• 1.

  a) F b) F c) T d) T e) F

A pregnant woman lying flat on her back will have a lower cardiac output, as the gravid uterus compressing the inferior vena cava will reduce venous return to the heart. A pregnant woman being resuscitated should therefore be positioned with a left-lateral tilt. Because of the 20–30% increase in blood volume during pregnancy, a pregnant woman can lose up to 1.5 litres of blood before the manifestation of clinical signs. A rising maternal heart rate is an early compensation for hypovolaemia, with maternal hypotension being a very late sign. There are no changes in spirometry parameters (FVC, FEV1, PEFR) during pregnancy; any abnormal results relate to underlying respiratory disease. Pregnant woman with pre-existing diabetes require higher doses of insulin because of a relative state of insulin resistance, as evidenced by a higher postprandial glucose level. Venous thrombo-embolism is more common during pregnancy because of an increase in coagulation factors and fibrinogen, accompanied by a decreased protein-S activity and increase in activated protein-C resistance.

• 2.

  a) T b) T c) F d) F e) T

Cardiac output increases 30–50% during pregnancy, and is a product of the stroke volume and heart rate. Although most of the increase in cardiac output is due to the increase in stroke volume which increases 20–30%, the heart rate which increases 15–20 beats per minute on average which contributes to this increase in cardiac output. Mean arterial blood pressure falls due to a lower systemic vascular resistance, effected by progesterone which reduces vascular smooth muscle tone. The 30% increase in oxygen consumption, 15% increase in metabolic rate and the lower functional residual capacity mean that pregnant women have lower reserves of oxygen, and have lower capacities to withstand hypoxia. The increase in minute ventilation during pregnancy leads to a higher PaO2 and a lower PaCO2 in the maternal circulation. The lower PaCO2 leads to a state of respiratory alkalosis, compensated by an increase renal excretion of bicarbonate so that the normal maternal pH is maintained. TSH decreases in the first trimester as a result of the rising HCG which has structural similarities to TSH and has thyroid stimulating properties.

• 3.

  a) F b) F c) T d) T e) F

In the UK, for every maternal death, approximately 118 near miss events or SAMM occur. Severe acute maternal morbidity (SAMM), or a near miss event, is defined as ‘a very ill pregnant or recently delivered woman who would have died had it not been luck or good care was on her side’. Approximately 30–40% of these events are preventable. Level 2 care is adequate in the circumstances described. However, critically ill women should receive the same standard of care for both their pregnancy related and critical care needs, delivered by professionals with the same level of competencies irrespective of whether these are provided in a maternity or general critical care setting. The maternal mortality rate is very high in under-resourced countries in contrast to high- income countries, where it is less than 16 per 100,000 live births. Perinatal mortality is indeed associated with maternal critical illness in approximately one in five cases. Approximately 50% of obstetric admissions to critical care are for less than 24 hours. This short period of intensive care provides a cost-effective and essential part of the management of acute life- threatening conditions

• 4.

  a) T b) T c) T d) T e) T

According to the Mississippi criteria the diagnosis of HELLP Syndrome requires these 3 criteria. After stabilising the blood pressure, delivery is the only definitive treatment for HELLP syndrome. Pre-eclampsia in a future pregnancy is about 1 in 4 (25%) if their preeclampsia was complicated by severe pre-eclampsia, HELLP syndrome or eclampsia and led to birth before 34 weeks, and about 1 in 2 (55%) if it led to birth before 28 weeks.

• 5.

  a) T b) T c) T d) T e) T

Sulphasalazine is safe during pregnancy and lactation. Current evidence suggests that both topical and oral agents are safe in pregnancy. Both azathioprine and 6 Mercaptopurine are also considered as safe in pregnancy. The risk of steroids in pregnancy is small and hence they should not be withheld during pregnancy when clinically indicated. Cleft palate and low birth weight have been rarely reported in humans with the use of steroids in pregnancy. Prednisolone is safe during lactation. Cyclosporin can be used during pregnancy and teratogenicity appears to be low. Methotrexate is absolutely contraindicated as it is a potent abortificient and is associated with congenital anomalies. Women and men taking methotrexate should stop this drug and use contraception for at least three months prior to conception. Experience with infliximab during pregnancy is limited. However animal models do not show any teratogenicity. The manufacturer advises that infliximab should be given to a pregnant woman only if clearly needed. Whether infliximab is excreted in human milk is unknown. As a result, continued use of infliximab should be based on the clinical condition of the mother.

• 6.

  a) T b) F c) F d) F e) F

In the most recent UK perinatal mortality report, 1 in 20 (5%) stillbirths in infants without congenital abnormality occurred in women with pre-eclampsia. The contribution of pre-eclampsia to the overall preterm birth rate is substantial; 1 in 250 (0.4%) women in their first pregnancy will give birth before 34 weeks as a consequence of pre-eclampsia and 8–10% of all preterm births result from hypertensive disorders. Half of women with severe pre-eclampsia give birth preterm. Small-for-gestational-age babies (mainly because of fetal growth restriction arising from placental disease) are common, with 20–25% of preterm births-some are associated with pre-eclampsia, some not. The following drugs, nitric oxide donors, progesterone, diuretics, low molecular weight heparin do not prevent hypertensive disorders during pregnancy. Supplementation with magnesium, folic acid, antioxidants (vitamins C and E) with the aim of preventing hypertensive disorders during pregnancy is not recommended.

• 7.

  a) T b) T c) T d) T e) T

There is a positive association with cholestatic disorders in hyper-oestrogenic states including both pregnancy and COCP use. Pruritus in the third trimester should always prompt a request for liver function tests as they may be due to OC which alters management. There are physiological variations in albumin and ALT levels in pregnancy (lowered) and pregnancy specific reference ranges for LFTs should be used to interpret them correctly. Series have shown the subsequent risk of recurrence in future pregnancies is at least 50%. UDCA is indeed not licensed for use in pregnancy, but does not appear to have adverse effects as there is extensive experience with it.

• 8.

  a) T b) T c) F d) T e) T

The workload, available resources in the hospital and the threshold for admission to the ICU determine the incidence of intensive care admissions in pregnancy. A woman who may receive intensive care in one hospital may have been cared for in a high dependency unit (HDU) in another. Patients with multi organ dysfunction would be likely to receive ICU care.

• 9.

  a) F b) F c) T d) T e) T

Even though the identification of the sequence from health to maternal death is easy, each case is different and therefore may not be generalisable. Relatively low incidence limits the value of maternal mortality data as a tool for deriving meaningful clinical conclusions. Even in resource poor settings, where maternal mortality figures are relatively high, maternal mortality data has been described as one of the worst performing health indices.

• 10.

  a) F b) F c) T d) T e) F

Available evidence suggests that the reported percentages of emergency hysterectomies vary from 0.04% to 0.26%. The upper range of the severe maternal morbidity rates varies from 3.21% in Middle Eastern, 4.92% in Latin American, through to 5.41% in Asia and up to 6.03% in African countries. In contrast, studies from high-income countries in Europe reported an upper near-miss rate from a low of 0.69%. The commonest reason for admission to obstetric intensive care in the postnatal period is due to the haemorrhage.

• 11.

  a) T b) F c) F d) F e) T

Sepsis is more common in developing counties. Peri-partum hysterectomy is the commonest intervention reported for
 postpartum hemorrhage in the literature. It is relatively easy to define severe obstetric morbidities according to the specific clinical entities rather than other criteria.

• 12.

  a) F b) F c) F d) F e) T

A woman must show only one of the following symptoms: dyspnoea on exertion; cough; orthopnea and paroxysmal nocturnal dyspnoea; abdominal discomfort; pleuritic chest pain; palpitations. The diagnosis is based on clinical and investigative findings and ECG, Echo and MRI scans only aid the diagnosis and cause. The diagnosis is indeed missed more easily the peripartum period compared to the non-pregnant population as many of the symptoms can be attributed to pregnancy and the puerperium and with unknown cardiac disease it is often not expected in a fit, healthy woman.

• 13.

  a) F b) T c) T d) T e) F

Heart failure is life threatening and treatment should always be instigated regardless of fetal risks. Most heart failure drugs are indeed not licensed for pregnancy but can be prescribed in circumstances on an individual basis on the principle of maternal survival being paramount. Guidelines for these women should indeed be available as part of robust obstetric governance and an interdisciplinary approach is vital to optimize outcome in these difficult cases. While delivery may often be necessary, there are times when there is a remediable cause allowing the pregnancy to continue e.g. under-treatment that is stepped-up.

• 14.

  a) T b) F c) T d) F e) T

Peripartum cardiomyopathy (PPCM) is the major cause of pregnancy-induced heart failure and is associated with high morbidity and mortality. The true incidence of PPCM is unknown, as clinical presentation varies. Current estimates, ranging between 1:299 (Haiti), 1:1,000 (South Africa) and 1:5,556 in the USA are primarily based on case series from single centre or retrospective questionnaires. No data exist on the frequency of the disease in Europe but personal experience suggests that PPCM occurs in 1 in 1,500 to 2,000 pregnancies in Germany. The patho-physiology of the disease is still far from well understood and it is likely that multiple factors contribute to induction and progression of PPCM. Nevertheless, decisive advances have been achieved in understanding some underlying molecular cascades deregulated in PPCM. Among those, elevated pro-inflammatory serum markers such as sFas/Apo1, C-reactive protein (CRP), Interferon gamma and Interleukin (IL)-6 point to pro-inflammatory processes (pathogen-induced or autoimmune response) involved in the induction and the progression of PPCM and may impact on the prognosis of patients. More recent work points to an angiogenic imbalance being responsible for PPCM involving an angiostatic and pro-apoptotic 16 kDa prolactin fragment and the soluble VEGF receptor 1 (sFlt1) which leads to massive endothelial damage and myocardial dysfunction, a notion that is further supported by observations showing that endothelial micro-particles are increased in acute PPCM. Genetic factors may contribute to the susceptibility to PPCM in patients with a positive family history of cardiomyopathy, who typically have a more severe course of disease and are therefore considered as risk factors.

• 15.

  a) F b) T c) F d) T e) T

In women under the age of forty, 50% of type A aortic dissection occur in the obstetric population. With an overall reported incidence between 0.4–3.5 cases per 100,000 patient-years it represents a rare condition. However, it is associated with a high neonatal and maternal mortality (up to 83%) usually in the third trimester or within the early postpartum period. Several inheritable connective tissue disorders and congenital heart diseases are associated with aortic pathologies predisposing to aortic dissection. The underlying vascular pathology consists of degeneration of collagen and elastin of the aortic wall causing media necrosis. Among these, Marfan’s syndrome represents the leading single underlying disease of pregnancy related aortic dissection. Arterial hypertension plays a pivotal role in this situation. Hypertension has been observed in up to 90% either as the single underlying disease or in combination with a predisposing disorder e.g. Marfan’s syndrome. Additionally, the overall risk of dissection increases with older maternal age and with growing aortic diameters.

• 16.

  a) F b) F c) F d) T e) F

Women during pregnancy are at increased risk of venous thromboembolism due to hypercoagulability. An increased D- Dimer level is not specific for CVT. Also false negative D- dimer levels are reported and can appear with CVT. Transcranial Doppler sonography investigates the arterial intracranial blood flow. Although the peripheral resistance may be increased in CVT, specific diagnosis of CVT cannot be made. History and examination by a neurologist focuses on pre-existing headache disorders, positive history of previous thrombotic events and focal neurological deficits. However, for confirmation of the diagnosis a magnetic resonance imaging venography is required and this is the technique of choice for diagnosis and follow up. It will show the thrombus in the sinus and therefore confirms diagnosis. CT is a good for excluding other pathologies e.g. space occupying lesions but poor at diagnosing CVT.

• 17.

  a) T b) T c) T d) F e) T

The optimal serum concentration should be determined at preconception. Physiological adaptations during pregnancy may cause serum levels to drop. The lowest effective optimal serum concentration is recommended throughout pregnancy and the postpartum period. In cases of planned pregnancy, monotherapy with the most appropriate AED at the lowest effective dose is recommended. In women with diagnosed epilepsy, AED treatment during pregnancy is required. The risk of uncontrolled seizures should be balanced against the teratogenic risk for the fetus. The risk appears to be highest with sodium valproate use. Supplemental folic acid prior to conception and during pregnancy in women on AEDs to reduce the risk of foetal neural tube defects is recommended.

• 18.

  a) F b) T c) T d) F e) F

The mutation affects the β-globin chain. HbSS patients will produce HbS predominantly (with small amounts of HbF and HbA ₂ ). Classically HbSS patients are more anaemic, have more severe and frequent acute crises and a lower life expectancy than those with the compound heterozygote sickling disorders. This clinical phenotype is also seen in pregnancy with those with HbSS SCD usually having more complications than those with HbSC SCD. Patients with SCD are anaemic but they have marked haemolytic parameters such as raised reticulocyte responses and raised LDH as a marker of increased cell breakdown and turnover. Patients will be anaemic due to their haemoglobinopathy and may also be microcytic due to their haemoglobinopathy status (eg co-inheritance of α thalassaemia trait). Iron supplementation should only be started if there is documented iron deficiency (i.e. reduced ferritin levels). Many patients who have received transfusions in the past will have adequate iron stores and may even need treatment for iron overload.

• 19.

  a) F b) T c) F d) F e) T

Currently there is no evidence to support the routine use of prophylactic red cell transfusions during pregnancy. Regular transfusions (exchanges) are usually used in those who have had a significant crisis (often life-threatening or needing prolonged admission) or in those who needed transfusions prior to conception. Top up transfusions may be needed in those who are severely anaemic. Each case is decided upon individually. Pregnant women with SCD are thought to be at increased risk of pregnancy induced hypertension and pre-eclampsia and current guidelines recommend the use of aspirin as prophylaxis in these patients. Prompt treatment of a painful crisis is important for the health of the woman with SCD. Analgesia should be administered within 30 mins of presentation and often parenteral opiates are required. Pregnant women may find that they suffer from an increased frequency of crises during pregnancy. NSAIDs and tramadol should be avoided. Babies are usually small for dates and born at earlier gestational ages. Mode of delivery should be decided upon with regards to obstetric requirements. Special consideration should be given to women who suffer from avascular necrosis of the hip who may find external rotation of the hips painful.

• 20.

  a) F b) F c) T d) F e) F

Concomitant usage of aspirin and warfarin is associated with an increase in risk of bleeding. LMWH is usually the preferred choice for anticoagulation due to the teratogenicity of warfarin in early pregnancy and greater difficulty with warfarin and bleeding during delivery including epidural anaesthesia. The patient is not considered to have high risk essential thrombocythemia. Hydroxycarbamide is not indicated and patient can be managed with aspirin which is continued throughout pregnancy. The post-partum state is associated with an increased risk of venous thromboembolism. Patients with ET should receive thrombo-prophylaxis with LMWH for up to 6 weeks post-partum. Aspirin alone is not sufficient for post-partum thromboprophylaxis in patients with ET. Even low risk patients with ET should be more monitored more carefully during pregnancy with fetal ultrasounds and an ongoing assessment of thrombotic risk. If there is any suggestion of intrauterine growth restriction or a significant increase in platelet count above 1500, cytoreductive agents and LMWH may be required. She currently has no high risk features and can be managed with aspirin alone unless an ongoing assessment of her thrombotic risks puts her into a high risk category.

• 21.

  a) T b) T c) F d) T e) F

The use of magnesium sulphate may half the rate of eclampsia even in cases of less severe preeclampsia. When preeclampsia is severe, the benefits of continuing pregnancy to the fetus are limited in view of deteriorating maternal health. Acute respiratory failure may complicate severe preeclampsia and is a frequent reason for critical care unit admission – it is invariably iatrogenic due to fluid overoad. Accurate assessment of fluid balance is therefore important to avoid iatrogenic pulmonary oedema. Targeting a systolic blood pressure lower than 140–150 mmHg and diastolic blood pressure of 80–90 mmHg minimizes the risk of haemorrhagic stroke. Rapid reduction in systolic blood pressure may result in acute hypoperfusion and ischaemia of vital organs

• 22.

  a) F b) F c) F d) F e) T

The single most important risk factor for postpartum infection is Caesarean section. The rate of endometritis is approximately three-fold higher in non-elective Caesarean sections compared to elective sections. The risk of major puerperal infection is 3-fold higher in low-risk planned Caesarean delivery compared to planned vaginal delivery at term. Ascending bacterial colonization of the genital tract may result in uterine contractions and/or membrane weakening that results in premature rupture of membranes. The antibiotic of choice in PROM is undetermined and clear recommendations cannot be made. Maternal sepsis is commonly associated with poly-microbial infections, reflecting colonization of the genital tract. In severe cases of puerperal pyrexia, Group A beta-haemolytic streptococcus ( S. pyogenes , GAS) should be suspected. Frequent (>5) vaginal examination is a risk factor. Other risk factors for maternal sepsis include maternal anaemia, obesity, poor nutrition, induced labour, and prolonged labour (>12 hrs).

• 23.

  a) F b) T c) T d) T e) T

Cut-off values for cardio-respiratory variables including blood pressure and respiratory rate for the definition of sepsis may not be directly applicable in the parturient. Nevertheless, any physiological value more than two standard deviations from the expected should be considered pathological. When accompanied by signs of infection-induced hypotension, organ dysfunction or tissue hypoperfusion (e.g. lactataemia or oliguria) severe sepsis is said to have occurred. As serum lactate does not usually change significantly in pregnancy this is likely to be a reasonable guide to resuscitation. Source control refers to the definitive management of a focus of infection amenable to surgical drainage or debridement. The central venous saturation (ScvO ₂ ), measured in blood drawn from the internal jugular vein or right atrium, reflects the balance of oxygen supply and demand within the body. With a normal arterial saturation (97–100%), the normal ScvO ₂ is 70–75%. Values below this range suggest ongoing tissue hypo-perfusion.

• 24.

  a) F b) F c) F d) T e) F

This patient has developed thyroid storm in pregnancy. She has a current history of thyrotoxicosis and presents with a high-grade fever and tachycardia, and is in heart failure.

Prompt delivery of the fetus is currently not recommended during thyroid storm. The most critical management of thyroid storm in pregnancy is early recognition of the condition and to institute treatments that ensure the safety of the mother. Thyroid function tests should be performed, but is not useful in diagnosing thyroid storm as the test is not distinguishable from those seen in patients with uncomplicated hyperthyroidism. It is important to remember that thyroid storm is a clinical diagnosis. The management of thyroid storm is directed at a rapid inhibition of thyroid hormone synthesis and its peripheral conversion, aggressive management of the systemic disturbances and to identify and treat a precipitating cause. Propylthiouracil is the preferred anti-thyroid medication as it additionally blocks the peripheral conversion of thyroxine to tri-iodothyronine. Beta-blockers are essential for survival from thyroid storm. This patient is in acute heart failure. The use of beta blockers should be used judiciously in a monitored setting. The short-acting β ₁ -selective antagonist, esmolol is preferred. Aggressive treatment should include oxygen therapy, bolus intravenous diuretics and fluid restriction. Glucocorticoids are used in thyroid storm to treat possible relative adrenal insufficiency. Several studies have demonstrated improved survival in those treated with glucorticoids. Hydrocortisone 100 mg intravenously every 6 hours can be given, with tapering as the signs of thyroid storm improve. However, in this setting, dexamethasone would be the preferred steroid as it helps in fetal lung maturation.

• 25.

  a) T b) T c) T d) F e) F

This patient has acute fulminant diabetes mellitus. During DKA, increase in glucagon levels in conjunction with an inefficient or low insulin levels promotes free fatty acid release from the adipose tissue, uptake by the liver and increased β-oxidation. Increased stress hormones e.g. cortisol, growth hormone and epinephrine plays a role in lipolysis, and also cause insulin resistance. The liver mitochondrial β-oxidation produces acetyl-CoA, which is then used in the tricarboxylic acid cycle to generate energy. Acetyl-CoA can also be used to produce ketone bodies. While the initial formation of ketone bodies is useful as an energy source, overproduction of ketone bodies leads to an accumulation of ketone bodies and ketonemia. The predominant ketone body during DKA is β–hydroxybutyrate. Insulin therapy is necessary to reduce ketogenesis. Effective management of DKA, including adequate hydration and adequate insulin therapy should improve both glycaemia and acidosis by 12 hours of treatment. Blood ketones should also be monitored to assess the adequacy of insulin therapy. Monitoring of β–hydroxybutyrate may be helpful in assessing the efficacy of DKA treatment. As DKA is resolving, the concentration of β–hydroxybutyrate will decrease and the concentration of acetoacetate will increase. By measuring urine ketones using the urine reagent strips, the ketosis status of the patient will be overestimated. This may lead to the prolongation of intensive treatment and monitoring. Prolonged starvation may also lead to ketogenesis and oral feeding should be initiated as DKA is resolving and as the patient is able to tolerate things orally. Aggressive fluid replacement during DKA helps to reduce hyperglycaemia and also to increase the renal clearance of ketone bodies. It is important to understand that persistent ketonemia is primarily driven by increased ketone production. Increased fluid replacement in this patient would not inhibit ketogenesis, and may predispose this patient to fluid overload. The degree of ketonemia is dependent on the production of ketone bodies (primary) and both metabolic and renal clearance of ketones. Impaired renal function may reduce clearance of the ketone bodies resulting in persistent ketonemia.

• 26.

  a) F b) F c) T d) F e) F

Prompt fetal delivery has not been shown to improve prolactinoma expansion or apoplexy, thus this is not recommended except for obstetric indications. Although cabergoline may be used, if there is evidence of clinically significant prolactinoma expansion during pregnancy, it has a limited role in pituitary apoplexy, as in this case. The presence of low blood pressure should raise suspicion of acute cortisol deficiency. Thus, glucocorticoid replacement should be initiated without delay. Deterioration in her level of consciousness or progressive visual deficits would warrant early neurosurgical intervention. Mannitol has been used to reduce intracranial pressure following acute cerebral insults while awaiting more definitive treatment. Though it has been described in case reports, the use of mannitol is not a standard therapy for acute pituitary apoplexy.

• 27.

  a) F b) T c) T d) F e) T

In high-income countries the incidence of sepsis-related maternal morbidity is reported to be 0.1–0.6 per 1000 deliveries, and accounts for 2.1% of all maternal deaths. However, in low-income countries, the mortality rate is significantly higher, and accounts for up to 11.6% of maternal death. Although the incidence of maternal sepsis is relatively low compared to other obstetric emergencies, the relative risk of mortality is significant. The mortality rate associated with maternal sepsis approaches 10% in developed countries. In low-income countries, the mortality related to puerperal sepsis is approximately 33%. Sepsis is now the most common cause of direct maternal death in the UK.

• 28.

  a) F b) T c) T d) T e) T

There has been an increase in deaths related to genital tract sepsis, despite a decline in the overall UK maternal mortality rate. This is related primarily to community acquired Group A streptococcal disease, with an increase in maternal mortality rate from 0.85 deaths per 100,000 maternities in 2003–2005 to 1.13 deaths in 2006–2008. A similar rise in the rates of maternal sepsis has been described in a recent large study in Maryland, USA. Deaths due to sepsis are 2 to 2.7-fold higher in Africa, Asia, Latin America and the Caribbean than in developed countries. The impact on neonatal mortality is also significant, with over one million infection-related neonatal deaths every year.

• 29.

  a) T b) F c) T d) F e) T

In severe cases of puerperal pyrexia, Group A beta-haemolytic streptococcus ( S. pyogenes , GAS) should be suspected. This organism has been the leading infective cause of puerperal deaths, and has an attributable mortality greater than many other invasive bacteria. Streptococcal throat infections are relatively common in the community, particularly among young children. Up to 30% of the population are carriers of GAS and are easily able to transmit the bacteria via droplet spread. Precautions against hand to genital tract transmission should be taken, including hand washing before and after using the lavatory and changing sanitary towels. This is particularly important when the mother has had recent close contact with someone with a sore throat or upper respiratory tract infection. GAS causes a wide spectrum of illness ranging from bacteraemia without a focus of infection (46%), to endometritis (28%), peritonitis (8%) and ‘invasive Group A streptococcus’ associated with necrotizing fasciitis (3%), and toxic shock syndrome (3%). Though less common than other clinical manifestations of GAS, invasive GAS is associated with a mortality of 3.5–14.3% and is the leading cause of sepsis-related deaths in the UK.

• 30.

  a) F b) T c) F d) T e) T

The maternal and neonatal morbidity and mortality associated with hypertensive crises is significant. Up to 70% of mothers with severe preeclampsia admitted to the intensive care unit develop multi-organ dysfunction. Maternal complications associated with severe preeclampsia include eclampsia, HELLP syndrome (10%–25%), acute kidney injury (AKI) (1%–5%), pulmonary oedema (2–5%), and placental abruption (1%–4%). The fetus may be small for gestational age with reduced fetal movements. Severe preeclampsia is significant risk factor for intrauterine fetal death, with an estimated stillbirth rate of 21 per 1000.