Ime ectopic gbawara agbawa na ọbara ọgbụgba n'oge¶

Ime ectopic na-eme mgbe akwa fatịlaịza tụbara wee malite itolite n'èzí oghere nke akpanwa, nke na-adịkarị n'ime obere oghere ** fallopian tube ** (pasent 95 ruo 97, nke a maara dị ka ime ime tubal), ma ọ bụ na-adịkarị obere na ovary, cervix, uterine cornua, ma ọ bụ akụkụ cesarean nke mbụ. N'ihi na tube fallopian bụ naanị ** 1 ruo 4 millimeters (0.04 ruo 0.16 sentimita) n'obosara ** ma enweghị nnukwu mgbidi muscular, embrayo na-eto eto na arịa ọbara placental na-apụghị ịgbatị agbatị ma na-esi na mgbidi tubal, nke na-adịkarị n'etiti ** 5 na 10 izu nke ime ime *** (mgbe tupu onye ọrịa ahụ ọbụna mara na ọ dị ime). Mgbe tube fallopian gbawara, alaka dị elu nke ** uterine na ovarian arteries ** wụsa ** 1,000 ruo 2,500 milliliters (2 ruo 5 pints) nke ọbara ** ozugbo banye n'ime oghere afọ (** hemoperitoneum ***) na obere ọbara ọgbụgba na-ahụ anya. Ime ime ectopic gbawara agbawa bụ ** ọnụ ọgụgụ-otu ihe na-akpata ọnwụ nne n'ime ọnwa atọ mbụ n'ụwa niile **, chọrọ njem ụgbọ ihe mberede ozugbo maka ịwa ahụ laparoscopic mberede na mmịnye ọbara.

Mee nke a ugbu a¶

1. Call your local emergency number immediately if a pregnant (or potentially pregnant) person has one-sided pelvic pain paired with dizziness, fainting, pale skin, or shoulder-tip pain. Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, or see all nọmba mberede. State clearly to the dispatcher: "Suspected ruptured ectopic pregnancy with internal bleeding and shock," so the ambulance crew prepares intravenous fluids and alerts the hospital obstetric operating room.
2. Lay the person flat on her back (or tilted slightly onto her left side) and do NOT let her stand or walk. Standing upright or sitting on the toilet when over a liter of blood has pooled inside the abdomen causes blood pressure to crash immediately (orthostatic syncope), leading to sudden loss of consciousness, head trauma on bathroom floors, and cardiac arrest. Keep her lying down on the bed or floor until paramedics lift her onto a stretcher.
3. Nye n'ọnụ (ọ dịghị mmiri, nri, ma ọ bụ ọgwụ mgbu). Debe onye ọrịa ahụ nke ọma ** ọ dịghị ihe ọ bụla site n'ọnụ (NPO) ka ọ ghara ịgbọpụta ma kunye ihe dị n'ime afọ n'ime akpa ume ya n'oge ntinye endotracheal mberede. Na mgbakwunye, ** enyela aspirin, ibuprofen, ma ọ bụ naproxen ***, nke na-emebi mkpụkọ ọbara platelet ma na-akawanye ọbara ọgbụgba n'ime.
4. Agbanyela tampons, ọ dịghịkwa douche, ma ọlịkwa na-arịda n'okpuru afọ. Ọ bụrụ na ọbara ọgbụgba dị n'ime ime, tinye ebe dị ọcha n'èzí ** Sanitary pad (pad mothernity)** n'ime uwe ime ka ndị dọkịta nwee ike tụọ ọbara n'èzí site n'ịgụ ole pad na-agbanye kwa elekere. Apịla ma ọ bụ kpatụ afọ ala: nrụgide siri ike na ime tubal agbajighị ma ọ bụ na-agbapụta nwere ike ịgbawa tube nke fallopian gbawara agbawa wee kpalite ọbara ọgbụgba akwara dị egwu.
5. ** Were blanket na-ekpo ọkụ ma nyochaa ụbụrụ ya na iku ume kwa nkeji 3 ruo 5.** Na-ekpuchi ya na blanket na-ekpo ọkụ ma tinye mkpuchi n'okpuru ya ma ọ bụrụ na ọ dina n'ala ala tile. Mgbochi hypothermia (okpomọkụ dị n'okpuru \(35^\circ\text{C}\) ma ọ bụ \(95^\circ\text{F}\)) dị oke mkpa n'ihi na ọbara oyi na-efunahụ ike imechi. Ọ bụrụ na ọ maghị ihe ọ bụla, tụgharịa ya n'akụkụ aka ekpe ya n'akụkụ mgbake n'akụkụ iji mee ka ụzọ ikuku ya kpochaa.
6. ** Gosipụta ọnọdụ afọ ime ma ọ bụrụ na amaghi ama ma chịkọta akụkọ ahụike maka ndị na-ahụ maka ahụike.** Rịba ama ụbọchị mbụ nke ya ** last normal menstrual period (LMP), ma o nwere ** intrauterine device (IUD / coil) ma ọ bụ tupu tubal ligation ("tube tied"), akụkọ ihe mere eme nke tupu afọ ectopic ma ọ bụ ọrịa pelvic pelvic mara, na ya ** R. Gwa ndị na-ahụ maka ahụike ozugbo ma ọ bụrụ na ọ nwetala ** mgbu mgbe ọ na-agbalị imeghe eriri afọ ya ma ọ bụ mamịrị**, nke bụ ihe ama ama nke ịgbakọ ọbara mmiri na pelvic * obere akpa Douglas*.

Nke mbụ ọnwa atọ na-agba ọbara na nnukwu pelvic mgbu ụlọ ọgwụ mkpebi osisi¶

Jiri eserese usoro nke a maka nwanyị ọ bụla torola ịmụ nwa (site na nwata ruo n'oge menopause, ihe dị ka afọ 12 ruo 52) na-egosi mgbu afọ ala ma ọ bụ ọbara ọgbụgba.

flowchart TD
    Start["Nwanyị nke Afọ ịmụ nwa (afọ 12 ruo 52) nwere: <br/>Nnwale ime ime nke ọma, oge efu / oge ikpeazụ, ma ọ bụ ntụpọ oge ọ bụla<br/> PLUS Pelvic/Abdominal Pain ma ọ bụ ọbara ọgbụgba nke ikpu"] --> RedFlagCheck{"Ọ nwere ọkọlọtọ Ectopic / Shock Uhie gbawara agbawa?<br/>1. Dizziness, ìhè isi, ma ọ bụ nkụda mmụọ (syncope) <br/>2. Mgbu dị nkọ n'ọnụ ọnụ ubu (akara Kehr)<br/>3. Ihe mgbu nke afọ dị ala ma ọ bụ nke na-akawanye njọ nke otu akụkụ (otu akụkụ)<br/>4. Mgbu/nrụgide mgbe ị na-agbalị ịfefe stool ma ọ bụ mmamịrị<br/>5. Icha mmirimmiri, oyi, akpụkpọ ahụ gbawara agbawa ma ọ bụ pulse ngwa ngwa (> 100 bpm) <br/>6. Nri> = 2 maxi pad kwa elekere maka awa 2"}

    RedFlagCheck -->|"EE: Otu ọkọlọtọ uhie ọ bụla dị"| Emergency911["CRITICAL SURGICAL EMERGENCY (Suspected Ruptured Ectopic / Hemorrhage):<br/>1. Call 911 / 112 / 999 Immediately<br/>2. Lay flat on back (or left side if nauseated/unconscious); DO NOT let walk<br/>3. Keep Strictly Nothing by Mouth (NPO) for emergency surgery<br/>4. Keep warm with blanket; use external sanitary pad only"]

    RedFlagCheck -->|"NO: Hemodynamically stable,<br/>no fainting, no shoulder pain"| PainVsBleed{"What symptoms are present right now?"}

    PainVsBleed -->|"Mild-to-moderate one-sided pelvic ache<br/>OR dark brown 'prune-juice' spotting"| UrgentSameDay["HIGH RISK FOR UNRUPTURED ECTOPIC PREGNANCY:<br/>Go to Emergency Department or Early Pregnancy Assessment Unit (EPAU) TODAY<br/>Requires same-day Transvaginal Ultrasound + Quantitative Serum beta-hCG<br/>Do NOT wait for a routine prenatal appointment next week"]

    PainVsBleed -->|"Midline menstrual-like cramping<br/>with pink/red vaginal bleeding"| MiscarriageEval["Possible Threatened, Incomplete, or Complete Miscarriage:<br/>Contact OB/GYN or Early Pregnancy Clinic within 24 hours for Ultrasound<br/>and Rh(D) Blood Type check (Anti-D / RhoGAM needed within 72 hrs if Rh-negative)<br/>Go to ER immediately if pain shifts to one side or bleeding increases"]

    PainVsBleed -->|"Painless light spotting only<br/>around expected period date"| LightSpotEval["Possible Implantation Bleeding, Cervical Ectropion, or Subchorionic Hematoma:<br/>Avoid tampons and sexual intercourse; schedule prompt ultrasound<br/>to confirm an intrauterine pregnancy (IUP) inside the uterus"]

Comparing causes of first-trimester bleeding and pelvic pain¶

Because up to 20 to 25 percent of all pregnancies experience some vaginal spotting or bleeding during the first 12 weeks, distinguishing a life-threatening ectopic pregnancy from a miscarriage or harmless subchorionic hematoma saves lives.

Anatomy and pathophysiology: Why a ruptured fallopian tube bleeds so fast¶

To understand why a woman with a ruptured ectopic pregnancy can go from walking and talking to full cardiac arrest in under 45 minutes, consider the anatomy of the female pelvis:

1. Why the fallopian tube cannot stretch like the uterus: The normal human uterus has a thick, multilayered smooth-muscle wall (myometrium) engineered to expand 500-fold in volume over 9 months. In contrast, the fallopian tube (ampulla and isthmus) is a delicate, hair-thin muscular conduit lined with microscopic cilia whose only job is to sweep a fertilized egg into the uterus over 3 to 5 days. When the embryo gets stuck in the fallopian tube, invasive trophoblast cells (which are programmed to burrow into deep maternal blood vessels to build a placenta) burrow straight through the paper-thin wall of the fallopian tube and tap directly into the tubal branches of the uterine artery and ovarian artery.
2. Dual arterial blood supply under pregnancy vasodilation: During early pregnancy, maternal hormones increase pelvic blood flow and cardiac output. Because the fallopian tube sits along an arterial arcade fed from both ends (by the uterine artery from the internal iliac artery medially, and by the ovarian artery directly off the abdominal aorta laterally), a tear across the fallopian tube opens a high-pressure two-way arterial gusher into the free peritoneal cavity.
3. Why Kehr's Sign (Shoulder-Tip Pain) happens: There is nothing wrong with the patient's shoulder joint. When \(500\text{ to }1,500\text{ milliliters}\) of liquid blood spill out of the pelvis and the woman lies down flat (or leans back on a couch), gravity causes the warm liquid blood to flow upward along the paracolic gutters and pool directly underneath the muscular diaphragm (the dome muscle separating the abdomen from the chest). The underside of the diaphragm is innervated by the phrenic nerve, which originates in the neck at cervical spinal nerve roots C3, C4, and C5. Because those exact same C3, C4, and C5 nerve roots also supply the skin over the top of the shoulder and collarbone (supraclavicular nerves), the brain misinterprets diaphragmatic blood irritation as sharp, stabbing pain right at the tip of the shoulder.
4. Why "Bathroom Fainting" and Rectal Pressure happen (Pouch of Douglas pooling): When the woman is upright or sitting, blood pools in the lowest gravity pocket of the female pelvis: the rectouterine pouch (Pouch of Douglas / posterior cul-de-sac), which sits immediately in front of the rectum. Blood distending this space presses directly on the rectum and pelvic parasympathetic nerves, giving the woman a sudden, intense urge that she "needs to have a bowel movement." She walks into the bathroom, sits on the toilet, and strains, which drops venous return to her heart and causes immediate syncopal collapse on the bathroom floor.

Hidden traps: Why you can still have an ectopic pregnancy with an IUD, "tubes tied," or after "getting your period"¶

Three common misunderstandings delay emergency care every day:

1. "She just had her period last week, so she cannot be pregnant"¶

Up to 30 percent of patients diagnosed with a ruptured ectopic pregnancy report that they had what they thought was a normal or slightly light menstrual period 1 to 3 weeks earlier. In reality, when an ectopic pregnancy implants in the fallopian tube, it produces lower-than-normal levels of human chorionic gonadotropin (\(\beta\text{-hCG}\)) and progesterone, causing the lining of the empty uterus to slough and bleed right around the time a period was due. Any female of reproductive age with acute unilateral pelvic pain, shoulder pain, or unexplained fainting must have a urine or blood pregnancy test immediately, regardless of her menstrual history.

2. "She has an IUD (Intrauterine Device / Coil) or had a Tubal Ligation ('Tubes Tied')"¶

While intrauterine devices (such as Mirena, Kyleena, Liletta, or Copper ParaGard IUDs) and surgical tubal sterilization are over 99 percent effective at preventing pregnancy inside the uterus, if a rare pregnancy DOES occur while an IUD is in place or after a prior tubal ligation, there is a 15 to 50 percent chance that the pregnancy is an ECTOPIC pregnancy in the fallopian tube. Having an IUD or tied tubes actually places a pregnant patient in the highest possible risk category for tubal rupture.

3. Major medical risk factors for ectopic pregnancy¶

While roughly 50 percent of all women diagnosed with an ectopic pregnancy have ZERO known risk factors, the risk is significantly elevated in patients with: - A previous ectopic pregnancy (10% to 25% recurrence risk). - Previous Pelvic Inflammatory Disease (PID) or prior Chlamydia trachomatis or Neisseria gonorrhoeae infection (which leaves microscopic scar adhesions inside the delicate cilia of the fallopian tube). - Prior fallopian tube surgery, tubal ligation reversal, appendectomy (especially ruptured appendix), endometriosis, or pelvic surgery. - In Vitro Fertilization (IVF) and Assisted Reproductive Technology (ART): Including a rare condition called a heterotopic pregnancy, where one embryo implants normally inside the uterus AND a second twin embryo implants simultaneously inside the fallopian tube (occurring in roughly 1 in 100 to 1 in 1,000 IVF pregnancies). - Cigarette smoking (nicotine and cotinine paralyze the rhythmic beating of fallopian tube cilia, slowing embryo transport).

How to evaluate external vaginal bleeding volume and the Rh-Negative (Anti-D / RhoGAM) 72-hour rule¶

If a first-trimester patient is having visible vaginal bleeding (whether from an ectopic pregnancy or a miscarriage), doctors need two critical pieces of information:

1. Counting maxi pads per hour (The "2 Pads Per Hour for 2 Hours" Hemorrhage Rule)¶

• Place a standard full-size external sanitary pad (maxi pad) in the underwear (never use a tampon or menstrual cup, which traps blood inside the vagina and can introduce bacteria through an open cervix).
• Emergency Hemorrhage Threshold: If vaginal bleeding is heavy enough to completely soak through 2 or more full-size maxi pads per hour for 2 consecutive hours (or 1 pad every 15 to 30 minutes), or if the patient passes blood clots larger than a golf ball or lemon (\(4\text{ to }5\text{ centimeters}\) / \(1.5\text{ to }2\text{ inches}\)), call 911 / 112 / 999 immediately.
• If grey or pink solid tissue is passed: If the patient passes solid tissue during a suspected miscarriage, gently place the tissue into a clean glass jar or plastic container (or wrap it in a damp clean paper towel inside a sealed plastic bag) and bring it to the hospital so pathologists can inspect it for chorionic villi (confirming an intrauterine miscarriage rather than an ectopic pregnancy).

2. Iwu Ụdị Ọbara Rh-Negative (Anti-D Immunoglobulin / RhoGAM)¶

Ọ bụrụ na nwanyị dị ime nwere Rh-negative blood ($ A\text{-negative}, B\text{-negative}, AB\text{-negative}, \text{ma ọ bụ } O\text{-negative}$) ma nwee ** afọ ime ectopic, ihe egwu ma ọ bụ ime ọpụpụ zuru oke, ma ọ bụ trauma nke afọ nwere ike ịbanye n'ọbara ọbara nke nwa ebu n'afọ. usoro iji wakpo ụmụ ọhụrụ n'ọdịnihu (** ọrịa hemolytic nke nwa ebu n'afọ na nwa amụrụ ọhụrụ**). - Jide n'aka na ị ga-ajụ ụlọ ọgwụ ma ọ bụ Ngalaba Ntụle Ịtụrụ ime n'oge ma ọ chọrọ ịgba ọgwụ intramuscular nke Anti-D immunoglobulin (RhoGAM) n'ime ** awa 72 nke mmalite ọbara ọgbụgba ma ọ bụ ịwa ahụ (na-agbaso ntuziaka mba sitere na ACOG na United States, RCOG/NICE na United Kingdom, na SOGC na Canada).

Ihe na-eme n'ụlọ ọgwụ: transvaginal ultrasound, hCG Discriminatory Mpaghara, na ọgwụgwọ¶

Ịmara otú ndị dọkịta mberede ụlọ ọgwụ na ndị obstetricians si achọpụta na ịgwọ ime ime ectopic na-enyere ndị mmekọ na ezinụlọ aka ịghọta ihe na-eme:

1. ** Ebe nlekọta ngwa ngwa Ultrasound na Transvaginal Ultrasound (TVUS): N'ime nkeji nke ụgbọ ihe mberede mbata maka onye ọrịa na-adịghị akwụ ụgwọ, ndị dọkịta mberede na-etinye nyocha ultrasound n'afọ (**Nnwale ngwa ngwa **: Nyocha lekwasịrị anya na Sonography na Trauma) na-ele anya ** Morison's pouch *** (n'etiti imeju na akụkụ aka nri). Ịhụ ọbara mmiri gbara ọchịchịrị na obere akpa Morison na-akwado opekata mpe \(500\ederede{ga }1,000\text{ milliliters}\) nke ọbara efu n'afọ ma na-ebute mbufe ozugbo n'ime ụlọ ịwa ahụ na-echeghị ọrụ ụlọ nyocha. N'ime ndị ọrịa kwụsiri ike, mkpebi siri ike ** transvaginal ultrasound ** na-enyocha akpanwa na adnexa maka akpa afọ ime, nkochi ime akwa, ma ọ bụ "mgbanaka tubel" / "mgbanaka ọkụ" n'akụkụ ovary.
2. ** Ọnụ ọgụgụ Serum \(\beta\text{-hCG}\) na Mpaghara ịkpa oke**: Ndị dọkịta na-ese ọbara iji tụọ ọkwa ọnụọgụgụ nke beta-human chorionic gonadotropin (\(\beta\text{-hCG}\)). Ozugbo ọbara \(\beta\text{-hCG}\) ruru ** mpaghara ịkpa ókè ** nke \(1,500\ederede{ka }3,500\text{ mIU/mL}\) (\(IU/L\)), afọ ime ahụike dị mma n'ime akpanwa kwesịrị ịdị na-ahụ ya mgbe niile na ultrasound transvaginal; akpanwa efu jikọtara ya na \(\beta ederede{-hCG}\) n'elu \(3,500 ederede{mIU/mL}\) (ma ọ bụ \(\beta ederede{-hCG}\) nke na-adaghị ebili nke ọma karịa awa 48 n'ime "Ịtụrụ ime nke Unknown Location" [PUL]) na-arụtụ aka na ime ime ectopic.
3. **Ịwa ahụ vs. Ọgwụgwọ ahụike ***:
4. ** Ịwa ahụ Laparoscopic mberede (Salpingectomy ma ọ bụ Salpingostomy) : achọrọ maka ** afọ ime ectopic ọ bụla gbawara agbawa , onye ọrịa ọ bụla nwere nsogbu hemodynamic, ọbara peritoneal efu, oke mgbu, ma ọ bụ nkụchi obi nwa ebu n'afọ n'ime tube fallopian. Ndị dọkịta na-awa ahụ na-ewepụ tube nke fallopian gbawara agbawa ( salpingectomy) ma ọ bụ mepee tube iji wepụ afọ ime ( salpingostomy**) ma na-amịnye O-negative ma ọ bụ ọbara crossmatched. (Iwepụ otu tube nke fallopian ka na-ahapụ ** pasent 70 ruo 85 nke ọmụmụ eke nkịtị ** site na tube nke fọdụrụ na ahụike).
5. ** Nlekọta ahụike na Intramuscular Methotrexate (naanị maka Stable, Unruptured ectopics): Ọ bụrụ na ejidere ime ectopic n'oge ** tupu ọ gbawaa, onye ọrịa ahụ kwụsiri ike na obere mgbu na obere ihe na-enweghị mgbagha, ndị dọkịta nwere ike zere ịwa ahụ site n'inye ọgwụ mgbochi intramuscular nke ** methotreate dividly sel placental ka ahụ wee nwetaghachi afọ ime n'ime izu 2 ruo 6). ** ịdọ aka ná ntị dị egwu post-methotrexate *: Ọbụlagodi na ọ nwetachara ogbunigwe methotrexate, tube fallopian na-anọgide na-emebi emebi ma nwee ike ** ịgbawa ụbọchị 3 ruo 14 ka e mesịrị; Ọ bụrụ na onye ọrịa natara methotrexate na-etolite nnukwu mgbu afọ mberede, mgbu n'ọnụ ọnụ, ma ọ bụ dizziness n'ụlọ, kpọọ 911/112/999 ozugbo.

Ebe ectopic na-adịghị ahụkebe nke na-agbawa site na nnukwu ọbara ọgbụgba¶

Ọ bụ ezie na pasent 95 ruo 97 nke ime afọ ime ectopic na-etinye n'ime nnukwu ampulla ma ọ bụ isthmus nke tube fallopian, ihe dị ka pasent 3 ruo 5 na-akụnye na saịtị anụ ahụ na-adịghị ahụkebe ebe nchoputa siri ike na ọbara ọgbụgba n'ime ime nwere ike ime ihe ike karị:

• Interstitial (Cornual) Ime Ectopic (2% ruo 4% nke ectopics): Akụnye n'akụkụ dị nso nke tube fallopian nke na-esi na mgbidi muscular siri ike nke akpanwa pụta, ozugbo ebe akpanwa na akwara ovarian anastomose. N'ihi na akwara uterine gbara ya gburugburu dị oke karịa tube nke dị n'èzí, ime interstitial nwere ike itolite ruo izu 8 ruo izu iri na anọ nke ime ime ** tupu ọ gbawa na mberede site na mpi uterine, na-eme ka ikpochapụ ngwa ngwa na ọnụọgụ ọnwụ ruru ugboro 2 ruo 5 dị elu karịa ime tubal ọkọlọtọ.
• **Cesarean Scar Pregnancy (CSP): A na-akụnye ozugbo n'ime ntụpọ fibrous microscopic (niche) nke ọnya akụkụ cesarean nke dị n'ihu. Dị ka placenta na-esi n'apa ahụ na-erute na eriri afo urinary, ọ nwere ike ịkpata ọdachi nke mbụ ma ọ bụ nke abụọ n'ime uterine ma ọ bụ ọbara ọgbụgba nke placenta acreta.
• ** Cervical, Ovarian, na Abdominal Ectopic Pregnancy ***: Ịkụnye n'ime ọwa mmiri endocervical (na-ebute ọbara ọgbụgba na-adịghị egbu mgbu), n'elu akwa akwa, ma ọ bụ ozugbo na peritoneal lining ma ọ bụ bowel serosa n'ime oghere afọ.

Ajụjụ a na-ajụkarị¶

enyochara isi mmalite¶

• ** American College of Obstetricians and Gynecologists (ACOG, United States):** Mpempe akwụkwọ akụkọ nke 193: Tubal Ectopic Pregnancy na Mpempe akwụkwọ nke 200: Mfu ime mmalite.
• ** National Institute for Health and Care Excellence (NICE, United Kingdom) na Royal College of Obstetricians and Gynecologists (RCOG, United Kingdom):**
• ** Ndị ọkachamara n'ọrịa ụmụ nwanyị na ndị ọkachamara n'ọrịa ụmụ nwanyị nke Canada (SOGC, Canada): ** * Ntuziaka Omume Clinical Nke 414: Nlekọta ime ime nke ebe amaghi ama na Tubal na ime ime ectopic na-abụghị Tubal *.
• ** Òtù Na-ahụ Maka Ahụ Ike Ụwa (WHO): *** Ịchịkwa nsogbu n'ime ime na ịmụ nwa: ọbara ọgbụgba n'ime ime n'oge mbụ yana ụkpụrụ ịwa ahụ ectopic ime ime*.

Ntuziaka emetụtara¶

• Nchọpụta ujo na njikwa enyemaka mbụ
• Ọkpụkpụ testicular, mgbaka ovarian, na nnukwu mgbu pelvic
• Omumu nwa mberede na ime ngwa ngwa
• Ntụle nkụda mmụọ na syncope
• Nọmba mberede na izipu mba ofesi