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PAM Semester 4 > Pharm Reproduction Exam 2 > Flashcards

Pharm Reproduction Exam 2 Flashcards

1
Q

Menopause and non hormonal therapy

A

The best studied agents with positive results include

SSRI
SNRI
Anti epileptics
Clonidine
Oxybutynin
Centrally acting drugs
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2
Q

MHT

A

Menopausal hormone therapy (MHT)

Broad term that describes unopposed estrogen use for women who have undergone hysterectomy,

and

combined estrogen-progestintherapy (EPT) for women with an intact uterus who need a progestin to prevent estrogen-associated endometrial hyperplasia.

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3
Q

The primary goal of MHT is to?

A

Relieve vasomotor symptoms (hot flashes).

Other symptoms associated with perimenopause and menopause that respond to estrogen include

sleep disturbances, depression/anxiety, and, in some cases, joint aches and pains.

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4
Q

Standard recommendations of use of MHT

A

3 to 5 years

Extended use can be done in severe or persistent cases

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5
Q

Which types of estrogen are good for hot flashes

A

All types of estrogen are equal for hot flashes

17 beta estradiol is preferred
structurally identical to estrogon secreted by ovary

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6
Q

Estradiol indications

A

Estrace (estrogen)

Moderate-to-severe vasomotor symptoms of menopause. Atrophic vaginitis. Hypoestrogenism. Osteoporosis prevention.

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7
Q

Estradiol
Contraindications
warnings

A 
Contra
Breast or estrogen dependent cancer
Thromboembolic disorders
Undiagnosed abnormal genital bleeding
Preg CAT X

Warnings
Increased risk of endometrial carcinoma or hyperplasia in women with intact uterus (adding progestin is essential).

Increased risk of cardiovascular events (eg, MI, stroke, VTE); discontinue if occurs. Manage risk factors for cardiovascular disease and venous thromboembolism appropriately.

Breast cancer, endo cancer, thrombo, preg, CV, bleed

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8
Q

Estradiol

Box warnings

A

Box Warnings

Endometrial cancer
Breast cancer
Cardiovascular disorders
Probable dementia

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9
Q

Estradiol Pregnancy category

A

CAT X

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10
Q

Amenorrhea (primary)

A

Absence of menses at age 15

in the presence of normal growth and secondary sex characteristics

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11
Q

Secondary amenorrhea

A

Absence of menstruation for 6 months or more

or a period of time of 3 consecutive cycles

in a woman who was previously menstruating

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12
Q

Secondary amenorrhea Causes

A

Pregnancy is most common cause

Drug use
stress
Significant weight changes
Excessive exercise
Asherman syndrome
PCOS
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13
Q

2 types of dysmenorrhea

A

Primary and secondary

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14
Q

Primary dysmenorrhea

A

Natural uterine contractions due to high prostaglandin concentration, aimed at shedding its lining

Begins 1st day of period
lasts 8-72 hours
Lower abdomen (radiate to legs and back)
Improves with age

Common and normal

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15
Q

Secondary Dysmenorrhea

A

Endometriosis
Uterine fibroids
PID

Begins 1-2 days before period
Lasts for over 3 days
Lower abdomen (radiate to legs and back)
Gets worse with age

Indicates reproductive tract disease

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16
Q

Which type of dysmenorrhea gets better with age

A

Primary dysmenorrhea

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17
Q

Dysmenorrhea treatment goal

A

Relief of pain
Should allow women to perform usual activities

Primary dysmenorrhea can be treated empirically

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18
Q

Dysmenorrhea resistant to treatment

A

NSAIDS
Hormonal contraceptives’

are mainstay of treatment

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19
Q

Dysmenorrhea resistant to treatment

NSAIDS

A

Ibuprofen 400-600 Q6 or
Ibuprofen 800 Q8

If no relief

mefenamic acid (Fenamate)
500mg loading dose
250mg Q6 x 3 days
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20
Q

Mefenamic acid

A

Ponstel (NSAID)
Dysmenorrhea

Contra
Aspirin allergy, CABG

Risk of serious cardiovascular and GI events

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21
Q

PMS First line and don’t want contraception

A

SSRI is first line
for moderate to severe
who do not contraception

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22
Q

PMS Treatment who don’t respond to SSRI

A

COC Combination oral contraceptives

If cannot tolerate COC or SSRI

GNRH trial
(Leuprolide)

COC, Leuprolide

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23
Q

Leuprolide

A

Lupron Depot (GNRH analogue)

Endometriosis (pain/lesions)

Contra
Vaginal bleeding, Pregnancy, Nursning

Adverse
Hot flashes, HA, Decreased libido, Depression, Dizziness, NV, Pain, weight change, Vaginitis, Amenorrhea, Acne, Bone density loss

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24
Q

therapies for PMS

A

SSRI

Ovulation suppression agents
COC (20/90), (20/3)
GNRH (Leuprolide)

Alprazolam (not recommended)

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25
Q

PID treatment

A

Inpatient
Cefoxitin/Cefotetan and Doxy
or
Clinda plus Genta

Outpatient
IM ceftriaxone plus
Doxy 14d
Flagyl 14d

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26
Q

Cervical cancer Types

A

Squamous cell carcinoma

Adenocarcinoma

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27
Q

Endometrial cancer

A

Affects postmenopausal women almost exclusively

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28
Q

Endometrial hyperplasia drug causes

A

Tamoxifen

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29
Q

Prevention for ovarian cancer

A

OCP (oral contraceptive pills)

Decreases risk of developing ovarian cancer
especially in young women who have used it for several years

If used for over 5 years, 50% less chance of ovarian cancer

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30
Q

First trimester abortion medication

A

Mifepristone (progesterone antagonist)
in combination with
Misoprostol (Synthetic Prostaglandin e1)

Can be used up to 70 days gestation
Routinely used up to 77 days (11weeks)

M&M

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31
Q

Mifepristone MOA

A

Blocks progesterone receptors on the uterus

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32
Q

Misoprostol MOA

A

Stimulates Uterine contractions

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33
Q

Mifepristone

A

Mifeprex (abortifacient)

Contraindications
Ectopic, Adnexal mass, IUD, Adrenal failure, Prostaglandin allergy, Bleeding disorder, Porphyria’s, long term steroid or anticoagulants

Box warning
Serious/fatal infection or bleeding

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34
Q

Misoprostol

A

Cytotec (prostaglandin analogue)

Contra
Pregnancy

Warning
Abortifacient properties (don't give to others)

Adverse
Diarrhea, abdominal pain, HA, Gyn Effects, Abortion, Birth defects, uterine rupture, premature birth

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35
Q

Abruptio Placentae

A

If less than 34 weeks with no evidence of major blood loss or coagulopathy

Conservative management until 37-38 weeks

Use antenatal corticosteroids

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36
Q

Oxytocin

A

Pitocin

Improve uterine contractions, abortion adjunct, control postpartum bleeding

Contra
In antepartum
Cephalopelvic disproportion
Unfavorable fetal position

Box warning
Not for induction of labor

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37
Q

Oxytocin MOA

A

Activates G protein coupled receptor IP3

Increases intracellular calcium

Increases local prostaglandin production

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38
Q

Ectopic pregnancy

A

Extrauterine pregnancy

96% in fallopian tubes

Can be treated with
Methotrexate
Surgery
or expectant management

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39
Q

Methotrexate MOA

A

Interferes with DNA synthesis by inhibiting synthesis of pyrimidines leading to trophoblastic cell death

Auto enzymes and maternal tissues then absorb the trophoblasts

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40
Q

Gestational diabetes Treatment

A

Insulin is first line

If cannot take insulin
Glyburide or metformin
Placental passage effects are unknown

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41
Q

Gestational diabetes test

A

Fasting = 95
1 hour after glucose = 180
2 hours after = 155
3 hours after = 140

100mg glucose load (drink)

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42
Q

Gestational trophoblastic disease

A

Low risk GTN = single agent chemo

Methotrexate over dactinomycin

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43
Q

Anti HTN Pregnancy meds

A

Labetalol - BB (combined Alpha/beta blocker)
Hydralazine - Peripheral vasodilator
Nifedipine - CCB
Nicardipine - CCB
Methyldopa - Centrally acting alpha agonist

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44
Q

Incompetent cervix

A

If prior spontaneous preterm birth
Progesterone at 16-20 weeks through 36 weeks

can be before/during/after cerclage

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45
Q

Corticosteroid MOA

A

Induces fetal lung antioxidant system
Regulates gene function in maturing lung
Induces pulmonary beta receptor
Increases surfactant production
Improves lung mechanics and gas exchange
Upregulates gene expression of Na channel
Accelerates development of type 1/2 pneumocytes
Induces production of surfactant protein
Induces production of phospholipid synthetase

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46
Q

Primary Post partum Hemorrhage

A

Primary PPH Occurs 24 hours after delivery

Causes
Atony, Trauma, acquired/congenital coagulation defects

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47
Q

Secondary Post partum hemorrhage

A

Secondary PPH occurs after 24 hours to 12 weeks after delivery

Causes
Atony, Trauma, acquired/congenital coagulation defects

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48
Q

4 T’s of post partum hemorrhage

A

Tone (atony)
Tissue (retained placenta)
Trauma,
Thrombin (coag)

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49
Q

Post partum hemorrhage

First line Treatment

A

Uterotonic Agents
Oxytocin
Ergot alkaloids (Ergometrine, Methyl ergonovine)
Prostaglandins (misoprostol, Dinoprostol)

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50
Q

Tranexamic acid

A

TXA (Lysteda) (antifibrinolytic)

Cyclic or heavy menstrual bleeding

Not recommended for children (Pre menarche)

Contra
Active/ history of thromboembolic events
Combination oral contraceptives

51
Q

TXA MOA

A

Antifibrinolytic

Inhibit the activation/action of plasmin

Stops conversion of plasminogen to plasmin

52
Q

Premature rupture of membranes vs PPROM

A

PROM >37 weeks

PPROM <37 weeks

53
Q

Premature rupture of membranes

managment

A

for stable patients <34 weeks
Expectant management

Antenatal steroids to reduce morbidity and mortality if preterm labor occurs

Prophylactic ABX
IV Ampicillin 2g q6 for 48 hours then,
Amoxicillin 875mg PO BID x 5 d
Also give 1g azithromycin PO on admission

Steroids & AAA

54
Q

Rh Incompatibility

Signs and symptoms

A 
Hemolysis
Jaundice
Anasarca
Resp Distress
Circulatory collapse
Kernicterus

occurs several days after delivery
Has poor feeding
Decreased activity

55
Q

Rhogam

A

Contra
RH positive patients

Preventing Rho(D) sensitization in nonsensitized Rho(D) negative or Du negative patients to the Rho(D) factor, following pregnancy or accidental transfusion.
-
-
-
-
-
RH neg mom, RH pos baby, mom builds AB,
If 2nd bay is RH pos, moms AB will attack babies blood cells
56
Q

Estrogen and progesterone are two types of?

A

Female sex hormones

57
Q

Estrogen and progesterone are both?

A

Steroid hormones

part of Contraceptive mix of birth control pills

58
Q

Estrogen and progesterone are secreted?

A

During menstrual cycle

and play a role in pregnancy

59
Q

Difference between Estrogen and progesterone

Secretion

A

Estrogen is secreted by ovaries prior to ovulation
Also produced by placenta

Progesterone
Secreted by ovaries after ovulation
Also produced by placenta
-
-
-
-
Estrogen before, Progesterone after ovulation
60
Q

Difference between Estrogen and progesterone

Regulation

A

Estrogen is regulated by FSH

Progesterone is regulated by LH

61
Q

Difference between Estrogen and progesterone

During pregnancy

A

Estrogen is involved in the enlargement of uterus and breasts

Progesterone is involved in the reduction of contractility of the uterus and the growth of the mammary glands

62
Q

Example of endogenous Estrogen

A

Estradiol

63
Q

Example of Exogenous estrogen

A

Ethinyl estradiol

64
Q

Progestins used in contraceptive pills

First gen

A

Norethindrone acetate
Ethynodiol diacetate
Lynestrenol
Norethynodrel

65
Q

Progestins used in contraceptive pills

second gen

A

Di-norgestrel

Levonorgesterel

66
Q

Progestins used in contraceptive pills

Third gen

A

Desogestrel
Gestodene
Etonogestrel
Norgestimate

67
Q

Progestins used in contraceptive pills

Unclassified

A

Drospirenone

Cyproterone acetate

68
Q

Etonogestrel

A

3rd gen Progestin

Found in Implant and Nuva Ring

69
Q

POPs

Progestin only contraceptive pills

A

Good for High risk patients with
CAD, CVD, PE, HTN (also migraines)

When estrogen is contraindicated

Have little effect on Coags, BP, inflammatory markers or lipids

70
Q

Vaginal contraceptives

A

etonogestrel / ethinyl estradiol vaginal

Nuva Ring, EluRyng

71
Q

etonogestrel / ethinyl estradiol vaginal

120mcg/15/mcg per day

A 
Nuva Ring 
Hormonal contraceptive (Progestin + estrogen)

Insert 1 ring, leave in for 3 weeks, remove for 1 week

Box warning
Smoking increases risk of serious cardiovascular events

Warnings
Smokers, especially over 35
Discontinue if thrombo event

Smoking, thrombo

72
Q

etonogestrel / ethinyl estradiol vaginal
120mcg/15/mcg per day
Nuva Ring
Contraindications

A

High risk of arterial or venous thrombotic disease

(eg, smokers or migraineurs over age 35, history of DVT or thromboembolism, cerebrovascular or coronary artery disease, thrombogenic valvular disease, atrial fibrillation, subacute bacterial endocarditis, hypercoagulopathies, uncontrolled hypertension, diabetes with vascular disease, headaches with focal neurologic symptoms).

Breast or other estrogen or progestin-sensitive neoplasms.

Hepatic disease or tumors.

Undiagnosed abnormal uterine bleeding.

Pregnancy.
-
-
-
Smoking, thrombo, liver, cancer, preg, bleed
73
Q

COC

Monophasic

A

Same amount of hormone in pill every day
Except in placebo pills

Most common type of BC pill

Usually start on low dose to reduce risk of stroke

Switch to higher dose if bleeding or spotting

74
Q

COC

Biphasic

A

Amount of hormone may change halfway through cycle

two sets of different strength pills

Progestin changes, estrogen stays same
then have placebo pills

75
Q

COC

Triphasic

A

Amount of hormone changes every week

Traditional:
Progestin usually changes and estrogen stays same
3 strengths of progestin (gradually increases)
Similar to bodies natural function

Most common, 7d, 7d, 7d, then 7d of placebo

Estrophasic
Estrogen changes

76
Q

COC

Quadriphasic

A

Estrogen and progestin changes

Four varying amounts throughout monthly pack

Levonorgestrel/ethinnyl estradiol
(fayoism, Quarette, Rivelsa)

Estradiol valerate/dienogest (Natazia)

77
Q

Drospirenone 3mg

Ethinyl estradiol 20mcg

A

YAZ (progestin + Estrogen)
Pill

Warning
Smoking increases risk of serious CV Events

Contra
Renal, adrenal, Hepatic, High risk VTE/CVD/CAD/Etc, Breast/uterine neoplasm, uterine bleeding, pregnancy

78
Q

Progestin only oral contraceptives

A 
Norethindrone
Drospirenone (Slynd)
79
Q

Injectable Contraceptive

A

Medroxyprogesterone acetate

Depo-Provera

80
Q

Intrauterine Contraceptive Device

Mirena

A

Mirena (progestin IUD)
Good for up to 6 years

Contra
Uterine anomaly, PID, Postpartum endometritis or septic abortion in last 3 months

Interactions
Antagonized by CYP3A4 inducers
Potentiated by CYP3A4 inhibitors
Caution with anti coags

Adverse
Bleeding pattern changes, Abdominal/pelvic pain, amenorrhea

81
Q

Medroxyprogesterone acetate

Depo-Provera

A

Depo-Provera (Progestin)
Injectable contraceptive

Contra
Thrombophlebitis, Stroke, Breast cancer, Liver, Vaginal bleeding, Pregnancy, VTE

Warning
Loss of bone mineral density

82
Q

Norelgestromin 150mcg/day
ethinyl estradiol 35mcg/day
Patch

A

Xulane (progestin + estrogen)
Transdermal contraceptive

Apply 1 patch per week for 3 weeks, 1 week off

Box warning
CVD risk with smoking, VTE

83
Q

Infertility medications

A

Clomiphene (clomid)

Letrozole (Femara)

Metformin (Glucophage)

Chorionic gonadotropin (Novarel)

84
Q

Aromatase inhibitors

A

In patients with PCOS

a double blind trial showed Letrozole was better than Clomiphene

for inducing ovulation and live birth

85
Q

Labor inducing drugs

A

Synthetic oxytocin (Pitocin) - Activates oxytocin receptors

Misoprostol - PGE1 analogue

Dinoprostone - PGE2 analogue

86
Q

Tocolytic Drugs

A

Nifedipine - CCB

Terbutaline - Beta 2 agonist

Mag sulfate - Unknown (might compete with calcium)

Indomethacin - COX inhibitor

Atosiban - Oxytocin/vasopressin competitive antagonist

87
Q

Tocolytics

A

inhibit labor

24-32 weeks gestation
indomethacin is first line for labor inhibition

If cant use indomethacin
Nifedipine

88
Q

Herbs used in reproduction

A 
Black cohash
Fenugreek
Maca
Red clover
Vitex
89
Q

Herbs

Black cohash

A

Supports female reproductive system
used for menopause, PMS, painful menstruation, Osteoporosis (weak/brittle bones)
others

90
Q

Herbs

Fenugreek

A

Supports the optimal production of breast milk

91
Q

Herbs

Maca

A

Supports healthy libido and normal fertility

92
Q

Herbs

Red clover

A

A rich source of naturally occurring phytoestrogens

93
Q

Herbs

Vitex

A

Supports female hormone production and balance

Especially during transitions of life

94
Q

Labor induction goals

A

To delay labor as long as possible

Give steroids for 48 hours <34 weeks

If first drug does not produce contractions,
stop and start next drug

95
Q

Which of the following classes of medications do not cause galactorrhea secondary to hyperprolactinemia?

1st generation antipsychotic meds
Tricyclic antidepressants
Salicylates
Antihypertensives

A

Salicylates

96
Q

Which of the following contraindications is a contraindication for the drug, tamoxifen (Soltamox)?

History of DVT
Pregnancy Category C
Renal impairment
Prolongation of QT interval

A

History of DVT

97
Q

Which of the below medications for breast cancer is an aromatase inhibitor?

Tamoxifen (Nolvadex)
Letrozole (Femara)
Raloxifene (Evista)
Estradiol (Estrace)

A

Letrozole (Femara)

98
Q

Which of the following medications has a MOA of blocking progesterone receptors on uterus?

Misoprostol (Cytotec)
Oxytocin (Pitocin)
Mifepristone (Mifeprex)
Tinidazole (Tindamax)

A

Mifepristone (Mifeprex)

99
Q

Which of the following medications is not used for patients with hypertension in pregnancy?

Labetalol (Trandate)
Lisinopril (Zestril)
Hydralazine (Apresoline)
Methyldopa (Aldomet)

A

Lisinopril (Zestril)

100
Q

Which of the following is an example of endo-estrogens?

Estradiol valerate
Estradiol
Ethinyl estradiol
mestranol

A

Estradiol

101
Q

Which of the following medications is considered a middle level of androgenic activity of progestins in contraceptive pills?

Norgestrel
Drospirenone
Norethindrone
Desogestrel

A

Norethindrone

102
Q

Which of the following terms best illustrates amount of weekly hormone changes every week within OCCs?

Monophasic
Biphasic
Triphasic
None of the above

A

Triphasic

103
Q

What are common dosages of oral estradiol (Estrace)?

  1. 1mg, 0.2mg, 0.5mg
  2. 2mg, 0.4mg, 0.6mg
  3. 5mg, 1mg, 1.5mg
  4. 5mg, 1mg, 2mg
A

0.5mg, 1mg, 2mg

104
Q

Which of the following is a contraindication for the drug, mefenamic acid (Ponstel)?

CABG
Acetaminophen allergy
GI tumor
Renal impairment

A

CABG

105
Q

Polypharmacy types

A

Same class (2 or more meds from same class)

Multi class (2 or more drugs from different classes for same symptoms) (i.e. ACE, CCB)

Adjunct (use of one med to treat side effects of another med)

Augmentation (use of one drug at a low dose from one class and another drug from a different class to get full therapeutic dose for same symptoms

106
Q

How many elderly patients find it difficult to afford meds

A

24%

107
Q

What is Area Agency on Agingfacilities

A

The Federal Government has mandatedArea Agency on Agingfacilities in every county/city.

These agencies have professionals who hold vast knowledge on all things ‘social services for the elderly’ related.

108
Q

Pharmacokinetics in aging

distribution

A

Albumin, the primary plasma protein to which drugs bind, is usually lower in older adults.

Because of that, there is a higher proportion of unbound (free) and pharmacologically-active drug.

With aging, there is a decrease in elimination resulting in the accumulation of the unbound drug in the body.

Examples are
ceftriaxone, phenytoin, valproate, warfarin, diazepam, and lorazepam.

109
Q

Drugs that build up in body due to aging

A 
ceftriaxone, 
phenytoin, 
valproate, 
warfarin, 
diazepam, 
lorazepam.
110
Q

Pharmacokinetics in aging

Elimination

A

Renal size and bloodflow is decreased

Glomerular filtration declines

111
Q

Over dose in elederly

A

An excessive dose of an appropriate drug may be prescribed for older adults if the prescriber does not consider age-related changes that affectpharmacokineticsandpharmacodynamics.

112
Q

Poor communication in elderly

A

Poor communication of medical information at transition points
(from one health care setting to another)

causes up to 50% of all drug errors and up to 20% of adverse drug effects in the hospital.

113
Q

Under prescribing in elderly

A

Drugs that are often underprescribed in older adults include those used to treat

depression, 
Alzheimer disease, 
pain (eg, opioids), 
heart failure, 
post-MI (beta-blockers), 
atrial fibrillation (warfarin), 
hypertension, 
glaucoma,
incontinence.
114
Q

BEERS criteria

A

the American Geriatric Society (AGS)
Beers Criteria®
for Potentially Inappropriate Medication Use in Older Adults

have been a leading source of information about safely prescribing medications for older people.

The AGS Beers Criteria®identify medications with risks that may be greater than their benefits for people age 65 and older.

115
Q

Drug categories that pose high risk in elderly

A 
analgesics, 
anticoagulants, 
antihypertensive, 
antiparkinsonian drugs, 
diuretics, 
hypoglycemic drugs, 
psychoactive drugs
116
Q

Elderly prescribing tips

A

Treat the disease process rather than symptoms

Be cautious about adding new medication

‘Start low, go slow’

Monitor closely for adverse effects

Manage the whole of the patients treatment
regimen

117
Q

Drug disease interactions
Cardiovascular
Heart Failure

A

May promote fluid retention and exacerbate heart failure

Cilostazol,
COX-2 inhibitors,
dronedarone
nondihydropyridine CCB’s (diltiazem,verapamil),
NSAIDs,
thiazolidinediones (pioglitazone,rosiglitazone)

118
Q

Drug disease interactions
CNS
Falls/Fractures

A

Can cause ataxia, impaired psychomotor function, syncope, and additional falls

Anticonvulsants, 
antipsychotics, 
benzodiazepines, 
nonbenzodiazepine hypnotics 
              (eszopiclone,zaleplon,zolpidem), 
opioids, 
TCAs, 
SSRIs
119
Q

Drug disease interactions
CNS
Delirium

A

Can worsen delirium,
antipsychs can increase stroke risk

Anticholinergics, 
antipsychotics, 
benzodiazepines,
chlorpromazine, 
corticosteroids, 
H2 blockers (cimetidine,famotidine,ranitidine),
meperidine, 
sedative hypnotics
120
Q

Drug disease interactions
CNS
Insomnia

A

Can cause CNS stimulant effect

Oral decongestants (pseudoephedrine,phenylephrine),

stimulants (amphetamine,armodafinil,methylphenidate,modafinil),

theobromines (theophylline, caffeine)

121
Q

Drug disease interactions
CNS
Parkinson’s

A

Dopaminereceptor antagonists with potential to worsen parkinsonian symptoms

Antiemetics (metoclopramide,prochlorperazine,promethazine),

antipsychotics (except foraripiprazole,quetiapine, andclozapine)

122
Q

Drug disease interactions
GI
Gastric/duodenal ulcers

A

Exacerbate existing ulcers or cause new ulcers

Can take PPI

Aspirin(> 325 mg/day),
non–COX-2 selective NSAIDs

123
Q

Drug disease interactions
Renal
CKD (stage 4) (CrCl <30)

A

Increased risk of acute kidney injury and further decline of renal function

NSAIDs (non-COX and COX-selective, oral and parenteral)

124
Q

Drug disease interactions
Renal
Lower UTI/BPH

A

May decrease urinary flow and cause urinary retention in men

Drugs that have strong anticholinergic effects (except antimuscarinics for urinary incontinence)

PAM Semester 4 (7 decks)

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