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Kalafat E, Liu B, Barratt I, Bhate R, Papageorghiou A, Khalil A. Risk factors associated with stillbirth and adverse perinatal outcomes in dichorionic twin pregnancies complicated by selective fetal growth restriction: a cohort study. BJOG 2024; 131:189-198. [PMID: 37308720 DOI: 10.1111/1471-0528.17564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 03/18/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The main aim of this study was to investigate the perinatal outcomes of dichorionic twin pregnancies complicated by selective fetal growth restriction (sFGR). DESIGN Retrospective cohort study. SETTING Tertiary reference centre. POPULATION Dichorionic twin pregnancies complicated by sFGR between 2000 and 2019 in St George's University Hospital. METHODS Regression analyses were performed using generalised linear models and mixed-effects generalised linear models where appropriate to account for pregnancy level dependency in variables. Time to event analyses were performed with mixed-effects Cox regression models. MAIN OUTCOME MEASURES Stillbirth, neonatal death or neonatal unit admission with morbidity in one or both twins. RESULTS A total of 102 (of 2431 dichorionic twin pregnancies) pregnancies complicated by sFGR were included in the study. The Cochrane-Armitage test revealed a significant trend for increased adverse perinatal outcome rates with more severe forms of umbilical artery flow impedance, i.e. reversed, absent, positive with resistant flow and positive flow without resistance. A multivariable model including maternal and conception characteristics had poor predictive accuracy for stillbirth (area under the curve: 0.68, 95% confidence interval [CI] 0.55-0.81) and composite adverse perinatal outcomes (area under the curve: 0.58, 95% CI 0.47-0.70). When umbilical artery Doppler parameters were added to the models, the area under the curve values improved to 0.95 (95% CI 0.89-0.99) and 0.83 (95% CI 0.73-0.92) for stillbirth and composite adverse perinatal outcomes, respectively. CONCLUSION In dichorionic twin pregnancies complicated by sFGR, the umbilical artery Z-scores were associated with both intrauterine death and adverse perinatal outcomes.
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Affiliation(s)
- Erkan Kalafat
- Department of Obstetrics and Gynaecology, School of Medicine, Koc University, Istanbul, Turkey
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - Becky Liu
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
| | - Imogen Barratt
- Fetal Medicine Unit, St George's University Hospitals, London, UK
| | - Rohan Bhate
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Le Doare K, Ladhani S, von Dadelszen P, Magee LA, Khalil A. COVID-19 and maternal and perinatal outcomes - Authors' reply. Lancet Glob Health 2021; 9:e1066. [PMID: 34297960 PMCID: PMC8293946 DOI: 10.1016/s2214-109x(21)00293-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Barbara Chmielewska
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Imogen Barratt
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Rosemary Townsend
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Erkan Kalafat
- Middle East Technical University, Faculty of Arts and Sciences, Department of Statistics, Ankara, Turkey; Koc University, School of Medicine, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Jan van der Meulen
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Morris
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, UK; North Bristol NHS Trust Department of Women's Health, Westbury on Trym, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London SW17 0QT, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London SW17 0QT, UK; Immunisation and Countermeasures Division, Public Health England, London, UK; British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Laura A Magee
- British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London SW17 0QT, UK.
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Townsend R, Chmielewska B, Barratt I, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Doare KL, Ladhani S, Dadelszen PV, Magee LA, Khalil A. Global changes in maternity care provision during the COVID-19 pandemic: A systematic review and meta-analysis. EClinicalMedicine 2021; 37:100947. [PMID: 34195576 PMCID: PMC8233134 DOI: 10.1016/j.eclinm.2021.100947] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has had a profound impact on healthcare systems globally, with a worrying increase in adverse maternal and foetal outcomes. We aimed to assess the changes in maternity healthcare provision and healthcare-seeking by pregnant women during the COVID-19 pandemic. METHODS We performed a systematic review and meta-analysis of studies of the effects of the pandemic on provision of, access to and attendance at maternity services (CRD42020211753). We searched MEDLINE and Embase in accordance with PRISMA guidelines from January 1st, 2020 to April 17th 2021 for controlled observational studies and research letters reporting primary data comparing maternity healthcare-seeking and healthcare delivery during compared to before the COVID-19 pandemic. Case reports and series, systematic literature reviews, and pre-print studies were excluded. Meta-analysis was performed on comparable outcomes that were reported in two or more studies. Data were combined using random-effects meta-analysis, using risk ratios (RR) or incidence rate ratios (IRR) with 95% confidence intervals (CI). FINDINGS Of 4743 citations identified, 56 were included in the systematic review, and 21 in the meta-analysis. We identified a significant decrease in the number of antenatal clinic visits (IRR 0614, 95% CI 0486-0776, P<00001, I2=54.6%) and unscheduled care visits (IRR 0741, 95% CI 0602-0911, P = 00046, I2=00%) per week, and an increase in virtual or remote antenatal care (IRR 4656 95% CI 7762-2794, P<00001, I2=90.6%) and hospitalisation of unscheduled attendees (RR 1214, 95% CI 1118-1319, P<00001, I2=00%). There was a decrease in the use of GA for category 1 Caesarean sections (CS) (RR 0529, 95% CI 0407-0690, P<00001, I2=00%). There was no significant change in intrapartum epidural use (P = 00896) or the use of GA for elective CS (P = 079). INTERPRETATION Reduced maternity healthcare-seeking and healthcare provision during the COVID-19 pandemic has been global, and must be considered as potentially contributing to worsening of pregnancy outcomes observed during the pandemic.
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Affiliation(s)
- Rosemary Townsend
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom
| | - Barbara Chmielewska
- Fetal Medicine Unit, St George's Hospital, St George's University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Imogen Barratt
- Fetal Medicine Unit, St George's Hospital, St George's University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Erkan Kalafat
- Middle East Technical University, Faculty of Arts and Sciences, Department of Statistics, Ankara, Turkey
- Koc University, School of Medicine, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Jan van der Meulen
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Ipek Gurol-Urganci
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Pat O'Brien
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
- The Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Edward Morris
- The Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, United Kingdom
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- North Bristol NHS Trust Department of Women's Health, Westbury on Trym, United Kingdom
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, United Kingdom
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
- Immunisation and Countermeasures Division, Public Health England, United Kingdom
- British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Asma Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom
- Fetal Medicine Unit, St George's Hospital, St George's University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
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Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Le Doare K, Ladhani S, von Dadelszen P, Magee L, Khalil A. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health 2021; 9:e759-e772. [PMID: 33811827 PMCID: PMC8012052 DOI: 10.1016/s2214-109x(21)00079-6] [Citation(s) in RCA: 539] [Impact Index Per Article: 179.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/15/2022]
Abstract
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]; I2=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 [1·22-1·53; I2=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]; I2=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 [0·84-0·99]; I2=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]; I2=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.
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Affiliation(s)
- Barbara Chmielewska
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK
| | - Imogen Barratt
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK
| | - Rosemary Townsend
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK
| | - Erkan Kalafat
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey; Department of Obstetrics and Gynaecology, School of Medicine, Koc University, Istanbul, Turkey
| | - Jan van der Meulen
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Morris
- The Royal College of Obstetricians and Gynaecologists, London, UK; Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, UK; North Bristol NHS Trust Department of Women's Health, Westbury on Trym, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, UK; Immunisation and Countermeasures Division, Public Health England, London, UK; British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Laura Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, UK.
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Kalafat E, Barratt I, Nawaz A, Thilaganathan B, Khalil A. Maternal cardiovascular function and risk of intrapartum fetal compromise in women undergoing induction of labor: pilot study. Ultrasound Obstet Gynecol 2020; 56:233-239. [PMID: 31710723 DOI: 10.1002/uog.21918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/23/2019] [Accepted: 10/13/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Identification of the fetus at risk of intrapartum compromise has many benefits. Impaired maternal cardiovascular function is associated with placental hypoperfusion predisposing to intrapartum fetal distress. The aim of this study was to assess the predictive accuracy of maternal hemodynamics for the risk of operative delivery due to presumed fetal compromise in women undergoing induction of labor (IOL). METHODS In this prospective cohort study, patients were recruited between November 2018 and January 2019. Women undergoing IOL were invited to participate in the study. A non-invasive ultrasonic cardiac output monitor (USCOM-1A®) was used for cardiovascular assessment. The study outcome was operative delivery due to presumed fetal compromise, which included Cesarean or instrumental delivery for abnormal fetal heart monitoring. Regression analysis was used to test the association between cardiovascular markers, as well as the maternal characteristics, and the risk of operative delivery due to presumed fetal compromise. Receiver-operating-characteristics-curve analysis was used to assess the predictive accuracy of the cardiovascular markers for the risk of operative delivery for presumed fetal compromise. RESULTS A total of 99 women were recruited, however four women were later excluded from the analysis due to semi-elective Cesarean section (n = 2) and failed IOL (n = 2). The rate of operative delivery due to presumed fetal compromise was 28.4% (27/95). Women who delivered without suspected fetal compromise (controls) were more likely to be parous, compared to those who had operative delivery due to fetal compromise (52.9% vs 18.5%; P = 0.002). Women who underwent operative delivery due to presumed fetal compromise had a significantly lower cardiac index (median, 2.50 vs 2.60 L/min/m2 ; P = 0.039) and a higher systemic vascular resistance (SVR) (median, 1480 vs 1325 dynes × s/cm5 , P = 0.044) compared to controls. The baseline model (being parous only) showed poor predictive accuracy, with an area under the curve of 0.67 (95% CI, 0.58-0.77). The addition of stroke volume index (SVI) < 36 mL/m2 , SVR > 7.2 logs or SVR index (SVRI) > 7.7 logs improved significantly the predictive accuracy of the baseline model (P = 0.012, P = 0.026 and P = 0.012, respectively). CONCLUSION In this pilot study, we demonstrated that prelabor maternal cardiovascular assessment in women undergoing IOL could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SVI, SVR or SVRI improved significantly the predictive accuracy of the baseline antenatal model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Kalafat
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Middle East Technical University, Department of Statistics, Ankara, Turkey
| | - I Barratt
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Nawaz
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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