Preoperative dilatation of the cervix by single vaginal administration of 15-methyl-PGF2α-methyl ester

Two different vaginal suppositories have been developed suitable for one single treatment for preoperative dilatation of the cervix prior to vacuum aspiration in late first trimester abortion. The study included 60 patients equally distributed in one control group (Group I) where vacuum aspiration was performed without pretreatment; one group (Group II) where the patients obtained 2.0 mg 15-methyl-PGF_2α-methyl ester in a rapid releasing base six hours prior to operation and one group (Group III) where the prostaglandin dose was increased to 2.5 mg 15-methyl-PGF_2α-methyl ester and a more slow releasing base was used and the operation performed after 12 hours. The mean cervical dilatation at operation was in Group II 9 mm and in Group III 11 mm in comparison with 4.8 mm in the control group. The bleeding at the operation was also significantly reduced.     

Preoperative dilatation of the cervix by single vaginal administration of 15-methyl-PGF2alpha-methyl ester.

Two different vaginal suppositories have been developed suitable for one single treatment for preoperative dilatation of the cervix prior to vacuum aspiration in late first trimester abortion. The study included 60 patients equally distributed in one control group (Group I) where vacuum aspiration was performed without pretreatment; one group (Group II) where the patients obtained 2.0 mg 15-methyl-PGF2alpha-methyl ester in a rapid releasing base six hours prior to operation and one group (Group III) where the prostaglandin dose was increased to 2.5 mg 15-methyl-PGF2alpha-methyl ester and a more slow releasing base was used and the operation performed after 12 hours. The mean cervical dilatation at operation was in Group II 9 mm and in Group III 11 mm in comparison with 4.8 mm in the control group. The bleeding at the operation was also significantly reduced.     

Administration of 15-methyl-prostaglandin F2α as a pre-operative means of cervical dilatation

Pre-operative dilatation of the cervix prior to vacuum aspiration was accomplished in 67 volunteers by extra-amniotic or intra-muscular administration of 15(S)-15-methyl-PGF_2α (15-me-PGF_2α). Ninety-four per cent of the patients were in the 11th–13th week of gestation and 61% were nulliparae. A single extra-amniotic instillation (mean of 400 μg) or 3 intramuscular injections (300–800 μg per injection) of the compound induced a satisfactory outcome in terms of either abortion or sufficient dilatation of the cervix in 81% of the patients. In the remaining cases, the cervix was found at operation to be open for 7–9 mm which simplified the process of additional instrumental dilatation. In general the outcome of the trial turned the operation into an easy and safe procedure. Vacuum aspiration was performed in all cases after a mean time lag of 16 hours following the onset of the treatment. Extra-amniotic administration was associated with a low incidence of gastro-intestinal side-effects, but there was a transient and moderate degree of uterine pain reaction. The intramuscular route was technically more simple and caused less uterine pain but the high incidence of vomiting and diarrhoea constituted a clinical disadvantage. In late first trimester abortions, particularly cases where the uterus appears larger than expected, it is believed that dilatation of the cervix by PG prior to vacuum aspiration is a sound clinical indication. The method offers definite advantages that compensate for the price of some minor side-effects.     

Clinical experiences with a new gel for intracervical application of prostaglandin E2 before therapeutic abortion or induction of term labor

A new gel for intracervical application of prostaglandin E₂ (PGE₂) has been elaborated and evaluated. The main component of the gel is a cross-linked starch polymer to which prostaglandins can be added and preserved for long-term storage (> 12 months).In a double blind study, 20 patients requiring legal abortion in late first trimester were given gel containing 0.25 mg PGE₂ or gel without PGE₂. The gel was applied within the cervical canal. In all patients receiving PGE₂-gel, a rapid ripening of the cervix occurred which facilitated the subsequent dilatation and evacuation. In patients receiving gel without PGE₂ cervix did not ripen. In a subsequent open study, 30 patients were treated with PGE₂-gel before therapeutic abortion. The same degree of cervical ripening was registered as for the patients receiving PGE₂-gel in the double blind study.In 50 patients at term, intracervical application of 3 ml gel containing 0.50 mg PGE₂ induced labor in 27 cases, i.e. 54 per cent of the patients. In the remaining undelivered women, a prominent cervical ripening occurred within 24 hours. No side effects of the treatment were observed.We conclude the new PGE₂-gel to be a promising future alternative in the treatment of patients with an unfavorable cervix, prior to surgical evacuation of the uterus in late first trimester abortion, as well as before induction of labor at term.     

Facilitation of suction termination using extra-amniotic prostaglandins in gel

Extra-amniotic prostaglandin E₂ (PGE₂) suspended in a slow release gel (Tylose) was instilled in 35 patients prior to a planned surgical termination in an attempt to dilate the cervix, minimize cervical trauma, and reduce the possible risk of cervical incompetence and its sequelae. Dilatation occurred in all patients to a minimum of 8 mm and 74% aborted before surgical evacuation performed 6 to 24 hours after injection. No serious side effects occurred. Extra-amniotic PGE₂ in gel should be considered as a primary procedure when the cervix is obviously immature on examination. If the cervix is found to be tight and unyielding at surgical dilatation, the latter procedure should be discontinued and PGE₂ in gel injected.     

Late midtrimester medical pregnancy terminations: three different procedures with prostaglandin F2 alpha and laminaria tents

One hundred twenty eight women underwent midtrimester induced abortion with: 1) combined regimen of intramniotic prostaglandin (PG) F2a injection and intracervical laminaria tents (group A, 50 women), 2) intramniotic PGF2a injection only (group B, 51 women) and 3) laminaria tents followed by intracervical PGF2a tablets insertion (group C, 27 women). The mean induction-abortion time (+/- SE) was 24.9 +/- 1.7 hours for group A, 28.2 +/- 2.2 hours for group B (p greater than 0.05) and 42.1 +/- 3.4 hours for group C, significantly longer than goup A and B (p less than 0.001 and p less than 0.01 respectively). In 48 hours 98% of the patients of group A, 90% of group B (p less than 0.05) and 59% of group C (p less than 0.001) completed the abortion procedure. Parous women of group A and B presented similar induction - abortion time, while in nulliparous the use of laminaria shortened the abortion procedure significantly (p less than 0.05). The complications rate was low. In conclusion, the intracervical PGF2a insertion is a simple but very slow abortion procedure with high failure rates. The intramniotic PGF2a injection is a successful method for late midtrimester medical pregnancy termination and the concurrent use of laminaria tents shortens the abortion procedure, particularly in nulliparous, reduces the number of prostaglandins' reinjections and increases the incidence of successful abortion within 48 hours.     

Cervical dilatation with 16, 16 dimethyl PGE2 p-benzaldehyde semicarbazone ester prior to vacuum aspiration in first trimester nulliparae

The efficacy of 16, 16 dimethyl PGE₂ p-benzaldehyde semicarbazone ester for cervical dilatation prior to evacuation of the uterus in 180 first trimester nulliparae has been studied. The drug was injected into the muscle of the cervix 3 hours before vacuum aspiration. In 143 patients (80%) the cervix had dilated adequately to enable evacuation of the uterus without mechanical dilatation. In the remaining 37 patients (20%) the cervix had dilated to 6 or 7 mm and additional mechanical dilatation could be performed easily in most of these patients. Side effects consisted of vomiting (11%), diarrhoea (7%), transient pyrexia and shivering (7%). There were no complications in any of the patients and no perforation of the uterus or damage to the cervix resulted during evacuation.     

Prostaglandin release from human cervical tissue in the first trimester of pregnancy after preoperative dilatation with hygroscopic tents

Preoperative dilatation with hygroscopic tents before first trimester abortion by vacuum aspiration is widely accepted and reduces the risk of early and late complications. A softening effect and a reduced compliance to mechanical dilatation occurs in addition to pure mechanical dilatation of the cervix. If this softening is an effect of local prostaglandin release, however, is unknown. Prostaglandin (PG) release in vitro from cervical biopsies following dilatation in vivo by a synthetic hygroscopic tent (Dilapan) for periods of 4 h and 18 h was compared with that of biopsies from untreated women. No difference was observed between the release of PGE₂, PGF_2α, or 6-keto-PGF_1α. No significant difference was found in the tissue water content between treated and untreated women (83.8% versus 83.2%). Prostaglandins were also extracted from an alternative cervical dilator, Lamicel (a polyvinyl sponge impregnated with magnesium sulfate), and compared with the corresponding values from women pretreated with the cyclooxygenase inhibitor indomethacin before application of the tent. Significantly higher concentrations of PGE₂ and PGF_2α but not of 6-keto-PGF_1α were found in women who had not been indomethacin-treated compared with indomethacin-treated women. Slices of the cervix from non-pregnant women operated upon for benign conditions were divided into an outer stromal layer and an inner layer, including the mucosa, and the PG-release in vitro was measured. The inner layer of the cervix showed a significantly higher release of PGE₂ and PGF_2α compared with the outer layer. Lamicel treatment before first trimester abortion results in a significant dilatation of the cervix and a reduced complaince to mechanical dilatation, and this study supports the hypothesis that this effect is mediated via a local PG-release from the cervix. It seems reasonable to believe that Dilapan treatment too has the capacity to induce PG-release from the cervix, but this could not be demonstrated in this study, probably because needle biopsies taken mainly from the outer cervical layers were analyzed.     

Facilitation of suction termination using extra-amniotic prostaglandins in gel

Extra-amniotic prostaglandin E2 (PGE2) suspended in a slow release gel (Tylose) was instilled in 35 patients prior to a planned surgical termination in an attempt to dilate the cervix, minimize cervical trauma, and reduce the possible risk of cervical trauma, and reduce the possible risk of cervical incompetence and its sequelae. Dilatation occurred in all patients to a minimum of 8 mm and 74% aborted before surgical evacuation performed 6 to 24 hours after injection. No serious side effects occurred. Extra-amniotic PGE2 in gel should be considered as a primary procedure when the cervix is obviously immature on examination. If the cervix is found to be tight and unyielding at surgical dilatation, the latter procedure should be dicontinued and PGE2 in gel injected.     

Cervical dilatation with prostaglandin analogues prior to vaginal termination of first trimester pregnancy in nulliparous patients

Dilatation of the cervix with prostaglandin analogues prior to vaginal termination of pregnancy was attempted in 125 nulliparous women in the first trimester of pregnancy. The patients were divided into five groups (25 in each group) and given a single extra-amniotic dose of one of the following prostaglandin analogues 14–16 hours prior to the evacuation of the uterus by vacuum aspiration. (Group A) 15 (S) 15 methyl PGE₂ (free acid); (Group B) 15 (S) 15 methyl PGE₂ methyl ester; (Group C) 15 (S) 15 methyl PGF_2α (free acid); (Group D) 15 (S) 15 methyl PGF_2α methyl ester and(Group E) a mixture of 15 (S) 15 methyl PGE₂ methyl ester and 15 (S) 15 methyl PGF_2α methyl ester. Evacuation of the uterus without mechanical dilatation of the cervix was possible in 111 (90%) of the patients. In an additional 10 patients (8%) there was some degree of cervical dilatation and further mechanical dilatation could be performed easily. With the combination of 15 (S) 15 methyl PGE₂ methyl ester and 15 (S) 15 methyl PGF_2α methyl ester the incidence of gastrointestinal side effects and pyrexia were considerably reduced.     

Effect of 15(S)15-methyl-PGF2α-methyl ester vaginal suppositories on circulating hormone levels in early pregnancy

Intravaginal administration of 15-methyl-PGF_2α-methyl ester in the form of suppositories terminated pregnancy in 70 percent of the cases whose last menstrual periods ranged from 35 to 56 days. The use of these suppositories in 49 patients, between 57 to 80 days of gestation, dilated the cervix by 10 mm or more, in one hundred percent of the cases. A decrease in circulating levels of estradiol-17β and progesterone was observed following 15-methyl-PGF_2α administration. The mean estradiol-17β levels declined by about 55.9 percent at 9 hours whereas, the corresponding fall in progesterone was 32.7 percent. This was indicative of a direct action of 15-methyl-PGF_2α on the corpus luteum. The vaginal use of 15-methyl-PGF_2α-methyl ester suppositories thus appears to be a promising method for the termination of early pregnancy and for pre-operative cervical dilatation. The termination of early pregnancy appears to be partly due to the luteolytic effect of 15-methyl-PGF_2α besides stimulating uterine contractions.     

Midtrimester abortion induced by serial intravaginal administration of prostaglandin E2 suppositories in conjunction with a contraceptive diaphragm

Midtrimester abortion was successfully induced in 68 of 69 patients with serial intravaginal administration of prostaglandin E₂ suppositories behind a contraceptive diaphragm. The mean abortion time for the successful inductions was 13.07 hours; multiparous patients aborted somewhat faster, mean 12.72 hours, as compared to nulliparous patients, mean 14.22 hours. In 36 patients the PGE₂ suppositories were placed behind an intact diaphragm and the mean abortion time was 14.89 hours. In 33 patients the PGE₂ suppositories were placed behind a diaphragm modified by having an opening incised in the center, the mean time in these patients was 11.96 hours. Of the 68 successful abortions 59% of the patients aborted in 12 hours or less and 88% aborted within 24 hours. The most frequently encountered side effect was temperature elevation of 2° F or higher which occurred in 68% of the patients. Temperatures returned to normal levels within 4 to 6 hours after the last administration of PGE₂. Gastrointestinal side effects occurred in 45% of patients, but these side effects were well tolerated and did not require termination of drug administration in any of the patients. Intravaginal administration of PGE₂ suppositories is a very effective abortifacient technique during the midtrimester, however the use of PGE₂ in conjunction with a diaphrgam did not appreciabley improve the technique although the amount of drug administered and the incidence of side effects was somewhat lower than when the PGE₂ suppositories are used alone. If a diaphragm is to be used, a modified diaphragm is indicated since it simplifies the clinical management of the abortion, eases administration of the suppositories and permits a more accurate estimation of cervical changes, vaginal bleeding and abortion.     

Cervical dilatation with prostaglandin analogues prior to vaginal termination of first trimester pregnancy in nulliparous patients.

Dilatation of the cervix with prostaglandin analogues prior to vaginal termination of pregnancy was attempted in 125 nulliparous women in the first trimester of pregnancy. The patients were divided into five groups (25 in each group) and given a single extra-amniotic dose of one of the following prostaglandin analogues 14-16 hours prior to the evacuation of the uterus by vacuum aspiration. (Group A) 15 (S) 15 methyl PGE2 (free acid); (Group B) 15 (S) 15 methyl PGE2 methyl ester; (Group C) 15 (S) 15 methyl PGF2alpha (free acid); (Group D) 15 (S) 15 methyl PGF2alpha methyl ester and(Group E) a mixture of 15 (S) 15 methyl PGE2methyl ester and 15 (S) 15 methyl PGF2alpha methyl ester. Evacuation of the uterus without mechanical dilatation of the cervix was possible in 111 (90%) of the patients. In an additional 10 patients (8%) there was some degree of cervical dilatation and further mechanical dilatation could be performed easily. With the combination of 15 (S) 15 methyl PGE2 methyl ester and 15 (S) 15 methyl PGF2alpha methyl ester the incidence of gastrointestinal side effects and pyrexia were considerably reduced.     

Prostaglandin E2 induced abortion with vaginal suppositories in a contraceptive diaphragm

PGE2 (prostaglandin E2), 20 mgm vaginal suppositories were administered to 2 groups of women seeking termination of pregnancy. 1 group had the suppository inserted inside a contraceptive diaphragm. Statistical comparisons were carried out for instillation to abortion time, side effects, and intrauterine pressure parameters. The usage of the diaphragm significantly reduced side effects, and resulted in an instillation to abortion time of 12.8 + or - 2.3 hours with no failures. The quantitative analysis of the uterine pressure recordings revealed activity significantly different than that seen with intraamniotic or extraovular PGF2alpha. The development of uterine activity simulates that of normal labor in that elevation of resting pressure does not occur and maximum active pressure evolves slowly.     

The effects of the prostaglandin E analogue Misoprostol and follicle-stimulating hormone on cervical penetrability in ewes during the peri-ovulatory period

Two experiments in parous Welsh Mountain ewes determined the pattern of natural cervical relaxation over the peri-ovulatory period and investigated FSH and Misoprostol as cervical relaxants to facilitate transcervical passage of an insemination pipette into the uterine cavity. Following synchronisation of oestrus using progestagen sponges and PMSG (500 IU) the depth of cervical penetration was determined using a modified cattle insemination pipette as a measuring device. Penetration of the cervix was least at the time of sponge removal and increased to a maximum at 72 h after sponge removal and then declined. Intra-cervical administrations of either ovine FSH (Ovagen; 2mg) or Misoprostol (1mg; a Prostaglandin E(1) analogue) facilitated cervical penetration. Ovagen given 24h after sponge removal allowed transcervical intrauterine penetration in 100% of ewes at 54 and 60 h after sponge removal while Misoprostol given 48 h after sponge removal allowed trans-cervical penetration in 100% of ewes at 54 h. A combination of Ovagen and Misoprostol was as effective but not more so than Ovagen or Misoprostol alone. These results show that there is natural relaxation of the cervix at oestrus and that maximum relaxation occurs 72 h after sponge removal, which is too late for the correct timing of insemination. The intra-cervical administration of FSH or Misoprostol enhanced relaxation of the cervix and both were able to relax the cervix to allow intrauterine penetration 54 h after sponge removal, the optimum time for insemination. The results also show that FSH is biologically active after intracervical, topical application.     

Plasma levels of 9-deoxo-16,15-dimethyl-9-methylene-PGE2 in connection with its development as an abortifacient

Gaschromatographic-mass spectrometric quantitation of 9-deoxo-16,16-dimethyl-9-methylene-PGE₂ in plasma samples obtained during constant intravenous infusion of the drug revealed that a plasma level of about 20 ng/ml was associated with high enough uterine contractility for induction of second trimester abortions. This level was therefore aimed for during the development of formulations and dose schedules for interruption of pregnancy with this drug. For the first time it was possible to induce second trimester abortions through oral administration of a prostaglandin analog, although the plasma levels were low giving a moderate success rate (about 50%) within 25 hours. Rectal administration of 20 mg of the drug at 6 hours intervals resulted in high enough plasma levels for second trimester abortions. Highly efficient dose schedules for interruption of early first trimester (“menses induction”) and second trimester pregnancies through vaginal administration were developed. The frequency of side effects in the early first trimester were so low that “home treatment” was possible. Formulations suitable for 3, 6 or 12 hours preoperative dilatation of the cervix were also developed.     

Use of prostaglandin E2 to ripen the cervix of the mare prior to induction of parturition

Eleven light-breed pregnant mares (335 to 347 d gestaton) were used to evaluate the use of prostaglandin E2 as a cervical ripening agent prior to induction of parturition during the months of April and May. Six hours prior to induction, each mare's cervix was examined per vagina for softness and dilation. Each mare was then assigned to 1 of 2 treatment groups: Group PGE mares (n = 7) received 2.0 to 2.5 mg prostaglandin E2 deposited intracervically; Group SAL mares (n = 4) received 0.5 mL of sterile NaCl deposited intracervically. Six hours later, the mares were readied for parturition by wrapping the tail, scrubbing and rinsing the perineum and udder, and examining the cervix as previously described. Each mare was then administered 15 U, i.v. oxytocin at 15-min intervals until the chorioallantois ruptured. Intervals from initial oxytocin injection until rupture of the chorioallantois, from initial oxytocin injection until delivery of the foal, from delivery of the foal until the foal stood unassisted, and from delivery of the foal until the foal suckled were recorded. Mean cervical dilation immediately prior to induction of parturition tended to be greater in Group PGE mares (3.9 +/- 1.7 cm) than in Group SAL mares (1.9 +/- 1.9 cm; P = 0.10). Mean change in cervical dilation over the 6-h period prior to induction (3.4 +/- 1.9 cm vs 1.5 +/- 2.1 cm), mean number of injections of oxytocin required until the chorioallantois ruptured (1.9 +/- 0.7 vs 2.5 +/- 1.0), and mean intervals from initial injection of oxytocin to rupture of the chorioallantois (20 +/- 10 min vs 28 +/- 19 min) and delivery of the foal (28 +/- 7 min vs 34 +/- 22 min) were not different between Group PGE and SAL mares, respectively (P > 0.10). The proportion of foals that stood within 1 h of birth also did not differ between Group PGE foals (6/7; 86%) and Group SAL foals (3/4; 75%; Chi-square = 0.17; P > 0.10). The proportion of foals that nursed within 2 h of birth was higher in Group PGE foals (6/7; 86%) than in Group SAL foals (1/4; 25%; Chi-square = 4.02; P < 0.05). Premature separation requiring manual rupture of the chorioallantois at the vulvar labia occurred in 1 Group PGE mare (cervical dilation of 1.5 cm at time of induction) and 1 Group SAL mare (cervix closed and firm at time of induction). Foals born from the 2 mares with premature placental separation had the longest intervals from initial oxytocin injection to delivery, delivery to ability to stand unassisted, and delivery to suckling within their respective treatment groups. In summary, it appears that cervical ripening prior to induction of parturition favors shorter deliveries and foal vigor. Intracervical administration of prostaglandin E2 may prove useful for ripening the cervix of the mare prior to induction of parturition. Further studies are indicated to determine optimal dosage and method of administration of prostaglandin E2.     

Induction of therapeutic abortion using either extra-amniotic prostaglandin F-2-alpha or hypertonic saline followed by oxytocin

160 women with uteri at 10-20 weeks gestation were treated with either PG(prostaglandin)F2alpha or saline solution followed by oxytocin to effect an abortion. 80 women were in each treatment group. The distribution of the patients according to age, parity, and gestation duration is tabulated. PGF2alpha was administered extraovularly in a concentration of .1 mg/ml with .7 mg being injected in the operating theater and nurses administering the rest based on response to previous injections. Administration continued for up to 30 hours. Saline was given in a volume in ml dependent on the duration of pregnancy multiplied by a factor of 10. Subcutaneous injections of oxytocin were given on subsequent days to speed the abortion. 85% of the PG patients successfully aborted without surgical dilatation of the cervix. The average dosage of PG required was 7.5 mg in 11 instillations. Side effects and complications in the PG group were minimal. 1 instillation of saline followed by 2 days of oxytocin were required to effect a 79% abortion rate in the saline group. Although the number of patients requiring surgical dilatation was the same for both groups, the procedure was much less time-consuming for the PG group. The complication rate was 26% for the saline group as compared to 14% for the PG group. The PG group required a shorter hospital stay.     

Midtrimester abortion induced by serial intravaginal administration of prostaglandin E2 suppositories in conjunction with a contraceptive diaphragm.

Midtrimester abortion was successfully induced in 68 of 69 patients with serial intravaginal administration of prostaglandin E2 suppositories behind a contraceptive diaphragm. The mean abortion time for the successful inductions was 13.07 hours; multiparous patients aborted somewhat faster, mean 12.72 hours, as compared to nulliparous patients, mean 14.22 hours. In 36 patients the PGE2 suppositories were placed behind an intact diaphragm and the mean abortion time was 14.89 hours. In 33 patients the PGE2 suppositories were placed behind a diaphragm modified by having an opening incised in the center, the mean time in these patients was 11.96 hours. Of the 68 successful abortions 59% of the patients aborted in 12 hours or less and 88% aborted within 24 hours. The most frequently encountered side effect was temperature elevation of 2 degrees F or higher which occurred in 68% of the patients. Temperatures returned to normal levels within 4 to 6 hours after the last adminstration of PGE2. Gastrointestinal side effects occurred in 45% of patients, but these side effects were well tolerated and did not require termination of drug administration in any of the patients. Intravaginal administration of PGE2 suppositories is a very effective abortifacient technque during the midtrimester, however the use of PGE2 in conjunction with a diaphragm did not appreciabley improve the technique although the amount of drug administered and the incidence of side effects was somewhat lower than when the PGE2 suppositories are used alone. If a diaphragm is to be used, a modified diaphragm is indicated since it simplifies the clinical management of the abortion, eases administration of the suppositories and permits a more accurate estimation of cervical changes, vaginal bleeding and abortion.     

Controlled trial of induction of labor by vaginal suppositories containing prostaglandin E2

A group of 84 women at 39 – 43 weeks of pregnancy were randomly allocated to a blind trial of induction of labor with vaginal suppositories containing inert material or either 0.2 mg or 0.4 mg of prostaglandin E₂. The suppositories were self-administered every two hours during waking hours on two successive days until labor started or 15 had been used. Side-effects were absent. Labor was established within 48 hr of insertion of the first suppository in 9.3% of control patients, 65.4% of those treated with 0.2 mg PGE₂ and 85.7% of those treated with 0.4 mg PGE₂. The mean Apgar scores in the three groups were the same. The mean total dose of PGE₂ were 2.0 mg (0.2 mg group) and 2.3 mg (0.4 mg group). It is concluded that vaginal PGE₂ is an effective and acceptable method of inducing labor at term.