Normalpuerperium.

Definition of Normal Puerperium

It is the period following delivery of the baby It is the period following delivery of the baby and placenta to and placenta to 6 weeks6 weeks postpartum. postpartum.

It is the period during it ,the It is the period during it ,the reproductive reproductive

organsorgans & & maternal physiologymaternal physiology returns returns towards the pre pregnancy state .towards the pre pregnancy state .

–First 24 hoursFirst 24 hours

–Early- up to 7 daysEarly- up to 7 days

–Remote- up to 6 weeksRemote- up to 6 weeks

Divided into

Objectives

To monitor physiological changes of To monitor physiological changes of puerperiumpuerperium

To diagnose and treats any To diagnose and treats any postnatal complicationspostnatal complications

To establish infant feedingTo establish infant feeding

To advise about contraceptionTo advise about contraception

Physiological changes in Normal Puerperium

Changes in Genital TractChanges in Genital TractChanges in breast and Lactation Changes in breast and Lactation Changes in other systemsChanges in other systems

Changes in Genital Tract

Involution of the Uterus Involution of the Uterus LochiaLochia Involution of Other Pelvic OrgansInvolution of Other Pelvic Organs MenstruationMenstruation

Uterine involutionUterine involution

A. Immediately after delivery:A. Immediately after delivery: fundus palpable atfundus palpable at level of umbilicuslevel of umbilicus

B. 10-14 days later, B. 10-14 days later, At level of theAt level of the symphysis pubis.symphysis pubis.C. 6 WKS post partun C. 6 WKS post partun ::non pregnant sizenon pregnant size

Decidua is cast off as a result of Decidua is cast off as a result of ischemia ischemia lochial flowlochial flow

Lochia= blood, leucocytes, shreds Lochia= blood, leucocytes, shreds of of decidua and organisms.decidua and organisms.

Initially; dusky red3-4 days(rubra), fades Initially; dusky red3-4 days(rubra), fades after after one-two week(serosa), clears within 4 one-two week(serosa), clears within 4 weeks weeks of delivery(alba). of delivery(alba).

New endometrium grows from New endometrium grows from basal layer basal layer of decidua.of decidua.

Endometrium Cavity

Cervix:

It has reformed within several hours of It has reformed within several hours of delivery delivery it usually admits only one finger by 1 it usually admits only one finger by 1

weeks weeks the external os is fish-mouth-shapedthe external os is fish-mouth-shaped it return to its normal state at 4 weeks it return to its normal state at 4 weeks

after birth after birth

Ovarian function

Return of menstruationReturn of menstruation

* * non-nursing mothers:non-nursing mothers:

menstruation returns by 6 menstruation returns by 6 –– 8 weeks. 8 weeks.

** nursing mothers: nursing mothers:

may develop lactating amenorrhea.may develop lactating amenorrhea.

time of ovulation is 3 months in non- time of ovulation is 3 months in non-

breast -feeding women breast -feeding women

Changes in Breast and Lactation

Mamogenesis (Mammary duct-Mamogenesis (Mammary duct-gland growth & dev.) gland growth & dev.)

Lactogenesis (Initiation Of Lactogenesis (Initiation Of milk secretion in alveoli)milk secretion in alveoli)

Galactopoiesis (Maintenance of Galactopoiesis (Maintenance of Lactation)Lactation)

Changes in other systems

Pulse slowPulse slow Temp. subnormalTemp. subnormal ShiveringShivering Fever up to first 24 hoursFever up to first 24 hours Hb. RisesHb. Rises TLC increasesTLC increases Diuresis- 2Diuresis- 2ndnd to 5 to 5thth day post delivery day post delivery

OTHER SYSTEMS:OTHER SYSTEMS:

Bladder & UrethraBladder & Urethra- Within 2-3 weeks- Within 2-3 weeks

Hydroureter and calycial dilatation of pregnancy is much less evident.Hydroureter and calycial dilatation of pregnancy is much less evident.

- Complete return to normal - Complete return to normal 6-8 weeks 6-8 weeks

Cardiovascular systemCardiovascular system

** cardiac output cardiac output & & plasma volume plasma volume gradually gradually returns to normal during the first returns to normal during the first 2 weeks2 weeks..

** marked marked weight loss weight loss occurs in the first week occurs in the first week as a result of the decrease of plasma volume as a result of the decrease of plasma volume and the deuresis of the extracellular fluid.and the deuresis of the extracellular fluid.

OTHER SYSTEMS:

Daily round by physical staff should incluid: Uterus:Uterus: palpate uterine funds to evaluate level and palpate uterine funds to evaluate level and

tonetone AbdomenAbdomen: examine for distension especially : examine for distension especially

postoperativepostoperative LochiaLochia :for quantity ,and unusual odors :for quantity ,and unusual odors PerineumPerineum: inspected for hematoma : inspected for hematoma

formation ,signs of infections, or wound formation ,signs of infections, or wound breakdown.breakdown.

BladderBladder: function may be abnormal after : function may be abnormal after traumatic delivery or epidural anethesia.traumatic delivery or epidural anethesia.

(Catheter may be left in place for 24 hr if there (Catheter may be left in place for 24 hr if there is marked periurtheral edema or repair).is marked periurtheral edema or repair).

Breasts Breasts :examined for engorgement or signs :examined for engorgement or signs of infectionof infection

LungsLungs :evaluated in all post CS patients. :evaluated in all post CS patients. ExtremitiesExtremities :because post partum pt are at :because post partum pt are at

increased risk of DVT especially post CS.increased risk of DVT especially post CS.

Post partum immunization

Adminster a booster dose in Rubella Adminster a booster dose in Rubella non immune wommen or MMR non immune wommen or MMR vacine.vacine.

Adminster 300 ug of RhoGAM Adminster 300 ug of RhoGAM within first 72 hours after delivery to within first 72 hours after delivery to RH –ve mothers .RH –ve mothers .

Breast feeding should be Encouraged

Help in rapid uterine involution, decreased risk of Help in rapid uterine involution, decreased risk of ovarian ,breast cancer,osteprosis.ovarian ,breast cancer,osteprosis.

Women shouldn't breastfed Women shouldn't breastfed if:if: Have infant with galactosemiaHave infant with galactosemia Are infected with HIV.Are infected with HIV. Have active untreated TB.Have active untreated TB. Are being treated for breast cancer.Are being treated for breast cancer.

Contraceptive advice

Breast feeding women shouldn’t relay on Breast feeding women shouldn’t relay on lactation amenorrhea as a method of lactation amenorrhea as a method of contraception (98% protection in first 6 months contraception (98% protection in first 6 months provided that feeding every 4 hours daily ,6 provided that feeding every 4 hours daily ,6 hours at nigth ,formula supply 10-15%)hours at nigth ,formula supply 10-15%)

Use a barrier method or hormonal Use a barrier method or hormonal contraception .POP 2-3 weeks postpartum contraception .POP 2-3 weeks postpartum

DMPA 6 weeks postpartum DMPA 6 weeks postpartum

Health & nutrition education

Calorie need per day-2200+700 =2900Calorie need per day-2200+700 =2900 Care of MLE stitches if anyCare of MLE stitches if any Care of nipples and areola Care of nipples and areola Sexual intercourse can be resumed after 6 Sexual intercourse can be resumed after 6

weeks after deliveryweeks after delivery Immunization of childImmunization of child

Health & nutrition education

Puerperal fever

Definition

Temperatures reach 100.4F(38.0C) or Temperatures reach 100.4F(38.0C) or higher on any two of the first 10 days higher on any two of the first 10 days postpartum, exclusive of the first 24 postpartum, exclusive of the first 24 hours. hours.

  

Benign single-day fevers following vaginal delivery

Fever in the first 24 hours after Fever in the first 24 hours after delivery often resolves spontaneously delivery often resolves spontaneously and cannot be explained by an and cannot be explained by an identifiable infection. identifiable infection.

Significance Fever is not an automatic indicator of Fever is not an automatic indicator of

puerperal infection. puerperal infection. A new mother may have a fever owing to prior A new mother may have a fever owing to prior

illness or an illness unconnected to childbirth. illness or an illness unconnected to childbirth. However, any fever within 10 days postpartum However, any fever within 10 days postpartum

is aggressively investigated.is aggressively investigated. Physical symptoms such as pain, malaise, loss Physical symptoms such as pain, malaise, loss

of appetite, and others point to infection. of appetite, and others point to infection.

Significance

Endometritis (most common),Endometritis (most common),Milk engorgment, Mastitis,breast abscessMilk engorgment, Mastitis,breast abscessUrinary tract infectionUrinary tract infectionpneumonia\atlectasis, pneumonia\atlectasis, CS ,perineal wound infection, fasiaties.CS ,perineal wound infection, fasiaties.Septic pelvic thrombophlebitis. Septic pelvic thrombophlebitis.

Causes

= uncommon complication usually develops after 2 – 4 weeks.

symptoms & signs

low grade fever , chills , indurated ,red and painful segment of the breast.

caused by Staphylococcus aureus bacteria from the infant’s oral pharynx.

Mastitis :

Mastitis

Mother should start antibiotics immediately,

such as dicloxacillin for 7-10 days.

Breastfeeding may be discontinued so, breast pump can be used to maintain lactation .

however , suppression of lactation is advisable. if a breast abscess develops , it should be

surgically drained.

Treatment

Endometritis

The most typical site of infection is the The most typical site of infection is the genital tract. genital tract.

Endometritis, which affects the uterus, is Endometritis, which affects the uterus, is the most prominent of these infections. the most prominent of these infections.

Endometritis is much more common if a Endometritis is much more common if a small part of the placenta has been small part of the placenta has been retained in the uterus. retained in the uterus.

Atelectasis

Caused by hypoventilation and is Caused by hypoventilation and is best prevented by coughing and deep best prevented by coughing and deep breathing on a fixed schedule breathing on a fixed schedule following surgeryfollowing surgery

Acute pyelonephritis Acute

Has a variable clinical picture, and Has a variable clinical picture, and postpartum, the first sign of renal postpartum, the first sign of renal infection may be fever, followed infection may be fever, followed later by costovertebral angle later by costovertebral angle tenderness, nausea, and vomiting.tenderness, nausea, and vomiting.

Incisional abscesses that develop following Incisional abscesses that develop following cesarean delivery usually cause persistent cesarean delivery usually cause persistent fever beginning fever beginning about the about the fourth dayfourth day

Perineal infection uncommon , caused by bacterial contamination during delivery

Antimicrobials and surgical drainage, with Antimicrobials and surgical drainage, with careful inspecticareful inspection on to ensure that the fascia is to ensure that the fascia is intact.intact.

Wound infections

Septic Thrombophlebitis A dignosis of exclusion .Thrombous spread by lymphatic's to the

iliac vessels or directly via the ovarian vessels.

Suspected by intermittent spiky fever which fails to response to ordinary antibiotics and improved with heparin .

Puerpral sepsis

Incidence

3%- 7% of all direct maternal deaths , excluding deaths after abortion.

Etiology:

Puerperal infection is usually poly microbial involves contaminants from the bowel that colonize the perineum and lower genital tract.

clinical course & severity of the infection is determined by

1. general health and resistance of the woman.

2. virulence of the causative organisms.

3. presence of predisposing factors as bl. Clots, hematoma or retained products of conception.

4. timing of antibiotic therapy.

Clinical course & severity of the infection is determined by

Risk factors

Prolonged PROMProlonged PROM Prolonged (more than 24 hours) labor Prolonged (more than 24 hours) labor Frequent vaginal examinationsFrequent vaginal examinations Retained products of conception Retained products of conception Hemorrhage Hemorrhage Anemia, poor nutrition during pregnancy.Anemia, poor nutrition during pregnancy. Obesity. Obesity. Diabetes. Diabetes.

Risk factors (CONT ..)

Cesarean birth (20-fold increase in Cesarean birth (20-fold increase in risk for puerperal infection). risk for puerperal infection).

Genital or urinary tract infection Genital or urinary tract infection prior to delivery. prior to delivery.

Urinary catheterUrinary catheter Fetal scalp electrode, internal FHR Fetal scalp electrode, internal FHR

during labor.during labor.

Pathogenesis of puerperal sepsis

Puerperal infection following vaginal delivery Puerperal infection following vaginal delivery primarily involves the primarily involves the placental implantation site, placental implantation site, decidua and adjacent myometrium, or decidua and adjacent myometrium, or cervicovaginal lacerations.cervicovaginal lacerations.

Uterine infection following cesarean delivery is that Uterine infection following cesarean delivery is that

of of an infected surgical incisionan infected surgical incision Bacteria that colonize the cervix and vagina gain Bacteria that colonize the cervix and vagina gain

access to amnionic fluid during labor, and access to amnionic fluid during labor, and postpartum, they invade devitalized uterine tissue. postpartum, they invade devitalized uterine tissue.

Postpartum uterine infection has been called Postpartum uterine infection has been called variously variously endometritis, endomyometritis,endometritis, endomyometritis, and and endoparametritis.endoparametritis.

Because infection involves not only the decidua Because infection involves not only the decidua but also the myometrium and parametrial tissues, but also the myometrium and parametrial tissues, the inclusive term the inclusive term metritis with pelvic cellulitismetritis with pelvic cellulitis..

UTERINE INFECTIONS

The The route of deliveryroute of delivery is the single most is the single most significant risk factor for the development of significant risk factor for the development of uterine infection uterine infection

1- to 6-% 1- to 6-% incidence of metritis after vaginal incidence of metritis after vaginal delivery. delivery.

If there is intrapartum chorioamnionitis, the risk If there is intrapartum chorioamnionitis, the risk of persistent uterine infection increases to of persistent uterine infection increases to 13 %13 %

Predisposing factor

CESAREAN DELIVERY

Single-dose perioperative antimicrobial Single-dose perioperative antimicrobial prophylaxis prophylaxis is given almost universally is given almost universally at CSat CS

10-50%10-50% incidence of metritis after CS incidence of metritis after CS Women with CS after labor (risk factors Women with CS after labor (risk factors

factors) who were not given perioperative factors) who were not given perioperative prophylaxis had prophylaxis had a a 90-percent 90-percent serious serious pelvic infection ratepelvic infection rate

A. Clinical Picture symptoms:

• fever ,rigors, malaise, headache.

• vomiting and diarrhoea.

• abdominal discomfort.

• offensive lochia.

• 2ry PP Hge.

Diagnosis

Pyrexia and tachycardiaUterus is large and tender Parametrial tenderness (parametritis)or Parametrial tenderness (parametritis)or fullness in pelvis

due to abscess is elicited on abdominal and bimanual is elicited on abdominal and bimanual examination examination

peritoneum and paralytic ileus (severe cases).

•

Signs

1. CBC anaemia, Leukocytosis Leukocytosis may range from may range from 15,000 to 30,000 cells/L15,000 to 30,000 cells/L, , but recall that cesarean delivery itself but recall that cesarean delivery itself increases the leukocyte count increases the leukocyte count

2. Coagulation Profile DIC.

3 Arterial blood gas acidosis & hypoxia. ( septiceamic shock)

Investigations

Bacterial cultures

4-Routine pretreatment genital tract cultures are of little clinical use and add significant costs

5-Similarly, routine blood cultures seldom modify care(25% +ve in septicPelvic thrombo phelbities.

6.Urine analysis: white blood cell casts is diagnostic of pyelonephrities.

7-Pelvic US : Retained products Adnexal mass in pelvic abscess.CT: Occult abscess or thrombous in

tthrombophelbities.

Investigations

Management

Awareness of general hygiene principles Good surgical technique with proper

hemostasis. Prophylactic antibiotics especially in

emergency CS.a single intra operative dose of cphalosporin+ metronidazole.

Prevention

Treatment Begins with I.V. infusion of broad Begins with I.V. infusion of broad

spectrum antibiotics and is continued spectrum antibiotics and is continued for 48 hours after fever is resolved.for 48 hours after fever is resolved.

Surgery may be necessary to remove Surgery may be necessary to remove any remaining products of conception any remaining products of conception or to drain local lesions, such as an or to drain local lesions, such as an infected episiotomy .infected episiotomy .

had a 95-percent response rate still considered by had a 95-percent response rate still considered by most to be the standard by which others are most to be the standard by which others are measured measured

Because enterococcal infections may persist despite Because enterococcal infections may persist despite this standard therapy, many add this standard therapy, many add ampicillinampicillin to the to the clindamycin-gentamicin regimen, either initially or clindamycin-gentamicin regimen, either initially or if there is no response by 48 to 72 hours.if there is no response by 48 to 72 hours.

CLINDAMYCIN-GENTAMICIN REGIMEN

Patients with persistant fever despite antibiotics TTT are assessed for

Ratained product of conceptionRatained product of conceptionWound infectionWound infectionPelvic abcessPelvic abcessOvarian vein thrombosisOvarian vein thrombosisSeptic pelvic thrombophelbitiesSeptic pelvic thrombophelbities ..

Complications

1- Metritis and parametitis.

2. Pelvic abscess

3 Pelvic Peritonitis

4. Septic Thrombophlebitis

*

Fatal infection of skin ,fascia and muscle. It occurs in the perineal tears, episiotomy sites & CS wounds.

caused by a variety of bacteria including anaerobes.

*

Necrotizing Fasciitis

Necrotizing fasciitis of the episiotomy site Necrotizing fasciitis of the episiotomy site may involve any of the several superficial or may involve any of the several superficial or deep perineal fascial layers, and thus may deep perineal fascial layers, and thus may extend to the thighs, buttocks, and abdominal extend to the thighs, buttocks, and abdominal wall wall

in addition to signs of infection ,there

is extensive necrosis

managed by surgical removal of the necrotic tissue under general anesthesia and split-thickness skin grafts

CASE SCENARIO

A 28-year-old primigravid underwent a A 28-year-old primigravid underwent a cesarean section secondary to having a cesarean section secondary to having a breech presentation and rupture of breech presentation and rupture of membranes at 36 weeks gestation. membranes at 36 weeks gestation.

The cesarean section was The cesarean section was uncomplicated, but on postpartum day uncomplicated, but on postpartum day two the patient was having fever two the patient was having fever (38.5C) and uterine tenderness. (38.5C) and uterine tenderness.

A diagnosis of postpartum A diagnosis of postpartum endometritis was made and the endometritis was made and the infection was treated with Mefoxine infection was treated with Mefoxine 1 g IV Q8H.1 g IV Q8H.

After 24 hours of antibiotics, the patient After 24 hours of antibiotics, the patient presented pain in the right lower abdomen presented pain in the right lower abdomen and loin, and her WBC count was and loin, and her WBC count was 12000/mm3. She continued to spike fevers .12000/mm3. She continued to spike fevers .

On Abdominal exam On Abdominal exam :: Soft, flat abdomen Soft, flat abdomen Tenderness on the right iliac fossa Tenderness on the right iliac fossa No rebound-tenderness, No rebound-tenderness, McburneyMcburney’’s point (+/-),Murphys point (+/-),Murphy’’s sign(-),s sign(-), Kindey region percussion (-).Kindey region percussion (-).

investigation

Urinalysis was unremarkable.Urinalysis was unremarkable.

On postpartum day four

The patientThe patient’’s condition showed no s condition showed no improvement after antibiotic treatment,improvement after antibiotic treatment,

An abdominal CT scan was obtained.An abdominal CT scan was obtained. A right ovarian vein thrombosis was noted A right ovarian vein thrombosis was noted

on the imaging.on the imaging.

Diagnosis : ovarian vein thrombophlebitis Diagnosis : ovarian vein thrombophlebitis

The patient started therapeutic The patient started therapeutic enoxaparin(clexane). enoxaparin(clexane).

After 48 hours of anticoagulation, the patient After 48 hours of anticoagulation, the patient was afebrile and asymptomatic. was afebrile and asymptomatic.

The patient was discharged home after being The patient was discharged home after being anticoagulated with warfarin anticoagulated with warfarin

After 6 weeks a CT scan was repeated. The After 6 weeks a CT scan was repeated. The right ovarian thrombosis was not present in right ovarian thrombosis was not present in the images and warfarin was discontinuedthe images and warfarin was discontinued

How to prevent ?

Avoid the risk factorsAvoid the risk factors Keep the episiotomy site clean Keep the episiotomy site clean Careful attention to antiseptic procedures Careful attention to antiseptic procedures

during childbirth is the basic key of during childbirth is the basic key of preventing infection.preventing infection.

Administer prophylactic antibiotics with Administer prophylactic antibiotics with Cesarean section, PROM, Cesarean section, PROM, cardiac ,diabetic patients and with any cardiac ,diabetic patients and with any uterine manipulationuterine manipulation. .

MCQ

Which change can be seen in puerperium?

A-maternal heart beat is increased 2 days after A-maternal heart beat is increased 2 days after deliverydelivery

B- endometrium repair is resumed three weeks B- endometrium repair is resumed three weeks after deliveryafter delivery

C- Ureters will return to non pregnant state after C- Ureters will return to non pregnant state after 8 weeks 8 weeks

D- Vaginal rugae appear after 3 months from D- Vaginal rugae appear after 3 months from deliverydelivery

Ans:CAns:C

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Which is true about puerpural changes?

A- total number of uterine muscular cells is not A- total number of uterine muscular cells is not reducedreduced

B-vaginal rugae occur in the third month from B-vaginal rugae occur in the third month from deliverydelivery

C-uterine connective tissue won’t changeC-uterine connective tissue won’t change

D-uterine is re-epithelialized totally in the first D-uterine is re-epithelialized totally in the first week of pregnancy week of pregnancy

Ans:AAns:A

Which organism is the least responsible in puerpural infection?

A- peptostreptococcusA- peptostreptococcus

B-enterococcusB-enterococcus

C- chlamydia trachomatisC- chlamydia trachomatis

D-mycoplasmaD-mycoplasma

Ans:DAns:D

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A patient comes to the clinic because of fever 4 days after C/S which persists 72 hours from antibiotic administration. What is the most likely reason of antibiotic failure?

A- wound infectionA- wound infection

B- pelvic thrombophlebitisB- pelvic thrombophlebitis

C- pyelonephritisC- pyelonephritis

D- adenexal infectionD- adenexal infection

Ans:AAns:A

What is wrong about puerpural immunization?

A- tetanus and diphtheria vaccine before A- tetanus and diphtheria vaccine before discharge from hospital is advocateddischarge from hospital is advocated

B-a woman already injected measles vaccine B-a woman already injected measles vaccine does not need a booster dosedoes not need a booster dose

C- Rh negative women with an Rh positive C- Rh negative women with an Rh positive newborn should take RhoGamnewborn should take RhoGam

D- women who have never taken rubella D- women who have never taken rubella vaccine should be vaccinatedvaccine should be vaccinated

Ans:BAns:B

Which is wrong about fever after delivery?

A-fever more than 39 c in the first 24 hours after A-fever more than 39 c in the first 24 hours after delivery is a sign of severe infectiondelivery is a sign of severe infection

B-fever in bacterial mastitis usually is late and B-fever in bacterial mastitis usually is late and persistent persistent

C-pulmonary infection usually occurs in the first C-pulmonary infection usually occurs in the first 24 hours mostly after C/S 24 hours mostly after C/S

D-pyelonephritis is one of the most common D-pyelonephritis is one of the most common reason of infection and is most often mistaken reason of infection and is most often mistaken for pelvic infectionfor pelvic infection

Ans: DAns: D

A woman has gone through C/S 7 days ago . Three days after the operation chills and fever (enigmatic fever) occured. She is given antibiotic with no improvement in her condition. She doesn’t look ill. What is your diagnosis?

A-pelvic abscessA-pelvic abscessB-parametrial phlegmonB-parametrial phlegmonC-pelvic septic thrombophlebitisC-pelvic septic thrombophlebitisD-adenexal infectionD-adenexal infection

Ans:CAns:C

Who can lactate?

A- mother of a galactosemic newbornA- mother of a galactosemic newborn

B- mother with HBV B- mother with HBV

C- mother with active untreated TBC- mother with active untreated TB

D-mother with breast herpetic lesionsD-mother with breast herpetic lesions

Ans:BAns:B

An infection after C/S which is not responsive to clinda+genta is because of:

A-clostridiumA-clostridium

B-enterococcusB-enterococcus

C-bacteroid fargilisC-bacteroid fargilis

D-chlamydia trachomatisD-chlamydia trachomatis

Ans:BAns:B

What is true about lactation period mastitis?

A-It occurs in the last days of the first weekA-It occurs in the last days of the first week

B- Most of the time it is bilateralB- Most of the time it is bilateral

C-nose and throat of the newborn is the source of C-nose and throat of the newborn is the source of infectioninfection

D-it is mostly a result of coagulase-negative D-it is mostly a result of coagulase-negative staphstaph

Ans:C Ans:C

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