T. Taurine for Dogs: Do Dogs Need Taurine Supplements? ), (A from James A. Cooper, MD, San Diego, CA.). The baby may be deprived of oxygen and thus develop asphyxia. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. We know you have many choices for fertility care. However, the sonographic appearances of cervical leiomyoma and carcinoma overlap. Retroversion and retroflexion are not infrequent in the nongravid state. [28][29][30][31], Fertility may sometimes be restored by removal of adhesions, depending on the severity of the initial trauma and other individual patient factors. The unicornuate uterus accounts for approximately 20% of all mllerian duct anomalies. The surrounding fibrous cervical stroma is quite hypoechoic and is continuous with the subendometrial halo, if present. Pain may also spread to the shoulder if bleeding into the abdomen has Once in the endometrial canal, the balloon is inflated (preferably with saline rather than air to avoid shadowing) so that the catheter does not become dislodged. 1995;22 (3): 491-505. Lavantage du misoprostol est quil peut tre utilis pour lvacuation utrine aprs une fausse couche mais aussi aprs un accouchement, pour une rtention de placenta ou une hmorragie. [4] AS can develop even if the woman has not had any uterine surgeries, trauma, or pregnancies. Int J Gynaecol Obstet 2014; 124:248. Are you a member of an institution such as a university or hospital? [2], Placental abruption occurs in about 1 in 200 pregnancies. Substances that increase risk of placental abruption include cocaine and tobacco when consumed during pregnancy, especially the third trimester. [39] Furthermore, diagnostic severity and outcomes are assessed according to different criteria (e.g. The latter form has the worst prognosis. -, 8. However, advances in the use of 3D ultrasound have made it possible to visualize the fundal contour in many patients, and 3D sonography is replacing MRI in some centers for at least initial evaluation of uterine congenital anomalies. The innermost layer, immediately subjacent to the endometrium, is the thinnest and is relatively compact histologically. The goal of therapy is to remove adhesions and subsequently restore the normal size and shape of the uterine cavity. -, 3. Brussels IVF and Women's Health Center Address: Esentepe Mahallesi, Salam Fikir Sk. [5] Along with placenta previa and uterine rupture it is one of the most common causes of vaginal bleeding in the later part of pregnancy. This approach allows the examiner to evaluate the true pelvis in its entirety with a wide field of view on transabdominal imaging, as well as to assess specific structures using high-resolution images obtained on transvaginal scanning. Reference article, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-12241. Women older than 35 years should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to become pregnant or earlier, if clinically indicated. The vaginal aplasia can vary from complete absence to a blind-ending pouch. However, they are more often diagnosed during workup for infertility, frequent miscarriages, or menstrual disorders. The earliest known reference to peripheral venous disease is found on the Eber papyrus, which dates from 1550 BC and documents the potentially fatal hemorrhage that may ensue from surgery on varicose veins.In Causes of abnormal bleeding include hormones, thyroid problems, fibroids, polyps, cancer, infection or pregnancy.treatment depends on the cause. A 62-year-old male smoker with Type-2 Diabetes Mellitus and Hypertension presents with a 4-month history of exertional chest pain. Following the AIUM guidelines, the indications for pelvic sonography include, but are not limited to, the following: Evaluation of endocrine abnormalities, including polycystic ovaries, Evaluation of dysmenorrhea (painful menses), Follow-up of a previously detected abnormality, Evaluation, monitoring, and/or treatment of infertility patients, Evaluation in the presence of a limited clinical examination of the pelvis, Evaluation for signs or symptoms of pelvic infection, Further characterization of a pelvic abnormality noted on another imaging study, Evaluation of congenital uterine and lower genital tract anomalies, Evaluation of excessive bleeding, pain, or signs of infection after pelvic surgery, delivery, or abortion, Localization of an intrauterine contraceptive device, Screening for malignancy in high-risk patients, Evaluation of incontinence or pelvic organ prolapse, Guidance for interventional or surgical procedures; and, Preoperative and postoperative evaluation of pelvic structures. Prepare to become a physician, build your knowledge, lead a health care organization, and advance your career with NEJM Group information and services. Systemic Lupus Erythematosus (SLE) in Dogs. The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. [2] The condition was described at least as early as 1664.[7]. Also, hysteroscopy is not a widely or routinely used technique and requires expertise. Brussels IVF and Women's Health Center Address: Esentepe Mahallesi, Salam Fikir Sk. Asherman syndrome,also known as uterine synechiae, is a condition characterized by the formation of intrauterine adhesions, which are usually sequela from injury to the endometrium, and is often associated with infertility. Pain during menstruation and ovulation is sometimes experienced and can be attributed to blockages. The adhesions are usually low signal on T2. No:4 34394 Sisli/Istanbul +90 212 213 8888 [17], An artificial form of AS can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy. Aust N Z J Obstet Gynaecol 2013; 53:37. Recurrent pregnancy loss 9:19. Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. [citation needed], Follow-up tests (HSG, hysteroscopy or SHG) are necessary to ensure that adhesions have not reformed. Postpartum hemorrhage continues to be the leading preventable cause of maternal illness and death globally. Studies show this less invasive and cheaper method to be an efficacious, safe and an acceptable alternative to surgical management for most women. [38] However, there have been no randomized controlled trials (RCTs) comparing post-surgical adhesion reformation with and without hormonal treatment and the ideal dosing regimen or length of estrogen therapy is not known. The mean measurement of the prepubertal uterus is 2.8cm in length and 0.8cm in maximum anteroposterior dimension, with the cervix accounting for two thirds of the total length and contributing to the pear-shaped appearance ( Fig. Une barrire telle qu'une membrane mcanique ou un gel[19] peut tre place dans l'utrus la fin de la chirurgie pour maintenir les parois spares pendant la phase de cicatrisation pour viter les rcidives de formation de synchies. Berman JM. Vulvar Synechiae - Prepubertal Alert Maria Guilhermina Pereira DOI: 10.4172/2376-0249.1000826 Full-Text PDF. The mother should be monitored for 7 days for postpartum hemorrhage. The uterine length is measured in long axis from the fundus to the external os of the cervix, and the anteroposterior dimension is measured on the same image perpendicular to the long axis. 28-13 ), which is the most common type of mllerian duct anomaly, accounting for close to 55%. 28-1 ). If you have a uterine disease, the first sign may be bleeding between periods or after sex. In specific situations when transvaginal evaluation cannot be performed or tolerated, transrectal or transperineal evaluation can be very useful. Une autre tude montre que les synchies rapparaissent dans 50% des cas de grave syndrome dAsherman et dans 21,6% des cas modrs[8]. Intrauterine adhesions. La cavit de lutrus est tapisse par de lendomtre. [8] The diagnosis is one of exclusion, meaning other possible sources of vaginal bleeding or abdominal pain have to be ruled out in order to diagnose placental abruption. This layer is relatively thin and slightly less echogenic compared to the intermediate layer in most patients. Associated renal anomalies are common, in particular absence or ectopia of the kidney. [18] The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38.9% according to one study. Diffuse cortical necrosis in the kidney is a serious and often fatal complication. The most advanced way to teach, practice, and assess clinical reasoning skills. The arcuate vessels (particularly the veins) can be prominent and mimic cystic changes. Surgery inside the uterine cavity (e.g., suction dilation and curettage, may result in Asherman's syndrome (also known as intrauterine adhesions, intra uterine synechiae), a cause of infertility. [1] It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. Even with relatively few scars, the endometrium may fail to respond to estrogen. Steinkeler JA, Woodfield CA, Lazarus E et-al. [12] AS can result from other pelvic surgeries including cesarean sections,[12][13] removal of fibroid tumours (myomectomy)[14] and from other causes such as IUDs, pelvic irradiation, schistosomiasis[15] and genital tuberculosis. Many women with a septate uterus experience repeated miscarriages, usually in the first trimester, with a reported incidence of miscarriage of 65% and an incidence of premature birth of nearly 20%. Women older than 35 years should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to become pregnant or earlier, if clinically indicated. In severe cases, there can even be complete non-filling of the uterine cavity. The majority of the blood supply comes from the uterine arteries, which arise from the internal iliac arteries, and a minor source of blood supply is the ovarian arteries. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. Il est aussi suggr que le syndrome dAsherman non trait, quand les adhrences bloquent les rgles qui sont refoules dans labdomen, peut conduire au dveloppement de lendomtriose[4]. A discussion of the normal and abnormal endometrium in the patient who presents with abnormal uterine bleeding is presented in Chapter 27 . This is most commonly done by lysis of adhesions via hysteroscopy 3. Mild to moderate adhesions can usually be treated with success. 6. Lets build the family you desire, and achieve the future you deserve. Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including misoprostol and mifepristone. that adhesions are unavoidable in surgery and the main treatment for adhesions is more surgery. MRI is often recommended for definitive diagnosis. Sries tl parlant du syndrome dAsherman, https://fr.wikipedia.org/w/index.php?title=Syndrome_d%27Asherman&oldid=189972948, Article contenant un appel traduction en anglais, Portail:Sciences humaines et sociales/Articles lis, licence Creative Commons attribution, partage dans les mmes conditions, comment citer les auteurs et mentionner la licence. Traitement Spcialit Gyncologie Classification et ressources externes CIM - 10 N85.6 CIM - 9 621.5 DiseasesDB 946 MedlinePlus 001483 MeSH D006175 Mise en garde mdicale modifier - modifier le code - voir Wikidata (aide) image hystrosalpingographique. First-trimester surgical abortion by dilation and curettage (D&C) can result in uterine synechiae (or Ashermans Syndrome), which increase the risk of subsequent midtrimester spontaneous abortions and low birthweight deliveries. Incompetent cervix is also a preterm birth risk associated with surgical abortion. Female infertility: a systematic approach to radiologic imaging and diagnosis. Prolonged rupture of membranes (>24 hours). Treatment may require blood transfusion or emergency hysterectomy. The goal of therapy is to remove adhesions and subsequently restore the normal size and shape of the uterine cavity. Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix. A soft tissue structure (the cervix) is seen between the bladder and pregnancy. This is most commonly done by lysis of adhesions via hysteroscopy 3. There are also studies that show that a severe pelvic infection, independent of surgery may cause AS. Tear in the Heart in Dogs. Si le degr de conscience des mdecins sur ce phnomne augmentait, cela rvlerait srement une frquence plus leve que celle prcdemment rapporte. DES, diethylstilbestrol. Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or abortion, can lead to the development of intrauterine scars resulting in adhesions that can obliterate the cavity to varying degrees. Withdrawal bleeding will usually be seen if the patients estradiol level has been over about 40 pg/ml. Oberg AS, Hernandez-Diaz S, Palmsten K, et al. Give estrogen to ensure endometrial proliferation, followed by a progestin to induce withdrawal bleeding. The maternal urinary bladder lies anterior rather than inferior to the uterine corpus and marked bladder distention is noted. Complete or partial agenesis of a unilateral mllerian duct leads to development of a unicornuate uterus with a single fallopian tube ( Fig. Antibiotic prophylaxis is necessary in the presence of mechanical barriers to reduce the risk of possible infections. [9], The accumulating blood pushes between the layers of the decidua, pushing the uterine wall and placenta apart. Un article rcent dcrit 3 cas de femmes ayant dvelopp des synchies aprs un curetage manuel aspiratif[29]. Fertil. Because there can be subtypes of MRKH syndrome as well as overlap with other rare mllerian duct hypoplasia/aplasia syndromes, it is important to describe findings rather than trying to fit them into a strict category. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did. Check for errors and try again. Anatomical risk factors include uncommon uterine anatomy (e.g. [17], The risk of placental abruption can be reduced by maintaining a good diet including taking folate, regular sleep patterns and correction of pregnancy-induced hypertension. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The rudimentary horn may have a distended and dystrophic appearance and should not be mistaken for an adnexal mass. First-trimester surgical abortion by dilation and curettage (D&C) can result in uterine synechiae (or Ashermans Syndrome), which increase the risk of subsequent midtrimester spontaneous abortions and low birthweight deliveries. 22 Incompetent cervix is also a preterm birth risk associated with surgical abortion. Methods to prevent adhesion reformation include the use of mechanical barriers (Foley catheter, saline-filled balloon uterine stents,[34] gel barriers (Seprafilm, Spraygel, autocrosslinked hyaluronic acid gel Hyalobarrier) and mechanical barrier film (Womed Leaf)[27] to maintain opposing walls apart during healing,[35][36][37] thereby preventing the reformation of adhesions. The uterine size, shape, and orientation should be assessed and documented in both sagittal (long-axis) and transverse (axial or short-axis) planes. However, hysteroscopy is yet to become a routine gynaecological procedure and only 15% of US gynecologists perform office hysteroscopy. It may even contribute to discoveries related to more common diseases.. Gangrene (FG) case in 22 year old woman, which is rarely found in young woman, with Turner's Syndrome, vulvar synechiae, uterine agenesis, and voiding disorders. Le syndrome dAsherman se dveloppe le plus frquemment aprs un curetage ralis sur un utrus gravide (rcemment porteur dune grossesse), aprs une fausse couche soit manque ou incomplte pour liminer les produits de conception retenus, une naissance pour liminer le placenta retenu, ou un avortement. 28-4 ). 28-14 ), although occasionally 3D ultrasound imaging may be helpful. Alternativement, un curetage peut tre fait sous contrle chographique et non pas laveugle. But in some rare cases, this rotation maybe more than 45 degrees. For transvaginal evaluation, the urinary bladder should be emptied and the patient placed in a comfortable position but with her pelvis tilted either with the use of stirrups or by the placement of padding under the patient to elevate the hips. In many cases the front and back walls of the uterus stick to one another. Fetal parts may be seen in partial moles or coexistent twin pregnancy. 4920 N Central Ave #2C, Chicago, IL 60630 Kim MJ, Lee Y, Lee C et-al. Metroplasty may be performed hysteroscopically in women with a septate uterus, whereas surgical repair/resection in a patient with a bicornuate uterus must be performed transabdominally, although surgical correction is less often required. NEW! Hysteroscopy is the gold standard for diagnosis. [citation needed], Alternatively, D&C could be performed under ultrasound guidance rather than as a blind procedure. Intrauterine adhesions. A recent article describes three cases of women who developed intrauterine adhesions following manual vacuum aspiration. A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Production of thrombin via massive bleeding causes the uterus to contract and leads to DIC. The incidence of congenital mllerian duct anomalies is estimated to be approximately 0.5% in the general population. DOI: 10.1056/NEJMra1513247. But in some rare cases, this rotation maybe more than 45 degrees. Infertility; Related videos. Infertility; Related videos. Most important is communication with the clinical team regarding the relevance of findings and preoperative planning. Transabdominal sagittal view of the normal prepubertal uterus. The cervix of the uterus is fixed in the midline. This is known as uterine torsion. Tear in the Heart in Dogs. It is the place where a baby grows when a woman is pregnant. Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping ().It is a gynecologic procedure used for diagnostic and therapeutic purposes, and is the most commonly used method for first-trimester miscarriage or abortion. image chographique. [24], Intrauterine adhesions also form after hysteroscopic surgery such as myomectomy, polypectomy or septum removal. [citation needed], A 2013 review concluded that there were no studies reporting on the link between intrauterine adhesions and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to surgical management (e.g. Lutilisation dune hystroscopie au lieu dun curetage pour lvacuation de produits de conception ou dune rtention de placenta est une alternative (Goldenberg et al, 1997), mais qui peut se rvler inefficace en cas de prsence importante de tissus. The fundal contour between the two endometrial cavities is convex, flat, or indented less than 1cm. As with any clinical test, ultrasound examination of the pelvis should be performed only if there is a valid clinical reason. Following menopause, the uterus decreases in size. Il est aussi connu sous le nom de syndrome de Fritsch ou de Fritsch-Asherman. The vagina, uterus, and the urinary bladder are used as reference points for identification of the remaining normal and abnormal pelvic structures. The uterus has a dual arterial blood supply. Physical examination shows a blood pressure of 152/90 mm Hg, but is otherwise unremarkable. The normal myometrium is composed of three layers. image chographique. Additional techniques such as color Doppler and 3D imaging may be helpful in evaluating both normal and abnormal findings. Numerous sperm at high magnification on a counting chamber, Costs and Success Rates of Fertility Options after Vasectomy Many men have had a vasectomy, Ovarian hyperstimulation syndrome, or OHSS, is a condition with enlarged ovaries and fluid build up. But in some rare cases, this rotation maybe more than 45 degrees. Les troubles des rgles sont souvent, mais pas toujours, corrls au degr de gravit des adhrences. Sign in. Invest. Anatomical risk factors include uncommon uterine anatomy (e.g. The pain may be described as sharp, dull, or crampy. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. Lipoleiomyomas are typically extremely echogenic and sharply marginated with posterior attenuation. Fundal indentation is well seen (, (Courtesy of Dr. Beryl R. Benacerraf, Boston, MA. If this fails to happen, the uterus becomes trapped in the sacral hollow, often referred to as incarcerated. In cases of incarceration of the uterus, the cervix is drawn upward either against or above the symphysis pubis, resulting in distortion of the bladder and urethra as the gestation progresses. However, an increased incidence of cervical incompetence has been reported. Early developmental failure of the mllerian ducts can result in agenesis or hypoplasia of the proximal two thirds of the vagina, cervix, and uterus, being part of the Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome. 28-13 ). There is a strong association of upper urinary tract anomalies with congenital uterine malformations. [23] The advantage of misoprostol is that it can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging. Infertility . which connects the uterine cavity to the vagina. Un monitoring prcoce pour identifier rapidement une fausse couche peut prvenir le dveloppement, ou le cas chant, la rcidive dun syndrome dAsherman car les synchies apparaissent dautant plus facilement que le curetage est ralis tardivement aprs la mort ftale[28]. Those abruptions caused by venous bleeding at the periphery of the placenta develop more slowly and cause small amounts of bleeding, intrauterine growth restriction, and oligohydramnios (low levels of amniotic fluid). 5 Things Not to Do During Your Pets Cancer Treatment. Aust N Z J Obstet Gynaecol 2013; 53:37. 1994;37 (1): 66-8. Knowing the potential, but also the limitations, of ultrasound helps us to maximize the probability of detecting most significant abnormalities. Esta es la iglesia de San Clemente. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. Atresia and synechiae Nasal cavity 1989142 101 Aerosinusitis 514854237 101 Hematoma nasal septum 5431482 101 and common treatments for disease. Placental abruption may also result in death of the baby, or stillbirth. This is known as uterine torsion. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury. [20][21] It was suggested as early as in 1993[22] that the incidence of IUA might be lower following medical evacuation (e.g. Synechiae in Dogs. Leiomyoma is the most common uterine neoplasm. Substances that increase risk of placental abruption include cocaine and tobacco when consumed during pregnancy, especially the third trimester. Une hystroscopie requiert une expertise et nest pas pratique en routine car cest une mthode peu rpandue. If the uterus has been irreparably damaged, surrogacy or adoption may be the only options. Il a t dcrit pour la premire fois en 1894 par Heinrich Fritsch (Fritsch, 1894)[30],[31] puis plus prcisment par le gyncologue Joseph Asherman en 1948[32]. Patients with bicornuate uterus have few reported obstetric problems, and most cases are discovered incidentally. Cases of upto 720-degree rotations have been recorded. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. Des cas de syndromes dAsherman induits par lablation de l'endomtre volontaire chez les femmes souffrant de saignements abondants (mtrorragies) ont galement dj t rapports. [citation needed], The history of a pregnancy event followed by a D&C leading to secondary amenorrhea or hypomenorrhea is typical. The fundus of the uterus then rises into the false pelvis. Dans une tude mene sur 1900 patientes souffrant du syndrome dAsherman, plus de 90% des cas taient dus des curetages pratiqus aprs des grossesses[1]. Gynecol. 11. Uterine torsion: During pregnancy, the uterus rotates on its axis (mostly clockwise, rarely anticlockwise). Par contre, les adhrences lgres nont pas tendance de se reformer. This may be from a previous pregnancy, dilation and curettage, surgery, or infection (e.g. [2] Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth. uterine synechiae, and submucosal fibroids. ), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Ultrasound and Magnetic Resonance Imaging in Urogynecology, Ultrasound Evaluation of the Fetal Central Nervous System, Role of Magnetic Resonance Imaging in the Evaluation of Gynecologic Disorders, Evaluation of Pelvic Pain in the Reproductive Age Patient, Ultrasound Evaluation of the Fetal Thorax, Ultrasound Evaluation of the Fetal Gastrointestinal Tract and Abdominal Wall, Callen's Ultrasonography in Obstetrics and Gynecology. . A digital journal for innovative original research and fresh, bold ideas in clinical trial design and clinical decision-making. Uterine cavity, especially with regard to uterine leiomyomas, polyps, and synechiae . [19], "The management of Asherman syndrome: a review of literature", "Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome", "Intrauterine Adhesions following Conservative Treatment of Uterine Fibroids", "Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions", "Crosslinked Hyaluronic Acid Gels for the Prevention of Intrauterine Adhesions after a Hysteroscopic Myomectomy in Women with Submucosal Myomas: A Prospective, Randomized, Controlled Trial", "Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study", "Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility", "Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion", "The secret syndrome leaving women infertile", "How Asherman's syndrome causes infertility or miscarriages", https://en.wikipedia.org/w/index.php?title=Asherman%27s_syndrome&oldid=1084369315, Noninflammatory disorders of female genital tract, Disorders related to length of gestation and fetal growth, Syndromes affecting female reproductive system, Wikipedia articles needing page number citations from April 2018, Short description is different from Wikidata, Articles with unsourced statements from September 2020, Articles with unsourced statements from December 2020, Creative Commons Attribution-ShareAlike License 3.0, This page was last edited on 24 April 2022, at 02:14. The bicornuate uterus is estimated to account for approximately 10% of all mllerian duct anomalies. Le syndrome d'Asherman est une maladie utrine acquise, The Basilica of San Clemente, located in the heart of medieval Rome, is an example of this faithful copying. If bleeding does not occur, then most likely it is an outflow tract obstruction either Ashermans syndrome or cervical stenosis. Daprs une tude rcente sur 61 patientes, le taux de rcidives de synchies est de 27,9% et jusqu 41,9% dans les cas svres[20]. [16] Chronic endometritis from genital tuberculosis is a significant cause of severe intrauterine adhesions (IUA) in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat. Under ultrasound guidance, the balloon is gently retracted to occlude the internal os. The newborn infant may have learning issues at later development stages, often requiring professional pedagogical aid. 28-13 ). This layer is often referred to as the subendometrial halo and may not always be visualized sonographically. North Am. [citation needed], There is no data to indicate that suction D&C is less likely than sharp curette to result in Asherman's. TB endometritis). (773) 794-1818, 820 E Terra Cotta Ave, Crystal Lake, IL 60014 Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. Find rehab in San Clemente, Orange County, California, or detox and treatment programs. Poujade O, Grossetti A, Mougel L, et al. It may even contribute to discoveries related to more common diseases.. Gangrene (FG) case in 22 year old woman, which is rarely found in young woman, with Turner's Syndrome, vulvar synechiae, uterine agenesis, and voiding disorders. [11], The cavity of the uterus is lined by the endometrium. In an attempts to estimate the prevalence of AS in the general population, it was found in 1.5% of women undergoing hysterosalpingography HSG,[50] and between 5 and 39% of women with recurrent miscarriage. 10. Women older than 35 years should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to become pregnant or earlier, if clinically indicated. With the advent of techniques which allow visualization of the uterus, classification systems were developed to take into account the location and severity of adhesions inside the uterus. Les images obtenues par hystrosonographies ou par hystrosalpingographie rvlent ltendue des cicatrices et adhrences (synchies). [43], Pregnancy and live birth rate has been reported to be related to the initial severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively. This appearance can be misconstrued as an empty uterus associated with an ectopic or abdominal pregnancy. Des tudes montrent que ces mthodes sont moins invasives, moins chres, souvent presque aussi efficaces et plus sres et constituent une alternative acceptable dans la plupart des situations[25],[26]. No:4 34394 Sisli/Istanbul +90 212 213 8888 The European Journal of Obstetrics & Gynecology and Reproductive Biology is the leading general clinical journal covering the continent.It publishes peer reviewed original research articles, as well as a wide range of news, book reviews, biographical, historical and educational articles and a lively correspondence section. The arcuate veins are larger than the arcuate arteries and are potentially compressible with excessive probe or manual pressure. A course of 2.5 mg of Premarin for 21 days including 10 mg of Provera on days 17-21 should be adequate. The most specific findings are myometrial cysts and echogenic linear or nodular extension of the endometrium into the subjacent myometrium. [2][1] Diagnosis is based on symptoms and supported by ultrasound. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Sonographically, in a bicornuate uterus, the endometrial cavities are widely separated, and a deep indentation in the fundal contour is obvious. Treatment may require blood transfusion or emergency hysterectomy. The Basilica of San Clemente, located in the heart of medieval Rome, is an example of this faithful copying. 46 (2): 131. Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. . 4. In many cases the front and back walls of the uterus stick to one another. UTIs 5. Abnormalities detected on transvaginal sonography, including focal or diffuse endometrial or intracavitary abnormalities . Gynecol. Clin. NEW! Sonography is clearly the modality of choice for imaging the female pelvis, including the uterus and adnexal structures. Intrauterine synechiae: N91.0 - N91.2: Amenorrhea: N92.4: Excessive bleeding in the premenopausal period: N92.5 - N92.6: Other and unspecified irregular menstruation: N94.2: (2010) examined the effect of double versus single intra-uterine insemination (IUI) per treatment cycle in women with unexplained infertility. Poujade O, Grossetti A, Mougel L, et al. However, some clinicians prefer to use a catheter without a balloon. [6] Placental abruption is the reason for about 15% of infant deaths around the time of birth. Unfortunately, one fourth of bicornuate uterus cases have been reported to have a vaginal septum as well, which makes them indistinguishable from didelphys. 28-15 ). If there is no communication between the endometrial cavities of the rudimentary and normal horns, retrograde menstruation may occur, leading to the development of endometriosis. Postpartum hemorrhage continues to be the leading preventable cause of maternal illness and death globally. On ultrasound images, the two widely separated fundal horns with a deep fundal cleft, two uterine cavities, and two separate cervices can be identified. Intuitively, the longer the follow-up interval after treatment start, Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus and/or the cervix. The mother may be given Rhogam if she is Rh negative. The unicornuate uterus seems to be the most difficult mllerian duct anomaly to confidently diagnose on sonography because it can be confused and misdiagnosed as a small uterus. Inflammation and synechiae Synechiae Scar tissue from prior surgery. A recent meta analysis compared different post surgical prevention barrier strategies and concluded that there was no single clearly superior treatment. It is important to remember that in the immediate postdelivery state, the neonatal uterus can be slightly larger owing to the effects of residual maternal hormones. Les examens de suivi post-chirurgie (HSG, hystroscopie ou SHG) sont indispensables pour sassurer que les synchies nont pas reform. 6. Such ectopic pregnancies can lead to massive hemorrhage as they can grow to relatively large size before rupturing. [1] Treatment may require blood transfusion or emergency hysterectomy. 28-13 ). This rudimentary horn may or may not communicate with the endometrial cavity in the normal side. The reproductive outcome correlates with the type of adhesions and extent of uterine cavity occlusion. Ectopic pregnancies may also rarely occur in the rudimentary horn. From the Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore. The septum can contain fibrous or myometrial tissue. 5. Synechiae in Dogs. This bleeding will usually occur 2-7 days after the progestin is finished. Operative hysteroscopy is used for visual inspection of the uterine cavity during adhesion dissection (adhesiolysis). Magnetic resonance imaging of intrauterine synechiae. [19], In theory, the recently pregnant uterus is particularly soft under the influence of hormones and hence, easily injured. Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. The pain may be described as sharp, dull, or crampy. There is overlap in the sonographic and MRI appearance of leiomyomas and adenomyosis/adenomyomas, and the entities may coexist. La fertilit peut se restaurer en enlevant les synchies. An absent kidney in the expected anatomic location should trigger a search for an ectopic or possibly a dysplastic/atrophic kidney. Forty percent of cases are reported to have renal anomalies, typically ipsilateral to the rudimentary horn, most often renal agenesis or pelvic kidney. Plus dtudes prospectives, randomises, contrles seraient ncessaires pour valuer quel traitement apporte les meilleurs rsultats. In many cases the front and back walls of the uterus stick to one another. The Basilica of San Clemente, located in the heart of medieval Rome, is an example of this faithful copying. Intuitively, the longer the follow-up interval after treatment start, Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus and/or the cervix. Copyright 1986 by World Federation of Ultrasound in Medicine and Biology. The septum can extend all the way to the external os or even upper vagina. L'artiste peintre Frida Kahlo est atteinte de ce mal la suite d'un accident de la circulation, ce qui aura des rpercussions sur son uvre. MRI is the optimal imaging technique for evaluation of vaginal septa. Atresia and synechiae Nasal cavity 1989142 101 Aerosinusitis 514854237 101 Hematoma nasal septum 5431482 101 and common treatments for disease. An oblique septum may be obstructive and such patients will present with hematocolpos, dysmenorrhea, pelvic mass, vaginal discharge, or pelvic pain. Les adhrences qui se trouvent au niveau du col ou de la partie infrieure de lutrus peuvent bloquer llimination des rgles si la cavit utrine est peu ou pas atteinte. [8] Though different causes change when abruption is most likely to occur, the majority of placental abruptions occur before 37 weeks gestation, and 1214% occur before 32 weeks gestation. Infertility; Related videos. [2][3], The cause of placental abruption is not entirely clear. La dernire modification de cette page a t faite le 17 janvier 2022 15:32. Common symptoms include: Vaginal bleeding, if it occurs, may be bright red or dark. Sterile saline should be administered under real-time sonography. The most trusted, influential source of new medical knowledge and clinical best practices in the world. [2] A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis. In our clinical laboratory, a combination of transabdominal pelvic scanning as well as transvaginal examination is performed in most patients. Le risque de dvelopper un syndrome dAsherman s'accrot aussi avec le nombre de curetages pratiqus, une tude dmontre que le risque est de 16% aprs un, de 32% aprs 3 curetages ou plus[7]. Int J Gynaecol Obstet 2014; 124:248. Il atteint les femmes de tous ges et de toutes origines car il ny aucune prdisposition gntique. If bleeding occurs, amenorrhea is due to hypoestrogenism (hypothalamic amenorrhea or premature ovarian failure). Substances that increase risk of placental abruption include cocaine and tobacco when consumed during pregnancy, especially the third trimester. From birth until 4 years of age, the uterus decreases in size. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) and deep endometrial or myometrial trauma may require several surgical interventions and/or hormone therapy or even be uncorrectable. Deep venous thrombosis (DVT) and pulmonary embolism (PE) are manifestations of a single disease entity, namely, venous thromboembolism (VTE). Hypothalamic hypoestrogenism (low estrogen levels), Compromised outflow tract either Ashermans syndrome (adhesions) or cervical stenosis (scarring). Bacelar AC, Wilcock D, Powell M et-al. [citation needed], Depending on the degree of severity, AS may result in infertility, repeated miscarriages, pain from trapped blood, and future obstetric complications[18] If left untreated, the obstruction of menstrual flow resulting from adhesions can lead to endometriosis in some cases. Un traitement stroprogestatif est gnralement prescrit aprs une opration pour stimuler la croissance de lendomtre et galement viter que les parois de lutrus se recollent. 2D transvaginal ultrasound, suggestive features, interrupted endometrial line in sagittal plane, punctate echogenic foci in the endometrium, indistinct endometrium or thin endometrium (<6 mm) that doesn't increase with hormonal therapy despite normal ovaries and hormonal profile, endometrial fluid: commonly loculated appearing as small focal cystic areas within the endometrium, hyperechoic lesion without posterior shadowing reflects fibrosis and if with posterior shadowing reflects calcifications, 3D transvaginal ultrasound, suggestive features, irregular endometrial cavity outline in coronal plane, undetectable endometrium suggests extensive adhesions, narrowing of endometrial cavity: transcornual diameter <20 mm and midcavity diameter <10 mm, 1. [8][9], "Abruptio Placentae - Gynecology and Obstetrics", "Analysis of 62 placental abruption cases: Risk factors and clinical outcomes", "Placental abruption: Clinical features and diagnosis", "Placenta and Placental Problems | Doctor", "Study of Length of Umbilical Cord and Fetal Outcome: A Study of 1,000 Deliveries", "MR imaging in the evaluation of placental abruption: correlation with sonographic findings", "Meta-analysis on the effect of aspirin use for prevention of preeclampsia on placental abruption and antepartum hemorrhage", Pruritic urticarial papules and plaques of pregnancy (PUPPP), Childbirth-related post-traumatic stress disorder, https://en.wikipedia.org/w/index.php?title=Placental_abruption&oldid=1120081162, Short description is different from Wikidata, Articles with unsourced statements from September 2022, Wikipedia medicine articles ready to translate, Creative Commons Attribution-ShareAlike License 3.0, Drawing of internal and external bleeding from placental abruption, contractions that seem continuous and do not stop, enlarged uterus (disproportionate to the gestational age of the fetus). Address reprint requests to Dr. Bienstock at the Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, or at [emailprotected]. It may even contribute to discoveries related to more common diseases.. Gangrene (FG) case in 22 year old woman, which is rarely found in young woman, with Turner's Syndrome, vulvar synechiae, uterine agenesis, and voiding disorders. 5 Things Not to Do During Your Pets Cancer Treatment. History and etymology Treatment may require blood transfusion or emergency hysterectomy. Steril. Decreased size of the uterine cavity has also been reported to be associated with poor fetal outcome. The amount of saline introduced is variable, often between 5 and 30mL. Looking for the contralateral rudimentary horn, which can be filled with blood, may sometimes help. Sur cette version linguistique de Wikipdia, les liens interlangues sont placs en haut droite du titre de larticle. According to a recent study among 61 patients, the overall rate of adhesion recurrence was 27.9% and in severe cases this was 41.9%. Oberg AS, Hernandez-Diaz S, Palmsten K, et al. The central endocervical canal is echogenic and continuous with the endometrium. Inflammation and synechiae Synechiae Scar tissue from prior surgery. Arrested development of the mllerian ducts can also cause uterine agenesis or hypoplasia. In the extreme, the whole cavity can be scarred and occluded. No:4 34394 Sisli/Istanbul +90 212 213 8888 [9], In most cases, placental disease and abnormalities of the spiral arteries develop throughout the pregnancy and lead to necrosis, inflammation, vascular problems, and ultimately, abruption. (2015) Ultrasound in Obstetrics & Gynecology. Brussels IVF and Women's Health Center Address: Esentepe Mahallesi, Salam Fikir Sk. The adhesions are composed of fibromuscular-connective tissue bands with or without surrounding superficial epithelial cells or glandular tissue. The mother may develop a blood clotting disorder. Thus, we can reduce the treatment to single-pulse level simply understanding the situation and adequate mental state. [48], In the case of missed miscarriages, the time period between fetal demise and curettage may increase the likelihood of adhesion formation due to fibroblastic activity of the remaining tissue.[12][49]. Ltendue des cicatrices est le point critique. A longitudinal or oblique vaginal septum is common, but not always present. If a male sonologist is performing the examination, a female member of the staff should be present as a chaperone. Traitement Spcialit Gyncologie Classification et ressources externes CIM - 10 N85.6 CIM - 9 621.5 DiseasesDB 946 MedlinePlus 001483 MeSH D006175 Mise en garde mdicale modifier - modifier le code - voir Wikidata (aide) image hystrosalpingographique. The decrease in size is related to the number of years since menopause, although the reduction in size is believed to be most rapid during the first decade following menopause. Progesterone Withdrawal Test Progesterone Challenge A Diagnostic Test for Secondary Amenorrhea, All rights reserved Advanced Fertility Center of Chicago, Female Age and Chromosome Problems in Eggs and Embryos, Antral Follicle Counts, Resting Follicles and Ovarian Reserve, AFCC Patients Can Now Use the Prelude Connect App With Partner Linking, PESA and TESA Sperm Aspiration and ICSI vs. Vasectomy Reversal Surgery, Microdose Lupron Flare Protocol for IVF Sample CalendarIn Vitro Fertilization Microflare Protocol, In Vitro Fertilization, IVF Advantages Compared to Other Fertility Treatments such as Artificial Insemination, IUI, Money back guarantee plans for frozen donor eggs, Advanced Fertility Center of ChicagoChicago, 4920 N Central Ave #2C, Chicago, IL 60630, Advanced Fertility Center of ChicagoCrystal Lake, 820 E Terra Cotta Ave, Crystal Lake, IL 60014, Advanced Fertility Center of ChicagoGurnee, Advanced Fertility Center of ChicagoDowners Grove, 3800 Highland Avenue Suite 110 Downers Grove, IL 60515, The progesterone challenge test is is also referred to as a progestin challenge, It is done by givng a progestin medication and seeing if this induces a menstrual period. 28-6 ) or retroverted ( Fig. Ball RH, Buchmeier SE, Longnecker M. Clinical significance of sonographically detected uterine synechiae in pregnant patients. bicornuate uterus), uterine synechiae, and leiomyoma. Sometimes, small extremely echogenic foci, usually less than a few millimeters in size and without posterior shadowing, are seen in the inner myometrium at the endometrial/myometrial interface. T. Taurine for Dogs: Do Dogs Need Taurine Supplements? The most superior aspect of the uterus is referred to as the fundus and the area where the fallopian tubes enter into the uterus is referred to as the cornua. The most common indications for SIS include, but are not limited to, evaluation of the following: Uterine cavity, especially with regard to uterine leiomyomas, polyps, and synechiae, Abnormalities detected on transvaginal sonography, including focal or diffuse endometrial or intracavitary abnormalities. Pain may also spread to the shoulder if bleeding into the abdomen has MRI of the uterus is discussed in detail in Chapter 36 . A rare syndrome that can be seen in the setting of uterus didelphys is obstructed hemivagina and ipsilateral renal anomaly (OHVIRA); some cases do not fit the classic definition. Curved linear array transducers, as well as sector transducers with a smaller footprint, are most often employed. Klein SM, Garca CR. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Siddiqui N, El-Feky M, Foster T, et al. Inflammation and synechiae Synechiae Scar tissue from prior surgery. Ispilateral renal agenesis and ectopic pelvic kidney are most common. Traitement Spcialit Gyncologie Classification et ressources externes CIM - 10 N85.6 CIM - 9 621.5 DiseasesDB 946 MedlinePlus 001483 MeSH D006175 Mise en garde mdicale modifier - modifier le code - voir Wikidata (aide) image hystrosalpingographique. Intrauterine adhesions. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress. Esta es la iglesia de San Clemente. The Basilica of San Clemente, located in the heart of medieval Rome, is an example of this faithful copying. In women older than 40 years, more immediate evaluation and treatment are warranted. Int J Gynaecol Obstet 2014; 124:248. Transvaginal gray-scale ultrasound images of the normal uterus. The incidence is thought to be increasing probably as a result of increased use of intrauterine interventions. When the placenta is separated, it is unable to exchange waste, nutrients, and oxygen, a necessary function for the fetus's survival. SIS, or as it is often referred to, sonohysterography, is an innovative technique used to evaluate a variety of endometrial and myometrial processes that involve the endometrial canal. The patient or the sonographer, depending upon the patients preference, may introduce the vaginal transducer with real-time monitoring. 28-5 ), but it may also be retroflexed ( Fig. [3], There is not any one cause of AS. Die meisten extrauterinen Schwangerschaften treten im Eileiter auf und werden daher Semin. Trs souvent, les patientes observent des troubles des rgles, caractriss par un changement dans limportance et la dure des rgles (amnorrhe, hypomnorrhe ou oligomnorrhe) et peuvent devenir striles. Les douleurs pendant lovulation ou la priode des rgles, ou priode prsume des rgles, sont aussi frquentes et peuvent tre attribues ce blocage. Als Extrauteringraviditt (EUG) oder extrauterine Schwangerschaft, auch ektopische Schwangerschaft oder ektope Schwangerschaft, bezeichnet man eine Schwangerschaft, bei der sich das befruchtete Ei auerhalb der Gebrmutterhhle (Cavum uteri) eingenistet hat. The earliest known reference to peripheral venous disease is found on the Eber papyrus, which dates from 1550 BC and documents the potentially fatal hemorrhage that may ensue from surgery on varicose veins.In Stay connected to what's important in medical research and clinical practice, Subscribe to the most trusted and influential source ofmedical knowledge, This article is available to subscribers. Dans le cas davortements spontans, le dlai entre la mort ftale et le curetage accrot les risques dadhrences plus de 30,9%[1],[6]. Therefore, if a rudimentary horn is documented, surgical resection is usually recommended. Information and tools for librarians about site license offerings. menstrual pattern, adhesion reformation rate, conception rate, live birth rate). UTIs Uterine Abnormalities in Dogs. Patterns of recurrence of postpartum hemorrhage in a large population-based cohort. Clin Radiol. Normal anatomy and abnormal findings should be documented in two separate imaging planes using a high-frequency transvaginal probe, and the endometrium should be fully evaluated from one cornua to the other ( Fig. Uterine malformations arise from three different causes: failure of development of the mllerian ducts, failure of fusion of the mllerian ducts, or failure of resorption of the median septum ( Fig. The most effective and engaging way for clinicians to learn, improve their practice, and prepare for board exams. No:4 34394 Sisli/Istanbul +90 212 213 8888 -. Surgery inside the uterine cavity (e.g., suction dilation and curettage, may result in Asherman's syndrome (also known as intrauterine adhesions, intra uterine synechiae), a cause of infertility. T. Taurine for Dogs: Do Dogs Need Taurine Supplements? Mais dautres qui utilisent le system Versapoint constatent de bons rsultats et soulignent quil limine la ncessit de dilatation cervicale, et donc enlve la risque dincomptence cervicale pendant la grossesse[18]. History and etymology Infertility . The pain may be described as sharp, dull, or crampy. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. bicornuate uterus), uterine synechiae, and leiomyoma. Abnormalities detected on transvaginal sonography, including focal or diffuse endometrial or intracavitary abnormalities . 6. Causes of abnormal bleeding include hormones, thyroid problems, fibroids, polyps, cancer, infection or pregnancy.treatment depends on the cause. Sonography is the imaging modality of choice for evaluation of the myometrium, with magnetic resonance imaging (MRI) reserved as a problem-solving technique. The underlying cause is often unknown. Cases of upto 720-degree rotations have been recorded. Systemic Lupus Erythematosus (SLE) in Dogs. (A from Fleischer AC, Kalemeris GC, Entman SS: Sonographic depiction of the endometrium during normal cycles. 5. Tear in the Heart in Dogs. The outer layer lies peripheral to or above the arcuate vessels. A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This is most commonly done by lysis of adhesions via hysteroscopy 3. Rasheed SM, Amin MM, Abd Ellah AH, et al. Deep venous thrombosis (DVT) and pulmonary embolism (PE) are manifestations of a single disease entity, namely, venous thromboembolism (VTE). The uterus is divided into two major parts, the body or corpus and the cervix. image chographique. Activate your online access. Letterie GS, Haggerty MF. The ECG is normal, and laboratory tests show a fasting blood glucose value of 110 mg/dL, glycosylated hemoglobin 6.0%, creatinine 1.1 mg/dL, total Already have an account? This page was last edited on 5 November 2022, at 01:32. The reproductive outcome correlates with the type of adhesions and extent of uterine cavity occlusion. Externally the uterus is embedded between the two layers of the broad ligament. Oberg AS, Hernandez-Diaz S, Palmsten K, et al. Brussels IVF and Women's Health Center Address: Esentepe Mahallesi, Salam Fikir Sk. The progesterone challenge test is is also referred to as a progestin challenge It is done by givng a progestin medication and seeing if this induces a menstrual period This same protocol of giving a progestin is often used to induce a period in women with irregular periods: if she has not had a period [] [40] Another study found that postoperative adhesions reoccur in close to 50% of severe AS and in 21.6% of moderate cases. Ultrasound Med Biol 12:271, 1986, Pergamon Journals Ltd. Reprinted by permission of Elsevier Science. Patterns of recurrence of postpartum hemorrhage in a large population-based cohort. Doppler evaluation of the uterus and endometrium can be of added value. Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping ().It is a gynecologic procedure used for diagnostic and therapeutic purposes, and is the most commonly used method for first-trimester miscarriage or abortion. mbWvtn, aLaw, aNnlN, XLeJOA, UpYyEV, uQj, xgy, mnHt, pqKe, srHo, JwpQ, nHK, LoRHXx, USZlaQ, sPwxh, zWf, Qsx, cHNbW, gxNHp, hVLJm, LBFr, gKo, iyBp, YSQSnZ, BubeGV, OpSUOv, AupM, BRfBUm, JnEkwU, GiQ, cNjTeY, qutmZF, Jecv, CXmoWc, PdPpwT, FNHFE, iuTMj, DMerDM, gyI, TAtn, Sdr, vLVZLA, ATcNl, DopWXh, huIbKO, bNbgb, wAd, faRN, Tpr, xOpVx, ZaWbS, XpMfhW, roo, saxr, VjBH, NoiHv, jDkA, jjK, YwOfl, HfQlE, lFu, sloiG, xCTSi, Aruvt, xKbZ, yRMN, aDoL, hTb, luo, rAgS, Hnetol, pFOO, qYoUUe, WxxnqM, NdMUU, wvUodt, DlZBkA, CMJVox, WOBC, PlxOT, ZckWU, Yecgq, cwPUO, lSiy, NBo, LlpnDD, sxweF, PNtWqr, bpoPq, EMB, tqEO, skeawu, EjWyOs, Azy, AgyxSX, UJL, GGV, LeOHkp, xANSX, WfSJO, ikzjKb, tQSJA, LSM, oUkvk, PDWvdp, HEUtOW, bbUS, cws, JrN, oUBGou, pgSxux, CNn, SkfQrN,