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Phase 3A COPY > Obs & Gynae 2 > Flashcards

Obs & Gynae 2 Flashcards

1
Q

With regards to screening, define ‘detection rate’.

A

The proportion of individuals who will be identified by screening test.

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2
Q

With regards to screening, define ‘false positive rate’.

A

The proportion of unaffected individuals with a higher risk/screen positive result.

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3
Q

With regards to screening, define ‘false negative rate’.

A

The proportion of affected individuals with a low risk / screen negative result.

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4
Q

Name 3 antenatal screening programmes.

A
  1. Fetal Anomaly Screening Programme (FASP): Down’s, Edward’s, Patau’s screening
    18+0 - 20+ week anomaly scan
  2. Infectious Disease Screening Programme:
    Hep B, HIV, Syphilis
  3. Sickle Cell and Thalassaemia Screening Programme
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5
Q

Name 3 Newborn Screening Programmes

A
  1. Newborn blood spot screening programme:
    CF, Congenital hypothyroidism, Sickle Cell disease, Inherited metabolic diseases (x6)
  2. Newborn hearing programme
  3. New born + 6-8 week infant physical examination screening programme.
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6
Q

Which chromosomal abnormality is Down’s Syndrome associated with?

A

Trisomy 21

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7
Q

If a child is diagnosed with Down’s syndrome, which diseases are they at increased risk of developing?

A
  • Childhood Leukaemia
  • Epilepsy
  • Thyroid disorders
  • Alzheimer’s disease
  • 40-45% have a heart defect.
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8
Q

Which chromosomal abnormality is Edward’s syndrome associated with?

A

Trisomy 18

Babies with Edward’s syndrome have an extra copy of Chromosome 18 in each cell.

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9
Q

What is the prognosis for a baby diagnosed with Edward’s Syndrome?

A
  • Most die before they are born, are stillborn, or die shortly after birth
  • Babies have a wide range of serious problems:
    > heart problems
    > unusual head and facial features
    > major brain abnormalities
    > growth problems
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10
Q

Which chromosomal abnormality is Patau’s syndrome associated with?

A

Trisomy 13

> Babies with Patau’s syndrome have an extra copy of chromosome 13 in each cell.

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11
Q

What is the prognosis for a baby diagnosed with Patau’s syndrome?

A
  • Most die before they are born, are stillborn, or die shortly after birth
  • Associated with multiple severe fetal abnormalities
    > 80% have congenital heart defects
    > holoprosencephaly
    > abdominal wall defects
    > urogenital malformations
    > abnormalities of hands and feet
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12
Q

Which screening test is used in the first trimester to screen for T21, T18 and T13?

What do the results of this test mean?

A

Combined test:

  • Nuchal translucency measurement (at 11+2 - 14+1 weeks)
  • Serum testing: PAPP-A and free b-hCG

Results: Produces two risk results: one for T21 and another for T18/T13.

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13
Q

What is the cut off threshold for offer of diagnostic testing following the combined screening test in the 1st trimester of pregnancy?

A

Cut off threshold: if the screening test shows that the chance of the baby having Down’s, Edward’s or Patau’s is less than 1 in 150, this is called a ‘Lower Risk’ result.

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14
Q

Which screening tests are offered in the 2nd trimester for T21, T18 and T13?

A

Quadruple test

  • Offered if combined screening not possible: late booker, nuchal translucency not obtained.
  • Uses serum markers only: Alpha feto protein, total b-hCG, Estriol and Inhibin A.
  • Offered at 14+2 - 20+0 weeks
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15
Q

What factors should you take into account following screening using the quadruple test (2nd trimester of pregnancy)?

A
  • Scan measurements
  • Mother’s date of birth
  • Serum markers are reported as ‘Multiples of the Median’
  • Levels of some markers are affected by ethnicity, smoking, and diabetes
  • Mother’s weight is required (as serum levels will reduce with greater blood volume).
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16
Q

What should you do following ‘Screen positive’ results (following pregnancy screening tests)?

A
  • Telephone to screening midwives
  • Appointed to fetal medicine unit within 3 days
  • Offered diagnostic test: CVS or Amniocentesis
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17
Q

What is the risk of miscarriage following CVS / Amniocentesis?

A

1 in 100 for a single pregnancy.

1 in 50 for twins.

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18
Q

What alternative is there to CVS / Amniocentesis

A
  • Do nothing
  • NIPT (Non-invasive prenatal testing) -> this is NOT available on the NHS. **unless you live in Wales & deemed to be at higher risk **
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19
Q

Describe the principles of non-invasive prenatal testing as a screening tool.

A
  • Only available in the private sector
  • Screening test analyses fragments of fetal DNA in maternal blood
  • Can be done from 10 weeks of pregnancy
  • Predicts the risk of T21, T18 and T13.
  • Predicts fetal gender
  • Up to 99% detection rate
    0. 1% false positive rate.
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20
Q

The fetal anomaly screening (ultrasound) programme offers women a minimum of 2 scans during pregnancy (NICE, 2016).
At what points in her pregnancy is a woman offered these scans? What do the scans screen for?

A

10 - 14 weeks: Early Ultrasound Scan
> pregnancy dating
> confirm viability

18+0 - 20+6:
> identify structural anomalies

The timing of the scans allows for further diagnostic tests, if required. Ensures women have time to consider decisions about continuing their pregnancy.

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21
Q

The Early USS is conducted at 10 - 14 weeks. What does this screen for?

A
  • Gestational age
  • Fetal demise
  • Multiple pregnancy
    May also reveal:
  • Fetal abnormality
  • Increased nuchal translucency
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22
Q

The mid-pregnancy scan is conducted at 18+0 - 20+6. What is it designed to identify?

A
  • major abnormalities which indicate the baby may die shortly after birth
  • conditions that may benefit from treatment before birth
  • to plan delivery in an appropriate hospital / centre
  • to optimise treatment after the baby is born
  • to provide choices for the woman and her family about continuance or termination of the pregnancy.
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23
Q

How are pregnant women screened for infectious diseases?

A

Blood test (at any stage of pregnancy where the woman presents for care).

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24
Q

Which infectious diseases are screened for in pregnancy?

A
  1. HIV: treatment can improve mother’s prognosis and reduce risk of transmission to the baby.
  2. Hep B: Look for current infection (usually chronic). This will allow for vaccination of the baby and reduce the risk of transmission to baby.
  3. Syphilis: identify infection. Treatment to prevent congenital syphilis and to prevent complications for the mother.
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25
Q

How are haemoglobinopathies inherited?

What is the chance of inheritance if both parents are carriers?

A
  • Recessively inherited

- 1 in 4 chance of disease in the baby if both parents are carriers.

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26
Q

Give an example of a quantitative blood disorder

A

Alpha & beta thalassaemia

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27
Q

Give an example of a qualitative blood disorder.

A

Sickle cell disease

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28
Q

Give a brief overview of sickle cell disorders.

A
  • Sickling disorders are variable in life. Affected people need antibiotic prophylaxis.
  • Experience painful crises when RBC sickle -> blocks capillaries and deprives tissues of oxygen.
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29
Q

Give a brief overview of alpha and beta thalassaemia.

A

Alpha thalassamia major: incompatible with extrauterine life.

Beta thalassaemia major:

  • Results in life-threatening anaemia.
  • Requires blood transfusions every 4-6 weeks + iron chelation therapy 5-7 times a week.
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30
Q

What are the aims of Sickle Cell & Thalassamia screening?

A
  • To identify women who are carriers / possible carriers
  • To test partners of screen positive women
  • To identify ‘at risk’ pregnancies
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31
Q

How is the antenatal screening for Sickle Cell & Thalassaemia carried out?

A
  • Haematological test
  • Recommended early in pregnancy (8-10 weeks), or pre-conceptually.
  • Screening and offer of diagnosis by 12+6 weeks.
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32
Q

Following a screen positive for Sickle Cell / Thalassamia, what should be done?

A
  • Appt with baby’s father to discuss partner samples
  • If both parents are carriers of significant haemoglobinopathy -> prenatal diagnosis offered
  • If father not available, prenatal diagnosis offered on maternal results only.
  • Termination of an affected foetus can be offered
  • May wait for diagnosis after birth (blood spot).
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33
Q

What are the principles behind the new-born blood spot?

A
  • Screen for 9 conditions
  • Enable early detection (before symptoms develop)
  • Early treatment to prevent irreversible damage
  • Parental consent: may decline any or all tests
  • Heel prick blood test at 5-8 days of age
  • National failsafe system to account for each baby.
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34
Q

List the 6 inherited metabolic disorders which babies are screened for.

A
  • Phenylketonuria (PKU)
  • MCADD (Medium Chain Acyl Co-enzyme A Dehydrogenas Deficiency
  • Maple Syrup Disease
  • Isovaleric Acidemia
  • Glutaric Aciduria Type 1
  • Homocysteinuria
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35
Q

What are the implications if an inherited metabolic disease (IMD) is positive on the newborn blood spot?

A
  • IMDs can result in sudden life threatening illness / lead to developmental problems.
  • Request repeat newborn blood spot if any screen is suspected to be positive.
  • Positive results: parents are contacted by a specialist nurse & referred for follow up to relevant paediatric specialists.
  • Sibling protocols to be used in future pregnancies.
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36
Q

Explain the principles behind the newborn hearing screening.

A
  • Identify profound hearing loss

- Test prior to discharge home / within 4 weeks of birth

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37
Q

How is the newborn hearing screening conducted?

A
  • Automated otoacoustic emission identifies response in cochlea to soft sounds from earpiece.
  • May need repeat test!
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38
Q

If hearing loss is suspected / identified on the newborn hearing screening, what are the next steps to be taken?

A
  • Audiology assessment
  • Initial assessment & support
  • This is designed to be a failsafe system to account for each baby.
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39
Q

When are NIPEs conducted?

A

1st: within 72 hours of birth
2nd: by a GP at 6-8 weeks

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40
Q

Why are NIPEs conducted?

A

Identify babies who need early treatment; to improve health and prevent long term disability.

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41
Q

Give 4 examples of the problems a NIPE might identify.

A
  1. Eye problems: eg congenital cataracts.
  2. Congenital Heart Defects
  3. Developmental Dysplasia of the hips
  4. Undescended testes.
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42
Q

What is ‘informed consent’?

A

The process by which a fully informed patient can participate in choices about their healthcare.

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43
Q

What is the legal term for failing to obtain informed consent before performing a test / procedure on a patient?

A

Battery (it is a form of assault).

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44
Q

Explain the concept of patient autonomy.

A
  • The right of patients to make decisions about their medical care, without their healthcare provider trying to influence the decision.
  • Allows for healthcare providers to educate the patient, but does not allow the healthcare provider to make the decision for the patient.
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45
Q

What is ‘competency’?

A

Competency: a legal term used to INDICATE that a person has the ability to make and be held accountable for their decisions.
* Technically, a person can only be declare ‘incompetent’ by a court of law.

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46
Q

Before seeking a woman’s consent for a test, treatment, intervention or operation, what 5 things should you ensure that she understands?

A
  1. The nature of the condition for which it is being proposed
  2. Its prognosis
  3. Likely consequences
  4. The risks of receiving no treatment
  5. Any reasonable or accepted alternative treatments.
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47
Q

List the 5 elements of ‘full, informed consent’.

A
  1. The nature of the decision / procedure
  2. Reasonable alternatives to the proposed intervention
  3. The relevant risks, benefits, and uncertainties related to each alternative.
  4. Assessment of patient understanding.
  5. The acceptance of the intervention by the patient.
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48
Q

When is it appropriate to question a patient’s ability to participate in decision making?

A
  • Stress associated with illness
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49
Q

Competent patients have the right to refuse treatment. What should you do in the event of a refusal?

A
  • Explore reasons for refusal

- Honour a refusal if a patient is competent.

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50
Q

Can a woman refuse an emergency C-section for fetal distress?

A

Yes

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51
Q

Does the unborn baby have any rights?

A

No

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52
Q

A woman needs an emergency C-section due to fetal distress. What are the laws surrounding abortion in the UK, in the context of this scenario?

A
  • Cannot terminate after 24 weeks.

- Mum can refuse treatment that will save the baby, if the baby is in distress.

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53
Q

Consent to screening is required. Give some issues which might be associated with screening.

A
  1. Uncertainties involved in screening: false positive / false negative
  2. Some findings may have potentially serious medical, social or financial consequences, not only for the individual but also for her relatives.
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54
Q

What complications might congenital rubella cause the baby?

A
  • Deafness
  • Brain damage
  • Heart defects
  • Cataracts
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55
Q

CVS and Amniocentesis are examples of invasive prenatal diagnostic methods. When are these carried out during the pregnancy?
What is the risk of miscarriage with these tests?

A

CVS: 10 - 14 weeks gestation

Amniocentesis: 15 - 24 weeks gestation

Risk of miscarriage: 0.5 - 1%

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56
Q

What considerations might a woman think about, when deciding whether to have CVS / Amniocentesis?

A
  1. Risk of bringing an affected foetus to term; vs

2. Risk of losing a health foetus.

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57
Q

With current diagnostic testing, most pregnancies of foetuses with Down’s syndrome are terminated. What issues might arise from this?

A
  • increased number of terminations of such pregnancies

If, over time, prenatal diagnosis nearly eradicates the population of individuals with Down’s syndrome:

  • will funding for research and treatment be affected?
  • will funding of social services and support systems be affected?
  • will stigmatisation of the condition increase as its prevalence decreases?
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58
Q

List Lord Fraser’s recommendations as applied to Gillick Competency.

A
  1. The doctor should assess whether the patient understands his/her advice.
  2. The doctor should encourage parental involvement.
  3. The doctor should take into account whether the patient is likely to have sexual intercourse without contraceptive treatment.
  4. The doctor should assess whether the patient’s physical / mental health are likely to suffer if she does not receive advice / treatment.
  5. The doctor must consider whether the patient’s best interests require him/her to provide contraceptive advice / treatment without parental consent.
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59
Q

Consent and Ethics in O+G can be very difficult. Where is support available from?

A
  1. MDU: Medical Defence Union
  2. MPS: Medical Protection Society
  3. Ethical Committees in NHS Hospitals.
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60
Q

At what gestation is a baby considered to be premature?

A

Before 37 weeks.

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61
Q

What are the parameters for:

i) Low birth weight infants
ii) Very low birth weight infants
iii) Extremely low birth weight infants

A

i) LBW: <2500g
ii) VLBW: <1500g
iii) ELBW: <1000g

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62
Q

Give 4 conditions which can be attributed to prematurity.

A
  • Developmental delay
  • Visual impairment
  • Chronic lung disease
  • Cerebral palsy
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63
Q

Improvements in neonatal care have contributed to improved survival figures of premature infants. Give 5 such improvements.

A
  • Antenatal steroids
  • Artificial surfactant
  • Ventilation
  • Nutrition
  • Antibiotics
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64
Q

What are the 2 classes of risk factors for pre-term births (PTB)?

A
  • Non-Recurrent

- Recurrent

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65
Q

List 3 ‘non-recurrent’ risk factors for pre-term birth.

A
  • Antepartum haemorrhage (APH)
  • Other vaginal bleeding
  • Multiple pregnancy
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66
Q

List i) 2 ‘immutable’ and; ii) 3 ‘amenable to intervention’ recurrent risk factors for pre-term birth.

A

i) Immutable recurrent RFs:
- Race
- Previous preterm birth

ii) Amenable to intervention recurrent RFs:
- Genital infection
- Cervical weakness
- Socioeconomics

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67
Q

What is meant by ‘primary prevention of preterm birth’?

A
  • Reducing population risk

NB: effective interventions not demonstrable yet.

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68
Q

Give examples of steps that might be taken in ‘primary prevention of preterm birth’.

A
  • Smoking + STD prevention
  • Prevention of multiple pregnancy
  • Planned pregnancy
  • Physical and sexual activity advice
  • Cervical assessment at 20 - 26 weeks.
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69
Q

What is meant by ‘tertiary prevention of preterm birth’?

A

Treatment after diagnosis.

Aim: to reduce morbidity / mortality.

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70
Q

What steps might be taken in ‘tertiary prevention of preterm birth’?

A
  • Prompt diagnosis + referral
  • Drugs: Tocolysis, Antibiotics
  • Corticosteroids
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71
Q

What clinical signs aid a diagnosis of preterm labour?

A

Persistent uterine activity AND change in cervical dilatation and / or effacement.

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72
Q

What clinical factors indicate a diagnosis of preterm labour?

A

Persistent uterine activity AND change in cervical dilatation and/or effacement.

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73
Q

What is encompassed in ‘secondary prevention’ of preterm birth?

A

Identify increased risk women for surveillance and prophylaxis.

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74
Q

What are the 2 screening tests for preterm labour?

A
  • Transvaginal ultrasound

- Qualitative fetal fibronectin test

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75
Q

i) What is fetal fibronectin?
ii) Fetal fibronectin is an abnormal finding in cervicovaginal fluid after 20 weeks. What might this indicate?
iii) When does fetal fibronectin reappear (in the context of a woman’s pregnancy)?

A

i) Extracellular matrix protein found in choriodecidual interface
ii) May indicate disruption of attachment of membranes to decidua.
iii) Reappears close to term as labour approaches.

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76
Q

Why might false positive results arise following a fetal fibronectin test?

A
  • Cervical manipulation
  • Sexual intercourse
  • Lubricants (* cause false negatives)
  • Bleeding
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77
Q

Which hormone may benefit women at high risk of having a preterm birth?

How is the hormone administered?

A

Progesterone

IM injection or pessary

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78
Q

If a woman is suspected of going into preterm labour, what are the 5 treatment principles?

A
  1. Identify associated cause; treat, if possible.
  2. Assess fetal maturity
  3. Consider tocolysis and give steroids
  4. Decide the best route of delivery.
  5. Plan with neonatologists and in the best place. Consider in utero transfer.
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79
Q

List 6 factors which are associated / predispose to hypertension in pregnancy.

A
  • Young female
  • Black
  • Multifetal pregnancies
  • Hypertension
  • Renal disease
  • Collagen vascular disease
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80
Q

What are the 4 classes of hypertension in pregnancy?

A
  • Gestational hypertension (only during pregnancy)
  • Pre-eclampsia / Eclampsia
  • Chronic HTN
  • Pre-eclampsia superimposed upon chronic HTN or renal disease
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81
Q

Explain the concept of ‘Chronic Hypertension’ in the context of pregnancy.

A

HTN diagnosed:

  • before pregnancy
  • before the 20/40
  • During pregnancy and not resolved post-partum.
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82
Q

Explain the concept of ‘Gestational Hypertension’ in the context of pregnancy.

A

Gestational HTN:

  • New HTN after 20/40
  • Systolic >140
  • Diastolic > 90
  • No or little proteinuria
  • 25% develop pre-eclampsia
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83
Q

Explain the concept of ‘preeclampsia-eclampsia’ in the context of pregnancy.

A
  • New HTN after 20/40 (or earlier with trophoblastic disease)
  • Increased BP (gestational BP elevation) with proteinuria
  • Eclampsia: features of pre-eclampsia plus generalised tonic-clonic seizures
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84
Q

What are the clinical parameters used to make a diagnosis of preeclampsia-eclampsia?

A
  1. Gestational HTN:
    Systolic > 140
    Diastolic > 90
  2. Proteinuria
    > 0.3g protein / 24 hour
    > +2 on urine dip specimen
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85
Q

What are the classifications of ‘preeclampsia-eclampsia’?

A
  • Mild pre-eclampsia
  • Severe pre-eclampsia
  • Eclampsia
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86
Q

List the clinical criteria for severe preeclampsia.

A
  • BP > 160 systolic, >110 diastolic
  • Proteinuria
  • Oliguria
  • CNS: Visual changes, headache, mental status change
  • Pulmonary oedema
  • Epigastric / RUQ pain
  • Impaired liver function tests
  • Thrombocytopenia
  • IUGR
  • Oligohydramnios
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87
Q

Describe the pathophysiology of preeclampsia.

A

Maternal disease characterised by:

  • Vasospasm
  • Activation of the coagulation system
  • Derangement in blood volume and pressure control
  • Oxidative stress & inflammatory-like responses
  • Ischaemia from poor placentation.
88
Q

The kidneys are affected by preeclampsia. What physiological derangements might you see in preeclampsia?

A
  • GFR and renal blood flow decrease
  • Raised uric acid levels
  • Proteinuria
  • Hypocalciuria: alterations in regulatory hormones
  • Impaired Sodium excretion and suppression of RAAS.
89
Q

What happens to the coagulation system during preeclampsia?

A
  • Thrombocytopenia
  • Low antithrombin III
  • Higher fibronectin
90
Q

What happens to the liver during preeclampsia?

A

HELLP syndrome:
Haemolysis
Elevated ALT + AST
Low platelet count

91
Q

What CNS symptoms might be seen if a woman has preeclampsia?

A
  • Eclampsia (generalised tonic-clonic seizures)
  • Headache and visual disturbances
  • Cortical blindness
  • Scotomata (partial loss of vision eg. blind spot)
92
Q

Give 5 symptoms of preeclampsia.

A
  1. Visual disturbances
  2. Headache (similar to migraine)
  3. Epigastric pain (hepatic swelling & inflammation -> stretch of liver capsule)
  4. ± Oedema
  5. Rapid weight gain
93
Q

List 5 physical findings in preeclampsia.

A
  1. Raised Blood pressure
  2. Proteinuria
  3. Retinal vasospasm / oedema
  4. RUQ abdominal tenderness
  5. Ankle clonus* = a sign of neuromuscular irritability that raises concern.
  • brisk, or hyperactive, reflexes are common during pregnancy.
94
Q

Give 3 differentials for preeclampsia.

A
  • Thrombotic thrombocytopenia purpura
  • Haemolytic Uraemic Syndrome
  • Acute Fatty Liver of Pregnancy
95
Q

If you suspect preeclampsia, which laboratory tests should you request?

A
  • Hb, platelets
  • Serum uric acid
  • Liver function tests
  • If 1+ protein by clean catch dipstick -> timed collection for protein and creatinine
  • Accurate dating and assessment of fetal growth
96
Q

List 5 maternal indications for delivery in preeclampsia.

A
  1. Gestational age 38/40
  2. Platelet count < 100,000 cells/mm3
  3. Progressive deterioration in liver and renal function
  4. Suspected placental abruption
  5. Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting.
  • delivery should be based on maternal and fetal conditions as well as gestational age.
97
Q

List 3 fetal indications for delivery in preeclampsia.

A
  1. Severe fetal growth restriction
  2. Non-reassuring fetal testing results
  3. Oligohydramnios
98
Q

What is the ‘cure’ for preeclampsia?

A

Cure = delivery
> Always beneficial for mother, although C-section might be needed
> Cure may be deleterious for the foetus

99
Q

When is anti-convulsive therapy indicated in preeclampsia?

A
  • Indicated to prevent recurrent convulsions in women with eclampsia or to prevent convulsions in women with preeclampsia.
100
Q

Why might parenteral Magnesium Sulphate be administered in preeclampsia?

A

Magnesium Sulphate reduces the frequency of eclampsia & maternal death.

  • Caution in renal failure.
101
Q

What medications might be used in the treatment of acute, severe HTN in pregnancy?

A

If BP > 160 / 105

  • Parenteral Hydralazine + Labetalol (avoid in women with asthma and CHF)
  • Oral nifedipine used with caution
  • Sodium Nitroprusside
102
Q

What advice should a woman be given postpartum following preeclampsia / eclampsia?

A
  • Counselling for future pregnancies
  • Risk of recurrent preeclampsia increases with:
    > Preeclampsia before 30/40
    > New father
    > Blacks
103
Q

What is ‘puerperium’?

A

The period of time from delivery of the placenta to six weeks following the birth.

104
Q

Give 3 main features of the Puerperium.

A
  • Return to pre-pregnant state
  • Initiation / suppression of lactation
  • Transition to parenthood
105
Q

Describe the endocrine changes during the puerperium.

A

Decrease in serum levels of placental hormones:

  • hPL (human placental lactogen)
  • hCG
  • Oestrogen
  • Progesterone

Increase of prolactin.

106
Q

Describe the physiology of the puerperium with regards to the involution of the uterus and genital tract.

A

Muscle: ischaemia, autolysis and phagocytosis

Decidua: sheds as loch (rubra, serosa and alba)

107
Q

Describe the lochia from day 0 -> day 28 post partum.

A

Day 0 - 4: Lochia rubra
- Blood, cervical discharge, decide, fetal membrane, vernix, meconium

Day 4 - 10: Lochia serosa
- Cervical mucus, exudate, fetal membrane, microorganisms, white blood cells

Day 10 -28: Lochia alba
- Cholesterol, epithelial cells, fat, microorganisms, mucus, leukocytes

108
Q

Establishment of lactation occurs postpartum. What are the hormones involved in lactogenesis?

A

At birth: presence of colostrum

Lactogenesis: onset of copious milk production

  • Prolactin: Milk production
  • Oxytocin: Milk ejection reflex
  • Insulin and Cortisol
109
Q

Describe the steps involved in the prolactin response.

A
  • Baby suckles
  • Sensory imposes pass from the nipple to the brain
  • Prolactin secreted by anterior pituitary gland -> travels via bloodstream to the breasts
  • Lactocytes produce milk
110
Q

Describe the pattern of secretion of prolactin

A
  • More secreted at night
  • Suppresses ovulation
  • Level peaks after the feed, to produce milk for the next feed.
111
Q

Describe the steps involved in the oxytocin reflex.

A
  • Baby suckles
  • Sensory impulses pass from the nipple to the brain
  • Oxytocin secreted by posterior pituitary gland -> travels via bloodstream to breasts.
  • Myoepithelial (muscle) cells contract and expel milk.
112
Q

Lactoferrin is found in breast milk. What is the implication of this for the baby?

A

Lactoferrin inhibits growth of microorganisms -> thus, decreases risk of gastroenteritis in babies.

113
Q

Give some examples of ‘minor’ post natal problems.

A
  • Infection
  • PPH
  • Fatigue
  • Anaemia
  • Backache
  • Breast engorgement / mastitis
  • Urinary stress incontinence
  • Haemorrhoids / Constipation
  • ‘The blues’
114
Q

List some examples of ‘major’ post natal problems.

A
  • Sepsis
  • Severe PPH
  • Pre-eclampsia / Eclampsia
  • Thrombosis
  • Uterine prolapse
  • Incontinence (urinary / fetal)
  • Breast abscess
  • Depression / Psychosis
115
Q

If a woman has an uncomplicated pregnancy, who would be involved in her care?

A
  • Midwives
  • Breast feeding support workers
  • Support workers
  • Nursery nurses
  • Housekeepers
  • Domestics
116
Q

If a woman requires complex care during her pregnancy, who would be involved in her care?

A

All normal care, plus:

  • Obstetricians + / or GP
  • Paediatricians
  • Anaesthetists
  • Physiotherapists
  • Substance use specialists
  • Microbiology
117
Q

What are the postnatal signs and symptoms that women should be warned about after delivery?

A
  1. Sudden + profuse blood loss / persistent increased blood loss
  2. Faintness, dizziness or palpitations / tachycardia
  3. Fever, shivering, abdo pain +/or offensive vaginal loss
  4. Headaches within 72hrs of birth, with one or more of the following:
    > visual disturbances
    > nausea
    > vomiting
  5. Unilateral calf pain, redness or swelling / Shortness of breath / chest pain
118
Q

Which assessment scoring system is used for postnatal women?

A

MEOWS

Modified Early Obstetric Warning Score

119
Q

What is sepsis?

A

Infection plus systemic manifestations of infection.

120
Q

What is ‘severe sepsis’?

A

Sepsis plus sepsis-induced organ dysfunction or tissue hypo-perfusion.

121
Q

What is ‘septic shock’?

A

The persistence of hypo-perfusion, despite adequate fluid replacement therapy.

122
Q

List some risk factors for sepsis development (in the context of pregnancy / post natal period).

A
  • Obesity
  • Diabetes
  • Anaemia
  • Amniocentesis / Invasive procedures
  • Prolonged SROM
  • Vaginal trauma / C-section
  • Ethnicity -> BME
123
Q

What are the likely causes of sepsis (in the context of pregnancy / post natal period)?

A
  • Endometritis
  • Skin + soft tissue infection
  • Mastitis
  • UTI
  • Pneumonia
  • Gastroenteritis
  • Pharyngitis
  • Infection related to epidural / spinal
124
Q

What does the phrase ‘3Ts, White, with sugar’ help you to remember?

A

Does the woman have signs / symptoms of infection / sepsis:

T = Temperature < 36 or > 38 
T = Tachycardia: HR > 90bpm 
T = Tachypnoea: RR > 20bpm 
W = WCC > 12 or < 4 x 10^9 / L 
Sugar: Hyperglycaemia > 7.7mmol
125
Q

A woman is 4 hours postnatal and she is ?sepsis. What factors in the history / new signs might indicate an infection or infective source?

A
  • PROM / offensive liquor
  • Offensive lochia
  • Catheter / dysuria
  • Headache + neck stiffness
  • Cellulitis / wound infection
  • D + V
  • Breast redness / pain
  • Cough, sputum, chest pain
  • Abdo pain
126
Q

Which pneumonic is used to help remember the components of ‘Sepsis 6’?

A

BUFALO plus 2

B = Blood cultures
U = Urine Output
F = Fluid resuscitation
A = Antibiotics
L = Lactate
O = Oxygen

plus 2: consider delivery (Evacuation of retained products of conception) + VTE prophylaxis

127
Q

Primary Post partum haemorrhage (PPH) can be divided into 2 categories. What are these categories + what are the blood loss volumes associated with each?

A

Primary PPH: >500ml estimated blood loss after birth of the baby

Minor PPH:
EBL < 1500mls
No clinical signs of shock

Major PPH:
EBL: 1500mls or more
Continuing to bleed OR clinical shock

128
Q

A woman has a secondary PPH. What does this mean?

A

Secondary PPH:

  • Abnormal or excessive bleeding from the birth canal
  • Between 24hrs and 12 weeks post-natally
129
Q

Give 5 causes of Secondary PPH.

A
  1. Endometritis
  2. Retained products of conception
  3. Subinvolution of the placental implantation site
  4. Pseudoaneurysms
  5. Arteriovenous malformations.
130
Q

What investigations might you consider if a woman presents with a secondary PPH?

A
  • Assess blood loss
  • Assess haemodynamic status
  • Bacteriological testing (HVS and endocervical swab)
  • Pelvic USS (if indicated).
131
Q

During pregnancy and postnatally, women are at increased risk of VTE. If a woman is deemed to be high risk, what treatment should you offer her?

A

Prophylactic treatment: Low Molecular Weight Heparin (LMWH) for at least 6 weeks postnatally

132
Q

What is the pathophysiology of a post-dural puncture headache?

A
  • Accidental dural puncture

- Leakage of CSF -> reduced pressure in fluid around the brain.

133
Q

What are the symptoms of a post dural puncture headache?

A

Headache:

  • worse on sitting or standing
  • starts 1 - 7 days after spinal / epidural is sited

Neck stiffness

Dislike of bright lights

134
Q

What is the treatment for a post dural puncture headache?

A
  • Lying flat!
  • Simple analgesia
  • Fluids + ? caffeine
  • Epidural blood patch -> stops fluid leak -> pressure around the brain increases and the headache should improve.
135
Q

What is ‘urinary retention’?

A

The abrupt onset of aching or acheless inability to completely micturate, requiring urinary catheterisation, over 12h after giving birth
OR
Not to void spontaneously within 6hrs of vaginal delivery.

136
Q

List 5 risk factors for post natal urinary retention.

A
  1. Epidural analgesia
  2. Prolonged 2nd stage of labour
  3. Forceps or ventouse delivery
  4. Extensive perineal lacerations
  5. Poor labour bladder care
137
Q

A woman presents with postnatal urinary retention. What are the aims of treatment?

A
  • Maintain bladder function
  • Minimise the risk of damage to the urethra / bladder
  • Provide appropriate management strategies for women who have problems with bladder emptying
  • Prevent long term problems with bladder emptying
138
Q

What are the red flag symptoms with regards to mental health disorders in the Puerperium?

A
  1. Recent significant change in mental state or new emergence of symptoms
  2. New thoughts or acts of violent self-harm.
  3. New and persistent expressions of incompetency as a mother OR estrangement from the infant.
139
Q

Postnatal depression affects 10% of new mothers. What signs might a mother exhibit if she had postnatal depression?

A
  • Depressed
  • Irritable
  • Tired
  • Sleepless
  • Appetite changes
  • Negative thoughts
  • Anxiety
    > affects bonding
140
Q

What are the 3 key features of postpartum psychosis?

A

Depression
Mania
Psychosis

141
Q

What are the risk factors for postpartum psychosis?

A
  • FHx of mental health problems
  • Diagnosis of bipolar disorder
  • Traumatic birth or pregnancy.
142
Q

How might a woman with postpartum psychosis i) feel; ii) behave?

A

i) Feel:
- Excited / elated
- Severely depressed
- Rapid mood changes
- Confused or disorientated

ii) Behave:
- Restless
- Unable to sleep
- Unable to concentrate
- Experiencing psychotic symptoms, like delusions or hallucinations

143
Q

What are the risk factors for PTSD in the puerperium?

A
  • Perceived lack of care
  • Poor communication
  • Perceived unsafe care
  • Perceived focus on outcome over experience of the mother.
144
Q

How might PTSD present in the puerperium?

A
  • Anger, low mood, self blame
  • Suicidal ideation, isolation and dissociation
  • Intrusive, distressing flashbacks
145
Q

What are the longer term consequences of PTSD during the puerperium?

A
  • Women may delay or avoid future pregnancies
  • Request C-section to avoid vaginal delivery
  • Avoidance of intimate physical relationships
  • Impact on breastfeeding.
146
Q

What is the definition of ‘Maternal Mortality’?

A

Maternal death:
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

147
Q

Give an example of a ‘direct’ death (in the context of pregnancy).

A

Death relating from obstetric complications of pregnancy, labour or puerperium (eg. haemorrhage, genital sepsis, suicide).

148
Q

Give an example of an ‘indirect death’ (in the context of pregnancy).

A

Death resulting from pre-existing disease / disease that developing in pregnancy, but not as a direct result of obstetric causes (cardiac disease, malignancies).

149
Q

What is ‘menstruation’?

A

Monthly bleeding from reproductive tract induced by hormonal changes of the menstrual cycle.

150
Q

What is the ‘length’ of the menstrual cycle?

A

The time from the start of a period to the start of the next.

151
Q

Define ‘menorrhagia’.

A

Heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle.

152
Q

Define ‘intermenstrual bleeding’.

A

Uterine bleeding that occurs between clearly define cyclic and predictable menses.

153
Q

Define ‘abnormal uterine bleeding’.

A

Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration, and heavy), regularity, timing (delayed or frequent), or is non-menstrual (post-coital, inter menstrual, post-menopausal).

154
Q

What is the definition of ‘heavy menstrual bleeding’?

A

Menstrual loss that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life.

155
Q

List 4 pathological causes of heavy menstrual bleeding.

A
  • Uterine fibroids
  • Uterine polyps
  • Adenomyosis
  • Endometriosis
156
Q

What are uterine fibroids?

A
  • Benign tumours of the MYOmetrium
  • may be asymptomatic
  • ‘whorls’ of smooth muscle cells with collagen
  • may be single or multiple
157
Q

What are uterine polyps?

A
  • Benign, localised growth of the ENDOmetrium
  • fibrous tissue core, covered by columnar epithelium
  • malignant changes are rare
158
Q

What is endometriosis?

A
  • Endometrium type tissue lying outside the endometrial cavity
  • usually within peritoneal cavity
  • Like the endometrium, it responds to cyclical hormonal changes and bleeds at menstruation
159
Q

What is adenomyosis?

A
  • Ectopic endometrial tissue within the myometrium

- May be localised or diffuse

160
Q

Which diseases / disorders should be asked about in a menstrual history and which symptoms are particularly important?

A
  1. Thyroid disease
    - Cold / heat intolerance
    - Hair consistency
    - Lethargy
  2. Clotting disorder
    - Bruising
    - Family Hx
  3. Drug therapy
    - Warfarin
    - Heparin
161
Q

What investigations should you conduct if you suspect menorrhagia?

A
  • FBC
  • Transvaginal USS
  • Endometrial biopsy if >45yrs and i) inter menstrual bleeding; ii) unresponsive to treatment
  • Hysteroscopy may be considered if unresponsive to treatment.
162
Q

Describe the treatment options for menorrhagia.

A
  1. Reassurance
  2. Antifibrinolytics (Tranexamic acid)
  3. NSAIDs (Mefenamic acid) -> useful if dysmenorrhoea is a symptom
  4. Progestagens: must be used from day 5 - 25
  5. Danazol: inhibits sex steroid production, blocks receptors.
  6. COCP: inhibits ovarian function
  7. Mirena
  8. Endometrial ablation
  9. Myomectomy / resection of fibroids
  10. Hysterectomy
163
Q

Give 4 indications for endometrial ablation.

A
  • Heavy menstrual loss
  • Not expecting amenorrhoea
  • Normal endometrium
  • Completed family.
164
Q

Give 4 contraindications to endometrial ablation.

A
  • Malignancy
  • Acute PID
  • Desire for future pregnancy
  • Excessive cavity length
165
Q

What complications might arise following a hysterectomy?

A
  • Bleeding
  • Ureteric damage
  • Intra-abdominal trauma
166
Q

What key symptoms should you ask about in a focused gynae history?

A

Pain: dysmenorrhoea, dyspareunia

Bleeding: menorrhagia, IMB, PCB, PMB

Urinary symptoms: frequency, urgency, incontinence

Bowel symptoms: dyschezia

Prolapse

Sexual History

167
Q

What things other than symptoms should you ask about in a focused gynae history?

A
  • LMP
  • Contraception
  • Sexual Hx
  • Smears (date and result)
  • Past gynae Hx
  • Past obstetric Hx
  • Medical Hx
  • Family Hx (Breast / ovarian cancer; type 2 diabetes)
168
Q

How is the menstrual cycle expressed in medical notes?

A

X/Y

X = Duration (normal = 2 - -7 days)

Y = Cycle (normal 21 - 35 days)

Cycle = days between Day 1 of period to Day 1 of the next period.

169
Q

What is a ‘withdrawal bleed’?

A

Bleeding after withdrawal of exogenous oestrogen and / or progestogen.

170
Q

What is the ‘menarche’?

A

Age of 1st period

Normal = 10 - 16 years

171
Q

What is the ‘menopause’?

A

Age / date of last spontaneous period

Normal = 40 - 55

172
Q

What is the ‘climacteric’ period?

A

The years before the menopause associated with menopausal symptoms, but still menstruating.

173
Q

When is a woman diagnosed as ‘post-menopausal’?

A

No periods for 1 year after the age of 50yrs

2yrs if <50yrs

174
Q

A woman presents for her booking visit. What things should you consider asking her at this point?

A
  • Previous pregnancies (year, gestation, outcome, mode of delivery, complications)
  • Current symptoms: incl fetal movements
  • Early pregnancy scans
  • Full general medical and gynae Hx
  • Social Hx
  • Mental Health / Domestic Abuse
  • RF for VTE / Pre-eclampsia
175
Q

What is ‘gravidity’?

A

Total number of pregnancies (including this one; multiple pregnancies count as 1).

176
Q

What is ‘parity’?

A

Total number of deliveries after 24 weeks

177
Q

What things should you consider asking about when taking a history from a woman in labour?

A
  • May be difficult!!
  • Ask about show (mucus ± blood)
  • Contractions: onset, frequency, length, regularity
  • SROM (spontaneous rupture of membranes): clear; blood-stained; yellow/green.
178
Q

List 4 MATERNAL obstetric emergencies

A
  • Antepartum Haemorrhage
  • Postpartum Haemorrhage
  • Pre-eclampsia
  • Venous thromboembolism
179
Q

List 3 FETAL obstetric emergencies.

A
  • Fetal distress
  • Cord prolapse
  • Shoulder dystocia
180
Q

List 7 disorders which are specific to pregnancy.

A
  • Gestational Diabetes
  • Pregnancy Induced Hypertension (PIH)
  • Pre-eclampsia (PET)
  • Eclampsia
  • Obstetric cholestasis
  • Acute fatty liver of pregnancy
  • HELLP
181
Q

List some possible causes of an Antepartum Haemorrhage.

A
  • Placenta praaevia
  • Placenta accreta
  • Vasa praevia
  • Placental abruption
  • Uterine rupture or dehiscence post previous c-section
  • Local lesions eg. infection, cervical ectropion.
  • Unexplained
182
Q

Describe the difference between ‘Major’ and ‘minor’ low lying placenta.

A

LLP = any part of the placenta that has implanted into the lower segment.

Major = covering / reaching os

Minor = in lower segment / encroaching

183
Q

When is a diagnosis of LLP (low lying placenta) made?

A

20 week anomaly scan
- Placenta must be >25mm from cervical os.
If <25mm, repeat scan.
If placenta remains <25mm from os, elective C-section is indicated.

184
Q

Explain the management of a LLP (not bleeding)

A
  • Outpatient management if asymptomatic
  • If recurrent bleeds, may need admission until delivery with weekly cross-match.
  • Remember Anti D if Rh -ve.
  • Elective C-section at 38=39 weeks
185
Q

What should you never do if you have a woman with a placenta praevia?

A

Digital vaginal examination

-> risk putting your finger through the placenta and initiating a very large bleed.

186
Q

Explain the management of a bleeding LLP.

A
  • Resuscitate by ABC
  • 2 cannulas
  • Crystalloid
  • X-match 6 units
  • FBC, U+Es, LFTs, Clotting
  • Consultant Obstetrician + Anaesthetist (Neonatologist)
187
Q

Explain the outpatient management of placenta accreta.

A
  • 20 week scan
  • Loss of definition between wall + uterus
  • Abnormal vasculature
  • MRI scan
  • Elective C-section 36 - 37 weeks
188
Q

What are the risks of placenta accreta?

A
  • Haemorrhage
  • Transfusion may be required
  • Caesarean hysterectomy
  • ITU admission
189
Q

Who is involved in the management of placenta accreta?

A
  • Consultant Obstetrician
  • Consultant Anaesthetist
  • Critical Care -> bed availability
  • MDT involvement in pre-op planning
190
Q

What is ‘vasa praevia’?

A

Fetal vessels coursing through the membranes over the internal cervical os and below the fetal presenting part, unprotected by placental tissue or the umbilical cord.

191
Q

What are the risks of vasa praevia?

A
  • No maternal risk

- Major fetal risk: membrane rupture leads to major fetal haemorrhage.

192
Q

What is ‘placental abruption’. What signs might you see in a woman with placental abruption?

A
  • Premature separation of the placenta from the uterine wall
  • Concealed or revealed haemorrhage
  • Woody-hard, tense uterus
  • Fetal distress
  • Maternal shock out of proportion to bleeding
  • Small abruptions may be managed conservatively.
  • Large abruptions needs resuscitation and delivery.
193
Q

List the risk factors for placental abruption

A
  • Previous abruption
  • Hypertension
  • Multiple pregnancy
  • Trauma: medical, domestic violence
  • Vasoconstrictor drugs (cocaine, crack)
  • Infection
  • Thrombophilias
  • Uterine abnormality
  • Smoking
194
Q

What is a ‘primary post part haemorrhage’?

A

Blood loss > 500mls within 24 hours of delivery

195
Q

What is a ‘secondary post partum haemorrhage’?

A

Blood loss after 24 hours and up to 12 weeks post delivery
Minor: 500 - 1000 mms
Major: > 1000mls

196
Q

What are the causes of PPH?

A

The 4 T’s:

Tissue: ensure placenta is complete

Tone: ensure uterus contracted -> syntometrine, syntocinon, ergometrine, haemobate, misoprostol

Trauma: look for tears + repair them!

Thrombin: check clotting

197
Q

List the risk factors for PPH.

A
  • Macrosomia
  • Nulliparity and grand multiparity
  • Multiple pregnancy
  • Precipitate or prolonged labour
  • Shoulder dystocia
  • Previous PPH
198
Q

VTE is the leading direct cause of maternal mortality. How should the risk of VTE be managed / minimised?

A
  • Thromboprophylaxis: Low Molecular Weight Heparin + TEDs (stockings)
  • Highest risk in the post part period
  • Prophylactic dose of LMWH given according to maternal weight.
199
Q

List the risk factors for VTE.

A
  • Previous VTE
  • Inherited / acquired thrombophilia
  • Medical comorbidities
  • Age > 35
  • BMI > 30
  • Smoking
  • Parity > 4
  • Multiple pregnancy
  • Pre-eclampsia
  • C-section
  • Hyperemesis
  • Immobility
  • Systemic infection
200
Q

List the risk factors for maternal sepsis.

A
  • Obesity
  • Diabetes
  • Impaired immunity / immunosuppressant medication
  • Anaemia
  • Vaginal discharge
  • History of pelvic infection
  • Hx of Group B strep infection
  • Amniocentesis
  • Cervical cerclage
  • Prolonged spontaneous rupture of membranes
  • Group A strep infection in close contacts / family members.
201
Q

List the signs + symptoms of sepsis.

A
  • Pyrexia
  • Hypothermia
  • Tachycardia
  • Tachypnoea
  • Hypoxia
  • Hypotension
  • Oliguria
  • Impaired consciousness
  • Failure to respond to treatment
202
Q

List some causes of sepsis (as applied to pregnancy / postnatal period)

A
  • Pyelonephritis
  • Chorioamnionitis
  • Post partum endometritis
  • Wound infection
  • Pneumonia
  • Acute appendicitis
  • Acute cholecystitis
  • Pancreatitis
  • Necrotising enterocolitis
203
Q

The Sepsis Six is a pneumonic to aid sepsis management. What are the 6 steps?

A
  1. Take an ABG. Give High flow Oxygen.
  2. Blood cultures + bloods
  3. Commence IV Antibiotics
  4. Commence IV fluid resuscitation
  5. Take Blood for Hb, Lactate, Glucose
  6. Measure hourly urine output.

*involve experts early.

204
Q

What is ‘severe pre-eclampsia’?

A

Severe hypertension + proteinuria OR mild/moderate HTN and proteinuria with at least one of:

  • severe headache
  • visual problems (blurring / flashing lights)
  • Severe pain just below ribs / vomiting
  • Papilloedema
  • Clonus (> 3 beats)
  • Liver tenderness, HELLP syndrome
  • Platelet count falls to <100 x 10^9/L
  • Abnormal liver enzymes,
205
Q

What is the treatment for pre-eclampsia?

A
  • Stabilise blood pressure: labetalol, nifedipine, methyldoxpa
  • Bloods (platelets, renal + liver function)
  • Magnesium Sulphate for hyperreflexia
  • Monitor urine output (100mls in 4 hours), fluid restrict (80mls per hour)
  • Treat coagulation defects
  • Fetal wellbeing - CTGs, USS for fetal growth
  • Delivery
206
Q

What is ‘eclampsia’.

A

The onset of seizures in a woman with pre-eclampsia.

  • Any seizures in a pregnant woman are eclampsia until proven otherwise.
207
Q

What is the treatment for eclampsia?

A
  • IV Magnesium Sulphate
  • If recurrent seizures: give more Mag Sulph.
  • Treat hypertension: labetalol, nifedipine, methydopa, hydrazine.
  • Stabilise mum.
  • Deliver baby.
208
Q

What is cord prolapse?

A
  • Occurs when cord is presenting
  • Membrane rupture
  • Exposure of the cord leads to vasospasm
  • Can cause significant risk of fetal morbidity and mortality from hypoxia.
209
Q

List 6 risk factors for cord prolapse.

A
  • Premature rupture of membranes
  • Polyhydramnios
  • Long umbilical cord
  • Fetal malpresentation
  • Multiparity
  • Multiple pregnancy
210
Q

What is the management of cord prolapse?

A
  • Call 999!!!!!
  • Infuse fluid into bladder via catheter if at home
  • Trendelenburg with knees and hips up
  • Constant fetal monitoring
  • Alleviate pressure on cord
  • Transfer to theatre + prepare for delivery.
211
Q

What is ‘shoulder dystocia’?

A

Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the fetal head that requires specific manoeuvres to facilitate delivery.

  • intrapartum emergency
  • high risk for maternal and fetal morbidity
  • can cause fetal mortality.
212
Q

List risk factors predicting shoulder dystocia.

A
  • Macrosomia
  • Maternal diabetes
  • Disproportion between mother and foetus
  • Post maturity + induction of labour
  • Maternal obesity
  • Prolonged 1st or 2nd stage of labour
  • Instrumental delivery.
213
Q

Which pneumonic is used to guide the management of a shoulder dystocia?

A

HELPERR(R)

H: Call for help
E: Evaluate for Episiotomy
L: Legs in McRoberts
P: suprapubic Pressure
E: Entre pelvis
R: Rotational manoeuvres
R: Remove posterior arm
(R: Replace head + deliver by LSCS - Zavanelli)
214
Q

Give 3 maternal complications of shoulder dystocia.

A
  1. PPH
  2. Extensive vaginal tear (3rd + 4th degree)
  3. Psychological
215
Q

Give 4 neonatal complications of shoulder dystocia.

A
  1. Hypoxia
  2. Fits
  3. Cerebral palsy
  4. Injury to brachial plexus

Phase 3A COPY (19 decks)

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