OB/GYN Flashcards

Terms Definitions
metorrhagia
irregular bleeding
preg prenatal terato

microceph
hydroceph
cerebral Ca++
chorioretinitis
toxoplasma
Chlamydia tx
Azythromycin, doxycline
partner tx
ectopic
treatment
diff laparotomy
vs laparoscope
laparotomy salpinectomy

vs
laparascope salingOstomy:
shorter stay, more comps from retained ectopic tissue

Both same inc repeat ectopics, both same fetility after.
What is tx for trich?
metronidazole
Oligomenorrhea
reduction in frequency of menses
preg prenatal terato

neural tube defect
fingernail hypoplasia
microceph
devel delay
IUGR
carbemezapine
What is the recommended initial modality to evaluate a breast mass in a patient < 40 years of age?
US
Fundal height approximates weeks gestation until what time
36 weeks
how do you treat bacterial vaginosis?
Metronidazole
endometr
how cause infertile
adnesions
alter peritoneal fluids composition, alter ovul or ovum travel
luteinized unruptured follice syndrome : ovulate but oocyte not released from ovary
endo preg
aldo-angioten
Aldosterone: main source MOM adrenal.
Effect: absorb Na and secrete K in distal tubule.
Renin rises in preg, higher aldosterone.

In preg-HTN: decine in aldo secrn and may fall below pre-preg levels.
nutr
vits key pre-conc
folate 0.4 mg
B6
B12
endometr
epidem
3-10% wmn repro age
25-35% infertile women
What pharmacologic treatment should be used in all hormone receptor + patients?
Tamoxifen
When considering the presence of an ovarian cyst, which of the following should also be kept on the differential diagnosis list?
appendicitis
Tertiary syphillis
severe damage to cardiovascular system or CNS, Gummas appear 1-10y after infection
how is the diagnosis of PMS made?
HISTORY
ob
chadwick
hagar
chadwick = blueish tinge upper vagina and cervix as inc vascularity and hyperemia

hagar: softening lower uter segment, a soft isthmus between uter and cervix

at 12 wks uterus is out of pelvis
mens
secretory phaseq
endomet phase
starts at ovul
ALWAYS 14 days so if 14 day cycle, ovul at 16 days.

Prog stim mucus &amp; glycogen prod by glands.
GLAnds tort and dilated.
COnvol spiral art extend to superficial layer of endometrium.
Stroma gets edematous.
endo
PCOS
drug Rx
Main: OCP, progestin, metformin
FOr hair: antiandrogens
Infert: clomiphene and sexmethasone or metformin.
For endomet hyperplasia/car risk reduction: OCP or progestin.
Rx CV RF and lipids, wt loss and exercise.
Risk factors for postpartum hemorrhage.
Too stretched
-Macrosomia
-Multiple gestation
-Polyhydramnios
-Grand multiparity (means having parity ≥ 5)

Too tired
-Long labor
-Fast labor
-Augmentation with oxytocin

Too damaged
-Episiotomy
-Forceps
-Clamps
-Chorioamnionitis
-Preeclampsia
-Fibroids
-Anesthesia
Repeat culture comes positive again, what do you do?
Treat again
firm, dome shaped papules with an umbilicated center 
molloscum contagiosum
What is the most common modality for evaluating the female pelvis
Ultrasound
After excluding pregnancy, what is the most common cause of secondary amenorrhea
Ovarian disease
Dx of PID
cervical motion tenderness or uterine or adnexal tenderness in presence of lower abdominal or pelvic pain
Temp>101
Mucopurulent cervical discharge
Abundant WBCs on microscopy of vaginal secretions
Elevated ESR, & CRP
2nd most common form of benign brest disease
Fibroadenoma
What is the primary therapy for endometriosis?
GnRH agonist
Pelvic Inflammatory Disease - most common cause?
Gonorrhea / Chlamydia
endo preg
PRL
peptide
Ant pit main source (plac cont very little to overall pool)
nml is 10 ng/ml
In preg PRL rises due to estogen stim ant pit.

Effects: stim post partum milk prod.
GU UTI
dysuria
urge
freq with sm amts voided
nocturia
suprapubic discomfort
occ incont and hematuria
cystitis
inflammed bladder
infert
varicoceles effect
lower sperm number
lower % forward motile (nml 50%)
more abn forms
contra
CI OCPS
preg
h/o thromboem dz : stroke CAD DVT
breast CA
undx abn vag bleed
est dep CA
liver tumor: ben or malig
cig smoke and over 35
endo
PCOS and insulin
have insul resist
high insulin, high sex hormone ginfing globulin, stimulates ovary and adrenal.

Test: low glu:ins ratio.
Screen all wmn w/ 2 hr glu level after 75g challenge and for dyslipidemia.
What is cystocele?
Protrusion of bladder into anterior vaginal wall
Which antibiotics are contraindicated in pregnancy?
Erythromycin: maternal liver damage.
Tetracyclines: stain infant teeth, affect long bone development
Sulfa drugs: anti folate properties, risk of kernicterus in T3
Metronidazole: anti-metabolite
Chloramphenicol: grey baby syndrome
Fluoroquinolones: risk of cartilage damage
After hormone replacement therapy was stopped, hot flashes got worst. what should you do?
SSRI, venlafaxine, neurontin
How is hypothlamic gonadotropin releaseing hormone regulated?
modulated by catecholmine secretion from the CNS and by feedback from sex steroids of the ovaries
Which of the following drugs is used to stop preterm labor?
magnesium sulfate
What is the main physiological stimulus for prolactin release?
Suckling of the breast.
IN primary amenorrhea, if the FSH is normal and uterus is absent, most likely
mullerian agenesis
What is the best diagnostic test for a 50 y/o female with no breast masses whose mother died of breast CA.
MMG
Lifestyle modification tx for premenstrual syndrome
Aerobic exercise, calcium carbonat supplement (1200mg), Mg (400-600mg)
Hulka clip as sterilzation method
Most readily reversible, greatest failure rate
What tx is used to prevent endometrial hyperplasia?
Progestin therapy
what are emergency contraceptives?
HIGH dose progestin-only pills (plan B, Yuzpe method, four OCs, Copper-T IUD)
GU UTI
define pyuria
5 WBC /hpf
If also RBC suggest infection.

If no bacturia, may be non-bacteria infection, FB, tumor. or TB.
breast
lg terdrop mass
overlying skin warm and red
solid and mobile
removed but recurs
cystosarcoma phyllodes
varient of fibroadenoma
more cellularity and pleo
recurs
some malig transform and 10% met (lungs)
more common AFr Amer
poorly encapsulated, microscopic penetration.

Rx: small ones excise with 1 cm/WIDE margin.
LG: simple mast w/o nodes
ovary cysts tumors
Pre-menarche cyst over 2cm :
Repro age : cyst under 6 cm -&gt;
Repro age : cyst 6-8 cm -&gt;
Repro age and over 8 cm -&gt;
Post Meno : over 4 cm :
Or
painful, multiloc, paritally solid -&gt;
ovary cysts tumors
Pre-menarche cyst over 2cm : ex lap
Repro age : cyst under 6 cm -&gt; watch 6 wks
Repro age : cyst 6-8 cm -&gt; Do U/S to tell if solid or cystic -&gt; watch if uniloc, explore if multi or solid
Repro age and over 8 cm -&gt; resect at lap
Post Meno : over 4 cm : resect at lap
painful, multiloc, paritally solid -&gt; surg explore
Contra choices for lactating wmn
depo :
medroxy progesterone

prog mini pills
fever ob
septic thrombophlebitis
Where: ovarian or iliofemoral vein, either site can cause vena cava thrombosis

Sx: like pelvic infection, after abx pain and clin sx's gone but spiking fevers that last after abx treatment, pts look well.

Diag: CT or MRI

Mgt: heparin, needs to be longer for femoral vein (switch to oral agents LT for months)


n.b. classicly heparin IV would resolve sx as diagnosis, now that isn't used as heparin doesn't change clin sx so much in studies
endo pub
tanner stages
Breast
2 Breast bud - no areola enlg
3. breast and areala more enlg
4. 2nd mound
5 mature

Pubic hair
2. downy on labia
3. to junction, darker and courser
4. adult type hair
5. to medial thughs
infert
cervical test
A. thick mucus
spinnbarkeit under 8 cm
B. shaking sperm
exclude:
poor timing of sex with ovul
A. inadeq estrogen
cervicitis esp if WBC high, do cx ureaplasma, chyla
Cervix trauma or sx
DES

B. shaking sperm : antisperm Ab in either partner, Rx steroid suppression or intrauterine insemination
When is beta HCG detectable in serum?
9 days post-conception
What do you do next?
Start suppressive treatment, give nitrofurantion, ampicillin, or cephalaxin every night for the rest of pregnancy. She must also evacuate bladder before and after intercourse.
Name three names of estrogen.
estradiol: MOST POTENT!!! produced by ovariesESTRONEESTRIOL
What is the life-span of a normal corpus luteum in the absence of pregnancy?
Approximately 14 days.
Filshie clip as sterilation method
lower failure rate than Hulka clip
what cells are diagnostic of bacterial vaginosis?
clue cells decreased WBCs
What is the best tx option for menorrhagia?
OCP (combo therapy)
presents:
abrupt fever, vomit
watery diarrh
repro age female
occ nonpur conjuctivitis
Toxic shock
5 days from onset of period in tampon users.
50% not related to tampons.

Desquam occurs in recovery.

Blood cx : usually NEGATIVE as Sx from toxins.

Rx hydrate, remove tampon/abscess from fracture or other source of
S AUREUS.

Anti staph meds: nafcillin, oxacillin.
IUGR when deliver
can deliver at 34 weeks if lungs mature
breast Ca staging
I under 2cm
II 2-5 cm
III : axill nodes
IV: dist mets, ipsi supraclav nodes, or infra clav
incont
who gets a urethrocystoscopy ?
think have bladder stones, stiches, tumor, diverticula
ob ter terato
epilepsy meds
even w/o meds inc risk congen malforms

RX: trial w/o meds pre preg, mono-therapy, take folate


valproic acid : 1-2% spina bifida
neonate
low bg
who ?
rx?
esp infants IUGR and mom DM
Rx glu, but not high conc solutions (25-50%) in asphyxiated infants as those made to lactic acid.
phys preg
blood flow changes
Blood flow dec to organs EXCEPT: kidney (inc 30%),
skin,
uterus (prepreg 2%-preg17%), breast

WHEN MAT CO falls flow to brain, kidney, and heart kept and shunts AWAY from uteroplac.
There is little autoreg in plac/uter as already max dilated.

Supine hypotensive synd : dont get reflex brady with it.
What is the blood supply to the external genitalia?
Internal pudendal artery.
If antenatal screening tests are abnormal, what additional tests should be performed?
• Fetal movement counting
• Non-stress test
• Ultrasound (growth and AFI)
• Fetal Doppler (umbilical artery ± other vessels)

Consider BPP and contraction stress test.
What is Polyhydramnios?
&gt; 20 amniotic fluid index, or 2 L.
what's the tx for chlamydia?
Azithromycin 1 g orally once or doxycycline 100 mg orally twice daily for seven days
the pH of the vagina in someone with trich will be what?
higher than 4.5
What predisposes a woman to yeast infections?
Diabetes, oral conntraceptives, and antibiotics.
Tx of yeast infection in non-pregnant pt?
uncomplicated: antimycotic rx, oral fluconazole single dose
complicated: fluconazole dbl dose
Most common cause of abnormal uterine bleeding
infrequent ovulation & chronic exposure to estrogen
What type of breast CA apprease as a subtle thickening in the upper-quadrant of the breast?
Infiltrating LObular Carcinoma
GU UTI
pt very ill, fever lasts over 72 hrs.
cinsider peri-nephric abscess
incont
uti symptoms : Freq urge dysuria post-void fullness
incont
dyspar
UCx clean
Chlam urethritis.
Post Men can be atrophic changes
ob
recurrent spont losses
most common chromo abn
50% spont losses chromo abn
(higher % in older wmn)
Most common tri16 (never seen at term)
45XO common losses also and in 1/2000 live births, 99% lost pre-term, from loss of material so no inc risks non-disjunction.

tri21/Downs: 75% lost pre-term
endo CA
uterine sarcoma
3% uter CA
tend to be more adv at Dx
pure or mixed (meseny and and epi)
homologous vs hetero (tissue present not nml to uterus, like bone)
leoimyosarcoma : transform from benign fibroid 1%.
Tell by mitotic count over 10 per 10 hpf.
Mean age 55, present pelvic pain, lower abd mass. rapidly enlarging.
Rx TAH-BSO. not helped by rad or chemo as die by distant mets.

stomal sarcomas
mixed mullerian sarcoma : tumor growing thru cervix into vagina as polyploidmass. 1/2 have mets at dx. aggressive.
ob gtd
hcg 60,000 urine
on molar evac
Path: beefy red hemmoragic, sheets cytotrophoblasts and syncytio, NO VILLI
choriocarcinoma

Diag: CSF bhcg nml over 40:1 if lower sign of CNS met.
* Signs of trophblastic Dz after nml preg nearly always choriocarcinoma.


Present with signs of met usually: hemoptysis, CNS: faint, LH, Vag bleed. check liver, brain, for mets.
cervix CA
process for ASC-H
ASC-H = atp squam cells cannot rule out high grade

Get colpo
No CIN2,3 repeat pap and HPV 6-12M
- if still pos colpo
- if neg routine screen


If CIN 2,3 manage lesion.
breast CA pharm
based on markers
All hormones +: get tamoxifen
ER neg all get chemo
HER2/neu : trastuzumab a mAb to these receptors.
Which liver enzyme goes up during pregnancy?
ALP doubles during pregnancy.
ASK, ALT, GGT and bilirubin levels are slightly lower.
After hysteroscopy, the nurse reported that the patient has difficulty breathing. On chest exam the patient has basal crackles. What will you do?
The patient was fluid overloaded. hysteroscopy requires a filling fluid. treat with diuretic.
how does an ovarian cyst develop?
when an ovarian follicle fails to rupture during follicular maturation, ovulation does not occur
What's the difference in how primary vs secondary syphillis manifests clinically?
Primary syphilis, the classic lesion is a painless ulcer associated with mild to moderate regional lymphadenopathy. Patients with secondary syphilis have marked systemic-malaise, fever, rash
What is the most common cause of postmenopausal bleeding?
Atrophic endometrium and/or atrophic vaginitis.
What is the most common cause of hypothalamic-pituitary dysfunction
Functional (weight loss, excessive exercise, obesity)
what is the proliferative phase of the uterine cycle influenced by?
estrogen! corresponds to follicular phase of ovarian)
what are the indications for a sentinel lymph node biopsy?
- early invasive, clinically node negative breast cancer-adenopathy on mammogram -full understanding for patient: further axillary dissection if the biopsy is positive
endo pub
1. what effects timing of puberty
2. brain signals
1. mainly genes
(delayed pub often familial)
geography
nutirtion
psycho
2. Brain signals:
Before puberty, ages 4-10, CNS inhibition of GnRH and max sens to inhibition of estradiol. Then, adrenal matures and makes androgens ~8-11yrs. Also loss of sens to neg inhibition -&gt; GnRH pulses esp at night, follicles mature and make sex steroids.
cervix
CA HPV pathogenicity
histology of dysplasia
HPV in 0ver 90% condyomas and nearly all cervical CA.
65% of time HPV resolves. Watch with serial PAPs 4-6 M for a year. With a year of neg revert to reg screening.
histology:
1/3 thickness : CIN I
halfway CIN II
full thick CIN III

HPV related to :
cervix ca,
vaginal intraep neo VAIN
vulvar intraepi neo VIN
penile neo

Are over 70 HPV strains
HIgh risk: 16, 18, 31, 33, 35, 45, 51, 52, 56, 58

Most common found 6, 11, 16, 18, 31, 33

18: more prog CAs, poor prog, younger pts with adenoCA and recur CAs.
16: lg cell keratinizing CA, rarely recur.
ovotestes OR dual ovary and testes
mix of female and male int and ext development.
true hermaphroditism
Usually 46 XX but some mosaisicm.

degree of mascul depends of testicular stroma present.

TO confirm : need lap scope.
What is the &quot;discriminatory zone&quot; for diagnosis of ectopic pregnancy?
Refers to the fact that when hCG reaches 1500 mIU/ml, then a gestational sac should be visible in the uterus on TVUS. If a gestational sac is NOT seen, then ectopic pregnancy is likely.
What is Oligohydraminos and what is the most common cause?
- Amniotic fluid index &lt;5
-Rupture of membranes.


What are risk factors for breast cancer?
agepersonal hx of breast cancerhx of atypical hyperplasia (ducta or lobular) on past biopsiesinherited genetic mutationsfirst degree relative with breast or ovarian cancer diagnosed at early ageearly menarche late cessation of menses age >55no term pregnancieslate age at first live birthnever breast fedalcohol consumptionrecent oral contraceptive useuse of hormone therapypersonal hx of endometrial, ovarian or colon cajewish heritage
What effect does estrogen therapy have on colorectal cancer?
It significantly decreases the risk of colorectal cancer.
What is the mode of action of methotrexate?
Methotrexate is a folic acid antagonist.
When do most pregnancies occur in fertile women
during the first 6 cycles of intercourse in the fertile phase
Which HPV commonly caused cervical dysplasia/neoplasia?
HPV 16, 18, 31, 33, 45- Condyloma accuminate - HPV 6 &amp; 11
incont
76 yo
hyster at age 48 for fibroids
genuine stress UI
hypermobile urethra
no cystcele or rectocele or vag prolapse
What sx :
kelly, AndP colpo, burch, abd sacral colpo, le fort colpo ?
&quot;gen stress urine incont&quot; = sph insuff due to loss of support


*** BURCH: best for Stress incont for her. Suspends bladder neck to coopers lig,

Kelly plication: older sx for SUI, less success, suspends urethra

AndP colpo: is for cystoceles and rectoceleswhich she does not have.

sacral colpo is for vag prolapse, suspends vault from sacrum.

lefort colpo: is for uter or vag prolapse
When do pregnant women usually start to perceive fetal movement?
20 weeks for primigravida
18 weeks for multiparous
A patient with cervical cancer presents with hydronephrosis, what stage of cervical cancer does she have?
Stage III it has extended to the pelvic wall.
What is the cause of mild hirsutism in menopause?
Increased free androgen to estrogen ratio as a result of decreased SHBG and estrogen.
How do you tx a pregnant pt w/ trichomonas
Metronidazole if symptomatic; tx for asymptomatic pts is not indicated
What do you do if the patient has a breast abscess that is NOT caused from breast-feeding?
must R/O cancer (inflammatory carcinoma) Requires more surgical exploration of the area involved
vagina CA
pt 50-60
upper post wall of vagina
assoc HPV
30% pts have h/o cervix dysplasia/CA and CA may be assoc to rad treatment for this esp if treated less than 5 yrs prior
squam cell carc vagina
(as long as no vulva or cervix CA)

RX: radiation usually
Surg IF
- stage I upper vagina
- young pts to save ovary
- exteration if adv
- fail radiation
The surg is for stage I: rad hyst w/ pelvic LN and part vaginectomy.
STages 2-4 ext and interstit rad.

RX for CIS: local exccise, laser/cryo, brachyrad
Women > 30 years of age..how often should they have a pap?
Women aged 30 years and older should have a Pap test every 2 years. After three normal Pap test results in a row, a woman in this age group may have Pap tests every 3 years ifshe does not have a history of moderate or severe dysplasiashe is not infected with human immunodeficiency virus (HIV)her immune system is not weakened (for example, if she has had an organ transplant)she was not exposed to diethylstilbestrol (DES) before birth
When can an intrauterine gestational sac be identified by an abdominal ultrasound?
In the fifth week. A fetal pole can be identified in the 6th week, and an embryonic mass with cardiac motion in the 7th.
What is stage II of pelvic organ prolapse grading system
leading edge within 1 cm proximal or distal to the hymen
STD / inf / vag
itchy vag d/c
yeast
RF incl preg, OCP. IUD, young at first sex
Normal PH (~4)
Uncomp: topical azole 1-3 days or fluconazole 1 dose.

Complicated = Over 4 x in a year, noncandida, HIV, DM , preg, IComp:
7-14 days top antifungal OR flucon x2 doses 72 hrs apart.

Treat azole resist cases with boric acid daily for 2 weeks.

No oral azoles in preg.
What properties of the fetus are you trying to assess with each step of the Leopold's maneuver?
1st - presentation
2nd - lie and also which side the back faces
3rd - engagement
4th - attitude
How often is an adnexal mass found in women with an ectopic pregnancy?
Fifty percent of women with an ectopic pregnancy have an adnexal mass on exam.
When is the first part of the SIPS done? second part?
First part: 11 - 13 weeks
Consists of PAPP-A and free βhCG

Second part: 16-18 weeks
AFP, total βhCG, uE3, inhibin A
infert
days to do the following tests :
luteal phase eval endomet bx
post coital
HSgram
serum prog for ovul confirm
check FSH to see if menopausal
1. Document ovul : serum prog day 21 ( 7 d post ovul).
2. Check luteal phase endomet bx day 26. 12 d after thermogenic shift/ 2-3 days before menses.
3. post-coital: peri-ovulatory, day 14, up to 12 hrs post coitus.
4. hysterosal done mid follicular phase to see FT, NOT when mense or after ovulation. day 8 .
5. not usually done but do on day 3.
Nagel's rule
LMP+7d-3mos=due date
Dx of menopause
Serum FSH
is trichomoniasis a STD?
Yes!
ob ectop
ectopic locations
preg GI
N/V
reflux
constipation
biliary chol -&gt; stones
Most common symptom of endometriosis
Pain
is bacterial vaginosis an STD?
NO
preg prenatal terato

nasal hypoplasia
stippled bone epiphyses
devel delay
IUGR
eye abn
coumadin warfarin
infert
clomiphine
MOA: anti-estrogen, non steroidal, enhances release of pit gonadotropins
IND:
PCO - follice maturation and ovul if wmn can still make est
creates cycle in oligo-ovul
luteal phase defect - stim follicle
Asst reprp tech - makes mult follicle
overprod of DHEAS by adrenals (stim follicles and supress adrenal DHEAS when use w/ cortsteroids)

Induces ovul in 70% pts
Preg in 40% pts


SE:
persist ovarian cyst 10%
Twins in 5-10%, under 1% over 2
ovarian hyperstim syndrome
hot flash, visual disturb
h/a
N abd bloat
mood labile
std
granuloma inguinale
raised firm red lesion
Calymmatobacterium granulomatis

Dx: clinical and smears showing Donovan bodies (bipolar staining bacteria)

Rx doxy, bactrim or cipro for 21 days
Most common etiology of UTI
E. coli
menometrorrhagia
frequent bleeding in excessive amounts and duration
incont
drugs that cause it
diureticsc
Anti-HTN: methyldopa,
--------------alpha blockers : Prazosin
-------------- Beta blockers : labetalol
Antihistamines
phenothiazines
diazepam
CCB
infert
PCOS
Hyper estrogen and virilizing state.
- ovaries make androgens some of which converted peripherally to estrogens.
- est inc pit making LH but supress FSH (nml feedback)
- high LH stil follicle to make androgens which inhibit folicle full maturation
- anovulation cycles
- hyperinsulinemic state stim more ovary androgens

Rx: clomiphene as ovary do fx and can make eset
If renal good use metformin.
preg renal
physiol hydronephrosis &lt;- ureter compressed

GFR inc 50%, Rplasma flow inc 30%

BUN and creat drop 25%
est and prog stim renin-aldo system and water retention and inc plasma volume.
Most common finding in congenital rubella syndrome.
Deafness.
Androgens are converted to what kind of estrogen?
estrone
The standard 300mg dose of RhoGAM protects against how much fetomaternal hemorrhage (FMH)?
Approximately
Findings in Trochomonal vaginitis
flagellated protozoan, inflammation, frothy-yellow-green gray discharge, fishy odor, strawberry cervix, pH>4.5
How many births do multiple count as
1
What is the best contraceptive method for parous women?
IUD
cervix CA
pregnant pts
Still colpo.
No endocervix curettage
only bx cervix if suspect high grade lesion.
breast
inraductal papilloma rx
eval: mammo, cytol of fluid

excisional bx of lesion and involved duct / wedge resection of ductal lesion
cefvix CA
abn findings on colpo
acetowhite
vessels punctate
vessels mosaic
comma, blind end
heaped up w. invasive CA

nml vesssels in trans zone are branching tree pattern
What is metrorrhagia?
Bleeding at irregular intervals particularly between expected menstrual periods
Ovarian cancer is the ___ most common of all cancers in women in US and most common cause of gynecologic cancer.
ovarian
How many deaths are attributed to cardiovasculr disease in women over 50?
It doubles.
Uterus is palpable when in pregnancy
12 wks gestation
Electrocautery as sterilzation method
Poor reversibility, greater incidence of ectopic pregnancy
SCreening in 1st trimester of pregnancy
10-13 weeks-nuchal, CVS
Pt presents with bilateral pain, vaginal Discharge, cervical tenderness, T>38 degree C, and leukocytosis...what are you thinking?
Pelvic inflammatory disease
what device is used to treat pelvic organ prolapse?
Pessary
ob us
distended bladder as w/ obst
look for oligohydram also
gyne prevent
speculum types
Graves
parous wmn, sex active wmn,
Wider higher and curved and sides.

Pederson
blades narrow, flat, barely curve on sides
Nulli, virgins, elderly with atrophic vaginaa

Both graves and pederson come in pediatric sizes.

Child exams:
vaginascope, hysteroscope
mens
PMDD
incidence
Diag crit
Rx
luteal phase dysphoric d/o
5% (mostly 25yr-44)
To Diag: daily diary for 2-3 mnths.
Crit: AT least 5
1. mood labile
2. persist anger/irritable
3. anx/tension
4. dec int activ
5. easy fatigue / low energy
6. subj sense diff concentrate
7. marked dep mood, feeling hopeless
8. mark change appetite, over eat or crave
9. hypersomnia/insomn
10. phy symptoms: breast tender, h/s,e dema, joint m pain, wt gain.
Interfere work/activ/relationships.

Rx:
diet: more ptn less carb
fluoxetine, venlafaxine in luteal phase equal to all month.
mens
nml parameters
3-7 days
30 ml
start 12.8 yrs
meno 51 yrs (one yr w/o)
men
abn anovul bleeding
cervix smears
? TFTs
U/S: preg, adnexa mass, If endomet stripe over 4/5 mm in POST MENOPASUSAL do bx (ECCurettage and endomet aspiration).

endomet bx: over 35, obese. PCOS for hyperplasia.

Rx: Progestins (medroxyprog acetate or norethidrone)f or 14 days to stimulate bleeding.

Heavy bleeding: estrogen IV Q6hrs.
try danazol, GnRh. If stable OCPs.
pre term
tocolytics
decsribe Prostaglandin synth i nhib
Indomethacin
Sht term use only to block PG synthesis.
MEtab: renal excr.
SE: ** dec fetal renal function (also used polyhydram), fetus inc risk NEC, intracran hemm and PDA so must eval w/ U/S.
ob
effect rad
10 rads threshold
1st tri:
heart and limbs

Later preg
brain

No effect karyo
No leuk in babies.
Compare/contrast vaginal discharge from BV and Trichomoniasis.
BV: grey, thin, fishy odour

Trichomoniasis: yellow-green, malodorous
What is symmetric vs. asymmetric IUGR caused by?
Symmetric:
-congenital anomalies
-TORCHES
-drugs, smoking, EtOH
-genetic syndromes

Asymmetric:
-placental insufficiency
Treatment of dysmenorrhea
NSAIDs
OCP to suppress ovulation and reduce menstrual flow
Indications for induction of labor.
Maternal factors: antepartum hemorrhage, preeclampsia, maternal medical problems.

Maternal-fetal factors: isoimmunization, PROM, chorioamnionitis, post-term pregnancy.

Fetal factors: suspected fetal jeopardy from monitoring, fetal demise, severe IUGR.
Pt presnts stating they have pain that often lasts longer than menstrual period. It may start before menstruation begins and become worse during menstruation then lasts after mensturation. what could it be?
secondary dysmenorrhea
Pt (who is btw 15 and 35) presents with well-defined, mobile mass on physical examination or a well-defined solid mass on ultrasound. They notice their seems to be some relationship to its growth and their menstrual cycle. WHat are you thinking?
fibroadenoma
During the follicular phase of the normal female menstrual cycle, the first hormone that is released is:
follicle-stimulating hormone (FSH).
Softening and enlargement of uteru occur when in pregnancy?
6 wks after LMP
Dx of Yeast infection
vaginal <4.5
wet mount w/ KOH "spaghetti & meatballs"
How can hypothalamic-pituitary dysfunction cause amenorrhea
When GnRH decreases, FSH/LH decreases, E2/P4 decreases, ovulation and menstruation are disrupted
Secondary amenorrhea
failed to menstruate 3+ cycles over 6+ months and has previously menstruated
When will insurance cover MRI with breast cancer?
if BRAC +
what is the most common presenting sx of Uterine fibroids?
bleeding (menorrhagia)
preg
hcg levels
nml preg levels double every 48 hrs
If slower, think ectopic.

In abx, levels decrease.

Peaks at 100,000 at 10 weeks, dec 2nd tri then levels off 3rd tri.

At 5000 transab see sac/fetus
At 1500 trans vag see something.
amen
causes of high PRL
PIF : Prolactin inhib factor

** stress
TRH hypothyroid
drugs: psych
malnutr
pit tumor, empty sella
GTD staging

Good prog

Bad
I uterus cure 100%
II outside uterus still in genitalia
III lungs cure 90%
IV all other met sites cure 40%

Good prog: cure 97%
under 4M since preg
hcg under 40,000 mIU/mL
no liver.brain mets
no prior chemo

Poor prog: cure 64%
over 4 M since preg
hcg over 40,000
liver /brain mets
prior chemo
FOLLOWING TERM PREG
pre term
steroids
risk to mom
low risk
pulm edema (inc with tocolytics, fluid overload, twins).

slight inc infection with PRPM
glu insulin control issues.
contra
OCP
combo
- MOA
- non contra bene's
inhibit FSH/LH
change mucus
endomet unsuitable preg
99% sucessful

bene's: protect ovarian and uterCA, dec incidence pevlic infectiob and ectopic. Menses predict and lighter.
ob us
diag
measures over 16 mm
empty gest sac
no yolk sac
no fetus

= blighted ovum aka early preg failure
infert

how IVF
Give GnRH to block premature LH in midluteal phase.
Then stim ovaries with FSH or hMG.
Inject HcG to induce completion of oocyte maturation.
aspirate oocytes.
inject sperm or washed IVF. fertilization.
WAit 2-5 days.
Retutn to uterus.

GIFT: gamete interfallopian tube transfer
oocytes and washed sperm places into tubes more consistant.

IVF success rates ~29% live deilery per retrieval.
Rates with egg donation higher.
Absolute contraindications to HRT.
A: Acute liver disease
B: undiagnosed vaginal Bleeding
C: Cancer (breast/uterine)
D: DVT (thromboembolic disease)
Branches of the pudendal nerve.
Dorsal nerve of clitoris
Perineal nerve
Inferior rectal nerve
When do you perform MSAFP test?
15-20 weeks of gestation.
What are the most common causes of cervicitis?
gonorrhea and chlamydia
What is the action of oxytocin?
It stimulates uterine contractions during labor and elicits milk ejection by myoepithelial cells of the mammal ducts.
How would you treat a nonpregnant pt w/ BV
Metronidazole*, Clindamycin, Tinidazole
Not necessary to tx partner
What type of breast CA appears as stellate (star-lke) or well circumscribed (rounded) on a mammogram?
Infiltrating ductal carcinoma
Cervical Dysplasia/ Neoplasia - Clinical Features
* Asymptomatic* Atypical changes at transformation zone* Advanced --&gt; vaginal bleeding and d/c, may see tumor on exam
GTD
RF
under 20 yrs or over 40 yrs
diet low in folate or B carotene
and bldo group

benign mole higher in Taiwan/Asia
chorio higher Nigeria
abx
mild cramp and bleeding
some POC expelled
visible tissue in vagina or ECCanal
Os open
U/S shows tissue in uterus
Incomplete abx
RX DandC
hemo stablize
ob
hcg levels in preg
on urine/serum test
under 5 IU/L neg
over 25 pos
between 5 and 25 REPEAT in 2 days

Nml rise is to double in 48 hrs for first month.

Reaches 100 at expected menses.
ob VBAC success rate ?
about 60-80%
risk rupture one csxn: 0.6%
2 c sxns: 1.8%
classic incision: 4-6%
Physical signs of pregnancy.
CHUG
Chadwick, 6 weeks - blue cervix and vagina
Hegar, 6-8 weeks - softening of cervical isthmus
Uterine enlargement
Goodell, 4-6 weeks - softening of cervix
What is secondary amenorrhea?
Absence of menses for six consecutive months in women who have passed menarche.
A nonspontaneous, nonbloody, bilateral nipple discharge is usually attributed to what?
fibrocystic changes or the breast or ductal ectasia
What's the tx for gonorrhea?
Cefixime 400 mg orally once or ceftriaxone 125 mg intramuscularly once are the primary treatments recommended; cefpodoxime, 400 mg orally once, is an alternative that is likely as effective, although fewer data to support its use are available. When intramuscular administration of ceftriaxone is given, lidocaine hydrochloride can be used as a diluent to decrease the discomfort associated with the injection.
What is the origin of breakthrough bleeding in continuous hormone replacement therapy?
Progestational dominance resulting in an atrophic endometrium.
Describe the whiff test
After applying KOH to a slide you would smell fishy amine odor in B.V.
Highest probability of conception takes place when?
intercourse takes place 1-2 days prior to ovulation
what is secondary amenorrhea? most common cause?
menstruated but failed to menstruate for more than 3 cycles or within 6 month MC cause is PREGNANCY!
ob
CVS when and risks
CVS
Advan : earlier than amnio , quicker results (no fetal culture)

Pro: transcervical catheter usally so painless

cons:
higher comp rate
MidTri CVS 1/150-200 vs amnio 1/300


VS 1st tri amnio higher risk: foot abn and limb reduction and higher comps vs CVS
preg
Naegles rule
due date = LMP + 9 months + 7 days
ob labor

pt 17 hrs painful ctx every 2-4 min, cervix unchanged at 2-3 cm and 50% effaced.

mgt ?
prolonged latent phase
Use demerol.
pre term
what counts as labor
reg uter contractions lastins 30 sec
persistance on this pattern for at least 30 min
progessive cervical change
incont
after repair of a cystocele what type of incont is common
stress incont often presents, pften cystocele obstructed and make pt continent.
incont
stong urge to void / urgency through out day (not related to exercise, cough)
frequency
Sometimes don't make it to bathroom
nocturia

RF: old, MS/dementia/neuro inj, preg, meno, pelvic sx, immobile, Meds: diur, CCB, smoker cough
Urge incont / detrussor instable-dysynergia

Etiol: detrussor hyperreflexia or sph dysfx due to inflamm conditions (cystitis, stone) or neurogenic d/o of bladder. ( spacticity, flaccicity, rectal sph tone)

Rx:
bladder training (timed voids), reduce excess liq and caffeine, antichol meds : oxybutynin, tolterodine (axn more specific to bladder), trospium, darifenacin, solifenacin, Elec stim of sph m,
TCAs,
patient 25 weeks pregnant develops genital herpes. What do you do?
Treat with acyclovir 400 mg BID
How can you determine Gestational Age?
LMP, Fundal height, Quickening, Fetal heart tone, Ultrasound.
Green, yellow or brown sticky nipple discharge can be due to 
ductal ectasia or fibrocystic changes of the breast
Name the hormones, and their source, that are involved in maintaining a normal menstrual cycle.
From the ovary: Estrogen and progesterone.From the pituitary: FSH and LH. From the hypothalamus: Gonadotropin releasing hormone (GnRH). (Prolactin and TSH are also vital in maintaining a normal menstrual cycle).
How is the appendix displaced during pregnancy?
Superiorly and laterally. Diagnosis of appendicitis in pregnant patients may be further complicated by the fact htat a normal pregnancy can itself cause an increased WBC. The WBC count usually does not increase beyond the normal value of 12,000 to 15,000. In a pregnant patient, pyuria with no bacteria suggests appendicitis. Pregnant patients may lack GI distress, and fever may be absent or low-grade.
42 year old female c/o small amounts of constant dribbling with coughing or lifting. What is the best therapy for this patient?
Sling proceure or bladder suspension
what do you have to R/O with PID?
gonococcal infection (can cause infertility)
What is the most common TYPE of breast CA?
Infiltrating Ductal carcinoma (IDC)
endo CA
eval post meno bleeding
transvag U/s : if wall thickness over 5 mm
then endomet bx 90% acc but 10% false neg so if neg
-&gt; need fractional D&amp;C under anesth for histo


In premeno but higher risk, may go to hysteroscopy after TVUS
ob
what to do when Rh titer reaches 1:16
test PUBS or amn fluid
twin plac
which can be ident or frat or either ?
monochor mono amn
mono di
di di fused
d di separate
twin:
monochor: must be monozygotic

Dichor: can be either.
(MonoZygotic twins-
70% monochor diamn
30% dichor diamn, rarest mono mono under 1%)

Dizygotic twins ALWAYS di di but placenta might be totally separate of fused.
std
sphillis
pen allery
1 and 2nd : pen g, tetra or docy
for 3 only pen so desensitize person.
breast
% of CA hereditary
risk w/ BRCA
5-10% hered
BRCA1/2 70% by age 65
When should a hypertensive disorder of pregnancy be admitted as inpatient?
Admit for inpatient tx
- Severe preeclampsia
- Severe hypertension

Could treat as outpatient with close follow-up, based on judgment
- Non severe preeclampsia
- Non severe hypertension
What is the median incubation period for syphillis?
21 days (range 3 to 90 days
Why does vaginitis increase during hte postmenopausal years?
due to estrogen deficincy, the vaginal pH increases from 3.5-4.5 to 6.0-8.0, predisposing to colonization of bacterial pathogens.
What are risk factors for a yeast infection?
ABX therapy, DM, pregnancy, obesity, cotton underwear, wet clothes
What is an alternative for women who cannot use HRT?
Isoflavones (soybeans, soy proucts) - have anti-oxident properties that protect against breast CA)
amen
or oligo (over 35 days)
have breasts and nml mullerians
------
low FSG Low LH low PRL
check other hormones for low levels (endo)
check excercise excess
anorexia
What is the threshold for number of fetal movements per unit of time when consulting an MD is appropriate?
&lt; 6 movements in 2 hours.
Repeat culture of the above patient is negative? What next?
Place the patient on suppressive treatment for the rest of the pregnancy.
What do you warn pts about when taking metronidazole?
don't drink because of disfulfiram like reaction
What is the most common sign of an ectopic pregnancy by transvaginal ultrasound: adnexal mass or absence of intrauterine pregnancy?
The absence of an intrauterine pregnancy at an hCG level >2,000mIU/mL is highly predictive of an ectopic pregnancy. An adnexal mass or gestational sac in the adnexal is less reliable finding and is not always seen in early ectopic pregnancies.
When is referral recommended for children exibiting precocious puberty?
when there are 2 or more signs of maturity before age 8
ob post partum
nml length of bloody lochia
if prolonged ?
Bloody lochia can go up to 2 wks.

Over 2 wks:
- plac subinvolution
- retention sm plac frags
Mgt: Eval blood loss degree, pelvic exam for lg uterus (subinvol: lger but otherwise asymto) or tenderness (endometriris)

Subinvolution:
Occurs in retained products and infection.
uterus lger and softer on PE than should be. At 4 wks uterus at non-preg state.
Pt usually prolonged bleeding and d/c.

Infetion: also fever and chills.
A patient with sickle cell disease asks for oral contraception. What do you do?
Give a progestin only pill, because it has a lower clotting risk.
When should you avoid treating a woman with Flagyl?
If she is in her first trimester, metronidazole may have teratogenic effects. Clotrimazole (Gyne-Lotrimin) may be used instead. Side effects of Flagyl include nausea, vomiting, and metallic tastes. It acts similarly to disulfiram (Antabuse) and therefore should not be taken with alcohol.
Why would you perform a vaginal biopsy
Abssess masses or women w/ a prio hx of hysterectomy for cervical cancer
cervix CA
what is nml colpo after abn PAP
- review PAP smear again confirm abn
- if high grade abn = need diagnostic cone bx like LEEP
antibodies to Rh antigens belong to which class of antibodies? Can they cross the placenta?
Belong to IgG class and they can cross the placenta
What is Paget’s Disease? What is the lesion most likely (no mass)? If a mass, what is it most likely?
- rare type of breast cancer (1%) - appearance: eczematoid lesion of the nipple cause by large malignant Paget Cells that arise from duts and invade the surrounding nipple endothelium – DO NOT MISTAKE FOR ECZEMA - most likely Intraductal Carcinoma (NO MASS) - IF MASS, it is most likely invasive ductal carcinoma
A young patient has a miscarriage and asks for an IUD before discharge.
You can safely put it in after the delivery
Endometritis WBC
>20,000
Fully dialated
10cm
HPV causes
koilocytotic atypia
First-line Endometritis treatment
Clindamycin
Monozygotic twins occur
randomly
Bleeding between periods
Metrorrhagia
Amniotomy
artificially rupturing the membranes
Early induction
minimal dilation/effacement; prostaglandin gel on cervix; may be repeated in 12 h
Most common fetal malpresentation
Breech
Abnormal placental implantation
Placenta previa
Herpes type genital lesions
HSV 2
Endometritis treatment if septic add
Metronidazole
Monozygotic twins
Fertilization of 1 ovum
Uterine Growth 12 weeks
Symphysis pubis
Chlamydia treatment
Azithromycin, doxycycline, and erythromycin
Glucose tolerance test @
24-28 weeks
Cytomegalovirus
Human herpes virus type 5
Mag Sulf toxicity treatment
Calcium Gluconate
The leading cause of infirtility
Chlamydia
Signs of preeclampsia
hypertension, proteinuria, hyperreflexia
Frequent menstruation (&lt;21 day cycle), anovular
Polymenorrhea
Slow, abnormal progression of labor
Dystocia
Tocolytics: Magnesium Sulfate
inhibits myometrial contractility mediated by calcium
Eclampsia is preeclampsia with the addition of
seizures
Early postpartum hemorrhage treatment
oxytocin, ergonovine, methylergonovine, prostaglandins
Fetal heart tones heard @
10-12 weeks
Normal or abnormal? WBC count increases during childbirth to more than 20 million/mL.
Normal
New-onset grand mal seizures in patients with pre-eclampsia
Eclampsia
Most common cause of secondary amenorrhea
Pregnancy
Premature separation of normally implanted placenta
Placenta abruption
What diagnostic study can differentiate breast cysts from solid masses?
Breast ultrasound
Station - at the ischial spines
0 (zero)
Other common complications with multiple gestation are
preeclampsia and anemia
Lactating mothers may have what vaginal symptom
Atrophic vaginitis
Can HIV be transmitted through breast milk?
Yes
PROM after 37 weeks treatment
hospitalize and monitor
Late induction
dilated >1cm and some effacement; oxytocin (Pitocin)
Type of spontaneous abortion in which no products of conception are expelled, membranes remain intact. There is uterine bleeding and abdominal pain. The fetus is still viable.
Threatened.
What is the most common congenital infection?
CMV
What antibiotic should be used to treat mastitis?
Dicloxacillin
What are Amsel's criteria?
Abnormal whitish-gray discharge, vaginal pH &gt;4.5, positive amine (&quot;whiff&quot;) test, clue cells.
3 out of 4 Amsel's criteria are required for the clinical diagnosis of bacterial vaginosis
Persistant decelerations
begin AFTER the peak of contraction are nonreassuring and warrent intervention
The leading indication for cesarean section is
diagnosis of dystocia
Biophysical profile
10 point system: nonstress test (NST), amniotic fluid level, gross fetal movements, fetal heart tone, and fetal breathing
Lochia or bleeding after delivery is
sloughing decidual tissue
Threatened abortion
Vaginal Bleeding: yes Cervix Open: no Products Passed: no
HSV 2 remains latent within the
sacral root ganglia
Internal fetal monitor
electrode attached to the infant's head that gives the most accurate fetal heart rate pattern because IT TRANSMITS THE R WAVE
Preterm premature rupture of the membranes occurs
before 37 weeks
GTD surgical treatment
Suctiona and curettage (to preserve fertility) and hysterectomy.
Beta-Mimetic adrenergic agents: Ridodrine and Terbutaline side effects
Maternal and fetal tachycardia, emesis, headaches, and pulmonary edema
Early decelerations
mirror the image of contractions and denote FETAL HEAD COMPRESSION; common approaching second stage of labor; benign
Initial Visit time
6-8 weeks after last menstrual period
Calcium Channel Blockers pharmacology
inhibits smooth muscle contractility by decreasing intracellular calcium ions, which therefore relax uterine muscle
Pregnant woman has signs of edema, polyhydramnios, and a large for gestational age fetus (&gt;90th percentile). Diagnosis?
Gestational diabetes
What is Asherman's syndrome?
Type of secondary amenorrhea associated with endometritis, scarring after delivery, or D&amp;C
What is the most common type of endometrial cancer?
Adenocarcinoma
What is the leading nonobstetric cause of postpartum death?
Pulmonary embolism
Fetal complications of multiple gestation are
intrauterine growth restriction, cord accidents, death of one twin, congenital abnormalities, abnormal or breech presentation, and plecental abruption or previa
Fetal complications of preeclampsia
hypoxia, low birth weight, preterm delivery, and perinatal death
Active management of PROM involves
induction with prostaglandin cervical gel or misoprostol and/or oxytocin to expediate delivery and decrease infection
Labs: 28 weeks
Repeat Rh antibody titers followed by Rh immunoglobulin, screen for gestational diabetes, hemoglobin and hematocrit
Early Postpartum hemorrhage occurs
less than 24 h after delivery
Bloody show
the passage of a small amount of blood-tinged mucus the has been plugging the cervical os, often precedes true labor
The most common cause of 3rd trimester bleeding
Abruptio placente
What hormone stimulates the release of the ovum from the follicle on day 14 of the menstrual cycle?
Luteinizing hormone (LH)
What stage of labor? The cervix is dilated 6 cm.
1st, active
Menstrual pain for which there is an organic cause
Secondary dysmenorrhea
What are the absolute contraindications to the use of IUDs?
Current pregnancy, abnormal vaginal bleeding, gynecologic cancer, acute cervical or uterine infection, history of PID
Placenta previa is associated with
advanced age, smoking, high parity, scarring of the lower uterine segment (cesarean delivery)
Complications of abruptio placente
compromise of placental blood flow to the fetus, hemorrhage, renal failure, coagulation failure, and death
Women who have had gestational diabetes should be screen postpartum @
6 weeks, and yearly thereafter
Variable decelerations
rapid drops in fetal heart tone with a return to baseline with variable shape and no pattern; often occur with CORD COMPRESSION; if mild or infrequent they are benign
First stage of labor
begins at onset of true contractions and ends with full dilatation
Signs and symptoms of Mag Sulf toxicity
decreased reflexes, respiratory depression, and cardiac collapse
Clinical diagnosis of ectopic pregnancy
B-hCH greater than 1,500 without intrauterine getstation on transvaginal US
Triple Screen: Abnormally high level
increased risk of neural tube deficit
If the head is not well engaged with ruptured membranes, what can occur?
Cord prolapse
If Congenital syphilis infants are not treated they may develop
interstital keratitis, Hutchinson's teeth, saddle nose, deafness, and CNS abnormalities
The most common complications of multiple gestation are
spontaneous abortion and preterm birth
Primary syphilis physical findings
painless chancre witha a clean base and firm, indurated margins at the site of inoculation (genitals)
Ruptured membranes can be confirmed by
direct visualization, NITRAZINE PAPER, FERN TEST, US to check amniotic fluid index
Where is the most common area for breast cancer to occur?
Upper outer quadrant
Lab findings in menopause
Increased FSH and LH, increased total cholesterol, decreased HDL
Placenta extends to the margin of the os
Marginal placenta previa
Placenta is in close proximity to the os
Low-lying placenta previa
Work-up for diagnosis of gestational diabetes
UA reveals glycosuria, abnormal glucose challenge test (routinely performed at 24-28 weeks gestation)
Amniotic fluid rupture occurs
before or during the first stage of labor
Cervical cerclage (closure of the cervix by mechanical means) is an option for
women with known cervical incompetence or a history of preterm birth
What are the risk factors for endometrial cancer?
Nulliparity, late menopause, DM, obesity, unopposed estrogen therapy, and use of tamoxifen
Spontaneous rupture of membranes that occurs at &lt;37 weeks gestation
Preterm premature rupture of membranes (PPROM)
Risk factors for the development of gestational diabetes include
a history of a previous large-birth-weight infant, obesity, age older than 25, glucosuria, family history of diabetes
First-line management to decrease seizuers
Mag Sulf (should be continued 24 h after delivery)
These ethnic groups have a higher risk of developing gestational diabetes
African American, Asian, Hispanic, or Indian
APGAR Grimace (reflex response)
0 = no response, 1 = Grimace, 2 = Sneeze, cough, pulls away
Mild Preeclampsia proteinuria
300 mg / 24 h or trace to 1+ on dipstick
What are the risk factors for gestational diabetes?
Age over 25 years, obesity, positive family history, history of macrosomia, and previous miscarriage
Length of second stage of labor nulliparous
30 min - 3 h (50 min avg)
Forceps and vacuum extractors are only indicated if
the head is engaged and the cervix is fully dilated
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