Obs & Gynae Flashcards
(284 cards)
1
Q
how many hrs post LH surge does ovulation occur
A
24-36h
2
Q
proliferative phase of uterine cycle runs alongside what part of the menstrual cycle
A
follicular phase
3
Q
secretory phase of the uterine cycle runs alongside what part of the menstrual cycle
A
luteal phase
4
Q
normal menstrual loss
A
10-80ml
5
Q
metorrhagia
A
intermenstrual bleeding
6
Q
amenorrhoea
A
absence periods >6m
7
Q
oligomenorrhoea
A
intervals > 35d
8
Q
Mx DUB
A
- Mirena IUS
cOCP
POP
Non-hormonal - Tranexamic acid
9
Q
normal vaginal pH
A
3-4
10
Q
bacteria causing BV
A
gardnerella vaginosis
11
Q
Ix BV
A
clinical Dx
or
HVS
12
Q
clue cells on microscopy
A
BV
13
Q
Mx vaginal candida if preg
A
only Topical Mx
no oral fluconazole
14
Q
what is trichomonas vaginalis
A
PARASITE (got this wrong in CAP)
15
Q
presentation trichomonas
A
strawberry cervix
musty smelling
frothy discharge
16
Q
Ix trichomonas vaginalis
A
HVS
17
Q
cause of chlamydia
A
chlamydia trachomatis
18
Q
presentation chlamydia
A
asymptomatic (70% women, 50% men)
or
urethritis (M), discharge (F)
19
Q
Ix chlamydia
A
F - endocervical swab
M - first pass urine
for PCR/NAAT (always do gonorrhea test too)
20
Q
why is PCR/NAAT the test for chlamydia
A
chlamydia doesn’t stain with gram stain
21
Q
Mx chlamydia
A
either:
doxycycline 7d
or
azithromycin 1g oral single dose
both are 1st line, using doxy more now
22
Q
Ix gonorrhoea
A
F - endocervical swab
M - first pass urine
for PCR/NAAT (always do chlamydia test too)
23
Q
disadvantage of PCR/NAAT
A
doesn’t give sensitivities
24
Q
what is gonorrhoea
A
gram negative diplococcus
25
cause of syphilis
treponema pallidum
26
shape of syphilis
spirochaete
27
stages of syphilis
1. painless chancre
2. "the great imitator" - lymphadenopathy, rash on palms, soles, trunk
3. gummas - small lesions on skin and bones, cardio + neuro complications
28
Ix syphilis
swab for dark ground microscopy
Screening: ELISA test (combined IgM and IgG)
TPPA: specific
VDRL: non-specific, used for monitoring
29
Mx syphilis
IM penicillin
30
HPV causing genital warts
6+11
31
Mx genital warts
1. solitary - cryotherapy, multiple - podophyllotoxin cream
| 2. Imiquimod (aldara)
32
Ix genital herpes
swab of ulcer for PCR
33
Mx pubic lice (crabs)
malathion lotion
34
RF for endometrial Ca
obesity
unopposed oestrogen
nulliparity
35
protective factors for endometrial Ca
smoking
| combined pill
36
genetic predisposition to endometrial Ca
Lynch syndrome
- autosomal dominant
- also colon ca
37
Mx endometrial Ca
total hysterectomy + bilateral salpingo-oophrectomy
38
presentation fibroids
bulky uterus
menorrhagia
subfertility
39
Ix fibroids
TVUs
40
Mx fibroids if fertility desired
Medical:
leuprorelin (GHRH agonist)
IUS
Surgical:
myomectomy
41
Mx fibroids if fertility not desired
Endometrial ablation
Uterine artery embolization
Hysterectomy
42
complication of fibroids
red degeneration:
| haemorrhage into the tumour, most commonly happens in pregnancy
43
what is adenomyosis
presence of endometrial tissue in the myometrium
44
presentation adenomyosis
menorrhagia
dysmenorrhea
boggy, tender uterus
45
Mx adenomyosis
Hormonal Tx:
GNRH agonists, POP, Mirena, COC
Only definitive Tx: hysterectomy
46
presentation endometriosis
```
cyclical abdo pain
dyspareunia
dysmenorrhea
menorrhagia
subfertility
```
47
Ix endometriosis
laparoscopy
48
Mx endometriosis
cOCP, IUS
| laser ablation
49
cOCP and increased discharge - Dx?
ectropion
50
meigs syndrome
adenoma + ascites + pleural effusion
51
HPV types cervical Ca
16 & 18
52
if a womas has symp suspicious of cervical Ca - Ix?
straight for colposcopy
53
smear shows mild dyskaryosis - what do you do
rpt smear 6m
54
smear shows moderate dyskaryosis - what do you do
refer colposcopy
55
smear shows severe dyskaryoisis - what do you do
urgent refer colposcopy
56
Mx CIN 1
observe
57
Mx CIN II
LLETZ
58
Mx CIN III
LLETZ
59
woman has had Tx for CIN - what do you do next
rpt smear and HPV test in 6m
- if -ve, go back to routine recall every 3y
if +ve, another colposcopy and follow up yrly for 5y
60
presentation of cervical ca
abnormal bleeding
- post-coital
- post-menopausal
- brownish or blood stained discharge
- contact bleeding
61
Mx cervical ca
radical hysterectomy
+
radiotherapy/chemotherapy
62
radical hysterectomy
removal of uterus, cervix and upper vag
63
hysterectomy
removal of uterus and cervix
64
cell type of cervical ca
SCC
65
risk factors ovarian ca
nulliparity
many cycles (early menarche, late menopause)
BRCA 1 and 2
increased age
66
protective factors for ovarian ca
COC pill
67
ovarian tumours arising from serous epithelium
serous
endometroid
mucinoid
clear cell
68
ovarian tumours arising from germ cells
teratoma (dermoid cyst) - BENIGN
choriocarcinoma
yolk sac - MALIGNANT
69
ovarian tumours arising from stroma
these are the hormone secreting tumours
granulosa - oestrogen
theca - androgen
fibroma (benign) - meig's syndrome
70
most common cancers to mets to ovary
breast
pancreas
stomach
GI
71
tumour marker ovarian ca
CA125
72
Ix ovarian Ca
1. CA125
2. USS/CT
3. CEA (to exclude GI primary)
73
risk of malignany index - ovarian Ca
menopausal status x US score x CA125
RMI > 250, refer to gynae
74
Mx ovarian ca
total hysterectomy + bilateral salpingoophrectomy + omental removal
chemo
75
pathophysiology of PCOS
Excess LH
- stimulates over production of androgens
and
Insulin Resistance
- suppresses hepatic production of SHBG which increase amount of circulating free androgens
76
presentation PCOS
oligomenorrhoea or amenorrhoea
hirsutism or acne
obesity
insulin resistance
77
Rotterdam criteria
must meet 2/3 for Dx of PCOS:
1 .oligo- or amenorrhoea
2. clinical or biochemical signs of ++ androgens
3. polycystic ovaries on US
78
Mx PCOS
1. wt loss, metformin
2. if pt doesn't desire pregnancy: OCP, dianette
2. if pt does want pregnancy: clomifene +/- metformin
3. for hirsutism: eflornithine cream/laser
79
location of Bartholin's glands
4 and 8 oclock positions
| - deep to the posterior aspect of the labia majora
80
difference in presentation of Bartholin's cyst and Bartholin's abscess
cyst - soft, fluctuant, non-tender
abscess - hard, non-fluctuant, tender, surrounding cellulitis
81
Mx Bartholin's cyst or abscess
marsupialisation
82
lichen sclerosis presentation
atrophic white patches
itch
fusion of clitoral hood, vaginal opening
83
Mx lichen sclerosis
topical steroids
84
Mx urge incontinence
reduce caffeine/alcohol
bladder training
muscarinic antagonists - oxybutynin, solifenacin, tolteridine
oestrogen pessary
85
Mx stress incontinence
lifestyle changes
pelvic floor training
duloxetine
rarely surgery
86
urethrocele
prolapse: urethra into vagina
87
rectocele
prolapse: rectum into vagina
88
enterocele
prolapse: small bowel into vagina
89
cystocele
prolapse: bladder into vagina
90
Mx of prolapse if incidental finding
pelvic floor work
91
Mx prolapse if old lady, multi morbidity and procidentia
pessary
92
grades of uterine prolapse
1. into vagina
2. at vaginal orifice
3. outside vagina
4. procidentia - entirely outside vagina
93
vaginal vault
vaginal prolapse
94
Mx vaginal vault prolapse
sacrospinous fixation
or
hysterectomy
95
what cancers does cOCP increase risk of
breast
| cervical
96
what cancers does cOCP decrease risk of
endometrial
| ovarian
97
UKMEC4 for cOCP
```
>35 and smoking >15/day
uncontrolled HTN
migraine with aura Hx of VTE/stroke/IHD
breast ca
breastfeeding and <6w post-partum
```
98
mode of action of cOCP
inhibits ovulation
99
effect of epilepsy medicines on cOCP
reduce function of cOCP, as they are CytP450 inducers,
100
mode of action of POP
thickens cervical mucus
101
how many hrs is the window for a missed POP
3h
102
if missed POP pill >3h ago - what do you do
take asap and advise condom using until pill-taking been re-established for 48h
103
mode of action of implant
inhibits ovulation
104
mode of action of IUS
prevents endometrial proliferation/implantation
105
s/e of IUD
heavier periods
106
s/e of depo
prolonged return of fertility
| increases appetite
107
mode of action of depo
inhibits ovulation
108
premature menopause
<40y
109
early menopause
<45y
110
late menopause
>54 y
111
criteria for menopause
>1y amenorrhoea
| FSH >30 IU/L
112
who gets oestrogen only HRT
post-menopausal women
| NO UTERUS
113
who gets combined sequential HRT
```
any of:
peri-menopausal women
<54y
<1y amenorrhoea
and WITH A UTERUS
```
114
who gets combined continuous HRT
```
any of:
post-menopausal women
>54y
>1y amenorrhoea
and WITH A UTERUS
```
115
Mx hot flushes in menopause
clonidine (alpha blocker)
116
why are women with a uterus not given oestrogen only HRT
increased risk of endometrial ca
117
Mx vaginal dryness and atrophy in menopause
oestrogen creams
118
what is tibolone
an alternative to CC HRT
119
levonorgestrel
emergency contraception
| take within 72h
120
ulipristal acetate
emergency contraception
| take within 120h
121
test for HIV
HIV Antibody Test
- ELISA
- Ab usually become +ve 4-6w after infection
p24 Antigen test
- positive between 1-4w after infection
122
ring enhancing lesions CT
cerebral toxoplasmosis (HIV)
123
kaposis sarcoma cause
HHV8
124
kaposis sarcoma presentation
purple papules on skin
125
Ix pneumocystis pneumonia
bronchoalveolar lavage and immunoluorescence
126
Mx pneumocystis pneumonia
high dose co-trimoxazole
127
if man has -ve ELISA test 4w after potentially contracting HIV, what do you do
rpt ELISA test in another 2m - can take up to 12w to develop Ab, even tho most men develop in 4-6w
128
when should implant ideally be inserted
in day 1-5 of cycle
- if not, need to use additional contraception for 7d
129
why should oxybutynin be avoided in frail old ladies1
increased risk of falls
130
2nd line medical Mx in urge incontinence
Mirabegron
131
what can be used as a short term option to rapidly stop heavy bleeding
Norethisterone 5 mg tds
132
most common cause of diarrhea in HIV pts
cryptosporidium
133
latest time that HIV post exposure prophylaxis can be given
72h
134
hormone that makes uterus contract
oestrogen
135
hormone that settles the uterus
progesterone
136
hormone that initiates contractions
oxytocin
137
ideal position of baby coming out
suboccipito bregmatic
138
stages of labour
1 - 0-10cm dilation
2 full dilation to delivery of baby
2 delivery of the placenta
139
CTG components
DR C BRAVADO
```
Define Risk
Contraction
Baseline RAte
Variability
Accelerations
Decelerations
Overall impression
```
140
Contractions in CTG
no. in 10 mins
| 1 big sq = 1 min
141
Baseline Rate in CTG
average HR in 10min
| normal 110-150
142
Variability in CTG
variation from 1 beat to the next
| normal 10-25bpm
143
Accelerations in CTG
Increase in FHR by 15bpm for >15secs
144
Decelerations in CTG
Decrease in FHR by 15bpm for >15secs
145
Early deceleration on CTG
start and end with the contraction - physiological
146
Variable deceleration on CTG
no relation to the contraction, variable duration - pathological
147
Late decelerations on CTG
start with the contraction, end after the contraction - pathological
148
what do late decels indicate
fetal distress e.g. asphyxia or placental insufficiency
149
what do variable decels indicate
cord compression
150
define miscarriage
fetal loss <24w
151
threatened miscarriage
pregnany test +ve
fetal HB present
some bleeding, pain minimal
CLOSED os
152
inevitable miscarriage
pregnancy test +ve
pain, bleeding
OPEN os
153
incomplete miscarriage
pregnancy test -ve
++ pain, ++ bleeding, +/- septic
products of conception at os
OPEN os
154
complete miscarriage
pregnancy test -ve
cessation of bleeding
no products at os
CLOSE os
155
missed miscarriage
pregnancy test -ve
no fetal heart on USS
no evidence of expulsion
156
Medical Mx of miscarriage
misoprostol (makes uterus contract) - prostaglandin
157
Surgical Mx of miscarriage
give misoprostal before - softens cervix and dilates it to reduce surgical trauma
surgical evacuation of uterus
158
Do all women who have a miscarriage get anti-D
no - only rhesus -ve women undergoing surgical Mx
159
most common site for ectopic pregnancy
ampulla of uterine tube
160
Ix ectopic pregnancy
diagnostic laparoscopy
B-hCG
serum USS
161
Mx ectopic pregnancy
stable -
IM methotrexate or laparoscopic salpingectomy/salpingotomy
unstable -
laparotomy
162
when can an ectopic pregnancy be managed expectantly
low B-hCG
no symptoms
tubal ectopic <35mm
no fetal heartbeat
163
complete hydatiform mole
egg has lost its DNA, so entirely paternal DNA (46XY)
164
partial hydatiform mole
egg fertilized by 2 sperms (69 XXY)
165
risk with hyatiform mole
malignant change to choriocarcinoma
166
Mx hydatiform mole
desires fertility - dilation and evacuation
doesn't desire fertility - hysterectomy
167
causes of placental abruption
PET
HTN
cocaine
blunt trauma
168
types of placenta abruption
revealed - visible vaginal bleeding
concealed - no vaginal bleeding but collection of blood behind the placenta
169
types of placenta praevia
1 - reaches lower uterine segment but doesn't reach os
2. reaches internal os but doesn't cover it
3. reaches internal os before dilation, but not when dilated
4. completely covers internal os
170
Mx placenta praevia
final US at 36-37w
if grade 1 - vaginal delivery
if grade 3/4 - do c-sec at 37/38w
171
placenta accreta
placenta attaches to myometrium
172
placenta increta
placenta invades into myometrium
173
placenta percreta
placenta invades through myometrium
174
primary PPH
loss of >500ml of blood <24h after birth
175
secondary PPH
loss of >500ml of blood between 24h and 12w after giving birth
176
Major PPH blood loss
>1500ml
177
4T's of PPH
tone
tissue
thrombin
trauma
178
most common cause of PPH
uterine atony (90%) i.e. uterus not contracting to deliver placenta
179
Mx PPH
1. ABC, grey cannula
Medical -
1. IV oxytocin 10units or IV ergometrine 500mcg
2. IM carboprost
Surgical -
1. Intrauterine balloon tamponade
2. B lynch suture
3. Ligation of the uterine arteries
4. If severe and uncontrolled - hysterectomy
180
grade 1 perineal tear
superficial, no muscle involvement
181
grade 2 perineal tear
involves perineal muscles, spares anal sphincter
182
grade 3 perineal tear
perineal muscles and into anal sphincter
183
grade 4 perineal tear
perineal muscles, anal sphincter and rectal mucosa
184
who repairs 1st and 2nd degree perineal tears
midwives
185
who repairs 3rd and 4th degree perineal tears
obstetricians
186
fasting glucose level for Dx of gestational diabetes
>5.6 mmol/L
187
Dx of gestational diabetes
oral glucose tolerance test - 75g
188
OGTT level for Dx of gestational diabetes
> 7.8 mmol/L
189
Mx gestational diabetes
1. wt loss, diet, exercise
2. metformin
3. insulin
190
additional care for gestational diabetes
extra scans at 28, 32 and 36w
191
delivery in gestational diabetes
37-38w
192
Mx shoulder dystocia in labour
mcrobert's manoeuvre
193
Mx hyperthyroid in pregnancy
proplthiouracil
194
Mx hypothyroid in pregnancy
increase levothyroxine dose 25-50mcg in 1st trim
195
pre-existing HTN
diagnosed prior to pregnancy or diagnosed <20w
```
>140/90mmHg on 2 occasions
or
diastolic >110mmHg
or
rise of 30/15 mmHg compared to booking BP
```
196
pregnancy induced HTN
diagnosed >20w
resolves within 6w after delivery
no features of PET
197
Mx of HTN in pregnancy
1. labetalol
2. methyldopa
3. nifedipine
198
when is Tx of HTN in pregnancy indicated
if BP >150/100 mmHg
199
who gets prophylaxis for PET and what is the prophylaxis
women with known risk factors
aspirin 150mg daily
200
triad of PET
1. HTN
2. proteinuria
3. oedema
201
how much is significant proteinuria in a 24h urine sample
>300mg in a 24h urine sample
or
>30 mg/mmol urinary protein:creatinine ratio
202
cause of PET
failure of normal trophoblast invasion - results in a high resistance flow
203
Mx of PET
1. ADMIT
2. Anti HTN - Labetalol
3. Delivery (prompt)
4. if risk of eclampsia - magnesium sulphate
204
eclampsia
tonic - clonic seuizure
205
Mx eclampsia
magnesium sulphate 4mg IV
then infusion of 1g/hr
delivery
206
HELLP syndrome
indicates severe PET
Haemolysis
Elevated Liver enzymes
Low Platelets
207
1st trim down's syndrome screening - timing and what's included in test
booking scan (11 - 13+6 weeks)
1. maternal age
2. nuchal translucency
3. B-hCG
4. PAPP-A
208
2nd trim down's syndrome screening - timings and what's included in test
used if women present later for booking (15-20w)
triple test:
AFP, B-hCG, unconjugated oestriol
quadruple test:
AFP, B-hCG, unconjugated oestriol, inhibin A
209
diagnostic testing for Down's syndrome screening
chorionic villus sampling (tests placenta)
amniocentesis (tests amniotic fluid)
maternal fetal blood sampling (better than above 2, but ++ expensive)
210
timing of chorionic villus sampling
11 - 13+6w
211
timing of amniocentesis
>15w
212
what do some women receive after diagnostic genetic testing
rhesus, if they are -ve
213
dose of folic acid women should be on
400mcg from 12w pre-conception
214
dose of folic acid for high risk women
5mg
215
Anticonvulsants to avoid in preg
AVOID sodium valproate
Give - Lamotrigine
216
Antidepressants to avoid in preg
AVOID SSRIs - pulmonary HTN, CVS defects
217
Antibiotics to avoid in preg
Tetracyclines - stain bone and teeth
Gentamicin - nephrotoxic and ototoxic
Trimethoprim - folic acid inhibitor, avoid in 1st trim (NTD)
Nitrofurantoin - neonatal haemolysis, avoid 2nd and 3rd trim
Chloramphenicol - CVS collapse (grey baby syndrome)
218
Anticoagulant to avoid in preg
Warfarin
219
Anticoagulant safe in preg
LMWH
220
why should ACEi/ARB be avoided in preg
renal agenesis, IUGR
221
Ix used on US to detect a SGA baby
abdomen circumference (used in Tayside)
also:
head circumference
femur length
222
if baby has normal head circumference and small abdo circumference, what does this indicate
placental failure
| - baby is redirecting blood to brain to compensate
223
if baby has small head circumference and small abdo circumference, what does this indicate
chromosomal abnormality
224
use of uterine artery doppler
measures placental resistance (i.e. from maternal side)
reduced resistance = normal
increased resistance = invasion hasn't taken place ("notching")
225
use of umbilical artery doppler
measures blood flow to baby (i.e. fetal side)
normal = flow during systole and diastole
abnormal = absent end diastolic flow
v abnormal = reversed end diastolic flow (pre-terminal)
226
Ix done after umbilical artery doppler if its abnormal
middle cerebral artery doppler
| - if shows increased flow, means the baby is compensating and these vessels are dilating to get blood to the brain
227
if baby is going to be delivered prem, what does mum get
steroids - 2 doses of betamethasone
and
4g Iv magnesium sulphate
228
if umbilical artery doppler abnormal <37w - Mx
section
229
if umbilical artery doppler abnormal at term - Mx
section
230
if umbilical artery doppler normal at term - Mx
VD
231
Mx placenta abruption
C-sec
232
most common cause of uterine rupture
many C-sections means scare more likely to burst, most commonly happens in labour
233
vasa praevia
abnormally sited fetal vessels - they run in the membranes rather than being protected by the placenta.
234
presentation vasa praevia
membranes rupture, then vaginal bleeding
+
fetal bradycardia
235
Mx vasa praevia
urgent c-sec
236
Mx vasa praevia if detected before membranes rupture
planed c-sec
237
parity
number of pregnancies delivered >24w
238
gravida
number of pregnancies
239
what is an ectropion
exposure of the columnar epithelium of the endocervix
240
what criteria means 'high risk' women for 5mg folic acid dose
obese (BMI >40)
twin pregnancy
anti-epileptics
Hx of NTD
241
how much vit D should a women take during preg
10mcg
242
how to detect if a woman is smoking during preg
CO level test - >4 is significant
243
what is tested for by midwife @ booking scan
```
Hb + platelets
blood group
rhesus group
Hep B, HIV, syphilis
Hep C - if Hx of drug use
Blood glucose
```
244
anomaly scan
18-24w
245
if Hx of cardiac probs, when does woman get extra scan
28w
246
how many midwife visits does prim mum have
10
247
how many midwife visits does mum having 2nd baby or more get
7
248
when do rhesus -ve women get their anti-D
28 + 34 w
249
prophylaxis of VTE in preg
LMWH (dose based on wt)
250
when should LMWH prophylaxis be started in preg in at risk women
immediately (i.e. at booking) - if 4 or more risk factors
28w - if 3 or less risk factors
251
how long should prophylactic LMWH be continued for after preg
6 weeks - if high risk
10d - if intermediate risk
252
Ix DVT in preg
compression duplex US
253
Mx DVT in preg
```
TEDS
give LMWH
stop onset at labour
restart 3h post-op
continue 3m post-natal
```
254
Ix PE in preg
1. V/Q scan
255
why are d-dimers not used as PE Ix in preg
raised anyway in preg, so not specific
256
why is CTPA not used as PE Ix in preg
increased risk of maternal breast ca
257
disadvantage of V/Q scan
increased risk of childhood ca
258
timing of baby blues
3-10 days
259
timing of post-natal depression
2-6 weeks
260
timing of puerperal psychosis
<6 weeks
261
cut off in tayside for medical TOP
18+6 w
262
cut off in tayside for surgical TOP
up to 12w
263
nationwide social acceptable termination cut off
23+6 w
264
cut off for TOP if fetal anomaly
no cut of f- any gestation
265
Medical Mx of TOP
oral mifepristone (anti-progesterone)
then
oral or vaginal misoprostal (prostaglandin) - 24h later
266
follow up for TOP
initiate contraception ON SITE prior to discharge
do pregnancy test 2-3w
anti D
counselling
267
location of spermatogenesis
Sertoli cells in the seminiferous tubules
268
where is testosterone produced and what is its role
Leydig cells - enhance spermatogenesis
269
what pituitary hormone stimulates testosterone production
LH
270
azoospermia
no sperm in the semen
271
obstructive causes of azoospermia
CF, vasectomy
272
non-obstructive causes of azoospermia
congenital, infection, genetic, endocrine
273
Ix of male infertility
1. testicular volume, confirm vas deferens present
2. semen analysis
if abnormal -
rpt 6 w later, endocrine profile, chromosome analysis
then
testicular biopsy
274
normal testicular volume
12-25 ml
275
testes size in obstructive causes of male infertility
normal size
276
testes size in non-obstructive causes of male infertility
reduced size
277
Mx azoospermia
surgical sperm retrieval
and then ICSI (inject sperm into egg)
278
Ix to confirm whether woman is ovulating
21d progesterone
(N.B) adjust day for the length of the womans cycle
279
how long do couple need to be trying for until they will be investigated for infertility
2y
280
criteria or qualifying for IVF on the NHS
no children already
healthy BMI
non-smoker
<42
281
Lambda sign on US
dichorionic diamniotic pregnancy
282
T sign of US
monochorionic diamniotic pregnancy
283
zygosity definition
number of eggs fertilized to produce twins
284
chorionicity definition
the membrane pattern of the twins
