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NURS 330: Obstetrics > LEC 5: Health Challenges in Pregnancy > Flashcards

LEC 5: Health Challenges in Pregnancy Flashcards

1
Q

Factors Placing a Woman at Risk During Pregnancy: Biophysical Factors

A
  • Genetic conditions
  • Chromosomal abnormalities
  • Multiple pregnancy
  • Defective genes
  • Inherited disorders
  • ABO incompatibility
  • Large fetal size
  • Medical and obstetric conditions
  • Preterm labour and birth
  • Cardiovascular disease
  • Chronic hypertension
  • Incompetent cervix
  • Placental abnormalities
  • Infection
  • Diabetes
  • Maternal collagen diseases
  • Pregnancy-induced hypertension
  • Asthma
  • Postterm pregnancy
  • Hemoglobinopathies
  • Nutritional status
  • Inadequate dietary intake
  • Food Fads
  • Excessive food intake
  • Under-or overweight status
  • Hematocrit value less than 33%
  • Eating disorder
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2
Q

Factors Placing a Woman at Risk During Pregnancy: Psychosocial Factors

A
  • Smoking
  • Caffeine
  • Alcohol
  • Drugs
  • Inadequate support system
  • Situational crisus
  • History of violence
  • Emotional distress
  • Unsafe cultrual practices
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3
Q

Factors Placing a Woman at Risk During Pregnancy: Sociodemographic Factors

A
  • Poverty status
  • Lack of prenatal cafre
  • Age younger than 15 yers or older than 35 years
  • Parity
    • All first pregnancies and more than five pregnancies
  • Marital status
    • Increased risk for unmarried
  • Accessibility to health care
  • Ethnicity
    • Increased risk in nonwhite women
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4
Q

Factors Placing a Woman at Risk During Pregnancy: Environmental Factors

A
  • Infections
  • Radiation
  • Pesticides
  • Illicit drugs
  • Industrial pollutants
  • Secondhand cigarette smoke
  • Personal stress
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5
Q

Hypertensive Disorders of Pregnancy

A
  • Other Names:
    • Pregnancy Induced Hypertension (PIH)
    • Gestational Hypertension (GH)
    • Pre-exlampsia
    • Tozemia
  • Incidence around 10%
  • Cause is unknown
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6
Q

Classification of Hypertensive Disorder in Pregnancy

A
  • Pre-Existing
    • Predates pregnancy or before 20 weeks
  • Gestational
    • Systolic > 140mmHg and/or Diastolic >90mmHg
    • After 20 weeks and upt o 12 weeks PP
      • Usually, of you remove the baby, you remove the hypertensive disorder
      • If we start seeing trends in the BP, then it might be necessary to follow the patient out in the community
  • Accuracy in BP measurment
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7
Q

Preclampsia

A
  • Systolic > 140mmHg and/or Diastolic > 90mmHg
  • Protenuria (2+ or greater) and/or 1 or more adverse conditionso r complications
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8
Q

Severe Preeclampsia

A
  • >160/110 mmHg
  • Heavy proteinuria (3-5g/ 24 hours)
  • 1 or more adverse conditions/ severe complications
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9
Q

Eclampsia

A
  • Seizure
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10
Q

Adverse Conditions

A
  • Headache
    • Common
  • Visual disturbances
    • Common
  • Abdominal/ Epigastric/ RUQ pain
    • Common
  • Nausea/ Vomiting
  • Chest pain/ SOB
  • Abnormal maternal lab values
  • Fetal morbitity
  • Edima/ Weight Gain
    • Need to be in combination with other conditions
  • Hyperreflexia
    • Need to be in combination with other conditions
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11
Q

Consequences of Preeclampsia: Maternal

A
  • Stroke
  • Pulmonary edema
  • Hepatic failure
  • Jaindice
  • Seizures
  • Placental abruption
  • Acute renal failure
  • HELLP syndrome and DIC
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12
Q

Consequences of Preeclampsia: Fetal

A
  • IUGR
  • Oligohydramnios
    • Too little fluid
  • ABsent or reversed end diastolic umbiliacl artery flow by Doppler
  • Placental abruption
  • Prematurity (iatrogenic)
  • Fetal compromise (metabolic acidosis)
  • Intrauterine death
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13
Q

What is the cause of gestational hypertension?

A

The cause is unknown

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14
Q

Risk Factors for Gestational Hypertension

A
  • Nullipara or first pregnancy with a new partner
  • Previous pregnancy with hypertension/ preeclampsia
  • Personal or family hisotry of hypertension
  • Poor nutrition
  • Obesity
  • Ethnicity
  • Advanced maternal age (>35)
  • Multiple gestation (twins,triplets)
  • Diabetes
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15
Q

Vasospasm

A

Increased blood pressure.

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16
Q

Hypoperfusion

A

Reduced amount of blood flow to the uterus, therfore the baby will get less blood.

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17
Q

Initial Managment of Gestational Hypertension?

A
  • Stress reduction/ reduced activity
  • Assessment of mother and fetus
    • Antipartum
    • Postpartum
    • Home visits
  • Treat nausea and vomitting
  • Treat epigastric pain
  • Treat blood pressure
  • Consider seizure prophylaxis
  • Consider timing/ mode of delivery
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18
Q

Managment of Gestational Hypertension

A
  • Home caer if non-severe hypertension
    • Client monitors her blood pressure
    • Measures weight and test urine protein daily
    • NST’s performed daily or bi-weekly
    • Advised to report signs of adverse conditions
  • In-Patient Hospital Care if Severe Hypertension/ Preeclampsia
    • ​Fetal evaluation
      • Fetal movement couting, NST< Biophysical profile, ultrasound, measurement of AFI, Serial U/S to assess growth, Imbilical artery doppler flow
    • Hourly intake and output
    • Frequent BP, pulse, respirations
    • Blood work (liver enzymes, platelets, Hct)
    • Monitor for adverse conditions
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19
Q

Medications to Treat Gestational Hypertension: Anti-Hypertensives

A
  • Labetalol
    • ​Adrenergic blocker
  • Nifedipine (Adalat)
    • ​Calcium cahnnel blocker
  • Hydralazine (Apresoline)
    • ​Arteriolar dilators
  • Aldomet (Methyldopa)
    • ​Centrally-acting sympatholytic
  • ACE inhibotros contraindicated
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20
Q

Medications to Treat Gestational Hypertension: Anti-Convulsant

A
  • Magnesium Sulfate MgSO4
    • Tachycardia
    • NB to test reflexes
    • Monitor urine output (excreted by kidneys)
    • Can slow labour
    • Musle weakness
    • Lack of energy and drowsiness
    • Respiratory depression
    • Lower blood pressure
  • Goal is to reduce risk for seizures
  • Do alot of monitoring because side effects are often CNS related
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21
Q

Magnesium Toxicity

A
  • Central Nervouse System Depression
    • Respiratory rate <12
    • Oligouria <30ml/hr
    • Diminished or absent DTR
    • Serum magnesium 4.8-9.7 mEq
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22
Q

Eclampsia = Seizure

A
  • Anticonvulsants:
    • Bolus of magnesium sulfate
  • Sedation and other anticonvulsants
    • Dilantin
  • Diuretics to treat pulmonary edema if present
    • Furosemide (Lasix)
  • Digitalis: For circulatory failure
  • Intensive nursing care
  • DELIVER
    • If fetus <34 weeks give corticosteroids to ­fetal lung maturity
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23
Q

HELLP Syndrome

A
  • Hemolysis
  • Elevated Liver enzymes
  • Low Platelets
    • Platelets aggregate at sites of vascular damage
    • Be ready to administer platelets if <20 x109/L
    • Epidural anaethesia may not be an option if low platelets
  • Mother might present with headache, nasuea, vomiting, RUQ pain, tired, increased BP
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24
Q

Disseminated Intravascular Coagulation (DIC)

A
  • Can be caused by pre-exlampsia, hemorrhage, intrauterine fetal demise, amniotic fluid embolism, sepsis, HELLP, other medical conditions
  • Over-activation of normal clotting mechanism
  • Mini clots develop
  • Depletes platelets and clotting factors → excessive bleeding
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25
Q

Pregnancy, Insulin, and Glucose

A
  • During early pregnancy, there is a decrease in maternal glucose levels because of the heavy fetal demand for glucose. The fruts is also drawing amino acids and lipids from the mother, decreasing the mother’s ability to synthesize glucose. Maternal glucose is diverted across the placenta to assits the growing embryo/fetus during early pregnancy. As a result, maternal glucose concentrations decline to a level that would be considered “hypoglycemic” in anon-pregnant woman. During early pregnancy there is also a decrease in maternal insulin production and insulin levels.
  • The pancreas is responsible for the production of insulin, which facilitates entry of glucose into cells. Although glucose and other nutrients easliry cross the palcenta to the fetus, insulin does not. Therefore, the fetus must produce its own insulin to facilitate the entry of glucose into its own cells.
  • After the first trimester, hPL from the placenta and steroids (cortisol) from teh adrenal cortex act against insulin. hPL acts as an antagonist against maternal insulin, and thus more insulin must be secreted to counteract the increasing level of hPL and cortisol during the alst half of pregnancy.
  • Prolactin,e strogen, and progesterone are also thought o possie insuline. As a reuslt, glucose is less likely to enter the mother’s cells and is more likely to corss over the placenta to the fetus.
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26
Q

Gestational Diabetes

A
  • Incidence between 3 to 20%
  • Pre-existing diabetes
  • Developes after 20 weeks
  • Gestationla diabetes GDM
    • Glucose intolerance in pregnancy
    • 3.5% of non-Aboriginal women and up to 18% of Aboriginal women
  • Pre-existing not previously diagnosed
  • Increased risk of stillbirth, comorbid hypertension, injuries at delivery (larger baby), risk of developing type 2 diabetes
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27
Q

What are the 2 ways that pregnancy alters carbohydrate metabolism in gestational diabetes?

A
  1. Fetus continually takes glucose from the mother
  2. Placenta creates hromones, which alter effects of and resistance to insulin and glucose tolerance
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28
Q

Carbohydrate Metabolism

A
  • Is a diabetogenic effect of pregnancy
  • First Trimester of Pregnancy
    • ​Rise in hormones stimulate insulin production and increase tissue response to insulin
    • In the 1st trimester insulin needs frequently decrease
  • Second and Third Trimester of Pregnancy
    • ​Placental secretion of hPL begins
    • Increase resistance to insulin and decrease glucose tolerance
    • Insulin needs increase (may douple or triple by end of pregnacy)
    • Increase insluin required ot maintian normal concentration

RESULTS IN

  • ​Renal thershold for glucose decrease
  • Progress of vascualr disease may be accelerated
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29
Q

Effects of Gestational Diabetes (GDM): Pregnancy/ Maternal

A
  • Preeclampsia/ exlampsia increase dt vascualr change
  • Polyhydramnios
  • PROM, premature rupture of membranes
  • Preterm labour
  • Worsening myopathies
    • Vascualr, renal, retinal
  • Pre-existing diabetes
    • Increase ketosis
  • Increase gestational hypertension
  • Increase type 2 diabetes later in life
30
Q

Effects of Gestational Diabetes (GDM): Fetus

A
  • Macrosomia
  • Intrauterine growth restriction
  • Fetal demise
  • Congenital anomalies
    • Associated with pre-existing diabetes
31
Q

Effects of Gestational Diabetes (GDM): Neonatal and Child

A
  • Neonatal Effects
    • Hypoglycemia
    • Hyperbilirubinemia
    • Immature respiratory develipment = RDS
  • Child Effects
    • ​Increased risk of developing diabetes and obesity
32
Q

Teaching for the Pregnant Woman with Diabetes

A
  • Be sure to keep your apporintments for frquent prenatal visits and tests for fetal well-being
  • Perform blood glucose self-monitoring as directed, usually before each meal and at bedtime. Keep a record of your results and call your health care provider with any levels outside the established range. Bring your results to each prenatal visit.
  • Perform daily “fetal kick counts”. Document them and reort any decrease in activity.
  • Drink 8 to 10 8-ounce glasses of water each day to prevent bladder indections and maintian hydration.
  • Wear proper, well-fitted footwear when walking to prevent injury.
  • Engage in a regular exercise program such as walking to aid in glucose control, but avoid exercising in temperature extremes.
  • Consider breastfeeding your ijnfant to lower your blood glucose levels.
  • If you are taking insulin:
    • Adminsiter the correct dose of insulin at the ocrrec time every day.
    • Eat breakfast within 30 minutes after injecting regular insulin to prevent a reaction.
    • Plan meals at a fixed time and snacks to prevent extremes in glucose levels.
    • Avoid simple sugars (cake, candy, cookies) , which rise blood glucose levels.
  • Know the signs and symptoms of hypoglycemia and trreatment needed:
    • Sweating; tremors; cold, clammy skin; headache
    • Feeling hungry, blurred vision, disorientation, irritability
  • Treatment: Drink 8 onces of milk and eat two crackers or glucose tablets
  • Carry glucose boosters to prevent hypoglycemia
  • Know the signs and symptoms of hypoglycemia and treatment needed:
    • Dry mouth, frequent urination, excessive thirst, rapid breathing
    • Feeling tired, flushed, hot skin, headache, drowsiness
    • Treatment: Notify healthcare provider, since hospitalization may be needed
  • Wear a diabetic identification bracelet at all times
  • Wash your hads frquently to prevent infections
  • Report any signs and symptoms of illness, infection, and dehydration to your health care provider, because these can affect blood glucose control.
33
Q

Risk Factors for Gestational Diabetes (GDM)

A
  • Being
    • 35 years of age or older
    • From a high-risk group
      • African, Arab, Asian, Hispanic, Indigenous, South Asian ethnicity
  • Using
    • Corticosteroid medication
  • Having
    • Obesity (BMI >30)
    • Prediabetes
    • GDM in a previous pregnancy
    • Previous newborn >4kg
    • A parent, brother or sister with type 2 diabetes
    • Polycystic ovary syndrome
  • Recommended
    • ​Breastfeed immediately after birth and for a minimum of 4 months in order to prevent hypoglycemia in your newborn, obesity in childhood, and diabetes for both you and your child
34
Q

Screening for Gestational Diabetes (GDM)

A
  • CDA quidelines suggest routine screening of all women
  • At 24 to 28 weeks gestation with 50g glucose challenge test (GCT), using a threshold of 7.8 mmol/L (140 mg/dL)
  • 75g fasting glucose tolerance test (GTT) if >7.8
35
Q

Care and Managment of Gestational Diabetes (GDM)

A
  • Goal: To attain and maintain a euglycemic state
  • Multidisciplinary team appraoch to controlling blood sugar
    • Aim for fasting of <5.3 mmol/L, 1 hour pc <7.8 mmol/L
  • Glucose monitoring
    • 4 to 7 times per day
  • Diet controled
  • Exercise
    • Daily
    • pc meals
  • Insulin as needed (still drug of choice)
  • Oral antiglycemics
  • Neeed for increase folic acid
  • Maternal risk for infections
  • Evaluate maternal/fetal conditon
36
Q

Intrapartum/ Labour Care for Gestational Diabetes (GDM)

A
  • If euglycemic on diet, no special considerations in lanour
  • For IDDM:
    • Balance insulin with need for increase energy in labour
    • Monitor blood sugars q1-2h
    • Individualized IV glucose and IV insulin
  • Postmartum
    • Insulin requirements decrease significantly
    • Aprox. 20% will have IGT
    • 45% to 50% incidence of Type 2 diabetes within 5 years
    • Rarely diabetic immediately postpartum
37
Q

Multiple Birth and Gestational Diabetes (GDM)

A
  • May be increased risk for
    • ​Preterm labour
    • Anemia and hypertension of pregnancy
    • Abnormal presentation
    • Twin-to-twin transfusion syndrome
    • Uterine dysfunction
    • Abription placenta/ placenta previa
    • Prolapsed cord
    • Postpartum hemmorhage
38
Q

Effects of Pregnancy/ Mother with Gestatonal Diabetes (GDM)

A
  • Increased risk for motehr
    • C/S, GHTN, PPH
  • Increased intensity of compliants
    • Chorness of breath
    • Edema
    • Nausea, vomiting, heartburn
    • Insomnia, fatigue
    • Weight gain
39
Q

Obesity

A
  • Excessive limitless weight gain in pregnancy is the most common cause of obesity in later life.
  • Women who gain >25 kg in pregnancy have a very difficult time losing PP weight and often it remains a lifelong struggle
  • Possible link to hypertension, diabetes and obesity in later life for children borne of obese mother
40
Q

Complications of Obesity: Pregnancy

A
  • Spontaneous abortion/ stillbirth
  • Hypertension
  • Diabetes
  • Challenging to assess fetus during labour
  • Anesthetics can be challenging
  • Harder to insert epidural catheter
41
Q

Complications of Obesity: Intrapartum

A
  • Macrosomia/ Shoulder dystocia
  • Challenges in assessing fetus/ contractions
  • Increase cesarean
  • Anesthesia challenges
  • Increase thromboembolism
42
Q

Complications of Obesity: Neonatal

A
  • Hypoglucemia
  • Breastfeeding issues
  • Birth defects
43
Q

Complications of Obesity: Postpartum

A
  • Infection
  • Mobility
  • Thrombosis
44
Q

SOGC Obesity Recommendations

A
  • Begin pregnancy with BMI < 30
  • Pre‐conceptual assessment and counseling
    • Weight gain for BMI > 30, total weight gain 7 kg (SOGC)
    • Nutrition ( increase folic acid preconception and first trimester)
    • Exercise
    • Risk of adverse outcomes for mom and baby
  • AP consultation with anesthesiologist
  • Assessment for risk of VTE
45
Q

Adolescent Pregnancy

A
  • Increased risk in physical and psycosocial
  • Physical
    • Preterm birth
    • Low birth weight infant
    • CPD
    • Anemia
    • GHTN
  • Psychosocial
    • Interruption of developmental tasks
    • Substance abuse
    • Poverty
    • Interruptiono r cessation of education
    • Less prenatal visits
46
Q

Adolescent Pregnancy Supports: Physical

A
  • Promote physical health of adolescent with regular prenatal
  • Prenatal education
  • Support
  • Information about complications
  • Family adaptationvisits
47
Q

Adolescent Pregnancy Supports: Psychosocial

A
  • Support in school
  • INter-generationla households
  • Trusting relationship with healthcare providers
  • Promoting self-esteem and problem solving skills
48
Q

Older Gravida

A
  • u35
    • SK 2009 – 2010; 8.6% to mom’s > 35; 1.6% to mom’s > 40
  • Decline in fertility
  • Increase in chronic diseases
  • Hypertension, cardiac, thyroid, cancers etc.
  • Increased difficulties in pregnancy
  • GDM, GHTN, PTL, Multiples, IUGR, Placenta previa, miscarriage, ectopic, stillbirth, neonatal death
  • Increased risk of c-section, induction
  • Increased genetic conditions, congenital anomalies
49
Q

Substance Use/ Abuse

A
  • 18.9% socially high-risk pregnant women use recreational drugs, 11% daily (Bowen, 2007)
  • 14% of Canadian women reported using alcohol during their last pregnancy, and 17% reported smoking during pregnancy. (SOGC, 2011)
  • In genreal, pregnant woman with substance use disorders are less likely to seek prenatal care, and they have higher rates of infectious disease such as HIV, hepatitis, and other sexually transmitted infections
50
Q

Effects of Selected Rugs on Pregnancy: Alcohol

A
  • Spontaneous abortion
  • Inadequate weight gain
  • IUGR
  • Fetal alcohol psectrum disorer
  • The leading cause of metnal retardation
51
Q

Effects of Selected Rugs on Pregnancy: Caffeine

A
  • Vasoconstriction and mild diuresis in mother
  • Fetal stimulation, but teratogenic effects not docu,entd via research
52
Q

Effects of Selected Rugs on Pregnancy: Nicotine

A
  • Vasoconstriction
  • Reduced uteroplacental blood flow
  • Decreased birth weight
  • Abortion
  • Prematurity
  • Abruption of placenta
  • Fetal demise
53
Q

Effects of Selected Rugs on Pregnancy: Cocaine

A
  • Vasoconstriction
  • Gestational hypertension
  • Abription placenta
  • Abortion
  • Snow baby syndrome
  • CNS defects
  • IUGR
54
Q

Effects of Selected Rugs on Pregnancy: Marijuana

A
  • Anemia
  • Inadequare weight gain
  • Amotivational syndrome
  • Hyperactive startle reflex
  • Newborn tremors
  • Prematurity
  • IUGR
55
Q

Effects of Selected Rugs on Pregnancy: Narcotics

A
  • Maternal and fetal withdrawal
  • Abruption placenta
  • Preterm labour
  • Premature rupture of membranes
  • Prenatal asphyxia
  • Newborn sepsis and death
  • Intelelctural impairment
  • Malnutrition
56
Q

Effects of Selected Rugs on Pregnancy: Sedatives

A
  • CNS depression
  • Newborn withdrawal
  • Maternal seizures in labour
  • Newborn abstinence syndrome
  • Delayed lung maturity
57
Q

Mathadone

A
  • Most commonly used for women dependent on opioids- heroin
    • Blocks withdrawal symptoms
    • Reduces or eliminates the craving for narcotics
    • Corsses the placenta
  • Associated with pregnancy complications and abnormal fetal presentation
  • Prenatal exposure
    • Reduced head circumference and lwoer birth weight
    • Withdrawal symptoms
58
Q

Cannabis and Pregnancy

A
  • Can negatively impact fertility
  • Crosses placenta
    • May harm a developing fetus
    • Associated with negative long-term effects in childhood and beyond
  • Passes into breastmilk
    • May cause negative developmental effects
  • Can negatively impact parenting
59
Q

Care for Mother with Substance Abuse

A
  • Watch for signs of withdrawal
  • Watch for signs of drug use
    • Leave unit, leave baby unattened, high
60
Q

Care for Baby and Substance Use

A
  • Watch for signs of withdrawal
  • Active use
    • NICU for observation and treatment
    • NAS scoring
61
Q

Don’t Forget Caffeine

A
  • Pregnant women and breastfeeding mothers should have no more than 300 mg of caffeine per day from all sources. This is approximately 2 (250 ml) cups of coffee
  • Large amounts of caffeine may increase the chances of:
    • Miscarriage
    • Premature delivery
    • Low birth weight
    • Withdrawal symptoms in newborn
62
Q

What are teratogens (things to avoid) during pregnancy?

A
  • Alcohol
  • Drugs
  • Presccribed medications
  • Pathogens
63
Q
A
64
Q

Infections During Pregnancy

A
  • CHEAP
    • ​Chickenpox and shingles
    • Hepatitis B, C, D, E
    • AIDS
    • Parvovirus B19
  • TORCHES
    • Toxoplasmosis
    • Other (STI’s, HIV, Hepatitis B, GBS)
    • Rubella
    • Cytomegalovirus
    • Herpes Simplx
    • Every STO
    • Syphilis
65
Q

Infections May Cause

A
  • Spontaneous abortions
  • Preterm delivery
  • Maternal and fetal morbidity and mortality
66
Q

Group B Streptococcus (GBS)

A
  • GBS are common bacteria which are often fround in the vagina, rectum, or bladder of 15 to 40% of women
  • Screening by vaginal/ rectal culture 35 to 37 weeks
  • Treated with antibiotics in labor
    • Screen and treatl all women who are GBS+
    • Treat based on risk factors
67
Q

Risk Factors for GBS Infections

A
  • Preterm labour before 37 weeks gestation
    • With or without ROM
  • Term rupture of membranes >18 hours
  • Unexplained, mild fever during labour
  • Previous baby with a GBS infection
  • Previous or present GBS beacteruria caused by the GBS bacteria
68
Q

HIV and Pregnancy

A
  • Modes of mother to child (vertical) transmission:
    • In utero (through the placenta)
    • During childbirth and delivery
    • Postpartum through breastfeeding
  • Without treatment: ≈ 25% chance of mother to child transmission
  • With proper treatment: less than 2% chance of mother to child transmission
69
Q

Factors Reducing Transmission Risk for HIV

A
  • Behaviours that support a health immune system (proper sleep,and nutrition, regular contact with health professionals)
  • Use of delivery, dependent on maternal viral load and use of cART
  • Complimentary treatments (traditional Aboriginal healing practices, acupuncture)
70
Q

HIV Care

A
  • Three-part antiretroviral treatment (ART) prophylaxis regimen reduces risk of transmission to infant
    • Pregnancy/Antepartum - cART
    • Labor – Add Intravenous ZDV during labor until birth/3 hrs. prior to Cesarean birth
  • —Infant – ZDV oral suspension
    • —Given for 6 weeks
    • —Testing at birth, 1 month, 3 months and 18 months
    • —No Breastfeeding
  • Following Birth
    • Positive antibody titer
    • Refleccts the passive transfer of meternal antibodies rather than HIV infection
  • No breastfeeding (3rd world contries ok)
    • Seeing some reduction in transmission if loew viral load and breastfeeding exclusively

NURS 330: Obstetrics (19 decks)

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