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Mullerian Anomalies in Pregnancy
1. What every clinician should know
How common are uterine anomalies?
Congenital anomalies of the uterus may be undiagnosed until a woman's reproductive years. While often asymptomatic, patients may present with gynecologic and obstetric complaints such as dysmenorrhea, pelvic pain and pregnancy loss. Patients may also be incidentally diagnosed with a uterine anomaly after imaging or surgery.
The prevalence of uterine anomalies varies depending on the population studied. Rates in the general population are likely between 0.5-5.5%. Prevalence of uterine anomalies is much higher among women with various adverse pregnancy outcomes, with rates between 6-25%. Women with primary infertility have prevalence rates similar to that of the general population.
How do uterine anomalies form?
Anomalies are most likely sporadic, with some polygenic, multifactorial inheritance that has yet to be delineated. Women with first-degree relatives with a uterine anomaly may have a slightly greater frequency of anomalies than the general population. Most women with uterine anomalies have a normal 46XX karyotype.
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The uterus and cervix are formed in a multistep process. The bilateral Müllerian ducts must develop by elongating, canalizing and migrating. The ducts then fuse, resulting in a uterus with a median septum by week 10. Ultimately, to form a single cavity, this septum is resorbed in a caudal to cranial procession between weeks 13-20. Errors in the various stages of the process lead to the wide array of Müllerian anomalies seen clinically.
How are uterine anomalies classified?
The American Fertility Society has made attempts to standardize the classification of Müllerian anomalies. Their chart provides pictorial testament to the varied abnormalities encompassed within the category of Müllerian anomalies. There are variations on these categories and the distinctions are at times blurred, so what is seen clinically may not fit easily into one of these categories. Ultimately, understanding the embryologic and anatomic defects guides our comprehension of the pathophysiology of obstetric complications and potential options for interventions and management.
Figure 13
Figure 14
Reports have varied in regard to prevalence of the various types of anomalies but are in the range of 10-46% bicornuate uterus, 25-50% uterine septum, 5-10% uterine didelphys, 4-20% unicornuate uterus and 3-10% Müllerian or vaginal agenesis. The variation likely stems from the inclusion criteria for any given study, as factors such as recurrent pregnancy loss, gynecologic symptoms and concurrent anomalies affect prevalence.
Agenesis and vertical fusion defects are less conducive to achieving pregnancy, and as a result are less likely to be encountered by the obstetrician. We will focus on the most common category of Müllerian anomalies affecting pregnancy – those resulting from defects of lateral fusion, including the unicornuate, didelphys, bicornuate and septate uterus.
2. Diagnosis and differential diagnosis
The diagnosis of a uterine anomaly can be suggested based on history (e.g. recurrent midtrimester pregnancy loss), physical exam (e.g. visualization of two cervices during a pelvic exam), surgical visualization or incidentally on imaging such as ultrasonography. When an anomaly is suspected, proceeding with various imaging modalities may be prudent to more fully characterize the genitourinary system.
Magnetic Resonance Imaging (MRI):Often considered the gold standard for the evaluation of uterine anomalies, MRI has proven efficacy for this purpose. It allows for evaluation of both the uterine cavity and contour without exposure to radiation. Signals vary between tissue types such as endometrium and myometrium so MRI can be used to differentiate between anomalies such as a functional rudimentary uterine horn or bicornuate versus septate uterus. Simultaneous evaluation of the renal system can be conveniently performed. MRI is a fairly costly technique and some patients have difficulty tolerating testing.
Ultrasound:Ultrasound is an imaging option that lends itself well to the investigation of uterine anomalies during pregnancy. It is noninvasive, relatively inexpensive and convenient, as most pregnant women undergo ultrasound testing routinely. The ability to accurately identify the nature of an anomaly becomes difficult as pregnancy progresses, but early in pregnancy three-dimensional ultrasound can be used to evaluate both the uterine contour and cavity. Although research is limited, studies note that ultrasound is comparable to MRI in its diagnostic efficacy with very good concordance (kappa index 0.880). Additionally, an evaluation of the kidneys and ovaries can be performed simultaneously.
Hysterosalpingogram (HSG):By injecting radiopaque dye through the cervix and taking radiographic images, HSG can be used to evaluate the uterine cavity. It does not provide information about uterine contour. HSG is not useful for the obstetrician trying to make a diagnosis in pregnancy, but outside of pregnancy it is a safe, available and relatively inexpensive test.
Saline infusion sonohysterogram: Saline is instilled through the cervix to distend the uterine cavity enough to enhance visualization of the uterus during transvaginal ultrasound. As with HSG, this study cannot be performed during pregnancy, but it can help characterize the uterine cavity in non-pregnant women. It can be quite useful in delineating intracavitary pathology and was noted to have nearly 78% sensitivity in detecting uterine malformations.
Laparoscopy:Surgical exploration via laparoscopy allows for an evaluation of the uterine contour but does not provide information about the cavity. The addition of hysteroscopy addresses this limitation. This technique is not favored in pregnancy because of its invasive nature. Other imaging modalities are typically preferred, but incidental findings during laparoscopic or open surgery can be diagnostic of a Müllerian anomaly, especially when paired with a thorough pelvic examination.
What findings are associated with specific anomalies?
Unicornuate uterus (Type II):This anomaly results from a defect in one of the Müllerian ducts. There is a single cervix with a single uterine horn, accompanied by its fallopian tube. The affected Müllerian duct may not develop, or may be partially developed, resulting in a rudimentary horn with or without functional endometrium. Up to 75% of women with a unicornuate uterus have a rudimentary horn, many without a communicating channel to the cervix, vagina or contralateral hemiuterus. Unicornuate uterus is associated with fairly poor obstetrical outcomes. Live birth rates of less than 30% have been noted, but have ranged from 29-100% in case series. (See Figure 1, Figure 2 and Figure 3.)
Uterine didelphys (Type III):This anomaly results from failure of the Müllerian ducts to fuse, leaving duplication of the uterus and cervix. Clinically, two cervices will be noted along with two uterine horns, each with their own fallopian tube. A longitudinal vaginal septum is often present. Although complications are still common, uterine didelphys is associated with overall better pregnancy outcomes than other uterine anomalies. In one series, a 75% fetal survival rate was noted and 89% of women desiring pregnancy had at least one living infant. A larger review was not so optimistic, noting an averaged live birth rate of 55.9%. (See Figure 4, Figure 5 and Figure 6.)
Bicornuate uterus (Type IV):This anomaly results from incomplete fusion of the Müllerian ducts. A single cervix, with complete or partial division of the uterine body, results. The uterine contour will reveal an indentation of the fundus or two separate uterine horns. The upper portion of the cervix may also be duplicated, but a single cervix on pelvic exam will be noted. Obstetric complications are very common in women with bicornuate uteri with term delivery rates of 31-50% and live birth rates of 44-63%. (See Figure 7.)
Uterine septum (Type V):A septum results from incomplete resorption of the midline septum between the two Müllerian ducts. The uterine contour will be normal, but a two-sided endometrial cavity develops because of the midline tissue. The fibromuscular septum can vary in length and thickness. Although differences in anatomy are more subtle than those of many other Müllerian anomalies, uterine septum has been associated with the poorest pregnancy outcomes, with live birth rates ranging from 28-69%. (See Figure 8, Figure 9, Figure 10, Figure 11 and Figure 12.)
What other anomalies are associated with Müllerian defects?
Kidney and pelvic organ development is embryologically intertwined. As a result, urinary tract anomalies are common in women with Müllerian defects. 20-30% of patients with a uterine anomaly will have a concurrent renal anomaly. Prevalence is highest with unicornuate uterus, with 40.5% of women having a renal anomaly, most commonly renal agenesis ipsilateral to their Müllerian defect. Renal collecting system duplication, pelvic kidney and horseshoe kidney, among other variations, have also been noted. Women with uterine anomalies should be evaluated for urinary tract anomalies with renal ultrasound, IV pyelogram, MRI or CT.
Conversely, about 40% of women with renal agenesis have a Müllerian anomaly. The finding of renal agenesis should prompt a gynecologic evaluation. One specific pattern of associated anomalies is obstructed hemivagina with ipsilateral renal anomaly (OHVIRA), seen occasionally with uterine didelphys.
Ectopic ovarian tissue may be present in women with uterine anomalies, most commonly occurring with unicornuate uterus. The affected ovary typically is ipsilateral to the missing or rudimentary horn and has been noted in varied locations from the upper abdomen to the inguinal canal.
Uterine anomalies have also been associated with gastrointestinal, cardiac, ophthalmologic and otologic abnormalities. Routine screening is not recommended because these findings are rare and the association has not been clearly outlined.
3. Management
Should surgical interventions be considered outside of pregnancy
In general, routine prophylactic surgical correction of the anomalous uterus is not indicated. One notable exception is in cases of unicornuate uterus with a rudimentary horn. Because of potential catastrophic obstetric outcomes of pregnancies with this anomaly, we recommend considering surgical removal of a rudimentary horn, particularly if it contains functional endometrium. Along with obstetric issues, women can have dysmenorrhea and severe endometriosis from retrograde menstruation if this horn has limited or no communication with the cervix.
Prophylactic removal of a uterine septum is controversial, but it may be prudent to consider surgery for patients with a history of poor pregnancy outcomes such as recurrent miscarriage or preterm birth. Because of comparable outcomes and the minimally invasive nature of hysteroscopic resection, it is favored over open techniques. Dramatic improvements in pregnancy outcomes have been noted in case series but no randomized studies with appropriate controls have been published to support these findings.
Patients with a poor obstetric history and uterine didelphys or bicornuate uterus also may seek surgical intervention. A small case series from Poland of 13 women with bicornuate uterus who underwent Strassman metroplasty noted increased fetal survival rates from 0-80%. Unfortunately, as with much of the data related to Müllerian anomalies, no randomized studies support the use of major uterine reconstruction to improve obstetric outcomes. Until more rigorous data are available, recommendations for major uterine reconstruction cannot be made.
4. Complications
What antepartum complications are associated with Müllerian anomalies?
Pregnancy complications associated with Müllerian anomalies can range from inconvenient to devastating for the patient and physician. Ectopic pregnancy, early and late miscarriage, cervical insufficiency, preterm delivery, hypertensive disorders, growth restriction and fetal demise are all antepartum issues more commonly faced by women with Müllerian anomalies. The risk of these complications varies with the type of uterine anomaly. Whether the diagnosis is made prior to or during pregnancy, patients should be counseled regarding the antenatal and intrapartum risks associated with their specific anomaly.
Ectopic pregnancy
Although the mechanism is unclear, women with Müllerian anomalies may have a higher rate of ectopic pregnancy. This risk may be related to an abnormal path that sperm, egg and embryo must traverse with the altered anatomy or possibly the higher rate of endometriosis seen with uterine anomalies. Reported ectopic pregnancy rates vary, with some studies citing rates as high as 20%. Most reviews note a prevalence more similar to the 1% seen in the general population.
Anomaly specific risks
Reports of anomaly-specific ectopic pregnancy prevalence also vary significantly, but ectopic rates of 1.2%, 1.3%, 0.3% and 0.6% for women with unicornuate, didelphys, bicornuate and septate uteri have been noted. One specific scenario that is often included within the category of ectopic pregnancy is pregnancy within a rudimentary uterine horn of a woman with unicornuate uterus. Transperitoneal migration of sperm can occur, resulting in fertilization and implantation of a pregnancy within a non-communicating rudimentary horn. This scenario poses particular risk to the woman because of the possibility of uterine rupture (see below).
Early ultrasound confirmation of pregnancy location and viability should be considered.Surgical or medical management with methotrexate and potassium chloride injection may be undertaken as indicated by the particular scenario, with referral to an experienced gynecologic specialist for complicated cases.Because of the significant risk of rupture, when an early rudimentary horn pregnancy is diagnosed, pregnancy termination should be advised.
Surgical removal of a rudimentary horn that has functional endometrium should be strongly considered.
Women with Müllerian anomalies commonly experience miscarriage and women with recurrent miscarriage are much more likely to have a uterine anomaly. In one study, 13% of women with recurrent pregnancy loss had a uterine malformation. The etiology is not delineated, but may be related to abnormal endometrium, uterine circulation or disruption of the pregnancy by abnormal intracavitary structures that diminish uterine capacity.
Anomaly specific risks
Miscarriage incidence varies widely, with rates of 12-67% for unicornuate uterus, 25-69% for uterine didelphys, 28-46% for bicornuate uterus and 25-67% for uterine septum being noted in the literature.
No specific interventions during pregnancy have been shown to improve the miscarriage rate in women with Müllerian anomalies.
Study findings vary in regard to the usefulness of uterine septum characterization in predicting obstetric complications. Some reports note higher rates of obstetric complications with shorter, vascularized septa, while others show no correlation with length or thickness. We do not recommend trying to measure or otherwise evaluate the septum at this time.
Review the signs and symptoms of miscarriage as well as bleeding precautions with the patient.
Patients who experience recurrent pregnancy loss should undergo evaluation for a uterine anomaly.
Cervical insufficiency
Cervical incompetence has been diagnosed in 30% of women with uterine anomalies in one study, possibly related to the abnormal fusion event resulting in dysfunctional cervical tissue composition. A greater ratio of muscular fibers to connective tissue has been noted. This may significantly contribute to the high preterm delivery rate seen in women with Müllerian anomalies.
Anomaly specific risks
Women with bicornuate uteri were found to have the highest rate of cervical insufficiency (38%) in a study of 98 women.
Historically, cerclage was often recommended for women with uterine anomalies. Case series have reported dramatic decreases in late miscarriage and preterm delivery from 50-21% with the use of cerclage. Increased rates of term deliveries from 26-63% were noted with its use in patients with cervical insufficiency.
Term delivery rates also were improved in patients without a history of early delivery attributed to cervical incompetence (96% vs 64%) when they received a cerclage. Unfortunately, the data is far from robust, no randomized trials have been performed and cerclage use has not been supported by more recent experience. Based on existing data, the use of cerclage to prevent or treat cervical insufficiency among women with Müllerian anomalies is not uniformly recommended.
Preterm delivery
Patients with uterine anomalies have higher rates of preterm delivery and the greatest contributor to neonatal morbidity and mortality associated with Müllerian anomalies is likely preterm delivery. Cervical insufficiency and decreased myometrial mass have been theorized as etiologies of the association with prematurity, but the mechanism has not been elucidated.
Anomaly specific risks
Preterm delivery rates vary widely. Unicornuate uterus has a preterm delivery rate of about 20%. This may be related to diminished musculature and abnormal uterine vasculature with a one-sided blood supply (one set of uterine and utero-ovarian arteries). Uterine didelphys, bicornuate uterus and uterine septum have had preterm delivery rates of 17-53%, 22-25% and 9-33% respectively.
Patients should be counseled regarding the signs and symptoms of preterm delivery. A lower threshold for prompting an evaluation should be considered.
The use of cervical length ultrasound to stratify patients at greatest risk of preterm delivery is routinely used in other high-risk obstetric populations and may prove beneficial in women with uterine anomalies. Using a cervical length threshold of 25mm between 14-24 weeks, one study noted 71% sensitivity, 91% specificity and 96% negative predictive value for predicting delivery prior to 35 weeks. An additional study using similar criteria found good negative predictive value in cervical length ultrasound but noted that it might not be as predictive in women with uterine didelphys. What has not been elucidated is what to do with patients found to have a short cervix.
Consideration for ultrasound indicated cerclage may be made, but this intervention has not been well studied in women with Müllerian anomalies. In one small series of six patients with uterine anomalies who received therapeutic cerclage, two delivered prior to 35 weeks despite cerclage.
Vaginal progesterone has been reported to reduce the risk of preterm birth among women with a sonographically short cervix. Women with Müllerian anomalies were excluded from the trial of Hassan et al and were not excluded from the trial of Fonseca et al. It is reasonable to offer vaginal progesterone to reduce the risk of preterm birth among women with Müllerian anomalies and sonographic short cervix less than 15 mm.
While 17 alpha-hydroxyprogesterone caproate (17OHPC) was shown to be effective at reducing the risk of recurrent preterm birth, women with Müllerian anomalies were excluded from the study. As a result, we know little of its efficacy in women with a history of preterm birth possibly related to a uterine anomaly. 17OHPC may be offered to these patients, but the limited applicability of the data from the original trial should be reviewed with patients and individual decisions regarding 17OHPC made.
Women with Müllerian anomalies should not be excluded from interventions routinely employed in the management of preterm labor, such as betamethasone administration and magnesium for fetal neuroprotection.
Uterine rupture
Cases of uterine rupture in women with various Müllerian anomalies have been reported, although the prevalence of this complication is difficult to ascertain. Rupture may be related to diminished uterine mass and higher rates of ectopic pregnancy. When uterine rupture occurs it often happens earlier in pregnancy, prior to the onset of labor.
Anomaly specific risk
Most reports of uterine rupture have occurred in women with unicornuate uteri with pregnancies in a rudimentary horn. These women are noted to have a 50% rupture rate. Rupture can occur anytime during pregnancy, but about 80% occur prior to the third trimester. Rupture usually occurs without antecedent symptoms. Regardless of timing, uterine rupture can lead to catastrophic outcomes with maternal mortality of 5.7%.
If an advanced uterine horn pregnancy is diagnosed, the use of tocolytics can be considered, with plan for early delivery once the risk of prematurity for the fetus is diminished.
Growth restriction
Further characterization of the risk of intrauterine growth restriction in women with Müllerian anomalies is needed. Diminished musculature and abnormal uterine vasculature have been speculated as possible etiologies, particularly when the pregnancy is supplied primarily by a single set of uterine/utero-ovarian arteries. One study found that 2/3 of women with uterine anomalies had a completely lateralized placenta, were more likely to have abnormal systolic/diastolic ratios in the contralateral uterine artery and had higher rates of fetal growth restriction.
Anomaly specific risk
Anomalies such as unicornuate uterus or uterine didelphys are more likely to have unilateral vascular supply to a pregnancy and may be associated with greater risk of fetal growth restriction. Case series have noted fetal growth restriction in 10% of women with unicornuate uterus and 11% of women with uterine didelphys. Similarly, women with a uterine septum or bicornuate uterus that leads to complete lateralization of the placenta and pregnancy may also have increased rates of fetal growth complications.
Fundal heights should be assessed and followed closely throughout the second half of pregnancy.
Obtaining serial growth ultrasounds every 3-4 weeks in the third trimester may be considered.
Hypertensive disorders of pregnancy
Hypertensive disorders are more likely to develop in pregnancies of women with uterine anomalies. Limited research has reported pre-eclampsia in 3-18% of women with uterine anomalies. Pre-eclampsia was found to be twice as common in women with uterine anomalies. A mechanism has not been elucidated, but additional pre-eclampsia risk factors associated with uterine anomalies have been outlined. Specifically, in one study 42% of women with renal agenesis and a uterine anomaly had a pregnancy complicated by gestational hypertension or pre-eclampsia. The relative risk for these complications was 2.33 compared to women with an anomalous uterus but without a renal anomaly.
Anomaly specific risk
The anomalies such as unicornuate uterus, which are most commonly associated with renal agenesis, may be at greatest risk for developing pre-eclampsia. One study found that 13% of women with uterine didelphys were diagnosed with pre-eclampsia. Regardless of the uterine anomaly, women found to have an associated renal anomaly are likely at risk for hypertensive complications.
If not done prior to pregnancy, patients with a uterine anomaly should have renal imaging to note the presence of bilateral kidneys. This may be conveniently performed during a first trimester or anatomy ultrasound.
Consider obtaining baseline labs such as creatinine and urine protein evaluation which may prove helpful if evaluating a patient for pre-eclampsia later in pregnancy.
The signs and symptoms of pre-eclampsia should be reviewed with the patient.
Intrauterine fetal demise
Possibly related to several of the antepartum complications such as pre-eclampsia and intrauterine growth restriction noted previously, women with Müllerian anomalies may be at increased risk for intrauterine fetal demise. Further characterization of this risk is needed.
Anomaly specific risk
Limited data notes a fetal demise rate of 10.5% rate in women with unicornuate uterus and a 3.5% risk in women with uterine didelphys.
⇒ Antenatal surveillance with non-stress tests or biophysical profiles in the third trimester can be considered, and should be performed in pregnancies complicated by hypertensive disorders or growth restriction.
⇒ Patients may be instructed to monitor fetal activity and counseled to present for evaluation if concerns arise.
What intrapartum complications are associated with Mullerian anomalies?
Malpresentation is very common among women with all types of uterine anomalies, with reports of 23-38% of fetuses presenting non-vertex at time of delivery. Higher rates of malpresentation may be related to the abnormal uterine cavity that inhibits rotation of the fetus to cephalic presentation and to more frequent preterm deliveries, when the fetus is more likely to be breech.
Women who have pregnancies complicated by malpresentation may face it as a recurrent issue. One study noted that women with Müllerian anomalies and a history of cesarean section for malpresentation had significantly higher rates of repeat cesarean section for breech than women with normal uteri (59.3 vs 14.4%).
Anomaly specific risk
Limited studies note a particularly elevated risk of malpresentation with uterine septum, with a 35-53% rate of breech presentation.
⇒ Confirming fetal presentation by pelvic examination or ultrasound is essential when a patient presents in labor or prior to labor induction.
⇒ Breech presentations are typically delivered by cesarean section.
⇒ Unfortunately no data on efficacy, risk or outcomes are available to guide the consideration of external cephalic version (ECV) in women with Müllerian anomalies. Success rates are likely much lower, and in most cases we advise against attempted ECV in this population.
Uterine rupture
Previously discussed as an antepartum risk, cases of uterine rupture during spontaneous labor and labor induction have been reported. Data on overall risk of rupture and outcomes are lacking.
Anomaly specific risk
Uterine rupture has occurred in spontaneous labor and during labor induction in pregnancies within rudimentary horns. The nearly 50% risk of rudimentary horn rupture does not vary whether or not the rudimentary horn communicates with the cervix, vagina or hemiuterus. Case reports of uterine rupture following hysteroscopic septum removal have also been noted, but this appears to be rare, with one event in a series of 180 term pregnancies. Hysteroscopic procedures likely confer a significantly lower risk of rupture and do not necessitate a cesarean delivery. Any woman who has undergone open or laparoscopic uterine metroplasty is at increased risk for uterine rupture.
⇒ Women with uterine anomalies should be monitored in labor.
⇒ Patients who have had a hysterotomy for uterine metroplasty should be delivered by cesarean section prior to the onset of labor.
⇒ Pregnancies within a rudimentary horn should be delivered by cesarean section prior to the onset of labor once the risk of prematurity for the fetus is diminished.
Labor dystocia
While noted in early reviews of uterine anomalies and associated complications, limited data exist on the risk of labor dystocia in pregnancies complicated by Müllerian anomalies. Abnormal uterine musculature and insufficient forces generated by abnormal myometrium may lead to labor dystocia and an increased rate of operative delivery.
Anomaly specific risk
Several anomalies pose particular risks for labor dystocia. A rudimentary horn can obstruct descent of the fetal presenting part even if the pregnancy is located in the unicornuate horn. Additionally, women with uterine didelphys frequently have a longitudinal septum that can occasionally obstruct labor progress.
Labor progress should be monitored and evaluation for factors contributing to dystocia such as vaginal septum or suboptimal fetal presentation should be performed.
Prophylactic resection of a longitudinal vaginal septum is generally not recommended, as the tissue often distends and moves aside because of the fetal presenting part. Controlled surgical resection with maneuvers to obtain hemostasis may be considered if a vaginal septum seems likely to bleed heavily with spontaneous disruption.
Attention must be paid to a patient's specific anomaly and pregnancy location when undertaking maneuvers to assess and augment labor. In particular, women with uterine didelphys should have the appropriate cervix identified when performing cervical exams and placing a foley bulb or pressure monitor.
Cesarean delivery
Cesarean delivery is common in women with uterine anomalies. Malpresentation is the most common indication for cesarean delivery, but it is likely that increased rates of pre-eclampsia, labor dystocia and growth restriction also contribute to the cesarean section rate. More research is needed to determine the risks and complications of cesarean section specific to this population.
Anomaly specific risk
Delivery by cesarean section is most common in women with uterine didelphys with a reported rate of 84%. Of note, about 3/4 of these pregnancies will be located in the right uterus – something to consider when orienting to the uterus and important structures prior to making a hysterotomy.
Awareness of the patient's specific anomaly at time of surgery is important. Knowing landmarks that may or may not be present because of altered anatomy can be extremely helpful when negotiating a rotated, scarred or otherwise abnormal uterus. Special attention should be paid to locating the uterine vessel(s) and bladder prior to making the hysterotomy. Additionally, closely inspecting the lower uterine segment to assess its adequacy for a low transverse incision is advised, as it is not uncommon to need a classical incision to deliver the fetus. Orienting yourself to the patient's anatomy can be even more essential should operative maneuvers such as hysterectomy be required to manage hemorrhage.
Post-partum hemorrhage
Bleeding complications can occur following delivery, most commonly associated with incomplete expulsion of the placenta, which occurs more frequently in women with Müllerian anomalies. Women with a vaginal septum in conjunction with a uterine anomaly are at risk for septum laceration. Data is limited regarding frequencies of these complications.
Consider active management of the third stage of labor.
The placenta should be inspected after delivery and ultrasound should be available to evaluate for retained products.
A thorough inspection of the perineum and vagina should be performed with repair of a vaginal or septum laceration as indicated.
Trial of labor after cesarean (TOLAC)
Given the high rate of cesarean delivery in women with uterine anomalies, the question of attempting a vaginal birth after cesarean (VBAC) is frequently faced. One early study noted an 80% successful VBAC rate along with an 8% rate of uterine rupture. While concerning, both cases of uterine rupture occurred in women who underwent prostaglandin induction, which is no longer standard practice.
Additionally, researchers found higher rates of urgent cesarean section for fetal tracing concerns, operative vaginal delivery and cord prolapse. A more recent and larger retrospective study noted no cases of uterine rupture among women electing for TOLAC. The most common indication for the primary c-section was malpresentation. This was a recurrent complication for 58% of the women who had desired a TOLAC. For all women who intended to VBAC, success rates were significantly lower for women with a uterine anomaly (37.6%) versus those with normal uterine anatomy (50.7%).
Considering only women with cephalic fetuses, success rates were comparable between women with and without a uterine anomaly (57.4% vs 54.2%).
The appropriateness of TOLAC is specific to each patient, her uterine anomaly, as well as her additional obstetric and medical history. Women should be counseled on their individual risks, benefits and likelihood of successful TOLAC, and consideration made for motivated women if appropriate.
Uterine torsion
Torsion of one uterine horn is a very rare complication reported with uterine didelphys that is most often encountered in labor . Patients may present with pain, labor dystocia or fetal distress. Resultant uterine ischemia and fetal compromise often requires emergent cesarean delivery.
Women with uterine anomalies should be monitored on a labor suite capable of emergent cesarean delivery if significant fetal compromise is noted that is unresponsive to conservative measures.
Evaluating and comparing the placental location in a non-emergent scenario can help illuminate the etiology of pain or dystocia. Specifically, an ultrasound on the labor suite may note an anterior placenta when previous ultrasounds documented a posterior placenta.
6. What is the evidence for specific management and treatment recommendations
Simon, C. "Mullerian defects in women with normal reproductive outcome". Fertil Steril. vol. 56. 1991. pp. 1192-3. (Study of 679 patients with normal reproductive outcomes to investigate the prevalence of various mullerian anomalies.)
Raga, F. "Reproductive impact of congenital Mullerian anomalies". Hum Reprod. vol. 12. 1997. pp. 2277-81. (Retrospective longitudinal study of 3181 women attempting conception to determine the incidence and reproductive impact of uterine malformations. The population analysed included fertile, infertile and sterile patients, so the study allows an investigtion into the differential rates of mullerian anomalies in these populations. The overall frequency of uterine malformations was 4.0%. Infertile patients (6.3%) had a higher incidence of Müllerian anomalies, in comparison with fertile (3.8%) and sterile (2.4%) women.)
Acien, P. "Incidence of Mullerian defects in fertile and infertile women". Hum Reprod. vol. 12. 1997. pp. 1372-6.
Chan, YY. "The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review". Hum Reprod Update. vol. 17. 2011. pp. 761-71. (Systematic review evaluating the prevalence of congenital uterine anomalies in unselected populations and in women with infertility, a history of miscarriage, or a history of preterm delivery.)
Grimbizis, GF. "Clinical implications of uterine malformations and hysteroscopic treatment results". Hum Reprod Update. vol. 7. 2001. pp. 161-74. (Clinical review of mullerian anomalies and their impact on fertility and pregnancy outcomes.)
Lin, PC. "Female genital anomalies affecting reproduction". Fertil Steril. vol. 78. 2002. pp. 899-915. (Clinical review of mullerian anomalies, including embryologic origins and a summary of the studies that look at the impact of anomalies on a woman's fecundity. Surgical therapies to potentially improve fertility are also reviewed.)
"The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions". Fertil Steril. vol. 49. 1988. pp. 944-55. (Most commonly used classification system for mullerian anomalies, depicted visually including subclassifications.)
Bermejo, C. "Three-dimensional ultrasound in the diagnosis of Mullerian duct anomalies and concordance with magnetic resonance imaging". Ultrasound Obstet Gynecol. vol. 35. 2010. pp. 593-601. (Study of 65 women with mullerian anomalies who underwent both 3D ultrasound and MRI noted comparable diagnostic efficacy and very good concordance.)
Soares, SR, Barbosa dos Reis, MM, Camargos, AF. "Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases". Fertil Steril. vol. 73. 2000. pp. 406-11. (Descriptive prospective study of 65 infertile women to evaluate the diagnostic accuracy of sonohysterography versus HSG and in uterine cavity diseases in infertile patients, comparing its results with those of hysterosalpingography (HSG) and transvaginal sonography (TVS). )
Nahum, GG. "Uterine anomalies, induction of labor, and uterine rupture". Obstet Gynecol. vol. 106. 2005. pp. 1150-2. (Editorial on mullerian anomalies and risk of uterine rupture with labor induction.)
Reichman, D, Laufer, MR, Robinson, BK. "Pregnancy outcomes in unicornuate uteri: a review". Fertil Steril. vol. 91. 2009. pp. 1886-94. (An excellent review article of pregnancy outcomes in women with unicornuate uteri.)
Heinonen, PK. "Clinical implications of the didelphic uterus: long-term follow-up of 49 cases". Eur J Obstet Gynecol Reprod Biol,. vol. 91. 2000. pp. 183-90. (One of the larger retrospective studies (49 cases) of uterine didelphys and the impact on pregnancy outcomes.)
Oppelt, P. "Female genital malformations and their associated abnormalities". Fertil Steril. vol. 87. 2007. pp. 335-42. (Study of 211 women with mullerian anomalies to evaluate the type and frequency of associated anomalies.)
Li, S. "Association of renal agenesis and mullerian duct anomalies". J Comput Assist Tomogr. vol. 24. 2000. pp. 829-34.
Fedele, L. "Urinary tract anomalies associated with unicornuate uterus". J Urol. vol. 155. 1996. pp. 847-8.
Heinonen, PK. "Gestational hypertension and preeclampsia associated with unilateral renal agenesis in women with uterine malformations". Eur J Obstet Gynecol Reprod Biol. vol. 114. 2004. pp. 39-43.
Reichman, DE, Laufer, MR. "Congenital uterine anomalies affecting reproduction". Best Pract Res Clin Obstet Gynaecol. vol. 24. 2010. pp. 193-208.
Pinsonneault, O, Goldstein, DP. "Obstructing malformations of the uterus and vagina". Fertil Steril. vol. 44. 1985. pp. 241-7.
Hunter, RH. "Tubal ectopic pregnancy: a patho-physiological explanation involving endometriosis". Hum Reprod. vol. 17. 2002. pp. 1688-91.
Heinonen, PK. "Unicornuate uterus and rudimentary horn". Fertil Steril. vol. 68. 1997. pp. 224-30.
Kupesic, S, Kurjak, A. "Septate uterus: detection and prediction of obstetrical complications by different forms of ultrasonography". J Ultrasound Med. vol. 17. 1998. pp. 631-6.
Golan, A. "Cervical cerclage – its role in the pregnant anomalous uterus". Int J Fertil. vol. 35. 1990. pp. 164-70.
Airoldi, J. "Transvaginal ultrasonography of the cervix to predict preterm birth in women with uterine anomalies". Obstet Gynecol. vol. 106. 2005. pp. 553-6.
Berghella, V. "Mullerian anomalies: prospective follow-up with transvaginal ultrasound of the cervix". Ultrasound Obstet Gynecol. vol. 16. 2000. pp. 55
Fonseca, EB. "Progesterone and the risk of preterm birth among women with a short cervix". N Engl J Med. vol. 357. 2007. pp. 462-9.
Hassan, SS. "Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial". Ultrasound Obstet Gynecol. vol. 38. 2011. pp. 18-31.
Meis, PJ. "Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate". N Engl J Med. vol. 348. 2003. pp. 2379-85.
Leible, S. "Uterine artery blood flow velocity waveforms in pregnant women with mullerian duct anomaly: a biologic model for uteroplacental insufficiency". Am J Obstet Gynecol. vol. 178. 1998. pp. 1048-53.
Ben-Rafael, Z. "The association of pregnancy-induced hypertension and uterine malformations". Gynecol Obstet Invest. vol. 30. 1990. pp. 101-4.
Green, LK, Harris, RE. "Uterine anomalies. Frequency of diagnosis and associated obstetric complications". Obstet Gynecol. vol. 47. 1976. pp. 427-9.
Zhang, Y, Zhao, YY, Qiao, J. "Obstetric outcome of women with uterine anomalies in China". Chin Med J (Engl). vol. 123. 2010. pp. 418-22.
Erez, O. "Trial of labor and vaginal birth after cesarean section in patients with uterine Mullerian anomalies: a population-based study". Am J Obstet Gynecol. vol. 196. 2007. pp. 537 e1-11.
Homer, HA, Li, TC, Cooke, ID. "The septate uterus: a review of management and reproductive outcome". Fertil Steril. vol. 73. 2000. pp. 1-14.
Golan, A. "Congenital anomalies of the mullerian system". Fertil Steril. vol. 51. 1989. pp. 747-55.
Ravasia, DJ, Brain, PH, Pollard, JK. "Incidence of uterine rupture among women with mullerian duct anomalies who attempt vaginal birth after cesarean delivery". Am J Obstet Gynecol. vol. 181. 1999. pp. 877-81.
Demaria, F. "Preterm torsion of a gravid uterus didelphys horn of a twin pregnancy". Obstet Gynecol. vol. 106. 2005. pp. 1186-7.
Daly, DC, Maier, D, Soto-Albors, C. "Hysteroscopic metroplasty: six years' experience". Obstet Gynecol. vol. 73. 1989. pp. 201-5.
Rechberger, T, Monist, M, Bartuzi, A. "Clinical effectiveness of Strassman operation in the treatment of bicornuate uterus". Ginekol Pol. vol. 80. 2009. pp. 88-92.
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- Mullerian Anomalies in Pregnancy
- 1. What every clinician should know
- 2. Diagnosis and differential diagnosis
- 3. Management
- 4. Complications
- What antepartum complications are associated with Müllerian anomalies?
- Ectopic pregnancy
- Miscarriage
- Cervical insufficiency
- Preterm delivery
- Uterine rupture
- Growth restriction
- Hypertensive disorders of pregnancy
- Intrauterine fetal demise
- What intrapartum complications are associated with Mullerian anomalies?
- Malpresentation
- Uterine rupture
- Labor dystocia
- Cesarean delivery
- Post-partum hemorrhage
- Trial of labor after cesarean (TOLAC)
- Uterine torsion
- 6. What is the evidence for specific management and treatment recommendations


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Airedale Terrier – After The Hunt
Gifts; Figurines, Sculptures, Statues and Trophies.
SKU: 61-003-10 Category: Airedale Tags: Beautiful Purebred Dog, Cold Cast Bronze Dog, Collectables, Dog, Figurines, Gifts, Sculptures, Statue
LIMITED EDITION OF 350 – After The Hunt Sculpture of Hunter and Dog – 10.5×6.5×10.5 plus cast base.
Also available in this breed: Windchimes, lamp, door knockers, pins/pendant, holiday ornaments, keychains and musical carousel.
Additional information
|11 lbs

subset: commoncrawl


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Who are the Twa People?
The Twa people are an African ethnic minority who can be found around the Great Lakes Region of Central Africa. They are sometimes referred to as the "forgotten people," since Twa society and culture has been heavily repressed by larger and more powerful ethnic groups. Some people have expressed concern about the survival of the Twa people in the highly unstable political climate of Africa, since they are vulnerable to discrimination, land pressures, and other issues.
In Rwanda, Uganda, the Democratic Republic of Congo, and Burundi, the Twa make up around one percent of the population. Overall, it is estimated that there are around 80,000 Twa people in Africa altogether. This small ethnic group lived in Central Africa long before other African peoples colonized the region, and they are part of a larger group of African peoples who are classified as pygmies due to their characteristic small statures. Generally, the term "pygmy" is not used, and ethnologists prefer to identify various pygmy groups by their unique ethnic groupings, as "pygmy" can be perceived as derogatory.
The traditional life of the Twa is semi nomadic, with a hunter-gatherer approach to finding food. Through thousands of years of existence in the Great Lakes Region, the Twa people have developed their own unique culture which includes dances, music, and religious traditions which vary from those of other ethnic groups in the region. As large, dominant tribes moved in, Twa culture began to undergo dramatic shifts.
Many ethnologists are concerned about the Twa people because they have been deprived of their traditional hunting and gathering grounds. Many modern Twa are landless, poor, and heavily discriminated against because of their different ethnic identity and obvious physical differences. Twa often have trouble accessing education, health care, and other vitally needed services, and they are excluded from society in general in some parts of their traditional homeland. They also face problems with violence; during the genocide in Rwanda, for example, it is estimated that up to 30% of the Twa population may have been murdered.
Members of this ethnic group are sometimes also referred to as the Batwa; as an ethnic minority, they often struggle for recognition and prominence with global organizations which are supposed to protect minorities and refugee populations. The United Nations estimates that the Twa population of Africa has undergone a steep decline, and that this ethnic group has experienced a great deal of disruption as a result of forcible displacement from their land and contact with the wars and violence which plague some parts of Africa.
Discussion Comments
@pastanaga - The Twa people aren't one homogeneous group and it's kind of rude to call them pygmies, particularly since a lot of them aren't.
As I understand it, there is a branch of the people who live in the forest and are shorter than average, but the majority live in villages on the plains and, in terms of height, you wouldn't look twice at them in an average town.
@indigomoth - I believe in the value of diversity as well, but unfortunately, the world doesn't work that way. It's the nature of evolution, it applies to cultures as well. If people can't adapt to the way the landscape around them is changing, then they won't survive.
I don't want to sound harsh, and I think in an ideal world everyone would try to conserve different cultures as much as possible, because that's good for everyone. But this isn't an ideal world. And it seems like a lot of folk try to cling to the ways their people did things in the past, which doesn't work in a modern world.
I don't know if the pygmy people are doing this, but it wouldn't surprise me.
It's so sad when a group is treated badly because they are a minority. It seems to happen a lot more when they are physically and visually different from the other groups around them too. I guess people are really superficial when it comes right down to it and think that a difference in height or skin color can make a difference to a person's worth.
I hope that the Twa people can find an equilibrium with the people around them so that their culture and people survive. The world is a better place when it cherishes diversity.


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Stardew Valley is a game that doesn't need any introduction. It is one of the most exciting and fun-filled game you will ever try. With various interesting elements, the game can provide you with hours of entertainment. But the fact that we humans are never satisfied and always looking for more, it is nothing surprising if you get bored of the game after some time. In case, you have already hit that point and looking for the best alternatives for Stardew Valley, you are in the right place. In this article, we are going to suggest you best alternatives of Stardew Valley.
List of 10 Best Games Similar to Stardew Valley
No need for you to search the internet as we have already prepared the list for you. Check it out.
#1. Fantasy Life
Fantasy life is a fun-filled game that is all about living and leading a happy fantasy life in the virtual world. With cute graphics and a vast open-world to explore, you are surely going to enjoy playing this game. The game also offers you various classes each of which has different activities and traits that add to the overall value of the game. The best thing about the game is that you get to pick the life you want to play and also enjoy the benefits and skills that come with the life you have chosen.
- Price: Buy ($57.90)
- Publisher: Nintendo
- Genre: RPG, Simulation
- Mode: Single Player
- Platform: Nintendo 3DS
#2. Animal Crossing: New Leaf
Animal Crossing gives you the platform to play and enjoy a full life simulation. In the game, you are put in a fantasy city-building where you get to lead your life the way you choose. The game has got interesting gameplay that is going to keep you hooked to it for hours. In the game, you start off as a Mayor of a small town which you have to turn into a tourist attraction. In short, this game is all about managing your town and people.
- Price: Buy ($19.99)
- Publisher: Nintendo
- Genre: Social Simulation
- Mode: Single Player
- Platform: Nintendo 3DS
#3. Farm For Your Life
Unlike other farming games, this game is not boring or repetitive. That's because the game is a mix of a lot of different genres. In the game, you grow your farm and protect it from zombies and undead by making use of your defenses. All the features together make this game an exciting one to play.
- Price:Buy ($5.50)
- Publisher: Hammer Labs
- Genre: RPG, Tower-defense, Simulation
- Mode: Single Player
- Platform: PC, Linux, Mac
#4. Wild Season
Wild Season happens to be the perfect alternative to Stardew Valley because it provides you with similar gameplay. You start off in the game as a young farmer whose main objective is to buy new land in the rural town. But for that, you need to overcome various obstacles and once that is done, you need to use farming tools to sow the land and start your farming story. When playing you will find yourself engrossed in the story.
- Price: Buy ($8.00)
- Publisher: Quickfire Games
- Genre: Simulation
- Mode: Single Player
- Platform: PC, Mac, Linux
#5. Staxel
Another great alternative to Stardew valley is Staxel. This is also the ideal game for the ones who love to play Minecraft. This RPG game provides you with a world like Minecraft but with social and farming aspects like Stardew Valley. If you like fast gameplay then you are surely going to enjoy playing this game.
- Price: Buy ($19.99)
- Publisher: Humble Bundle
- Genre: Simulation
- Mode: Single Player
- Platform: PC
#6. Moonlighter
This is basically a management game where you play the role of a shopkeeper but by the night's fall you turn into a warrior. The game has also got an interesting storyline. It is the perfect combination of family drama, destiny, and anguish. If you loved playing Stardew Valley, there are full chances that you are going to love this game as well.
- Price: Buy ($19.99)
- Publisher: 11 Bit Studios
- Genre: Action role-playing game, Economic simulation
- Mode: Single Player
- Platform: Nintendo Switch, PlayStation 4, Xbox One, Microsoft Windows, Macintosh operating systems, Linux
For Game Lovers: 10 Best Hamachi Alternatives for Virtual LAN Gaming
#7. Don't Starve Together
This is the sequel to the popular game Don't Starve and is also one of the best alternatives of Stardew Valley. If you like adventure then you are not going to get disappointed by this game. Your main aim in the game is to stay alive as long as you can. Apart from that you also get to gather resources, explore the surrounding, develop structures and craft items in order to survive in the wretched hands.
- Price: Buy ($5.99)
- Publisher: Klei Entertainment
- Genre: Action-adventure game, Survival horror
- Mode: Single Player, Multiplayer
- Platform: PlayStation 4, Microsoft Windows, Xbox One, macOS, Linux
#8. World's Dawn
The next best alternative to Stardew Valley is World's Dawn. In this game, you get the chance to spend your life in a village located beside the sea where you grow crops, go fishing and raise livestock. You can also go for hunting. You can get all the features you expect to get from a life simulation game. The best part is that you get to decide what you want in the game. You can either go for hunting or tend to your crops, the choice is yours. The game also promotes social interaction with 32 different townsfolk.
- Price: Buy ($9.99)
- Publisher: Wayward Prophet
- Genre: Farming Simulation
- Mode: Multiplayer
- Platform: Microsoft Windows
#9. Voodoo Garden
Voodoo Garden is a very popular game where players grow trees, herbs, plants and more at a relaxing pace. This game is suitable for the ones who are looking for time pass gaming. If you love to play simulations and life-based games then this game could be the perfect option for you. In addition, the game also comes with many unique features and twists. The game definitely has something in store for all its players.
- Price: Buy ($1.49)
- Publisher: Liu Lidan
- Genre: Farming Simulation
- Mode: Multiplayer
- Platform: Microsoft Windows
#10. Rune Factory 4
Lastly, we have Rune Factory 4 which is an interesting alternative to Stardew Valley. This game comes with great RPG elements and farming simulation. This unique game is sure to keep you hooked to the game. Instead of a small farm area, you get a whole town to manage and work towards its development. Other than that the game also provides you with some interesting elements like discovering evil forces in dungeons and defeating them. The game is really an interesting one with many exciting elements in it.
- Price: Buy ($29.99)
- Publisher: Xseed Games
- Genre: RPG, Simulation
- Mode: Single Player
- Platform: Nintendo 3DS
We hope you liked this list of games like Stardew Valley, If you like Terraria, here are some very interesting alternatives.
Conclusion – Play Similar Games to Stardew Valley
So these are 10 of the best games like Stardew Valley. If you have played Stardew Valley then it's guaranteed that you are going to like these games as well. You don't have to take the word for it. Try out the games and you will know it for yourself.


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During last month's Blood In the Snow Canadian Film Festival (BITS), I had the pleasure of meeting Mexican-Canadian film director extraordinaire Gigi Saul Guerrero. Over the past few years, Guerrero has been making waves in the genre film scene not only as director but also as a writer. Her recent successes include the short films Dia De Los Muertos, Madre de Dios, and Bestia, which won Best Short at BITS this year.
HM: There are so many questions I could ask, but let's start with some general details for those who do not know much about your work. Please share who or what are some of your early influences in your career?
Gigi Saul Guerrero (GSG): There was always something about visual story telling that caught my attention since childhood. I had an obsession with classical animated Disney film when I was a kid, all I would do was sit there and press forward and re
wind to find continuity mistakes. Right?! That doesn't sound fun at all! But it was my most favourite thing to do, and boy did I find mistakes in films like Bambi (1942). I never considered to become a story teller myself, I just enjoyed immersing myself in a film growing up. But it wasn't until I was 16 years old where Children of Men (2006) changed my life! Literally… I walked out of that theatre saying out loud, "I want to be a filmmaker, I want to tell stories like that!". From that moment on my maturity for films grew! I started watching everything Cuaron, Iñarritu, and Del Toro had made. Then slowly moved on to Robert Rodriguez and Tarantino's early work! Yup my mind was set on what I wanted to do for the rest of my life.
HM: I understand you considered being an animator and a cartoonist before settling into mainly being a filmmaker. I assume your creative, artistic self has a lot to do with the visuals we see in your films, yes? Care to talk a bit about your creative process… writing, directing, and so on?
GSG: Like I mentioned above, animated films is what first attracted me into story telling. I was sure I was going to be an animator/cartoonist. Growing up painting and drawing really has been a huge aid for me when explanting my vision for our films. Storyboarding and simply concept art I've made doesn't just help my crew understand the vision, but it gives me clarity on the voice I want to audiences to listen. Another process I love to do before starting a new project is listening to scores, music that has the genre, style and/or message that will inspire a story. I grew up in a very musical family (sister is an Opera & Jazz singer, and my Father plays violin and cello) so hearing classical music everyday helped create this process for me!
HM: Being a female filmmaker may still have its challenges, but I believe you are making waves in the industry. I also like how much of our Latin American culture you include in your stories. Are your raíces (culture) always at the forefront of most of the work you do?
GSG: Gracias hermosa!! Hehehe thank you!! You know yeah it can be challenging being a female in one of the toughest and most competitive industries … but that's not to say that life is already challenging. At the end of the day we are going to face obstacles in whatever we choose to pursue, one can't look at it and a" bad luck" or "negative thing" – we just use that obstacle to force ourselves to work harder.
For me my latin roots are the most important thing. I feel blessed everyday to be Mexicana, hahaha Chilanga de corazon! Born and raised in the world's most beautiful country filled with rich traditions and culture. Leaving Mexico at a young age was a tough transition, especially working on fitting in an English speaking country (Canada). I had to learn a new language fast, new way of living, everything! So I never wanted to lose touch of my roots, because after all it's what makes me who I am today. Hehe I guess that's where the description to my films – "TEX-MEX HORROR" came from! It's probably the best way to describe not only my work, but me!
HM: I noticed you mention your abuelita on social media on various occasions; giving credit where credit is due. How have the women in your family/life inspire you in your filmmaking career?
GSG: I consider myself so Lucky to live with three incredible strong, inspiring, talented and charming women. My beautiful and talented sister, my intelligent and caring mom, and of course Badass Abuelita. They have taught everything there is to know about being a good human, and I couldn't ask for better women in my life to inspire me to work hard everyday. Not to mention Mexico has some of the most gorgeous and insanely unique inspiring women, who influenced me growing up: Frida Kahlo, Maria Felix and Lola Beltran just to name a few. But who I am today doesn't just give credit to the ladies sin my life…. but to my Father as well. He is the reason why my family and I are happy everyday of our lives, he is the reason I chase my dreams and never quit. La Familia es todo.
5. At BITS you mentioned your upcoming series La Quinceañera, as well as working on some CAPCOM game content. How are these projects going… any updates you can share now?
GSG: IT'S GOING AWESOME! CAPCOM has been one of the biggest highlights of my career, writing a new video game for such a big company was intimidating at first, also in such a competitive industry where the fans are intense! I didn't want to mess this up… Working at this new gig has given practice in my writing skills and also learn how to use my creative imagination in new ways! I am so used to telling ONE STORY, ONE POINT OF VIEW from start to finish. But in video games there are many outcomes, many decisions that are manipulated by the audience (the player). I have to remember that there isn't just one story to be told, but there can be many ways to tell the same story because we don't know what the player is going to do. SO excited to see what people think when this game gets announce in 2018!
As for the Warner Brothers show La Quinceañera THERE'S HUGE NEWS HAPPENING IN THE FIRST QUARTER OF 2018! I wish I could share more but… I promise its huge and exciting! This 7 episode series really has been the best thing that's happened for my team – Luchagore Productions. I can't wait for the world to see this.
With the many projects, great creativity, and amazing energy, I think we can safely say this is only the beginning for Guerrero and team. I'm for one very much looking forward to seeing what she delivers next! Stay tuned for more…


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ARxIUM Privacy Policy
Last Updated: April 4, 2018
ARxIUM values integrity and transparency and we appreciate your trust in our company. We have outlined many of the details within our Privacy Notice that are of importance to our customers. The main reason for our Privacy Policy is to protect your privacy and personal information. Our Policy explains our practices pertaining to the collection, use and disclosure of personal information obtained through our website. This privacy policy applies to the ARxIUM group of companies including: ARxIUM Inc. a Canada corporation and ARxIUM, Inc. a Delaware corporation (collectively "ARxIUM").
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The amount and type of information we receive depends on how you use our website. Your user ID and password may be temporarily stored in a cookie allowing us to free resources for other customers if you are logged on but not actively using the portal. Data stored in the cookie will allow you to automatically log back on without re-entering your information during the same session. User ID and password information is used only to identify and access your account to provide the requested services. Cookies and all data stored in the cookie will expire once you log off our website.
We provide e-mail links on our "Contact Us" page that allow you to contact us directly with any questions or comments regarding our company, products or services you may have. We may receive a confirmation when you open any e-mail that we send to you, if your computer supports such capabilities. If you send us any e-mail, we will retain such e-mail and your e-mail address for response. We also may compare our customer list to lists received from other companies, in an effort to avoid sending unnecessary or duplicate messages to you.
We provide you with a means to consent to receiving information from us periodically regarding our company, products and services. Should you decide to give us your consent to provide you with this information, we will store your e-mail address and the date and time of your consent. You may withdraw your consent to receive communications at any time by using the unsubscribe link on the consent page. We also include unsubscribe instructions at the bottom of each e-mail we send.
If you access or use our website without using our customer portal, we do not collect or store information that will identify you. However, we may collect and store other information such as the name of your Internet Service Provider, the referral website, requested pages including date and time of requests and other information to generate statistics and measure site activity to improve the usefulness of customer visits.
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How can you earn enough points to travel as a family? The release of the Chase Sapphire Reserve® means now is the perfect time to talk about how Ultimate Rewards can facilitate family travel. There are several features of the Sapphire Reserve that make it the ideal card for traveling as a family.
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Additionally, Ultimate Rewards are known to transfer into destination accounts faster than other transferable points currencies, placing you in a better position to take advantage of award availability as soon as it opens up (one of the hardest factors of family travel using points and miles is finding sufficient award space).
Fantastic Signup Bonus with The Sapphire Reserve
The Chase Sapphire Reserve® currently offers 60,000 bonus points after you spend $4,000 on purchases in the first 3 months from account opening. That's $900 toward travel when you redeem through Chase Ultimate Rewards® The value of those Ultimate Rewards can be extended by transferring them to one of Chase's transfer partners at a 1:1 ratio.
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Additionally, the Sapphire Reserve covers you for Lost Baggage, Baggage Delay, Travel Accident, and an Emergency Medical and Dental Benefit. The terms and conditions for all the perks on the Sapphire Reserve are complex and require a careful study to ensure you understand exactly how they work. For details, see our recent post comparing the benefits on Chase's two Sapphire cards, or view the Sapphire Reserve Guide to Benefits.
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Combining Ultimate Rewards points with a household member
Chase's rules for transferring Ultimate Rewards points are strict and not to be ignored. If you do, you risk having your credit card shut down, and you'll lose your points.
If we suspect that you've engaged in fraudulent activity related to your credit card account or Ultimate Rewards, or that you've misused Ultimate Rewards in any way (for example by buying or selling points, moving or transferring points with or to an ineligible third party or account, or repeatedly opening or otherwise maintaining credit card accounts for the sole purpose of generating rewards) we may temporarily prohibit you from earning points or using points you've already earned. If we believe you've engaged in any of these acts, we'll close your credit card account and you'll lose all your points.
You can, however, transfer Ultimate Rewards points to a household member that resides at your current address. The language is sufficiently vague that this can be a spouse, immediate or extended family member, or partner. If you are in doubt, call Chase and clarify the matter, the consequences of getting it wrong and losing your points is a bad scenario to comprehend.
Final Thoughts
While that may feel like a lot to digest, we haven't covered the $300 Annual Travel Credit, bonus points on Travel & Dining, or $100 Global Entry Statement Credit, all of which we touched on in our initial review of the card.
It's worth noting that this card is subject to Chase's 5/24 policy, and you may have trouble getting approved if you've opened up more than 5 new personal credit cards in the previous 24 months.
Trying to plan a trip for your family using points and miles can be a daunting task, but focusing on a highly transferrable currency like Ultimate Rewards opens up an entire toolbox of options and perks that aren't available through other programs.
With its massive signup bonus and fantastic benefits, the Chase Sapphire Reserve® is the ideal card to facilitate family travel.
The comments on this page are not provided, reviewed, or otherwise approved by the bank advertiser. It is not the bank advertiser's responsibility to ensure all posts and/or questions are answered.


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Another year is almost over and it's beginning to look like we're stuck in a perpetual time loop. It's been another crap year with lockdowns, COVID-19 in its various incarnations, and I've had two falls injuring both knees, which I am only now slowly beginning to recover from. After all this, it's not easy to end the year on a cheerful note and stop being a 'Debbie Downer!'
To be honest with you, I've become physically and emotionally drained, and I'm sure I'm not the only one! 2021 has been a very long, exhausting year, a year where I have really had to push myself to get any writing done, finding my motivation somewhat lacking (and that's another post in itself). But having said that, I did manage to publish two novellas, so it's not all bad! 😉
If nothing else, COVID-19 has revealed what's important in life, which for me is my health, family, and writing. After having read The Relaxed Author by Joanna Penn and Mark Leslie Lefebvre, I believe that as an indie author, the writing is the main thing, and that there is nothing wrong with taking the slow and steady approach.
It's also been a time to take a step back, analyse, and enjoy the little things. Going out to be amongst nature can be beneficial both physically and mentally. Ever since I was a kid, this has always been my 'escape,' and the opportunity to let my imagination run wild.
The epidemic, so far, has taught me not to take anything for granted and to take one day at a time. The future is unpredictable, but it has always been that way. We learn to adapt. The new year brings with it new opportunities and a chance to start afresh.
I hope you have a happy Christmas, and a safe and healthy new year! Here's to new beginnings!
What things have you done to cope during 2021? Do you have any big plans for the new year, or do you intend to take things one day at a time?


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Dear Bolehians,
Development of a custom bolehvpn app on android and iOS is in works.
However we are focusing on the PC application at the moment before going into mobile application.
There are no ETA on when it will be done. But once a timeline has been agreed and establish we will update.
Thank You


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This is a custom-tailored program designed to help large law firms increase the capacity of their lawyers to innovate. It can include one or more of the following components:
Innovation Keynote: We can deliver a keynote about fostering innovation in lawyers–a crisp, riveting 90 minutes. Introduces lawyers to the latest science–in a completely engaging way.
Innovation Workshops: We can conduct an introductory "Welcome to Innovation" 2-hour teaser workshop, or a half-day "Legal Innovation Laboratory" workshop.
Horizons Program: We work with your firm to custom-design a multi-faceted program to bring out the inner innovator in your lawyers, using the latest behavioral science findings, and supported, of course, by our unique and extensive library of personality data on what makes lawyers tick.
Interested? Call LawyerBrain.


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Looks like ask.com is throwing in the towel
Month: August 2010
Google Voice for everyone
I've had Google Voice since the very beginning. I, for one, LOVE getting my voicemails in my eMail… being able to have my phone AUTOMATICALLY go to voice mail after a certain time… what is NOT to love about Google Voice?!?!
Wave Good bye!
We barely new ya! But I am sure we will be WAVEing somewhere else on Google… like in Google DOCS already? And perhaps "Google Me" – which is coming soon!!?! I for one, gave up on it very quickly when I saw how slow and cumbersome and awkward it was. I am starting to get a little tired of being an unpaid ALPHA tester for Google…
The WAR between Google and Facebook
I disagree that Google is "struggling" to survive here, but this is a good synopsis of Google vs Facebook and the issue of the the latter's LIKE button.
Trademark Terms In Adwords
Be careful about buying trademarked words in AdWords!
"Google said today any trademark owner that believes a third-party ad in Europe confuses users about the origin of the good or service can also file a complaint. The ad will be removed if Google agrees, it said."
via Trademark Terms In Adwords Text Extending to Canada, UK, Ireland @SEWatch.
Google, Verizon Net Neutrality Talks
There is a BIG RUMOR that Google and Verizon are teaming up to deal with the FCC and Net Neutrality… this article seems to suggest they are only after one thing… APPLE! At this point it is JUST a rumor!
Google, Verizon Net Neutrality Talks Raise Ire — Net Neutrality — InformationWeek.
Here is another article on this: http://mashable.com/2010/08/05/google-verizon-net-neutrality/
Hard to know WHAT they are doing until there is an announcement perhaps next week!


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Cube Mosaic is an After Effects project, resolution: 1280×720. It can be used as an Opener, Logo Intro, Title, or whatever you want!
- VIDEO tutorial!
- Easy to change color!
- No plugins required!
Sound Effects included (whooshes, impacts…), background music is from Audio Jungle here is the link: http://audiojungle.net/item/outta-space/154992
Please rate this project if you like it.


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Five tips on taking interesting photos at a museum2 min read
Most people who visit a museum feel like taking a photo of every possible exhibit on display. This often consumes a lot of your time and your photos don't seem to capture the real beauty and greatness of the exhibits. For many people, it is quite hard to take a good photo at a museum, but here are some tips that can help you do a better job.
1. Think about your equipment
Using a professional camera leads to better photos, but you don't need expensive equipment to take good photos at a museum. You can use one or two lenses in a range of 24mm to 70mm or a smartphone with a nice camera. What you do need to be careful about is whether you can use flash at the museum or not. In some museums, it is prohibited to use flash as it can damage the exhibits and you certainly don't want to do that.
2. Pay attention to lighting
Light plays an important role when taking photos and museums don't always have the best lighting so you should make sure to pay attention to this. Before taking a photo, you should find the source of light and see how the light rays fall on the exhibit and find the best angle to take a photo from accordingly.
3. Consider having people in your photos
Most people like to take photos of individual exhibits or a few pieces without any people around them. However, your photos can be more interesting if you consider including people while observing the exhibits. This will make your photos look spontaneous and unique and it can give you a different perspective on a certain exhibit.
4. Take a look at the interior of the museum
It is obvious that most visitors want to see the exhibits at the museum, but there may be other amazing things to see and take a photo of at the museum. Many museums have specially decorated interiors with astonishing ceilings or columns and staircases. Instead of focusing on just one exhibit, you could take a photo of a whole display room or a few exhibits in one frame. A photo of a large room with good lighting taken from a specific angle will definitely be more interesting than just another photo of an exhibit and the wall behind it.
5. Consider photographing the museum's architecture
Many museum buildings are works of art themselves. Museum architecture is quite special as museums must be able to host different exhibitions and keep the exhibits in proper conditions. Therefore, before entering a museum, take a moment to look around and pay attention to the museum's architecture. Maybe you will want to take a photo of the wonderful building before you move on to taking photos of the exhibits. Even if you need to crouch or lie down on the ground to capture the whole building, it will surely be worth the effort.


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According to studies, 93% of people who conducted research on a review site also make purchases from the business they look up, Restaurants being the highest converters on Yelp at 78%. Yelp gets a lot of visibility on Google organic search results. It is important that you are taking full advantage of Yelp for your Business.
Find and Claim your Business Page - Respond to viewers as the business owner and Measure visitor activity on your page. According to Yelp, "$8,000 is the average annual incremental revenue generated by a business claiming its free Yelp Business Page." Also, "$23,000 is the average annual revenue from Yelp as reported by Yelp advertisers." Sounds like it is worth the time to claim your Yelp Business Page, if nothing else you have access to your Yelp Analytics.
Free Tools from Yelp - Allows you to fully fill out your business page with business name, address, phone, website, etc. It also allows you to respond to reviews as the business owner. You can upload photos to show off your products and create a Yelp Deal.
Yelp Deals are, "...prepaid vouchers that offer consumers an attractive discount (e.g., $10 for $20) at your business. It's an easy way to give consumers who are already searching for a business like yours an incentive to choose you over the competition. Yelp users can buy your deal or gift certificate directly on your business page via the Yelp website or mobile app."
Yelp Analytics - You get business analytics to track visitor engagement and customer leads from your Yelp Business Page.
Finally the free subscription comes with a mobile app to get all of this information on the go.
Self Service Advertising - Wait 30 days from when you sign up to do any advertising. More than likely Yelp will give you $100 or more to test out the self service advertising platform. This level of service from Yelp will remove competitor ads from your business page. You also get the ability to use Yelp SeatMe.
Yelp SeatMe gives restaurants and bars tools for front-of-house management. Yelp Seatme also allows you to capture online reservations without the cover fee, reservations can be taken on Yelp and your own website. Plus you can let people waiting for a table know their table is ready with a quick ping from Yelp SeatMe.
Full Service Yelp - In addition to all the services you receive for the free version of Yelp, the full service version can add a call to action, a slideshow or restrict competitor's ads for a fee of course.
Yelp Review Badges - "You have a website, and you want to show off your Yelp love. Just copy the HTML code next to any of the buttons and paste it into your website. The review counters will update automatically every time a Yelper writes a review of your business."
I got a bad review, what do I do? If your customers have posted legitimate complaints, don't be afraid to publicly apologize, be sincere. Also, Describe what has been done to correct the problem.
Lastly, you get a weekly update of your analytics sent to you by email. Easily keep track of how many impressions and clicks you get for your Yelp Business Listing.


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Ever wish that React had a CLI? Something to let you generate a component, along with related files like SCSS or Redux ducks or whatever else.
You can build your very own, with Bash and a couple lines of script. I'll show you how in this post.
Here's what our CLI will do:
- create the component folder
- add a barebones component file to the folder
- add a blank SCSS file to the folder
- include the SCSS in the component
If you're on a system like Mac or Linux this is all possible with the shell. (Probably Windows too, but I don't know enough about Windows shell).
You might already know how to create a directory (
mkdir path/to/dir) and how to create an empty file in it (
touch path/to/dir/thing.scss).
A Bash script is nothing more than a bunch of shell commands put into a file. So if you create a new file, say,
make_component.sh and just put those commands into it, you've just made the beginnings of your own CLI.
Follow along! Create a new blank file called
make_component.sh and put this in it:
mkdir -p src/components/Whatever
touch src/components/Whatever/Whatever.scss
So far all it does is create a hard-coded directory "src/components/Whatever" and an empty
Whatever.scss file in it (the
-p flag creates the whole tree of directories if they don't already exist). We still need to figure out how to:
- parameterize the name of the component in those commands
- copy in a template component file
- modify it to match the component name
So how could you parameterize the component name? Well, Bash lets you access the command line arguments inside your script – as
$1 for the first one,
$2 for the second, etc. So let's say you'll call your script like:
./make_component.sh Button
The script would have a access to a
$1 variable assigned to "Button", which you could use all over the place. Using that in the file you've got so far, it would look something like this:
mkdir -p src/components/$1
touch src/components/$1/$1.scss
Now you need to make a template component file and store it somewhere. Your home directory is a good spot, maybe in a subfolder. Let's say you make a folder with
mkdir ~/code_templates and a file at
~/code_templates/component.js that looks like this:
import React from 'react';
import './COMPONENT_NAME.scss';
function COMPONENT_NAME() {
return
Hello
;
export default COMPONENT_NAME;
This is super barebones of course, but do whatever you like here. The important thing is that you use distinct strings for the
COMPONENT_NAME that will be easy to search-and-replace.
Then, to search and replace from the shell you can use
sed (short for string editor). You can pass it a regular expression to replace all occurrences of a string in a file. So back in
make_component.sh, you can add that
sed command to the end so the whole thing would look like:
mkdir -p src/components/$1
touch src/components/$1/$1.scss
sed -e "s/COMPONENT_NAME/$1/g" ~/code_templates/component.js > src/components/$1/index.js
That command is a mouthful but here's what it does:
-e flag means "execute this regular expression".
The next argument, in quotes, is the regular expression
"s/COMPONENT_NAME/$1/g". We're using double quotes so that Bash will replace
$1 with our component name. (If we used single quotes, Bash would not interpolate that string and we'd end up with a literal "$1" in our file. Unlike JS, single and double quotes mean different things in Bash!)
The way to read this regular expression is "substitute (
COMPONENT_NAME with
$1, globally ". The
g means "global", and it refers to globally within a single line because sed only looks at a single line at a time. Without the
g there, it would only replace the first occurrence on each line, so if you had a line like
const COMPONENT_NAME = function COMPONENT_NAME() the result would be
const YourThing = function COMPONENT_NAME() – it would skip the second occurrence.
The next argument,
~/code_templates/component.js, is the file to that sed will operate on.
By default
sed prints out the result to standard output. It does not modify the original file. Normally, standard output would appear as text printed to the console, but the
> redirects that output to a new file located at
src/components/$1/index.js. The
> will overwrite the file if it exists, so be careful!
That's pretty much it for the script. All that's left is to mark the script as executable (with the command
chmod +x make_component.sh) and you're good to go!
It's not fancy, but it's your very own DIY customizable CLI :) Feel free to make it your own. Leave a comment with any cool customizations you come up with.
Learning React can be a struggle — so many libraries and tools!
My advice? Ignore all of them :)
For a step-by-step approach, check out my Pure React workshop.
Learn to think in React
- 90+ screencast lessons
- Full transcripts and closed captions
- All the code from the lessons
- Developer interviews
Dave Ceddia's Pure React is a work of enormous clarity and depth. Hats off. I'm a React trainer in London and would thoroughly recommend this to all front end devs wanting to upskill or consolidate.


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If you have been playing Grand Theft Auto 5 for the past few days, then you are certainly planning to get 100% completion in the game, but this might sound like an impossible task. The truth is that it's not really the case, and we are here to tell you how to get 100% completion in GTA 5.
So let's check out the list of things that you have to do (generally, completing missions) in order to get there:
1. Complete all the Story missions (there's 69 of them for all the characters. What a nice number!)
2. Complete 42 specific Hobbies and Pastimes missions:
– the Shooting Range missions (you need Bronze at least)
– the Flight School missions (again, you need Bronze)
– Street races (5)
– Sea races (4)
– Off-road Races (6)
– Lap Dance at Strip Club
– Parachuting
– Sports (Gold, Darts, Tennis, and 3 Triathlon Races)
3. Complete 20 specific Strangers and Freaks missions:
– Pulling Favors
– Pulling Another Favor
– Pulling Favors Again
– Still Pulling Favors
– Pulling One Last Favor
– Shift Work
– Paparazzo
– Paparazzo 2
– Paparazzo The Partnership
– Paparazzo Reality Check
– A Starlet in Vinewood
– Grass Roots – Franklin
– Grass Roots – The Smoke-In
– Exercising Demons – Franklin
– Far Out
– The Final Frontier
– Risk Assessment
– Liquidity Risk
– Targeted Risk
– Uncalculated Risk
4. Complete 14 Random Events
5. Complete 16 Miscellaneous missions
And this is it! After you do this, you will have 100% completion in Grand Theft Auto 5. It's not too difficult as it doesn't involve getting strange achievements, but it certainly is time consuming. The good thing is that the game is great, so we'll have fun doing it!


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Back Pain
Back Pain Specialist
At his Hampton Courts-based practice, Dr. Eliel Nataki has helped many patients who suffered from back pain. Highly regarded as one of the leading back pain specialists in Laredo, Texas, Dr. Nataki is both honored and pleased to serve the city.
- 956-727-7246
Back Pain Q & A
by Eliel Nataki, MD
Is All Back Pain the Same?
Back pain can take many different forms, ranging from a general soreness in muscles to shooting, sharp pains. Sometimes the pain comes and goes, and sometimes it's constant. It may occur anywhere in the back.
How Is Back Pain Treated?
Several different treatments are available for back pain. Depending on the precise location and type of pain that a patient is experiencing, a doctor might recommend:
- massage therapy
- over-the-counter medication
- prescription medication
- chiropractic treatments
- other treatments
In rare cases, surgery is necessary. Operations are necessary only in the most severe cases, though; usually, back pain can be managed with non-invasive treatments like those listed.
What Should Patients Look for When Choosing a Back Pain Specialist?
When selecting a doctor, patients who suffer from back pain should first look for a highly experienced physician who specializes in back pain management and treatment. Additionally, patients may want to seek out someone who has an office near them, as back pain treatments can take several appointments. Going to a doctor who is conveniently located makes it easy to get to and from appointments.
Who Should Consider Seeing a Doctor for Back Pain?
Anyone who is suffering from pain or discomfort in their back may benefit from seeking medical treatment. Doctors are able to provide treatment for lower-, mid- and upper-back pain caused by both musculoskeletal and neurological issues. Anyone who is unsure whether they should see a doctor for their back pain ought to make an appointment for a consultation.
Is Back Pain Treatment Covered by Insurance?
In many cases, back pain treatments are covered by health insurance. All insurance policies are different, though, so patients should contact their insurer to find out whether their treatment will be covered and whether they need a referral to see a back pain specialist.


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Since landing at British Vogue, Edward Enninful has cemented himself as one of the greatest editors of our time. This year alone, the magazine's front covers have featured everyone from Naomi Campbell to Lila Moss. Gisele Bündchen blew us away with pure glamour on last month's cover. The publication's latest cover conquest? None other than global sensation Beyoncé who returns to the British fashion bible for July 2022. Photographed by Rafael Pavarotti, the icon sits on a horse for the grand cover shot wearing a look from Alaïa's Fall 2022 collection and a headpiece from a special collaboration between Harris Reed and milliner Vivienne H. Lake.
British Vogue's latest caused a great divide on our forums. "Tacky," described WinstonH20 the moment the cover dropped.
"Not good. Beyoncé's best Vogue cover is still her first American Vogue because it's simple not this tacky," echoed caioherrero.
"Wow, this is even tackier than Beyoncé herself," MDNA chimed in.
[ Not a tFS forum member yet? Click here to join! ]
Marc10 is also underwhelmed: "I'm not crazy about the styling, it's way too early 2010s Lady Gaga. Beyoncé doesn't really carry these heavy camp fashion looks because she doesn't have a larger-than-life persona so the clothes end up wearing her."
"My energy just depletes whenever I see Beyoncé. The Kendall Jenner of musicians on magazine covers, giving us nothing and overpowered immensely here by the theatrics of Rafael Pavarotti's photography and Edward Enninful's styling," voiced vogue28.
But not everyone agreed. "The photograph has a strong Jean-Paul Goude vibe and is certainly one memorable cover," raved aracic.
"I'm obsessed with how camp this is," approved crmsnsnwflks.
See more of British Vogue's July 2022 issue and join the conversation here.
Credit: Source link


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We started this portion of our road trip with the intention of finally seeing the Franz Josef Glacier that we missed previously due to storms, land slides, fallen trees and closed roads. However, Cyclone Gita had other plans for us. So, as we headed off westbound across the south island we stopped in at Greymouth before scurrying north to avoid road closures.
There is no photographic evidence of our ferry crossing northbound. Due to the passing of Cyclone Gita the Cook Straits were very choppy with 3 to 4 metre swells. I was focused on my happy place and keeping my breakfast as opposed to trying to frame a photograph while being tossed about.
The variety of sights to see in this country is a bit much at times. Everywhere you turn there is something a bit different to enjoy. I am looking forward to the coming weeks as we push toward the northern end of the country.


text:
Saturday, September 1, 2012
Hey this is NEWS!...sad news =(
As you may have noticed The post's here on the Book Paparazzi have been getting fewer and fewer. NOT because of lack of content BUT because WERE all heading back to school. Yes, the horrible SCHOOL!
Nikki & Eileen are headed off to school once more and I, Lisseth, will be starting COLLEGE!! @_@ It kinda feels surreal. SO with school comes the Homework and the projects and the tests...so were gonna all be stressed, I know Nikki is hating that MATH already XD
PLUS on top of that we all have our own BLOGS! That just add so much more to our plates [P.S Eileen runs like 4 blogs O_O] SO with much heartache, it pains me to say...
That we are CLOSING DOWN.
NO! This is NOT GOODBYE...
it's just a break. We'll be back here SOON and hopefully with an AWESOME welcome back giveaway [Hosted by Me, here]. Their might be a post here and there once in a while BUT nothing everyday. We tried, really we did, BUT we just can't, were NOT all WONDER WOMAN, you know ;D
Yes, a break will do us all good! We'll be back with a TON of content and HAPPY! =D We thank & HUG each and every one of you for following us! HOPEFULLY you will still be here when we come back.
So until next time, BYE!
-From Lisseth, Nikki, and Eileen [Check us on our blogs!]
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