Sequential use of oral and vaginal misoprostol versus oral or vaginal misoprostol alone for induction of labor and the caesarean delivery risk: a retrospective study

Background: Induction of labor is now a common practice and every institute faces the task of developing a safe and cost-effective protocol. We aimed to study the effects of sequential use of oral and vaginal misoprostol when compared to oral or vaginal misoprostol alone. Our primary objective was to determine the caesarean delivery rates and secondarily the maternal and neonatal complications between the different induction regimes.Methods: A single-center retrospective observational study was conducted, with patient records divided into three groups based on their methods of induction: those who were administered vaginal misoprostol only, those who had oral misoprostol only, and those who had oral misoprostol followed by vaginal misoprostol. We extracted all the necessary data from the records and analyzed it using SPSS.Results: 768 records with comparable demographic characteristics were reviewed. The majority of women were induced at 39 completed weeks. There was no significant difference in the proportion of caesarean deliveries when comparing the three groups but the number of caesarean sections was lower among women who had been administered vaginal misoprostol alone. Among the patients included in the study, the women who developed postpartum hemorrhage received a higher mean dose of misoprostol (130±70 mcg) compared to those who did not (104±57 mcg).Conclusions: Sequentially administering misoprostol may not decrease the caesarean section rate compared to using only one route of administration. However, it is important to monitor the amount of misoprostol given to each patient to prevent the incidence of PPH.

Use of Panicker’s cannula in management of atonic postpartum hemorrhage

Postpartum hemorrhage (PPH) is leading cause of maternal mortality worldwide. Panicker’s cannula creates negative pressure inside the uterus that causes shrinking of the uterus which can assist the physiological process of contraction and retraction to stop atonic postpartum hemorrhage. It is safe and simple technique to prevent and treat PPH. It can be used in low-resource and primary care settings, where even para medical personnel can use this method effectively to prevent morbidity and mortality. This can also be used in non-PPH conditions. In this study total 20 women with singleton pregnancy (14 had vaginal delivery and 6 underwent cesarean section), who developed atonic postpartum hemorrhage were included in the study. Panicker’s cannula was used in the patients, in whom bleeding was not stopped despite using uterotonics. Cessation of complete bleeding was observed in all 20 women within 4 minutes, which was associated with contraction and firm retraction of the uterus. Amount of the blood in bottle ranged from 150-250 ml. Vacuum retraction of uterus assists in the normal physiological process of contraction and retraction. This simple and cost effective technique, takes very little time to stop bleeding. This lifesaving technique is useful in all settings especially in low resource settings.

Evaluating the efficacy of metal suction cannula for atonic postpartum haemorrhage management in rural south Gujarat: a two-year observational study

Background: In resource-constrained regions characterized by limited healthcare infrastructure, low female literacy rates, and constrained access to medical resources, postpartum hemorrhage (PPH) remains a dire obstetric emergency. This research article investigates the effectiveness of metal suction cannula as a simple, safe and cost-effective technique for atonic PPH management in a private hospital in Rural South Gujarat. The primary aim of this study was to examine the effectiveness of the metal suction cannula in managing atonic PPH and the maternal outcome after suction technique.Methods: This observational study was conducted in Shreeji hospital, a private multifacility hospital in rural south Gujarat over the period of two years, between June 2021-May 2023 and involved 148 patients who were admitted for labour and delivery but later developed atonic PPH after AMTSL. Metal cannula and high vacuum suction machine was used. Data like patient demographics, risk factors, and post-procedural outcomes were studied.Results: Following application of the metal vacuum cannula technique, bleeding stopped within five minutes in 78 women (52.7%). For 53 women (35.8%), bleeding ceased between 5-10 minutes. In 17 women (11.4%), bleeding was effectively halted after more than ten minutes. In 87 women (58.8%), negative pressure was applied only once, resulting in successful hemorrhage control. 38 women (25.6%) required suction application two times and 25 women (20.8%) needed three applications of negative pressure to effectively stop the bleeding. The volume of blood collected in the bottle after metal vacuum cannula application ranged from 100 to 300 ml.Conclusions: Factors such as ease of use, affordability, and improved clinical outcomes make suction cannulas an effective tool in the management of PPH in resource limited areas. It requires minimal training, conserves the uterus, is technically less challenging and reduces the requirement of blood and blood products.

Effectiveness of compression of myometrium and occlusion of uterine artery by COMOC-MG suture in management of atonic postpartum hemorrhage

Background: Postpartum haemorrhage (PPH) remains a significant cause of maternal morbidity and mortality globally, with uterine atony being a primary etiological factor. This prospective interventional study aimed to assess the effectiveness of the compression of myometrium and occlusion of uterine artery by COMOC-MG suture technique in managing atonic PPH.Methods: A prospective study was conducted at GK general hospital, Bhuj, Gujarat, from December 2020 to July 2022. The study enrolled 100 pregnant women without identified risk factors undergoing complicated caesarean or vaginal deliveries. The COMOC-MG suture technique was employed for the study group, while the control group received standard atonic PPH management. Outcomes included success rates, blood transfusion needs, complications, and mortality.Results: The study group (n=50) demonstrated comparable demographic characteristics to the control group. Notably, the COMOC-MG group exhibited higher success rates in normal (100%) and cesarean deliveries (95.3%) compared to the control group (72.7% and 60.7%, respectively). Lower blood transfusion needs (34% vs. 48%) and fewer complications were observed in the COMOC-MG group. Hemoglobin (Hb) levels on post-partum day 1 showed no significant difference.Conclusions: The study suggests that COMOC-MG suture technique is effective in managing atonic PPH, showing superior success rates and potentially reducing blood transfusion needs. While further research, including larger trials, is warranted, these findings underscore promise of COMOC-MG as an innovative intervention in obstetric care, offering potential benefits in maternal outcomes. The observed safety profile supports its consideration in clinical practice.

Comparison of risk factors of postpartum hemorrhage among normal versus cesarean delivery cases at a secondary care center in Naogaon

Background: Postpartum hemorrhage (PPH) involves excessive blood loss of 500 mL or more after vaginal delivery (NVD) or 1,000 mL or more after cesarean section within 24 hours postpartum. PPH significantly contributes to maternal mortality worldwide. Understanding the diverse effects of distinct risk factors is essential for effective mitigation. This study aimed to compare the risk factors of PPH among normal versus cesarean delivery (CD) cases at 250 bed modernized general hospital.Methods: Conducted at the department of obstetrics and gynaecology, 250 bed modernized general hospital, Naogaon, Bangladesh, this prospective study investigated PPH in 100 women from 01 July, 2022 to 30 June, 2023. Participants were divided into two equal groups in number: Group A (normal vaginal delivery) and group B (caesarean-section delivery). Data collection and analysis were performed using MS office.Results: In terms of risk factors, group A saw 4% maternal ages <19 and >40, while group B had 4% and 8% respectively. Artificial reproductive technique use was 2% in group A and 4% in group B. Weight gain >15.0 kg during pregnancy was 8% in group A and notably higher at 20% in group B. Gestational age <36 weeks affected 14% in group A and 8% in group B.Conclusions: In normal vaginal deliveries, maternal age <19 years, gestational age <36 weeks, labor induction/augmentation by oxytocin and neonatal birth weight <2499 gm are prominent risk factors. For cesarean-section deliveries, maternal age >40, weight gain >15.0 kg, pre-eclampsia, and neonatal birth weight >3500 gm also pose significant risks.

A retrospective study on epidemiology and outcomes of peripartum hysterectomy

Background: Peripartum hysterectomy is a rare condition which is associated with maternal morbidity and mortality, and the last resort to control hemorrhage when all the other methods fail. The main aim of this study was to evaluate the indications, incidence and complications, maternal and perinatal outcome and compare the risk of peripartum hysterectomy in women who underwent LSCS previously with the women who did not have previous LSCS.Methods: A retrospective study was done over one year at a tertiary care teaching hospital in southern Rajasthan. All the women who underwent peripartum hysterectomy were included. Patients were divided into two groups, one who did not have any previous lower segment caesarean section (LSCS) and other who had history of previous LSCS, and their data was compared. The, results were calculated and represented as mean, frequency or median as appropriate.Results: 34 women underwent peripartum hysterectomy yielding the incidence of 2.21/ 1000 deliveries. The main indication of peripartum hysterectomy was abnormally adherent placenta followed by rupture uterus. 73% cases of peripartum hysterectomy were associated was the history of LSCS.Conclusions: The indication of peripartum hysterectomy has changed from atonic PPH to placenta spectrum syndrome. A major change can be brought about by the reduction of index cases of LSCS which has been on the rise in the recent years. Strict protocols should be made. Early transportation facility and institutional deliveries should be promoted to prevent the emergency peripartum hysterectomy.

Carbetocin versus oxytocin in primigravida for active management of third stage of labor: a prospective study

Background: Postpartum haemorrhage (PPH) stands as a prominent global contributor to maternal mortality. Oxytocin's short half-life and heat sensitivity pose challenges in resource-limited areas. Carbetocin, not requiring cold storage, is utilized in third-stage labor management. Consequently, this study aimed to compare the effectiveness of carbetocin with oxytocin in third-stage labor management.Methods: In this prospective study of 200 primigravida patients, group A received heat-stable carbetocin (100 ?g), while group B received oxytocin (10 IU) postpartum. Primary outcome such as mean blood loss in ml and Secondary outcomes such as proportion with blood loss >500 ml, need for uterotonic agents, blood transfusion, surgical PPH management, and drop in haemoglobin after 48 hours were recorded and compared.Results: Groups A and B, comparable in age, blood pressure, and mild anaemia, exhibited significant gestational age differences (p<0.0001). Group B had higher mean blood loss (377.68 ml) than group A (345.34 ml) with a significant p=0.0118*. Side effects showed no differences among groups. Postpartum, group B saw a significant 7% incidence of haemorrhage compared to none in group A (p=0.0071).Conclusions: Carbetocin showed superiority over oxytocin in the active management of third stage of labor, exhibiting a statistically significant reduction in PPH incidence and decreased requirement for additional uterotonic drugs.

Secondary postpartum hemorrhage after pineapple juice- a case report

Postpartum hemorrhage (PPH) is defined as blood loss through the genital tract, exceeding 500 mL following vaginal birth and 1000 mL following caesarean section. PPH occurring between 24 hours to 12 weeks postpartum is defined as secondary PPH. PPH is the most common preventable cause of maternal morbidity and mortality. Detailed history and careful clinical examination can help in proper diagnosis. This is a case report of consumption of pineapple juice, that caused secondary PPH. Bromelain in pineapple juice is known to have proteolytic, fibrinolytic, anti-inflammatory and antithrombotic properties. It causes moderate prolongation of activated partial thromboplastin time (APTT), thus delaying coagulation. This action of bromelain was found to be concentration dependent. Prompt activation of the transfusion protocol can be lifesaving. Coagulation parameters should be monitored and respective blood products should be given. Thromboelastogram (TEG)/ Rotational Thromboelastometry (ROTEM) can be used for the same. To conclude, a multi-disciplinary approach is ideal. Mechanical and medical management of PPH should be started simultaneously. This should be followed by surgical procedures. If interventional radiology procedures like uterine artery embolization are available, they can be utilised, without risking the life of the mother.

A study for the efficacy of Amr's cervical traction maneuver along with AMTSL in prevention of postpartum hemorrhage

Background: Postpartum hemorrhage (PPH) contributes to 25% maternal mortality worldwide (WHO, 2007). In poor resource settings where facility of refrigeration is not available uterotonics may not prove to be useful in prevention of PPH. The aim of this study is to find out the efficacy and acceptability of Amr’s cervical traction maneuver in prevention of PPH in such set up.Methods: This interventional observational study was conducted among 220 patients coming in labour eligible for vaginal delivery in Department of Obstetrics and Gynaecology, S. N. Medical College, Agra between December 2020 to May 2022. Patients were divided into two groups: study group (110 patients) where Amr’s maneuver along with AMTSL is done and control group: where AMTSL is done alone.Results: The mean age of participants in study group was 23.76 years and control group was 23.75 years. In both groups, 59.5% were primigravidae. Mean BMI in both group was 25.02 kg/m2. Almost 61% had spontaneous labour. Nearly 92% delivered normally without instruments. In study group 66% patients had blood loss less than 400ml. Average blood loss was 255.23 ml in study group and 300.25 ml in control group. The difference is clinically significant. The mean blood loss in PPH patients in study group was 603.75 ml, and in control group it is 753.25 ml, which is clinically significant.Conclusions: Amr’s maneuver is a simple maneuver when done in combination with AMTSL results in reducing the incidence of PPH and amount of blood loss post-delivery to a great extent.

Secondary postpartum hemorrhage after pineapple juice- a case report

Postpartum hemorrhage (PPH) is defined as blood loss through the genital tract, exceeding 500 mL following vaginal birth and 1000 mL following caesarean section. PPH occurring between 24 hours to 12 weeks postpartum is defined as secondary PPH. PPH is the most common preventable cause of maternal morbidity and mortality. Detailed history and careful clinical examination can help in proper diagnosis. This is a case report of consumption of pineapple juice, that caused secondary PPH. Bromelain in pineapple juice is known to have proteolytic, fibrinolytic, anti-inflammatory and antithrombotic properties. It causes moderate prolongation of activated partial thromboplastin time (APTT), thus delaying coagulation. This action of bromelain was found to be concentration dependent. Prompt activation of the transfusion protocol can be lifesaving. Coagulation parameters should be monitored and respective blood products should be given. Thromboelastogram (TEG)/ Rotational Thromboelastometry (ROTEM) can be used for the same. To conclude, a multi-disciplinary approach is ideal. Mechanical and medical management of PPH should be started simultaneously. This should be followed by surgical procedures. If interventional radiology procedures like uterine artery embolization are available, they can be utilised, without risking the life of the mother.

A study for the efficacy of Amr's cervical traction maneuver along with AMTSL in prevention of postpartum hemorrhage

Background: Postpartum hemorrhage (PPH) contributes to 25% maternal mortality worldwide (WHO, 2007). In poor resource settings where facility of refrigeration is not available uterotonics may not prove to be useful in prevention of PPH. The aim of this study is to find out the efficacy and acceptability of Amr’s cervical traction maneuver in prevention of PPH in such set up.Methods: This interventional observational study was conducted among 220 patients coming in labour eligible for vaginal delivery in Department of Obstetrics and Gynaecology, S. N. Medical College, Agra between December 2020 to May 2022. Patients were divided into two groups: study group (110 patients) where Amr’s maneuver along with AMTSL is done and control group: where AMTSL is done alone.Results: The mean age of participants in study group was 23.76 years and control group was 23.75 years. In both groups, 59.5% were primigravidae. Mean BMI in both group was 25.02 kg/m2. Almost 61% had spontaneous labour. Nearly 92% delivered normally without instruments. In study group 66% patients had blood loss less than 400ml. Average blood loss was 255.23 ml in study group and 300.25 ml in control group. The difference is clinically significant. The mean blood loss in PPH patients in study group was 603.75 ml, and in control group it is 753.25 ml, which is clinically significant.Conclusions: Amr’s maneuver is a simple maneuver when done in combination with AMTSL results in reducing the incidence of PPH and amount of blood loss post-delivery to a great extent.

Carbetocin versus Oxytocin in placental separation and postpartum haemorrhage in caesarean section-comparative observational study

Background: Carbetocin and oxytocin are indicated for the prevention of postpartum haemorrhage (PPH) due to uterine atony. Carbetocin is a newer analogue of oxytocin with longer half life and more heat stable. PPH can be effectively reduced by the prophylactic use of uterotonics. The aims of the present study were to compare effects of oxytocin and carbetocin in separation of placenta, in controlling the blood loss and the additional uterotonic needed in caesarean section (CS) at high risk of primary PPH. Methods: Women in the carbetocin group (group A) received a bolus of 100 µg IV; women in the control group (group B) received 20 IU of oxytocin in 1000 ml of 0.9% NaCl solution IV (150 mL/ hour). The efficacy of drugs in controlling blood loss was evaluated. Also, the haemodynamic effects and the need for additional uterotonic agents was compared. In addition, we compared the drop in haemoglobin level, the placental separation, the uterine tone. Results: Both drugs produce hypotension but the effect was greater in oxytocin group. Placental separation was seen early in oxytocin group. Uterine tone was attained earlier in oxytocin group however the tone was maintained persistently in carbetocin group. Additional uterotonic agents were needed in the oxytocin group (46% vs 0%, p=0.05).Conclusions: A single injection of carbetocin appears to be more effective than a continuous infusion of oxytocin to maintain sustained and adequate uterine tone and to prevent the PPH. However, there is delayed placental separation and delayed attainment of adequate uterine tone after use of carbetocin.

Study of fetomaternal outcome in emergency peripartum hysterectomy at pannadhay zanana hospital, Udaipur, India

Background: Peripartum or obstetric hysterectomy is the removal of the corpus uteri alone or with the cervix at the time of a caesarean section or shortly after a vaginal delivery. On one hand, it is the last resort to save a woman's life and on the other hand, her reproductive capability is sacrificed. Many times it is a very difficult decision and requires good clinical judgment. Most of the time the operation is carried out when the condition of patient is too critical to withstand the risks of anesthesia or surgery, but proper timing and meticulous care may reduce or prevent maternal complications.Methods: The study is prospective study and was conducted on cases of peripartum emergency hysterectomy performed at PDZH, Udaipur, during the period from April 2021 to October 2022.Results: Our study depicts following results on the basis of 31498 deliveries during the study period (April 2021 to October 2022), so the overall incidence of peripartum hysterectomy is 1 in 1049 (0.095%). Incidence of hysterectomy following vaginal delivery found to be 0.15%, whereas following caesarean incidence found to be 0.24%.Conclusions: Increase in caesarean section rates may lead to a rise in the number of peripartum hysterectomies required in the future because of increased chances of scar dehiscence and morbidly adherent placenta and Thus, there is a need for institutions to reassess their indication for first caesarean section to decrease the incidence of caesarean sections.

Monoamniotic twins with complications and their outcome: case series

Monoamniotic twins are identical twins sharing the same amniotic sac and placenta, with two separate umbilical cords. Although uncommon, monoamniotic twins are associated with high antenatal and perinatal morbidity and mortality. We present here a series of three cases of monoamniotic twin gestations with fetal complications who delivered in our hospital over a period of one month. Our first case Mrs. ABC with 33 weeks of gestation with Monoamniotic twins presented with twin anemia polycythemia sequence, second case, Mrs XYZ presented as primigravida with 35 weeks of gestational age with monoamniotic twins with severe preeclampsia presented with Cord entanglement who went into postpartum hemorrhage and was conservatively managed for the same. Our third case, Mrs. DEF G2P1L1 with previous scar 1.5 years back with 23 weeks of gestation with monoamniotic twins presented with Twin reversal arterial perfusion sequence and underwent medical termination of pregnancy.

Feto maternal outcome in placenta previa and morbidly adherent placenta

Background: Placenta forms the most important link between the developing foetus and the mother. The placenta's health is crucial for the foetus' proper growth and development. The outcome of pregnancy is changed when there is a change in the placental location or architecture for both the mother and the foetus. No matter the cause, placenta previa increases maternal and foetal risks by several times. Aim and objectives of current study are to investigate the incidence of placenta previa in hospital obstetric patients and the maternal and fetal outcome in cases of placenta previa.Methods: 100 patients delivered in the Govt. Medical College, Kota with cases of placenta previa. Risk factors like Gestational age at the onset of bleeding, expectant management, gestational age at delivery and the mode of delivery. The birth weight and APGAR score of the newborn were observed.Results: The risk of placenta previa is 3 time higher in multigravida than primigravida. 52% chances of placenta previa with male babies. Peak incidence of bleeding is noted around 34-36 weeks. 92% of placenta previa cases were delivered LSCS. PPH was main morbidity out of all morbidities. 55% of babies were less than 2.4 Kg. 44% were anterior, 38% posterior and rest 6% central placenta previa.Conclusions: Placenta previa poses a serious risk to both the mother and the foetus, whether it is accidentally discovered by ultrasound or as a result of a clinical emergency like a haemorrhage in the mother. The best outcome can be achieved with an accurate diagnosis, prudent expectant management, blood transfusion as necessary, and prompt delivery.

Role of slow decompression, injection carbetocin and Samarth Ram cannula for preventing postpartum haemorrhage in a patient of acute severe polyhydramnios

We presented a case of a 30-year-old woman G3P1L1A1 who was diagnosed with severe polyhydramnios at 29 weeks of gestation. The patient was managed conservatively with amnioreduction. However, after one week of conservative management showed a further increase in the AFI (54-55 cm) with severe breathlessness and abdominal pain. A decision to terminate pregnancy was taken in view of failed conservative management. Emergency LSCS done under general anaesthesia. Amniotomy was done by slow uterine decompression. Simultaneously injection carbetocin 100 mcg IV bolus over 1 minute given. Postpartum haemorrhage was prevented by using Samarth Ram cannula. Further recovery was uneventful and patient discharged on day 3 of surgery.

Role of slow decompression, injection carbetocin and Samarth Ram cannula for preventing postpartum haemorrhage in a patient of acute severe polyhydramnios

We presented a case of a 30-year-old woman G3P1L1A1 who was diagnosed with severe polyhydramnios at 29 weeks of gestation. The patient was managed conservatively with amnioreduction. However, after one week of conservative management showed a further increase in the AFI (54-55 cm) with severe breathlessness and abdominal pain. A decision to terminate pregnancy was taken in view of failed conservative management. Emergency LSCS done under general anaesthesia. Amniotomy was done by slow uterine decompression. Simultaneously injection carbetocin 100 mcg IV bolus over 1 minute given. Postpartum haemorrhage was prevented by using Samarth Ram cannula. Further recovery was uneventful and patient discharged on day 3 of surgery.

A study on thrombocytopenia in pregnancy and feto-maternal outcome conducted at tertiary care center Rajkot, Gujarat

Background: Thrombocytopenia is second only to anemia as the most common hematological abnormality encountered in pregnancy. Better antenatal care has led to increased detection. Once diagnosed, it is Important to further evaluate and to determine the cause to optimize management. The objectives were to study feto-maternal outcome in patient of thrombocytopenia in terms of maternal and neonatal complications and to study the causes of thrombocytopenia in pregnancy.Methods: The present study was a hospital-based study carried out from June 2021 to June 2022 at the department of obstetrics and gynecology, PDU medical college, Rajkot, Gujarat. During this period 100 patients in the third trimester of pregnancy with thrombocytopenia were selected randomly.Results: In this study 41% cases were mild thrombocytopenia, 39% with moderate and 20% were severe cases. 50% cases were gestational thrombocytopenia, 31% were cases associated with hypertensive disorders of pregnancy, 8% cases were associated with abruption, 13% cases were associated with IUFD, 2% cases were idiopathic thrombocytopenic purpura (ITP), 8% cases were associated with viral (dengue) and bacterial (malaria) infection, 1% cases were associated with SLE, 1% cases was thrombotic thrombocytopenic purpura (TTP). Maternal complications were encountered in form of DIC in 13% cases, jaundice in 7% of cases, 2% cases were complicated by PPH, 4% cases were complicated by acute kidney injury, 2% cases were associated with sickle cell crisis and 4% cases were maternal mortality. 12% were stillbirth and 5% cases had neonatal mortality.Conclusions: Thrombocytopenia in pregnancy induced hypertension carries a risk for both the mother and her fetus. Thrombocytopenia in pregnancy if timely diagnosed do not cause any mortality, however management of these patients require a multidisciplinary approach and close collaboration between obstetrician, physician, and neonatologist.

Comparison of oral misoprostol versus intramuscular oxytocin for active management of third stage of labour: a single centre randomised controlled study

Background: This study was conducted to compare the efficacy and safety of oral misoprostol against intramuscular oxytocin in the active management of the third stage of labour, so that it can be widely used in the areas of limited resources to contribute in preventing post-partum haemorrhage and thus decreasing maternal mortality ratio.Methods: This was a prospective randomised controlled clinical study. Two hundred patients fulfilling inclusion criteria were randomized to receive either oral misoprostol (600 mcg) or intramuscular oxytocin (10 IU) in the active management of third stage of labour. Primary outcome measured was mean blood loss and incidence of primary PPH.Results: The mean blood loss during third stage of labour in oral misoprostol group and oxytocin group was 239.16�.78 ml and 240.19�.70 ml respectively with p value-0.7331 which was insignificant. Similarly mean fall in haemoglobin was also not significant. There was no significant differences between the two groups with regard to the incidence of PPH (3% vs. 2% respectively; p=0.651). Women experiencing side effects like shivering and fever were significantly higher among misoprostol group than in oxytocin group.Conclusions: In this study, oral misoprostol was found to be comparable to intramuscular oxytocin regimen, in terms of amount of blood loss, occurrence of postpartum hemorrhage, duration of third stage of labour, fall in hemoglobin and fall in blood pressure. However, shivering and fever were more common with misoprostol, but no other serious side effects were noted.