, intensive care admission 77%. Both previous CS and CS in the index pregnancy were associated with a significant increased risk of EPH. The number of previous CS was related to an increased risk of placenta accreta, from 0.19% for one previous CS to 9.1% for four or more previous CS. Conclusion Emergency peripartum hysterectomy is associated with a high incidence of maternal morbidity and a case fatality rate of 4%. It is significantly related to CS in index or previous pregnancy. Placenta accreta is the most common indication to perform a peripartum hysterectomy.

Risk factors for emergency peripartum cesarean hysterectomy

Emergency peripartum hysterectomy was performed for management of intractable obstetric hemorrhage that was unresponsive to other treatment. The procedure is often associated with a relatively high morbidity and mortality especially when performed under emergency life-threatening situation. Most current case series reported the incidence of 1—3 per 1000 deliveries. This study was performed as case control study to evaluate data regarding the risk factors of emergency peripartum hysterectomy. The study design was a case-control study of pregnant women who delivered at Ramathibodi Hospital Mahidol University Bangkok Thailand during January 1997 to December 2002. Inclusion criteria was a pregnant woman who underwent emergency peripartum hysterectomy within 24 h after delivery which delivered a single infant or twins and gestational age = 28 weeks. (excerpt)

Is Peripartum Hysterectomy More Common in Multiple Gestations?

To compare the occurrence of peripartum hysterectomy between singleton and multiple gestations. This was a historical cohort study comparing the occurrence of peripartum hysterectomy between singleton and multiple gestations at Banner Good Samaritan Regional Medical Center, Phoenix, Arizona, from January 1, 1996, to December 31, 2001. During the study years, 42,595 singleton, 1,131 twin, 164 triplet, 35 quadruplet, and 2 quintuplet deliveries occurred. A total of 100 peripartum hysterectomies were performed. Of these hysterectomies, 88 occurred in singletons, 5 in twins, 6 in triplets, and 1 in quadruplets. The overall occurrence of peripartum hysterectomy was 2.28 per 1,000, and the occurrence of emergent peripartum hysterectomy was 1.73 per 1,000. Multiple gestations had a significantly greater risk of emergent peripartum hysterectomy than singletons (odds ratio [OR] 6.04, 95% confidence interval [CI] 3.28-11.11; P < .001). This difference was more pronounced among higher-order multiple gestations: twins (OR 2.95, 95% CI 1.22-7.13, P = .03), triplets (OR 25.22, 95% CI 11.02-57.77, P < .001), and quadruplets (OR 19.53, 95% CI 3.34-114.69, P = .04). When compared with singletons, higher-order multiple gestations had nearly a 24-fold increased risk of emergent peripartum hysterectomy (OR 23.97, 95% CI 11.05-51.99, P < .001). Multiple gestations have a significantly higher occurrence of emergent peripartum hysterectomy than singletons. This information should be used in counseling and managing patients with these pregnancies.

Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey

Objectives: The aim of this study was to find the incidence and clinical implications of peripartum hysterectomy in our hospital at the Eastern region of Anatolia. Study design: We analyzed retrospectively all cases of peripartum hysterectomy performed at YYU Medical Faculty Hospital between January 1995 and April 2003. Emergency peripartum hysterectomy was performed for hemorrhage which cannot be controlled with other conventional treatments within 24 h of a delivery. There were 24 cases of emergency peripartum hysterectomy performed. Results: The incidence of emergency peripartum hysterectomy was 5.09 per 1000 deliveries. Half of the hysterectomies followed cesarean section. Eleven patients were referred to our clinics from other hospitals. Uterine atony (45.8%) was the most common indication and placenta accreta (25.0%) was the second most common. Eighteen patients (75%) had subtotal hysterectomy. Bladder injury was seen in three cases. Re-exploration was performed in three cases (12.5%). Seventeen patients stayed in hospital over 7 days. There were four (16.7%) maternal deaths all of whom were referred from other hospitals. Conclusion: The mortality and morbidity of performing a peripartum hysterectomy is elevated, especially if performed in critical patients referred from other hospitals.

Emergency peripartum hysterectomy in a tertiary London hospital

The objective was to review all emergency peripartum hysterectomies performed at a tertiary hospital in London, UK, and to identify the risk factors for emergency peripartum hysterectomy. A retrospective case control study. The cases consisted of all women who had emergency peripartum hysterectomy between 1 January 1993 and 31 December 2003. Controls were women who delivered immediately before and after the indexed case. Demographic data, medical and surgical histories, pregnancy, intrapartum and postpartum data were collected. Differences between cases and controls were compared with chi2, Fisher exact and Student t tests. Multiple logistic regression analysis was performed to identify independent risk factors for emergency peripartum hysterectomy. There were 15 cases of emergency peripartum hysterectomy in 31,079 deliveries, giving a rate of 0.48 per 1,000. Women who had emergency peripartum hysterectomy were significantly older (mean age 37 years vs. 29 years, P<0.001) and multiparous (P=0.02). More of the cases had a history of uterine surgery (67 vs. 30%, P=0.01), placenta praevia (60 vs. 3%, P<0.0001) and were delivered by caesarean section (86.7 vs. 30%, P=0.003). Eighty percent of the hysterectomies were performed in the daytime and all were done by consultants. Haemorrhage due to placenta praevia was the main indication for emergency peripartum hysterectomy (47%). Independent risk factors for emergency peripartum hysterectomy were older age (odds ratios [OR] 1.2, 95% confidence interval [95% CI] 1.2-1.6), multiparity (OR 2.6, 95% CI 1.3-10.2), history of previous caesarean section (OR 13.5, 95% CI 2.7-65.4), caesarean delivery in index pregnancy (OR 11.6, 95% CI 2.1-68.6) and caesarean delivery in index pregnancy for placenta praevia (OR 18, 95% CI 3.6-69). Caesarean deliveries, especially repeat caesareans in women with placenta praevia, significantly increase the risk of emergency peripartum hysterectomy.

Emergency Peripartum Hysterectomy due to Placenta Previa/Accreta: 10 Years' Experience

To identify risk factors for and sonographic findings, complications and outcomes of emergency peripartum hysterectomy due to placenta previa/accreta. This was a retrospective review and descriptive study of women who underwent emergency peripartum hysterectomy due to placenta previa/accreta at Chang Gung Memorial Hospital between 1992 and 2001. All emergency peripartum hysterectomies were considered by the responsible physician to be a lifesaving procedure. Each chart was reviewed with emphasis on risk factors, sonographic findings, complications and outcomes. There were 16 cases of emergency peripartum hysterectomy due to placenta previa/accreta (0.6/1,000 births). The mean hospitalization time was 8 days (range, 5–24 days) and the mean operation time was about 150 minutes (range, 85–335 mins). The estimated mean blood loss was 3,800 mL (range, 2,700–12,000 mL) and the mean amount of whole blood transfused was 15 units (range, 10–38 units). Two cases of bladder injury occurred when dissecting the bladder from the lower uterine segment and cervix. The association of placenta previa and prior cesarean delivery with placenta accreta and emergency peripartum hysterectomy is well documented. Emergency peripartum hysterectomy remains a potentially lifesaving procedure with which every practitioner of obstetrics must be familiar. In facilities that have interventional radiological services and well-trained angiographers available on a 24-hour basis, prophylactic placement of catheters for possible selective embolization may be considered in patients with placenta previa and a prior cesarean section and sonographic findings of placenta accreta. There should be a clear, tried and tested protocol for dealing with massive obstetric hemorrhage to decrease maternal morbidity and mortality.

Analysis of 59 cases of emergent peripartum hysterectomies during a 13-year period.

The objective was to investigate the incidence, indications, and risk factors of peripartum emergent hysterectomy. Fifty-nine cases of emergent peripartum hysterectomy performed at Zeynep Kamil Women and Children's Education and Research Hospital during a 13-year period between January 1990 and January 2003 were evaluated retrospectively. Emergent peripartum hysterectomy was defined as that performed for haemorrhage unresponsive to other therapeutic interventions within the first 24 h of delivery. Emergent peripartum hysterectomy was performed in 59 cases of 234,958 women (25.1/100,000). Total and subtotal hysterectomy was performed in 25 and 34 cases respectively. The rates of emergent peripartum hysterectomy after vaginal and caesarean deliveries were 8.7/100,000 and 104.5/100,000 respectively. Uterine atony was the most frequent indication (62.7%). The rates of emergent peripartum hysterectomy due to uterine atony in primiparous and multiparous women were 61.1 and 65.2% respectively. The rate of maternal mortality was 8% (5 cases). Uterine atony was the most common indication for emergent peripartum hysterectomy.

Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy

Objectives The purpose of this study was to evaluate the incidence, risk factors, indications, outcomes, and complications of emergency hysterectomy performed after cesarean deliveries (cesarean hysterectomy) and vaginal deliveries (postpartum hysterectomy). Study design We conducted a retrospective cohort study from 1990 to 2002 of patients who had peripartum hysterectomies at a single tertiary hospital. Comparisons were made between cesarean and postpartum hysterectomies. Results There were 55 cases of emergency peripartum hysterectomy (38 cesarean hysterectomies, and 17 postpartum hysterectomies), for a rate of 0.8 per 1000 deliveries. Overall, the most common indication for hysterectomy was uterine atony (56.4%), followed by placenta accreta (20.0%). Average estimated blood loss was 3325.6±1839.2 mL, average operating time was 157.1±75.4 minutes, average time from delivery to completing the hysterectomy was 333.8±275.7 minutes, and the average length of hospitalization was 11.0±7.9 days. The cesarean delivery rate at Grady Memorial Hospital during the study period was 14.2%. There were no statistically significant differences between variables examined when comparisons were made by cesarean vs postpartum hysterectomy. Conclusion Uterine atony is the leading indication for emergency hysterectomy performed following cesarean and vaginal deliveries.

Emergency peripartum hysterectomy

Objective: To review the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy. Study design: We analyzed retrospectively 38 cases of emergency peripartum hysterectomy operations performed between January 1996 and June 2001 at Zekai Tahir Burak Women’s Health Research and Education Hospital. The indications, risk factors and the associated complications were noted. Standard tests were used to calculate odds ratios (ORs) and their 95% confidence intervals (CI). Results: Thirty-eight cases of postpartum hysterectomy were performed. All of these cases were referred to our center from rural areas. The rate of peripartum hysterectomy was 1/3736 deliveries. The main indications for hysterectomy were placenta accreata, uterine rupture and uterine atony. There were four maternal deaths. Conclusion: Peripartum hysterectomy is a necessary life saving operation. Timely operation minimizes the morbidity and mortality.

Emergency peripartum hysterectomy in Northern Jordan: indications and obstetric outcome (an 8-year review).

To review cases of emergency peripartum hysterectomy regarding their incidence, risk factors, indications and complications and their results were carefully analysed. A retrospective study of cases of emergency peripartum hysterectomy which were performed in the period between February 1994 and February 2002 at the Princess Badeea Teaching Hospital in Northern Jordan. Demographic and clinical data were extracted and closely interpreted In the study period there were a 70,252 deliveries and 61 cases of emergency peripartum hysterectomies. The overall incidence was 0.87 peripartum hysterectomies per 1,000 deliveries. There were 50 cases (82%) delivered by caesarean section and 11 cases (18%) were delivered vaginally. Caesarean hysterectomy was performed in 50 cases and postpartum hysterectomy was performed in 11 cases. Total hysterectomy was performed in 39 cases (64%) and subtotal hysterectomy was performed in 22 cases (36%). The main indications for hysterectomy were morbidly adherent placenta (47.5%), ruptured uterus (27.9%) and uncontrollable haemorrhage from uterine atony (21.3%). There were two maternal deaths and 7 cases of stillbirths and 4 cases of early neonatal deaths. Peripartum hysterectomy is a dramatic with high risk but a life saving operation. It is usually associated with significant maternal and fetal morbidity and mortality. Obstetricians should identify patients at risk and anticipate the procedure and complications, as early intervention and proper management facilitate optimal outcome.

Route of Delivery as a Risk Factor for Emergent Peripartum Hysterectomy

In Brief OBJECTIVE To evaluate whether cesarean delivery is a risk factor for emergent postpartum hysterectomy. METHODS We performed a case–control study of patients who delivered at Women & Infants Hospital between January 1989 and February 2000. Fifty cases of emergent postpartum hysterectomy performed within 14 days of delivery met our inclusion criteria. Using a computer-generated list, two patients admitted to the labor department at a time point similar to that of each case patient were selected as controls (n = 100). We reviewed medical records for demographic data, route of delivery, labor characteristics, surgical history, and indication for hysterectomy. Cases and controls were compared, and logistic regression was used to calculate the odds ratio (OR) and the 95% confidence interval (CI) for the association of delivery route and emergent hysterectomy. RESULTS Cesarean delivery was associated with a 13-fold increased risk of emergent hysterectomy when we controlled for previous cesarean delivery, dilation and curettage or abortion before the index pregnancy, use of prostaglandin, and use of pitocin (OR 12.9; 95% CI 5.2, 32.3). CONCLUSION Cesarean delivery is a significant risk factor for postpartum hysterectomy. Cesarean delivery and the use of magnesium sulfate are associatedwith an increased risk of emergent peripartum hysterectomy.

Cardiac Tamponade from a Central Venous Catheter in an Obstetric Patient

Objective: Cardiac tamponade has a high mortality rate if aggressive and proper therapeutic measures are not undertaken. Herein we report a case of cardiac tamponade secondary to perforation of the superior vena cava by a central venous catheter in an obstetric patient. Case Report(s): A 32-year-old woman underwent a cesarean section due to placenta previa totalis and a previous cesarean section. An emergency peripartum hysterectomy was performed due to placenta accreta and intractable hemorrhage. A central venous catheter was inserted for hemodynamic monitoring and blood transfusion. Cardiac tamponade occurred secondary to perforation of the superior vena cava by the central venous catheter. The patient’s hemodynamic status became stable after pericardiocentesis. One week later she was discharged with no sequelae during the three month follow-up. Conclusion(s): Obstetricians should remain alert for the possibility of postoperative complications. Difficulty in inserting of a central venous catheter should raise suspicions of possible pericardial disruption or other complications. Prompt recognition and treatment of cardiac tamponade are imperative if a disastrous outcome is to be prevented.

Indication of emergency peripartum hysterectomy: review of 17 cases.

The objectives were to determine the incidence, indications, associated risk factors and complications with emergency peripartum hysterectomy at King Abdulaziz University Hospital, Saudi Arabia. This is a retrospective analysis of 17 cases of emergency peripartum hysterectomy done from January 1, 1991 to December 31, 2002. Seventeen patients of emergency peripartum hysterectomy were identified among 34,379 deliveries and the incidence rate was 0.5 per 1,000. Uterine atony 11 (64.7%, 9 without previa and 2 with previa) and followed by morbid adherent placenta with previa 6 (35.3%, 1 complete placenta accreta and 5 partial adherent placenta) was the most common indication of hysterectomy. Of the atonic group, 3 were primigravidae, 2 of 3 induced and 1 placenta previa. In morbid adherent placenta group the gravidity, previous abortions and prior cesarean deliveries were higher compared to the atonic group and were statistically significant. Conservative surgery performed in 6 (35.3%) patients before proceeding to hysterectomies, 3 (17.7%) patients had uterine artery ligation and 3 (17.7%) internal iliac ligation. Eight (47.1%) hysterectomies were subtotal. Nine (53%) patients developed disseminated intravascular coagulopathy (DIC) and one case (6%) had bilateral ureteric ligation and bladder injury. No maternal deaths occurred. Uterine atony still is the leading cause of primary postpartum hemorrhage and the main indications of emergency peripartum hysterectomy. The combination of high parity, cesarean section, prior cesarean delivery and current placenta previa were identified as risk factors, and should alert the obstetrician that an emergency peripartum hysterectomy may needed. Although no maternal mortality occurred morbidity remained high.

Maternal and Perinatal Outcome of Massive Postpartum Hemorrage: A Review of 33 Cases

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

Emergency peripartum hysterectomy: experience at a community teaching hospital

OBJECTIVES: To estimate the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy at a community-based academic medical center. METHODS: We analyzed retrospectively 47 of 48 cases of emergency peripartum hysterectomy performed at Winthrop-University Hospital from 1991 to 1997. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 hours after delivery. Fisher exact test, Wilcoxon rank sum test, and Cochran-Armitage exact trend test were used for analysis. RESULTS: There were 48 emergency peripartum hysterectomies among 34,241 deliveries for a rate of 1.4 per 1000. Most frequent indications were placenta accreta (48.9%, 12 with previa, 11 without previa), uterine atony (29.8%), previa without accreta (8.5%), and uterine laceration (4.3%). Placenta accreta was the most common indication in multiparous women (58.8%, 20 of 34), uterine atony the most common in primiparas (69.2%, nine of 13). Twenty-two of 23 (95.6%) women with placenta accreta had a previous cesarean delivery or curettage. The number of cesarean deliveries or curettages increased the risk of placenta accreta proportionally. Thirty-eight (80.9%) of the hysterectomies were subtotal. Postoperative febrile morbidity was 34%; other morbidity was 26.3%. CONCLUSION: Placenta accreta has become the most common indication for emergency peripartum hysterectomy.

Cesarean Hysterectomy Revisited

This study sought to evaluate the morbidity and cost associated with planned and emergent peripartum hysterectomy in a residency setting. The authors also evaluated planned hysterectomy compared with delivery and subsequent hysterectomy. The charts of 64 patients who underwent emergent or planned peripartum hysterectomies were reviewed. Comparisons were made in the following areas: gravidity and parity, number of prior cesarean sections, fetal weight, blood loss, number of transfused blood units, length of stay, charges, and indications for hysterectomy. A cost analysis was performed comparing planned peripartum hysterectomy with delivery and subsequent hysterectomy. When planned cesarean hysterectomies were compared with delivery and subsequent hysterectomy, it was found that the planned hysterectomy for cervical dysplasia and leiomyoma had no significant complications. There were also significant cost savings when vaginal or cesarean delivery was compared with interim hysterectomy. Planned hysterectomies also resulted in shorter hospital stays, lower blood loss, and lower hospital costs compared with emergent hysterectomies. Residents who participated in planned cesarean hysterectomy felt more prepared when an emergent hysterectomy arose at a later date than those who had not participated in any. Peripartum hysterectomy is an option when the patient has a concurrent gynecologic indication for surgery, and it has significantly less morbidity than emergent peripartum hysterectomy.

Risk factors for emergency peripartum hysterectomy — An experience of a developing country

International Journal of Gynecology & ObstetricsVolume 70, Issue S2 p. B91-B91 Surgical complications: Obstetric Risk factors for emergency peripartum hysterectomy — An experience of a developing country S. Rou, S. RouSearch for more papers by this authorN. Nasrin, N. NasrinSearch for more papers by this authorJ. Begum, J. BegumSearch for more papers by this authorR. Begum, R. BegumSearch for more papers by this authorA. Begum, A. BegumSearch for more papers by this author S. Rou, S. RouSearch for more papers by this authorN. Nasrin, N. NasrinSearch for more papers by this authorJ. Begum, J. BegumSearch for more papers by this authorR. Begum, R. BegumSearch for more papers by this authorA. Begum, A. BegumSearch for more papers by this author First published: 10 December 2003 https://doi.org/10.1016/S0020-7292(00)85218-2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume70, IssueS22000Pages B91-B91 RelatedInformation