ࡱ> ! n &)2N +;PNG  IHDRSWtEXtSoftwareMicrosoft Office5qPLTER:J:J{{:{RZJBZZsZJZk))k)sZJZJέJZֽZJ1{){)1k)1ťkZccZ11ZZccZ)ZZ){c1c{1{Υ{{ZccZZZRRJsZk凜{c{{!1!޽1BޜֽֽJJ{ֽ{BZ{Zk1BBk1ZkBB)1c攭){)BBkBB)歔ﭔk)1kkkkkk)kkkk)ZkcZZZ){ZJ{JZ{ZJBBJBB攌BέBJBBέJkkkJkkkέkJkZZZ{޽ν{c1c{c1c{111{{)Z{){1c{Z{)ZZ1RB)!1:Z1)ZRZk{1{Z)1{ZJJ{{ZZZ11ŵ)JZssZZεZ{1ŔJZRRZZΔJ)J)JJJ)J)JJ!cR{Z11{111:R:{:R5S cmPPJCmp0712Hs|IDAThCZ;rHE<Mɀ,'"jHNEBE:Þ@GK3(kbFU X yԘ,{R?5G6餩ԵyYphtjD'*I ,y*$h>j$I 5$ K s*n:д@Ƈ$Y "YfDΖ`[NZZvf/gri\">jq5zVA-;) @;5pӥ BR(Q):b9-֨`@M<ZA$|'*C/o.?z^Q4)N)(ަapBk.a9>d9Jʇ⟽Tpp*diȋc]IJ㸯 COrSܹ?dI.wR7  z?[MuOKġ(M,DS$#Ev^܌nFvMhxR)B㰤0C Y9 N䰥 _ىH`_z3ԙK-gN MR*{[[/blۄ# s."s_ËxRlo4s9mլ<7}S{{qwZ'Y"B=MзqnVcpn'dִp-cUL.h7鼕=՜7(,\\;SɁ) \6\ٙnYw+w7pXt6+?1wVҍJV4S_A$ӓ& Y M2a3ؠȈS[r[[yŶ:8'}J]l~mn(w09QyV"QKy7yl[5UD8 몏x3"??­ZE=⪋dHIENDB`F`jǪ<"D@GJFIFHHBExifMM* nw(12idv418111Adobe Photoshop 7.02002:12:04 08:10:57Q*2(:HH$Photoshop 3.08BIMxdv418111T271Medics LandscapeWomanFemaleMotherBabyChildInfantNew BornBlack and White MonochromeSmileSmilingHappyLovingCaring Maternity8BIM%Z[Am%"X8BIM com.apple.print.PageFormat.PMHorizontalRes com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMHorizontalRes 72 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMOrientation com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMOrientation 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMScaling com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMScaling 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMVerticalRes com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMVerticalRes 72 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMVerticalScaling com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMVerticalScaling 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.subTicket.paper_info_ticket com.apple.print.PageFormat.PMAdjustedPageRect com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMAdjustedPageRect 0.0 0.0 734 576 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMAdjustedPaperRect com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMAdjustedPaperRect -18 -18 774 594 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PaperInfo.PMPaperName com.apple.print.ticket.creator com.apple.print.pm.PostScript com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMPaperName na-letter com.apple.print.ticket.client com.apple.print.pm.PostScript com.apple.print.ticket.modDate 2000-07-28T22:57:04Z com.apple.print.ticket.stateFlag 1 com.apple.print.PaperInfo.PMUnadjustedPageRect com.apple.print.ticket.creator com.apple.print.pm.PostScript com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMUnadjustedPageRect 0.0 0.0 734 576 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PaperInfo.PMUnadjustedPaperRect com.apple.print.ticket.creator com.apple.print.pm.PostScript com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMUnadjustedPaperRect -18 -18 774 594 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2002-12-04T16:10:52Z com.apple.print.ticket.stateFlag 0 com.apple.print.PaperInfo.ppd.PMPaperName com.apple.print.ticket.creator com.apple.print.pm.PostScript com.apple.print.ticket.itemArray com.apple.print.PaperInfo.ppd.PMPaperName Letter com.apple.print.ticket.client com.apple.print.pm.PostScript com.apple.print.ticket.modDate 2000-07-28T22:57:04Z com.apple.print.ticket.stateFlag 1 com.apple.print.ticket.APIVersion 00.20 com.apple.print.ticket.privateLock com.apple.print.ticket.type com.apple.print.PaperInfoTicket com.apple.print.ticket.APIVersion 00.20 com.apple.print.ticket.privateLock com.apple.print.ticket.type com.apple.print.PageFormatTicket 8BIMxHH@Rg(HH(dh 8BIMHH8BIM&?8BIMx8BIM8BIM 8BIM 8BIM http://www.gettyimages.com/8BIM' 8BIMH/fflff/ff2Z5-8BIMp8BIM@@8BIM8BIMEQdv418111QnullboundsObjcRct1Top longLeftlongBtomlongQRghtlongslicesVlLsObjcslicesliceIDlonggroupIDlongoriginenum ESliceOriginautoGeneratedTypeenum ESliceTypeImg boundsObjcRct1Top longLeftlongBtomlongQRghtlongurlTEXTnullTEXTMsgeTEXTaltTagTEXTcellTextIsHTMLboolcellTextTEXT horzAlignenumESliceHorzAligndefault vertAlignenumESliceVertAligndefault bgColorTypeenumESliceBGColorTypeNone topOutsetlong leftOutsetlong bottomOutsetlong rightOutsetlong8BIM8BIM8BIM!UAdobe PhotoshopAdobe Photoshop 7.08BIMhttp://ns.adobe.com/xap/1.0/ adobe:docid:photoshop:09ec7da8-08f2-11d7-b054-94afc45ec890 http://www.gettyimages.com/ dv418111 T271 Medics Landscape Woman Female Mother Baby Child Infant New Born Black and White Monochrome Smile Smiling Happy Loving Caring Maternity Adobed         Q@  s!1AQa"q2B#R3b$r%C4Scs5D'6Tdt& EFVU(eufv7GWgw8HXhx)9IYiy*:JZjzm!1AQa"q2#BRbr3$4CS%cs5DT &6E'dtU7()󄔤euFVfvGWgw8HXhx9IYiy*:JZjz ?YOolUaWLUӊ;*/-ݾxo5kO|UߦSrM)\5w锯گ*Ե1E銰=NCLwbXƭxܰ'x j*Ts[x6ciex#nVS*Sj4T{T:wRvaXqWb]hbAPÑ!wZx⨫k#=+VoS;?zQuShC)>G[ L*LliZoኲ!TUsOmbn#XցA/1TEHTf#?E[+,5_SjRG)Z8r†=Urzt&6 uDoUYv]LU$ژ?P?Uo-Gz{ޣcB'rh:}U;ek[Ӈ1WUثW*RٍiV*],?UI3h}@rGT.2H?Xa#s ڱG,U5K ?cߥ V})X+J=Z?hbPBZTS%5"⪋{W]ȼ}W-3rRiX *C8Go㊸UaB+3qW8hקӊz ?*|14OYJqW(~ͦFX) kJtaCEҤ.0@{]myq>U4HĞEIw#@UUثWbNs*UZ?w.Vyk0NZU_O8W![] U\G;|w*Z]$Tf튦zp^QMIHG Y8p UE-:zE¾'ȇ;T#'%Gq\UAapTъ@@ت-YnݱUBn(+kZb]PgjT. NI-uY04 PGb*}R ejEA⬳JhqW~ ֪wnCzO bhVygnv:!V5=a4e튦QR U|2_61UŇ*vUxzت!(@|UTPZcjm0 n;*1U#sb~EN*(jqx.=&#_7STQE劫-S⪫b+ZtWHxOZLUzvۦ*;bu[[75\‡qUۨ튡b*Z~a}eiOpqW=%߶*uvO?*V*STrh# n2EBA }okjw'm&/E<@oE=Hcbp+;bF wV,:l>U,d=((ኾOowqWWbUi'#@zUVY91޻0UjYyS*Ps*hJuB}N JGJvU?}w9ucOd\UXWTm!G!bN[_UW ㊫˧S)j6늶Mipl^o^<1T5>ъrӭHO ^OP9}ok"y3KR9zQUۯ4S.*שW=U?V*_dZ=h{W)v!mUQ@:劯ԌU1Uڸuڵ8OO1W=:WCGj^o$tƵ1V#WF ⯓?7-jꡉ#5TyƮ:)CBqT8ث@it6* iQ8E{JkDjR|U:uuJwcC*ϴe $&oS iӾ*SMe&GLUf-Dy[yD)8<樵Hؘ|@G*ϴ=em||1T>\h)Ȟ48&1 "*uq^&S*-Gz^+ifwfaY(G? l>LD|,_3wz|?bL khCDJ *Ne E@5{W*jF-QԎLa{7nv+LUwvN>?hNF>w5S*VT{b;.(/#~ya]kWRevb68#0V>5Q9*ҡ 뿆Y6g=Ť1bt+b<l-F+tZxb (}>늯ڻWtt_&mB: 8~ UY =b*Hjhhv<;犯AWXQҍηCqj>El*H _UI8_"$fj3t 튾g`Άf!iWy+5bWc)*ت튷Q49|qV_"=6MUu.Җ$FGF'lU(wɴШ;37/⨋[7_CoAqȥ *zJ\bAs$5UPYڟ-TdvW",$ڕYm.ӵEqWyKTKB* kHyS*M5k^SJP銼C:^KRD2%h w>boo#QNDԟlU\QS!JA"o U4T`ZbkQĶY# Cz1U=bǶ*^R/2WO;⯊4u!u[-U@}aXWbqTMU#qUInB*g%,=6*T}>8nȑG[=z3.o<H8v!HF*H 'qT@>qUJLUm*7㊷S㊿mqU`NتqJeMO㊣b5ڀ!4\UPir]6^|qUT$>b=v$v|UN}&WJt4AEYĔ*6EPbCJ늫ŤIPJQ0 Sxϖ'uD$oO17@u(g`=l~qbe>[bSllUæ*71Vm'U+⬲ג(dh(>4}U'ӶONxPZvX,bm1T9QCGnUX_q{qpBG_N4m<{{üqJ91`i4]T-|G"("¿9ꗓIsPj1Wۯ}H&[Y+v!L_|w2hi -ZQX/OWibn(YTeSMoUupu+ć3TO@V?v*W˥ѪcyPM ݄S?oqT+Te}؃|U3u"SUh~*e;|1V~m*G6$XF]X{]:|U'* WS˜FkbZ>rڥjGN?lUwNث? 4|s,"YX! |OPFOQFU~/*Z U㊭?kLt4z Uz,+7u0-֘6kRU Nb6Rp}iO1Vql=W-iS›|TU!F~,""5RG#*-%?t ]˶*{b7Q a+`dVT0ڔzU>fxњɍLԠ%O#U_澧OWVQZ_gsz~rK$UbcJcƾIQlDp+ <\^)WAɸ6*4O#\-C@QdxdE 9_ }OUM>ck$C4j/'F^U=JGfP@X Q.;UIrV6^OPZE ⯍dbIk늻o^v=劣!!fZNiZ'ҁ_LTW$ b񴔓EU AN~ϰ;Uwvq.5)"QՔ~}O-4=.- NM:ZzZ"U劵ʧ{x⫕w*c\UQj^*_lU_hjbnp_][PkS*k*ѩpz bwtEE$e|jbty`]Ҥ34a;i0Tb'x]|qU*F**2*jqtH#~߮*4q=6_L0$hZzkJ ߰*/,9G`1THkتM)S"޷] }cb;SzSaJ|TqUoR((:U'HEA'cz-"ƪ|V޴#*5mH-~-,5|qT,:с*G(By LU7nn(<_WlU6bE|]=*T**Yj1U7݊\!8Mi4?1WD5\ኢc}hi+5aXZ*EqUhdaqU+Y61m k~ԑU:c=2ehZe`<bH`*#U #MLliJVI"̞ت_*I]8tp>#kqV4VVT1UA+]~Uثgt`qW^Xm's6Ȯo*KP|WZE.ŀw][*9Z9VE?G:Kh,*l~29۩ޕӊ+|B7"TQӗ# *5 0Ɓ_l~U)v=({TgvN*yjp>>>_J=j(~xlU)LU)1U))qTvv$ҠvTI]֧zVi,yϐz*-3C܀|Uih;m[DFڸ!=F*c`tU)^PwzpևlUn/|dnKmP%] i_LUa㊦}PL.FjbXϣ˷D=g#aucBFqVJ\U4I 1^jݻS}8t_+DRyBh~&iTn:UiALUUblI4[U犮_uZ3ubUCqVۦ*)nZH]Ujw[5'n%IgoEsEň3FG_fYlKKf=c(qUkoqS/zlO|UXӝXҘߜ"HOእOsV*U$Rc'rHe5S;GZ?ثAw**U;⮩b\OUWW[1VbKm*#*LU5늺*!qUQEiR6?#b=|. 6[9M@|+_ Un**UتOūe zP}8)nc-؏㊧vӎ =)Czm$ߖU:ƊA T*ū_bqW+G*LKZe@< &nN*K!<bZF _1V:$+ڍB'L)h9$8:Rj>fcnΛrE⨚|UăT`xqGxއ|{+bIqU'.EY~N*sS_H ܟSOy*Lj˻HOOXe0o?(bR0h P|)2cb !Wf$GU/tzQr{UB7sP(v5ث|帕k&mwsAŅBtbqVh1UثVW UثV]ZoklUqWWVwV'qUT"8w**7p1T<% cژ߿hbȤ0@XtxȖY=_cӦ*٭&<**UثTE*ȠIšF*ϨN*MX~=kLĶSHi8=Λj8$n]~UYeUGP+*%WVp*;n*B\A3WlUQ*槶*򢏇lU,\lU*Nx+~U2PT1VONUh55⬪|+*#*fZPʪGacam$⯐8|u}ZHbz*36銫8(9E\^~U╚ɵESQ%:\ÓzbWb]?#c|Uي0WrZfS&iI)@կ*THԓ@<ܪRH.j}U ѩ^qUHÐy 1V=}go}i.Xt&Wu+ NIRvc$Tx]lb *4**HOU[¾8 $tqSzk~>;]Zsy㊽ADi^]+KPLUb 0oPwUMs[@,j\UB]8*)އQ1VnG"y)ex,(~x*m_銽G󆟩m8Z[brFۓzξ*1Wj}F{XdnI_:<#*[d .% }]R⪖E-,~m3]EV"d}1RyP]t"';ckcrO%;0ðU".daEW VaNث8|6̆WED35C튢ퟙ7a튦PiLUv*Jӿ]Uvд3G j*HʊcA_N2CMrՑ7k*<;ȟtXejr'PMZ鿍1WYiYq5BT Vy;Ǽd`VMzxinbMqV/#lUf*i}_*V*IdIG,K15N/Y#]/bȦwn=T"EU)%xmZJ{ܳQSާs*"X4ۊimV#jۮ*u& "/_ d4O⠏|U}6lbUUثVWbuX1V ⫈SA NPu|U^m{bv ǩ늣H BN*ykVzbIUvo x⭋q5\UeXQ=V?:TXĎx* _.`o^n7m`H$٘^yj|R4YqTk۩PByx+Ȩ^U5F*6=VMe-( bͭŠ({Uo>>CNت2[ֶ=IOOaBqT&hR_Wb:Ƹ<vgig4hŞF(6ߴqV_O]>bXv(#DG]-lc=BLUvH8y|N|+ 'L[ElU^y{hcjGj*OTy9kbbnnMI銠p*!@vt[D (J*mڈDȄTJy+J/ZȤw1nRF坥mُ"qTMR6b+8)+W*Fm iA{-u7`&^r_G躊TKʆ*I݆*Kh|ABN*疍|=VlyTAbvb&Ѯ~b a8ļ-D nBx.x͹ UXcWcNdGׯt]hZ5t9/*c7S۷+(~%Cbn.A??U2N{Z}N1Upkb {VTJ0bkVE#NVۋs{ooRB@&;WJu;:a֤=6g@1Wk跊G qWz7V$Rآi@QRVpRoAěރ :T)  S>z'ޟݧLتe ;&O/UVO0BU@Z~Ue0ڬqYEz)1XÓM>UFM19B֛ t@ͤE}qU)|q AN$tlU&|e+< )i]v^9/ic"eR8k)@F*T>؛L)[hG*钃#jbz͓%j*l.3Fk 5YʂF ]:bT)=1TB*URBƾrw1VjFe&5rny”ۿ5frĵMH]銱k9n6iڬit]}wffvܓVQ֍P(5gڴ=)_kD[\i/Y@XT X+VSH[ˊdj(]AAت_uu$1$s7ɺ*$@XUI(኶w⪑WqT J.P2ޖaT~GC0h|U<#jfWd>TvV2hZ:qW^II"jUQD#p1Vȳ6?eTJUTb_0Ti}⨝Oq*f 6R^OjJ@0Wk%Ο)p`v!1U]yƩ!Yh5|`wR^<a Uwjt'~F30S̕ڬm*V@,p{Ud^11@*i_=[bcJВI*J@zb wv[_UaNos b^PwB9~c{LVA2)++byKY7ǔ*lbP.!b=WA:Մ]9R#f-PPzbbJ&SvQv*ġBN* UBIM7TEޣK4OImMIHD2wBǩkA5ژSyj&8Ǩ>5*~`>X5J|-נ_׊4n澽wV2H%'jd:VC/s_*ޚI-@[@wS+vq"’AR* >N,iߋ1UiUBTRҧ犡.,KFxO늣4F%c45ހ-?*h{ÝTv]ZU:zJ8۽1TF=)VOSHq^~㊫}#FK@[hzt튤>``TR Ѷ_?~d~]){p85 (_[I#[:ѕ!@hO7S,ܥ*)zmJۅSqVs 0rIweck?)Q OM7Gc1*$`)&|.UxdC0wZU~*7x\1I$)qUJB+Ҹ|1T}7P U~n,UTwSqT]Y0z⩐fsRUWxH4?F*2,Uo|1UgH nzCኽηz,LcibM qW^Vaos mS%uoAďq8,zӨ-V'*;銱0b(c, 4=UVvnG늮bV`TUھ81U$ FT횫́Uj#vМUicfP:צ -Z1ӱ#qW/, U, :n'vtԯ/}T^gَզLUi Q+%%M+FQw ۓw6Y5B׈v⩬1JK sN.InR5*A1PRiBhz U5Kg@zSLS(qTls4ኢntrw*@I <7#lUČUXST'cblg6w:(miLUV-5~E}"UL||=7%KzU6I 2xw48u`;W*"!ָk'c)gjqWy^፼55$urܙW}*R2m3PcޤP=w8nzu>ڔ581Ub)J85[%>qUGAN*|*h֤vUQ=PSg <TcՓG_S1WP:V/!hWԛB6'JWaZL 'Ě PtSKg&׹Rԥ$omJ]],*=k%w5$=W?^`ϒZIAMWyIY[OrqV]02X/R7o*H z{,Z[^GU-P9_\QU޵Y+M@|NqUON'&t(\U ks{ȑ Dr~ hW~YƆb,V?ej#{TaVmM^*E2?ۿlUTOMUTQCƦn)Z1'}WV^4S ~X".AQֽqUBb70,Āi=V-C} S*]4⯔1|sj< rc޾=b/<$Ȥ2>qVIP?V*ʭi'%PlcIQab;x.&z}~?[w#t4 vkOMeՖXC1VuZq(D1ۮ*V2Mi㊣QZbeoV)n;bHA+D~*E|B UP $V8ZVLUuZ *^<1W~h Y5 TURX]}^++?:_Uy*݇QXs} D.~83Y,?+u3+,oNg݊:B|UW^K忪h.ukT֣qΆ⬿>}Ӽ-(U 'emr2\< ,3!Z +kXTeKv*e`*|-ڃd|"E*GZbڃ16KP x⩜2P;DKne^!8U'G׭䉒|u? bRyڃSŖ+ևf^euU 7SZ\U*=rjW>Z˿bw"2G*?:%=[:r\xXAB::-G*bߒGHg_B4d׀UJNs <45|;EPjŇتs խ}TAT@SZp8>5,VCQ~U֕_Yjv2XZմÌ8xV3XA_oٰc<_*h/*u%^TN G_#ኣw\v8ElU;M7*9Ov1W/E O Uo^\4UW,@b~2w&-epXM*[y$:Pt;U2. ֝qV?A%m4~OOgfrԝUV?U( * *ɣ c l+LU-ka޸Y2QbX(/1VM!H㊦_̳=knHwJbY[\1(ڻ}*?-+5?ЪJ,UM8]\L9_b]gLYoA0H?joOt %#HRIj1V;bZF[L #*:X! _#zbO7IkPw+㊦F@6jnTݚqTޞ4 9'jibE֯o4q 7K  QkO|UaK+/߃&i^7\1TIdGF*y+PqW~[~u[ϧ&ʱ^B65:6Zt)߼jCAЀINu;"e1+q8:=wZJG{2)H@Jbauh#1w*#}V"P\O#yQ ꨡREQ UAniԓW<Ө -.E=َ{V8alGo1!r|Ug@ҭS4>k77Nk!6 k1Wڭ8PK0ԎpS;ѱF8L]B@⨹|koZm3z%U,qV)*Xԟc잢Ն*{vXgn'*][[Zq-P*j?*tJN t'a^*5$snRqVUw\JrW)ZҘ -i}aT5v\U4.ܢ(ӯ|U]FUbg%|VX{ȲHimT+iot4CLUy{2։}IO&;⬎RCEmч]*^Td6R? AZoncFF"5:Wzb^\)'`I*mEckX Xqo˜4toiM[næ*ϼruZ\_i*.;FѢqeVb H-Q銣oQ xһ{o^ثӐaFZTJ8^54S}:rG^ M늲6N]\U:DLU08׷_oU`aOwQ8bv89*c}jF}!q`}CBy|<*8~otJ=͝U  *8}_Gi&E>Ekb~vAPnƴYJ#_[d>kQZȲ+*pT+>%ܵRҁ ^yZ!&E >U&hH; mA*/SuT&e@Ƈ*Z{Mq)׮*iSa*֒6TM w튡$Ѧ@lUI[qUM:tUI#NPzi{-|~6x,\'_Hx8TE(t U%r**| 0+qVFxXmQЍ^c˭>4{k#4=*qWyF3z)bAIХM*G_*k$)N_@FXZY3뗶Z @^c(;JyjfܗnRGqUd+sSCQI(*w8ynmm,-xԥV犲8|ZY)F#v^^Y)՗1V4;nG\UHeVtP8x([zNتqǡmOtD-b@ϙZ >^>U2>Jsniם*GθmoāW}Gn#In{cT'ʕQPj1; vU$JHJ}boUݗFlWUl>Uih:Ǘ.`F)r:H=#*ϯYYnb4R #2> JWKbKf*EkV軝[qVayt br>grSYU% 20S|[qm&6#>#^s(x8'o*:AVXm?!c>^ðZya|U/`ѯшQS`;@EV[s8Ei>lE>+%G+'I6PM_LU6'ӊGRSSJyPj+SP7e͹1MS(y.h {^m+N&X~*M%*PqU1+*byCA_QVOΧ^eeZCE ƃ`@UbDaLU61TμcZbpq\L 8QJ1UHH8 `⨘MU[*lUkU #銡n[ѯ oZobm֒KwݪJԟኤ7ZV@Vee#1T3߿;mqTRjj5vv*XX#tuኣ/RQV]qV7l5=IK^G(hqTϟWuZIYDPA6=Rˊg<Ǩ:ڞpgz:*(튠^K{ #==:U%=w|UD˷ӊif\ m:{ۆo+STB?58ħIKAhc^gf:?gjVOW;WV1qWvlj?y&?$WhSТO:|VQȃY[qT+P[cin*~%AȎU o/8p{PKu72!ኤZETX]ͻ\9$k_튭CWw{6*'^Y޲*HRbO;%*bث:KeU縷7%…Cӷ~*|ϡ[!JI9/U4?N*=+K㌃PM6q?N*@eV݀;t*!om%BzOLUsOWi 0}Y"d*I UZccKQN_-Ÿ"\UJ6#v*UتymZAI5qTm^[s)RHHXyRB>î*KεRwf}*ҔBIS_.%3zzh?fX{oqT˖YЁ-O͊m56.JWJa4T4Q#xbF-f0fv%5S;GqO UXلbثLh++lU e}TV4 7 n|qULUتʿ늿6VEE+Jllp1Uqөb⪮SbmU?UXvsU7]U#~تh犩Tpv8"⣉܎u 2U+Laxx U[ BU]q]v*U2V4.j|W[P]\:E~+Jbv%;vxBVE!QB=@PS㊩RH,MnI튾l"M7KTEіi#?c,UT%"E?hr|?*ԲU` b̟˩<1Uai֕#*ԯuOQ4&Ifʒ(ܜUSSQR}FQP7bh)Nū-71x*SM8iv:z"NT uz⨸P>GP;ubMAGW_M7-튦V6EGy7)6*(SnPh>XQS5*-m"|8*UثWq^ QڌNH:bIZ1UuqU/4=?θt_|UWKr~UYj֝T3Q튪bnwZ1UbImˮ*?hkqV#lUe,Uxm6XU]v*|UuqVWbX%@䛂B*Ӭ%h]ȡԎlUOQtx"AN*7xd+SPiJf*U/ M*S΄~U-fQ`@k\UvІOb[ЌUoQV;M)|qT+7&qTţZvO4H$Cs㊦1HiqUkgfIU7]zjdTb+^BA$tQZ\I,d#qTӶ*߶*qV*VU*銮;7i%?9-ԗMo Ա$84nm:szME;o]U8eh;U uCTNnٸJ|UtOPaSQA⪩S*VZG-ĒI۞^ba8Rdn+R|Uѻ7ztTT$֠nF*Y*SR|qT8]_qUȻV]O+BiҽTSL~**ӡe* *j:mBPՊvJ>}hb $*aaP:j7Q`Uv5$F*,rFoVb UN'24 Gъ8Mܑ<$5p4'N?[Ea:$Q<ƨ0("{SbJ)*p*YpPqGZ[}t|Uam̛'Um*%hz澄*!Fa*@\b?0MǷws኶,a_M")CLUYUiն动KsMڸF֠vQkCQQ_۹*⨅tml8֌S][Vq*Ei-]qTu1VAZV:J5 kwRIu=ɥ)f:Tn[28Y2D;o!?UHPHׯኩE<}U]_n*DzP1Vb=U"qTXHi IIf64@67 ݅D(BSShdQEqT KNe@>ኺ"/3ZTm.VI@.qTY㊬6$lU|v'e NbXcR*\UP#PjW0Hup ^þ*E UpU'*}Y=9\|NO F#BQӿQVIVPC<2Kr҅4b n"P~TPbёi=OU\~UOsT~UX7?FWSnB׊SDC*NJOC\T?ob*㊻ib78qT]ya׊=1T^}T*A1U_*}U~Gb_~x.ۨ>uclb[PsfbuWEhmqU[OsXmelb*UثT*gd?N}nNbo*cc?b?\U?*d|** ( `/ 0DArialNew Romantt jx: 0DTimes New Romantt jx: 0@ .  @n?" dd@  @@`` dZ#  8 "$$%&'X0U23478;=>??FGHIJLMO1PRSTVXY/Xb$&)2N +; R$`jǪ<"D@G 0AA 3@8*R ʚ;6ʚ;g4BdBdPUx: 0Rppp@ <4dddd@ 0ti<4!d!d@ 0ti <4BdBd@ 0tg48d8d;x: 0p@ pp80___PPT10pp? % ) Clinical care issues during pregnancy ,*&,$$Mr Steve Walkinshaw  Aspects of care during pregnancy!! Optimising glycaemic controlMaternal and fetal surveillanceManaging maternal and fetal complicationsProviding information A'Previous findings on glycaemic control*(( Enquiry findings;Issues underlying suboptimal glycaemic control in pregnancy<< 178 comments on clinical care: Failure to change insulin regimes to improve glycaemic controlNon-responsive local strategy of antenatal careLack of supportFailure of follow upPoor integration of careProblems within multidisciplinary teamz ZoZ>Z'ZZ o>'  <IIssues underlying suboptimal glycaemic control during labour and deliveryJJ wInadequate insulin regimes to achieve good controlDelays in commencing intravenous regimesPoor subsequent management xx.Maternal surveillance( Antenatal fetal surveillance + CIssues underlying suboptimal fetal monitoring for big babies (n=58)DD oLack of timely follow-upPoor interpretation of ultrasound scansIncorrect actions taken as a response to testsC 3Managing maternal complications: antenatal steroids44 D!Providing information54% of women in the enquiry had glycaemic control target ranges for pregnancy in the medical records or hospital guidelines. 79% had glycaemic control target ranges for labour and delivery. 86% had a documented discussion about the mode and timing of delivery, by 38 weeks gestation. Z/ Panel assessment of overall care1QIssues underlying suboptimal maternity and diabetes care in the antenatal periodRRProblems with the multidisciplinary teamSuboptimal fetal surveillancePoor management or monitoring of maternal risksNeed for more senior obstetrician inputPoor communication between health professionalsInappropriate mode and/or timing of delivery )3Postnatal care>4Issues underlying suboptimal postnatal diabetes care55 wSuboptimal management of glycaemic controlLack of contact with the diabetes teamInadequate plan of care at discharge@Are we providing the best care?;Good practice:78% of women monitored for nephropathy68% receiving antenatal steroids had an intravenous insulin regime commenced86% had a documented discussion about mode and timing of delivery81% had a written plan for post-delivery diabetes management65% had optimal maternity care during labour and delivery0Z-Z-5Recommendations IXAn individualised care plan covering the pregnancy and postnatal period up to 6 weeks should be clearly documented in the notes, ideally using a standard template. As a minimum, the care plan should include:Targets for glycaemic controlRetinal and renal screening schedulesFetal surveillancePlan for deliveryDiabetes care after deliveryBZZZ6Recommendations IIpThe care plan should be implemented from the outset of pregnancy by a multidisciplinary team present at the same time in the same clinic. Pregnancies with ultrasound evidence of macrosomia should have a clear management plan put in place by a consultant obstetrician. This should include timing of follow-up scans, fetal surveillance and mode and timing of delivery.qZq:Recommendations IIIA care plan for postnatal management should be clearly documented in the notes for all women. As a minimum, this should include:Plan for management of glycaemic controlNeonatal careContraceptionFollow-up care after discharge from hospital<rr;Recommendations IVResearch should be carried out to investigate:the most appropriate management strategy following antenatal evidence of macrosomia in babies of women with diabeteshow best to achieve optimal blood glucose control during pregnancy, labour and delivery. /K"The Challenge This is the bit we thought we did well inHow do we get the information to change?Continuity and the multidisciplinary teamCommunication <*a*c / "*,=FGH I J    0` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@$|?" dd@   " @ ` n?" dd@   @@``PV    @ ` ` p>>  N(    nAL Y?$dv418111ucPreview_imgMain#" `S  6, ,  T Click to edit Master title style! !  0( 'g  RClick to edit Master text stylesSecond levelThird levelFourth levelFifth level!   S`  C *APicture1"   0P Y&  TCEMACH Diabetes in Pregnancy National Report Launch, Sheffield, 26th February 2007UUH  0޽h ? 3380___PPT10.O2 Default Design  0 xp@ (    6( > T Click to edit Master title style! !  0h  `  W#Click to edit Master subtitle style$ $  nAL Y?$dv418111ucPreview_imgMain#" `S`  C *APicture1"   0L Y&  UCEMACH Diabetes in Pregnancy National Report Launch, Birmingham, 27th February 2007VV H  0޽h ? 3380___PPT10.OO 0 zr@ (    0d;j P   jP*    0X@j    jR*  d  c $ ?  j  0lCj  0 jRClick to edit Master text stylesSecond levelThird levelFourth levelFifth level!   S  6Ij _P  jP*    6,Nj _  jR*  H  0޽h ? 3380___PPT10.Mg x8(  x x 0Lj P   j>*  x 0|j    j@*  x 6j _P  j>*  x 6\j _  j@* H x 0޽h ? 3380___PPT10.M i} 0  $(  r  S W   r  S  t4  H  0޽h ? 33___PPT10i.O2+D=' =@B +} 0 $(  r  S @m,G:  r  S H'  H  0޽h ? 33___PPT10i.M`/;+D=' =@B +e  0 |t4 (  4r 4 S ,      vQ 4 #"& vQ  /4 <? vUk#% of HbA1c tests with a result < 7%$$ @` -4 <; ?"`  UZWeeks of gestation @` 4 <K? R vQa66%(1757/2655)   @` 4 <R? R  QO 27+ weeks   @` 4 <h? S vR a70%(1632/2348)   @` 4 < ?"` S  R d18  23+6 weeks @` 4 <f? TvS `39%(999/2597)   @` 4 < ?"` T S O <13 weeks   @`  4 <(~? UvT`28%(382/1384)   @`  4 < ?"` U TSPre-pregnancy @`ZB 4 s *1 ? TvTZB 4 s *1 ? S vS ZB 4 s *1 ? R vR ZB .4 s *1 ? UvUZB E4 s *1 ?  Q`B 4 0o ? v`B 4 0o ?  Q`B 4 0o ?vvQ`B 4 0o ? QvQ =4 04< 2   4 6PvJ~H*CEMACH: Pregnancy in women with type 1 and type 2 diabetes in 2002-2003IIH 4 0޽h ? 33___PPT10i.kM08+D=' =@B + 0 IA #(  r  S 8,   9 'g " #""_2T   <f ?  gg5.2 [3.3, 8.2] &" @`  <m ?~ t 37%(76/209)6"" " @`  <f ? ~ v71% (146/205)6" " @`  <lp ?'  -After 1st trimester up to labour and delivery,. % @`   < D  ?"`  g X3.4 [2.1, 5.7] @`   <Dz  ?"`~  c61%(118/192)$  @`   <  ?"` ~ c84%(171/204)$  @`   <K  ?"`'  nIn 1st trimester,   @`  <U ?  g g3.9 [2.2, 7.0] &" @`  <H ?~   c69%(115/167)$  @`  <4 ?  ~ c88%(165/187)$  @`  < ?'  XBefore pregnancy @`  <̊ ? g uAdjusted ORa [95% CI].    @`  <\ ?~   V Good outcome @`  <( ? ~  V Poor outcome @`  < ?'  {1Panel assessment of suboptimal glycaemic control22 @`fB  6o ?'g`B  01 ?' g `B  01 ?' g fB  6o ?'g`B  01 ?  `B  01 ?~ ~ `B  01 ?  `B  01 ?' g fB  6o ?''fB  6o ?gg # B̫'t2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 3380___PPT10.Mnk} 0 `$(  r  S ,t  r  S ]T  H  0޽h ? 33___PPT10i.M&+D=' =@B + 0  w(   x   c $tT,  x   c $'g  b   0H  50% of 354 women with ongoing pregnancies at 24 weeks were assessed to have suboptimal glycaemic control during labour and delivery48Z 2&W $    0HOfMu%No association with pregnancy outcome& 2&% H   0޽h ? 33___PPT10i.Mq+D=' =@B + 0  p (  r  S 4',     ]]   #""kJ2]]    <  ?n c55%(142/258)$  @`  <(E ?n o#- Assessment through dilated pupils$$ @`   < f  ?"`n ] c78%(343/441)$  @`   <$s  ?"`n ] bMonitoring for nephropathy @`  <|c ?c59%(258/441)$  @`  <r ?#Retinal assessment in 1st trimester,$   @`  <R+D=' =@B +$ 0 0$(  r  S d,{  r  S l'g   H  0޽h ? 3380___PPT10.-M0<1  0 H@0<(  <x < c $d,    'g .< #"&'g  < <U!? gV J5% @` < <`!?' V i#Subcutaneous insulin regime changed$$ @`  < <h!?V gK68% @`  < <a!?'V o)Intravenous insulin and dextrose infusion** @`  < <z!?g J5% @`  < <s!?' n(Increased checking of blood glucose only)) @` < <d!?egK11% @` < <!?'e]No change in management @` < <|!?geNN=56 @` < <4!?'eEManagement of glycaemic control in women receiving antenatal steroidsFF @``B < 0o ?'gZB < s *1 ?'egeZB < s *1 ?'gZB < s *1 ?' g `B < 0o ?'g`B < 0o ?''ZB < s *1 ?`B < 0o ?ggZB < s *1 ?'V gV z 0< 0p!f'0 RStandard: As corticosteroids can lead to maternal hyperglycaemia, additional insulin must be given to prevent the development of diabetic ketoacidosis. 2   &  H < 0޽h ? 33___PPT10i.kM@+D=' =@B +} 0 @$(  @r @ S !,  ! r @ S !/ `+ ! H @ 0޽h ? 33___PPT10i.lMp+D=' =@B +) 0 @8 (  r  S !, w ! 0 g+  #"" ;2g+ ! 4 <!  ?"`  g+v1.7 [1.1, 2.6] 4" @` 2 <!  ?"`~ +g58%(118/204)(" " @` 0 <,n  ?"` ~ +v72% (146/204)6" " @` . <ԙ  ?"`  +q)Suboptimal diabetes care during pregnancy** @`   <0  ?"`  g X1.3 [0.8, 1.9] @`   <   ?"`~  b 34%(72/213)$  @`   <*  ?"` ~ b 39%(78/199)$  @`   <8  ?"`  |4Suboptimal maternity care during labour and delivery55 @`  < ? "g i1.9 [1.2, 2.8] (" @`  <<& ?~ "  b 44%(95/215)$  @`  <I ? "~ c58%(125/215)$  @`  <L ?" }5Suboptimal maternity care during the antenatal period66 @`  <5 ? g"uAdjusted ORa [95% CI].    @`  <x ?~  "V Good outcome @`  <t ? ~ "V Poor outcome @`  <y ? "V   @`fB  6o ?g`B  01 ?"g"`B  01 ? g `B  0o ?+g+`B  01 ?  +`B  01 ?~ ~ +`B  01 ?  +`B  01 ? g `B N 0o ?"+fB  6o ?"`B [ 0o ?g"g+fB  6o ?gg"  BI0t2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 33___PPT10i.CM@Xd+D=' =@B +} 0 $(  r  S H!, ! r  S !'gf ! H  0޽h ? 33___PPT10i.NMЅWW+D=' =@B +  0 >V(  r  S ,    'gX  = #"v'gX     <  ?"`!% gX Z 1.8 [1.2, 2.7] @`   <ب  ?"` % !X c50%(106/211)$  @`   <  ?"`M % X c66%(133/203)$  @`   <,  ?"`'% M X j"Suboptimal postnatal diabetes care## @`  < ?!g% i 4.2 [2.4, 7.4](" @`  < ? !% b 16%(26/163)$  @`  < ?M  % b 44%(63/143)$  @`  <ԁ ?'M % j"No postnatal contraceptive advice ## @`  <P ?!guAdjusted ORa [95% CI].    @`  < ? !V Good outcome @`  <T ?M  V Poor outcome @`  < ?'M V   @`fB  6o ?'g`B  01 ?'g`B  01 ?'% g% `B  0o ?'X gX `B  01 ?M M X `B  01 ?  X `B  01 ?!!X `B  0o ?''X fB  6o ?''`B  0o ?ggX fB   6o ?gg > B(!s 'Z t2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 33___PPT10i.OMq+D=' =@B +$ 0 ($(  (r ( S Ģ,  r ( S h'g   H ( 0޽h ? 3380___PPT10.XMPKt 0  0(  0r 0 S X'gY   0 s t0e0e #" 0e,{  H 0 0޽h ? 33___PPT10i.hM`=+D=' =@B +} 0 $(  r  S ,   r  S H'gY  H  0޽h ? 33___PPT10i.OM@">c+D=' =@B +} 0 $(  r  S M,   r  S 'g  H  0޽h ? 33___PPT10i.OMf+D=' =@B +} 0 `$(  r  S ,   r  S /'gI  H  0޽h ? 33___PPT10i.UMvB+D=' =@B +$ 0 p$(  r  S &j,   r  S \'j'g  j H  0޽h ? 3380___PPT10.VM j$ 0 d$(  dr d S pj,  j r d S j'g  j H d 0޽h ? 3380___PPT10.'T2G 0 PW(  X  C    j  S [j 0  jY#A panel assessment of suboptimal glycaemic control at any stage of pregnancy was associated with poor preganncy outcome. This information is also included in the presentation on Social and lifestyle issues which is prior to this session, so this slide is really just to remind the audience.f H  0޽h ? 3380___PPT10.Mg 0 p(  X  C    j  S ej 0  jMany comments related to social and lifestyle issues which have been presented in the previous session, but there were 178 comments on clinical care.H  0޽h ? 3380___PPT10.Mp?  0  O(  X  C    j  S mj 0  jQ=Suboptimal fetal monitoring was not associated with poor pregnancy outcome for babies with antenatal evidence of fetal growth restriction, however, suboptimal fetal monitoring was associated with poor pregnancy outcome (specifically fetal and/or neonatal death from 20 weeks gestation up to 28 days after delivery). H  0޽h ? 3380___PPT10.-M0kV  0 @(  X  C    j  S wj 0  jNB to speakers: a few of the specific panel comments are within Chapter 9 of the report. I am happy to provide additional comments if needed. (Jo M)H  0޽h ? 3380___PPT10..M1J- 0 -%$(  $^ $ S    j $ c $}j 0  jThe most frequent issue identified by panels in relation to suboptimal glycaemic control during labour and delivery was inadequate intravenous insulin regimes.H $ 0޽h ? 3380___PPT10.MS! 0 ZR H(  HX H C    jR H S ̅j 0  jWomen should be informed about what glycaemic control targets they are trying to achieve. Panel assessors reviewed medical records and hospital guidelines for evidence that glycaemic control targets had been set. H H 0޽h ? 3380___PPT10.mM@*O 0 YQ0L(  LX L C    jQ L S j 0  jJust over half of all women in the enquiry had a retinal assessment in the first trimester (or at booking if later, and only half of these 258 women had the assessment recorded as being done through dilated pupils.H L 0޽h ? 3380___PPT10.N`, 0  @P(  PX P C    j P S j 0  jWomen with a poor pregnancy outcome were more likely to receive suboptimal postnatal diabetes care and no postnatal contraceptive advice.H P 0޽h ? 3380___PPT10.N*y 0 `X(  XX X C    j X S 4j 0  j]The majority of HbA1c test results before pregnancy and in the first trimester were above 7%.EH X 0޽h ? 3380___PPT10.N@z2^  0 ` (  `X ` C    j ` S 0j 0  j" H ` 0޽h ? 3380___PPT10.Npagr@ )8 4b;@TN.5d'"v(y*0]. k1ӷ3X5 @:PJf@ ;=C F`tK1Oh+'0T `hx  Slide 1rosie.houstonrosie.houston186Microsoft Office PowerPoint@@oZP@_u2\|GSg  )'    """)))UUUMMMBBB999|PP3f333f3333f3ffffff3f̙3ff333f333333333f33333333f33f3ff3f3f3f3333f33̙33333f333333f3333f3ffffff3f33ff3f3f3f3fff3ffffffffff3ffff̙fff3fffff3fff333f3f3ff3ff33f̙̙3̙ff̙̙̙3f̙3f333f3333f3ffffff3f̙3f3f3f333f3333f3ffffff3f̙3f3ffffffffff!___www4'A x(xKʦ """)))UUUMMMBBB999|PP3f3333f333ff3fffff3f3f̙f3333f3333333333f3333333f3f33ff3f3f3f3333f3333333f3̙33333f333ff3ffffff3f33f3ff3f3f3ffff3fffffffff3fffffff3f̙ffff3ff333f3ff33fff33f3ff̙3f3f3333f333ff3fffff̙̙3̙f̙̙̙3f̙3f3f3333f333ff3fffff3f3f̙3ffffffffff!___wwwmmݼe⦊e݊ݦe՜.+,0   On-screen ShowCEMACH  ArialTimes New RomanDefault Design* Clinical care issues during pregnancy !Aspects of care during pregnancy(Previous findings on glycaemic control*Enquiry findings<Issues underlying suboptimal glycaemic control in pregnancyJIssues underlying suboptimal glycaemic control during labour and deliveryMaternal surveillanceAntenatal fetal surveillanceDIssues underlying suboptimal fetal monitoring for big babies (n=58)4Managing maternal complications: antenatal steroidsProviding information!Panel assessment of overall careRIssues underlying suboptimal maternity and diabetes care in the antenatal periodPostnatal care5Issues underlying suboptimal postnatal diabetes care Are we providing the best care?Recommendations IRecommendations IIRecommendations IIIRecommendations IVThe Challenge  Fonts UsedDesign TemplateSlide Titles%_prosie.houstonrosie.houston  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdfghijklmnopqrstuvwxyz{|}~    "Root EntrydO)Pictures%Current UserSummaryInformation(TPowerPoint Document(eDocumentSummaryInformation8