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The Journal of Obstetrics and... Aug 2021Postpartum hemorrhage (PPH) has remained the leading cause of maternal mortality. While anemia is a leading contributor to maternal morbidity, molecular, cellular and... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Postpartum hemorrhage (PPH) has remained the leading cause of maternal mortality. While anemia is a leading contributor to maternal morbidity, molecular, cellular and anemia-induced hypoxia, clinical studies of the relationship between prenatal-anemia and PPH have reported conflicting results. Therefore, our objective was to investigate the outcomes of studies on the relationships between prenatal anemia and PPH-related mortality.
MATERIALS AND METHODS
Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, and the Cochrane Central Register of Controlled Trials) were searched for studies published before August 2019. Keywords included "anemia," "hemoglobin," "postpartum hemorrhage," and "postpartum bleeding." Only studies involving the association between anemia and PPH were included in the meta-analysis. Our primary analysis used random effects models to synthesize odds-ratios (ORs) extracted from the studies. Heterogeneity was formally assessed with the Higgins' I statistics, and explored using meta-regression and subgroup analysis.
RESULTS
We found 13 eligible studies investigating the relationship between prenatal anemia and PPH. Our findings suggest that severe prenatal anemia increases PPH risk (OR = 3.54; 95% CI: 1.20, 10.4, p-value = 0.020). There was no statistical association with mild (OR = 0.60; 95% CI: 0.31, 1.17, p-value = 0.130), or moderate anemia (OR = 2.09; 95% CI: 0.40, 11.1, p-value = 0.390) and the risk of PPH.
CONCLUSION
Severe prenatal anemia is an important predictive factor of adverse outcomes, warranting intensive management during pregnancy. PROSPERO Registration Number: CRD42020149184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149184.
Topics: Anemia; Female; Humans; Maternal Mortality; Oxytocics; Postpartum Hemorrhage; Postpartum Period; Pregnancy
PubMed: 34002432
DOI: 10.1111/jog.14834 -
Tropical Medicine & International... Jul 2022Given that women of reproductive age in dengue-endemic areas are at risk of infection, it is necessary to determine whether dengue virus (DENV) infection during... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Given that women of reproductive age in dengue-endemic areas are at risk of infection, it is necessary to determine whether dengue virus (DENV) infection during pregnancy is associated with adverse outcomes. The aim of this systematic review and meta-analysis is to investigate the consequences of DENV infection in pregnancy on various maternal and foetal-neonatal outcomes.
METHODS
A systematic literature search was undertaken using PubMed, Google Scholar, and Embase till December 2021. Mantel-Haenszel risk ratios were calculated to report overall effect size using random effect models. The pooled prevalence was computed using the random effect model. All statistical analyses were performed on MedCalc Software.
RESULT
We obtained data from 36 studies involving 39,632 DENV-infected pregnant women. DENV infection in pregnancy was associated with an increased risk of maternal mortality (OR = 4.14 [95% CI, 1.17-14.73]), stillbirth (OR = 2.71 [95% CI, 1.44-5.10]), and neonatal deaths (OR = 3.03 [95% CI, 1.17-7.83]) compared with pregnant women without DENV infection. There was no significant statistical association established between maternal DENV infection and the outcomes of preterm birth, maternal bleeding, low birth weight in neonates, and risk of miscarriage. Pooled prevalences were 14.9% for dengue shock syndrome, 14% for preterm birth, 13.8% for maternal bleeding, 10.1% for low birth weight, 6% for miscarriages, and 5.6% for stillbirth.
CONCLUSION
DENV infection in pregnant women may be associated with adverse outcomes such as maternal mortality, stillbirth, and neonatal mortality. Hence, pregnant women should be considered an at-risk population for dengue management programmes.
Topics: Abortion, Spontaneous; Dengue; Female; Humans; Infant; Infant Mortality; Infant, Newborn; Maternal Mortality; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Premature Birth; Stillbirth
PubMed: 35689528
DOI: 10.1111/tmi.13783 -
International Journal of Gynaecology... Oct 2022To evaluate the risk levels for maternal and perinatal complications at > 40, > 45 and > 50 years old compared with younger controls. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the risk levels for maternal and perinatal complications at > 40, > 45 and > 50 years old compared with younger controls.
METHODS
Electronic databases were searched from their inception until March 2021. We included studies reporting pregnancy outcome in pregnant women aged 40, 45, and 50 years or older compared with controls at the time of delivery. Case reports and case series were excluded. The primary outcome was the incidence of stillbirth. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI). Heterogeneity was measured using I (Higgins I ). Subgroup analyses in women older than 45 years and in those older than 50 years were performed.
RESULTS
Twenty-seven studies, including 31 090 631 women, were included in the meta-analysis. The overall quality of the included studies was moderate to high. Most of the included studies were retrospective cohort studies (21/27), four were population-based studies, and two were cross-sectional studies. Women aged ≥40 years had significantly higher risk of stillbirth (RR 2.16, 95% CI 1.86-2.51), perinatal mortality, intrauterine growth restriction, neonatal death, admission to neonatal intensive care unit, pre-eclampsia, preterm delivery, cesarean delivery, and maternal mortality compared with women younger than 40 years old (RR 3.18, 95% CI 1.68-5.98). The increased risks for maternal mortality were 42.76 and 11.60 for women older than 50 years and for those older than 45 years, respectively, whereas those for stillbirth were 3.72 and 2.32. The risk of stillbirth and cesarean delivery was significantly higher in women >45 years compared with those aged 40-45 years, and in those aged >50 years compared with those aged 45-50 years. The risk of maternal mortality was significantly higher in women aged >50 years compared with those aged 40-45 (RR 60.40, 95% CI 13.28-274.74).
CONCLUSION
The risk of stillbirth, cesarean delivery, and maternal mortality increases with advancing maternal age. The risk ratios for maternal mortality were 3.18, 11.60, and 42.76 in women older than 40, older than 45, and older than 50 years, respectively. These data should be used when women with advanced maternal age are counseled regarding their risk in pregnancy.
SYSTEMATIC REVIEW REGISTRATION
The review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration No.: CRD42020208788).
Topics: Adult; Female; Humans; Infant, Newborn; Maternal Age; Middle Aged; Perinatal Death; Pregnancy; Pregnancy Outcome; Premature Birth; Retrospective Studies; Stillbirth
PubMed: 35044694
DOI: 10.1002/ijgo.14100 -
The Lancet. Global Health Jun 2021The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has been undertaken. We aimed to assess the collective evidence on the effects on maternal, fetal, and neonatal outcomes of the pandemic.
METHODS
We did a systematic review and meta-analysis of studies on the effects of the pandemic on maternal, fetal, and neonatal outcomes. We searched MEDLINE and Embase in accordance with PRISMA guidelines, from Jan 1, 2020, to Jan 8, 2021, for case-control studies, cohort studies, and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications, and intrapartum and neonatal outcomes before and during the pandemic. We also planned to record any additional maternal and offspring outcomes identified. Studies of solely SARS-CoV-2-infected pregnant individuals, as well as case reports, studies without comparison groups, narrative or systematic literature reviews, preprints, and studies reporting on overlapping populations were excluded. Quantitative meta-analysis was done for an outcome when more than one study presented relevant data. Random-effects estimate of the pooled odds ratio (OR) of each outcome were generated with use of the Mantel-Haenszel method. This review was registered with PROSPERO (CRD42020211753).
FINDINGS
The search identified 3592 citations, of which 40 studies were included. We identified significant increases in stillbirth (pooled OR 1·28 [95% CI 1·07-1·54]; I=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 [1·22-1·53; I=0%, two studies [both from low-income and middle-income countries], 1 237 018 and 2 224 859 pregnancies) during versus before the pandemic. Preterm births before 37 weeks' gestation were not significantly changed overall (0·94 [0·87-1·02]; I=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 [0·84-0·99]; I=63%; 12 studies, 159 987 and 635 118 pregnancies), where spontaneous preterm birth was also decreased (0·81 [0·67-0·97]; two studies, 4204 and 6818 pregnancies). Mean Edinburgh Postnatal Depression Scale scores were higher, indicating poorer mental health, during versus before the pandemic (pooled mean difference 0·42 [95% CI 0·02-0·81; three studies, 2330 and 6517 pregnancies). Surgically managed ectopic pregnancies were increased during the pandemic (OR 5·81 [2·16-15·6]; I=26%; three studies, 37 and 272 pregnancies). No overall significant effects were identified for other outcomes included in the quantitative analysis: maternal gestational diabetes; hypertensive disorders of pregnancy; preterm birth before 34 weeks', 32 weeks', or 28 weeks' gestation; iatrogenic preterm birth; labour induction; modes of delivery (spontaneous vaginal delivery, caesarean section, or instrumental delivery); post-partum haemorrhage; neonatal death; low birthweight (<2500 g); neonatal intensive care unit admission; or Apgar score less than 7 at 5 min.
INTERPRETATION
Global maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression. Some outcomes show considerable disparity between high-resource and low-resource settings. There is an urgent need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises.
FUNDING
None.
Topics: COVID-19; Female; Global Health; Humans; Infant, Newborn; Pregnancy; Pregnancy Outcome
PubMed: 33811827
DOI: 10.1016/S2214-109X(21)00079-6 -
PLoS Medicine Dec 2019Infection is an important, preventable cause of maternal morbidity, and pregnancy-related sepsis accounts for 11% of maternal deaths. However, frequency of maternal... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Infection is an important, preventable cause of maternal morbidity, and pregnancy-related sepsis accounts for 11% of maternal deaths. However, frequency of maternal infection is poorly described, and, to our knowledge, it remains the one major cause of maternal mortality without a systematic review of incidence. Our objective was to estimate the average global incidence of maternal peripartum infection.
METHODS AND FINDINGS
We searched Medline, EMBASE, Global Health, and five other databases from January 2005 to June 2016 (PROSPERO: CRD42017074591). Specific outcomes comprised chorioamnionitis in labour, puerperal endometritis, wound infection following cesarean section or perineal trauma, and sepsis occurring from onset of labour until 42 days postpartum. We assessed studies irrespective of language or study design. We excluded conference abstracts, studies of high-risk women, and data collected before 1990. Three reviewers independently selected studies, extracted data, and appraised quality. Quality criteria for incidence/prevalence studies were adapted from the Joanna Briggs Institute. We used random-effects models to obtain weighted pooled estimates of incidence risk for each outcome and metaregression to identify study-level characteristics affecting incidence. From 31,528 potentially relevant articles, we included 111 studies of infection in women in labour or postpartum from 46 countries. Four studies were randomised controlled trials, two were before-after intervention studies, and the remainder were observational cohort or cross-sectional studies. The pooled incidence in high-quality studies was 3.9% (95% Confidence Interval [CI] 1.8%-6.8%) for chorioamnionitis, 1.6% (95% CI 0.9%-2.5%) for endometritis, 1.2% (95% CI 1.0%-1.5%) for wound infection, 0.05% (95% CI 0.03%-0.07%) for sepsis, and 1.1% (95% CI 0.3%-2.4%) for maternal peripartum infection. 19% of studies met all quality criteria. There were few data from developing countries and marked heterogeneity in study designs and infection definitions, limiting the interpretation of these estimates as measures of global infection incidence. A limitation of this review is the inclusion of studies that were facility-based or restricted to low-risk groups of women.
CONCLUSIONS
In this study, we observed pooled infection estimates of almost 4% in labour and between 1%-2% of each infection outcome postpartum. This indicates maternal peripartum infection is an important complication of childbirth and that preventive efforts should be increased in light of antimicrobial resistance. Incidence risk appears lower than modelled global estimates, although differences in definitions limit comparability. Better-quality research, using standard definitions, is required to improve comparability between study settings and to demonstrate the influence of risk factors and protective interventions.
Topics: Anti-Bacterial Agents; Cesarean Section; Cross-Sectional Studies; Delivery, Obstetric; Female; Humans; Infections; Labor, Obstetric; Parturition; Peripartum Period; Postpartum Period; Pregnancy; Sepsis
PubMed: 31821329
DOI: 10.1371/journal.pmed.1002984 -
Nutrients Feb 2020Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during... (Meta-Analysis)
Meta-Analysis
Vitamin and Mineral Supplementation During Pregnancy on Maternal, Birth, Child Health and Development Outcomes in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.
Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child, but could be mitigated by interventions like micronutrient supplementation. To our knowledge, this is the first systematic review that aimed to compile evidence from both efficacy and effectiveness trials, evaluating different supplementation interventions on maternal, birth, child health, and developmental outcomes. We evaluated randomized controlled trials and quasi-experimental studies published since 1995 in peer-reviewed and grey literature that assessed the effects of calcium, vitamin A, iron, vitamin D, and zinc supplementation compared to placebo/no treatment; iron-folic (IFA) supplementation compared to folic acid only; multiple micronutrient (MMN) supplementation compared to IFA; and lipid-based nutrient supplementation (LNS) compared to MMN supplementation. Seventy-two studies, which collectively involved 314 papers (451,723 women), were included. Meta-analyses showed improvement in several key birth outcomes, such as preterm birth, small-for-gestational age (SGA) and low birthweight with MMN supplementation, compared to IFA. MMN also improved child outcomes, including diarrhea incidence and retinol concentration, which are findings not previously reported. Across all comparisons, micronutrient supplementation had little to no effect on mortality (maternal, neonatal, perinatal, and infant) outcomes, which is consistent with other systematic reviews. IFA supplementation showed notable improvement in maternal anemia and the reduction in low birthweight, whereas LNS supplementation had no apparent effect on outcomes; further research that compares LNS and MMN supplementation could help understand differences with these commodities. For single micronutrient supplementation, improvements were noted in only a few outcomes, mainly pre-eclampsia/eclampsia (calcium), maternal anemia (iron), preterm births (vitamin D), and maternal serum zinc concentration (zinc). These findings highlight that micronutrient-specific supplementation should be tailored to specific groups or needs for maximum benefit. In addition, they further contribute to the ongoing discourse of choosing antenatal MMN over IFA as the standard of care in LMICs.
Topics: Anemia; Child; Child Development; Child, Preschool; Developing Countries; Dietary Supplements; Female; Humans; Income; Infant; Maternal Nutritional Physiological Phenomena; Micronutrients; Minerals; Poverty Areas; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Premature Birth; Randomized Controlled Trials as Topic; Vitamins
PubMed: 32075071
DOI: 10.3390/nu12020491 -
Annals of the New York Academy of... Aug 2019Maternal anemia is a well-recognized global health problem; however, there remain questions on specific hemoglobin (Hb) thresholds that predict health risk or protection... (Meta-Analysis)
Meta-Analysis
Maternal anemia is a well-recognized global health problem; however, there remain questions on specific hemoglobin (Hb) thresholds that predict health risk or protection for mother and child. We conducted a systematic review and meta-analysis to examine the associations of maternal Hb concentrations with a range of maternal and infant health outcomes, accounting for the timing of measurement (preconception, and first, second, and third trimesters), etiology of anemia, and cutoff category. The systematic review included 272 studies and the meta-analysis included 95 studies. Low maternal Hb (<110 g/L) was associated with poor birth outcomes (low birth weight, preterm birth, small-for-gestational-age (SGA), stillbirth, and perinatal and neonatal mortality) and adverse maternal outcomes (postpartum hemorrhage, preeclampsia, and blood transfusion). High maternal Hb (>130 g/L) was associated with increased odds of SGA, stillbirth, preeclampsia, and gestational diabetes. Relationships varied by the timing of measurement and cutoff category (stronger associations with lower cutoffs); limited data were available on anemia etiology. There were insufficient data for other maternal outcomes and long-term child health outcomes. Current data are insufficient for determining if revisions to current Hb cutoffs are required. Pooled high-quality individual-level data analyses, as well as prospective cohort studies, would be valuable to inform the reevaluation of Hb cutoffs.
Topics: Child Health; Female; Hemoglobins; Humans; Infant, Small for Gestational Age; Maternal Health; Obstetric Labor Complications; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Premature Birth
PubMed: 30994929
DOI: 10.1111/nyas.14093 -
Healthcare (Basel, Switzerland) Feb 2022Hypertension in pregnancy causes significant maternal and fetal mortality and morbidity. A comprehensive assessment of the effectiveness of antihypertensive drugs for... (Review)
Review
BACKGROUND
Hypertension in pregnancy causes significant maternal and fetal mortality and morbidity. A comprehensive assessment of the effectiveness of antihypertensive drugs for severe hypertension during pregnancy is needed to make informed decisions in clinical practice. This systematic review aimed to assess the efficacy and safety of antihypertensive drugs in severe hypertension during pregnancy.
METHODS
A systematic review using the electronic databases MEDLINE (PubMed) and Cochrane Library was performed until August 2021. The risk-of-bias 2 tool was used to assess the risk-of-bias in each study included. Meta-analysis was conducted to assess heterogeneity and to estimate the pooled effects size.
RESULTS
Seventeen studies fulfilled the inclusion criteria and 11 were included in the meta-analysis. Nifedipine was estimated to have a low risk in persistent hypertension compared to hydralazine (RR 0.40, 95% CI 0.23-0.71) and labetalol (RR 0.71, 95% CI 0.52-0.97). Dihydralazine was associated with a lower risk of persistent hypertension than ketanserin (RR 5.26, 95% CI 2.01-13.76). No difference was found in the risk of maternal hypotension, maternal and fetal outcomes, and adverse effects between antihypertensive drugs, except for dihydralazine, which was associated with more adverse effects than ketanserin.
CONCLUSIONS
Several drugs can be used to treat severe hypertension in pregnancy, including oral/sublingual nifedipine, IV/oral labetalol, oral methyldopa, IV hydralazine, IV dihydralazine, IV ketanserin, IV nicardipine, IV urapidil, and IV diazoxide. In addition, nifedipine may be preferred as the first-line agent. There was no difference in the risk of maternal hypotension, maternal and fetal outcomes, and adverse effects between the drugs, except for adverse effects in IV dihydralazine and IV ketanserin.
PubMed: 35206939
DOI: 10.3390/healthcare10020325 -
Clinical Microbiology and Infection :... Jan 2021Previous outbreaks of severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV) have been associated with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Previous outbreaks of severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV) have been associated with unfavourable pregnancy outcomes. SARS-CoV-2 belongs to the human coronavirus family, and since this infection shows a pandemic trend it will involve many pregnant women.
AIMS
This systematic review and meta-analysis aimed to assess the impact of coronavirus disease 19 (COVID-19) on maternal and neonatal outcomes.
SOURCES
PubMed, EMBASE, MedRxiv, Scholar, Scopus, and Web of Science databases were searched up to 8th May 2020. Articles focusing on pregnancy and perinatal outcomes of COVID-19 were eligible. Participants were pregnant women with COVID-19.
CONTENT
The meta-analysis was conducted following the PRISMA and MOOSE reporting guidelines. Bias risk was assessed using the Joanna Briggs Institute (JBI) manual. The protocol was registered with PROSPERO (CRD42042020184752). Twenty-four articles, including 1100 pregnancies, were selected. The pooled prevalence of pneumonia was 89% (95%CI 70-100), while the prevalence of women admitted to the intensive care unit was 8% (95%CI 1-20). Three stillbirths and five maternal deaths were reported. A pooled prevalence of 85% (95%CI 72-94) was observed for caesarean deliveries. There were three neonatal deaths. The prevalence of COVID-19-related admission to the neonatal intensive care unit was 2% (95%CI 0-6). Nineteen out of 444 neonates were positive for SARS-CoV-2 RNA at birth. Elevated levels of IgM and IgG Serum antibodies were reported in one case, but negative swab.
IMPLICATIONS
Although adverse outcomes such as ICU admission or patient death can occur, the clinical course of COVID-19 in most women is not severe, and the infection does not significantly influence the pregnancy. A high caesarean delivery rate is reported, but there is no clinical evidence supporting this mode of delivery. Indeed, in most cases the disease does not threaten the mother, and vertical transmission has not been clearly demonstrated. Therefore, COVID-19 should not be considered as an indication for elective caesarean section.
Topics: Adult; COVID-19; Cesarean Section; Female; Humans; Infant; Infant Mortality; Infant, Newborn; Intensive Care Units, Neonatal; Live Birth; Maternal Mortality; Pregnancy; Prevalence; SARS-CoV-2; Stillbirth
PubMed: 33148440
DOI: 10.1016/j.cmi.2020.10.007 -
Obstetrics and Gynecology Apr 2020To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the United States and to highlight...
OBJECTIVE
To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the United States and to highlight opportunities for intervention and future research.
DATA SOURCES
We performed a systematic search using Ovid MEDLINE, CINAHL, Popline, Scopus, and ClinicalTrials.gov (1990-2018) using MeSH terms related to maternal mortality, morbidity, and social determinants of health, and limited to the United States.
METHODS OF STUDY SELECTION
Selection criteria included studies examining associations between social determinants and adverse maternal outcomes including pregnancy-related death, severe maternal morbidity, and emergency hospitalizations or readmissions. Using Covidence, three authors screened abstracts and two screened full articles for inclusion.
TABULATION, INTEGRATION, AND RESULTS
Two authors extracted data from each article and the data were analyzed using a descriptive approach. A total of 83 studies met inclusion criteria and were analyzed. Seventy-eight of 83 studies examined socioeconomic position or individual factors as predictors, demonstrating evidence of associations between minority race and ethnicity (58/67 studies with positive findings), public or no insurance coverage (21/30), and lower education levels (8/12), and increased incidence of maternal death and severe maternal morbidity. Only 2 of 83 studies investigated associations between these outcomes and socioeconomic, political, and cultural context (eg, public policy), and 20 of 83 studies investigated material and physical circumstances (eg, neighborhood environment, segregation), limiting the diversity of social determinants of health studied as well as evaluation of such evidence.
CONCLUSION
Empirical studies provide evidence for the role of race and ethnicity, insurance, and education in pregnancy-related mortality and severe maternal morbidity risk, although many other important social determinants, including mechanisms of effect, remain to be studied in greater depth.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42018102415.
Topics: Female; Healthcare Disparities; Humans; Maternal Mortality; Pregnancy; Social Determinants of Health; United States
PubMed: 32168209
DOI: 10.1097/AOG.0000000000003762