dysfunctional uterine bleeding
DESCRIPTION
Dysfunctional Uterine Bleeding. Yasser Orief M.D. Fellow Lübeck University, Germany. DAOG, Auvergné University, France. Case 1. C/O Irregular menses x 6 months 23 yo G1P1 2 menses in past 6 months, heavier and longer than normal. Menses previously regular since menarche - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/1.jpg)
Dysfunctional Uterine Bleeding
Yasser Orief M.D.Fellow Lübeck University, Germany.DAOG, Auvergné University, France.
![Page 2: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/2.jpg)
Case 1 C/O Irregular menses x 6 months 23 yo G1P1 2 menses in past 6 months, heavier and
longer than normal. Menses previously regular since
menarche No contraception x 3 years, desires
pregnancy 15 kg weight gain since birth of 3 year
old daughter
![Page 3: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/3.jpg)
Case 2
C/O: Heavy menses x 4 months
44 yo G1P1. Normal, regular menses until 4 months ago
PMH: negativePSH: BTLMeds: none
![Page 4: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/4.jpg)
DEFINITIONAny deviation in normal frequency, duration or amount of menstruation in women of reproductive age.
NORMAL MENSES
Normal AbnormalDuration 4-6 days <2d, >7d
Volume 30-35cc >80cc
Cycle length 21-35d <21d, >35
![Page 5: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/5.jpg)
CLINICAL TYPESPolymenorrhoeaOligomenorrhea
MenorrhagiaMetrorrhagiaMenometrorrhagia
Intermenstual bleedingHypomenorrhoea
![Page 6: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/6.jpg)
CAUSES. Dysfunctional uterine bleeding. Pregnancy complications . Genital disease Tumors Endometriosis. Infection IUCD. . Prolapse
. Extragenital
.Endocrine. Iatrogenic. Haematological Emotional. Chronic systemic disease. Obesity.
![Page 7: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/7.jpg)
DefinitionAbnormal uterine bleeding in absence of pelvic organ disease or a systemic disorder
Incidence 60 % of AUB
Dysfunctional uterine bleeding
![Page 8: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/8.jpg)
Endocrine abnormality EndometriumAnovulatory90% Insufficient follicles Inadequate proliferative or atrophic Persistent follicles Proliferative or hyperplastic Ovulatory10% Short proliferative phase Normal Long proliferative phase Normal Insufficient C. luteum Irregular or deficient secretory leading to short luteal phase Persistent C luteum leading to Irregular shedding long luteal phase
Pathology
![Page 9: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/9.jpg)
DiagnosisAim: 1. Nature & severity of bleeding2. Exclusion of organic causes3. Ovulatory or anovulatoryHow:HistoryExaminationInvestigations
![Page 10: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/10.jpg)
Life Phase Ovulatory Status Etiology
R/O Pregnancy
Adolescent Likely anovulation
Consider bleeding disorder Pregnancy
Reproductive age
(Usually DUB)
Ovulatory(Secretory)
Anovulatory (Proliferative)
HormonalDUB
Anatomic
Coagulopathy R/O PregnancyPerimenopause Early EMB/TV Sono
Postmenopause R/O Endometrial CA
![Page 11: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/11.jpg)
I. History:1. Personal: age, wishes of the patient2. Menstrual3. Obstetric4. Past5. Present: amount, duration, color, smell, relation to sexual intercourse, associated symptoms
![Page 12: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/12.jpg)
II. Examination:1. General: pallor, endocrinopathy, coagulopathy, pregnancy
2. Abdominal: liver, spleen, pelvi abdominal mass
3. Pelvic: origin of the bleeding, cause
![Page 13: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/13.jpg)
III.InvestigationsLaboratory1. CBC2. B-hCG3. Hormonal profile (Prolactin, TSH, FSH, LH, free & total T4)
4. Coagulation profile (Prothrombin time, partial thrmoplastin time, bleeding time, platelets, Von Willebrand factor)
LocalU/S D & CPap smear HysteroscopyEndometrial biopsy
![Page 14: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/14.jpg)
Ultrasonography
1. TAS2. TVS3. Saline sonography
![Page 15: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/15.jpg)
Endometrial biopsyIndications: .Between 20 & 40.If endometrial thickness on TVS is >12mm, endometrial sample should be taken to exclude endometrial hyperplasia (Grade A).
Failure to obtain sufficient sample for H/P does not require further investigation unless the endometrial thickness is >12 mm (Grade B)
Aim: diagnosis of the type of the bleeding
Advantages: An adequate & acceptable screening procedure in females under 40 yrs
![Page 16: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/16.jpg)
Methods: As an outpatient procedure, without general anesthesia.1.Pipelle curette2.Sharman curette, Gravlee jet washer, Isac cell sampler3.Accrette4.vabra aspirator
![Page 17: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/17.jpg)
D & CIndications:1. Mandatory after 4o yrs 2. Persistent or recurrent bleeding between 20 & 40 yrsAim:1.Diagnosis of organic disease2.Diagnosis of the type of the endometrium3.Arrest of the bleedingDisadvantages: 1.Small lesions can be missed2.The sensitivity of detecting intrauterine pathology is only 65%
![Page 18: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/18.jpg)
Fractional curretageIndication: >40 yrs
Method: 3 samples:
• endocervical,
• lower segment •& upper segment
![Page 19: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/19.jpg)
Hysteroscopy:Indications: Mandatory after 40 yrs
1. Erratic menstrual bleeding2. Failed medical treatment3. TVS suggestive of intrauterine pathology e.g. polyp, fibroid (Grade B)
![Page 20: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/20.jpg)
Advantages over D &C1.The whole uterine cavity can be visualized 2.Very small lesions such as polyps can be identified & biopsied or removed3.Bleeding from ruptured venules & echymoses can be readily identified4.The sensitivity in detecting intrauterine pathology is 98% 5.Outpatient procedure
Disadvantages1.Cost of the apparatus2.Lack of availability or experience
![Page 21: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/21.jpg)
Diagnostic algorithm
![Page 22: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/22.jpg)
Evaluation TestsChoices are extensive Not practical or cost effective to do every testThey are not used as general screening tests for all
women with DUB.Selection should be tailored to suspected causes
from the history and physical exam.Stepwise process should be considered
![Page 23: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/23.jpg)
Step One:
Rapid assessment of vital signsHemodynamically stableHemodynamically unstable
Step Two: (simultaneous with step 1)Baseline CBC, quantitative beta hCG
![Page 24: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/24.jpg)
Step Three (adolescents): Low risk for intracavitary or cancerous lesionHigh coagulopathy risk
coagulation profileif abnormal, further testing and consultation is
warrantedIf screen is normal, a diagnosis of anovulatory DUB
is assumed and appropriate therapy begun
![Page 25: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/25.jpg)
Step Four (Adults):Transvaginal ultrasound
Lesion presentbiopsyhysteroscopy
No lesionHigh risk for neoplasia
endometrial biopsyLow risk for neoplasia
can assume DUB and treat
![Page 26: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/26.jpg)
Step Five (Adults):Secretory endometrium
>50% have polyp or submucosal fibroid
next step is dx hysteroscopylesion present
biopsy/excisionlesion absent
consider systemic diseaseassume DUB and treat if disease
absent
![Page 27: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/27.jpg)
Step Six (Adults):Proliferative endometrium or
hyperplasia without atypiaassume DUB manage according to desired fertility
Hyperplasia with atypia or CAtreat accordingly
![Page 28: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/28.jpg)
Treatment
Medical
Hormonal
Non hormonal
Surgical
Ablation
Hystrectomy
![Page 29: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/29.jpg)
MedicalI. Hormonal1.Progestagen2.Oestrogen3.COCP4.Danazol5.GnrH agonist6.Levo-nova (Merina)
II. Non –hormonalProstaglandin synthetase inhibitors (PSI) (Ponstan)Antifibrinolytics (Cyclocapron)Ethamsylate (Diacynon)
Surgical1. Endometrial ablation2. Hysterectomy
Treatment
![Page 30: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/30.jpg)
<20 yrs 20-40 yrs > 40 yrs
Medical Always First resort after endometrial biopsy Temporizing & if surgery is refused or imminent menopause
Surgical Never Seldom, only if medical treatment fail First resort if bleeding is recurrent
Strategy of treatment
![Page 31: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/31.jpg)
Antifibrinolytics: Tranexamic acid (Cyklokapron)
Mechanism of action: The endometrium possess an active fibrinolytic system & the fibrinolytic activity is higher in menorrhagia. Effect: Greater reduction of menstrual bleeding than other therapies (PSI, oral luteal phase progestagen & etamsylate)(Cochrane library,2002).
Medical treatment
![Page 32: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/32.jpg)
Side effects:•Dose related. •Nausea , vomiting, diarrhea, dizziness. •Rarely transient color vision disturbance, intracranial thrombosis. But, no evidence that tranxemic acid increases the risk in absence of past or family history of thrombophilia.
Dose: 3-6 gm /d for the first 3 days of the cycle
![Page 33: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/33.jpg)
PSI:Mechanism; the endometrium is a rich source of PGE2 & PGF2œ & its concentrations are greater in menorrhagia. PSI decreases endometrial PG concentrations.Effect: PSI decreased menstrual blood by 24% & norethisterone by 20%.Dose: mefenamic acid (Ponstan) 500 mg tds during menses. Side effects: •Nausea, vomiting, gastric discomfort, diarrhea, dizziness. •Rarely: haemolytic anemia, thrombocytopenia.•The degree of reduction of MBL is not as great as it is with tranxamic acid but PSI have a lower side effect profile.
![Page 34: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/34.jpg)
Etamsylate (Dicynone)Mechanism of action:
• maintain capillary integrity• anti-hyalurunidase activity• inhibitory effect on PG
Dose: 500 mg bid, starting 5 days before anticipated onset of the cycle & continued for 10 days
Effect: 20% reduction in MBL. There is no conclusive evidence of the effectiveness of etamsylate in reducing menorrhagea (Grade A)
Side effects: headache, rash, nausea
![Page 35: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/35.jpg)
Hormonal treatmentAcute bleeding
Estrogen therapy Oral conjugated equine estrogens
10mg a day in four divided doses treat for 21 to 25 daysmedroxyprogesterone acetate, 10 mg per day for the last 7
days of the treatment if bleeding not controlled, consider organic cause
OR25 mg IV every 4 to 12 hours for 24 hours, then switch to
oral treatment as above.Bleeding usually diminishes within 24 hours
![Page 36: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/36.jpg)
Hormonal treatment
Acute bleeding (continued)High dose estrogen-progestin therapy
use combination OCP’s containing 35 micrograms or less of ethinylestradiol
four tablets per daytreat for one week after bleeding stopsmay not be as successful as high dose estrogen
treatment
![Page 37: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/37.jpg)
Hormonal treatmentRecurrent bleeding episodes
combination OCP’sone tablet per day for 21 days
intermittent progestin therapymedroxyprogesterone acetate, 10mg per
day, for the first 10 days of each monthhigher doses and longer therapy my be
tried if no initial response prolonged use of high doses is associated
with fatigue, mood swings, weight gain, lipid changes
![Page 38: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/38.jpg)
Hormonal treatmentRecurrent bleeding episodes
(continued)Progesterone releasing IUDlevonova, Mirena: Delivers 20ug LNG /d.
for 5 yrMetraplant: T shaped IUCD &
levonorgestrel on the shoulder & stemAzzam IUCD: Cu T & levonorgestrel on the
stem
Effect 1.Comparable to endometrial resection for management of DUB.2.Superior to PSI & antifibrinolytics3.May be an alternative to hysterectomy in some patients
![Page 39: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/39.jpg)
Side effects1. BTB in the first cycles2. 20% develop amenorrhea within 1 yr3. Functional ovarian cysts
Special indications1. Intractable bleeding associated with chronic illness2. Ovulatory heavy bleeding
![Page 40: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/40.jpg)
Hormonal treatmentDanazol:
Synthetic androgen with antioestrogenic & antiprogestagenic activityMechanism; inhibits the release of pituitary GnRh & has direct suppressive effect on the endometriumEffect: reduction in MBL (more effective than PSI) & amenorhea at doses >400 mg/d
![Page 41: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/41.jpg)
Side effects:
•headache, weight gain, acne, rashes, hirsuitism, •mood & voice changes, flushes, muscle spasm,• reduced HDL, diminished breast size. •Rarely: cholestatic jaundice.IIt is effective in reducing blood loss but side effects limit it to a second choice therapy or short term use only (Grade A)
Dose: 200 mg/d
![Page 42: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/42.jpg)
Hormonal treatmentGnRh analog
• Treatment results in medical menopause• Blood loss returns to pretreatment levels when discontinued
• Treatment usually reserved for women with ovulatory DUB that fail other medical therapy and desire future fertility
• Use add back therapy to prevent bone loss secondary to marked hypoestrogenism
![Page 43: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/43.jpg)
Endometrial ablationI.Hysteroscopic: 1. Laser2. Electrosurgical: a. Roller ball b. ResectionII.Non-hysteroscopic:1. Thermachoice2. Microwave.
Surgical treatment
![Page 44: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/44.jpg)
Indications:1. Failure of medical treatment2. Family is completed3. Uterine cavity <10 cm4. Submucos fibroid <5 cm5. Endometrium is normal or low risk hyperplasia.
Complications 1. Uterine perforation2. Bleeding3. Infection.4. Fluid overload5. Gas embolism
![Page 45: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/45.jpg)
HysterectomyIndications:1. Failure of medical
treatment2. Family is completedRoutes:1. Abdominal 2. Vaginal 3. Laparoscopic
Advantages:1. Complete cure2. Avoidance of long term medical treatment3. Removal of any missed pathology
Disadvantages:1.Major operation2.Hospital admission3.Mortality & morbidity
![Page 46: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/46.jpg)
Case 1
23 yo G1P1Oligomenorrhea15 kg weight gainDesires fertilityPMH: negativeSH: husband in USA, due
to return in 3 months
![Page 47: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/47.jpg)
Physical Exam
BP 136/82, Wt 95, BMI 31kg/m2Normal Head, neck, heart, lung, abdominal
examNormal breast, pelvic examNo signs hyperandrogenismSkin: normal, no acne, no hirsuitism, no
acanthosis nigricansDifferential?
![Page 48: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/48.jpg)
Differential DiagnosisPregnancyPolycystic Ovary DiseaseThyroid diseaseProlactinoma
![Page 49: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/49.jpg)
Labs/studies?
![Page 50: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/50.jpg)
LabsHCG negativeTSH 2.9Prolactin normalLH/FSH normalDHEA sulfate normalTestosterone not doneCBC normalGC/chlamydia negativeNormal Pap within previous year
![Page 51: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/51.jpg)
UltrasoundNormal uterusAt least 10 small follicles in the R ovary, multiple
small follicles in L ovaryDominant follicle left ovary, 15 mmDiagnosis?
![Page 52: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/52.jpg)
Case 1 Working diagnosis: PCOS
Management and CourseNutritional counseling for weight lossNo medications, since patient trying to
conceiveCould consider clomiphene and/or
metforminPatient succeeded in losing 10 kg and
regular menses returned
![Page 53: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/53.jpg)
Case 244 yo G1P1Heavy menses x 4 monthsDifferential Diagnosis?
![Page 54: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/54.jpg)
Physical Exam
BP 118/56, BMI 25.7Neck, Heart, Lungs, Abdomen normalBreasts: normalPelvic normalLabs?
![Page 55: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/55.jpg)
LabsHCG negHb 10, Hct 32, Platelets normal, low-
normal RBC indicesFSH/LH normalTSH normalPap normalEndometrial biopsy: normal, no
hyperplasia
![Page 56: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/56.jpg)
Case 2 Diagnosis?
![Page 57: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/57.jpg)
Case 2: Diagnosis and ManagementPerimenopausal anovulatory bleedingNon hormonal treatmentFeSO4, repeat Hct in 4-6 weeksConsider OCPs if menorrhagia persists
![Page 58: Dysfunctional Uterine Bleeding](https://reader033.vdocuments.mx/reader033/viewer/2022061517/56816641550346895dd9b212/html5/thumbnails/58.jpg)
Thank you For
your attention