high risk conditions.rtu.intro
TRANSCRIPT
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High Risk Conditions: Bleeding Disorders of Pregnancy
1st Trimester• Abortion
• Ectopic
pregnancy
nd Trimester
• Hydatidiformmole
• !ncompetentcer"i#
3rd Trimester
PlacentaPrevia
AbruptionPlacenta
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• $olic AcidDe%ciency Anemia
• !ron de%ciency
Anemia• !soimm&ni'ation
• (estational HT)
–
Pre*eclampsia+Eclampsia
• Hyperemesisgra"idar&m
• Pica• Pse&docyesis
Multiplepregnancy
HELLP
Syndrome
CardiacDiseases
HIDiabetes
Mellitus
STD!sDIC
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Risk $actorsAge , &nder 1- o"er ./
0eight
)&tritional stat&s
(ra"ida and Parity
ocioeconomic stat&s
2B score
$amily history of genetic disorders
&bstance &se + !nfertility medication
Psychological 3ell*being
Predisposing chronic illness , diabetes4 heart conditions4renal4 etc5
Pregnancy related conditions , hyperemesis gra"idar&m4
P!H4 etc5
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High Risk Pregnancy
(oals of Care
Pro"ide 3ith optim&m carefor the mother and the fet&s
Assist the patient and herfamily to &nderstand and
cope 3ith the "ariations in aHigh Risk Pregnancy andcope 3ith her feelings
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• Co&"ade syndrome , dade#periences 3hat mom goesthro&gh , lihi6 *sympathy pain 7
psychosomatic condition
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THE CHED89E 2$
PRE)ATA9 CHEC*8P
;onthly , <=6 Pregnant to > 3eeks
<1st - months 6
E"ery 3eeks , from > 3eeks to
.? 3eeks <> , @ months 6
E"ery 3eek , from .? 3eeks ñli"ery
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SI"# P$SSI%LE CA&SE
3elling of face and %nger HT) of pregnancy4thromboplebitis <for
s3elling of legs6
HA <contin&o&s andse"ere6
HT) of pregnancy
Abdominal 7 chest pain Ectopic pregnancy4 &teriner&pt&re4 p&lmonary
embolismaginal bleeding Placenta problems
< placenta pre"ia4 abr&ptioof placenta4
omiting persistent !nfection <3+ fe"er 7 chills64
hyperemesis gra"idar&mis&al changes HT) pregnancy
Escape of "aginal &ids Premat&re r&pt&re ofmembrane
3elling of face4 %nger4
legs
HT) of pregnancy
S
H
A
S
DA#"E' SI"#S $( P'E"#A#C)
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• aginal Bleeding , it sho&ld bereported no matter ho3 slight4beca&se some serio&s bleedingbegins 3ith spotting
• Persistent omiting , once or# a day is not &ncommon
d&ring 1st trimester ho3e"erfre&ent episodes are notnormal5
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•
Chills and $e"er , may indicateintra&terine infection4 a serio&scomplication for both mother andfet&s
• &dden Escape of $l&id from theagina , this may indicate that themembranes may ha"e r&pt&red5
Altho&gh this may be one of the %rstsigns of labor4 mother and fet&s areno3 both threatened4 beca&se itincreases the risk of infection
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• Abdominal or Chest Pains , thissignals that something is abnormal5 !tco&ld be an ectopic pregnancy4 a
premat&re separation of the placentapreterm labor or something &nrelatedto pregnancy as appendicitis4 &lcer orpancreatitis5 Chest pain may indicate
a p&lmonary embol&s secondary tothrombophlebitis5
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• Pregnancy !nd&cedHypertension , increase BPd&ring pregnancy
• !ncrease or Decrease $etal;o"ement , this may indicatethat the fet&s is responding tothe need of o#ygen
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TERATOGENIC
MATERNAL INFECTIONS
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• 5 T2RCH: To#oplasmosis4 2ther4 R&bella4Cytomegalo "ir&s4 Herpes simples "ir&s5
T , to#oplasmosis , mom takes care of
cats5 $eces of cat go to ra3 "egetables ormeat
2 , others5 Hepa A or infectio&s heap ,oral+ fecal <hand 3ashing6
Hepa B4 H! , blood 7 body &ids 4yphilis R , r&bella , (erman measles ,
congenital heart disease <1st month6normal r&bella titer 1:1
F1:1 , less imm&nity to r&bella4 afterdeli"ery4 mom 3ill be gi"en r&bella"accine5 DonGt get pregnant for .months5 accine is terratogenic
C , cytomegalo "ir&s
H , her es sim le# "ir&s
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• T2RCH <Teratogenic6 !nfections , "ir&ses – CHARACTER!T!C: gro&p of infections
ca&sed by organisms that can cross the
placenta or ascend thro&gh birth canal andad"ersely aect fetal gro3th andde"elopment5
T2I2P9A;2! *proto'oan to#oplasmagondii
Eating ra3 foods or poorly cook or contact 3+feces of infected animals
+: myalgia4 malaise4 rashes4 splenomegaly4posterior cer"ical lypmphadenopathy
Diagnostic : serologic test s&ch as abin*$eldmandye test
T2I2P9A;2
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T2I2P9A;2!
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• To#oplasmosis , a proto'oaninfection4 is spread most
commonly thro&gh contact 3ithcat stool in soil or cat litter4 mayalso be contacted by eating&ndercooked meats5
• The 3oman 3ill e#periencealmost no symptoms of thedisease e#cept for fe3 days of
malaise and posterior cer"icallymphadenopathy5
•
0ith this an infant may be born3ith C) damage4
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'&%ELLA
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'&%ELLAD&ring 1st trimester <greatest risk6 4 .rd 7 nd 3k
<death fet&s64 nd trimester : permanent hearingimpairment5 9e&kemia in childhood has been noted7 die early in infancy5
Best pre"ention <not pregnant6 , li"e atten&ated"accine
Pregnant , tested 3ith imm&nity
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• R&bella <(erman ;easles6 , ca&sesonly mild systemic illness to motherb&t the eect on
• $et&s is de"astating 3hich incl&desdeafness4 mental and motor
retardation4 cataracts4 cardiacdefects <most fre&ently the PDA andP&lmonary tenosis64 retarded
intra&terine gro3th4 dental and facial
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CJT2;E(A92!R8
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CJT2;E(A92!R8
Belongs to herpes gro&p 7 ca&ses
both congenital 7 ac&ired infectionsreferred to as cytomegalic incl&siondisease
ir&s be transmitted by asymptomatic
3oman across the placenta orcer"ical ro&te d&ring deli"ery5 ir&scan be fo&nd in &rine4 sali"a4 cer"icalm&c&s4 semen 7 breast milk
Principal organ 7tiss&e aected:blood4 brain 7 li"er res<s tohemolysis leads to anemia 7
hyperbilir&binemia4 thrombocytopenia
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17
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17 Herpes imple# ir&s <(enital Herpes
!nfection6(enital irritation or itching4"aginal &rethraldischarge<copio&s4 fo&lsmelling64 enlarged tender
lymph nodes 7 dys&ria5Begins 3ith reddened pap&les3+c becomes itchy p&st&lar"esicles that may break 7
form painf&l 3et &lcers 3hichthen dry 7 de"elop cr&sts
*/K sponteneo&s abortion<1st trimester64 premat&re
birth <3ks64 s&r"i"ors has
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• yphilis , this can place thefet&s at risk for congenital
syphilis5 The ca&sati"espirochete4 TreponemaPallid&m4 can
• E#tensi"ely damage thefet&s after 1?th to 1>th
3eek of intra&terine life5 !fleft &ntreated beyond the1>th 3eek of gestation4deafness4 cogniti"eim airment osteochondritis
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Bleeding Disorders
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• Hemorrhage , rapid loss of morethan 1K of body 3eight in blood
3hich res< to inade&ate tiss&eperf&sion4 depri"e gl&cose 7 2in tiss&e 7 b&ild &p of 3asteprod&cts5
– Hypo"olemic shock , bleedingres<s in blood loss amo&nting to
15/ , li5
• Perinatal hemorrhage , d&ring
pregnancy4 labor 7 deli"ery
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– !ntrapart&m hemorrhage: d&ring labor3hich are placental abr&ption4 &teriner&pt&re4 &terine in"ersion4 abnormaladhesion of placenta4 C complication
– Post part&m ,blood loss more than/ml )D or 1 ml C : Early:
&terine atony 7 laceration <d&ring 1st
Lhrs6 3hile late post part&m :retained placental fragment 7s&bin"ol&ntion of &ter&s5
RE!E0
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RE!E0 :• D)A , carries genetic code
• Chromosomes , threadlike strands composed of
hereditary material , D)A• )ormal amo&nt of eMac&lated sperm . , / ml54 1 tsp
• 2"&m is capable of being fertili'ed 3ith in L , .?hrs after o"&lation
• perm is "iable 3ithin L> , - hrs4 *. days• Reprod&cti"e cells di"ides by the process of
meiosis <haploid6
• permatogenesis , mat&ration of sperm
• 2ogenesis , process * mat&ration of o"&m
• (ematogenesis , formation of haploid into diploid. = . N L? or diploid
•
Age of Reprod&cti"ity , 1/ , LLyo
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Estrogen OHormone of the 0oman,
•
Primary f&nction: de"elopment secondaryse#&al characteristic female5
• 2thers:
15 inhibit prod&ction of $H < mat&ration of
o"&m65 hypertrophy of myometri&m
.5 pinnbarkeit 7 $erning < billings method+cer"ical6
L5 de"elopment d&ctile str&ct&re of breast/5 increase osteoblast acti"ities of long bones
?5 increase in height in female
-5 ca&ses early clos&re of epiphysis of long
bones
Progestin O Hormone of the ;other
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Progestin Hormone of the ;other
• Primary f&nction: preparesendometri&m for implantation offertili'ed o"&m making it thick 7torto&s <t3isted6
• econdary $&nction: &terine
contractility <fa"ors pregnancy6
• 2thers:
15inhibit prod of 9H <hormone for
o"&lation6
5inhibit motility of (!T
.5 mammary gland de"elopment
• 9&teini'ing hormone <9H also kno3n
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• 9&teini'ing hormone <9H4 also kno3nas l&tropin and sometimes l&trophin6is a hormone prod&ced by
gonadotroph cells in the anteriorpit&itary gland5 !n females4 an ac&terise of 9H <Q9H s&rgeQ6 triggers
o"&lation and de"elopment of thecorp&s l&te&m
• H&man chorionic gonadotropininteracts o"ary and promotes themaintenance of the corp&s
l&te&md&ring the beginning of
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tages of $etal (ro3th and
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tages of $etal (ro3th andDe"elopment
• .*L days tra"el of 'ygote , mitoticcell di"ision begins
• Pre*embryonic tage
a5 Sygote* fertili'ed o"&m5 9ifespan of'ygote , from fertili'ation to months
b5 ;or&la , m&lberry*like ball 3ith 1? ,
/ cells4 L days free oating 7m<iplication
c5 Blastocyst , enlarging cells that
forms a ca"ity that later becomes
• L phases of ;enstr&al Cycle
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• L phases of ;enstr&al Cycle
15 Proliferati"e
5 ecretory
.5 !schemic
L5 ;enses
•
Parts of body responsible for mens: – hypothalam&s
– anterior pit&itary gland , master clock ofbody
– o"aries
– &ter&s
• !nitial phase , .rd day , decreased
estrogen
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• igns of implantation:
• 15 slight pain
• 5 slight "aginal spotting
• * if 3ith fertili'ation , corp&sl&te&m contin&es to f&nction 7
become so&rce of estrogen 7progesterone 3hile placenta is notde"eloped5
. processes of !mplantation
15 Apposition
5 Adhesion
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Abortions Termination of pregnancy at any
time before the fet&s has reachedthe age of "iability <1* 3eeksA2(6
2cc< pregnancy , 'ygotes that3ere aborted before pregnancy isdiagnosed or recogni'ed
Either: spontaneo&s , occ&rring nat&rally
ind&ced , arti%cial
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pontaneo&s Abortion
• Threatened ;iscarriage
•!ne"itable ;iscarriage
!mplantation Bleeding
Decid&al Bleeding
Ectopic Pregnancy
EA'L) P'E"#A#C)%LEEDI#"
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• Abortion* is the most commonbleeding disorder of early
pregnancy5 Abortion is thetermination of pregnancy before"iability4that is4 before 3eeks5
• Abort&s* a fet&s that is abortedbefore it is / gms in 3eight5
• Early abortion* termination ofpregnancy before 1? 3eeks5
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%lig*ted ovum+ a small macerated
fet&s4 sometimes there is no fet&s4s&rro&nded by a &id inside the sac5
Maceration* a dead fet&s&ndergoing necrosis5
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Ca&ses of abortion:
$ETA9 CA8E*
• The most common ca&se of earlyspontaneo&s abortion is abnormalde"elopment of the 'ygote4embryo4 and fet&s5
• This abnormalities areincompatible 3ith life and 3o&ld
ha"e res<ed to se"ere congenitalanomalies if pregnancy has notbeen aborted5
f b i
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Ca&ses of abortion:;ATER)A9 CA8E*
• These are congenital or ac&iredconditions of the mother anden"ironmental factors that had
ad"ersely aected the pregnancyo&tcome and led to abortion5
• &ch conditions incl&de D;4
incompetent cer"i#4 e#pos&re toradiation and infection5
Spontaneous AbortionT*reatened
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Spontaneous AbortionT*reatened
Etiology + Predisposing
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Etiology + Predisposing$actors
• $a<y germ plasm ** imperfect o"a or sperm4fa<y implantation4 genetic make*&p <chromosomaldisorders64 congenital abnormalities
• Decrease in the prod&ction of progesterone
• Dr&gs or radiation
• ;aternal ca&ses ** infections4 endocrine disorders4maln&trition4 hypertension
Assessment
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Assessment Types of Abortions
Threatened• igns and ymptoms – "aginal bleeding4 spotting
– ;ild cramps4 backache4 softening&ter&s
– Cer"i# remains C92ED• )o "aginal assessment as may pro"oke &terine acti"ity
• A pregnancy test is carried o&t and <raso&nd performed to assess
"iability• Hea"y or increased amo&nt of bleeding in an omino&s sign and may
precede ine"itable abortion
• Treatment and )&rsing Care –
Bed rest4 sedation
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!ne"itable Abortion
• igns and ymptoms – 9oss is certain
– Bleeding is more prof&se
– Painf&l &terine contractions
– Cer"i# D!9ATE
• Treatment and )&rsing Care – Assess all bleeding5 a"e all pads5
<;ay need to 3eigh the pads6 – 8se the bedpan to assess all prod&cts
e#pelled
–
Treated by e"ac&ation of the &ter&s
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The de"elopment of abortion is asfollo3s:
contin&ing
pregnancy
• complete
ine"itable abortion
abortion
incomplete
abortion
threatenedabortion
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Complete Abortion
• All prod&cts of conception aree#pelled
• )o treatment is needed4 b&t may doa D 7 C
l b i
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!ncomplete Abortion
• Parts of theprod&cts ofconception aree#pelled4 3ith
placenta andmembranesretained
• Treated 3ith a D 7C or s&ction
e"ac&ation
l b i
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!ncomplete Abortion
• (estational sac is incompletelye#pelled4 3ith &s&ally the placentaltiss&e retained
• tatic or slo3ly falling HC( le"els
• E"ac&ation of retained prod&cts ofconception from the &ter&s carriedo&t
• !f s&rgical e"ac&ation re&ired43oman sho&ld be screened forchlamydial infection
• Transf&sion ma be i"en if blood
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;issed Abortion
• The fet&s dies in*&tero and is note#pelled <no $HT6
• 8terine gro3th ceases
• Breast changes regress
• ;aceration occ&rs
• Treatment: – D 7 C
– Hysterotomy
Habit&al Abortion +
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Habit&al Abortion +Premat&re Cer"ical Dilation• Abortion occ&rs consec&ti"ely in
three or more pregnancies
• 8s&ally d&e to an !ncompetentCer"ical 2s4 that res<s from cer"icaltra&ma4 cer"ical lacerations4
repeated D 7 C4 or coni'ation5
• 2cc&rs most often abo&t 1>*3eeks gestation5
H bit l Ab ti
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Habit&al Abortion
•
Treatment –Cerclage proced&re ** p&rse*
string s&t&re placed aro&nd theinternal os to hold the cer"i# in anormal state:
• hirodkar 7 ;cDonald techni&e
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Electi"e
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Electi"eAbortions+Therape&tic
Abortions Electi"e Abortion is the intentional termination ofpregnancy before *L3eeks5
Therape&tic Abortion is the termination of the
pregnancy for medical reasons5 The termination of the pregnancy is done by
s&rgery , Dilatation and C&rettage <D7C6 or 3ithmedications called abortifacts
The n&rse sho&ld be a3are of the stateGsspeci%c reg&lations go"erning abortions5
Abortions ha"e many ethical iss&es5 The n&rsesho&ld kno3 beliefs concerning this iss&e5
$ETA9 92
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$ETA9 92• !f client spontaneo&s loses baby r it
is an intra&terine death and if theclient+family 3o&ld like to "ie3and+or "isit 3ith baby4 Pro"ide the
opport&nity in a pri"ate area• Allo3 the client to name the baby
• Take pict&res
• (i"e something for the client to takehome
• Clean the baby 3ith soft cloth or
cotton
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)&rsing Care
• Bedrest in a slight trendlenb&rgposition to decrease the press&re
on the ne3 s&t&res• Teach:
– Assess for leakage of &id4 bleeding
– Assess for contractions
– Assess fetal mo"ement and reportdecrease mo"ement <if old eno&gh6
– Assess temperat&re for ele"ations
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Deli"ery
• 0hen time for deli"ery there arese"eral options: – physician 3ill clip s&t&re and allo3
patient to go into labor on her o3n – ind&ce labor
– cesarean deli"ery
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Complication of Abortion
• Hemorrhage
• !nfection or septic abortion
• Disseminated intra"asc&larcoag&lation <D!C6 , if retained 3ithin a month
ey Concepts to
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ey Concepts toRememberUU
• !f a 3oman is Rh*4 Rho(am is gi"en3ithin - ho&rs
• Pro"ide emotional s&pport5 $eelingsof shock or disbelief are normal
• Enco&rage to talk abo&t theirfeelings5 !t begins the grief process
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• Abortion , termination of labor before age of "iability
P2)TA)E28 AA i i
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P2)TA)E28 AA miscarriage
• Ca&ses Chromosomal aberrations d&e to ad"anced
maternal age 7 Blighted o"&m and Plasma germ defect
– )at&res 3ay of e#pelling defecti"e babiesClassi%cations :
• Threatened
• pregnancy is Meopardi'ed by bleeding and cramping b&t the cer"i#is closed and can be sa"ed5
• !ne"itable * can )2T be pre"ented
• moderate bleeding4 cramping4 tiss&e protr&des from the cer"i# and
the cer"i# is open5 Types :
Complete * all prod&cts of conception are e#pelled5 ;gt : emotional s&pport!ncomplete * placenta and membranes retained5 ;gt : D7C
;issed abortion , $et&s die in &ter&s4 b&t it is not e#pelled
Habit&al abortion , . , ? abortions
!)D8CED