Massive Postpartum Hemorrhage Research Articles

Placenta Accreta Spectrum in Normal Situated Placenta and Unscarred Uterus

Placenta accreta, one of the morbidly adherent placenta components and currently known as placenta accreta spectrum (PAS), is a condition characterized by abnormal adherence of the placenta to the uterine wall. This can lead to significant blood loss and may lead to high morbidity and mortality rates for the mother. It is a failure of placenta separation during the third stage of labor, which is thought to be high prevalence in those with previous cesarean delivery, especially with the presence of placenta previa. However, PAS is possible in cases of a normally-situated placenta without previous cesarean delivery. We reported an interesting case of a 41-year-old woman, gravida 8 para 7, admitted to the labor room for augmentation of labor, who needed emergency lower segment cesarean section. The incidental finding of PAS was made intraoperatively and was complicated with a hysterectomy. PAS in a normally situated placenta (upper segment) in a virgin abdomen that has been discovered during emergency lower segment cesarean section could cause a nightmare to the obstetrician as it leads to massive postpartum hemorrhage, ureteric injury, and high maternal morbidity and mortality.

Management and outcomes of women with low fibrinogen concentration during pregnancy or immediately postpartum: A UK national population-based cohort study.

Pregnant women with a fibrinogen level <2 g/L represent a high-risk group that is associated with severe postpartum hemorrhage and other complications. Women who would qualify for fibrinogen therapy are not yet identified. A population-based cross-sectional study was conducted using the UK Obstetric Surveillance System between November 2017 and October 2018 in any UK hospital with a consultant-led maternity unit. Any woman pregnant or immediately postpartum with a fibrinogen <2 g/L was included. Our aims were to determine the incidence of fibrinogen <2 g/L in pregnancy, and to describe its causes, management and outcomes. Over the study period 124 women with fibrinogen <2 g/L were identified (1.7 per 10 000 maternities; 95% confidence interval 1.4-2.0 per 10 000 maternities). Less than 5% of cases of low fibrinogen were due to preexisting inherited dysfibrinogenemia or hypofibrinogenemia. Sixty percent of cases were due to postpartum hemorrhage caused by placental abruption, atony, or trauma. Amniotic fluid embolism and placental causes other than abruption (previa, accreta, retention) were associated with the highest estimated blood loss (median 4400 mL) and lowest levels of fibrinogen. Mortality was high with two maternal deaths due to massive postpartum hemorrhage, 27 stillbirths, and two neonatal deaths. Fibrinogen <2 g/L often, but not exclusively, affected women with postpartum hemorrhage due to placental abruption, atony, or trauma. Other more rare and catastrophic obstetrical events such as amniotic fluid embolism and placenta accreta also led to low levels of fibrinogen. Maternal and perinatal mortality was extremely high in our cohort.

Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country.

The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand. This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016. Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001). The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.

Emergency Bilateral Internal Iliac Artery Ligation in Antepartum Haemorrhage with Complete Placenta Previa and Placenta Accreta at Previous Caesarean Scar Site: A Case Report

Implantation and placentation at the normal site are critical for a successful pregnancy. Many complications associated with pregnancy, which manifest late in pregnancy, such as preeclampsia and preterm labour, have been reported to have origins early during pregnancy with abnormalities in implantation and placental development. Placental abnormalities result from impaired embedding of the placenta in the endometrium, encompassing a wide range of placental pathologies associated with high maternal morbidity and mortality. Pregnancy-related complications such as Postpartum Haemorrhage (PPH) and hysterectomy have been closely linked to the Placenta Accreta Spectrum (PAS). PAS refers to the aberrant and invasive implantation of the placenta into the myometrium. Invasiveness in placenta accreta is marginal, followed by placenta increta (partial), placenta percreta (total), and placenta previa (covering the cervix). Here, the authors present a unique case report of an antenatal woman with antepartum haemorrhage, placenta previa, and placenta accreta at the previous Lower Segment Caesarean Section (LSCS) scar site, with massive PPH at 35 weeks, who benefited from an emergency LSCS with bilateral uterine and internal iliac artery ligation procedure, resulting in a life-saving outcome. The most common risk factors for PAS include prior caesarean section and curettage. The adhered placenta can lead to pelvic bleeding and necessitate an emergency hysterectomy. Therefore, it poses unique diagnostic and treatment issues, with the majority of cases requiring preterm termination of pregnancy.

Panhypopituitarism due to Sheehan’s Syndrome in a Patient with Recurrent Hyponatremia: Case Report from Nepal

Introduction: Panhypopituitarism, deficiency of all pituitary hormones (anterior pituitary hormones: adrenocorticotropic hormone, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, prolactin, growth hormone; posterior pituitary hormones: oxytocin, vasopressin). Sheehan’s syndrome also known as postpartum hypopituitarism is one of the causes of panhypopituitarism, which is characterized by hypopituitarism due to necrosis of pituitary gland secondary to massive postpartum hemorrhage. In this case, a 50 years female presented with the history of vomiting and loss of appetite since 2 years with severe hyponatremia, and decreased pituitary hormones levels in laboratory findings with significant obstetric history is diagnosed with Sheehan’s Syndrome.

Cavernous haemangioma and mid trimester pregnancy loss leading to severe haemorrhage and hysterectomy: a case report and review of literature.

Cavernous haemangiomas are benign vascular tumours that are known to occasionally involve the female genital tract, including the uterus. They are often underdiagnosed during pregnancy, although they can also lead to severe postpartum or antepartum haemorrhage. Describe our case of an uncommon second-trimester pregnancy loss in a woman with a diffuse cavernous haemangioma of the uterus and cervix and review the wider literature. The review was conducted using MEDLINE, Scopus and PubMed electronic databases from beginning of the database to May 2023, using the following keywords: arteriovenous malformation; cavernous haemangioma/hemangioma; uterine neoplasms; pregnancy complications; abnormal vaginal bleeding. Description of the characteristics of cavernous haemangioma during pregnancy as well as diagnostic criteria and treatment options. Twenty publications were included in the review, which included English-language case reports over a period from 1959 to 2022. No pathognomonic symptoms for cavernous haemangioma of the uterus in a pregnant woman were noted. Complications including massive secondary postpartum haemorrhage, haemoperitoneum, and severe thrombocytopenia with anaemia after delivery were reported. Diagnosis and management during pregnancy can be challenging and requires considerable attention, with a multidisciplinary approach including gynaecologists, radiologists, and pathologists to avoid major complications. An additional case of diffuse cavernous haemangioma of the uterus and cervix is described, that adds to the little existing literature.

Postpartum acute adrenal insufficiency of early-onset Sheehan syndrome: A case series study in a single center.

To identify the symptoms and relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. We retrospectively reviewed the charts of 125 women admitted to our intensive care unit because of postpartum hemorrhage between January 2011 and December 2021. Three women developed acute adrenal insufficiency. We investigated the total blood loss, shock status, consciousness level upon arrival, and intensive care provided to the women. We also analyzed the symptoms and laboratory data that led to the diagnosis of acute adrenal insufficiency. Continuous variables were presented by median (minimum-maximum). The medians and ranges of age, total blood loss, and shock index [heart rate/systolic blood pressure] on admission were 33.1 (17.2-45.3) years, 3351 (595-20 260) g, and 0.94 (0.55-2.94), respectively. Seven women were older than 40 years, 28 experienced >5000 g blood loss, 17 had shock index >1.5, 27 had impaired consciousness upon arrival, and 15 underwent hysterectomy. Women who developed acute adrenal insufficiency were <40 years old and had a bleeding volume of over 5000 g, impaired consciousness upon arrival, and had undergone hysterectomy. They had experienced lactation failure, presented with hyponatremia-related symptoms onpostpartumdays 8-9, experienced general malaise, headache, and impaired consciousness, and showed severe hyponatremia. Massive postpartum hemorrhage over 5000 g, impaired consciousness upon arrival, and hysterectomy as a hemostatic measure were relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. Hyponatremia-related symptoms occurring after lactation failure are indicative of the onset of acute adrenal insufficiency.

EP16.01: Prediction of massive postpartum bleeding of serial change of cervical length in placenta previa without placenta accreta syndrome

EP16.01: Prediction of massive postpartum bleeding of serial change of cervical length in placenta previa without placenta accreta syndrome

Placental lesion complicated by massive postpartum hemorrhage

Placental lesion complicated by massive postpartum hemorrhage

Exploring trends of severe postpartum haemorrhage: a hospital-based study

BackgroundOver the past two decades several high-income countries have reported increased rates of postpartum haemorrhage (PPH). Many of the studies are registry studies with limited access to detailed information. We aimed to explore trends of severe PPH in the largest labour ward in Norway during a 10-year period with a hospital based study. Our population constituted all women who gave birth after week 22 at Oslo University Hospital between 2008 and 2017. The main outcome measure was severe PPH, defined as registered blood loss greater than 1500 ml, or transfusion of blood products due to PPH.MethodsWe estimated the incidence of severe PPH and blood transfusions, and performed temporal trend analysis. We performed Poisson regression analysis to investigate associations between pregnancy characteristics and severe PPH, presented using crude incidence rate ratios (IRR) with 95% confidence intervals (CI)s. We also estimated annual percentage change of the linear trends.ResultsAmong 96 313 deliveries during the 10-year study period, 2621 (2.7%) were diagnosed with severe PPH. The incidence rate doubled from 17.1/1000 to 2008 to 34.2/1000 in 2017. We also observed an increased rate of women receiving blood transfusion due to PPH, from 12.2/1000 to 2008 to 27.5/1000 in 2017. The rates of invasive procedures to manage severe PPH did not increase, and we did not observe a significant increase in the number of women defined with maternal near miss or massive transfusions. No women died due to PPH during the study period.ConclusionWe found a significant increasing trend of severe PPH and related blood transfusions during the 10-year study period. We did not find an increase in massive PPH, or in invasive management, and we suspect that the rise can be at least partly explained by increased awareness and early intervention contributing to improved registration of severe PPH.

Efficacy of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control in patients with abnormally invasive placenta: a historical cohort study

BackgroundPatients with abnormally invasive placenta (AIP) are at high risk of massive postpartum hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA), as an adjunct therapeutic strategy for hemostasis, offers the obstetrician an alternative for treating patients with AIP. This study aimed to evaluate the role of REBOA in hemorrhage control in patients with AIP.MethodsThis was a historical cohort study with prospectively collected data between January 2014 to July 2021 at a single tertiary center. According to delivery management, 364 singleton pregnant AIP patients desiring uterus preservation were separated into two groups. The study group (balloon group, n = 278) underwent REBOA during cesarean section, whereas the reference group (n = 86) did not undergo REBOA. Surgical details and maternal outcomes were collected. The primary outcome was estimated blood loss and the rate of uterine preservation.ResultsA total of 278 (76.4%) participants experienced REBOA during cesarean section. The patients in the balloon group had a smaller blood loss during cesarean Sect. (1370.5 [752.0] ml vs. 3536.8 [1383.2] ml; P < .001) and had their uterus salvaged more often (264 [95.0%] vs. 23 [26.7%]; P < .001). These patients were also less likely to be admitted to the intensive care unit after delivery (168 [60.4%] vs. 67 [77.9%]; P = .003) and had a shorter operating time (96.3 [37.6] min vs. 160.6 [45.5] min; P < .001). The rate of neonatal intensive care unit admission (176 [63.3%] vs. 52 [60.4%]; P = .70) and total maternal medical costs ($4925.4 [1740.7] vs. $5083.2 [1705.1]; P = .13) did not differ between the two groups.ConclusionsAs a robust hemorrhage-control technique, REBOA can reduce intraoperative hemorrhage in patients with AIP. The next step is identifying associated risk factors and defining REBOA inclusion criteria to identify the subgroups of AIP patients who may benefit more.

Pregnancy Outcomes in Patients with Placenta Previa Due to Site of Placentation

Background: The aim of this research is to evaluate pregnancy outcomes in patients with placenta previa due to the site of placentation. Method: This retrospective study included 105 cases conducted in the OBG department of Al AIN hospital for three years (January 2015 to October 2018). All cases of placenta previa admitted during this period were included in the study. Case records were obtained from the medical record section and carefully analyzed to find out the incidence, various types of placenta previa, its clinical presentation, and its outcome in relation to mode of delivery, birth weight, and maternal and perinatal morbidity. Results: Placental attachment site influenced the outcome of pregnancy. Placental attachment to the anterior wall was associated with shorter gestational age, low birth weight, low Apgar score, higher prenatal bleeding rate, increased postpartum hemorrhage, longer duration of hospitalization, higher blood transfusion and higher hysterectomy rates compared to cases with lateral/posterior wall placenta. Placental attachment at the incision site of previous cesarean section significantly increased the incidence of complete placenta previa compared with placental attachment at a site without incision, but did not significantly influence pregnancy outcomes. Placental attachment to the anterior wall was an independent risk factor for postpartum hemorrhage in patients with placenta previa. Conclusion: The site of placental attachment in patients with placenta previa influences the pregnancy outcome. When the placenta is located on the anterior wall, clinicians should pay attention to the adverse pregnancy outcomes and the possibility of massive postpartum hemorrhage.

Hemostasis restoring in postpartum hemorrhage — algorithm 2023

Postpartum hemorrhage (PPH) is still the leading cause of perinatal death in women of reproductive age. It is characterized by high dynamics, and most women die within the first day of puerperium and as many as 88% of them within the first 4 hours from the onset of hemorrhage. Management of each massive obstetric hemorrhage requires interdisciplinary, team-based and multidirectional action. The need for simultaneous application of uterotonic agents, surgical and/or endovascular methods as well as procedures aimed at restoring volume and hemostasis should be emphasized. The protocol for the management of severe PPH should be individualized and take into account hemorrhage etiology. Each time the volume of circulating blood as well as the degree of blood loss have to be determined, and the adequate procedures, the starting points for implementing aggressive treatment and the satisfactory end points must be defined. The most common cause of severe, life-threatening PPH is uterine atony. Restoration of hemostasis in massive PPH consists in transfusion of blood components, administration of antifibrinolytic drugs and coagulation factor concentrates, rFVIIa included. Patient survival is often determined by the very risk assessment for hemorrhage, early diagnosis and rapid implementation of PPH management algorithms.

Efficacy of rotational thromboelastometry for diagnosis and correction of coagulopathy in massive postpartum hemorrhage: a cohort retrospective multi-center DiPTEM study

INTRODUCTION: Continuous monitoring of the hemostasis system during postpartum hemorrhage is an essential aspect of intensive care. Rotational thromboelastometry (ROTEM) provides rapid and differentiated detection of hemostasis system disorders. OBJECTIVE: To evaluate the effect of implementing the rotational thromboelastometry on the need for blood transfusion in massive postpartum hemorrhage in the practice of perinatal centers. MATERIALS AND METHODS: A retrospective cohort multicenter study was conducted in two perinatal centers. The BEFORE group included females with massive postpartum hemorrhage (PPH) (&gt; 30 % of circulating blood volume (CBV) or &gt; 2 L) within 2 years prior to ROTEM implementation in tertiary care hospitals; the AFTER group included females with massive postpartum hemorrhage within 2 years after ROTEM implementation. The primary endpoint of the study was a comparative evaluation of the frequency of fresh frozen plasma (FFP) transfusion for hemostasis correction in massive PPH before and after ROTEM implementation as an urgent method for coagulopathy diagnosis. RESULTS: A total of 97 patients were included in the study: 48 in the BEFORE group and 49 in the AFTER group. A significant relative risk (RR) of reduced frequency of FFP transfusion RR = 0.53 (0.32, 0.85; p = 0.009) with NNT = 3.6 after implementation of ROTEM into clinical practice was found. The frequency of cryoprecipitate transfusion increased. Analysis of cases of PPH over 50 % of the CBV (PPH in the BEFORE and AFTER groups 68.2 ± 12.4 and 72.3 ± 35.9, respectively, p = 0.673) showed a twofold significant risk of reducing the number of parturient women requiring FFP transfusion: RR = 0.5 (0.25, 0.99); p = 0.049), with NNT = 2. CONCLUSION: Rapid information on the status of the hemostasis system can reduce unnecessary FFP transfusion. Introducing the ROTEM method into the clinical practice of obstetric hospitals will improve the outcomes of intensive care for one of the most challenging categories of patients — postpartum women with massive postpartum hemorrhage.

Shock index as a predictor of maternal outcome in postpartum hemorrhage: an experience from a tertiary care centre in Northern India

Introduction: Postpartum hemorrhage (PPH) is one of the commonest causes of maternal morbidity and mortality. Serious adverse outcomes mostly occur due to delays in the recognition and management of massive PPH. Shock index (SI) has been proposed as an early diagnostic indicator to monitor PPH women. Aims and objectives: To study SI as a predictor of maternal outcome in PPH patients. Patients and methods: This retrospective study was conducted over a duration of 1year (January 2021- December 2021) on the cohort of patients having PPH at the department of obstetrics and gynecology at a tertiary care hospital in northern India. The Age, parity, number of pregnancies, booked/unbooked pregnancy, singleton/multiple pregnancies, mode of delivery (vaginal or caesarean section), SI, blood transfusions, type and severity of PPH, type of management- medical/surgical, ICU admissions and maternal outcomes were recorded. Results: This study included a total of 105 women with PPH for analysis. 43.8% of patients had severe PPH and required massive blood transfusion &gt; 4 units while 40% required ICU admission. 68 patients had S.I&gt;0.9 while 46 patients had S.I&gt;1.1. The value of S.I&gt;1.1 correlated significantly with all studied adverse outcomes like ICU admission, massive blood loss, massive blood transfusion, and need for surgical intervention(p value&lt;0.05). SI value of ≥1.1 had maximum sensitivity and specificity. Conclusion: The shock index seems to be an easy, practical, and effective clinical method for predicting adverse outcomes objectively in postpartum hemorrhage patients. Our study suggests a cut-off value of 1.1 for predicting adverse clinical outcomes.

Pharmacological Management of Postpartum Haemorrhage

Despite improvements in healthcare technologies, massive postpartum haemorrhage is still the leading cause of maternal morbidity and mortality worldwide. Delayed and poo r-q uality obstetric care can result in irreversible consequences. Wel l-t imed assessment of blood loss, effective management of the peripartum period, and participation of multidisciplinary teams are essential to provide a specialized care. This review presents the evidenc e-b ased management of patients with the development of obstetric haemorrhage. The article presents existing contradictions in the methods of diagnosis and treatment as well as new advances in this field of medicine which require continuation of research in this direction.

Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS)

Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS)

Wider perspectives: It's a changing world-The use of ABO-incompatible plasma for resuscitating massively bleeding patients.

Wider perspectives: It's a changing world-The use of ABO-incompatible plasma for resuscitating massively bleeding patients.

INTRAUTERINE BALLOON TAMPONADE AS AN EFFECTIVE METHOD OF CONSERVATIVE TREATMENT OF POSTPARTUM BLEEDING

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide and accounts for approximately a quarter of all maternal deaths today. In May 2021, the World Health Organization (WHO) published updated recommendations that intrauterine balloon tamponade is an effective treatment for postpartum hemorrhage when first-line treatment is ineffective. The implementation of balloon intrauterine tamponade during postpartum hemorrhage after cesarean section appears to be safe and effective, which contributes to the reduction of both invasive procedures and the frequency of transfusions. Objective of the study To evaluate the effectiveness of the complex treatment of hypotonic postpartum hemorrhage and bleeding with placental abruption or placentaaccreta during cesarean section by using intrauterine balloon tamponade to prevent periportal hysterectomy. Methods An analysis of 30 cases of postpartum bleeding, which were treated with intrauterine balloon tamponade (IBT), and ended with effective conservative treatment without hysterectomy, was conducted. Research results and their discussion Parity of childbirth is important as a risk factor for the occurrence of hypotonic bleeding. A stretched uterus due to a large fetus was present in 4 (13.3%), twins - in 3 (10%), polyhydramnios - in 2 (6.6%), that is, every third woman had such a risk factor for bleeding. The course of childbirth plays an important role in the exhaustion of the contractile activity of the uterus and the occurrence of postpartum bleeding. Massive obstetric bleeding was more than 1.5% of the weight in 3 (13.6%) women, up to 1.5% in 17 (77.2%), up to 1% in 2 (9.2%). Intrauterine balloon tamponade was performed for the treatment of PPK after ineffective first-line measures. According to our data, finding an intrauterine balloon gradually stopped the bleeding. 1 hour after UBT of the uterus, the amount of blood loss decreased to 400 ml per hour, gradually decreasing to 4-6 hours. After 6 hours of VBT being in the uterus, the bleeding was stopped and the volume of circulating blood was restored. Conclusions Thus, women who have a history of massive postpartum bleeding, multiparous women, pregnant women with a stretched uterus due to a large fetus, multiple pregnancy, women who give birth with a violation of the contractile activity of the uterus are a risk group for the occurrence of postpartum bleeding. Intrauterine balloon tamponade is an effective method of conservative treatment of postpartum bleeding, which should be widely used in obstetric practice.

What is the Economic Cost of Providing an All Wales Postpartum Haemorrhage Quality Improvement Initiative (OBS Cymru)? A Cost-Consequences Comparison with Standard Care.

Background and ObjectiveA postpartum haemorrhage quality improvement initiative (the Obstetric Bleeding Strategy for Wales [OBS Cymru]), including about 60,000 maternities, was adopted across Wales (2017–2018). We performed a cost-consequences analysis to inform ongoing provision and wider uptake.MethodsAnalysis was based on primary data from the All Wales postpartum haemorrhage database, with a UK National Health Services perspective, a time horizon from delivery until hospital discharge and no discounting. Costs were based on UK published sources with viscoelastic haemostatic assay costs provided by the OBS Cymru national team. Mean costs per eligible patient (postpartum haemorrhage > 1000 mL) were calculated for OBS Cymru, using the early implementation period as a comparator. Modelling allowed comparisons of three scenarios (two predefined and one post hoc) and implementation in different sizes of maternity unit.ResultsAll analyses demonstrated consistent savings in blood products, critical care and haematology time, and also a reduced occurrence of massive postpartum haemorrhage (> 2500 mL). Incremental postnatal length of stay varied between scenarios, substantially impacting on total costs. Mean incremental cost of OBS Cymru, compared with standard care, across Wales was £18.41 per patient (postpartum haemorrhage > 1000 mL) or − £10.66 if the length of stay was excluded. Modelling a maternity unit of 5000 births per annum, OBS Cymru incurred an incremental cost of £9.53 per patient with postpartum haemorrhage > 1000 mL.ConclusionsOBS Cymru reduces the occurrence of massive postpartum haemorrhage, need for transfusions, quantity of blood products and intensive care. In medium-to-large maternity units (>3000 maternities per annum), the OBS Cymru intervention approaches cost neutrality compared to standard care.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-022-00362-2.