Puerperium

PuerperiumBy  dr. sumeya

puerperium
Puerperium : Is period during which the reproductive organs and all the system of the body returns to their normal condition following the delivery of the placenta and The puerperium refers to the 6-week period following completion of the third stage of labour.

puerperium

When the endocrine influences of the placenta removed the physiological changes of pregnancy is reversed

The Principal Changes

Uterine Involution :

Involution is the process by which the postpartum uterus, weighing about 1 kg, returns to its prepregnancy state of less than 100 g. Immediately afterdelivery, the uterine fundus lies about 4 cm below the umbilicus or, more accurately, 12 cm above the symphysis pubis. However, within 2 weeks, the uterus can no longer be palpable above the symphysis. Involution occurs by a process of autolysis, where by muscle cells diminish in size as a result of enzymatic digestion of cytoplasm. This has virtually no effect on the number of muscle cells, and the excess protein produced from autolysis is absorbed into the bloodstream and excreted in the urine

Involution appears to be accelerated by the release of oxytocin in women who are breastfeeding, as the uterus is smaller than in those who are bottle-feeding. The height of the uterine fundus is measured daily to ascertain the trend in involution. causes of delayed involution• Full bladder• Loaded rectum• Uterine infection• Retained products of conception• Fibroids• Broad ligament haematoma Uterine involution :

Retained products of placenta

Infection at the uterus

Para-vaginal haematoma

A delay in involution in the absence of any other signs or symptoms, e.g. bleeding, is of no clinical significance.

Genital tract changes

Following delivery of the placenta, the lower segment of the uterus and the cervix appear fl abby and there may be small cervical lacerations. In the first few days, the cervix can readily admit two fingers, but by the end of the first week it should become increasingly difficult to pass more than one finger, and certainly by the end of the second week the internal os should be closed. However, the external os can remain open permanently, giving a characteristic appearance to the parous cervix.


The vagina almost , always shows evidence of parity . In the first few days of puerperium , the vaginal walls are smooth , soft and edematous . The distention which has resulted from labor remains for a few days but the return to the normal capacity quit quick . the episiotomies or vaginal and perennial tears healed well provide adequate suturing has been undertaken . Healing may be impaired in the presents of infection or haematoma but even if this happens, healing by granulation is usually occurs.

Lochia

Lochia is the blood-stained uterine discharge that is comprised of blood and necrotic decidua. Only the superfi cial layer of decidua becomes necrotic and is sloughed off. The basal layer adjacent to the myometrium is involved in the regeneration of new endometrium and this regeneration is complete by the third week. During the first few days after delivery, the lochia is red; this gradually changes to pink as the endometrium is formed, and then ultimately becomes serous by the second week.

Persistent red lochia

Persistent red lochia suggests delayed involution that is usually associated with infection or a retained piece of placental tissue. Offensive lochia, which may be accompanied by pyrexia and a tender uterus, suggests infection and should be treated with a broad-spectrum antibiotic. Retained placental tissue is associated with increased red blood cell loss and clots, and this may be suspected if the placenta and membranes were incomplete at delivery. Management includes the use of antibiotics and evacuation of retained products under regional or general anaesthesia.

Other systems

During the first few days the bladder and urethra may show evidence minor trauma sustained at delivery but don't usually remains in evidence for long . The physiological hydroureter & hydronephrosis will disappears within 6 weeks . there is usually a diuresis during first day of the puerperium and there is fall in plasma volume.

Management of normal puerperium

Management of normal puerperium
The majority of mothers are perfectly well during the puerperium and should be encouraged to establish normal activities. Immediately following the delivery of the placenta observation of :

Daily maternal observations include temperature, pulse, blood pressure, urinary function, bowel function, breast examination and feeding, assessment of uterine involution, appearance of lochia, perineal inspection, examination of legs and pelvic floor exercises. These observations should be made more frequently in high-risk women or if an abnormality has been detected, for example the presence of maternal pyrexia. It is traditional to check haemoglobin levels on day 3 unless otherwise indicated, and most women who are particularly symptomatic should be transfused if their haemoglobin level at this time is 8 g/dL.

Puerperal disorders

Perineal complications
Perineal discomfort is the single major problem for mothers, and about 80 per cent complain of pain in the fi rst 3 days after delivery, with a quarter continuing to suffer discomfort at day 10. Discomfort is greatest in women who sustain spontaneous tears or have an episiotomy, but especially following instrumental delivery. A number of non-pharmacological and pharmacological therapies have been used empirically with varying degrees of success.

However, local cooling (with crushed ice, witch hazel or tap water) and topical anaesthetics, such as 5 per cent lignocaine gel, provide short-term symptomatic relief. Effective analgesia following perineal trauma can be achieved with regular paracetamol. If necessary, diclofenac given rectally or orally may also be added. Codeine derivatives are not preferable, as they have a tendency to cause constipation.

Infections of the perineum are generally uncommon considering the risk of bacterial contamination during delivery; therefore, when signs of infection (redness, pain, swelling and heat) occur, especially when associated with a raised temperature, these must be taken seriously. Swabs for microbiological culture must be taken from the infected perineum, and broad-spectrum antibiotics should be commenced. If there is a collection of pus, drainage should be encouraged by removal of any skin sutures; otherwise infection would spread, with increasing morbidity and a poor anatomical result.



Spontaneous opening of repaired perineal tears and episiotomies is usually the result of secondary infection. Surgical repair should never be attempted in the presence of infection. The wound should be irrigated twice daily and healing should be allowed to occur by secondary intention. If there is a large, gaping wound, secondary repair should only be performed when the infection has cleared, there is no cellulitis or exudate present and healthy granulation tissue can be seen.

Bladder function

Voiding difficulty and over-distension of the bladder are not uncommon after childbirth, especially if regional anaesthesia (epidural/spinal) has been used. It is now known that after epidural anaesthesia the bladder may take up to 8 hours to regain normal sensation. During this time, about 1 L of urine may be produced and therefore if urinary retention occurs, considerable damage may be inflicted on the detrusor muscle. Over-stretching of the detrusor muscle can dampen bladder sensation and make the bladder hypocontractile, particularly with fibrous replacement of smooth muscle.


In this situation, overfl ow incontinence of small amounts of urine may erroneously be assumed to be normal voiding. 1-Fluid overloading prior to epidural analgesia,2- the antidiuretic effect of high concentrations of oxytocin during labour, increased postpartum diuresis (particularly in the presence of oedema) and3- increased fl uid intake by breastfeeding mothers all contribute to the increased urine production in the puerperium. Therefore, an intake/output chart alone may not detect incomplete emptying of the bladder.


Women who have undergone a1- traumatic delivery, such as a difficult instrumental delivery, or who have 2-suffered multiple/extended lacerations or a3- vulvovaginal haematoma, may find it difficult to void because of pain or periurethral oedema. Other causes of pain, such as 1-prolapsed haemorrhoids, anal 2-fissures, 3-abdominal wound haematoma or 4-even stool impaction of the rectum, may interfere with voiding. The midwife needs to be particularly vigilant after an epidural or spinal anaesthetic to avoid bladder distension. The distended bladder should either be palpable as a suprapubic cystic mass or it may displace the uterus laterally or upwards, thereby increasing the height of the uterine fundus.


In order to minimize the risk of over-distension of the bladder in women undergoing a Caesarean section under regional anaesthesia, a urinary catheter may be left in the bladder for the first 12–24 hours. The benefi t of leaving a catheter in situ for about 12 hours after epidural insertion should be evaluated against a vigorously enforced postpartum voiding protocol and the small risk of urinary tract infection. However, any woman who has not passed urine within 4 hours of delivery should be encouraged to do so before resorting to catheterization. In general, a clean-catch specimen of urine should be sent for microscopy,

culture and sensitivity, and if the residual urine in the bladder is 300 mL, a catheter should be left in to allow free drainage for 48 hours. Although vaginal delivery is strongly implicated in the development of urinary stress incontinence, it rarely poses a problem in the early puerperium. Therefore, any incontinence should be investigated to exclude a vesicovaginal, urethrovaginal or, rarely, ureterovaginal fi stula. Obstetric fistulae are a source of considerable morbidity in developing countries. Pressure necrosis of the bladder or urethra may occur following prolonged obstructed labour, and incontinence usually occurs in the second week when the slough separates. Small fistulae may close spontaneously after a few weeks of free bladder drainage; large fi stulae will require surgical repair by a specialist.

Bowel function

Constipation is a common problem in the puerperium. This may be due to an1- interruption in the normal diet and2- possible dehydration during labour. Advice on adequate fl uid intake and increase in fi bre intake may be all that is necessary. However, constipation may also be the result of fear of evacuation due to pain from a1- sutured perineum, 2 -prolapsed haemorrhoids or3- anal fissures. Avoidance of constipation and straining is of utmost importance in women who have sustained a third-degree or fourth-degree tear.



A large, hard bolus of stool in this situation would disrupt the repaired anal sphincter and cause anal incontinence. It is important to ensure that these women are prescribed lactulose and ispaghula husk (Fybogel, Regulan) or methylcellulose immediately after the repair, for a period of 2 weeks.


The high prevalence of anal incontinence and faecal urgency following childbirth has only recently been recognized. One prospective study using anal endosonography has identified evidence of occult anal sphincter trauma in one-third of primiparous women, although only 13 per cent admitted to defaecatory symptoms by 6 weeks postpartum. Larger, retrospective, short-term studies of parous women indicate a prevalence of between 6 and 10 per cent.Long-term anal incontinence following primary repair of a third-degree or fourth-degree tear occurs in 5 per cent of women, and anovaginal/rectovaginal fi stulae occur in 2–4 per cent of these women

It is therefore important to consider a fistula as a cause of anal incontinence in the postpartum period particularly if the woman complains of passing wind or stool per vagina. Approximately 50 per cent of small anovaginal fi stulae will close spontaneously over a period of months, but larger fi stulae will require formal repair.

Secondary postpartum haemorrhage

Secondary postpartum haemorrhage (PPH) is defi ned as fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery). The most common time for secondary PPH is between days 7 and 14, and the cause is most commonly attributed to retained placental tissue. Associated features include 1-crampy abdominal pain, 2-a uterus larger than appropriate,3- passage of bits of placental tissue or tissue within the cervix and 4-symptoms and signs of infection.

The management

The management of heavy bleeding includes an 1-intravenous infusion, 2-cross-match of blood, 3-Syntocinon,4- an examination under anaesthesia and 5-evacuation of the uterus.6- Antibiotics should be given if placental tissue is found, even without evidence of overt infection. If blood loss is not excessive, the use of pelvic ultrasound to exclude retained products is contentious; distinction between retained products and blood clot can be extremely diffi cult. Other causes of secondary PPH include1- endometritis,2- hormonal contraception, 3-bleeding disorders, e.g. von Willebrand’s disease, and 4-rarely choriocarcinoma.

Obstetric palsy

Obstetric palsy, or traumatic neuritis, is a condition in which one or both lower limbs may develop signs of a motor and/or sensory neuropathy following delivery. Presenting features include sciatic pain, footdrop, parasthesia, hypoaesthesia and muscle wasting. The mechanism of injury is unknown and it was previously attributed to compression or stretching of the lumbosacral trunk as it crosses the sacroiliac joint during descent of the fetal head. It is now believed that herniation of lumbosacral discs (usually L4 or L5) can occur, particularly in the 1-exaggerated lithotomy position and during 2-instrumental delivery.

The management

An orthopaedic opinion should be sought and management includes bed rest with a firm board beneath the mattress, analgesia and physiotherapy. Peroneal nerve palsy can occur when the nerve is compressed between the head of the fibula and the lithotomy pole, resulting in unilateral foot-drop. The development of urinary and faecal incontinence is most likely due to structural damage to the anal sphincter muscle and supporting fascia.

Symphysis pubis diastasis

Separation of the symphysis pubis can occur spontaneously in at least 1 in 800 vaginal deliveries. 1-Deliberate surgical separation of the pubis in labour (symphysiotomy) is rarely performed in extreme cases of shoulder dystocia. Spontaneous separation is usually noticed after delivery and has been associated with 1- forceps delivery, 2-rapid second stage of labour or 3-severe abduction of the thighs during delivery.

Common signs and symptoms include 1-symphyseal pain aggravated by weight-bearing and walking, 2-a waddling gait, 3-pubic tenderness and a 4- palpable interpubic gap. Treatment includes1- bed rest, 2-anti-infl ammatory agents,3- physiotherapy and a pelvic corset to provide support and stability.

Thromboembolism

The risk of thromboembolic disease rises fi ve-fold during pregnancy and the puerperium. The majority of deaths occur in the puerperium and are more common after Caesarean section. If deep vein thrombosis or pulmonary embolism is suspected, full anticoagulant therapy should be commenced and a lower lim compression ultrasound and/or lung scan should be carried out within 24–48 hours

Puerperal pyrexia

Puerperal pyrexia
Significant puerperal pyrexia is defined as a temperature of 38؛C or higher on any two of the fi rst 10 days postpartum, exclusive of the fi rst 24 hours (measured orally by a standard technique). A mildly elevated temperature is not uncommon in the fi rst 24 hours, but any pyrexia associated with tachycardia merits investigation. In about 80 per cent of women who develop a temperature in the fi rst 24 hours following a vaginal delivery, no obvious evidence of infection can be identifi ed.

. Common sites associated with puerperal pyrexia include chest, throat, breasts, urinary tract, pelvic organs, Caesarean or perineal wounds and legs

Chest complications

Chest complications are most likely to appear in the fi rst 24 hours after delivery, particularly after general anaesthesia. Atalectasis may be associated with fever and can be prevented by early and regular chest physiotherapy. Aspiration pneumonia (Mendleson’s syndrome) must be suspected if there is wheezing, dyspnoea, a spiking temperature and evidence of hypoxia.

Genital tract infection

Genital tract infection following delivery is referred to as puerperal sepsis and is synonymous with older descriptions of puerperal fever, milk fever and childbed fever. Until 1937, puerperal sepsis was the major cause of maternal mortality. The discovery of sulphonamides in 1935 and the simultaneous reduction in the virulence of the haemolytic streptococcus resulted in a dramatic fall in maternal mortality.


Aetiology of genital tract infections
A mixed flora normally colonizes the vagina with low virulence. Puerperal infection is usually polymicrobial and involves contaminants from the bowel that colonize the perineum and lower genital tract. The organisms most commonly associated with puerperal genital infection are listed in the box below. Following delivery, natural barriers to infection are temporarily removed and therefore organisms with a pathogenic potential can ascend from the lower genital tract into the uterine cavity.


Placental separation exposes a large raw area equivalent to an open wound, and retained products of conception and blood clots within the uterus can provide an excellent culture medium for infection. Furthermore, vaginal delivery is almost invariably associated with lacerations of the genital tract (uterus, cervix and vagina). Although these lacerations may not need surgical repair, they can become a focus for infection similar to iatrogenic wounds, such as Caesarean section and episiotomy.

Signs of puerperal pelvic infection

Pyrexia and tachycardia• Uterus – boggy, tender and larger• Infected wounds – Caesarean/perineal• Peritonism• Paralytic ileus• Indurated adnexae (parametritis)• Bogginess in pelvis (abscess)

Symptoms of puerperal pelvic infection

Malaise, headache, fever, rigors• Abdominal discomfort, vomiting and diarrhoea• Offensive lochia• Secondary PPH

Investigations for puerperal genital infections

Common risk factors for puerperal infection
Antenatal intrauterine infection• Caesarean section• Cervical cerclage for cervical incompetence• Prolonged rupture of membranes• Prolonged labour• Multiple vaginal examinations• Instrumental delivery• Manual removal of the placenta• Retained products of conception• Non-obstetric, e.g. obesity, diabetes, humanimmunodefi ciency virus (HIV)

Chlamydia trachomatis puerperal parametritis may develop in one-third of women who had a preexisting infection, but presentation is usually delayed. There are a number of factors that determine the clinical course and severity of the infection, namely the 1- general health and resistance of the woman, 2-the virulence of the offending organism, 3- the presence of haematoma or 4- retained products of conception and 5-the timing of antibiotic therapy and 6- associated risk factors.


The common methods of spread of puerperal infection are as follows: An ascending infection from the lower genital tract or primary infection of the placental site may spread via the Fallopian tubes to the ovaries, giving rise to a salpingo-oophoritis and pelvic peritonitis. This could progress to a generalized peritonitis and the development of pelvic abscesses.

Infection may also spread by contiguity directly into the myometrium and the parametrium, giving rise to a metritis or parametritis, also referred to as pelvic cellulitis. Pelvic peritonitis and abscesses may also occur. Infection may also spread to distant sites via lymphatics and blood vessels. Infection from the uterus can be carried by uterine vessels into the inferior vena cava via the iliac vessels or, directly, via the ovarian vessels. This could give rise to a septic thrombophlebitis, pulmonary infections or a generalized septicaemia and endotoxic shock


In contrast to pelvic inflammatory disease unrelated to pregnancy, tubal involvement in puerperal sepsis is in the form of perisalpingitis, which, rarely, causes tubal occlusion and consequent infertility. Tubo-ovarian abscesses are also a rare complication of puerperal sepsis.


Mild to moderate infections can be treated with a broad-spectrum antibiotic, e.g. co-amoxiclav or a cephalosporin, such as cefalexin, plus metronidazole. Depending on the severity, the fi rst few doses should be given intravenously. With severe infections, there is a release of infl ammatory and vasoactive mediators in response to the endotoxins produced during bacteriolysis. The resultant local vasodilatation causes circulatory embarrassment and hence poor tissue perfusion. This phenomenon is known as septicaemic/ septic/endotoxic shock, and delay in appropriate management could be fatal.


Necrotizing fasciitis is a rare but frequently fatal infection of skin, fascia and muscle. It can originate in perineal tears, episiotomies and Caesarean section wounds. Perineal infections can extend rapidly to involve the buttocks, thighs and lower abdominal wall. A variety of bacteria can be involved, but anaerobes predominate and Clostridium perfringens is usually identified.


In addition to general signs of infection, there is extensive necrosis, crepitus and infl ammation.

As well as the measures usually taken to manage septic shock, wide debridement of necrotic tissue under general anaesthesia is absolutely essential to avoid mortality. Split-thickness skin grafts may be necessary at a later date.


Increased awareness of the1- principles of general hygiene,2- a good surgical approach and3- the use of aseptic techniques have contributed to the decline in severe puerperal sepsis. However, the risk of sepsis is higher following Caesarean section, particularly when performed after the onset of labour. There is now overwhelming evidence that prophylactic antibiotics during emergency Caesarean section reduce the risk of post-operative infection, namely wound infection, metritis, pelvic abscess, pelvic thrombophlebitis and septic shock.



A single intraoperative dose of antibiotics (amoxiclav or cephalosporin plus metronidazole) should be given after clamping of the umbilical cord to avoid unnecessary exposure of the baby to antibiotics. The benefi t of prophylaxis for elective Caesarean section is of greater signifi cance in units where the background infectious morbidity is high.

breast feeding

Lactation
Lactation : In those mothers who breast feed , lactation is the most dominant physiological event of puerperium . The primary function of breast feeding to continuing of nutrition for newborn . The secondary function : protection agonist infant infection . Inhibition of ovarian activity . Encouragement of uterine involution .

The breast during lactation

Breast changes

Milk production

Two similar independent mechanisms for successful lactation : Prolactin release from A .p mammary glandular tissue stimulation of milk secretion . Prolactin has direct action on the secretory cells to synthesize milk proteins.

Milk production

Prolactin level during lactation depending on the suckling ( strength , frequency and duration ) Prl. release from A.p reaching peak blood level at 30 -45 min. after suckling and returns to the basal level after 2 hour after suckling . Prolactin is a long-chain polypeptide produced from the anterior pituitary; levels rise up to 20-fold during pregnancy and lactation.


Prolactin is essential for lactation and it is hypothesized that nipple stimulation prevents the release of prolactin-inhibiting factor from the hypothalamus, thereby initiating the production of prolactin by the anterior pituitary. This theory is supported by the fact that lactation can be arrested with bromocryptine, a dopamine agonist that inhibits prolactin. A similar phenomenon occurs following pituitary necrosis (Sheehan’s syndrome) when prolactin production ceases.

Milk production

2 ) – milk ejection reflex ( milk lead down ) mediated by release of oxytocin from posterior pituitary: causing contraction of myoepithelial cells around the milk –secretary . dilatation of main ducts .So , Expelling milk from glands . oxytocin released in response to : suckling , and sensory input like mother seeing or hearing their baby crying .

Milk production

Highest levels of oxytocin occurring before suckling in response to the baby cry . Milk ejection reflex may be inhibited by emotional stress and maternal anxiety and leads to failure of lactation . So , the key of both mechanisms activated by suckling and mediated through neuro-endocrianological pathways .

Breast feeding & fertility

during lactation there is inhibition of the normal pulsatile release of luteinizing hormone from the anterior pituitary. Breastfeeding therefore provides a contraceptive effect, but it is not totally reliable, as up to 10 per cent of women conceive during this period. However, it has recently been shown that a mother who is still in the phase of postpartum amenorrhoea while fully breastfeeding her baby has a less than 2 per cent chance of conceiving in the fi rst six months.

Painful nipples

The nipple can become very painful if the covering epithelium is denuded or if a fissure develops giving rise to ‘cracked nipples’. The cause is usually attributed to poor positioning of the baby on the breast, although thrush (candidiasis) may also cause soreness. Cracked nipples are also associated with an increased risk of a breast abscess developing. Treatment involves resting the affected nipple and manually expressing milk. Breastfeeding should then be reintroduced gradually.

Blood-stained nipple discharge

Blood-stained nipple discharge of pregnancy is typically bilateral and believed to be due to epithelial proliferation. It usually occurs in the second or third trimester of pregnancy and rarely persists beyond three months postpartum. As the condition is self limiting, no investigation or treatment is necessary, and the woman should be reassured.

Galactocele

A galactocele is a retention cyst of the mammary ducts following blockage by inspissated secretions. It is identified as a fluctuant swelling with minimal pain and inflammation. It usually resolves spontaneously but may also be aspirated; with increasing discomfort, surgical excision may become necessary.

Breast engorgement

Engorgement of the breasts usually begins by the second or third postpartum day and if breastfeeding has not been effectively established, the over-distended and engorged breasts can be very uncomfortable. Breast engorgement may give rise to puerperal fever of up to 39؛C in 13 per cent of mothers. Although the fever rarely lasts more than 16 hours, other infective causes must be excluded.

A number of remedies for the treatment of breast engorgement, such as 1-manual expression, 2- firm support, 3- ice bag 4-- electric breast pump, have all been recommended in the past, but allowing the 5-baby easy access to the breast is the most effective method of treatment and prevention

Mastitis

Infl ammation of the breast is not always due to an infective process. Mastitis can occur when a blocked duct obstructs the fl ow of milk and distends the alveoli. If this pressure persists, the milk extravasates into the perilobular tissue, initiating an infl amatory process. The affected segment of the breast is painful and appears red and oedematous Flulike symptoms develop associated with a tachycardia and pyrexia. In the first few postpartum days, about 15 per cent of women will develop a temperature of up to 39؛C, lasting less than 24 hours, due to breast engorgement..

By contrast, in infective mastitis, the pyrexia develops later and persists for longer. In general, suppurative mastitis usually presents in the third to fourth postpartum week and is usually unilateral. Symptoms include rigors, fever, pain and reddened, swollen breasts. The most common infecting organism is Staphylococcus aureus, which is found in 40 per cent of women with mastitis. Other bacteria include coagulase-negative staphylococci and Streptococcus viridans. The most common sources of infection are, first, from the baby’s nose or throat and, second, from an infected umbilical cord

Management includes1- isolation of the mother and baby,2- ceasing breastfeeding from the affected breast3- expression of milk either manually or by electric pump, and4- microbiological culture and sensitivity of a sample of milk. Flucloxacillin can be commenced while awaiting sensitivity results. About 10 per cent of women with mastitis develop a breast abscess. Treatment is by a radial surgical incision and drainage under general anaesthesia.

Perinatal death

Stillbirth: a baby born with no signs of life• Perinatal death: stillbirth 24 weeks gestation ordeath within 7 days of birth• Live birth: any baby that shows signs of lifeirrespective of gestation.

Investigations into perinatal death

The post-natal examination
This is carried out at about 6 weeks postpartum by the general practitioner or by the obstetrician if delivery had been complicated. The examination includes an assessment of the woman’s mental and physical health, as well as the progress of the baby. In particular, direct questions must be asked about urinary, bowel and sexual function. Incontinence and dyspareunia are embarrassing issues that women do not volunteer to discuss readily. Weight, urine analysis and blood pressure are checked and a complete general, abdominal and pelvic examination is performed. If a cervical smear is due, it can be taken, although it is preferable to take one after three months postpartum. Contraception and pelvic fl oor exercises are also discussed.


THIS IS THE END OF THE LECTUR . HOPE YOU ENJOYED IT !
THANK YOU ! ! !