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Gestational Diabetes Mellitus Management Guidelines

The Challenges And Recommendations For Gestational Diabetes Mellitus Care In India: A Review

The Challenges And Recommendations For Gestational Diabetes Mellitus Care In India: A Review

Gestational diabetes mellitus (GDM) is a primary concern in India affecting approximately five million women each year. Existing literature indicate that prediabetes and diabetes affect approximately six million births in India alone, of which 90% are due to GDM. Studies reveal that there is no consensus among physicians and health-care providers in India regarding management of GDM prepartum and postpartum despite available guidelines. Also, there is no consensus among physicians as to when a woman should undergo oral glucose tolerance test after delivery. This clearly shows that management of GDM is challenging and controversial in India due to conflicting guidelines and treatment protocols, despite availability of straightforward protocols for screening and management. Also, a collaborative approach remains a key for GDM management, as patient compliance and proper educational interventions promote better pregnancy outcomes. Management of GDM plays a pivotal role, as women with GDM have an increased chance of developing diabetes mellitus 5–10 years after pregnancy. Also, children born in GDM pregnancies face an increased risk for obesity and type 2 diabetes. The cornerstone for the management of GDM is glycemic control and quality nutritional intake. GDM management is complex in India, and existing challenges are multifactorial. However, there are little published data outlining these challenges. This review gives an account of some of the key challenges from self-management and health-care provider perspective. The recommendations in this review provide insights for building a more structured model for GDM care in India. This research has several practical applications. First, it points out to reaching a consensus on approaches for screening, diagnosis, and treatm Continue reading >>

Current Management Of Gestational Diabetes Mellitus

Current Management Of Gestational Diabetes Mellitus

Current Management of Gestational Diabetes Mellitus Guido Menato; Simona Bo; Anna Signorile; Marie-Laure Gallo; Ilenia Cotrino; Chiara Botto Poala; Marco Massobrio Expert Rev of Obstet Gynecol.2008;3(1):73-91. Treatment of Gestational Diabetes Mellitus Diet is the mainstay of treatment in GDM whether or not pharmacologic therapy is introduced. Dietary control with a reduction in fat intake and the substitution of complex carbohydrates for refined carbohydrates seeks to achieve and maintain the maternal blood glucose profile essential during gestation. Two approaches are recommended: decreasing the proportion of carbohydrates to 40% in a daily regimen of three meals and three or four snacks, or lowering the glycemic index so that carbohydrates make up approximately 60% of the daily intake.[ 9 , 10 , 11 , 12 ] The ADA also recommends nutritional counseling, if possible by a registered dietitian, with individualization of the nutrition plan based on height and weight.[ 13 ] For normal-weight women (BMI: 20-25 kg/m2) 30 kcal/kg should be prescribed; for overweight and obese women (BMI > 24-34 kg/m2) calories should be restricted to 25 kcal/kg, and for morbidly obese women (BMI > 34 kg/m2) calories should be restricted to 20 kcal/kg or less.[ 12 ] In normal pregnancy expected weight gain varies according to the prepregnancy weight. The Fifth International Workshop-Conference on GDM recommends a relatively small gain during pregnancy of 7 kg (15 lb) or more for obese women (BMI 30 kg/m2) and a proportionally greater weight gain (up to 18 kg or 40 lb) for underweight women (BMI < 18.5 kg/m2) at the onset of pregnancy. However, there are no data on optimal weight gain for women with GDM.[ 14 ] Caloric composition includes 40-50% from complex, high-fiber carbohydrates, 20% from Continue reading >>

Guidelines For Gestational Diabetes Mellitus

Guidelines For Gestational Diabetes Mellitus

Guidelines for Gestational Diabetes Mellitus Obstet Gynecol; ePub 2017 Jul; Caughey, et al The American College of Obstetricians and Gynecologists (ACOG) has issued clinical management guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM) in pregnancy. The document provides a brief overview of the understanding of GDM, reviews management guidelines that have been validated by appropriately conducted clinical research, and identifies gaps in current knowledge. Among the recommendations offered: Women in whom GDM is diagnosed should receive nutrition and exercise counseling, and when this fails to adequately control glucose levels, medication should be used for maternal and fetal benefit. When pharmacologic treatment of GDM is indicated, insulin is considered the first-line treatment for diabetes in pregnancy. All pregnant women should be screened for GDM with a laboratory-based screening test(s) using blood glucose levels. In women who decline insulin therapy or for those women whom the obstetrician or obstetric care provider believes the patient will be unable to safely administer insulin, metformin is a reasonable second-line choice. Glyburide treatment should not be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin. Health care providers should counsel women of the limitations in safety data when prescribing oral agents to women with GDM. Women with GDM should be counseled regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 g or more. Gestational diabetes mellitus. Practice Bulletin No. 180. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2017;130:e1731. Continue reading >>

Guidelines

Guidelines

There is now extensive evidence on the optimal management of diabetes, offering the opportunity of improving the immediate and long-term quality of life of those living with the condition. Unfortunately such optimal management is not reaching many, perhaps the majority, of the people who could benefit. Reasons include the size and complexity of the evidence-base, and the complexity of diabetes care itself. One result is a lack of proven cost-effective resources for diabetes care. Another result is diversity of standards of clinical practice. Guidelines are part of the process which seeks to address those problems. IDF has produced a series of guidelines on different aspects of diabetes management, prevention and care. The new IDF Clinical Practice Recommendations for managing Type 2 Diabetes in Primary Care seek to summarise current evidence around optimal management of people with type 2 diabetes. It is intended to be a decision support tool for general practitioners, hospital based clinicians and other primary health care clinicians working in diabetes. Pocket chart in the format of a Z-card with information for health professionals to identify, assess and treat diabetic foot patients earlier in the "window of presentation" between when neuropathy is diagnosed and prior to developing an ulcer. The content is derived from the IDF Clinical Practice Recommendations on the Diabetic Foot 2017. Available to download and to order in print format. The IDF Clinical Practice Recommendations on the Diabetic Foot are simplified, easy to digest guidelines to prioritize health care practitioner's early intervention of the diabetic foot with a sense of urgency through education. The main aims of the guidelines are to promote early detection and intervention; provide the criteria for Continue reading >>

Management Of Pregnancy Complicated By Diabetes

Management Of Pregnancy Complicated By Diabetes

Preconception Care AACE guidelines specify that preconception care is important for all women with preexisting type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) or previous gestational diabetes mellitus (GDM). One of the primary goals of preconception care is to educate patients about strategies to maintain adequate nutrition and glucose control before conception, during pregnancy, and in the postpartum period.1 Intensive glycemic management of women with diabetes prior to conception and throughout pregnancy has been shown to confer significant health benefits to both mother and child.2 When women with diabetes establish normoglycemia before pregnancy and maintain it through the first trimester, the risk of complications (eg, congenital anomalies and spontaneous abortion) is comparable to levels for women without diabetes.3 Glycemic Targets Glycemic targets during pregnancy are defined in the 2011 AACE guidelines, shown in the table below. For all glucose management protocols, AACE recommendations stress that patient safety must be the first priority.1,4 Table 1. AACE and ADA Glycemic Target Guidelines for Pregnant Women With GMD, T1DM, or T2DM1,5 Glucose Increment Patients With GDM Patients With Preexisting T1DM or T2DM Preprandial, premeal ≤95 mg/dL (5.3 mmol/L) Premeal, bedtime, and overnight glucose: 60-99 mg/dL (3.4-5.5 mmol/L) Postprandial, post-meal 1-hour post-meal: ≤140 mg/dL (7.8 mmol/L) or 2-hour post-meal: ≤120 mg/dL (6.7 mmol/L) Peak postprandial glucose 100-129 mg/dL (5.5-7.1 mmol/L) A1C ≤6.0% ≤6.0% Table 2. Expert Recommendations for Glycemic Target Guidelines for Pregnant Women With GMD, T1DM, or T2DM*1,5,6 Some experts recommend more stringent goals, in particular, for patients on insulin therapy, to prevent maternal and fetal Continue reading >>

12. Management Of Diabetes In Pregnancy

12. Management Of Diabetes In Pregnancy

For guidelines related to the diagnosis of gestational diabetes mellitus, please refer to Section 2 “Classification and Diagnosis of Diabetes.” Pregestational Diabetes Provide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. B Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examinations should occur before pregnancy or in the first trimester and then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. A Preferred medications in gestational diabetes mellitus are insulin and metformin; glyburide may be used but may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta, and all lack long-term safety data. A General Principles for Management of Diabetes in Pregnancy Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B Fasting, preprandial, and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and pregestati Continue reading >>

Guidelines For The Management Of Gestational Diabetes Mellitus Revisited

Guidelines For The Management Of Gestational Diabetes Mellitus Revisited

Guidelines for the management of gestational diabetes mellitus revisited David S Simmons, Barry N J Walters, Peter Wein and N Wah Cheung, on behalf of the Australasian Diabetes in Pregnancy Society To the Editor: In 1998, the Australasian Diabetes in Pregnancy Society (ADIPS) published management guidelines for gestational diabetes mellitus (GDM). 1 Recently, the American College of Obstetricians and Gynecologists (ACOG) published its clinical management guidelines for GDM. 2 The Table shows there are few differences from the ADIPS guidelines. At this stage, ADIPS does not consider existing evidence warrants revision of its guidelines. ADIPS will retain its existing criteria for the diagnosis of GDM based on a 75 g oral glucose tolerance test (OGTT) pending publication of the Hyperglycaemia and Adverse Pregnancy Outcome Study. 3 The results of this international prospective study of 25 000 pregnant women should be available in June 2004. The full article is accessible to AMA members and paid subscribers. If you are an AMA member or have a subscription login to read more or purchase a subscription now. Continue reading >>

Gestational Diabetes Mellitus: A Review Of The Diagnosis, Clinical Implications And Management | Wong | Reviews In Health Care

Gestational Diabetes Mellitus: A Review Of The Diagnosis, Clinical Implications And Management | Wong | Reviews In Health Care

Gestational Diabetes Mellitus: a review of the diagnosis, clinical implications and management DOI: Gestational diabetes mellitus (GDM) is a condition that affects the wellbeing of mother and fetus. Women with GDM are at risk of type 2 diabetes mellitus in the future, while fetal exposure to hyperglycaemia in-utero may affect their glycometabolic profile later in life. Appropriate screening and management of this problem is important in ensuring good pregnancy outcomes. In this review, the clinical implications, the various ways to screen and diagnose GDM, and management strategies during pregnancy will be discussed. For years, insulin is the mainstay of treatment if medical nutrition therapy fails to maintain adequate glycaemic control, but use of other oral pharmacotherapy may gain greater acceptance in the future. Following delivery, ongoing follow-up of these women is worthwhile as early intervention through lifestyle or pharmacotherapy may prevent the development of diabetes. Gestational diabetes; Insulin therapy; Pregnancy outcomesrapy, pregnancy outcomes Diagnosis and classification of diabetes mellitus. Diabetes Care 2012; 35 Suppl 1: S64-71; Anna V, van der Ploeg HP, Cheung NW, et al. Sociodemographic correlates of the increasing trend in prevalence of gestational diabetes mellitus in a large population of women between 1995 and 2005. Diabetes Care 2008; 31: 2288-93; Dornhorst A, Paterson CM, Nicholls JS, et al. High prevalence of gestational diabetes in women from ethnic minority groups. Diabet Med 1992; 9: 820-5; Hoffman L, Nolan C, Wilson JD, et al. Gestational diabetes mellitus--management guidelines. The Australasian Diabetes in Pregnancy Society. Med J Aust 1998; 169: 93-7 Hod M, Yogev Y. Goals of metabolic management of gestational diabetes: is it all a Continue reading >>

Acog Guidelines At A Glance: Gestational Diabetes Mellitus

Acog Guidelines At A Glance: Gestational Diabetes Mellitus

Committee on Practice Bulletins—Obstetrics ACOG Practice Bulletin 137: Gestational Diabetes Mellitus, August 2013 (Replaces Practice Bulletin Number 30, September 2001, Committee Opinion Number 435, June 2009, and Committee Opinion Number 504, September 2011). Obstet Gynecol. 2013;122:406-16. Full text of ACOG Practice Bulletins is available to ACOG members at _Bulletins_--_Obstetrics/Gestational_Diabetes_Mellitus. Gestational diabetes mellitus Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. Debate continues to surround both the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purpose of this document is to 1) provide a brief overview of the understanding of GDM, 2) provide management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed. Used with permission. Copyright the American College of Obstetricians and Gynecologists. By Haywood L. Brown, MD Dr. Brown is Roy T. Parker Professor and Chair, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke Medicine, Durham, NC. He is also a member of the Contemporary OB/GYN Editorial Board. Practice Bulletin 137 on gestational diabetes mellitus provides a rationale for current screening guidelines for a pregnancy population in which prevalence of obesity and Type 2 diabetes has increased over the past several decades. Review of the bulletin underscores several questions pertinent to diagnosis and management, which are reflected by and addressed similarly in the evidence-based recommendations in the document.1 Is GDM overdiagnosed or underdiagnosed? Obviously, the prevalence of gest Continue reading >>

Eal

Eal

Gestational Diabetes (2016) Evidence-Based Nutrition Practice Guideline The focus of this guideline is on nutrition practice during the treatment of women with gestational diabetes mellitus (GDM). According to the American Diabetes Association (ADA), GDM is diabetes diagnosed in the second or third trimester of pregnancy that is not clearly either type 1 or type 2 diabetes (ADA, 2016)." All pregnant women are generally tested for GDM between 24-28 weeks of gestation, [American College of Obstetricians and Gynecologists (ACOG), 2013] if they have not previously been diagnosed with overt diabetes. Screening and diagnosis of GDM may be made by one of two strategies at 24-28 weeks of gestation: Perform a 75g oral glucose tolerance test (OGTT), with plasma glucose measurement when patient is fasting and at 1 and2 hours. The OGTT should be performed in the morning after an overnight fast of at least 8 hours.A GDM diagnosis is made when any of the following plasma glucose values are met orexceeded: Step 1: Perform a 50g glucose load test (GLT) (nonfasting), with plasma glucose measurement at 1 hour. If the plasma glucose level measured 1 hour after the load is 140 mg/dL* (7.8 mmol/L), proceedto a 100g OGTT. [Note:*The ACOG recommends 135mg/dL(7.5mmol/L) in high-risk ethnic populations with higher prevalence of GDM; some experts alsorecommend 130mg/dL (7.2 mmol/L).] Step 2: The 100g OGTT should be performed when the patient is fasting.A GDM diagnosis is made if at least two of the following four plasma glucose levels(measured fasting and 1 h, 2 h, 3 h after the OGTT) are met or exceeded: The above One-Step and Two-Step Strategies were adapted from Table 2.5Screening for and diagnosis of GDM (ADA, 2016). Refer to ADA, 2016 for more information on diagnosis of GDM. Pregnant wome Continue reading >>

Diabetes Management Guidelines

Diabetes Management Guidelines

Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including class of recommendation and level of evidence. Jump to a topic or click back/next at the bottom of each page Diabetes in Pregnancy (Gestational Diabetes) Glycemic Targets in Pregnancy Pregestational diabetes Gestational diabetes mellitus (GDM) Fasting ≤90 mg/dL (5.0 mmol/L) ≤95 mg/dL (5.3 mmol/L) 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) ≤140 mg/dL (7.8 mmol/L) 2-hr postprandial ≤120 mg/dL (6.7 mmol/L) ≤120 mg/dL (6.7 mmol/L) A1C 6.0-6.5% (42-48 mmol/L) recommended <6.0% may be optimal as pregnancy progresses Achieve without hypoglycemia Recommendations for Pregestational Diabetes Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM Spontaneous abortion Fetal anomalies Preeclampsia Intrauterine fetal demise Macrosomia Neonatal hypoglycemia Neonatal hyperbilirubinemia Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life Maintain A1C levels as close to normal as is safely possible Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia Discuss family planning Prescribe effective contraception until woman is prepared to become pregnant Women with preexisting type 1 or type 2 diabetes Counsel on the risk of development and/or progression of diabetic retinopathy Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum Management of Pregestational Diabetes Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin Insulin* management during pre Continue reading >>

Gestational Diabetes Guidelines Revised

Gestational Diabetes Guidelines Revised

The Ministry of Health has released revised guidelines strengthening its stand on universal screening of all pregnant women for gestational diabetes mellitus (GDM). According to the report titled Diagnosis and Management of Gestational Diabetes Mellitus released last week, if the first prenatal test was found negative, a second test should be done at 24-28 weeks of gestation. Worldwide, one in 10 pregnancies is associated with diabetes, 90% of which are GDM. Undiagnosed or inadequately treated GDM can lead to significant maternal and foetal complications. Moreover, women with GDM and their children are at increased risk of developing type 2 diabetes later in life. Hema Divakar, Federation of Obstetric and Gynaecological Societies of India (FOGSI) ambassador to International Federation of Gynaecology and Obstetrics (FIGO), who is one of the contributors to the guidelines, told The Hindu on Thursday that the focus was on making the original guidelines released in 2014 implementable and feasible in the Indian context. Pointing out that the original guidelines were implemented with great difficulty in Hoshangabad of Madhya Pradesh on a pilot basis, she said there were several logistical issues and the health workers found it difficult to test all pregnant women. But every time they came across a hurdle, it was resolved to ensure it is implemented, she said. Based on Hoshangabad experience, we felt there is an urgent need to prevent and minimise maternal and foetal morbidity associated with GDM. The revised guidelines strengthen the provision of universal screening and management of GDM as part of the essential antenatal package, she said. The report also underlines post-delivery testing. Apart from this, the new guidelines provide for creating a cadre of healthcare provide Continue reading >>

3.4.4 B5.4 Management Of Gestational Diabetes - Diabetes Guidelines

3.4.4 B5.4 Management Of Gestational Diabetes - Diabetes Guidelines

The Grampian Diabetes Network is guided by the Grampian Diabetes MCN the service is implemented by different pratices in a manner sensitive to local needs. Gestationaldiabetes mellitus (GDM) has been defined as carbohydrate intolerance ofvariable severity with onset or first recognition during pregnancy. During pregnancy the normal range for fasting bloodglucose is much lower than in non-pregnant women and glycosuria with normalblood glucose levels is common due to a lowering of the renal threshold forglucose. The optimal methods to screen for,diagnose and treat GDM are under review. The National Screening Committee isconsidering screening for GDM. NICE guidelines recommend use of risk factorsfor screening and SIGN, which currently recommend the process below (SIGN 55),are to consider the topic as part of an updated guideline. Important trials arealso due for publication and, in the meantime, Grampian guidelines forscreening, diagnosis and treatment are unchanged until the Scottish nationalguideline is updated. Women with a history of gestationaldiabetes, who have not progressed to diabetes in the interim, should have anOGTT around 16-18 weeks during subsequent pregnancies. Recommended populationscreening protocol for gestational diabetes mellitus Women diagnosed ashaving gestational diabetes should be seen by a physician and obstetrician witha special interest in diabetes and should receive intensive management withdiet and/or insulin if macrosomia is suspected or if blood glucose levels arein the range for established diabetes. Up to 50% of women may go on todevelop Type 2 diabetes later in life and this group presents an excellentopportunity for screening and intervention.Studies have shown that lifestyle intervention can reduce the incidenceof diabetes in at risk p Continue reading >>

13.3 Gestational Diabetes Mellitus

13.3 Gestational Diabetes Mellitus

Clinical context Gestational diabetes, or GDM, is defined as glucose intolerance that begins or is first diagnosed during pregnancy. It may appear earlier, particularly in women with a high level of risk for GDM. GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy. GDM affects about 9.6–13.6% of pregnancies in Australia.245,246 The reported prevalence of GDM varies for a number of reasons. One reason is the use of different screening and diagnostic criteria. The prevalence is also affected by maternal factors such as history of previous gestational diabetes, ethnicity, advanced maternal age, family history of diabetes, pre-pregnancy weight and high gestational weight gain. Mothers of different ethnicity born in areas with high diabetes prevalence such as Polynesia, Asia and the Middle East, are three times as likely to have GDM as mothers born in Australia. Among Aboriginal and Torres Strait Islander mothers, GDM is twice as common, and pre-gestational diabetes affecting pregnancy is three to four times as common as in non-Indigenous mothers.245 In pregnancy, there is a natural increase in levels of hormones including cortisol, growth hormone, human placental lactogen, and progesterone and prolactin levels, causing two to three fold increases in insulin resistance. The action of these hormones is usually compensated by increased insulin release. In pregnant women with abnormal glucose tolerance or impaired β-cell reserve, the pancreas is unable to sufficiently increase insulin secretion in order to control BGLs. Potential maternal complications during pregnancy and delivery include pre-eclampsia and higher rates of caesarean delivery, maternal birth injury, postpartum haemorrhage. For the neonate, complications can inc Continue reading >>

Screening, Diagnosis, And Management Of Gestational Diabetes Mellitus

Screening, Diagnosis, And Management Of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) affects approximately 6% of pregnancies in the United States, and it is increasing in prevalence. Pregnant women without known diabetes mellitus should be screened for GDM after 24 weeks of gestation. Treatment of GDM results in a statistically significant decrease in the incidence of preeclampsia, shoulder dystocia, and macrosomia. Initial management includes glucose monitoring and lifestyle modifications. If glucose levels remain above target values, pharmacologic therapy with metformin, glyburide, or insulin should begin. Antenatal testing is customary for women requiring medications. Induction of labor should not occur before 39 weeks in women with GDM, unless glycemic control is poor or another indication for delivery is present. Unless otherwise indicated, scheduled cesarean delivery should be considered only in women with an estimated fetal weight greater than 4,500 g. Women with a history of GDM are at high risk of subsequently developing diabetes. These patients should be screened six to 12 weeks postpartum for persistently abnormal glucose metabolism, and should undergo screening for diabetes every three years thereafter. Gestational diabetes mellitus (GDM) is a condition of glucose intolerance with onset or first recognition in pregnancy that is not clearly overt diabetes.1,2 Normal pregnancy is characterized by pancreatic β-cell hyperplasia resulting in higher fasting and postprandial insulin levels. Increased secretion of placental hormones leads to increasing insulin resistance, especially throughout the third trimester. GDM occurs when β-cell function is insufficient to overcome this insulin resistance.3 Clinical recommendation Evidence rating References Comments Screening for GDM should occur after 24 weeks of gestat Continue reading >>

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