Gynecology

Trusted Gynecological Expertise

We provide a wide range of quality gynecological services, to women of all ages, with a variety of conditions. Click on the links below to learn more!

Annual Gynecological Exams 

Your annual exam is your yearly preventative health visit. At this visit, you will first meet with your physician or nurse practitioner in his or her office, and discuss any concerns that have arisen over the past year. We will update your history, review your health habits, and determine what screening tests may be due. You will then have a full physical exam, with a breast exam, pelvic exam, and Pap smear if needed. It is important to realize that even if you are not due for a pap smear, you still need an annual exam! Finally, if you have medications prescribed through our offices, such as contraceptives or hormonal therapy, we will refill those for you if needed. Remember, the annual is not a problem visit. Sometimes minor issues may be addressed at your annual. However, if you have a specific problem (for example heavy periods, urine leakage, difficulty getting pregnant, etc.) they will need to be addressed at a separate office visit.

    Breast Exams

    Clinical breast exams by a health care provider are a routine part of the annual gynecologic exam. Your health care provider will examine your breasts by feeling them with the pads of his or her fingers in a systematic, structured way for detection of any changes in texture or lumps. The nipple and armpit area will be examined as well, due to the fact that breast tissue extends into the armpit area. Your health care provider is experienced in detecting changes that need further testing. Breast exams, along with mammograms, can improve the chances of early breast cancer detection.

    HPV, Pap Smears, Colposcopy, LEEP, Genital Warts

    • Q: What is HPV?

      A: Human papillomavirus, or HPV, is a virus that is transmitted from person to person by direct contact, including skin to skin contact, vaginal intercourse, and oral or anal sex. HPV is one of the most common venereal diseases in the world. There are over 100 different HPV viruses and 30 of those can cause disease in the genital area.


      HPV is the major inciting event of most cervical cancers. It is also associated with vaginal, vulvar, anal, penile and head and neck cancers. The virus also causes genital warts, which can occur anywhere in the male and female genital areas. Those infected with the virus most often show no symptoms and, in many cases, especially in young women, the body produces antibodies and removes the virus. Cigarette smoking increases the risk of HPV associated diseases.

    • Q: What is a pap smear?

      A: A pap smear is a procedure that collects a sample of cells from your cervix using soft brushes. The pap smear is done to screen for cervical dysplasia (precancerous changes) or cervical cancer caused by HPV.  

    • Q: Do I need a pap smear?

      A: Recently, pap smear guidelines were updated such that most women do not need yearly pap smears.  If you have risk factors for cervical changes, including a recent history of abnormal pap smears, or certain medical conditions that affect your immune system, pap smears may still be done on a yearly basis.  It is important to realize that even if you are not due for a pap smear, you still need an annual exam!

    • Q: What happens if my pap smear is abnormal?

      A: Dysplasia of the cervix is a very common problem. It is almost always asymptomatic and found on a routine pap smear. Abnormal pap smears are broadly classified into ASCUS (abnormal cells of uncertain significance), LSIL (“low-grade”) and HSIL (“high-grade”). Low-grade changes return to normal without any treatment over 90% of the time. High-grade changes have a higher chance of becoming cancerous if not treated. An ASCUS pap smear has a small risk of progressing as well. To further evaluate an abnormal pap smear, you will need to have a procedure called a colposcopy.

    • Q: What is a colposcopy?

      A: If you have an abnormal pap smear, you may need a procedure called a colposcopy. Colposcopy involves your doctor looking at your cervix through a microscope.  A speculum is placed in your vagina, like when you have your pap smear.  A solution of weak acetic acid (white vinegar) is placed on the cervix.  Abnormal areas of the cervix turn white while normal cervical cells stay pink.  If abnormal areas are seen, a biopsy may be performed.  The biopsy is very quick and usually feels like a pinch or cramp.  The discomfort resolves very quickly.  The biopsy is then sent to pathology, to determine if you have a precancerous lesion and if you will need further treatment.  

    • Q: What is a LEEP?

      A LEEP (loop electrosurgical excision procedure) is an office procedure used to treat cervical dysplasia or precancerous changes of the cervix. LEEP uses a thin wire loop, that acts like a knife when an electric current passes through it,  to remove the area of the cervix that contains the abnormal cells.  The LEEP is highly effective at getting rid of all the abnormal cells, but close follow up with Pap smears is essential. 

    • Q: What treatment options are available for genital warts?

      A: Diagnosis of the HPV virus is easy when there are external genital warts. Treatment will be based on the number and location of warts. Treatment options at Manchester OB/GYN Associates include, but are not limited to: 

       

           - Bichloroacetic acid (BCA)

           - Imiquimod (aldara)

           - Liquid nitrogen

           - Laser ablation

           - Excision

    Gardasil

    Avoidance of HPV is of paramount importance in reducing the risk of cervical dysplasia (abnormal cells found on pap smear), various cancers including cervical cancer, and genital warts. There are vaccines available that prevent infection with the virus. At Manchester OB/GYN Associates we offer Gardasil 9, a 3 vaccine series. This vaccine protects against HPV 16 and 18, which are most often responsible for cervical cancers. It also protects against HPV 6 and 11, which are most often responsible for genital warts. It further protects against HPV types 31, 33, 45, 52 and 58. Early vaccination, prior to sexual activity, provides the greatest protection. However, recently these vaccines have been approved for women up to the age of 45!

    Contraception

    There are many options available to help prevent unintended pregnancy. We are happy to schedule a consult with you to discuss which form best meets your needs. The following is a brief overview of the methods available to you.

    • Q: What are barrier methods?

      A: Barrier methods include diaphragms and condoms.  Condoms are the only form of contraception that protects against sexually transmitted diseases.

    • Q: What are Combined Hormonal Contraceptives (CHCs)?

      A: These include the following: 

           - Oral contraceptives (OCPs, "the pill")

           - Contraceptive patch

           - Vaginal ring (NuvaRing)

    • Q: What are progesterone-only methods?

      A: These include the following: 

           - Progesterone-only pills (the mini-pill)

           - Depo Provera injection

           - Nexplanon (implantable rod)

           - IUDs (Skyla, Mirena, Kyleena, Liletta)

    • Q: What are Long-Acting Reversible Contraceptives (LARCs)?

      A: These include the following: 

           - Nexplanon (implantable rod)

           - IUDs (Skyla, Mirena, Kyleena, Liletta, Paragard)

    • Q: What is sterilization?

      A: Sterilization is a permanent and irreversible procedure for men and women who have completed their families. Vasectomy is male sterilization which is typically performed by a urologist.  Tubal ligation is female sterilization.  It can be performed in several ways but is usually done via an outpatient surgical procedure. 

    • Q: How is a tubal ligation performed?

      A: Tubal ligation is a general term used to describe the process by which the fallopian tubes are blocked to prevent a woman from getting pregnant again. There are multiple ways to perform this procedure.


      Most commonly, tubal ligation is performed in the operating room, via laparoscopy, under general anesthesia.  In the past, we blocked the tubes with clips, rings or cautery.  However, now we usually remove the entire tube since this has been shown to decrease the occurrence of ovarian cancer.  


      Tubal ligations can also be performed at the time of cesarean sections, or in the operating room the day after a vaginal delivery (via a small incision under the belly button).

    • Q: What is emergency contraception?

      A: Emergency contraception is available.  Plan B can be purchased over the counter without a prescription.  Ella requires a prescription.  Paragard IUDs can be placed in the office as a form of emergency contraception.  Birth control pills can be used, at high doses, in emergency settings but are not as effective as other methods.  It is best to use an emergency contraceptive as soon as possible after unprotected intercourse.  

    Miscarriage

    • Q: What is a miscarriage?

      A: A miscarriage is when the embryo or fetus dies before the 20th week of pregnancy.  It is most common in the first three months of pregnancy.

    • Q: How common are miscarriages?

      A: Miscarriages are very common.  They occur in about 1 in 5 pregnancies.  

    • Q: Why did I have a miscarriage?

      A: A miscarriage is usually caused by a chromosomal problem that is not compatible with life.  You did nothing wrong.  There is nothing you could have done to prevent this from happening.  

    • Q: Can I have a normal pregnancy in the future?

      A: Yes!  Miscarriages are very common and there is nothing to say that you cannot have a completely normal pregnancy in the future.  

    • Q: How is a miscarriage treated?

      A: There are a few different options for treating a miscarriage:  

      • Wait for the pregnancy to pass on its own (expectant management).
      • Take misoprostol (medication, oral or vaginal) to cause the uterus to pass the pregnancy.
      • Have a D&C (dilation and curettage) procedure in the office (with local anesthesia) or in the operating room (with general anesthesia).

      We recommend a consult to further discuss these options and decide which choice is best for you.  Please give us a call at (603)622-3162.

    • Q: How long do I have to wait before attempting pregnancy again?

      A: We typically recommend not having intercourse for 2 weeks after passing the pregnancy.  There is no quality data to support delaying a subsequent pregnancy after an early miscarriage.

    Ectopic Pregnancy

    An ectopic pregnancy is a pregnancy that is located outside of the uterus, most commonly in a fallopian tube.  This is a dangerous condition because the growing pregnancy can stretch, and eventually rupture, the tube.  This results in internal bleeding which is a life threatening situation.  We evaluate for an ectopic pregnancy when a woman has a history of an ectopic pregnancy, or when a woman has any bleeding or severe pain early in pregnancy.  Treatment usually includes a medication called methotrexate or surgery to remove the pregnancy.  Unfortunately, ectopic pregnancies are not able to survive nor are we able to reimplant these pregnancies into the uterus.    
    ACOG Information: Ectopic Pregnancy

    Abnormal Uterine Bleeding, Endometrial Biopsy

    • Q: What is abnormal uterine bleeding (AUB)?

      A: A typical menstrual cycle is usually between 21-35 days and lasts 5 days.  AUB consists of any of the following: 

           - Heavy menstrual bleeding

           - Bleeding between periods

           - Bleeding that occurs more frequently than every 21 days

           - Bleeding that occurs less frequently than every 35 days


      One third of visits to the gynecologist are for abnormal uterine bleeding!

    • Q: What causes AUB?

      A: The following conditions can cause abnormal uterine bleeding: 

           - Polyps

           - Fibroids

           - Adenomyosis

           - Precancerous conditions

           - Cancers

           - Bleeding disorders

           - Ovulatory dysfunction

           - Medication side effects


      Manchester OB/GYN Associates can diagnose the cause of your abnormal bleeding and offer you a wide array of treatment options!

    • Q: What are fibroids?

      A: Fibroids are benign muscle growths of the uterus. They can be single or multiple and can be found throughout the uterus. Sizes can vary greatly from less than an inch to 10 inches or more. Many fibroids are asymptomatic but they can be associated with heavy menstrual bleeding, spotting, pelvic pressure, pelvic pain, cramping, pain with intercourse, urinary frequency, infertility, and miscarriage.

    • Q: What tests are used to diagnose AUB?

      A: Several tests may be used to diagnose the cause of your AUB including: 

           - Bloodwork

           - Pap smear

           - Genital cultures

           - Pregnancy test

           - Ultrasound

           - Sonohysterogram

           - Endometrial biopsy

           - Hysteroscopy

           - D&C

    • Q: What is an endometrial biopsy (EMB)?

      A: An endometrial biopsy is a simple office procedure that samples the tissue from the lining of your uterus.  The tissue is sent to pathology to look for cancer and other abnormal changes.  A biopsy may be recommended if you have AUB.  

    • Q: What treatment options are available for AUB?

      A: Treatment options for AUB depend on the cause of abnormal uterine bleeding.  Some options may include: 

           - Medications (eg thyroid medication)

           - Contraception

           - Hysteroscopy to remove polyps or fibroids

           - Endometrial ablation

           - Hysterectomy


      Call us today to discuss your options... you don't have to suffer with abnormal uterine bleeding!

     Fibroids, Sonata

    Gynecological Equipment — Novasure in Manchester, NH

    Fibroids are benign muscle growths of the uterus. They can be single or multiple and can be found throughout the uterus. Sizes can vary greatly from less than an inch to 10 inches or more. Many fibroids are asymptomatic but they can be associated with heavy menstrual bleeding, spotting, pelvic pressure, pelvic pain, cramping, pain with intercourse, urinary frequency, infertility, and miscarriage.


    There are many ways to treat fibroids including myomectomy (removal of the fibroids), hysterectomy (removal of the entire uterus) or Sonata treatment. 


    Sonata is an incisionless outpatient procedure that treats fibroids from the inside of the uterus.  Our office is the first in the state to offer this treatment!  Learn more here.

    Sonohysterography

    A sonohysterogram is a special ultrasound used primarily to check abnormalities in the lining (endometrium) of the uterus. When a patient experiences irregular bleeding a sonohysterogram can be used to check for thick endometrium, uterine polyps or fibroid location. The procedure is very simple and not much more than a regular routine vaginal ultrasound. In the ultrasound room, a small catheter will be placed into the uterus, sterile water is then administered into the uterus and images of the endometrial space are obtained. With this information, we can determine the best treatment available for each patient.

    Cost-Effective In-Office Procedures

    Over the years we have offered a variety of in-office procedures including endometrial ablation, hysteroscopy, dilation and curettage (D&C), and loop electrosurgical excisional procedure (LEEP).   We make our patients comfortable using a variety of methods.  There are several benefits to an in-office over a procedure at the hospital or surgery center.  These include: 
    • Avoidance of general anesthesia.
    • No fasting.
    • Time savings.  Your procedure is more likely to run on time if performed in our office.  You will also need to spend less time in our office before and after your procedure than you would be required at the hospital or surgery center.
    • Cost-efficiency.  Your out-of-pocket expense is typically much less in an office setting than a hospital or surgery center.
    Most other OB/GYN offices in the area do not offer in-office procedures.  

    Hysteroscopy, TruClear

    Hysteroscopy is a diagnostic or therapeutic procedure done either in the hospital or the office. During hysteroscopy, the physician uses a small optical instrument like a small telescope to see inside the uterus. A clear solution is placed in the uterus allowing visualization of the full lining of the uterus as well as the openings to the tubes. Many lesions can be easily removed or treated by utilizing small flexible instruments.
    Hysteroscopy is used to diagnose and treat abnormalities of the inside (lining) of the uterus. It is used to treat and diagnose polyps, fibroids, scar tissue, blocked tubes, cancer, and heavy bleeding. It is used to find IUDs and used in conjunction with other medical procedures such as endometrial ablations.
    With our office TruClear hysteroscopy system, we can diagnose and treat uterine abnormalities, like polyps, all in one procedure. One patient, who recently had two large polyps (4cm and 1.5cm) removed, said this about her in-office TruClear polypectomy: "I felt absolutely nothing at all during the procedure.  It was a very easy procedure to do in the office. I could have taken a nap during it."

    Endometrial Ablation

    Endometrial ablation is a minimally invasive procedure available for women with heavy menstrual bleeding. The goal is to significantly decrease or stop menstrual bleeding. We offer the Minerva endometrial ablation, a new and improved technology over our former endometrial ablation.  Minerva uses thermal energy to destroy the endometrial layer of the uterus. It has 90% success rate in treating heavy bleeding and 60% of women do not get a period after the procedure. This upgraded technology has made the procedure more comfortable for patients and the vast majority of the ablations can be done in the office. Women who have had an endometrial ablation should not become pregnant so reliable contraception is necessary to avoid pregnancy. 

    Hysterectomy

    Hysterectomy is an operation to remove a woman's uterus (womb). Reasons or conditions may vary from irregular bleeding, endometriosis, fibroids, pain, cancer or prolapse. Typically, a total hysterectomy is performed where both the uterus and cervix are removed.  Occasionally, a supracervical hysterectomy may be performed where the cervix is left in place.   Ovaries and/or tubes may also be removed. Sometimes other reconstructive repairs, such as cystocele correction, may be combined with the hysterectomy. 

    The type of hysterectomy depends on the indication and the woman's state of health.  Healing time and recovery will be affected by the approach. The open or abdominal hysterectomy approach involves an incision in the lower abdomen with a 2-3 day stay in the hospital. The other approaches are less invasive and include:
    • Vaginal hysterectomy (the uterus is removed through the vagina)
    • Laparoscopic hysterectomy/ Laparoscopic-assisted hysterectomy (small incisions with guidance by a camera)
    • Robot-Assisted Laparoscopic Hysterectomy (using a Robotic system of surgical tools from outside the body through small incisions that assist to perform the surgery)

    Laparoscopy

    A laparoscopy is an approach to surgery that uses a thin, lighted tube that is placed through a small incision in the abdomen (belly) to view the female organs and pelvis. This type of surgery is used to diagnose and treat various conditions such as ovarian cysts, pelvic pain, abnormal bleeding, endometriosis, scar tissue, infertility and infections. This is done under general anesthesia in a surgical center or hospital setting.  A variety of instruments are available to allow these procedures to be done more easily. The length of this surgery will vary depending on the reason and the goals for the procedure. Often, one can go home the same day of surgery.

    Surgery — Da Vinci Robotic Surgery in Manchester, NH
    DaVinci Robotic Surgery is an approach to perform minimally invasive surgery through small incisions (operating ports). It utilizes similar instruments as laparoscopy but further enhances their functions. The instruments are controlled by very fine movements of robotic arms which the surgeon controls while sitting at a command console. These tools function like your hand and wrist giving more flexibility than traditional laparoscopic operating instruments with the addition of 3 D viewing of the operative field. The advantages can be helpful in certain types of gynecologic surgery.

    • Q: What is menopause?

      A: Menopause is the time in a woman's life when the ovaries begin to reduce their production of hormones. By definition, menopause is diagnosed when there have been no periods for a year. The average age of menopause is just over 51 years old but varies greatly from mid-forties to late fifties.


      The symptoms of menopause are multiple and varied including hot flashes, difficulty sleeping, decreased sexual interest, vaginal dryness, fatigue, difficulty concentrating, difficulty reaching orgasm, excess hair growth, dry skin, and irritability. Each woman will experience menopause in an individual fashion with varied symptoms. 


      No woman has to suffer from her symptoms.  Call us today to discuss treatment options! 



    • Q: What are hot flashes?

      A: Hot flashes and night sweats are very common. Women describe hot flashes as a wave of heat spreading throughout their body. They can occur at any time of the day in varying intensities and number. Hot flashes are often accompanied by sweating, especially during night hours. Hot flashes and night sweats can be very bothersome and interrupt your daily activities and sleep.


      You do not have to live with unbearable hot flashes.  Call us today to discuss treatment options!


    • Q: How are menopausal symptoms treated?

      A: Menopausal symptoms can be treated in a variety of ways.  Hormone replacement therapy (HRT) can be considered for hot flashes.  Additional options include herbal medications, SSRIs, and other prescription medications.  Treatment for vaginal dryness includes vaginal estrogen.  Call us today to schedule a consult to discuss your options!

    Urinary Incontinence, Urodynamic Testing, Incontinence Treatment and Surgery, Solyx

    • Q: What is urinary incontinence?

      A: Urinary incontinence is the loss of bladder control. It is a common and often embarrassing problem. The symptoms can range from occasional minor leaks to spontaneous loss of large volumes of urine.

    • Q: What are the different types of urinary incontinence?

      A: Stress incontinence is the loss of urine when pressure, or “stress,” is exerted on the bladder by coughing, sneezing, lifting, laughing or exercising. This occurs when the pelvic muscles that support the bladder are weakened. This can occur as a result of pregnancy, childbirth, and menopause. This type of incontinence is very common in women.


      Urge incontinence is a sudden intense urge to urinate followed by an involuntary loss of urine. It is caused by bladder muscle contractions that may give only a brief warning or ‘urge' to get to a toilet. Urge incontinence can cause a frequent need to urinate including at night. The term ‘overactive bladder' is often used for the symptoms of frequency or frequent mild bladder contractions. 


      Mixed incontinence is a combination of more than one type of incontinence.


      Functional incontinence occurs in individuals who have physical or mental impairments that prevent them from making it to the bathroom in time to prevent an accident. 

    • Q: What is urodynamic testing?

      A: Urodynamic testing is performed in our office.  You will be asked to come in with a full bladder.  Our specially trained staff will take measurements to evaluate your bladder function.  During the procedure, you will be asked questions about the sensations in your bladder. You will be asked to strain, cough, and jump to see if there is any urinary leakage. This testing helps us determine your type of incontinence  and the best method of treatment.

    • Q: How is incontinence treated?

      A: Treatment depends on your type of incontinence but options may include kegel exercises, physical therapy, pessaries, medication, or surgery.  


      You may feel uncomfortable discussing your symptoms but treatment could greatly improve your quality of life. If incontinence is causing you to restrict your activities or social interactions in order to avoid an embarrassing situation, then evaluation is important.  Give us a call to schedule an appointment!

    • Q: What incontinence surgeries are available?

      A: If you have stress incontinence, surgery is the mainstay of treatment.  There are three types of procedures performed by the doctors in our office: transobturator tape (TOT), transvaginal tape (TVT) and Solyx Single Incision Sling.  These procedures involve placing a small piece of mesh underneath the urethra to prevent urinary leakage.  Schedule a consult today to see if you are a candidate for one of these procedures.


      Per ACOG, "Although controversy exists about the role of synthetic mesh used in the vaginal repair of pelvic organ prolapse, there are substantial safety and efficacy data that support the role of synthetic mesh midurethral slings as a primary surgical treatment option for stress urinary incontinence in women. For this reason, and to clarify uncertainty for patients and practitioners, the American Urogynecologic Society and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction published a position statement recognizing polypropylene mesh midurethral slings as the “standard of care” in the surgical treatment of stress urinary incontinence."

    Learn more about treatment options for incontinence, including the Solyx Single Incision Sling here.

    Prolapse, Pessaries, Pelvic Reconstruction

    • Q: What is pelvic organ prolapse?

      A: Pelvic organ prolapse is the herniation of the pelvic organs to or beyond the vaginal walls.  This is caused by weakness of pelvic floor structures (muscles and ligaments) which may have been damaged by childbirth, repeated heavy lifting, or from chronic diseases. Symptoms can include discomfort/pressure/pain from a bulge in the vagina, urinary incontinence or retention, and/or difficulty passing stool. 


      There are several different types of prolapse: 

           - Cystocele - prolapse of the bladder

           - Rectocele - prolapse of the rectum

           - Enterocele - prolapse of the small intestine

           - Uterine prolapse - prolapse of the cervix/uterus


      ACOG Prolapse and Pessary Videos


      Treatment options typically include pessaries or surgery.  

    • Q: What are pessaries?

      A: Pessaries are soft, flexible, silicone devices that are placed in the vagina to help support prolapsing organs (bladder, rectum, intestines, uterus).  They come in a variety of shapes and sizes and are fitted in the office. Pessaries are non-surgical options for treating pelvic organ prolapse. 

    • Q: What is pelvic reconstruction?

      A: Pelvic reconstruction is a general term that covers a variety of surgical procedures to repair pelvic organ prolapse. These procedures are typically performed through the vagina without any abdominal incisions. The goal of reconstructions is to restore the normal structure and function of the pelvis.  Examples of pevlic reconstruction surgeries include: 

           - Total vaginal hysterectomy

           - Anterior colporrhaphy (cystocele repair)

           - Posterior colporrhaphy (rectocele repair)

           - Sacrospinous ligament fixation (enterocele repair)


      Patients are usually discharged home the same day or the next day following surgery.  

    • Q: What is pelvic pain?

      A: Pelvic pain is lower abdominal pain that may occur in various locations and has many potential causes. This pain may be short-lived or of a chronic nature. The pelvis contains many organs (bladder, uterus, ovaries, and intestines), muscles with their attachments, and nerve tissue. Abnormalities of any of these structures can cause pain. Some gynecologic conditions which cause pelvic pain include ovarian cysts, endometriosis, adhesions (scar tissue), fibroids, and pelvic organ prolapse. 


      A complete history and physical exam are needed to help determine the cause. Further diagnostic testing may include ultrasound or a laparoscopy. Treatment may include observation, medication, or surgery.

    • Q: What is endometriosis?

      A: Endometriosis is a condition in which tissue that lines the inside of the uterus (womb) can be found on structures/organs outside the uterus. These tissue implants can bleed into the pelvic cavity during your period, become inflamed or swollen, and form scar tissue. The cause of this displaced tissue has many theories. Approximately, 10% of females have this condition.


      Symptoms range from none to severe depending on the location and severity. Possible symptoms include painful menstrual cramps, painful bowel movements, urinary discomfort, abnormal bleeding, painful sexual intercourse and difficulty becoming pregnant. Other conditions can sometimes cause similar complaints.


      There is no known cure for endometriosis. It can be diagnosed by laparoscopy. Most of the time the symptoms can be controlled either through destruction of the implants at the time of the laparoscopy or with medications. The extent of the surgery will depend on the patient's goals and the severity of her symptoms.

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