Offering women a choice in induction of labour: a prospective cohort study.

PURPOSE: To evaluate women's choice in the method of labour induction between oral misoprostol, PGE2 pessary and the Foley catheter. To compare women's satisfaction according to their choice and to identify factors associated with patient satisfaction. METHODS: We conducted a comparative, prospective cohort study of 520 women who chose their preferred method for labour induction, in a French tertiary hospital, from July 2019 to October 2020. Before and after the delivery, they were asked to argue their choice and to evaluate their satisfaction through the use of questionnaires. The primary outcome was global level of satisfaction. RESULTS: Of the 520 women included, 67.5% of women chose oral misoprostol compared to 21% PGE2 pessary and 11.5% Foley catheter. Regarding global satisfaction, we found no significant difference between the three groups: 78.4%, 68.8% and 71.2% (p = 0.107) for, respectively, oral misoprostol, PGE2 pessary and Foley catheter. Factors that seem to improve women's satisfaction were nulliparity (aOR = 2.03, 95% CI [1.19-3.53]), delivery within 24 h after the start of induction (aOR = 3.46, 95% CI [2.02-6.14]) and adequate information (aOR = 4.21, 95% CI [1.869.64]). Factors associated with lower satisfaction rates were postpartum haemorrhage (aOR = 0.51, 95% CI [0.30-0.88]) and caesarean section (aOR = 0.31, 95% CI [0.17-0.54]). CONCLUSION: Women satisfaction rates were not different between the three methods, when chosen by the patients themselves. These finding should encourage caregivers to promote shared decision making when possible. TRIAL REGISTRATION: The protocol was approved by the French ethics committee for research in obstetrics and gynaecology (CEROG, reference number 2019-OBS-0602) on 1st June 2019.

[Factors associated with cesarean delivery of the second twin after vaginal delivery of the first twin: A case-control study]. / Facteurs de risque de césarienne sur deuxième jumeau après accouchement voie basse du premier jumeau : étude cas-témoins.

OBJECTIVES: To identify risk factors for cesarean section of the second twin after vaginal delivery of the first twin. METHODS: Case-control study conducted between 2004 and 2018 in a tertiary center, CHU Toulouse. Cases were women with twin pregnancy who had vaginal delivery of the first twin and emergency cesarean of the second twin. Controls were women with twin pregnancy who delivered both twins vaginally. Deliveries before 24 weeks of gestation, birth weight of less than 500 grams, fetal death in utero, terminations of pregnancy and delayed delivery were excluded. The association between potential risk factors and cesarean delivery of the second twin was analyzed using multivariable logistic regression. RESULTS: Twenty-four patients who had vaginal delivery of the first twin and emergency cesarean of the second twin and 48 patients who delivered both twins vaginally were included. Neonatal morbidity was increased in the group of women who had an emergency cesarean of the second twin. In multivariable analysis, overweight (OR=10.5 [95% CI: 1.78-62.03] for women with body mass index above 25 compared to women with body mass index below 25), weight gain during pregnancy (OR=1.27 [95% CI: 1.01-1.48] for each kilogram) and preterm labor (OR=4,43 [IC 95%:1,10-17,80]) were associated with significantly increased risk of cesarean section of the second twin. CONCLUSION: Overweight and weight gain during pregnancy are associated with increased risk for cesarean section of the second twin.

Glucose Abnormalities and Inappropriate Weight Gain Predict Negative Pregnancy Outcomes After Gastric Bypass Surgery.

PURPOSE: Pregnancy after gastric bypass (RYGB) surgery remains at high risk for gestational diabetes mellitus, prematurity, and small for gestational age infants (SGA). Our objective was to describe the interstitial glucose (IG) profiles and weight changes during such pregnancies, and the association of these factors with adverse pregnancy outcomes. MATERIAL AND METHODS: One hundred twenty two pregnancies were analyzed in a monocentric retrospective study. IG profiles were evaluated by continuous glucose monitoring for 4 days. Maternal (hypertension, hospitalizations, and caesarean section) and neonatal outcomes (prematurity, weight for gestational age, hospitalizations, and malformations) were recorded. A logistic stepwise regression model assessed the influence of weight gain and impaired IG on pregnancy outcomes. RESULTS: Pregnancies occurred 33 (SD 21 months) after surgery. 73% of the women had IG abnormalities (55% with an increased % of time >140 mg/dl and 69% with an increased % of time <60 mg/dl). Five (4%) children were large for gestational age (LGA), 24 (20%) were SGA and 16 (13%) were born prematurely. There were 3 malformations but no stillbirth. LGA was associated with a high % of time >140 mg/dl and an excessive maternal weight gain. Prematurity was associated with a high % of time <60 mg/dl and an insufficient maternal weight gain. In the multivariate analysis, inappropriate weight gain explained LGA and prematurity independently. SGA was associated with a shorter % of time <60 mg/dl. CONCLUSION: The relationship between IG abnormalities and/or maternal weight gain and neonatal outcomes in pregnancies after RYGB, suggests a careful monitoring of these parameters.

Asymmetric pelvis and term breech presentation: is planned vaginal delivery still a safe option?

PURPOSE: To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis. METHODS: An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by < 1 cm. The primary outcome was the rate of vaginal delivery. Secondary outcomes were a composite variable of neonatal and maternal morbidity and mortality. RESULTS: Of the 370 patients who attempted a vaginal breech delivery, 8% (n = 29) had an AP and 92% (n = 341) had a SP. In the AP group, the vaginal delivery rate was higher (93% versus 78%, p = 0.05). There was no statistically significant difference in neonatal (3% versus 1% in the AP and SP groups, respectively, p = 0.4) and maternal (17% versus 23% in the AP and SP groups, respectively, p = 0.5) morbidity and mortality. CONCLUSION: When a pelvimetry is performed before an attempt of vaginal breech delivery, a difference of less than two centimetres between both oblique diameters does not seem to reduce the rate of vaginal birth and is not an indication for an elective caesarean section.

Smoking and smoking cessation in pregnancy. Synthesis of a systematic review.

OBJECTIVES: To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy and the post-partum period. STUDY DESIGN: A systematic review of the international literature was undertaken between January 2003 and April 2019. MEDLINE, EMBASE databases and the Cochrane library were searched for a range of predefined key words. All relevant reports in English and French were classified according to their level of evidence ranging from 1(highest) to 4(lowest). The strength of each recommendation was classified according to the Haute Autorité de Santé (French National Authority for Health) ranging from A (highest) to C (lowest). RESULTS: "Counselling", including all types of non-pharmacological interventions, has a moderate benefit on smoking cessation, birth weight and prematurity. The systematic use of measuring expired air CO concentration does not influence smoking abstinence, however, it may be useful in assessing smoked tobacco exposure prior to and after quitting. The use of self-help therapies and health education are recommended in helping pregnant smokers quit and should be advised by healthcare professionals. Nicotine replacement therapies (NRT) may be prescribed to pregnant women who have failed to stop smoking after trying non-pharmacological interventions. Different modes of delivery and dosages can be used in optimizing their efficacy. Smoking in the postpartum period is essential to consider. The same treatment options as during pregnancy can be used. CONCLUSION: Smoking during pregnancy concerns more than a hundred thousand women each year in France resulting in a major public health burden. Healthcare professionals should be mobilised to employ a range of methods to reduce or even eradicate it.

Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients.

PURPOSE: Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery. METHODS: We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics. RESULTS: 164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005]. CONCLUSION: The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

[Other Methods of Consumption: Electronic Cigarette, Heated Tobacco, Shisha and Snus - CNGOF-SFT Expert Report and Guidelines on the management for Smoking Management During Pregnancy]. / Autres méthodes de consommation pendant la grossesse : cigarette électronique, tabac chauffé, chicha et snus ­ Rapport d'experts et recommandations CNGOF-SFT sur la prise en charge du tabagisme en cours de grossesse.

Other methods of cigarette consumption include a variety of electronic products, as well as heated tobacco, snus and shisha. The questions in this chapter are: what other methods of consumption are used during pregnancy (either electronic or containing tobacco) and what is their prevalence? What is their benefit/risk balance? Can their use during pregnancy be proposed? Although the fetus is not exposed to the combustible toxins of tobacco, e-cigarette products may contain nicotine, which maintains the exposure of the fetus. Further research is needed on the other components of the electronic cigarette, such as flavorings and propylene glycol and/or glycerol, in order to assess the benefit/risk balance. In addition, some solvents contain ethanol. In the current state of knowledge, the precautionary principle should be respected and not recommend the initiation or continuation of the electronic cigarette during pregnancy (professional agreement). For smoking cessation or electronic cigarette cessation, it is recommended to provide the same advice and to use methods that have already been evaluated (professional agreement). For the JUUL, there are currently no data on obstetrical outcome when used. The use of shisha during pregnancy is associated with decreased fetal growth. It is recommended not to use shisha during pregnancy (GradeC). There are currently no data on the use of heated tobacco and obstetrical outcome.

[Physiological and Psychological Data influencing Pregnant Women Smoking Behavior - CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]. / Données physiologiques et psychologiques influençant le comportement tabagique de la femme enceinte ­ Rapport d'experts et recommandations CNGOF-SFT sur la prise en charge du tabagisme en cours de grossesse.

Nicotine is the main addictive substance in tobacco and its addictive effects mainly involve dopamine. Nicotine is mainly metabolized (C-oxidation) in the liver to cotinine by the cytochrome P450 enzyme system. Nicotine half-life is short being about 2hours. Nicotine metabolism appears to be increased during pregnancy, mainly due to an increased cytochrome activity and maternal cardiac output. Thus, the smoking behavior of the pregnant woman is subsequently modified with an increase in withdrawal syndromes and an increased desire to smoke. These pharmacological elements should be taken into account when prescribing nicotine replacement therapy. Regarding the markers of tobacco intoxication, there is a good correlation between the importance of smoking and the measurement of expired air carbon monoxide. Although there is no evidence of decreased obstetrical complications related to its use, it is simple and non-invasive and therefore may be useful in routine practice. It gives an instantaneous value of tobacco intoxication, and represents a starting point for dialogue and management and can help to highlight the reality of withdrawal. Regarding the evaluation of tobacco addiction, the most commonly used questionnaires are the Fagerström tests (FTCD, HSI…), which are well correlated with cotinine concentration. However, there is insufficient evidence of their usefulness in reducing tobacco consumption during pregnancy to recommend them in current practice. DSM-V diagnostic criteria for addiction should be known as they can also be used to characterize the intensity of this addiction.

[CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy-Short Text]. / Rapport d'experts et recommandations CNGOF-SFT sur la prise en charge du tabagisme en cours de grossesse­texte court.

OBJECTIVES: To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy. METHODS: Systematic review of the international literature. We identified papers published between January 2003 and April 2019 in Cochrane PubMed, and Embase databases with predefined keywords. All reports published in French and English relevant to the areas of focus were included and classified according the level of evidence ranging from 1 (highest) to 4 (lowest). The strength of the recommendations was classified according to the Haute Autorité de santé, France (ranging from A, highest to C, lowest). RESULTS: "Counseling", involving globally all kind of non-pharmacological interventions, has a modest benefit on smoking cessation, birth weight and prematurity. Moderate physical activity did not show a significant effect on smoking cessation. The systematic use of feedback by measuring the expired air carbon monoxide concentration do not influence smoking abstinence but it may be used in establishing a therapeutic alliance. The use of self-help interventions and health education are recommended in helping pregnant smokers quit. The prescription of nicotine replacement therapies (NRT) may be offered to any pregnant woman who has failed stopping smoking without medication This prescription can be initiated by the health care professional taking care of the pregnant woman in early pregnancy. There is no scientific evidence to propose the electronic cigarette for smoking cessation to pregnant smokers; it is recommended to provide the same advice and to use methods that have already been evaluated. The use of waterpipe (shisha/narghile) during pregnancy is associated with decreased fetal growth. It is recommended not to use waterpipe during pregnancy. Breastfeeding is possible in smokers, but less often initiated by them. Although its benefit for the child's development is not demonstrated to date, breastfeeding allows the mother to reduce or stop smoking. The risk of postpartum relapse is high (up to 82% at 1 year). The main factors associated with postpartum abstinence are breastfeeding, not having a smoker at home, and having no symptoms of postpartum depression. CONCLUSIONS: Smoking during pregnancy concerns more than hundred thousand women and their children per year in France. It is a major public health burden. Health care professionals should be mobilized for reducing or even eradicating it.

[Intrauterine contraception: CNGOF Contraception Guidelines]. / Contraception intra-utérine. RPC Contraception CNGOF.

OBJECTIVE: To provide national clinical guidelines focusing on intrauterine contraception. METHODS: A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well. RESULTS: Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B). CONCLUSION: Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

[Evolution of clinical practices in the surgical management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015: A paradigm shift towards pluripotency]. / Évolution des pratiques dans la chirurgie du prolapsus au sein d'une école vaginaliste sur la période 2010­2015.

OBJECTIVES: To determine whether the 2011 FDA alert and French Guidelines have impacted the routine surgical practice in the management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015. METHODS: Retrospective study involving all patients undergoing surgical management of anterior and/or apical symptomatic pelvic organ prolapse during the civil years 2010 and 2015. Both naive and relapsed prolapses were eligible. RESULTS: Overall, 338 patients were included: 187 in 2010 and 151 in 2015. Among patients with naive prolapse, we observed a significant increase in the number of laparoscopic sacrocolpopexies (11.1% in 2010 versus 34.4% in 2015, P=0.001) and a significant decline in the use of native tissue repair (67.6% in 2010 versus 39% in 2015, P=0.001). While the number of transvaginal meshes did not decline over the study period, their indications displayed a significant evolution towards a restricted use to advanced stages. We did not observe any difference regarding the treatment of recurred pelvic organ prolapse. Vaginal route remained the preferred approach in this indication. CONCLUSION: In our "vaginalist" team, routine practice has significantly evolved over the period 2010-2015, resulting in a diversification of the healthcare offer. This paradigm shift towards pluripotency is mandatory, since patients' preference should also drive the choice of both surgical route and technique.

[Targeted screening for pre-eclampsia in the first trimester of pregnancy at Toulouse University Hospital]. / Le dépistage ciblé de la pré-éclampsie au premier trimestre de la grossesse au CHU de Toulouse.

GOALS: Preeclampsia (PE) is a leading cause of maternal and neonatal morbidity and mortality. Early treatment by aspirin has been shown to significantly reduce PE risk before 37weeks supporting the implementation of first-trimester screening. SUBJECTS AND METHODS: A targeted screening was recently implemented at Toulouse University Hospital for women in their first pregnancy or those with personal or familial history of PE. It uses Fetal Medicine Foundation (FMF) algorithm that combines maternal characteristics, clinical, biophysical and biochemical (PAPP-A, Pregnancy Associated Plasma Protein-A, and PlGF, Placental Growth Factor) data. We describe this first population of pregnant women and compare our results with those of a mini-test that excludes PlGF and biophysical data. RESULTS: Between October 2016 and September 2017, 500women have benefited from this screening. In such targeted population, we identified 3,6 % (n=18) of women at high risk to develop PE before 34weeks and 9,6 % (n=48) of women at high risk to develop PE between 34 and 37weeks. When we recalculated the risk using the mini-test, only 10women (56 %) were identified at high risk of early PE. CONCLUSION: For the first time in France, we report the result of a targeted screening of PE during the first trimester using the FMF algorithm. We describe the screened population and show that it is more efficient than the mini-test.

[Laparoscopic sacrocolpopexy for exteriorized pelvic organ prolapse: Mid-term functional results]. / Promontofixation cœlioscopique pour les prolapsus extériorisés: qualité de vie et résultats fonctionnels à moyen terme.

OBJECTIVES: To assess feasibility and postoperative outcomes associated with laparoscopic sacrocolpopexy in patients presenting with exteriorized pelvic organ prolapse (stage>3). METHODS: Prospective study involving patients undergoing laparoscopic sacrocolpopexy for advanced stage pelvic organ prolapse. Symptoms and quality of life were evaluated at baseline and at 1, 4 and 18 months after surgery using validated questionnaires (PFDI-20 and PFIQ-7). RESULTS: Sixty-three patients were included between September 2012 and January 2014. Sub-total hysterectomy and sub-urethral sling were performed at the time of surgery in 36% and 34% of patients, respectively. We observed 1 per-operative complication (bladder wound). De novo stress urinary incontinence and de novo dyspareunia persisting at 18 months occurred in 10% and 3% of cases, respectively. Recurrence rate was 1.6% at 18 months. The follow-up also revealed a significant and prolonged improvement in PFDI-20 and PFIQ-7 scores: from 98.8 at baseline to 33.9 at 18 months (P<0.01) and from 89.6 to 26.5 (P<0.001), respectively. CONCLUSION: Laparoscopic sacrocolpopexy seems feasible and safe in patients suffering from exteriorized pelvic organ prolapse, leading to high anatomic success rate. It is also associated with a prolonged improvement in quality of life and a positive impact on symptoms related to prolapse.

[Paraplegia and pregnancy]. / Paraplégie et grossesse : à propos d'une série rétrospective continue sur 11 années au CHU de Toulouse.

OBJECTIVES: To describe the characteristics of the management of pregnancy and child birth in women with spinal cord injury. MATERIALS AND METHODS: Retrospective cohort study including paraplegics patients with motor deficit (whatever the etiology) who gave birth at the University Hospital of Toulouse between March 2003 and March 2014 (11 years). Monitoring and outcome of pregnancy were studied. RESULTS: Seventeen deliveries (15 patients) were performed on a total of 46,888 in the studied period (prevalence=0.4‰). All patients had urinary tract infections: lower urinary tract (100%), recurrent cystitis (75%), pyelonephritis (31.3%). One patient (6.3%) presented dysautonomia during pregnancy. The cesarean rate was 47% (the indication was in any case an obstetrical reason). Among vaginal deliveries, four (44%) required an instrumental extraction. Epidural analgesia was the method of choice in the absence of contraindication. CONCLUSION: Pregnancy associated with spinal cord injury requires a multidisciplinary approach. Autonomic hyperreflexia syndrome must be known and can be avoided by epidural analgesia in early labor. Vaginal delivery should be the rule.

[Oxidative stress and preeclampsia: A review]. / Implication du stress oxydant dans la physiopathologie de la pré-éclampsie: mise au point.

Preeclampsia is a leading cause of pregnancy complications and affects 3-7% of pregnant women. Pathophysiology of preeclampsia is still unclear. According to the two-stage model of preeclampsia, the abnormal and hypoperfused placenta (stage 1) releases factors to the bloodstream, which are responsible for the maternal symptoms (stage 2), characterised by a systemic inflammation and endothelial dysfunction. Oxidative stress plays an important role in the pathophysiology of the preeclampsia and could be the common denominator between the two. This review summarizes the current knowledge of a new potential etiology of the disease, with a special focus on oxidative stress. We also review the different factors that have been proposed to cause endothelial cell dysfunction in preeclampsia, and trials investigating the role of antioxidant supplementation in preeclampsia.

[Obstetric and anesthetic specificities in the management of a postpartum hemorrhage (PPH) associated with cesarean section]. / Spécificités obstétricales et anesthésiques de la prise en charge d'une hémorragie du post-partum (HPP) associée à la césarienne.

OBJECTIVES: To describe the characteristics of post-partum hemorrhage (PPH) associated with cesarean section (CS), the modalities diagnosis and specific obstetric and anesthetic management. MATERIALS AND METHODS: Bibliographic search restricted to French and English languages using Medline database(®) and international guidelines of medical societies. RESULTS: Primary PPH associated with CS (incidence 3-15%) is defined as vaginal bleeding ≥500mL within 24hours after surgery. Severe PPH is defined by bleeding ≥1000mL (professional consensus). The intervention threshold to initiate an active management depends on the flow rate of bleeding, the etiology and the clinical context. It can be higher than 500mL after cesarean (professional consensus). The main risk factor for bleeding is the realization of an emergency CS during labor (EL 3). In the case of persistent or severe intraoperative PPH due to uterine atony, conservative surgical procedures should be initiated in association with maternal resuscitation and second-line uterotonic therapy (sulprostone) (professional consensus). If general anesthesia is required, it is recommended to opt for a maintenance treatment limiting sevoflurane or desflurane in case of uterine atony (professional consensus). Severe bleeding during or after cesarean is a thrombotic risk factor and requires antithrombotic prophylaxis with heparin (the duration of treatment may vary depending on the associated risk factors) after normalization of coagulation (professional consensus). Postoperative hemoperitoneum (ultrasound) or suspected vascular wound require urgent laparotomy under general anesthesia (professional consensus). Otherwise, an uterotonic therapy (oxytocin or sulprostone depending on the severity) should be initiated. Balloon intrauterine tamponade or embolization may be discussed in the absence of hemodynamic instability (professional consensus). CONCLUSION: The occurrence of PPH associated with cesarean delivery requires close collaboration between obstetrician and anesthesiologist to ensure a rapid and coordinated management (professional consensus).