Incompetent Cervix

HI hun. Having myself had the nightmare of IC at 24wks, I totally understand how stressed out you must be feeling :hugs:

Firstly, your cervix length was still quite good, and within normal ranges. It shouldn't be soft and thinning at this stage, but bear in mind that when my cervical stitch was placed at 12wks, my cervix was floppy and had zero tone - this is definitely not normal at 12wks. Despite this, I still went to 38wks with 16Ibs of baby on board. My cervix did funnel at 25wks, but the stitch prevented it from opening further.

I'm guessing that the concern with you, is less about you having IC, and more that you are at risk of preterm labour - the two are very different things. Your cervix could be thinning because your body is putting you into early labour - tho I don't know this for certain, and it appears neither do your doctors. At this stage they are watching and waiting - and the strict bed rest is for a reason. it really does work hun - that and drinking lots of water.

Some women are like you and show early signs of labour which never amounts to anything. The cramps you describe could just be BH and irritable uterus. It is always worth having them checked out tho to make sure they're not having an effect on your cervix. I had constant BH, and occasionally painful cramps in my lower abdomen - they never came to anything.

At this stage I'd say don't panic - but be aware, and take precautions. It is possible for some women to be in full blown labour and still continue with their pregnancy. Keep an open mind and take good care of yourself. Good luck x :hugs:
 
Thanks.

I did end up going into the ER here in town; what a joke. So I gave them my history, and then, because I was supposed to be on bedrest, they did get me in quickly... but only so I could lay down. So I wait a good 40 mins or so, and finally the Dr comes in. He goes right for the speculum, and I stop him and explain that he can't do a speculum exam on me, and that really I need an ultrasound. I tried explaining quickly why I wouldn't submit to a speculum exam, and he just shut down completely, said you are limiting my care, and was just about to walk out the door, when I asked if he could at least do a urine dip and blood test. He said fine, he'll call the lab, and that was it!!

Seriously?!?!? Now I know for a fact that this Dr doesn't even handle pregnant women in his clinic. As soon as a woman gets pregnant she is outsourced to another clinic. So why on earth would I let this arrogant snot, who won't deal with pregnant women in the first place, stick a speculum up there when we have no clue how short my cervix is, or if I've lost my plug or what...

So my husband and I waited another half hour or so, and he finally went to ask if the lab was coming, and the nurses asked my husband if the lab had even been called!! Ummm, how should we know. So then he said, well are you guys going to give her a cup to pee in. And they look all confused and ask if I even need to pee..... Ummm yeah, I'm asking for the hell of it!! So I do the urine test, and no one is talking to us, we have no idea if we need to wait there or not. So I decide to call the hospital an hour south of us where my OBGYN works out of (she is on holiday now), to see what they suggested I do. Right away the girl couldn't believe that at 22+2, I wasn't admitted to the maternity ward and my GP called. She said that is standard protocol for anyone over 20 weeks. So then she asked if I had even had a urine test or blood test yet, so I told her I had, but was still waiting on the results. She asked if I could get transferred to their hospital, but that requires talking to the Dr again, and he wan't coming back. So in anticipation of driving down there ourselves, I waited in the ER while my hubby gassed up our Jeep. 30 mins later, he's back, but still no test results. So hubby asks about the urine test; yep it shows she has signs of infection. So we're waiting on the blood test. We wait another 15 minutes. Hubby asks if blood test is in.... yes it is but now we need to wait for the Dr to come back in. We wait 20 more minutes.... then we just walked out.

Drive an hour south. I present at their ER, they immediately buzz me up to maternity where I am put in their labour room. Right away she does a urine test, checks the discharge on my underwear, tries a dip for amniotic fluid with that discharge, puts me in the bed with the fetal monitors on. She tested for movement as well as contractions. Lots of fetal movement, no contractions or irritability. She calls in the OB on call and explains the situation. While waiting for OB to come in, she explains to me that although my urine dip came back as positive for white blood cells, signalling infection, it was obviously VERY minimal as the dip had barely changed colour. She did hook me up to an IV for fluid. OB came in; she couldn't do much... she couldn't use the ultrasound, so that wasn't done. She also declined to try and check my cervix manually as she said if she did get a bad measurement, there would be no way to do a scan to get a more accurate read, and it would just cause me more undue stress. She did want to do a speculum just to see if they could get a swab for amniotic fluid, but I can't do them.... So she said fine, did a vag swab without the speculum, and said it didn't appear to be much discharge at all at that point.

So she said since I wasn't showing contractions or irritability in the uterus, that was a good sign. The swab on the discharge in my underwear was inconclusive, but since I don't get gushes or trickling etc, they think its doubtful I have a leak in the amniotic sac. She can't say how my cervix is holding up or if it was my mucous plug coming out. All she could do was determine that the baby is good for now, and if I have an infection, it isn't bad and can wait to be treated until the swab and urine culture come back, hopefully tomorrow. She did give me a prescription for an antibiotic to fill if the discharge got extrememly bad. As for the pain in my lower abdomen, at this time she is just chalking it up to the muscles down there moving more and streching the cerclage. She figures the discharge I described is an increase of hormones coupled with irritation after last Wednesdays exam.

So I am home. I have an appt with my GP tomorrow afternoon. I will see if he can book an emergent scan for my cervix.

So far, the discharge seems to have backed off. I still get a bit, and its still yellowish, but not as much as before. I still have that abdominal pain only sporadically. I still have a bit of cervical pain, but only sporadically, but the Drs tell me get sporadic sharp pains there are normal due to the normal ligaments streching on top of the stiches... I'm back on bedrest, and have felt the baby move, although not much today. That concerns me a bit, as this is kid of what Greg did. He never moved lots to begin with, unlike this one, but as his birth drew closer he seemed to move less. So it does worry me a bit.

I'm suffering from nausea, and have lost my appetite, and have had loose stools on and off for days. Once again, don't know if these are warning signs of early labour or a result of my starting the take the prometrium suppository again... thus causing a rise in my hormone levels. I guess I won't know til I get a scan; hopefully tomorrow.

Bascially I hope I can hold on for 2.5 more weeks. That will get me to Greg's gestation. I haven't had any pink spotting yet, knock on wood, and I have no back pain or pelvic pressure. So another week and a half could be doable... I think. Then if I get that extra I will be golden.
 
Oh what a nightmare for you, fingers crossed for you that you can hold on for at least 2.5 weeks
 
Hi ladies,

Glad I found this thread. I would like to introduce myself.

I conceived on New Years and was having a really easy pregnancy (first pregnancy). No nausea, no pain, no spotting - basically no indication that things weren't going smoothly. Then, at 24w3d, after a wonderfully lazy day lying around doing nothing, I went to the loo and something didn't feel right. Next thing i knew this big blue balloon (turned out to be my amniotic sac) just bulged right out (I mean like RIGHT out - i could see it easily) and then burst - fluid everywhere! I was in a total panic. DH phoned the maternity ward and we quickly drove there (thankfully the hospital is only 3 min away). They put me in a labour room and tried to calm me down while we waiting for my obgyn to show up. He arrived about 10 min later (it was a Saturday so he had to come in from home) and when i explained what had happened he said it sounds like a classic Incompetent Cervix. He took me up to his rooms to scan me (i was still gushing fluid) and although the scan showed that baby was still fine there was no fluid left at all and he didn't look hopeful. Back down to maternity where they kindly put me in a private room and gave me a steroid injection. Then i was on bed rest (only allowed up for hte loo) through the night and they monitored my bp and temp every 4 hours to check for infection. Baby was still kicking nicely. Next morning still no sign of contractions or infection so i was getting hopeful - doctor said if baby stayed in for 48 hours (time for both steroid shots to take effect) then chances of survival go up to 50%.

Unfortunately, at 13:45 i went to the loo again and when i wiped there was a lot of blood. i called the nurse and she said now i'm not allowed out the bed for anything, not even the loo. 10 min later contractions started - 4 min apart. At 17:45 Jarrod was born weighing 625g and measuring 34cm. He came before i had a chance to get the second steroid injection and his lungs just weren't mature enough to inflate/absorb oxygen yet. He died in my arms shortly after birth.

Obgyn says that next time i will get a McDonald stitch put in at about 14 weeks and that should prevent this happening again. He is fairly confident that things will go better next time. He'll monitor me closely for cervical changes and infection etc but seems to think all will go well.

We have decided to wait until January 2011 to try again as we are still dealing with losing Jarrod.

It's taken me about 3 hours to read all 29 pages of this thread and i'm really glad i did. I will definitely be posting on this thread more - and especially next year - as I am so nervous that this happens again. I'm sure the stitch will hold - especially if it held lizzy's twins! - but one can't help but worry.

So anyway, just wanted to introduce myself in the meantime.
 
Hi ladies,

Glad I found this thread. I would like to introduce myself.

I conceived on New Years and was having a really easy pregnancy (first pregnancy). No nausea, no pain, no spotting - basically no indication that things weren't going smoothly. Then, at 24w3d, after a wonderfully lazy day lying around doing nothing, I went to the loo and something didn't feel right. Next thing i knew this big blue balloon (turned out to be my amniotic sac) just bulged right out (I mean like RIGHT out - i could see it easily) and then burst - fluid everywhere! I was in a total panic. DH phoned the maternity ward and we quickly drove there (thankfully the hospital is only 3 min away). They put me in a labour room and tried to calm me down while we waiting for my obgyn to show up. He arrived about 10 min later (it was a Saturday so he had to come in from home) and when i explained what had happened he said it sounds like a classic Incompetent Cervix. He took me up to his rooms to scan me (i was still gushing fluid) and although the scan showed that baby was still fine there was no fluid left at all and he didn't look hopeful. Back down to maternity where they kindly put me in a private room and gave me a steroid injection. Then i was on bed rest (only allowed up for hte loo) through the night and they monitored my bp and temp every 4 hours to check for infection. Baby was still kicking nicely. Next morning still no sign of contractions or infection so i was getting hopeful - doctor said if baby stayed in for 48 hours (time for both steroid shots to take effect) then chances of survival go up to 50%.

Unfortunately, at 13:45 i went to the loo again and when i wiped there was a lot of blood. i called the nurse and she said now i'm not allowed out the bed for anything, not even the loo. 10 min later contractions started - 4 min apart. At 17:45 Jarrod was born weighing 625g and measuring 34cm. He came before i had a chance to get the second steroid injection and his lungs just weren't mature enough to inflate/absorb oxygen yet. He died in my arms shortly after birth.

Obgyn says that next time i will get a McDonald stitch put in at about 14 weeks and that should prevent this happening again. He is fairly confident that things will go better next time. He'll monitor me closely for cervical changes and infection etc but seems to think all will go well.

We have decided to wait until January 2011 to try again as we are still dealing with losing Jarrod.

It's taken me about 3 hours to read all 29 pages of this thread and i'm really glad i did. I will definitely be posting on this thread more - and especially next year - as I am so nervous that this happens again. I'm sure the stitch will hold - especially if it held lizzy's twins! - but one can't help but worry.

So anyway, just wanted to introduce myself in the meantime.

Hey sweetie,

I am so sorry that you lost little Jarrod, life can be so very cruel.

Your journey in some ways sounds quite similar to mine except I had the majority of my cervix removed. As they conserved a small portion of it, they didn't think it was necessary to put a stitch in pre pregnancy. I was considered high risk (because of my lack of cervix) and they measured my cervical length every 2 weeks. My cervical length didn't change but at about 18 weeks I finally got to see a specialist in London who deals with cerclages.

He examined me and decided that it was best to put a vaginal stitch in (I think Macdonald, at that time I didn't know the types so didn't question) so I was taken in a week later for the operation.

I had a follow up appt 4 weeks later, he examined me and said that everything was perfect and if he was a betting man, he would put money on me going to 40 weeks. We were absolutely elated, I bought lots of maternitywear, we starting looking at nursery furniture.

4 days later our world came crashing down!! I started to leak, it was only a tiny bit, so I just thought it was a bit of wee. Later on that evening it happened again but a little bit worse and it just didn't feel right. In my head I was convinced everything was fine but I was shaking, so deepdown I knew something wasn't quite right! We went straight to the maternity unit and my ob/gynae confirmed my worse fears it was my amniotic fluid. He said that if it continued to trickle, then we may be in with a chance, but it didn't look good. They kept me and by the morning I had lost more than 50% and then again the following night I lost the rest. I was 23+3 weeks.

Baby was still kicking and I had no infection, like you I was monitored every 4 hours. Sadly on the fourth day, our little girl Amelia passed away in utero and I gave birth 2 days later (after being induced). I had developed an infection and my little girl lost her fight.

Because of my lack of cervix and my failed vaginal stitch, the only way I would have felt comfortable carrying another baby would be to have an abdominal stitch (TAC) this was placed in August last year (Just the day after what was my due date).

I was fortunate to fall pregnant quite quickly and I gave birth to a beautiful baby boy on the 3rd June. I know his big sister was watching down on us and keeping him safe.

I think a lot of doctors aren't keen to give an abdominal stitch before a vaginal stitch as the surgery is more evasive, but the abdominal stitch does carry higher success rates (I think 95%).

Its not for everyone but if you did want to know more about the TAC then I would be more than happy to answer any questions. Also the abby loopers website is fab.

Sending you all the luck in the world as pregnancy after losing a baby is a scary scary time.

xxx
 
Hi huggles. So sorry to read about your loss hun, IC is truly a terrifying and devastating condition which takes you completely by surprise.

I did carry 9 and 7Ib twins to term with a stitch hun, and am living proof that cervical stitches can work. What I would say is that in my case IC was due probably to the traumatic birth of my first (also a big baby), and was weak, not entirely incomptent. It began to open in the twin pregnancy, but not until 25wks.

Since your IC showed itself in you first pregnancy, I'd recommend asking about the Shirodkar stitch. It is placed higher up the cervix than the macdonald, and is sewn thru the bladder and vaginal walls as well. My consultant wouldn't hear of me having anything else because i was carrying twins, and the strain is so much greater, and the strength of the shirodkar much better. If I had another singleton pregnancy, that's what I'd opt for.

All that said, the macdonald has a great track record, and for a singleton pregnancy is probably adequate most of the time. I wish you all the best for any future pregnancies hun - I never thought I'd have a full term baby after our 24wk daughter, but I was proven very wrong. If you need any advice/support you know where I am xxx
 
Well as mostknow by now, I did lose Devon 8 days ago. My OB is still on vacation so she doesn't even know yet. I really don't know where we go from here.

This was my first cerclage ever; just the standard kind. After in internal exam on July 28 I got an infection in the stich. After going without treatment, which I was begging for by that sunday, pre term labour started. I was refused treatment to stop my contractions at my hospital. By the time they agreed to transfer me to my OBs hospital who DID treat my contractions with indomethacin... it was too late and the cervix continued to dilate. As soon as the membranes slipped into the birth canal they broke, allowing the infection into the sac. Devon was born alive but died after about 30 minutes.

If my hospital had have stopped contractions when my cervix was still 3 cm long, things would have been different. So it was an infection which triggered everything.

I'm not sure if this qualifies me for an abdominal stich now as I've heard there's less risk of infection. My stich was not removed until after she was born which means I had a 10cm tear. No one will know until my 6 week checkup how bad the damage is. They said they have to give it time to try to heal.
 
i'm really so sorry things happened the way they did. :hugs:
 
Well as mostknow by now, I did lose Devon 8 days ago. My OB is still on vacation so she doesn't even know yet. I really don't know where we go from here.

This was my first cerclage ever; just the standard kind. After in internal exam on July 28 I got an infection in the stich. After going without treatment, which I was begging for by that sunday, pre term labour started. I was refused treatment to stop my contractions at my hospital. By the time they agreed to transfer me to my OBs hospital who DID treat my contractions with indomethacin... it was too late and the cervix continued to dilate. As soon as the membranes slipped into the birth canal they broke, allowing the infection into the sac. Devon was born alive but died after about 30 minutes.

If my hospital had have stopped contractions when my cervix was still 3 cm long, things would have been different. So it was an infection which triggered everything.

I'm not sure if this qualifies me for an abdominal stich now as I've heard there's less risk of infection. My stich was not removed until after she was born which means I had a 10cm tear. No one will know until my 6 week checkup how bad the damage is. They said they have to give it time to try to heal.

Oh Sherri, I'm so sorry :cry: I had no idea you lost your little one until reading this. I am gutted for you darlin, this breaks my heart :nope: You have been thru so much already, it is so unfair that this should happen :hugs:

If there is anything I can do, then please let me help. I have lots of direct experience regarding IC, prem labour and having cervical stitches. TAC is definitely an option for you, tho it very much depends on the reason for your prem deliveries. A stitch will not stop prem labour, only IC. I too laboured with the stitch in during my second pregnancy, but my cervix remained intact. A stitch can still support a damaged cervix, but it is maybe time to look into things more closely to find out exactly what is going on with you hun.

Why not PM me your story from start to finish, and I'll see if I can help.

In the meantime, I'm sending you all my love to help get you thru hun :hugs::hugs::hugs:
 
Lizzie, her story is up in great detail in the Stillbirth, neonatal death and SIDS section if you want to read.
 
Well as mostknow by now, I did lose Devon 8 days ago. My OB is still on vacation so she doesn't even know yet. I really don't know where we go from here.

This was my first cerclage ever; just the standard kind. After in internal exam on July 28 I got an infection in the stich. After going without treatment, which I was begging for by that sunday, pre term labour started. I was refused treatment to stop my contractions at my hospital. By the time they agreed to transfer me to my OBs hospital who DID treat my contractions with indomethacin... it was too late and the cervix continued to dilate. As soon as the membranes slipped into the birth canal they broke, allowing the infection into the sac. Devon was born alive but died after about 30 minutes.

If my hospital had have stopped contractions when my cervix was still 3 cm long, things would have been different. So it was an infection which triggered everything.

I'm not sure if this qualifies me for an abdominal stich now as I've heard there's less risk of infection. My stich was not removed until after she was born which means I had a 10cm tear. No one will know until my 6 week checkup how bad the damage is. They said they have to give it time to try to heal.

Ah sweetie - I am so sad to read this. :hugs: :hugs:

I had an abdominal cerclage so if you have any questions - when you are ready of course. Abbyloopers is a fab support network for the TAC. I'm sure there will be someone in a similar situation that may be able to give better advice than I can.

There is also a list of surgeons that place abdominal cerclages

xxxx
 
My wife is 25 weeks and has been in the hospital for 3 nights now. Sounds like the same situation as you. We are so worried. She is doing really well. Bedrest and her bed is angled so her feet are higher than her ead to take any pressure off of her cervix. We'd love to buddy with you since you are a little further along and to support you in your similar situation! Is there anything we can do to improve our chances of keeping little felix in to full term or at least a few weeks longer?

fingers crossed,
Adam

Hi, thought I would add my own experience here. I've never had any treatment on my cervix or previous miscarriages or anything, but started getting really bad cramps at 22 weeks, went to hospital and they said cervix was closed (no scan, just looked visually).

Went back at 23 weeks with more cramps and was put on bed rest at home but they said cervix was still closed (again just by looking). At 25 weeks cramps got much worse and this time they found that cervix was 2cm dilated and membranes bulging so got put on hospital bedrest, given steroids for baby's lungs etc. Scan showed funnelling as well and liklihood is that had been funnelling back at 22 weeks but obviously they couldn't tell just my looking. Makes me so mad that they didn't check properly and give me a scan!!

Anyway, am now 30 weeks and been on hospital bed rest for last 5 weeks. Incredibly dull, very stressful but very grateful to have got so far. Discussed getting cerclage (stitch) put in but after going over the risks with the consultant dcided against it as I had barely any cervix left to stitch and was a high risk of my waters breaking in surgery. So now just left on bedrest.

Anyone else on bed rest for same reason and want to buddy up?!
 
My wife is 25 weeks and has been in the hospital for 3 nights now. Sounds like the same situation as you. We are so worried. She is doing really well. Bedrest and her bed is angled so her feet are higher than her ead to take any pressure off of her cervix. We'd love to buddy with you since you are a little further along and to support you in your similar situation! Is there anything we can do to improve our chances of keeping little felix in to full term or at least a few weeks longer?

fingers crossed,
Adam

Hi, thought I would add my own experience here. I've never had any treatment on my cervix or previous miscarriages or anything, but started getting really bad cramps at 22 weeks, went to hospital and they said cervix was closed (no scan, just looked visually).

Went back at 23 weeks with more cramps and was put on bed rest at home but they said cervix was still closed (again just by looking). At 25 weeks cramps got much worse and this time they found that cervix was 2cm dilated and membranes bulging so got put on hospital bedrest, given steroids for baby's lungs etc. Scan showed funnelling as well and liklihood is that had been funnelling back at 22 weeks but obviously they couldn't tell just my looking. Makes me so mad that they didn't check properly and give me a scan!!

Anyway, am now 30 weeks and been on hospital bed rest for last 5 weeks. Incredibly dull, very stressful but very grateful to have got so far. Discussed getting cerclage (stitch) put in but after going over the risks with the consultant dcided against it as I had barely any cervix left to stitch and was a high risk of my waters breaking in surgery. So now just left on bedrest.

Anyone else on bed rest for same reason and want to buddy up?!

Hi Adam :hugs:

I know you weren't addressing me directly, but wanted to offer you and your wife my support at this difficult time for you both.

You may have seen that we had our second child in 2004 at 24wks due to incompetent cervix :nope: She survived after a 5 months fight in the NICU.

THis year I had very large twins at 38wks after an elective stitch was placed at 12wks. It worked for us and is proof that you can beat IC. Even without a stitch, there are many, many women I have now encountered who go on to term after presenting with a dilated cervix around 24wks.

Your wife is in the right place, and doing all the right things. Have they said anything about a stitch? Now she is 25wks, it is less likely a stitch will be placed, and if she can just make it another 2/3wks the threat of IC will have passed.

I would advise total rest, plenty of water and avoiding being on her feet at all. There is hope, and you must not loose it. Head over to the other IC thread here if you like. It is a more active thread with women currently experiencing IC and many who are now past 32wks having been told at 22wks there was no hope.

I will be thinking of you and little Felix, and send my warmest wishes your way. If you or your wife have ANY questions please ask - I really would like to help x
 
I had a LEEP procedure done about 10 years ago. Last year I had two early miscarriages and now I am pregnant again and finally made it to my second trimester!!! I am currently 13 weeks. I had called my doctor to set up an appointment to get my cervix checked to make sure the length was normal, but he said that that will not be done until around 18 weeks. Does this sound normal? I would have thought that since I had a LEEP they would want to check earlier. Do you think I should call back and ask to go in sooner?

I also read on here that it should be done around 16 weeks to get the most accurate reading. I have an check-up around 16 weeks, should I just wait until then? Thanks!!
 
Good luck to everyone here struggling with IC.

This is my third pregnancy, and I'm carrying twins. I have a cerclage which was placed at 12 weeks due to my previous preterm delivery of my second child at 24wks. So far my cervix remains closed at 23mm, and didn't begin to shorten until 25wks.

There isn't anything I don't know about IC, so if anyone needs any advice or support, please get in touch.

I have been thru the whole emergency stitch, fortnightly scans, bulging membranes and funneling cervix nightmare, so please draw on me for support. To the ladies wondering if a 1-2mm cervix is too short to place a cerclage, it isn't. If your cervix is closed, there is still hope. That said, even if there is some funneling or dilation, ladies can still make it to term.

My consultant says that she has had twin ladies walking around with no cervix left, and only the stitch holding the babies in, and they still make it.

Love to all - and don't struggle on alone xxx

hi im reallt worrrying about this as i have had a lil red blood which was nearly jelly like and still spotting and been feeling pressure down there near my cervix do u think i should get it checked??? also i didnt have problem with mt last child so does that mean im not likely 2 thnak you im 12 w 3 dxxx
 
I had my cerclage placed at 12 weeks,I had my first one done at 20 weeks(found out late I was pregnant)So far so good and am so hoping I take my boys as close to full term as possible.
 
Hi Kim - spotting and pressure at 12wks can be perfectly normal, but it can never hurt to mention it to your midwife and/or get checked at labour and delivery. I had a full term first child, and then delivered early in my second pregnancy, so it can happen but is less likely if you have a "proven track record". Every pregnancy is unique tho, and complications can arise. At the moment I don't think you have any particular reason to worry hun x

Ashley - welcome hun. I have seen you over at twins section, and didn't realise you had a stitch placed in your twin pregnancy. I did too and delivered two healthy boys at 38wks weighing 9 and 7Ibs! If you need me, please feel free to get in touch x
 
Yea I had it placed at 12 weeks,I was nervous when they did it too!So far everything is looking good and other than my er visit last week things are going well.Im hoping I can go as far as you did (38 weeks)Thank you!
 
Hi Ashley, there is no reason why you shouldn't get to term with the twins. Once IC is fixed with an elective stitch it works very well. Obviously twins can be born prem anyway due to other reasons, but you are at no more risk of that than any other twin lady. Have answered you over in twins hun ;) x
 

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