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Year 5 - Obstetrics and Gynaecology > Contraception > Flashcards

Contraception Flashcards

1
Q

What is the definition of LARC in the UK?

A

Long-acting reversible contraception - a method that requires administration less than once per month (so includes the implant, IUD, IUS, injection)

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2
Q

What are the most effective contraceptive methods?

A

Longacting reversible methods of contraception (LARC) a.k.a. ‘fit and forget methods’ e.g.

  • copper intrauterine device (Cu-IUD),
  • levonorgestrel intrauterine system (LNG-IUS)
  • progestogen-only implant
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3
Q

What are the currently available MOA of contraception?

A

Prevent ovulation:

  • combined hormonal methods (pill, patch and vaginal ring),
  • progestogen-only injectables,
  • progestogen-only implant (Nexplanon®),
  • oral emergency contraception,
  • lactational amenorrhoea.

Prevent sperm reaching the oocyte: sterilisation

Prevent an embryo implanting in the uterus: Cu-IUD and LNG-IUS.

Allow sperm into the vagina but poison them e.g spermicides.

Allow sperm into the vagina but block further passage e.g. diaphragm, cap, progestogens.

Prevent sperm entering the vagina

  • male and female condoms
  • avoid sex during the fertile time of the cycle
  • fertility awareness-based methods (FAB)
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4
Q

Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use

A
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5
Q

‘What % of couples will concieve within 12 months without use of any contraception

vs

male condom with typical and perfect use?

A

85% without any contraception

18% with typical use and 2% with perfect use will become pregnant within 12 months

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6
Q

What does efficacy vs effectiveness of a contraceptive depend on?

A

Efficacy - depends on MOA

Effectiveness - real life factors e.g. compliance and continuation.

Compliance depends on route of administration and continuation on use acceptability.

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7
Q

What WHO criteria is used to guide the safety of contraceptive use in different health conditions?

A

Medical eligibility criteria (MEC) - categories 1-4, where 1 is no restriction on use while 4 represents an unacceptable health risk

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8
Q

Name the MEC conditions.

A
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9
Q

Which categories of medication may interact with hormonal contraception?

A
  • Anticonvulsants
  • Antifungals
  • Antiretrovirals
  • Antibiotics

Interact with…. by inducing liver enzyme cytochrome P450 and reducing the reliability of the contraceptive.

  • COCP
  • Patch
  • Ring
  • Progestogen-only implant
  • POP
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10
Q

List 5 examples of MEC category 4 conditions as given by WHO.

A
  1. Age >35 and smoking
  2. BP >160/100mmHg
  3. HTN with vascular disease
  4. DVT, curent or past
  5. MI, current or past
  6. CVA, current or past
  7. Multiple serious RFs for CVD
  8. Thrombophilia
  9. Current breast cancer
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11
Q

List 5 examples of MEC category 3 conditions.

A
  • > 35 years old and smoking <15 cigarettes/day
  • BMI > 35 kg/m^2*
  • family history of VTE disease in 1st degree relatives < 45 years
  • controlled HTN
  • immobility e.g. wheel chair use
  • carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
  • current gallbladder disease
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12
Q

Which MEC criteria does breast feeding < 6 weeks post-partum fulfil?

A

UK MEC4 i.e. an unacceptable health risk

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13
Q

Name an antifungal which is known to decrease efficacy of hormonal contraception through induction of liver enzymes.

A

Griseofulvin

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14
Q

Name 2 antiretrovirals which are known to decrease efficacy of hormonal contraception through induction of liver enzymes.

A

Protease inhibitors e.g. ritonavir, lopinavir

NNRTIs e.g. efavirentz, nevirapine

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15
Q

Name 2 anticonvulsants which are known to decrease efficacy of hormonal contraception through induction of liver enzymes.

A

Carbamazepine

Phenobarbital

Phenytoin

Eslicarbazepine

Oxcarbazepine

Primidone

Topiramate

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16
Q

Name 2 antibiotics which are known to decrease efficacy of hormonal contraception through induction of liver enzymes.

A

Rifampicin
Rifabutin

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17
Q

What SE are commonly reported with hormonal contraceptives?

A
  • Unexpected bleeding - common (15%)
  • Weight gain - evidence for progestogen-only injectable in adolescents
  • Headaches - may occur with COCP in pill-free interval so advise to continue serial packs. If they occur frequently or are severe then change method of contraception.
  • Mood swings
  • Loss of libido
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18
Q

Do hormonal contraceptives cause weight gain?

A

With the exception of progesterone-only injectable in adolescents there is no good evidence that hormonal methods can cause weight gain.

This includes for Cu-IUD, LNG-IUS etc.

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19
Q

Do hormonal contraceptives affect mood and libido?

A

There is not good evidence that they affect mood or libido

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20
Q

With unexpected bleeding on hormonal contraception, when should you refer for further investigations?

A

If bleeding persists for >3 months

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21
Q

What are some determinants of contraceptive method acceptability?

A
  • Personal characteristics (e.g. age).
  • Fertility intentions.
  • Perceptions of effectiveness.
  • Perceptions of safety.
  • Fear of side-effects.
  • Familiarity.
  • Experience of others.
  • Ease of use and of access.
  • Need to see a health professional.
  • Intrusiveness.
  • Non-contraceptive benefits.
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22
Q

What are 3 non-contraceptive health benefits of progestogen-only injectable (depot medroxyprogesterone
acetate)?

A
  • Heavy menstrual bleeding
  • Endometriosis
  • Dysmenorrhoea
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23
Q

What are 3 non-contraceptive health benefits of COCP?

A
  • Heavy menstrual bleeding
  • Irregular menses
  • Hirsutism
  • Acne
  • Premenstrual syndrome
  • Reduces risk of ovarian cancer
  • Reduces risk of endometrial cancer
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24
Q

What are 3 non-contraceptive health benefits of LNG-IUS (52mg)?

A
  • Heavy menstrual bleeding
  • Endometriosis
  • Adenomyosis
  • Dysmenorrhoea
  • Endometrial protection
  • Simple hyperplasia
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25
Q

What type of information must you give a patient when prescribing hormonal contraceptives?

A

Need to address:

  1. Method of use and what to do in misuse (e.g. missed pill)
  2. SE
  3. Health benefits
  4. Failure rates
  5. Fertility on stopping
  6. Follow up

Always useful to provide a leaflet.

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26
Q

What are 3 barrier contraceptives? How effective are they?

A
  1. Male condom - thin latex or plastic sheath placed over the man’s erect penis to stop sperm during ejaculation, must be put on before any contact ; oil/petroleum jelly will damage the rubber
  2. Female condom - a thin sheath which is inserted into the vagina.
  3. Diaphragm/cap +/- spermicide cream - should always be used together; consists of dome of rubber which is fitted by the woman over her cervix before intercourse.

All are between 92-95% effective if used correctly.

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27
Q

What are the advantages and disadvantages of each type of barrier contraception?

A

Male condoms

  • Adnvantages: widely avaialable, free from clinics, protect from STDs like HIV, no health risks with use
  • Disadvantages: none, but must be correctly applied as failure rates can rise to 24% with improper use.

Female condom

  • Advanatges: less likely to split than a male condom and not damaged by oil lubricants, protects from UTI,
  • Disadvantage: noisy, penis may be inserted between the condom and vaginal wall

Diaphragm/cap

  • Advantages: can be inserted 3hrs before intercourse, reusable
  • Disadvantages: 18% failure rates with improper use, increased rates of UTI and vaginal discharge following use, must be taught how to insert these, must be left in for 6hrs after intercourse,

Spermicides:

  • Disadvantages: low efficacy if used alone, may increase risk of HIV transmission according to some data
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28
Q

What are the intrauterine types of contraception available? Describe each.

A

LNG-IUS- progestogen releasing types include:

  • Jaydess - 13.5mg LNG-IUS - 3 years contraception, narrower and shorter frame so better in nullips, silver band on proximal end helps distinguish it from Mirena.
  • Mirena - 52mg LNG-IUS - 5 years contraception

Copper IUD - can also be used for emergency contraception, or normal for 3-10 years depending on device and age at insertion

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29
Q

What are the advantages and disadvantages of intrauterine methods of contraception?

A

LNG-IUS

  • Advantages: effective as does not rely on compliance, lighter less painful menses, most effective against HMB and effective for dysmenorrhoea, no effect on fertility once removed.
  • Disadvantages: expulsion may occur, increased risk of infection first few weeks after insertion, may cause long term acne, breast tenderness, mood disturbance and headaches.

Cu-IUD

  • Advantages: reduced risk of ectopic pregnancy but if pregnancy does occur then it is rlatively more likely to be ectopic than normal, no effect on fertility once removed.
  • Disadvantages: more painful/heavier menses
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30
Q

How does the IUS/IUD work? Is ovulation inhibited?

A

IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions and the inflammation caused)

IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening (does not prevent ovulation)

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31
Q

How soon after insertion does intrauterine contraception work?

A

IUD - immediately

IUS - 7 days later

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32
Q

What are the complications of IUS/IUD insertion?

A

Immediate/short term:

  • Pain
  • Perforation of uterus - 1 in 500 risk, higher in breastfeeding women
  • Infection - small increase in risk of PID after insertion in first 20 days
  • Expulsion - 1 in 20 risk, most likely in the first 3 months

Long-term

  • Ectopic pregnancy proportion increased - relative risk increase but overall risk still low
  • Frequent bleeding and spotting followed by amenorrhoea
33
Q

Describe the use of IUS/IUD around menopause.

A

IUD:

  • if inserted >40 years then can be used as contraception until menopause

IUS:

  • if inserted >45 years then can be used as contraception until menopause
  • can be used as the progesterone component to HRT for endometrial protection in women taking oestrogen-only hormone replacement for 4 years
34
Q

What types of contraception are recommended for transgender and non-binary peopole?

A

NB: ask whether hysterectomy/sterilisation or orchidectomy has been done as no need for contraception then.

Trasngender men:

  • Testosterone does not protect against pregnancy - any oestrogen containing pills will anatagonise the effects of testosteroene
  • Progesterone only IUS/injection may be used with testosterone therapy
  • Non-hormonal contraception may be used but IUD can exacerbate bleeding which may be unacceptable to some trans men
  • Neither emergency contraceptive options interact with testosterone so may be used

Transgender women:

  • Oestrogen, GnRH analogs, finasteride and cyproterone acetate use cannot be relied on as contraception - despite reducing or cessating sperm production
  • Condom use is advised if engaging in vaginal sex
35
Q

Counsel a patient on IUS/IUD insertion.

A

An IUD/IUS can be fitted at any time during your menstrual cycle, as long as you’re not pregnant. You’ll be protected in X.

Before your IUD/IUS is fitted, a GP or nurse will check inside your vagina to check the position and size of your womb. You may be tested for any existing infections, such as STIs, and be given antibiotics.

The appointment takes about 20 to 30 minutes, and fitting the IUD/IUS should take no longer than 5 minutes:

  • the vagina is held open, like it is during cervical screening (a smear test)
  • the IUD is inserted through the cervix and into the womb

Having an IUD fitted can be uncomfortable, and some people might find it painful, but you can have a local anaesthetic to help. Discuss this with a GP or nurse beforehand. You can ask to stop at any time. You can also take painkillers after having an IUD fitted if you need to.

You may get period-type cramps afterwards, but painkillers can ease the cramps. You may also bleed for a few days after having an IUD fitted.

Once your IUD has been fitted, you may be advised to get it checked by a GP after 3 to 6 weeks to make sure everything is fine. Tell the GP if you have any problems after this initial check or if you want the IUD removed.

An IUS has 2 thin threads that hang down a little way from your womb into the top of your vagina. You should check if the threads are still in place a few times a month and after periods. If you cannot feel the threads you may need additional protection and contact GP/nurse straight away.

36
Q

Counsel a patient on IUD/IUS removal.

A

Your IUS can be removed at any time by a trained doctor or nurse.

If you’re not having another IUS/IUD put in and do not want to become pregnant, use additional contraception, such as condoms, for 7 days before you have it removed.

It’s possible to get pregnant as soon as the IUS/IUD has been taken out.

37
Q

What are the options for emergency contraception/postcoital contraception?

A
  1. Levonorgestrel 1.5mg
    • doubled dose if BMI>26 or >70kg
    • must be taken within 72hours* of UPSI;
    • 84% effective within this time.
  2. Ulipristal (EllaOne) 30mg -
    • must be taken within 120 hours of UPSI;
  3. Cu-IUD -
    • can be inserted within 5 days of UPSI and up to 5 days after the likely ovulation date;
    • should be kept in until the next period if they want it removed
    • MOST effective (99%)

*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

38
Q

What is the MOA of each type of emergency contraception?

A

Levonorgestrel -MOA not fully understood - acts both to stop ovulation and inhibit implantation

Ulipristal - a selective progesterone receptor modulator; primary MOA is thought to be inhibition of ovulation

Cu-IUD - may inhibit fertilisation or implantation

39
Q

What are the special considerations for each emergency contraception type?

A

Levonorgestrel:

  • can be used more than once in a cycle (same as Ulipristal)
  • double dose in BMI>26 or >70kg
  • safe and well tolerated but SE include vomiting (1%) - if within 3hrs then repeat dose
  • hormonal contraception can be started ASAP after
  • no restrictions on breastfeeding (unlike Ulipristal)

Ulipristal

  • cannot be used with levonorgestrel
  • may reduce the efficacy of normal contraception - barrier needed for 5 days
  • restart normal pill/patch/ring 5 days after ulipristal
  • caution with severe asthma
  • can also be used more than once in menstrual cycle
  • delay breastfeeding for 1 week

Cu-IUD

  • offer to all women as most effective
  • prophylactic abx may be given if high risk of STI
40
Q

When can Cu-IUD be offered until in a patient who presents >5 days after UPSI and who has a 28 day cycle?

A

In a 28-day cycle, predicted ovulation day 14 + 5 days = insert up to day 19 for EC

Failure rate is 1 in 1000

41
Q

Name a type of chemical contraception, its efficacy and complications.

A

Spermicide - Nonoxinol 9 (usually this is applied on the cap/diaphragm but is not recommended for use on condoms)

Use - cap is filled a third with spermicide; if diaphragm is inserted dome down then put spermicide on upper surface and rim (but not on rim of cap)

Efficacy - with perfect use of cap is 82% and typical use is 72%; lower efficacy if cap/diaphragm has been in for >3hrs before intercourse.

Complications -disrupts cell membranes and increases risk of HIV

Source: FSRH

42
Q

What is ‘natural family planning’ also known as? What does this encompass?

A

Fertility awareness method

Encompasses abstinence around normal cycles as well as coitus interrupts/withdrawal and lactational amenorrhoea method.

43
Q

What are the advantages and disadvantages of FA for contraception?

A

Advantages:

  • no side-effects
  • no change to menstrual cycles - so any abnormalities identified quicker
  • may be more acceptable to some
  • awareness helps to concieve in the future

Disadvantages:

  • less effective than LARC due to reliance on user and partner
  • no non-contraceptive benefits of hormones
  • no protection from STIs
  • should not be used where pregnanc yposes a significant health risk
44
Q

What are the contraindications to FA method?

A
  • Menstrual cycle irregularity
  • Postpartum period (4 weeks if not breastfeeding)
  • Recent hormonal contraception use
  • Use of teratogenic drugs
  • Antibiotics and other medications like NSAIDs
  • Medical conditions for which pregnancy is high risk
  • Other medical conditions

Trained medical professional should help patients with this method of contraception. Charts may be used to track cycles as here.

45
Q

What is the estimated survival of the ovum after ovulation and sperm?

A

ovum = ~24hrs

sperm = up to 7 days (although mean survival is 1.47 days)

So a woman’s fertile window is ~8-9 days of the cycle

46
Q

How effective is LAM ?

A

If <6 months postpartum, amenorrhoeic, fully breastfeeding: 98% effective

NB: risk of pregnancy is increased if the frequency of breastfeeding decreases (stopping night feeds, supplementary feeding, use of pacifiers/dummies), when menstruation returns or when >6 months postpartum.

47
Q

What is the efficacy of the withdrawal method? What is suggested to increase the efficacy?

A

Efficacy - ~96% with perfect use, 78% with typical use

Men advised to urinate between successive ejaculations to remove sperm from pre-ejaculate (although this is debatable and sperm usually remain)

NB: a few studies have shown no motile sperm in the pre-ejaculate

48
Q

Can you switch from hormonal contraception to FA straight away?

A

Not until regular menstrual cycles have been established , usually recommended until 3 cycles have occurred

49
Q

What are the different fertility and urinary hormone methods used in natural family planning?

A

Temperature - basal body temp monitored when ovulation occurred

Cervical secretions - wet, slippery and clear if ovulation is approaching

Cervical palpation - cervix rises 1-2 cm and feels softer and more moist midcycle

Personal fertility monitor - analyses diposable urine dipsticks that record the presence of metabolites of
oestrogen and LH in the urine e.g. preovulatory LH peak

Two-day method - if secretions seen then avoid sex

Calendar - tracked over minimum 12 cycles and fertile window calculated using shortes and longest

Standard Days Method - combination of all above

Lactational amenorrhoea method - breastfeeing providing contraception

50
Q

How effective is use of FA method?

A

If using one indicator: with typical use ~76% so not recommnded . But perfect symptothermal method then 0.4% failure (NB: COCP is 0.3% failure rate)

51
Q

What temperature is used for FA?

A

Basal body temperature i.e. waking/ temperature at the same time of day/ after at least 3hrs rest

52
Q

What is the method with the lowest amount of combined hormone?

A

The combined hormonal ring is a flexible ring of 54 mm diameter that releases 15 μg ethinyloestradiol
and 120 μg etonorgestrel daily, and as such is the lowest dose combined hormonal method.

53
Q

How is the ring contraceptive used?

A

The ring is self inserted and worn in the vagina for 21 days, followed by a 7-day hormone-free interval, during which a withdrawal bleeding occurs. Women should not feel discomfort from the ring and it can be removed for a short time (<3 hours) and can be cleaned and replaced.

54
Q

What transdermal contraception is available? How long is it used?

A

Evra patch - only combined contraceptive patch licensed for use in UK

The patch cycle lasts 4 weeks. For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.

55
Q

What happens with delayed application of the patch in each of the three weeks?

A

Delayed at the end of week 1 or week 2:

  • < 48hr delay = changed immediately + no further precautions .
  • >48hr delay = changed immediately + barrier contraception for next 7 days. If UPSI during this extended patch-free interval or if UPSI in the last 5 days, then emergency contraception needs to be considered.

Removal delayed at the end of week 3:

  • Removed ASAP + the new patch applied on the usual cycle start day. No additional contraception is needed.

Application is delayed at end of week 4 (patch free week):

  • Additional barrier contraception for 7 days following any delay at the start of a new patch cycle
56
Q

What is the implantable contracepive? What is its MOA? How long does it last?

A

Etonogestrel- Nexplanon® contains 68 mg of 3-keto-desogestrel (a metabolite of desogestrel). (a type of progestogen)

MOA: inhibits ovulation, also thickens cervical mucus

Lasts 3 years

57
Q

What are some complications of the implant? How quickly is fertility restored after removal?

A

Can be inserted too deep which may result in difficult removal

After removal, serum levels of etonorgestrel levels are undetectable within 1 week, and fertility is
restored immediately after removal

58
Q

How can the implant be visualised if removal is difficult or if it is impalpable?

A

Nexplanon® contains a small quantity of barium, which permits it to be visualized by X-ray. It can also be localized using low-frequency ultrasound probes, which can help aid removal of implants that are not easily palpable.

59
Q

Are the implant and injection effective immediately?

A

If the implant/injection is given during the first 5 days of your menstrual cycle, you’ll be immediately protected against becoming pregnant

If not, use barrier for 7 days.

60
Q

How big is the implantable contraceptive? Where is it inserted?

A

Similar in size to a match stick (40 mm × 2 mm) and is inserted subdermally 8 cm above the medical epicondyle, usually of the non-dominant arm.

Should be palpable but not visible

Local anaesthesia is used

Only done by a professional who has been specifically trained

61
Q

What is the most common side effect of the implantable contraceptive?

A

Irregular bleeding

62
Q

What is the injectable contraceptive? What is its MOA? How long does it last?

A

Medroxyprogesterone acetate given IM (buttock, upper arm, lower abdomen) (Depoprovera® (150 mg)) or micronized lower-dose formulation of Sayana press® SC.

MOA: Inhibits ovulation, also thickens cervical mucus

Lasts 12 weeks

63
Q

What is the main disadvantage of the injectable contraceptive?

A

Delay of return to fertility - may take up to 1 year after the last injection for ovulation to return to normal in some cases

Weight gain

Loss of bone mineral density (5% loss at lumbar spine)

64
Q

What is the benefit of SC over IM contraceptive?

A

With SC the user can be taught to self-administer or can be given by other health professionals e.g. pharmacists, improving access and acceptability

65
Q

What is the MOA of COCP vs POP?

A

COCP - inhibits ovulation. SE: increases risk of VTE.
Increases risk of breast and cervical cancer

Progestogen-only pill (excluding desogestrel*) - thickens cervical mucus. SE: irregular bleeding a common side-effect

66
Q

What should you counsel the patient about regarding the COCP?

A

Potential harms and benefits, including

  • the COC is > 99% effective if taken correctly
  • small risk of blood clots
  • very small risk of heart attacks and strokes
  • increased risk of breast cancer and cervical cancer
67
Q

Is the COCP effective straight away?

A

If started in first 5 days of the cycle then no need for additional contraception. If started at any other time then use additional contraception for 7 days.

68
Q

Does the progesterone only pill work straight away?

A

If started in first 5 days of the cycle, no contraception is required. If not then additional contraception is required for 2 days.

NB: careful in women with short cycles

69
Q

What are the advnatages of the COCP?

A

Advantages of combined oral contraceptive pill

  • highly effective (failure rate < 1 per 100 woman years)
  • doesn’t interfere with sex
  • contraceptive effects reversible upon stopping
  • usually makes periods regular, lighter and less painful
  • reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
  • reduced risk of colorectal cancer
  • may protect against pelvic inflammatory disease
  • may reduce ovarian cysts, benign breast disease, acne vulgaris
70
Q

What are the disadvantages of the COCP?

A

Disadvantages of combined oral contraceptive pill

  • people may forget to take it
  • offers no protection against sexually transmitted infections
  • increased risk of venous thromboembolic disease
  • increased risk of breast and cervical cancer
  • increased risk of stroke and ischaemic heart disease (especially in smokers)
  • temporary side-effects such as headache, nausea, breast tenderness may be seen
71
Q

Does the COCP cause weight gain?

A

Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane review did not support a causal relationship.

72
Q

What happens with missed COC pills?

A

If pills are missed in:

  • Week 1 (Days 1-7): emergency contraception should be considered if she had UPSI in the pill-free interval or in week 1
  • Week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
  • Week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
73
Q

What are the adverse effects of the POP?

A

Potential adverse effects

  • irregular vaginal bleeding is the most common problem
74
Q

What happens if you switch from COCP to POP?

A

If switching from a COCP the POP gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)

75
Q

How is the POP taken?

A

should be taken at the same time every day, without a pill-free break (unlike the COC)

76
Q

What happens with missed pills with the POP?

A

If < 3 hours* late: continue as normal

If > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

NB: for Cerazette (desogestrel) a 12 hour period is allowed

77
Q

What should you tell women >40yrs about the Depo-Provera?

A

Women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years

Use is associated with a small loss in bone mineral density which is usually recovered after discontinuation

78
Q

How long do you continue each of these methods in peri-menopausal women?

  1. Non-hormonal
  2. COCP
  3. Depo-provera
  4. Implant, POP, IUS
A
79
Q

Do antibiotics affect the COCP/POP?

A

Not unless they affect the P450 enzymes e.g. rifampicin

Year 5 - Obstetrics and Gynaecology (87 decks)

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