Risk Of PPH Research Articles

POSTPARTUM HAEMORRHAGE;

Objectives: To determine the frequency of postpartum haemorrhage in obeseprimigravid women. Study Design: Case series study. Period: Six months was conductedfrom 1st October 2014 to 30 March 2015. Setting: Department of gynecology and obstetricsat Liaquat University Hospital Jamshoro. Patients and Methods: All the primigravid obese(≥30kg/m2) ladies 18 to 35 years of age with 37-42 weeks of gestational age were evaluate forthe occurrence of PPH by estimating blood loss of greater than 500 ml of blood following vaginaldelivery or 1000 ml of blood loss following caesarean section. All data was entered and analyzedthrough statistical package SPSS version 17, the chi-square statistical test was applied and thep-value ≤0.05 was considered as statistical significant. Results: Total 203 primigravid obeseladies were studies, the age group was analyzed which shows that in age group between 18-25years were 105(52.00%) women, in age group of 26-30 years were 62(30.69%) women and agegroup of 30 years and above were 35 (17.31%) women. The modes of delivery were evaluatedwhich shows that 66.5% women underwent C-section and 33.4% women had normal vaginaldelivery. The PPH was observed in 34.97% patients (70.4% with C-Section and 29.6 with NVD).Conclusion: Obesity carries a significant increased risk of complications during pregnancyand maternal risks during labour are PPH and more frequent C-section and nulliparous obesewomen have twofold high risk for PPH

Maternal Outcomes and Management of the Third Stage of Labor Following Midtrimester Delivery [6L

INTRODUCTION: Preterm delivery is associated with a prolonged third stage of labor. Our objective was to evaluate the risk of maternal morbidity associated with duration of the third stage after midtrimester delivery. METHODS: We performed a retrospective cohort study examining vaginal deliveries between 14-24 weeks gestation. Univariate logistic regression was used for statistical analysis. A receiving operating characteristics (ROC) curve was generated to estimate sensitivity and specificity of the composite outcome (PPH, maternal infection, D&C) at 60 minutes. The proportion of undelivered placentas and risk of PPH or infection were plotted over length of third stage of labor. RESULTS: Of 131 participants, 38.2% had a third stage duration greater than or equal to 60 minutes. The risk of PPH was significantly higher among women with a third stage of labor greater than 60 minutes (OR=4.85, 95% CI: 2.11-11.11). This group was also more likely to undergo a post-delivery D&C (OR=18.6, 95% CI: 5.15-67.04). There was no difference in infection risk (OR=0.76, 95% CI: 0.17-3.30). The AUROC was 0.70 (sensitivity 67.0%, specificity 71.0%) for the composite outcome at 60 minutes. The proportion of undelivered placentas demonstrated exponential decay over time, while the risk of PPH and/or infection increased after 90 minutes. CONCLUSION: Maternal risk of PPH and need for post-delivery D&C at the time of midtrimester delivery increases with a third stage of labor greater than 60 minutes. Our data suggest that if the placenta is undelivered after 90 minutes, manual extraction or D&C is indicated to mitigate the increasing risk of maternal morbidity.

Grouping parturients by parity, previous cesarean and mode of delivery identifies parturients at risk for postpartum-hemorrhage

Background: The prevalence of postpartum-hemorrhage varies between studies depending on the definition of postpartum-hemorrhage and the population studied. Significant differences are reported among sub-groups stratified by single risk factors including parity, mode of delivery and management of labor. Objective: Our primary goal was to form a clinical classification aimed to identify sub-groups of parturients at risk for postpartum-hemorrhage by combining clinical universal risk factors. Study design: Retrospective cohort including all women who delivered at Shaare Zedek Medical Center, an affiliated university medical center, managing 10% of national deliveries, between January 2006 and December 2014. Parturients were grouped according to three characteristics, all known as universal risk factors for PPH: parity (primiparous, multiparous), previous cesarean and mode of delivery (spontaneous vaginal delivery, instrumental delivery, non-planned and elective cesarean): P-C-MoD classification. All together the classification included 12 sub-groups. Postpartum-hemorrhage was defined as a decrease of ≤3 g% hemoglobin or transfusion of blood products and was calculated for each of the sub-groups independently. A univariate analysis followed by a multivariate analysis was performed to study the risk for postpartum-hemorrhage among the sub-groups studied, controlling for confounding factors including age, onset of delivery, number of fetus and fetal birth weight. Results: The crude rate of postpartum-hemorrhage, for all 126,693 parturients was 7%. The prevalence for PPH differed significantly between independent risk factors compared to the combined risk factors of the P-C-MoD classification. Among primiparous, the prevalence was 14%, this changed significantly when combining primiparous with mode of delivery, ranging from 11% for spontaneous vaginal delivery to 27% among those with instrumental delivery. The prevalence of PPH among multiparous varied between 3% (spontaneous vaginal delivery) and 20% (emergency CD). There was significant difference in the prevalence of PPH between the sub-groups of the P-C-MoD classification. Primiparous who underwent ID were at increased risk for PPH, approximately one of four women in this group (27%) experienced PPH. Applying a univariate analysis revealed that the risk for PPH was significantly increased for primiparous undergoing ID compared to all other sub-groups reaching an OR of 12.8 (95% CI: 11.9; 13.8) compared to multiparous undergoing SVD. Applying a multivariate analysis minimally altered the results. Conclusions: Grouping parturients by parity, previous cesarean and mode of delivery (P-C-MoD classification) is a useful tool to identify parturients at risk for postpartum-hemorrhage and is superior compared to single independent risk factors. Future studies are needed to confirm the external validity of this classification.

Why is post-partum haemorrhage more common in women with congenital heart disease?

ObjectiveTo identify the factors associated with an increased post-partum blood loss in women with congenital heart disease (CHD). MethodsThe study was a retrospective cohort study, which included 366 nulliparous women with CHD and a singleton pregnancy cared for in a single tertiary centre (Chelsea and Westminster Hospital) between 1994 and 2014. The women were classified into one of 12 different functional groups and univariate and multivariate regression analysis were used to identify factors associated with increased blood loss at delivery. ResultsThe average volume of blood loss in women with CHD was twice that expected. Univariate analysis showed that White European women had the lowest blood loss. Women who had been on anticoagulants, had a forceps delivery, emergency Caesarean section or general anaesthesia lost more blood than those having a spontaneous vaginal birth under regional analgesia. Higher CARPREG scores were associated strongly with increased blood loss. Women with a Fontan circulation had the highest blood loss and the difference remained significant after correcting for other significant variables. ConclusionsWomen with CHD are at increased risk of PPH. We have identified several potentially modifiable risk factors that may be targeted to reduce this risk. In addition, women with a Fontan circulation were most prone to PPH, independent of other risk factors, suggesting the existence of lesion-specific abnormalities and the need for extra vigilance in this group of women at the time of birth.

Fetomaternal Outcome in Cesarean Sections Done in Second Stage of Labor

Objective: To study the fetomaternal outcome in cesarean sections done in second stage of labor. Method: It is a prospective observational study of 26 cases of cesarean sections done in second stage of labor in Adichunchanagiri institute of medical sciences from January to September 2014. Result: There were 1533 deliveries including 468 cesarean sections in the study period. The cesarean rate was 30%. Of 468 cases 26 were performed in second stage of labor contributing 1.6% of total deliveries and 5.5% of all cesarean sections. Most common indication for cesarean section in second stage of labor is deep transverse arrest. Second stage cesarean sections are associated with increased risk of atonic PPH requiring surgical management (7.69%), lower segment tears including angle extension and broad ligament hematoma(15.38%) along with other complications like extraction difficulty, post operative fever, wound sepsis, longer duration of hospital stay. Meconium stained amniotic fluid is present in 30.76% cases. Though timely second stage ceserean sections reduce perinatal mortality few complications like neonatal hyperbilirubinemia occur. Conclusion: Cesarean sections done in second stage of labor are associated with increased intra-operative maternal complications and neonatal morbidity. Theme: Healthy mother, healthy baby: Timely intervention to reduce fetomaternal complications. Key words: Cesarean section, Second stage of labor, Maternal morbidity, Complications

Controlled cord traction for the third stage of labour.

Active management of the third stage of labour (AMTSL) consists of a group of interventions, including administration of a prophylactic uterotonic (at at or after delivery of the baby), baby, cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage. Recent recommendations are to delay cord clamping until the caregiver is ready to initiate CCT. The package of AMTSL reduces the risk of postpartum haemorrhage, (PPH), as does one component, routine use of uterotonics. The contribution, if any, of CCT needs to be quantified, as it is uncomfortable, and women may prefer a 'hands-off' approach. In addition its implementation has resource implications in terms of training of healthcare providers. To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 January 2014), PubMed (1966 to 29 January 2014), and reference lists of retrieved studies. Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally. Two authors assessed trial quality and extracted data using a standard data extraction form. We included three methodologically sound trials with data on 199, 4058 and 23,616 women respectively. Blinding was not possible, but bias could be limited by the fact that blood loss was measured objectively.There was no difference in the risk of blood loss ≥ 1000 mL (three trials, 27,454 women; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.77 to 1.08). Manual removal of the placenta was reduced with CCT (two trials, 27,665 women; RR 0.69, 95% CI 0.57 to 0.83). In the World Health Organization (WHO) trial the reduction in manual removal occurred mainly in sites where ergometrine was used routinely in the third stage of labour. The non-prespecified analysis excluding sites routinely using ergometrine for management of the third stage of labour found no difference in the risk of manual removal of the placenta in the WHO trial (one trial, 23,010 women; RR 1.03, 95% CI 0.73 to 1.46). The policy of restricting the third stage of labour to 30 minutes (4057 women; RR 0.69, 95% CI 0.53 to 0.90) may have had an effect in the French study.Among the secondary outcomes, there were reductions in blood loss ≥ 500 mL (three trials, 27,454 women; RR 0.93, 95% CI 0.88 to 0.99), mean blood loss (two trials, 27,255 women; mean difference (MD) -10.85 mL, 95% CI -16.73 to -4.98), and duration of the third stage of labour (two trials, 27,360 women; standardised MD -0.57, -0.59 to -0.54). There were no clear differences in use of additional uterotonics (three trials, 27,829 women; average RR 0.95, 95% CI 0.88 to 1.02), blood transfusion, maternal death/severe morbidity, operative procedures nor maternal satisfaction. Maternal pain (non-prespecified) was reduced in one trial (3760 women; RR 0.78, 95% CI 0.61 to 0.99).The following secondary outcomes were not reported upon in any of the trials: retained placenta for more than 60 minutes or as defined by trial author; maternal haemoglobin less than 9 g/dL at 24 to 48 hours post-delivery or blood transfusion; organ failure; intensive care unit admission; caregiver satisfaction; cost-effectiveness; evacuation of retained products; or infection. CCT has the advantage of reducing the risk of manual removal of the placenta in some circumstances, and evidence suggests that CCT can be routinely offered during the third stage of labour, provided the birth attendant has the necessary skills. CCT should remain a core competence of skilled birth attendants. However, the limited benefits of CCT in terms of severe PPH would not justify the major investment which would be needed to provide training in CCT skills for birth attendants who do not have formal training. Women who prefer a less interventional approach to management of the third stage of labour can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without increased risk of severe PPH, but that the risk of manual removal of the placenta may be increased.Research gaps include the use of CCT in the absence of a uterotonic, and the place of uterine massage in the management of the third stage of labour.

137: Incidence, risk factors and outcomes associated with cesarean delivery of a 2nd twin following vaginal delivery of the first infant

DEE and PPH and severe PPH. After adjustment, risks for PPH and severe PPH remained increased for each supplementary 10 minutes of EE (see Table). Forceps delivery and episiotomy were also significantly associated with risk of PPH and severe PPH (aOR 1.79[1.34-2.38] and 2.12[1.52-2.97] for forceps, compared with spontaneous delivery and aOR 1.74[1.35-2.33] and 2.46[1.75-3.48] for episiotomy). CONCLUSION: Duration of expulsive efforts is associated with an increased risk of PPH and severe PPH. However, options to reduce this phase, i.e. performs forceps or episiotomy, are also associated with a higher risk of PPH and severe PPH. Physicians should take these results into consideration for management of the active second stage of labor.

Survey of prophylactic use of uterotonics in the third stage of labour in the Netherlands

Objectiveaim of this study was to investigate current knowledge and practice regarding AMTSL in midwifery practices and obstetric departments in the Netherlands. Designweb-based and postal questionnaire. Settingin August and September 2011 a questionnaire was sent to all midwifery practices and all obstetric departments in the Netherlands. Participantsall midwifery practices (528) and all obstetric departments (91) in the Netherlands. Measurements and findingsthe response was 87.5%. Administering prophylactic uterotonics was seen as a component AMTSL by virtually all respondents; 96.1% of midwives and 98.8% of obstetricians. Cord clamping was found as a component of AMTSL by 87.4% of midwives and by 88.1% of obstetricians. Uterine massage was only seen as a component of AMTSL by 10% of the midwives and 20.2% of the obstetricians. Midwifery practices routinely administer oxytocin in 60.1% of births. Obstetric departments do so in 97.6% (p<0.01). Compared to 1995, the prophylactic use of oxytocin had increased in 2011 both by midwives (10–59.1%) and by obstetricians (55–96.4%) (p<0.01). Key conclusionsprophylactic administration of uterotonics directly after childbirth is perceived as the essential part of AMTSL. The administration of uterotonics has significantly increased in the last decade, but is not standard practice in the low-risk population supervised by midwives. Implications for practicethe evidence for prophylactic administration of uterotonics is convincing for women who are at high risk of PPH. Regarding the lack of evidence of AMTSL to prevent PPH in low risk (home) births, further research concerning low-risk (home) births, supervised by midwives in industrialised countries is indicated. A national guideline containing best practices concerning management of the third stage of labour supervised by midwives, should be composed and implemented.

Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study

BackgroundIncreasing rates of postpartum haemorrhage in developed countries over the past two decades are not explained by corresponding changes in risk factors and conjecture has been raised that maternal obesity may be responsible. Few studies investigating risk factors for PPH have included BMI or investigated PPH risk among nulliparous women. The aim of this study was to determine in a cohort of nulliparous women delivering at term whether overweight and obesity are independent risk factors for major postpartum haemorrhage (PPH ≥1000ml) after vaginal and caesarean section delivery.MethodsThe study population was nulliparous singleton pregnancies delivered at term at National Women’s Hospital, Auckland, New Zealand from 2006 to 2009 (N=11,363). Multivariable logistic regression was adjusted for risk factors for major PPH.ResultsThere were 7238 (63.7%) women of normal BMI, 2631 (23.2%) overweight and 1494 (13.1%) obese. Overall, PPH rates were increased in overweight and obese compared with normal-weight women (n=255 [9.7%], n=233 [15.6%]), n=524 [7.2%], p <.001) respectively. There was an approximate twofold increase in risk in obese nulliparous women that was independent of confounders, adjusted odds ratio [aOR (95% CI)] for all deliveries 1.86 (1.51-2.28). Being obese was a risk factor for major PPH following both caesarean 1.73 (1.32-2.28) and vaginal delivery 2.11 (1.54-2.89) and the latter risk was similar after exclusion of women with major perineal trauma and retained placentae. Three additional factors were consistently associated with risk for major PPH regardless of mode of delivery: increasing infant birthweight, antepartum haemorrhage and Asian ethnicity.ConclusionNulliparous obese women have a twofold increase in risk of major PPH compared to women with normal BMI regardless of mode of delivery. Higher rates of PPH among obese women are not attributable to their higher rates of caesarean delivery. Obesity is an important high risk factor for PPH, and the risk following vaginal delivery is emphasised. We recommend in addition to standard practice of active management of third stage of labour, there should be increased vigilance and preparation for PPH management in obese women.

Maternal and neonatal outcomes of macrosomic pregnancies

SummaryBackgroundTo compare maternal and neonatal outcomes of term macrosomic and adequate for gestational age (AGA) pregnancies.Material/MethodsA retrospective analysis was performed on all term singleton macrosomic (birth weight ≥4000 g) and AGA (birth weight >10th percentile and <4000 g) pregnancies delivered at our hospital between 2004 and 2008. Data collected included maternal age, gestational age at delivery, mode of delivery, birth weight, fetal gender, maternal and neonatal complications. Comparisons were made between macrosomic and AGA pregnancies and between different severities of macrosomia (4000–4250 g, 4250–4500 g and ≥4500 g).ResultsThe study population comprised of 34,685 pregnancies. 2077 neonates had birth weight ≥4000 g. Maternal age and gestational age at delivery were significantly higher for macrosomic neonates. Significantly more macrosomic neonates were born by cesarean section, and were complicated with shoulder dystocia, neonatal hypoglycemia, and had longer hospitalization period (both in vaginal and cesarean deliveries). Specifically, the odds ratio (OR) relative to AGA pregnancies for each macrosomic category (4000–4250 g, 4250–4500 g and ≥4500 g) of shoulder dystocia was 2.37, 2.24, 7.61, respectively, and for neonatal hypoglycemia 4.24, 4.41, 4.15, respectively. The risk of post partum hemorrhage was statistically increased when birth weight was >4500 g (OR=5.23) but not for birth weight between 4000–4500 g. No differences were found in the rates of extensive perineal lacerations between AGA and the different macrosomic groups.ConclusionsMacrosomia is associated with increased rate of cesarean section, shoulder dystocia, neonatal hypoglycemia, and longer hospitalization, but not associated with excessive perineal tears. Increased risk of PPH was found in the >4500g group.

How can benfluorex-related heart valve disease be identified by echocardiography?

) and cabergoline (Dostinex ). The so-called ‘recreational’drug 3,4-methylene-dioxy-methylamphetamine (better known as ‘ecstasy’ [5]) has alsobeen potentially associated with fibrotic valvular disease. Benfluorex was withdrawn fromsale in France in November 2009 and from the European market in June 2010 followingreports strongly suggesting an increased risk of valvular disease and PPH in patients withprevious exposure to this drug. In France, benfluorex was prescribed as an adjuvant to anappropriate diet in overweight diabetics; its indication as an adjuvant to an appropriatediet in patients with hypertriglyceridaemia was withdrawn in 2007, following assessmentof a very poor efficacy in this setting. Benfluorex had also been widely prescribed in Franceas an appetite suppressant.

0.10a Risk of PPH in women using therapeutic dosage of LMWH during pregnancy and puerperium

0.10a Risk of PPH in women using therapeutic dosage of LMWH during pregnancy and puerperium

Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case–control study

ObjectivesPostpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may...

Post partum haemorrhage, estimated blood loss at delivery and relationship with duration, concentration and total dose of exogenous oxytocin administered in labour

BackgroundPost partum haemorrhage (PPH) is a major cause of maternal morbidity. Induction and augmentation of labour with exogenous oxytocin are associated with increased estimated blood loss (EBL) at delivery, and...

Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial.

BackgroundThe third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60–70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care.ObjectiveThe primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package.MethodsA hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period.ManagementOverall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field.Expected outcomesThe main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field.Trial RegistrationACTRN12608000434392

Rectal misoprostol versus oxytocin in the prevention of postpartum hemorrhage — A pilot study

Oxytocin has been the oxytocic of choice for Active Management of Third Stage of Labor (AMTSL) [1]. Misoprostol would be a suitable alternative in low resource settings where drug delivery is hampered by storage and problems of parenteral administration. In patients who are vomiting, unable to take medications or under anesthesia, rectal administration may be associated with fewer side effects and ease of administration [2].The use of additional uterotonics is significantly higher with rectal 400 mcg misoprostol than with oxytocin [3]. It is possible that a higher dose of rectal misoprostol may be more effective in reducing blood loss. A prospective, double-blind, randomized pilot study was undertaken in the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India to determine the effectiveness and safety of rectal administration of 600 mcg misoprostol compared to oxytocin as part of the AMTSL in women at low risk for PPH. The study was approved by the ethical committee of the Institute. Two hundred women in spontaneous labor were recruited, and a written informed consent was ob-

A double-blind randomized controlled trial to compare sublingual misoprostol with methylergometrine for prevention of postpartum hemorrhage

Postpartum hemorrhage is the leading cause of maternal mortality in India, accounting for 25---30% of all maternal deaths [1]. A large number of deliveries still occur at home, especially in rural areas. Injectable uterotonics are not necessarily applicable to these settings, as their effective use requires safe administration and special storage to maintain stability. In this prospective double blind randomized study conducted in 2005-06 at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 200 women at low risk of PPH were randomized to receive either two tablets of misoprostol (400 mcg) sublingually or 1ml of methylergometrine (200 mcg) intramuscularly at the delivery of anterior shoulder of baby. Identical looking placebo tablets and injections were used. Primary and secondary outcomes measured are shown in Table 1. The duration of third stage, mean blood loss and need for additional oxytocics was similar in both

Active management of third stage of labour reduces risk of PPH

Active management of third stage of labour reduces risk of PPH

EMERGENT OBSTETRIC MANAGEMENT OF POSTPARTUM HEMORRHAGE

Early PPH remains a significant problem in obstetrics with serious maternal morbidity and mortality. Many patients at risk for PPH can be antenatally identified. Such identification allows these patients delivery at medical facilities where personnel, blood banking, laboratory, and radiographic expertise exist to expeditiously manage PPH. Even so, some patients without antecedent risk factors suffer PPH. This discussion provides a practical approach to establish an accurate diagnosis of PPH and an expeditious application of medical, surgical, and radiographic management. It is the responsibility of every obstetric health care provider to maintain proficiency in the diagnosis and management of PPH to reduce its incidence and associated morbidity and mortality to an unpreventable minimum.