Sonographic Findings of Vascular Signals for Retained Products of Conception in Women Following First-Trimester Termination of Pregnancy.

OBJECTIVES: To evaluate the occurrence of retained products of conception (RPOC) after termination of pregnancy in the first trimester and to assess the vascular signals with transvaginal ultrasonography (TVUS) examination in the detection of retained products. METHODS: A retrospective cohort study was performed using TVUS examination in patients following termination of pregnancy. In cases of RPOC, 3 scales of vascular signal were identified: type 1, no or small amount, spot flow signals; type 2, medium amount, strip-like flow signals; type 3, rich amount, circumferential-like flow signals. The correlation between vascular signals and placenta accreta spectrum (PAS) staging was proposed by sonography and histopathology findings. RESULTS: The 3 vascular patterns were differently distributed within non-RPOC as well as RPOC patients with and without PAS: type 1 vascular signal detection rates of non-RPOC and RPOC were 97.8% (262/268) and 28.1% (18/64), respectively. Of 64 cases of RPOC, 48.4% (31/64) of the patients had type 2 vascular signals. Vascular signals were enhanced in RPOC with PAS patients whose diagnosis was confirmed by histopathology. CONCLUSIONS: The vascularity (amount of flow), vascular pattern (spot, strip- or circumferential-like flow), and the flow penetrating myometrium were significant findings for distinguishing concomitant RPOC with and without PAS. Additionally, RPOC may contribute to PAS progression, or PAS and RPOC in coordination strengthen the observed vascular signals.

Association between first-trimester ultrasound imaging of eccentric implantation and retained placenta.

OBJECTIVES: To evaluate first-trimester ultrasound imaging of eccentric implantation in predicting the probability of retained placenta. METHODS: A total of 61 cases with gestational sac eccentrically implanted in first-trimester ultrasound imaging was selected. Demographic and obstetric data were collected through data extraction of the electronic medical record at the time of delivery admission. Baseline characteristics (including age, gestational age of first-trimester ultrasound, size of gestational sac, gestational age of delivery), delivery outcomes (mode of delivery, retained placenta or placental fragments, blood loss, postpartum hemorrhage and postpartum ultrasound imaging) were collected and analyzed. RESULTS: The risk difference for a woman with eccentric implantation to have a retained placenta was -0.18 (95% CI -0.28 to -0.08, p = 0.000) and the incidence of retained placenta in the study group was higher than in the control group (18% vs. 0%, p = 0.006). First-trimester ultrasound imaging of eccentric implantation was also found to be an independent risk factor for the incidence of inhomogeneous mass in postpartum ultrasound imaging (27.9% vs. 10.8%, adjusted OR 0.19, 95% CI 0.05 to 0.79, p = 0.012). Though 2 cases in the study group suffered postpartum hemorrhage, the risk difference for a woman with eccentric implantation to suffer postpartum hemorrhage was -0.03 (95% CI -0.08 to -0.01, not significant) and eccentric implantation did not increase postpartum hemorrhage rates (3.3% vs. 0%, not significant). CONCLUSIONS: First-trimester ultrasound imaging of eccentric implantation was associated with an increased risk of retained placenta and inhomogeneous mass in postpartum ultrasound imaging.

Ultrasound for diagnosis of postpartum retained products of conception-How accurate we are?

OBJECTIVE: Postpartum retained products of conception (RPOC) can cause short- and long-term complications. Diagnosis is based on ultrasound examination and treated with hysteroscopy. This study evaluated the size of RPOC that can be related to a positive pathology result for residua. MATERIALS AND METHODS: This retrospective cohort study included women who underwent hysteroscopy for postpartum RPOC diagnosed by ultrasound, 4/2014-4/2022. Demographics, intrapartum, sonographic, intraoperative, and post-operative data were retrieved. We generated a ROC curve and found 7 mm was the statistically sonographic value for positive pathology for RPOC. Data between women with sonographic RPOC ≤ 7 mm and > 7 mm were compared. Positive and negative predictive values were calculated for RPOC pathology proved which was measured by ultrasound. RESULTS: Among 212 patients who underwent hysteroscopy due to suspected RPOC on ultrasound, 20 (9.4%) women had residua ≤ 7 mm and 192 (90.6%) had residua > 7 mm. The most common complaint was vaginal bleeding in 128 cases (60.4%); more so in the residua > 7 mm group (62.5% vs. 40%, p = .05). Among women with residua ≤ 7 mm, the interval from delivery to hysteroscopy was longer (117.4 ± 74.7 days vs. 78.8 ± 68.8 days, respectively; p = .02). Positive pathology was more frequent when residua was > 7 mm. PPV for diagnosis of 7 mm RPOC during pathology examination was 75.3% and NPV 50%. CONCLUSIONS: Sonographic evaluation after RPOC showed that residua > 7 mm was statistically correlated with positive RPOC in pathology and PPV of 75% and NPV of 50%. Due to the high NPV and low complication rate of office hysteroscopy, clinicians should consider intervention when any RPOC are measured during sonographic examination to reduce known long-term complications.

Retained products of conception - a retrospective analysis of 200 cases of surgical procedures for the diagnosis of residua postpartum.

OBJECTIVES: Postpartum retained products of conception are a relatively rare diagnosis occurring in approximately 1% of cases after spontaneous deliveries and abortions. The most common clinical signs are bleeding and abdominal pain. The diagnosis is based on clinical signs and ultrasound examination. MATERIAL AND METHODS: Retrospective analysis of 200 surgical procedures for the diagnosis of residua postpartum obtained in 64 months. We correlated the method and accuracy of diagnosis with definitive histological findings. RESULTS: During 64 months, we performed 23 412 deliveries. The frequency of procedures for diagnosis of retained products of conception (RPOC) was 0.85%. Most (73.5%) of the D&C were performed within six weeks of delivery. Histologically, the correct diagnosis was confirmed in 62% (chorion + amniotic envelope). There was interestingly lower concordance of histologically confirmed RPOC in post-CS patients (only 42%). In women after spontaneous delivery of the placenta, the diagnosis of RPOC was confirmed by histological correlate in 63%, and the highest concordance occurred in women after manual removal of the placenta in 75%. CONCLUSIONS: Concordance with histological findings of chorion or amnion was seen in 62% of cases; this means that the incidence rate in our study was around 0.53%. The lowest concordance is after CS deliveries, 42%. D&C for RPOC should be performed after adequate clinical evaluation and in the knowledge of 38% false positivity. There is certainly more space for a conservative approach under appropriate clinical conditions, especially in patients after CS.

Medical management of retained products of conception: A prospective observational study.

OBJECTIVE(S): To measure the success rate of primary medical therapy in managing retained products of conception (RPOC) in women with secondary postpartum haemorrhage (PPH) and to identify factors associated with need for surgical management. STUDY DESIGN: Postpartum patients presenting to a tertiary women's hospital Emergency Department between July 2020 and December 2022 with secondary PPH and evidence of RPOC on ultrasound were recruited. Clinical information relating to the presentation was collected prospectively. Antenatal and intrapartum data were collected from medical record and Birthing Outcome System database review. The primary outcome was the success of medical management for RPOC, defined by the implementation of medical or expectant management without subsequent need for surgical intervention. RESULTS: Forty-one patients with RPOC underwent primary medical or expectant management. Twelve patients (29%) were managed successfully with medical management, while twenty-nine (71%) proceeded to surgical management. Medical management involved antibiotics (n = 37, 90%), prostaglandin E1 analogue (n = 14, 34%) and other uterotonics (n = 3, 7%). A greater endometrial thickness on ultrasound was significantly associated with a requirement for secondary surgical intervention (p < 0.05). There was an association approaching statistical significance between a higher sonographic volume of RPOC and the failure of medical management (p = 0.07). There was no statistically significant association between the mode of delivery or the number of days postpartum with the success of medical management. CONCLUSION(S): For patients presenting with secondary PPH and sonographic RPOC, over two thirds required surgical management. Increased endometrial thickness was associated with an increased requirement for surgical management.

The role of ultrasound imaging in the management of partial placental retention after third trimester livebirth.

OBJECTIVES: To evaluate the impact of different ultrasound signs in the management and the role of ultrasound guidance in the surgical evacuation of partial placental tissue retention. METHODS: This is an observational cohort study and retrospective case assessment of 82 patients with clinical symptoms of partial placental retention following a third trimester singleton livebirth between January 2013 and May 2019. The ultrasound signs were recorded using a standardized protocol and the outcome of the management strategy and the use of ultrasound guidance during any surgical procedure was evaluated. RESULTS: Out of the 64 patients who had a vaginal birth, 25 (39.1%) had a manual removal of the placenta at delivery. Fifteen patients were confirmed as not having retained placental tissue and did not require further treatment. Four patients were referred after failed surgical management and four after failed conservative management. All surgical procedures were vacuum aspiration and forceps removal under continuous ultrasound guidance. A significantly lower gestational age at delivery (p < .05), shorter interval between delivery and ultrasound diagnosis (p < .05) and lower number of patients presenting with heavy bleeding was found in the conservative compared to the surgical management subgroups (p < .05). The incidence of feeding vessels was significantly (p < .05) higher in the surgical than in the conservative management subgroups and associated with increased myometrial vascularity. Six patients developed intra-uterine adhesions. In four of these cases, ultrasound examination showed a hyperechoic mass surrounded by normal myometrial vascularity and no feeding vessel. CONCLUSIONS: Ultrasound imaging accurately differentiated between patient with and without partial placental retention after third trimester livebirth. Ultrasound-guided vacuum aspiration is safe and efficient in these cases.

Managing patients with suspected postpartum retained products of conception using a novel sonographic classification.

BACKGROUND: Suspicion of retained products of conception (RPOC) often arises after delivery and still poses a diagnostic and management challenge. PURPOSE: To prospectively evaluate a sonographic classification for the management of patients with suspected RPOC after delivery. MATERIAL AND METHODS: Based on grayscale and Doppler ultrasound parameters, patients were classified into high, moderate, or low probability of RPOC. For the low and moderate probability groups, an ultrasound follow-up at the end of the puerperium was recommended. For the high probability group, a follow-up examination was conducted 10-14 days after the first ultrasound, and patients with persistent high probability findings were referred for surgical intervention. RESULTS: The sample was composed of 215 patients at risk of RPOC. Of these, 100, 93, and 22 patients were classified as having a low, moderate, or high probability of RPOC, respectively. Rates of RPOC were 55%, 2%, and 2% in the high, moderate, and low probability categories, respectively. When the categorization was based on the most recent ultrasound obtained during the puerperium, the adjusted RPOC prevalence rates were 71% in the high, 6% in the moderate, and 0% in the low probability groups. CONCLUSION: This study confirms the effectiveness of our sonographic classification for managing patients with suspected RPOC after delivery. In all three categories, it is recommended to adhere to a conservative management protocol in clinically stable women until the end of the puerperium. This approach provides good predictability for RPOC and can reduce unnecessary surgical interventions.

Managing Reproduction Emergencies in the Field: Part 2: Parturient and Periparturient Conditions.

Selected conditions affecting broodmares are discussed, including arterial rupture, dystocia, foal support with ex utero intrapartum treatment, uterine prolapse, postpartum colic, the metritis/sepsis/systemic inflammatory response syndrome complex, and retained fetal membranes. Postpartum colic beyond third-stage labor contractions should prompt comprehensive evaluation for direct injuries to the reproductive tract or indirect injury of the intestinal tract. Mares with perforation or rupture of the uterus are typically recognized 1 to 3 days after foaling, with depression, fever, and leukopenia; laminitis and progression to founder can be fulminant. The same concerns are relevant in mares with retention of fetal membranes.

Diagnostic criteria for retained products of conception-A scoping review.

INTRODUCTION: Numerous studies have been performed assessing optimal treatment regimens for evacuating (retained) products of conception from the uterus, but standardized criteria for diagnosing retained products of conception (RPOC) are still lacking. We aim to provide an overview of diagnostic criteria in current literature, used to diagnose RPOC after induced first-trimester abortion or early pregnancy loss. MATERIAL AND METHODS: Pubmed, EMBASE, and the Cochrane library were searched systematically up until March 2020 for English articles reporting on induced abortion or early pregnancy loss. Articles not specifying diagnostic criteria used to assess completeness of treatment were excluded, as were conference abstracts, expert opinions, reviews, and case reports. Four elements of diagnostic criteria were described: diagnostic tools, parameters used within these tools, applied cut-off values, and timing of follow up. Additionally, a meta-analysis was performed assessing diagnostic qualities of the most often applied diagnostic tool and parameter. RESULTS: The search strategy yielded 1233 unique articles, of which 248 were included, with a total of 339 517 participants. In the 79 included randomized controlled trials, six diagnostic tools to assess RPOC were identified, combined in 14 ways, with 55 different cut-off values. In 169 observational studies, seven diagnostic tools were identified, used in 28 combinations, applying 89 different cut-off values. Transvaginal ultrasonographic measurement of endometrial thickness with a cut-off value of at least 15 mm indicating RPOC, was used most frequently. In the timing of follow-up there was great variation, with 55 and 107 different combinations in randomized controlled trials and observational studies, respectively. Assessment of treatment success was scheduled most often around 2 weeks after treatment. Diagnostic qualities of endometrial thickness of 15 mm or more was not adequately assessed. CONCLUSIONS: There is wide variation in the way RPOC are assessed, and the criteria used to define RPOC following induced abortion and early pregnancy loss; ultrasonographic measurement of endometrial thickness, with a cut-off of 15 mm or more 2 weeks after primary treatment is the most widely used diagnostic approach. A meta-analysis on diagnostic accuracy of endometrial thickness of 15 mm or more did not lead to solid results. These findings can be a first step to develop a workable standard of establishing RPOC after induced abortion or early pregnancy loss.

Retained Products of Conception Fed by the Inferior Mesenteric Artery: A Case Report.

Retained products of conception (RPOC) refer to the persistence of placental or fetal tissue in the uterus following delivery or miscarriage. RPOC may cause massive postpartum or post-abortion hemorrhage. Arterial embolization (AE) is an effective choice of management for postpartum hemorrhage including RPOC. We report a case of hemorrhagic RPOC, in which uterine artery embolization with transcervical resection did not achieve hemostasis, and laparotomy with uterine compression sutures was subsequently required. The RPOC was apparently fed by an aberrant branch derived from the inferior mesenteric artery (IMA). AE of IMA was not performed because of possible necrosis of the descending colon and rectum. A physician should be aware that AE is not an all-encompassing hemostatic technique for postpartum bleeding, such as with RPOC, and should keep alternatives in mind.

Placenta mórbidamente adherente asociada a malformaciones congénitas: reporte de caso / Morbidly adherent placenta associated with congenital malformations: a case report

INTRODUCCIÓN: Las alteraciones en la placentación son causa importante de morbilidad materna y neonatal y, en ocasiones, de mortalidad. La literatura científica menciona la posible asociación entre acretismo placentario y alteraciones en los parámetros bioquímicos para aneuploidía, sin descripciones de casos en que coincidan estos dos hallazgos. OBJETIVO: Este es un reporte de caso de una gestante con placenta percreta y producto con trisomía 13 REPORTE DE CASO: Gestante de 34 años, gesta 4 cesáreas 2, abortos 1, vivos 2, con embarazo de 20.4 semanas, sin antecedentes de importancia, con hallazgos en ecografía de iii nivel de alteraciones morfológicas en el sistema nervioso central, onfalocele, malformación cardiaca y deformidades en miembros. Con doppler de placenta que evidencia placenta mórbidamente adherida variedad percreta; hallazgos ecográficos confirmados con el estudio anatomopatológico. CONCLUSIONES: La trisomía 13 es una condición genética que debido a las múltiples malformaciones asociadas se considera incompatible con la vida, la placenta mórbidamente adherida se ha asociado con morbimortalidad neonatal y fetal, la no evidencia en la literatura de estas dos condiciones asociadas puede ser debido a la interrupción temprana de las gestaciones en las que se confirma el primer diagnóstico.

BACKGROUND: Alterations in placentation are an important cause of maternal and neonatal morbidity and, sometimes, deaths. The scientific literature mentions the possible association between placental accreta and alterations in the biochemical parameters for aneuploidy, without descriptions of cases in which these two findings coincide. OBJECTIVE: This is a case report of a pregnant woman with placenta percreta and trisomy 13, in which an ultrasound and pathological analysis were made. The use of keywords, in different databases, did not yield information that directly comply with these associations. CASE REPORT: A 34-year-old pregnant woman, G4C2A1V2 with a 20.4-week pregnancy, without significant medical records, with findings at III level ultrasound of morphological alterations of the central nervous system, omphalocele, cardiac malformation and limb deformities. Also, with placental Doppler that evidences morbidly adhered placenta variety percreta; ultrasound findings confirmed with the pathological study. CONCLUSION: The morbidly adhered placenta has been associated with neonatal and fetal mortality, in which some of the identified causes of fetal death are congenital anomalies. This way this case report allows for the first time to describe the association of placental accreta with aneuploidy, type trisomy 13, demonstrated by the morphological alterations of the pathological and karyotype study.

Natural history of pregnancy-related enhanced myometrial vascularity following miscarriage.

OBJECTIVES: Our primary aim was to report the incidence of enhanced myometrial vascularity (EMV) in consecutive women attending our early pregnancy assessment unit, following first-trimester miscarriage. We aimed further to evaluate the clinical presentation and complications associated with expectant and surgical management of EMV in these women. METHODS: This was a prospective cohort study conducted in a London teaching hospital between June 2015 and June 2018, including consecutive patients with an observation of EMV on transvaginal ultrasonography following first-trimester miscarriage. The diagnosis was made following the subjective identification of EMV using color Doppler ultrasonography and a peak systolic velocity (PSV) ≥ 20 cm/s within the collection of vessels. Women were followed up with repeat scans every 14 days. Management was expectant unless intervention was indicated because of excessive or prolonged bleeding, persistent presence of retained tissue in the endometrial cavity or patient choice. The final clinical outcome was recorded. Time to resolution of EMV was defined as the interval from detection of EMV until resolution. RESULTS: During the study period, there were 2627 first-trimester fetal losses in the department and, of these, 40 patients were diagnosed with EMV, hence the incidence of EMV following miscarriage was 1.52%. All cases were associated with ultrasound evidence of retained products of conception (RPOC) at presentation (mean dimensions, 22 × 20 × 20 mm). Thirty-one patients opted initially for expectant management, of which 18 had successful resolution without intervention, five were lost to follow-up and eight subsequently had surgical evacuation due to patient choice. No expectantly managed case required emergency intervention. Nine patients chose surgical evacuation as primary treatment. No significant correlation was seen between PSV within the EMV at presentation and blood loss at surgery. Median PSV was 47 (range, 20-148) cm/s. The estimated blood loss in all cases managed surgically ranged from 20-300 mL. Presence of RPOC was confirmed in all specimens that were sent for analysis following surgery. For cases successfully managed expectantly, the mean time to resolution was 48 (range, 21-84) days. In the nine cases managed surgically from the beginning, the mean time to resolution of EMV was 10.6 (range, 3-29) days. CONCLUSIONS: This study suggests that EMV is an uncommon finding following miscarriage and is associated with the presence of RPOC. Expectant management was a safe option in our cohort, with minimal bleeding, although it was associated with protracted time to resolution. In patients who opted for surgery, the maximum blood loss was 300 mL and no patient required blood transfusion or embolization. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Office hysteroscopy in removing retained products of conception - a highly successful approach with minimal complications.

Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4-60), patient pain estimation with VAS was 2.3 (0-8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and ß-hCG levels up to 80 U/L did not affect the outcome.Impact statementWhat is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC.What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data.What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal.

Conservative management of retained products of conception in the normal placental position: A retrospective observational study.

OBJECTIVES: To clarify the outcome of retained products of conception (RPOC) without placenta previa. STUDY DESIGN: This was a retrospective cohort study consisting of 59 patients who abdominally or vaginally gave birth to infants after 14 weeks without placenta previa and had RPOC between April 2006 and December 2018. Patients' background, characteristics, and outcomes were compared between those requiring and not-requiring intervention for RPOC. RESULTS: Of the 59 patients, pregnancies after assisted reproductive technology accounted for 18 (31%). The ultrasound-measured RPOC length was 4 cm (median) and 39 (66%) showed hypervascularity within RPOC. Interventions were required in 36 patients (61%), with all due to bleeding-related events. Multivariate regression analyses revealed that the interventions were significantly more likely in the following situations: younger than 35 years (aOR: 4.2, 95%CI: 1.1-18.5), RPOC length ≥4 cm (aOR: 8.6, 95%CI: 2.4-39.2), and RPOC hypervascularity (aOR: 4.6, 95%CI: 1.3-18.8). Methotrexate was administered to 8 patients, of whom 4 (50%) required further hemostatic interventions. CONCLUSION: In patients with RPOC without previa, 61 and 39% did and did not require hemostatic interventions, respectively. In the latter, a wait-and-see strategy resulted in the resolution of RPOC. Patients with larger RPOC (≥4-cm fragment length) and hypervascularity were significantly more likely to require hemostatic intervention.

Use of Postpartum Magnetic Resonance Imaging for Diagnosis and Classification of Retained Placenta Tissue.

OBJECTIVE: To study the potential application of magnetic resonance imaging (MRI) for classification of retained placental tissue (RPT) in the uterus postnatally. METHODS: Twenty-two patients with clinically or pathologically proven RPT were studied. RESULTS: The thickness ratio (D1/D2) of invaded (D1) to normal (D2) myometrium could be categorized into 3 groups (>0.6, 0.1-0.6, and <0.1) correlating with the 3 types of RPT: accreta vera (RPA), increta (RPI), and percreta (RPP) (r = -0.861, P < 0.01). After uterine arterial embolization, the RPT showed lower signal intensity than the myometrium without flow voids on T2-weighted images. Two cases of RPP showed gradual enhancement, except 1 case of infection and 2 cases that did not involve enhancement examinations, whereas 17 cases of RPA and RPI showed early enhancement. CONCLUSIONS: Magnetic resonance imaging can facilitate diagnosis of RPT severity. Dynamic contrast enhancement can indicate RPT activity and blood supply, thereby ensuring appropriate clinical decision making.

Operative hysteroscopy for retained products of conception: Efficacy and subsequent fertility.

Retained product of conception complicates nearly 1% of pregnancies and can lead to synechiae and compromise ulterior fertility. The aim of this study is to evaluate efficiency of operative hysteroscopy in management of retained products of conception (RPOC). Secondary objectives are assessments of intra-uterine adhesions rate and later fertility. This unicentric retrospective study includes women who undertook an operative hysteroscopy for retained products of conception between January 2012 and March 2014. Assessment of the efficiency of operative hysteroscopy is defined by a complete resection of retained products of conception confirmed by office hysteroscopy. One hundred fourteen women were included in the study. Efficiency of operative hysteroscopy for retained products of conception is 91% for women with a postoperative office hysteroscopy. The authors observed a 7.5% rate of postoperative intra-uterine adhesions. Fertility rate was 83% (30 women out of 36 with a desired pregnancy). Hysteroscopic resection of retained products of conception is an efficient procedure and seems to be a real alternative.