Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas
Objetivo: Describir desenlaces obstétricos asociados al uso de dinoprostona y su efectividad en la maduración cervical en gestantes con trastornos hipertensivos asociados al embarazo frente a gestantes normotensas. Métodos: Estudio de cohorte retrospectivo en hospital de tercer nivel en Medellín, Co...
- Autores:
-
Molina Barrera, Laura Camila
Bustamante de la Ossa, Maria Sady
- Tipo de recurso:
- Tesis
- Fecha de publicación:
- 2025
- Institución:
- Universidad de Antioquia
- Repositorio:
- Repositorio UdeA
- Idioma:
- spa
- OAI Identifier:
- oai:bibliotecadigital.udea.edu.co:10495/47743
- Acceso en línea:
- https://hdl.handle.net/10495/47743
- Palabra clave:
- Trabajo de parto inducido
Labor, Induced
Hipertensión inducida por el embarazo
Hypertension, Pregnancy-Induced
Dinoprostona
Dinoprostone
Sulfato de magnesio
Magnesium Sulfate
Preeclampsia
Pre-Eclampsia
Cuello uterino/efectos de los fármacos
https://id.nlm.nih.gov/mesh/D007751
https://id.nlm.nih.gov/mesh/D046110
https://id.nlm.nih.gov/mesh/D015232
https://id.nlm.nih.gov/mesh/D008278
https://id.nlm.nih.gov/mesh/D011225
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades
- Rights
- openAccess
- License
- http://creativecommons.org/licenses/by-nc-sa/4.0/
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Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| title |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| spellingShingle |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas Trabajo de parto inducido Labor, Induced Hipertensión inducida por el embarazo Hypertension, Pregnancy-Induced Dinoprostona Dinoprostone Sulfato de magnesio Magnesium Sulfate Preeclampsia Pre-Eclampsia Cuello uterino/efectos de los fármacos https://id.nlm.nih.gov/mesh/D007751 https://id.nlm.nih.gov/mesh/D046110 https://id.nlm.nih.gov/mesh/D015232 https://id.nlm.nih.gov/mesh/D008278 https://id.nlm.nih.gov/mesh/D011225 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| title_short |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| title_full |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| title_fullStr |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| title_full_unstemmed |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| title_sort |
Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensas |
| dc.creator.fl_str_mv |
Molina Barrera, Laura Camila Bustamante de la Ossa, Maria Sady |
| dc.contributor.advisor.none.fl_str_mv |
Zuleta Tobon, John Jairo |
| dc.contributor.author.none.fl_str_mv |
Molina Barrera, Laura Camila Bustamante de la Ossa, Maria Sady |
| dc.contributor.jury.none.fl_str_mv |
Velasquez Penagos, Jesus Arnulfo Colonia Toro, Alejandro |
| dc.subject.decs.none.fl_str_mv |
Trabajo de parto inducido Labor, Induced Hipertensión inducida por el embarazo Hypertension, Pregnancy-Induced Dinoprostona Dinoprostone Sulfato de magnesio Magnesium Sulfate Preeclampsia Pre-Eclampsia |
| topic |
Trabajo de parto inducido Labor, Induced Hipertensión inducida por el embarazo Hypertension, Pregnancy-Induced Dinoprostona Dinoprostone Sulfato de magnesio Magnesium Sulfate Preeclampsia Pre-Eclampsia Cuello uterino/efectos de los fármacos https://id.nlm.nih.gov/mesh/D007751 https://id.nlm.nih.gov/mesh/D046110 https://id.nlm.nih.gov/mesh/D015232 https://id.nlm.nih.gov/mesh/D008278 https://id.nlm.nih.gov/mesh/D011225 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| dc.subject.proposal.spa.fl_str_mv |
Cuello uterino/efectos de los fármacos |
| dc.subject.meshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D007751 https://id.nlm.nih.gov/mesh/D046110 https://id.nlm.nih.gov/mesh/D015232 https://id.nlm.nih.gov/mesh/D008278 https://id.nlm.nih.gov/mesh/D011225 |
| dc.subject.ods.none.fl_str_mv |
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| description |
Objetivo: Describir desenlaces obstétricos asociados al uso de dinoprostona y su efectividad en la maduración cervical en gestantes con trastornos hipertensivos asociados al embarazo frente a gestantes normotensas. Métodos: Estudio de cohorte retrospectivo en hospital de tercer nivel en Medellín, Colombia (marzo 2020 - octubre 2024). Se incluyeron gestantes con embarazo único, mayores de 30 semanas, feto vivo en presentación cefálica y maduración cervical con óvulo de dinoprostona. Se excluyeron mujeres con uso de otros métodos de maduración, cérvix favorable al ingreso o trastorno hipertensivo no clasificado. Los desenlaces principales fueron maduración cervical exitosa, parto vaginal, tiempos hasta Bishop favorable y parto, e indicaciones de cesárea. Se consideraron eventos adversos como abrupcio placentario, estado fetal no tranquilizador, taquisistolia y empeoramiento hipertensivo. Resultados: Se incluyeron 400 pacientes (200 hipertensas, de éstas, 100 con preeclampsia grave). La tasa de éxito en la maduración cervical fue similar en pacientes con trastornos hipertensivos y mujeres sanas RR crudo 0.95, IC 95%: 0.88-1.03, RR ajustado por edad gestacional, edad materna y paridad 0.96, IC 95%: 0.88-1.04. La tasa de parto vaginal fue similar 44 y 55% (p: 0.16). La mediana de tiempo a Bishop favorable y al parto fue comparable entre normotensas e hipertensas, incluso en casos graves. La cesárea se debió principalmente a maduración fallida y decisión médica. Los eventos adversos, excepto la taquisistolia, fueron más frecuentes en hipertensas, sin significación estadística. Conclusión: La dinoprostona es eficaz en pacientes hipertensas, incluso con uso de sulfato de magnesio, sin diferencias significativas frente a normotensas Palabras clave: Trabajo de parto inducido; Hipertensión inducida por el embarazo; Dinoprostona; Sulfato de magnesio; Preeclampsia; Cuello uterino/efectos de los fármacos |
| publishDate |
2025 |
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2025-10-14T21:08:22Z |
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2025 |
| dc.type.none.fl_str_mv |
Trabajo de grado - Especialización |
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draft |
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Molina-Barrera, L., Bustamante-De la Ossa,M. & Zuleta-Tobón, J. (2025). Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo: análisis comparativo con gestantes normotensas [Trabajo de grado especialización]. Universidad de Antioquia, Medellín, Colombia. |
| dc.identifier.uri.none.fl_str_mv |
https://hdl.handle.net/10495/47743 |
| identifier_str_mv |
Molina-Barrera, L., Bustamante-De la Ossa,M. & Zuleta-Tobón, J. (2025). Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo: análisis comparativo con gestantes normotensas [Trabajo de grado especialización]. Universidad de Antioquia, Medellín, Colombia. |
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https://hdl.handle.net/10495/47743 |
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spa |
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Garovic VD, Dechend R, Easterling T, Karumanchi SA, McMurtry Baird S, Magee LA, et al. Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association. Hypertension. 2022; 79(2): e21-41. Doi: 10.1161/HYP.0000000000000208 Instituto Nacional de Salud. Mortalidad. Boletín epidemiológico. 2023; semana 52. Doi: 10.33610/23576189.2023.52 American College of Obstetricians and Gynecologists' Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Medically indicated late-preterm and early-term deliveries: ACOG Committee Opinion, Number 831. Obstet Gynecol. 2021; 138(1): e35-9. Doi: 10.1097/AOG.0000000000004447 Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin Summary, Number 222. Obstet Gynecol. 2020; 135(6): 1492-5. Doi: 10.1097/AOG.0000000000003892 Tsakiridis I, Giouleka S, Arvanitaki A, Giannakoulas G, Papazisis G, Mamopoulos A, et al. Gestational hypertension and preeclampsia: an overview of national and international guidelines. Obstet Gynecol Surv. 2021; 76(10): 613. Doi: 10.1097/OGX.0000000000000942 Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009; 374(9694): 979-88. Doi: 10.1016/S0140-6736(09)60736-4. Taliento C, Manservigi M, Tormen M, Cappadona R, Piccolotti I, Salvioli S, et al. Safety of misoprostol vs dinoprostone for induction of labor: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2023; 289: 108-28. Doi: 10.1016/j.ejogrb.2023.08.382 Grobman WA, Rice MM, Reddy UM, Tita ATN, Silver RM, Mallett G, et al. Labor Induction versus Expectant Management in Low-Risk Nulliparous Women. N Engl J Med. 2018; 379(6): 513-23. Doi: 10.1056/NEJMoa1800566 de Paiva MRMC, Souza ASR, de Lucena FFE, da Costa AAR, Amorim MMR. Maternal and perinatal outcomes in women with and without hypertensive syndromes submitted to induction of labor with misoprostol. Hypertens Pregnancy. 2017; 36(1): 1-7. Doi: 10.1080/10641955.2016.1197935 Gofton EN, Capewell V, Natale R, Gratton RJ. Obstetrical intervention rates and maternal and neonatal outcomes of women with gestational hypertension. Am J Obstet Gynecol. 2001; 185(4): 798-803. Doi: 10.1067/mob.2001.117314 Gornisiewicz T, Huras H, Kusmierska-Urban K, Galas A. Pregnancy-related comorbidities and labor induction - the effectiveness and safety of dinoprostone compared to misoprostol. Ginekol Pol. 2021; 92(9): 647-58. Doi: 10.5603/GP.a2021.0092 Xenakis EM, Piper JM, Field N, Conway D, Langer O. Preeclampsia: is induction of labor more successful? Obstet Gynecol. 1997; 89(4): 600-3. Doi: 10.1016/S0029-7844(97)00043-4 Penfield CA, Nageotte MP, Wing DA. Disparate Rates of Cesarean Delivery in Term Nulliparous Women with Hypertensive Disorders of Pregnancy. Am J Perinatol. 2019; 36: 997-1001. Doi: 10.1055/s-0039-1681057 Hagans MJ, Stanhope KK, Boulet SL, Jamieson DJ, Platner MH. Delivery outcomes after induction of labor among women with hypertensive disorders of pregnancy. J Matern Fetal Neonatal Med. 2022; 35(25): 9215-21. Doi: 10.1080/14767058.2021.2022645. Park KH, Cho YK, Lee CM, Choi H, Kim BR, Lee HK. Effect of Preeclampsia, Magnesium Sulfate Prophylaxis, and Maternal Weight on Labor Induction: A Retrospective Analysis. Gynecol Obstet Invest. 2006; 61(1): 40-4. Doi: 10.1159/000088424. Arrowsmith S, Neilson J, Wray S. The combination tocolytic effect of magnesium sulfate and an oxytocin receptor antagonist in myometrium from singleton and twin pregnancies. Am J Obstet Gynecol. 2016; 215(6): 789.e1-789.e9. Doi: 10.1016/j.ajog.2016.08.015 Mei JY, Lee D, Negi M. Duration of labor induction in nulliparous women receiving magnesium sulfate and maternal and neonatal outcomes. Am J Obstet Gynecol. 1 de enero de 2023;228(1):S662. Doi: 10.1016/j.ajog.2022.11.1112 Sheibani L, Raymond K, Rugarn O, Wing DA. Associations of hypertensive disorders of pregnancy and outcomes of labor induction with prostaglandin vaginal inserts. Hypertens Pregnancy. 2018; 37(1): 51-7. Doi: 10.1080/10641955.2017.1420800 Gornisiewicz T, Kusmierska-Urban K, Huras H, Galas A. Comparison of Misoprostol versus Dinoprostone for delivery induction among pregnant women without concomitant disease. Ginekol Pol. 2020; 91(12): 726-32. Doi: 10.5603/GP.2020.0119 Robinson D, Campbell K, Hobson SR, MacDonald WK, Sawchuck D, Wagner B. Guideline No. 432a: Cervical Ripening and Induction of Labour - General Information. J Obstet Gynaecol Can. 2023; 45(1): 35-44.e1. Doi: 10.1016/j.jogc.2022.11.005 Sanchez-Ramos L, Levine LD, Sciscione AC, Mozurkewich EL, Ramsey PS, Adair CD, et al. Methods for the induction of labor: efficacy and safety. Am J Obstet Gynecol. 2024; 230(3): S669-95. Doi: 10.1016/j.ajog.2023.02.009 WHO Consultation on Obesity. Obesity: preventing and managing the global epidemic. report of a WHO consultation. World Health Organization; 2000. Citado: 25 de diciembre de 2024. Disponible en: https://iris.who.int/handle/10665/42330 Ananth CV, Schisterman EF. Confounding, causality, and confusion: the role of intermediate variables in interpreting observational studies in obstetrics. Am J Obstet Gynecol. 2017; 217(2): 167-75. Doi: 10.1016/j.ajog.2017.04.016 López Jiménez N, García Sánchez F, Pailos RH, Rodrigo Álvaro V, Pascual Pedreño A, Moreno Cid M, et al. Prediction of an effective cervical ripenning in the induction of labour using vaginal dinoprostone. Sci Rep. 2023; 13(1): 6855. Doi: 10.1038/s41598-023-33974-7 Chang TA, Li YR, Ding DC. Oxytocin and vaginal dinoprostone in labor induction: A systematic review and meta-analysis. Int J Gynecol Obstet. 2024; 166(2): 626-38. Doi: 10.1002/ijgo.15443 Cañadas JV, González MT, Limón NP, Alguacil MS, Prieto MGL, Riaza RC, et al. Intracervical double-balloon catheter versus dinoprostone for cervical ripening in labor induction in pregnancies with a high risk of uterine hyperstimulation. Arch Gynecol Obstet. 2021; 304(6): 1475-84. Doi: 10.1007/s00404-021-06071-1 Yan M, Li L, Wang J. Impact of dinoprostone versus cook cervical ripening balloon on induction in pregnancies complicated by small-for-gestational-age fetuses at term. J Matern Fetal Neonatal Med. 2024; 37(1): 2381584. Doi: 10.1080/14767058.2024.2381584 Levast F, Legendre G, Hachem HE, Saulnier P, Descamps P, Gillard P, et al. A mathematical model to predict mean time to delivery following cervical ripening with dinoprostone vaginal insert. Sci Rep. 2019; 9(1): 9910. Doi: 10.1038/s41598-019-46101-2 PMid:31289277 Wing DA, Brown R, Plante LA, Miller H, Rugarn O, Powers BL. Misoprostol Vaginal Insert and Time to Vaginal Delivery: A Randomized Controlled Trial. Obstet Gynecol. 2013; 122(2 PART 1): 201. Doi: 10.1097/AOG.0b013e31829a2dd6 Lapaire O, Zanetti-Dällenbach R, Weber P, Hösli I, Holzgreve W, Surbek D. Labor induction in preeclampsia: Is misoprostol more effective than dinoprostone? 2007; 35(3): 195-9. Doi: 10.1515/JPM.2007.028 Huang F, Chen H, Wu X, Li J, Guo J, Zhang X, et al. A model to predict delivery time following induction of labor at term with a dinoprostone vaginal insert: a retrospective study. Ir J Med Sci. 2024; 193(3): 1343-50. Doi: 10.1007/s11845-023-03568-3 Wolfe KB, Rossi RA, Warshak CR. The effect of maternal obesity on the rate of failed induction of labor. Am J Obstet Gynecol. 2011; 205(2): 128.e1-128.e7. Doi: 10.1016/j.ajog.2011.03.051 Ellis JA, Brown CM, Barger B, Carlson NS. Influence of Maternal Obesity on Labor Induction: A Systematic Review and Meta-Analysis. J Midwifery Womens Health. 2019; 64(1): 55-67. Doi: 10.1111/jmwh.12935 Yenuberi H, Mathews J, George A, Benjamin S, Rathore S, Tirkey R, et al. The efficacy and safety of 25 μg or 50 μg oral misoprostol versus 25 μg vaginal misoprostol given at 4- or 6-hourly intervals for induction of labour in women at or beyond term with live singleton pregnancies: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2024; 164(2): 482-98. Doi: 10.1002/ijgo.14970 Weeks AD, Lightly K, Mol BW, Frohlich J, Pontefract S, Williams MJ, et al. Evaluating misoprostol and mechanical methods for induction of labour: Scientific Impact Paper No. 68 April 2022. BJOG Int J Obstet Gynaecol. 2022; 129(8): e61-5. Doi: 10.1111/1471-0528.17136 Morikawa M, Cho K, Yamada T, Yamada T, Sato S, Minakami H. Do uterotonic drugs increase risk of abruptio placentae and eclampsia? Arch Gynecol Obstet. 2014; 289(5): 987-91. Doi: 10.1007/s00404-013-3101-8 Martinez de Tejada B, Martillotti G, Lapaire O, Hoesli I, Irion O. The risk of placental abruption when using prostaglandins for cervical ripening in women with preeclampsia: Comparing misoprostol versus dinoprostone. J Matern Fetal Neonatal Med. 2010; 23(9): 988-93. Doi: 10.3109/14767050903443475 |
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Universidad de Antioquia |
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Especialización en Ginecología y Obstetricia |
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Medellín, Colombia |
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Facultad de Medicina |
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Zuleta Tobon, John JairoMolina Barrera, Laura CamilaBustamante de la Ossa, Maria SadyVelasquez Penagos, Jesus ArnulfoColonia Toro, Alejandro2025-10-14T21:08:22Z2025Molina-Barrera, L., Bustamante-De la Ossa,M. & Zuleta-Tobón, J. (2025). Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo: análisis comparativo con gestantes normotensas [Trabajo de grado especialización]. Universidad de Antioquia, Medellín, Colombia.https://hdl.handle.net/10495/47743Objetivo: Describir desenlaces obstétricos asociados al uso de dinoprostona y su efectividad en la maduración cervical en gestantes con trastornos hipertensivos asociados al embarazo frente a gestantes normotensas. Métodos: Estudio de cohorte retrospectivo en hospital de tercer nivel en Medellín, Colombia (marzo 2020 - octubre 2024). Se incluyeron gestantes con embarazo único, mayores de 30 semanas, feto vivo en presentación cefálica y maduración cervical con óvulo de dinoprostona. Se excluyeron mujeres con uso de otros métodos de maduración, cérvix favorable al ingreso o trastorno hipertensivo no clasificado. Los desenlaces principales fueron maduración cervical exitosa, parto vaginal, tiempos hasta Bishop favorable y parto, e indicaciones de cesárea. Se consideraron eventos adversos como abrupcio placentario, estado fetal no tranquilizador, taquisistolia y empeoramiento hipertensivo. Resultados: Se incluyeron 400 pacientes (200 hipertensas, de éstas, 100 con preeclampsia grave). La tasa de éxito en la maduración cervical fue similar en pacientes con trastornos hipertensivos y mujeres sanas RR crudo 0.95, IC 95%: 0.88-1.03, RR ajustado por edad gestacional, edad materna y paridad 0.96, IC 95%: 0.88-1.04. La tasa de parto vaginal fue similar 44 y 55% (p: 0.16). La mediana de tiempo a Bishop favorable y al parto fue comparable entre normotensas e hipertensas, incluso en casos graves. La cesárea se debió principalmente a maduración fallida y decisión médica. Los eventos adversos, excepto la taquisistolia, fueron más frecuentes en hipertensas, sin significación estadística. Conclusión: La dinoprostona es eficaz en pacientes hipertensas, incluso con uso de sulfato de magnesio, sin diferencias significativas frente a normotensas Palabras clave: Trabajo de parto inducido; Hipertensión inducida por el embarazo; Dinoprostona; Sulfato de magnesio; Preeclampsia; Cuello uterino/efectos de los fármacosObjective: To describe obstetric outcomes associated with the use of dinoprostone and its effectiveness in cervical ripening in pregnant women with hypertensive disorders of pregnancy compared to normotensive pregnant women. Methods: A retrospective cohort study was conducted at a tertiary-level hospital in Medellín, Colombia (March 2020 – October 2024). The study included pregnant women with singleton pregnancies, beyond 30 weeks of gestation, with a live fetus in cephalic presentation, and undergoing cervical ripening with dinoprostone vaginal insert. Women were excluded if they had used other ripening methods, had a favorable cervix at admission, or had an unclassified hypertensive disorder. Primary outcomes included successful cervical ripening, vaginal delivery, time to favorable Bishop score and to delivery, and indications for cesarean section. Adverse events considered were placental abruption, non-reassuring fetal status, tachysystole, and worsening of hypertensive condition. Results: A total of 400 patients were included (200 with hypertensive disorders, of whom 100 had severe preeclampsia). The success rate of cervical ripening was similar between patients with hypertensive disorders and healthy women (crude RR 0.95, 95% CI: 0.88-1.03; adjusted RR for gestational age, maternal age, and parity 0.96, 95% CI: 0.88-1.04). The vaginal delivery rate was also similar (44% vs. 55%, p= 0.16). The median time to favorable Bishop score and to delivery was comparable between normotensive and hypertensive groups, even in severe cases. Cesarean delivery was mainly due to failed ripening and medical decision. Adverse events, except for tachysystole, were more frequent in the hypertensive group but did not reach statistical significance. Conclusion: Dinoprostone is effective in hypertensive pregnant women, including those receiving magnesium sulfate, with no significant differences compared to normotensive women. Keywords: Labor, Induced; Hypertension, Pregnancy-Induced; Dinoprostone; Magnesium Sulfate; Pre-Eclampsia; Cervix Uteri/drug effects.Este artículo ya fue publicado en la revista Colombia Médica, adicionalmente en proceso de posible TESIS CON DISTINCIÓN, en análisis en estos momentos por cómite del departamento.EspecializaciónEspecialista en Ginecología y Obstetricia25 páginasapplication/pdfspaUniversidad de AntioquiaEspecialización en Ginecología y ObstetriciaDepartamento de Ginecología y ObstetriciaMedellín, ColombiaFacultad de MedicinaCampus en el Área de la saludhttp://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/openAccessAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://purl.org/coar/access_right/c_abf2Inducción del trabajo de parto con dinoprostona en trastornos hipertensivos del embarazo : análisis comparativo con gestantes normotensasTrabajo de grado - Especializaciónhttp://purl.org/coar/resource_type/c_46echttp://purl.org/redcol/resource_type/COtherTexthttp://purl.org/coar/version/c_b1a7d7d4d402bcceinfo:eu-repo/semantics/otherinfo:eu-repo/semantics/draftGarovic VD, Dechend R, Easterling T, Karumanchi SA, McMurtry Baird S, Magee LA, et al. 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ltbywgc2kgZnVlcmUgYXBsaWNhYmxlKSwgeS9vIChpaSkgZWwgbm9tYnJlIGRlIGxhIHBhcnRlIG8gbGFzIHBhcnRlcyBxdWUgZWwgQXV0b3IgT3JpZ2luYWwgeS9vIGVsIExpY2VuY2lhbnRlIGh1YmllcmVuIGRlc2lnbmFkbyBwYXJhIGxhIGF0cmlidWNpw7NuICh2LmcuLCB1biBpbnN0aXR1dG8gcGF0cm9jaW5hZG9yLCBlZGl0b3JpYWwsIHB1YmxpY2FjacOzbikgZW4gbGEgaW5mb3JtYWNpw7NuIGRlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBkZWwgTGljZW5jaWFudGUsIHTDqXJtaW5vcyBkZSBzZXJ2aWNpb3MgbyBkZSBvdHJhcyBmb3JtYXMgcmF6b25hYmxlczsgZWwgdMOtdHVsbyBkZSBsYSBPYnJhIHNpIGVzdMOhIHByb3Zpc3RvOyBlbiBsYSBtZWRpZGEgZGUgbG8gcmF6b25hYmxlbWVudGUgZmFjdGlibGUgeSwgc2kgZXN0w6EgcHJvdmlzdG8sIGVsIElkZW50aWZpY2Fkb3IgVW5pZm9ybWUgZGUgUmVjdXJzb3MgKFVuaWZvcm0gUmVzb3VyY2UgSWRlbnRpZmllcikgcXVlIGVsIExpY2VuY2lhbnRlIGVzcGVjaWZpY2EgcGFyYSBzZXIgYXNvY2lhZG8gY29uIGxhIE9icmEsIHNhbHZvIHF1ZSB0YWwgVVJJIG5vIHNlIHJlZmllcmEgYSBsYSBub3RhIHNvYnJlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBvIGEgbGEgaW5mb3JtYWNpw7NuIHNvYnJlIGVsIGxpY2VuY2lhbWllbnRvIGRlIGxhIE9icmE7IHkgZW4gZWwgY2FzbyBkZSB1bmEgT2JyYSBEZXJpdmFkYSwgYXRyaWJ1aXIgZWwgY3LDqWRpdG8gaWRlbnRpZmljYW5kbyBlbCB1c28gZGUgbGEgT2JyYSBlbiBsYSBPYnJhIERlcml2YWRhICh2LmcuLCAiVHJhZHVjY2nDs24gRnJhbmNlc2EgZGUgbGEgT2JyYSBkZWwgQXV0b3IgT3JpZ2luYWwsIiBvICJHdWnDs24gQ2luZW1hdG9ncsOhZmljbyBiYXNhZG8gZW4gbGEgT2JyYSBvcmlnaW5hbCBkZWwgQXV0b3IgT3JpZ2luYWwiKS4gVGFsIGNyw6lkaXRvIHB1ZWRlIHNlciBpbXBsZW1lbnRhZG8gZGUgY3VhbHF1aWVyIGZvcm1hIHJhem9uYWJsZTsgZW4gZWwgY2Fzbywgc2luIGVtYmFyZ28sIGRlIE9icmFzIERlcml2YWRhcyB1IE9icmFzIENvbGVjdGl2YXMsIHRhbCBjcsOpZGl0byBhcGFyZWNlcsOhLCBjb21vIG3DrW5pbW8sIGRvbmRlIGFwYXJlY2UgZWwgY3LDqWRpdG8gZGUgY3VhbHF1aWVyIG90cm8gYXV0b3IgY29tcGFyYWJsZSB5IGRlIHVuYSBtYW5lcmEsIGFsIG1lbm9zLCB0YW4gZGVzdGFjYWRhIGNvbW8gZWwgY3LDqWRpdG8gZGUgb3RybyBhdXRvciBjb21wYXJhYmxlLiAgCmQuIFBhcmEgZXZpdGFyIHRvZGEgY29uZnVzacOzbiwgZWwgTGljZW5jaWFudGUgYWNsYXJhIHF1ZSwgY3VhbmRvIGxhIG9icmEgZXMgdW5hIGNvbXBvc2ljacOzbiBtdXNpY2FsOgoKaS4gUmVnYWzDrWFzIHBvciBpbnRlcnByZXRhY2nDs24geSBlamVjdWNpw7NuIGJham8gbGljZW5jaWFzIGdlbmVyYWxlcy4gRWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGV4Y2x1c2l2byBkZSBhdXRvcml6YXIgbGEgZWplY3VjacOzbiBww7pibGljYSBvIGxhIGVqZWN1Y2nDs24gcMO6YmxpY2EgZGlnaXRhbCBkZSBsYSBvYnJhIHkgZGUgcmVjb2xlY3Rhciwgc2VhIGluZGl2aWR1YWxtZW50ZSBvIGEgdHJhdsOpcyBkZSB1bmEgc29jaWVkYWQgZGUgZ2VzdGnDs24gY29sZWN0aXZhIGRlIGRlcmVjaG9zIGRlIGF1dG9yIHkgZGVyZWNob3MgY29uZXhvcyAocG9yIGVqZW1wbG8sIFNBWUNPKSwgbGFzIHJlZ2Fsw61hcyBwb3IgbGEgZWplY3VjacOzbiBww7pibGljYSBvIHBvciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIGRpZ2l0YWwgZGUgbGEgb2JyYSAocG9yIGVqZW1wbG8gV2ViY2FzdCkgbGljZW5jaWFkYSBiYWpvIGxpY2VuY2lhcyBnZW5lcmFsZXMsIHNpIGxhIGludGVycHJldGFjacOzbiBvIGVqZWN1Y2nDs24gZGUgbGEgb2JyYSBlc3TDoSBwcmltb3JkaWFsbWVudGUgb3JpZW50YWRhIHBvciBvIGRpcmlnaWRhIGEgbGEgb2J0ZW5jacOzbiBkZSB1bmEgdmVudGFqYSBjb21lcmNpYWwgbyB1bmEgY29tcGVuc2FjacOzbiBtb25ldGFyaWEgcHJpdmFkYS4KaWkuIFJlZ2Fsw61hcyBwb3IgRm9ub2dyYW1hcy4gRWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGV4Y2x1c2l2byBkZSByZWNvbGVjdGFyLCBpbmRpdmlkdWFsbWVudGUgbyBhIHRyYXbDqXMgZGUgdW5hIHNvY2llZGFkIGRlIGdlc3Rpw7NuIGNvbGVjdGl2YSBkZSBkZXJlY2hvcyBkZSBhdXRvciB5IGRlcmVjaG9zIGNvbmV4b3MgKHBvciBlamVtcGxvLCBsb3MgY29uc2FncmFkb3MgcG9yIGxhIFNBWUNPKSwgdW5hIGFnZW5jaWEgZGUgZGVyZWNob3MgbXVzaWNhbGVzIG8gYWxnw7puIGFnZW50ZSBkZXNpZ25hZG8sIGxhcyByZWdhbMOtYXMgcG9yIGN1YWxxdWllciBmb25vZ3JhbWEgcXVlIFVzdGVkIGNyZWUgYSBwYXJ0aXIgZGUgbGEgb2JyYSAo4oCcdmVyc2nDs24gY292ZXLigJ0pIHkgZGlzdHJpYnV5YSwgZW4gbG9zIHTDqXJtaW5vcyBkZWwgcsOpZ2ltZW4gZGUgZGVyZWNob3MgZGUgYXV0b3IsIHNpIGxhIGNyZWFjacOzbiBvIGRpc3RyaWJ1Y2nDs24gZGUgZXNhIHZlcnNpw7NuIGNvdmVyIGVzdMOhIHByaW1vcmRpYWxtZW50ZSBkZXN0aW5hZGEgbyBkaXJpZ2lkYSBhIG9idGVuZXIgdW5hIHZlbnRhamEgY29tZXJjaWFsIG8gdW5hIGNvbXBlbnNhY2nDs24gbW9uZXRhcmlhIHByaXZhZGEuCiAgICAgIAplLiBHZXN0acOzbiBkZSBEZXJlY2hvcyBkZSBBdXRvciBzb2JyZSBJbnRlcnByZXRhY2lvbmVzIHkgRWplY3VjaW9uZXMgRGlnaXRhbGVzIChXZWJDYXN0aW5nKS4gUGFyYSBldml0YXIgdG9kYSBjb25mdXNpw7NuLCBlbCBMaWNlbmNpYW50ZSBhY2xhcmEgcXVlLCBjdWFuZG8gbGEgb2JyYSBzZWEgdW4gZm9ub2dyYW1hLCBlbCBMaWNlbmNpYW50ZSBzZSByZXNlcnZhIGVsIGRlcmVjaG8gZXhjbHVzaXZvIGRlIGF1dG9yaXphciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIGRpZ2l0YWwgZGUgbGEgb2JyYSAocG9yIGVqZW1wbG8sIHdlYmNhc3QpIHkgZGUgcmVjb2xlY3RhciwgaW5kaXZpZHVhbG1lbnRlIG8gYSB0cmF2w6lzIGRlIHVuYSBzb2NpZWRhZCBkZSBnZXN0acOzbiBjb2xlY3RpdmEgZGUgZGVyZWNob3MgZGUgYXV0b3IgeSBkZXJlY2hvcyBjb25leG9zIChwb3IgZWplbXBsbywgQUNJTlBSTyksIGxhcyByZWdhbMOtYXMgcG9yIGxhIGVqZWN1Y2nDs24gcMO6YmxpY2EgZGlnaXRhbCBkZSBsYSBvYnJhIChwb3IgZWplbXBsbywgd2ViY2FzdCksIHN1amV0YSBhIGxhcyBkaXNwb3NpY2lvbmVzIGFwbGljYWJsZXMgZGVsIHLDqWdpbWVuIGRlIERlcmVjaG8gZGUgQXV0b3IsIHNpIGVzdGEgZWplY3VjacOzbiBww7pibGljYSBkaWdpdGFsIGVzdMOhIHByaW1vcmRpYWxtZW50ZSBkaXJpZ2lkYSBhIG9idGVuZXIgdW5hIHZlbnRhamEgY29tZXJjaWFsIG8gdW5hIGNvbXBlbnNhY2nDs24gbW9uZXRhcmlhIHByaXZhZGEuCiAgCjUuIFJlcHJlc2VudGFjaW9uZXMsIEdhcmFudMOtYXMgeSBMaW1pdGFjaW9uZXMgZGUgUmVzcG9uc2FiaWxpZGFkLgpBIE1FTk9TIFFVRSBMQVMgUEFSVEVTIExPIEFDT1JEQVJBTiBERSBPVFJBIEZPUk1BIFBPUiBFU0NSSVRPLCBFTCBMSUNFTkNJQU5URSBPRlJFQ0UgTEEgT0JSQSAoRU4gRUwgRVNUQURPIEVOIEVMIFFVRSBTRSBFTkNVRU5UUkEpIOKAnFRBTCBDVUFM4oCdLCBTSU4gQlJJTkRBUiBHQVJBTlTDjUFTIERFIENMQVNFIEFMR1VOQSBSRVNQRUNUTyBERSBMQSBPQlJBLCBZQSBTRUEgRVhQUkVTQSwgSU1QTMONQ0lUQSwgTEVHQUwgTyBDVUFMUVVJRVJBIE9UUkEsIElOQ0xVWUVORE8sIFNJTiBMSU1JVEFSU0UgQSBFTExBUywgR0FSQU5Uw41BUyBERSBUSVRVTEFSSURBRCwgQ09NRVJDSUFCSUxJREFELCBBREFQVEFCSUxJREFEIE8gQURFQ1VBQ0nDk04gQSBQUk9Qw5NTSVRPIERFVEVSTUlOQURPLCBBVVNFTkNJQSBERSBJTkZSQUNDScOTTiwgREUgQVVTRU5DSUEgREUgREVGRUNUT1MgTEFURU5URVMgTyBERSBPVFJPIFRJUE8sIE8gTEEgUFJFU0VOQ0lBIE8gQVVTRU5DSUEgREUgRVJST1JFUywgU0VBTiBPIE5PIERFU0NVQlJJQkxFUyAoUFVFREFOIE8gTk8gU0VSIEVTVE9TIERFU0NVQklFUlRPUykuIEFMR1VOQVMgSlVSSVNESUNDSU9ORVMgTk8gUEVSTUlURU4gTEEgRVhDTFVTScOTTiBERSBHQVJBTlTDjUFTIElNUEzDjUNJVEFTLCBFTiBDVVlPIENBU08gRVNUQSBFWENMVVNJw5NOIFBVRURFIE5PIEFQTElDQVJTRSBBIFVTVEVELgogIAo2LiBMaW1pdGFjacOzbiBkZSByZXNwb25zYWJpbGlkYWQuCkEgTUVOT1MgUVVFIExPIEVYSUpBIEVYUFJFU0FNRU5URSBMQSBMRVkgQVBMSUNBQkxFLCBFTCBMSUNFTkNJQU5URSBOTyBTRVLDgSBSRVNQT05TQUJMRSBBTlRFIFVTVEVEIFBPUiBEQcORTyBBTEdVTk8sIFNFQSBQT1IgUkVTUE9OU0FCSUxJREFEIEVYVFJBQ09OVFJBQ1RVQUwsIFBSRUNPTlRSQUNUVUFMIE8gQ09OVFJBQ1RVQUwsIE9CSkVUSVZBIE8gU1VCSkVUSVZBLCBTRSBUUkFURSBERSBEQcORT1MgTU9SQUxFUyBPIFBBVFJJTU9OSUFMRVMsIERJUkVDVE9TIE8gSU5ESVJFQ1RPUywgUFJFVklTVE9TIE8gSU1QUkVWSVNUT1MgUFJPRFVDSURPUyBQT1IgRUwgVVNPIERFIEVTVEEgTElDRU5DSUEgTyBERSBMQSBPQlJBLCBBVU4gQ1VBTkRPIEVMIExJQ0VOQ0lBTlRFIEhBWUEgU0lETyBBRFZFUlRJRE8gREUgTEEgUE9TSUJJTElEQUQgREUgRElDSE9TIERBw5FPUy4gQUxHVU5BUyBMRVlFUyBOTyBQRVJNSVRFTiBMQSBFWENMVVNJw5NOIERFIENJRVJUQSBSRVNQT05TQUJJTElEQUQsIEVOIENVWU8gQ0FTTyBFU1RBIEVYQ0xVU0nDk04gUFVFREUgTk8gQVBMSUNBUlNFIEEgVVNURUQuCiAgCjcuIFTDqXJtaW5vLgkKYS4gRXN0YSBMaWNlbmNpYSB5IGxvcyBkZXJlY2hvcyBvdG9yZ2Fkb3MgZW4gdmlydHVkIGRlIGVsbGEgdGVybWluYXLDoW4gYXV0b23DoXRpY2FtZW50ZSBzaSBVc3RlZCBpbmZyaW5nZSBhbGd1bmEgY29uZGljacOzbiBlc3RhYmxlY2lkYSBlbiBlbGxhLiBTaW4gZW1iYXJnbywgbG9zIGluZGl2aWR1b3MgbyBlbnRpZGFkZXMgcXVlIGhhbiByZWNpYmlkbyBPYnJhcyBEZXJpdmFkYXMgbyBDb2xlY3RpdmFzIGRlIFVzdGVkIGRlIGNvbmZvcm1pZGFkIGNvbiBlc3RhIExpY2VuY2lhLCBubyB2ZXLDoW4gdGVybWluYWRhcyBzdXMgbGljZW5jaWFzLCBzaWVtcHJlIHF1ZSBlc3RvcyBpbmRpdmlkdW9zIG8gZW50aWRhZGVzIHNpZ2FuIGN1bXBsaWVuZG8gw61udGVncmFtZW50ZSBsYXMgY29uZGljaW9uZXMgZGUgZXN0YXMgbGljZW5jaWFzLiBMYXMgU2VjY2lvbmVzIDEsIDIsIDUsIDYsIDcsIHkgOCBzdWJzaXN0aXLDoW4gYSBjdWFscXVpZXIgdGVybWluYWNpw7NuIGRlIGVzdGEgTGljZW5jaWEuCmIuIFN1amV0YSBhIGxhcyBjb25kaWNpb25lcyB5IHTDqXJtaW5vcyBhbnRlcmlvcmVzLCBsYSBsaWNlbmNpYSBvdG9yZ2FkYSBhcXXDrSBlcyBwZXJwZXR1YSAoZHVyYW50ZSBlbCBwZXLDrW9kbyBkZSB2aWdlbmNpYSBkZSBsb3MgZGVyZWNob3MgZGUgYXV0b3IgZGUgbGEgb2JyYSkuIE5vIG9ic3RhbnRlIGxvIGFudGVyaW9yLCBlbCBMaWNlbmNpYW50ZSBzZSByZXNlcnZhIGVsIGRlcmVjaG8gYSBwdWJsaWNhciB5L28gZXN0cmVuYXIgbGEgT2JyYSBiYWpvIGNvbmRpY2lvbmVzIGRlIGxpY2VuY2lhIGRpZmVyZW50ZXMgbyBhIGRlamFyIGRlIGRpc3RyaWJ1aXJsYSBlbiBsb3MgdMOpcm1pbm9zIGRlIGVzdGEgTGljZW5jaWEgZW4gY3VhbHF1aWVyIG1vbWVudG87IGVuIGVsIGVudGVuZGlkbywgc2luIGVtYmFyZ28sIHF1ZSBlc2EgZWxlY2Npw7NuIG5vIHNlcnZpcsOhIHBhcmEgcmV2b2NhciBlc3RhIGxpY2VuY2lhIG8gcXVlIGRlYmEgc2VyIG90b3JnYWRhICwgYmFqbyBsb3MgdMOpcm1pbm9zIGRlIGVzdGEgbGljZW5jaWEpLCB5IGVzdGEgbGljZW5jaWEgY29udGludWFyw6EgZW4gcGxlbm8gdmlnb3IgeSBlZmVjdG8gYSBtZW5vcyBxdWUgc2VhIHRlcm1pbmFkYSBjb21vIHNlIGV4cHJlc2EgYXRyw6FzLiBMYSBMaWNlbmNpYSByZXZvY2FkYSBjb250aW51YXLDoSBzaWVuZG8gcGxlbmFtZW50ZSB2aWdlbnRlIHkgZWZlY3RpdmEgc2kgbm8gc2UgbGUgZGEgdMOpcm1pbm8gZW4gbGFzIGNvbmRpY2lvbmVzIGluZGljYWRhcyBhbnRlcmlvcm1lbnRlLgogIAo4LiBWYXJpb3MuCmEuIENhZGEgdmV6IHF1ZSBVc3RlZCBkaXN0cmlidXlhIG8gcG9uZ2EgYSBkaXNwb3NpY2nDs24gcMO6YmxpY2EgbGEgT2JyYSBvIHVuYSBPYnJhIENvbGVjdGl2YSwgZWwgTGljZW5jaWFudGUgb2ZyZWNlcsOhIGFsIGRlc3RpbmF0YXJpbyB1bmEgbGljZW5jaWEgZW4gbG9zIG1pc21vcyB0w6lybWlub3MgeSBjb25kaWNpb25lcyBxdWUgbGEgbGljZW5jaWEgb3RvcmdhZGEgYSBVc3RlZCBiYWpvIGVzdGEgTGljZW5jaWEuCmIuIFNpIGFsZ3VuYSBkaXNwb3NpY2nDs24gZGUgZXN0YSBMaWNlbmNpYSByZXN1bHRhIGludmFsaWRhZGEgbyBubyBleGlnaWJsZSwgc2Vnw7puIGxhIGxlZ2lzbGFjacOzbiB2aWdlbnRlLCBlc3RvIG5vIGFmZWN0YXLDoSBuaSBsYSB2YWxpZGV6IG5pIGxhIGFwbGljYWJpbGlkYWQgZGVsIHJlc3RvIGRlIGNvbmRpY2lvbmVzIGRlIGVzdGEgTGljZW5jaWEgeSwgc2luIGFjY2nDs24gYWRpY2lvbmFsIHBvciBwYXJ0ZSBkZSBsb3Mgc3VqZXRvcyBkZSBlc3RlIGFjdWVyZG8sIGFxdcOpbGxhIHNlIGVudGVuZGVyw6EgcmVmb3JtYWRhIGxvIG3DrW5pbW8gbmVjZXNhcmlvIHBhcmEgaGFjZXIgcXVlIGRpY2hhIGRpc3Bvc2ljacOzbiBzZWEgdsOhbGlkYSB5IGV4aWdpYmxlLgpjLiBOaW5nw7puIHTDqXJtaW5vIG8gZGlzcG9zaWNpw7NuIGRlIGVzdGEgTGljZW5jaWEgc2UgZXN0aW1hcsOhIHJlbnVuY2lhZGEgeSBuaW5ndW5hIHZpb2xhY2nDs24gZGUgZWxsYSBzZXLDoSBjb25zZW50aWRhIGEgbWVub3MgcXVlIGVzYSByZW51bmNpYSBvIGNvbnNlbnRpbWllbnRvIHNlYSBvdG9yZ2FkbyBwb3IgZXNjcml0byB5IGZpcm1hZG8gcG9yIGxhIHBhcnRlIHF1ZSByZW51bmNpZSBvIGNvbnNpZW50YS4KZC4gRXN0YSBMaWNlbmNpYSByZWZsZWphIGVsIGFjdWVyZG8gcGxlbm8gZW50cmUgbGFzIHBhcnRlcyByZXNwZWN0byBhIGxhIE9icmEgYXF1w60gbGljZW5jaWFkYS4gTm8gaGF5IGFycmVnbG9zLCBhY3VlcmRvcyBvIGRlY2xhcmFjaW9uZXMgcmVzcGVjdG8gYSBsYSBPYnJhIHF1ZSBubyBlc3TDqW4gZXNwZWNpZmljYWRvcyBlbiBlc3RlIGRvY3VtZW50by4gRWwgTGljZW5jaWFudGUgbm8gc2UgdmVyw6EgbGltaXRhZG8gcG9yIG5pbmd1bmEgZGlzcG9zaWNpw7NuIGFkaWNpb25hbCBxdWUgcHVlZGEgc3VyZ2lyIGVuIGFsZ3VuYSBjb211bmljYWNpw7NuIGVtYW5hZGEgZGUgVXN0ZWQuIEVzdGEgTGljZW5jaWEgbm8gcHVlZGUgc2VyIG1vZGlmaWNhZGEgc2luIGVsIGNvbnNlbnRpbWllbnRvIG11dHVvIHBvciBlc2NyaXRvIGRlbCBMaWNlbmNpYW50ZSB5IFVzdGVkLgo= 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