CEN GI/GU/OB/GYN Flashcards
Ectopic Pregnancy interventions include administering _______if mother is RH _____; therapy with _____ ________and consider __________IM
RHOGAM; Negative; IV crystalloids; methotextrate
What color is the discharge that occurs with TRICHOMONAS with a _____odor What color is the discharge in candida vaginal? What color is the discharge of VAGINOSIS
Yellow-Green; fishy White Gray
4 Processes of the GI system are ___ ___ ___ __ and assisting the body’s metabolism is a function of the ________system
Ingestion Digestion Absorption Elimination Pulmonary
Abdominal pain in RUQ is most likely______ Leukocytosis, fever and diarrhea likely______ the result of the release of digestive pancreatic enzymes into tissue of the pancreas
Cholecystitis appendicitis Acute pancreatitis
Somastatin is secreted from the _____cells GLUCAGON is secreted from the ________cells INSULIN is secreted from the ________
Delta Alpha Beta
Spastic to dull pain around the abdomen and HYPERACTIVE BS may cause a change in bowel habits an is a sign of
EARLY bowel obstruction
What is PHIMOSIS? condition in which the _______ ____ predisposing factors are
penis is tight ended and unable to retract over the gland; poor hygiene, congenital condition, scarring and inflammation.
Wearing a lap belt would result in _______; For MVC patient, look for the _______sings which consists of
bladder rupture; seat belt: abrasion and contusion.
Possible causes of peritonitis
appendicitis pancreatitis trauma from a GSW or knife Peritoneal dialysis
Clay colored stool indicates_________ and it is a blockage of any duct that carries bile from the liver to the gallbladder; Tarry stool is indication of ________; BRIGHT RED BLOOD is indication of ________
Biliary obstruction; Upper GIB; lower GIB.
The death of expulsion of the fetus or ______ ______ before the age of viability is_______
products of conception; Abortion
A __________spontaneous abortion is one in which the patient experiences moderate cramping with MODERATE vaginal bleeding and her CERVICAL OPEN More than 3CM with a GROSS RUPTURE OF MEMBRANES
Inevitable .
A __________spontaneous abortion is one in which the patient experiences moderate cramping with MILD UTERINE CRAMPING with SLIGHT vaginal bleeding and her CERVICAL CLOSED with a SOFT ENLARGED UTERUS
THREATENED
A __________spontaneous abortion is one in which the patient visually identified symptoms that signal the LOSS OF THE PRODUCTS OF CONCEPTION
IMMINENT
A __________spontaneous abortion is one in which the patient does not experience cramping or contraction, only has SLIGHT VAGINAL BLEEDING< her CERVICAL OS remains CLOSED, and her body RETAINS DEAD PRODUCTS OF CONCEPTION
MISSED
When the stomach uses PEPSIN to break down proteins, what do the proteins become?
Polypeptides
When the stomach uses PEPSIN to break down proteins, what do the proteins become? _______ They are then broken down into ____ and _____ in the small intestines
Polypeptides ; Proteins; amino acids.
In the stomach, Carbohydrates are broken down into __________ and the process begins in the _____
Disaccharides; mouth
When you hear TYMPANY percussion tone over an abdomen, what does it normally indicate
A gastric bubble or gas
A float percussion tone indicates a ________ A dull percussion indicates the _______, a full ______ or a full _______
Bone Liver, sigmoid colon, bladder
Stage I of labor is when the patient is ______
Stage II of labor is when the patient _____
Stage III of labor is when the infant ______
Stage IV of labor is when the ______
Experiencing regular contractions and dilating
has full cervical dilation and infant ready to crown
has been delivered but the PLACENTA has not
Placenta has been delivered for four hours.
What is the defined point of neutrality in the pH scale?
What does it mean when the patient’s urine has a decreased acidity level?
Seven
It is indication that the patient’s kidney is retaining acids and SODIUM
An increased in urine acitity means what?
That the patient’s body is retaining bicarbonate
A UTI is associated with ________(alkaline or acidic) urine.
Renal tubular acidosis is associated with (acidic or alkaline) urine and serum (alkalinity or acidity)
Alkaline
Alkaline; Acidosis
What is the normal pH of the vagina?________
STI with erythema of the cervix is __________
_______causes rash that itches and is reddish in color
______ rash that is reddish in color
Rash red or reddish bronw with PENNY-SIZED SORES
3.8 - 4.5
Chlamydia
Gonorrhea
Genital Herpes
Siphillis
When the vagina pH is less ______, there is more chance for infection.
4 Factors that make vagina less acidic
acidic
Diabetes, unprotected sex, poor hygiene and Multiple sex partners
Vaginosis, STIs, yeast infection.
Tests used to evaluated renal function:
BUN is affected by _________
- *BUN and creatinine** are both _________
- *IVP** is used to rule out what _______
BUN and Creatinine
Diet
Waste products of protein metabolism
Obstruction
- *Not** a symptom of UPPER GI bleed is _______
- *Symptoms of UPPER GIB**
Hematochezia
Hematemesis, melena, coffee-groud emesis, Weakness dizzines, postural hypotension and potentially sx of hypovolemic shock
5 Common causes of Upper GIB
Mallory Weiss syndrome, peptic or gastric ulcers, esophagitis, frequent NSAIDs use, ESOPHAGEAL VARICES
Which portion of the male urethra enters the perineum
The Membraneous portion
3 Segments of the male urethra are
The male urethra is _____than the femal urethra
The prosthatic portion enters what?_____
The penile portion forms within the ___
prostatic, membranous and spongy
Longer
Prostate gland
Shaft of the penis.
Male urethra conducts urine from the bladder and semen from __________
Ejaculatory ducts
The MANTRES score is used to help diagnose a patient’s probability of having _______. Each diagnostic test is worth one point except __________ and __________which are worth 2 points
Appendicitis; tenderness in the RLQ; Leukocytosis
MANTRES score stands for:
(M) Migration of pain to the RLQ
(A) Anorexia
(N) Nausea and vomiting
(T) Tenderness in RLQ
(R) Rebound pain
(E) Elevated Temperature
(S) shift of WBCs to the left.
Used to detect gestational diabetes is _______. It measures glucose level _____hour after administation of a ____gram of oral glucose loads. Blood sugar values over ____mg/DL identifies ____% women with gestational diabetes.
Glucose challenge; one; 50; 140; 80
A___________ test is used to determine if there are fetal red cells in the maternal circulation
Kleihauer-Betke test
A _______ ___ screen is used to determine if there is a potential incompatibility in the blood type between the mother and the fetus
Antibody screen
RLQ pain can be caused by appendicitis, _______, Ovarian torsion and cysts, ___________, ______, Tubo-ovarian abscess, ____________ or_________ diverticulitis
inguinal hernia, ruptured ectopic pregnancy, PID, mesenteric adenitis, Meckel’s
Normal chloride is ________mEq/L and when the patient chloride is low it could be a sign of ____ ____ _______
96-106; diarrhea, vomiting and intestinal obstruction
When a patient’s chloride is high, suspect ____
_______May be a factors if a patient’s calcium levels are low
_______may be a factor if the patient’s phosphorus levels are low
Dehydration
Acute pancreatitis
Malnutrition/ Malabsorption syndrome
Light palpation with large pulsating mass is suggestive of _________and you should _____the palpation because rupture is life threatening. A light palpation is when you use fingers to depress ___ to ___ cm into various areas of the abdomen
Abdominal Aortic Aneurysm ; STOP; 1-2
A PERCUSSION tone, drum-like, loud, high pitch quality generally heard in the STOMACH or BOWEL
TYMPANY
PERCUSSION tone with a booming quality and is located around the HYPERINFLATED LUNGS.
________is the percussion tone that has a HOLLOW QUALITY located around the normal lung
HYPERRESONANT ; RESONANT
________is the percussion tone that has a thud-like quality and is located around the _____, ____ or _____
DULL; liver, spleen, heart
The normal phosphorus level is __ to ___ mg/Dl. Pt with elevated phosphorus has ______dsease
3.0-4.5 ; Kidney
What does it mean when hernia becomes INCARCERATED? there will be _____ and _____ and the site of herniation with possible signs of _____ ______
Its blood supply is compromised; pain and swelling; interstinal obstruction.
A male patient who has priaprism should have a ____________conducted in order to rule out ___________ ________ Leukemia.
peripheral blood smear
CHRONIC MYELOID LEUKEMIA
A _____ ___ ____ should be conducted to assess the patient’s glucose concentration level
Corpus Cavernosum aspirate
Does a sonogram meausre the bladder volume?’
A sonogram generates a localized ?
No;
deep heat to the tissues, monitors a developing fetus, and images an internal body structure
How does the US detect abnormalities?
Using high frequency sound waves to detect abnormalities.
_________ is the gold standard for ruling out GIB
Endoscopy
Term used to indicate that a female has not had any live births________
Term used to indicate that the female’s pregnany is her first ______
Term used to indicate that the female has given birth to more than one live child
Nullipara
Primipara
Multipara
Most appropriate medication for a patient with H. Pylori infection? ______ or ______x __ days in addition to a ____ ____ -_____ and ____ are absolutely contraindicated
Clarithromycin/ AMOXICILLIN; 10; Proton Pump inhibitor. NSAIDs
Causes of priaprism :
Tumor
sickle cell disease
PHOSPHODIESTERASE TYPE 5 INHIBITOR and pharmacological injections injected directly into the corpus cavenosum in the treament of Erectile dysnfuntion.
What is IMPALEMENT? It is an example of ________Trauma as it penetrates the body> Examples are .
Penetrating
GSW, projectiles, stab wounds
_______ the result of applied force without the creation of an OPEN WOUND
BLUNT TRAUMA
When a loop of bowel telescopes within itself, a mechanical obstruction known as _________ occurs. 3 symptoms are: ____ ____ _____ most common in children 3 ____ to ____ years of age
Intussusception
Currant jelly stools
Sausage-shaped abdominal mass
vomiting
FACIAL GRIMACING WITH LEGS DRAWN TO CHEST
3 months- 5
When a loop of intestine completely twists around its mesenteric attachment site? _______
VOLVULUS
- *Endocrine function** involves the secretion of _______ and ______
- *Exocrine function** include the secretion of _______ to neutralize chyme and the secrtion of _______juice for the digestion of _______
Insulin; glucagon
Bicarbonate; pancreatic; carbohydrates.
What is placenta previa?
What is marginal previa?
Placeneta is located abnormally in her lower uterine segment and over the opening
Placenta’s edge os at the Internal Os’s margin typically 2-3 cm of the os
________ Previa means that placental tissue is COMPLETELY covering the internal OS.
________Previa means that the placental tissue is partially covering the internal os
Total ; Partial ;
An appropriate intervention for managing the woman with the BARTHOLIN’S CYSTS Abscess? _______and______compresses. Symptoms include swelling and tenderness of _______
Sitz Baths
Warm compresses
Vulva
If a patient is having difficulty with INGESTION with which compoent of the GI system is the patient MOST likely having trouble with?
OROPHARYNX
First and second stage of swallowing , ingestion, salivation, and mastication are functions of the ___________but the third stage of swallowing and vent for extra gastric pressures are function of the___________. Functions of the _______Inlude secretion of gastric enzymes, absorption of water, and reduction of os_malality of food a_nd the ________include r_eceiving biles and pancreatic fluid in order_ to aid digestion and moving chyme by using _______and _________
Nasopharynx; Esophagus; stomach; small intestine; peristalsis, segmentation.
OUTERMOST layer of the GI tract is the __________ cell layer and it is continuous with the ________. The ________Cell layer is the thin cell layer composes of smooth muscle and that is found betweeb the serosa and the___________ ; the _________ dense cell layer composed of connective tissue that supports the mucosa. the________cell layer is the INNERMOST layer of the GI tract that is exposted to dietary material
SEROSA; Muscularis; Submucosa; mucosa
For Hepatitis B, interferon agenst are given ______ (route) and other four drugs _____ ,_______,_____,______ are given orally. The drug approved for HIV patients is called _________
Injection; lamivudine, adefovir, dipivoxil, entevir, telbivudine; Zidovidine
The MOST COMMON type of PEPTIC ULCERS is
Peptic ulcers are due to the disruption of the protective ______Barrier and increased ______secretion
Duodenals are characterized by increased _______Cells
and stress ulcers are the result of _______stress and develop after period of illness, ______or _______
DUODENAL ULCERS;mucosal ; acid
Parietal cells
ischemic stres; trauma; injury.
A patient test positive for GENITAL HERPES would be started on ______or ______
A patient tested positive for GONORRHEA or CHANCROID would be prescribed
A patient tested positive for CHLAMYDIA would be prescribed_______
Acyclovir or FamCYCLOVIR
Ceftriaxone / CefiXime for gonorrhea
Doxycycline
Signs of impending delivery:
bloody show
mother stating needs to defecate
bulging of vulva membranes
Rupture of amniotic fluid
If the patient has UTERUS pain,it is caused by _____and_____
If the patient has fallopian or ovary pain, the pain is caused by ______or _______
If the patient has PERITONEAL PAIN, it is related to _________ accumulation from an _______Cyst
and the pain is causd by _________
Contractions and spasms
Distention, inflammation
blood; ovarian; inflammation
If the patient experienced a postpartum hemorrhage after delivery , which of the following occured? Blood loss of ______Within____hours after delivery.
Blood loss is severe if it’s more than________within _____ after delivery. It is early hemorrhage if it occurs within _____hours after delivery; It is late hemorrhage if it occurs after ____to ___weeks after delivery.
A blood loss GREATER THAN 500ml.; 24
1000; 24 hours
24 hours’; 6 weeks
Management of postpartum hemorrhage include:
Manual pressure
High flow Oxygen
Large bore IV
blood transfusion
Oxytocic agents OXYTOCIN
What is the most common PRIAPRISM? It is caused by ____________blood flow and _______ stasis
Ischemic priaprism
decreased venous blood flow
vascular
Ischemic priaprism is associated with progressive __________ of the ________ tissues and ___________ ________.
___________priaprism is caused by the fistula between the ________tissue and the _______artery
__________priaprism is caused by clumping of erythrocytes that leads to the venoocclusion. the best describing word is INTERMITTENT
_________ priaprism is caused by the invasion of __________ ______ by malignant neoplasm
fibrosis; carvenosal; Erectyle dysfunction.
Nonischemic; corporal tissue ; carvenosal.
Stuttering priaprism
Malignant; Corpora Carvenosa
Regulation of bile flow is a function of the _________
Functionof the liver is ___________ of bacteria; conversion of ammonia to ______ and the formation of _______. Conversion of complex sugar to ______sugar, carbs to ______; stored glucose to _______ ; amino acids to ______ and CREATINE to ________
GALLBLADDER
Urea
Cholesterol.
Simple; fats; glucose; proteins; creatinine
__________should always be considered in a patient with abdominal pain and tachycardia
Hypovolemia
Through which of the followng do the kidnes excrete urine_________.there are ______ureters , one located in the ______and the bottom half of the _______. They are ____ to ____inches long.Urine excreted from kidneys are stored in the _____ which uses the ______to expel the urine from the body.
URETER;
2; abdomen; pelvis
10-12
Bladder; urethra.
Basic absorption mechanism that requires an energy and is known to absorb substance such as proteins, glucose, potassium and sodium__________.
Basic absorption mechanism uses a PASSIVE movement to absorb substance such as water and free fatty acids is ________
_________is a basic absorption mechanism that requires a carrier and is known to absorb _______
_______ _______transport is basic absorption mechanism that is known to absorb drugs and _____ _____ _______
Active transport
PASSIVE DIFFUSION
Faciliated Diffusion; fructose
Non-ionic ; Unconjugated bile salts.
What is the most COMMON cause of GASTROENTERITIS? such as ________ and ________
Infectious agents
SALMONELLA and E.COLI
Parts of the ALIMENTARY CANAL includes: start with the ______ and ends at the ______
Accessory organs are _____, ______, ______, _____and _____
Mouth; anus; Includes to
oropharynx; esophagus; stomach; small intestine; large intestine
tongue; salivary glands; pancreas; gallbladder, liver
__________ presents as an abdominal pain that is located in the RUQ and is described as cramping pain
_______ presents as an abdominal pain that is located in the LUQ and is described as boring and worsens when lying down
___________ is inflammation of the lining of the stomach, caused by chronic NSAID use and presents as pain accompanied by N/V
cholecystitis. or Peptic ulcer gnawing and burning pain
Pancreatitis
Gastritis
The _________ sphincter or upper _______sphincter opens when food enters the _______ so that it can move through the esophagus
The _________ or lower ________sphincter opens so that food can enter the stomach from the _________ this final phase in swallowing is involuntary and takes approximately __to __-seconds to complete
HYPOPHARYNGEAL; ESOPHAGUS; ESophagus
Gastroesophageal ; esophageal ; 5-10
Drugs used in an acute GI hemorrhage_______ and _______ is used to cause vasoconstriction in a GI hemorrhage. ________acting as a mucosal barrier.
Proton Pump inhibitor;(omeprazole, pantoprazole).
Vasopression
Sucralfate.
Nausea is not a symptom associated with______but is associated with PID, menstrual syndrom, tubal-ovarian abscesses and torsion of ovary.
Endometriosis ; ______,_____,____,_____
Syphillis is generally associated with _____lesions; Multiple shallow vesicles are associated with _____ _____
Chancre; genital herpes.
_________is a STI caused by Neisseria Gonorrhea or Chlamydia Trachomatis: Caused by an infection ________ fromt the urinary tract. Treatment include _____,_____ and _______ .
Epididymitis. ASCENDING, cytoscopy, postate surgery, catheterization of the urinary bladder.
______Fractures often seen as a results from sitting in a straddling position during a motorcycle collision
Pelvic fractures.
__________ bacterial infection, often caused by E.Coli that causes inflammation of the kidneys involving the ____, _____ and ______ pelvis.
Symptoms include severe flank of back pain, fever, chills headaches, pyuria, hematuria, and bacteremia
PYELONEPHRITIS; tubules, glomeruli, renal pelvis
Toxin-mediated systemic response usually caused by a strain of S.aureus is known as
Toxic Shock syndrome (TSS).
yyyhWhen a child is in a bicycle collision, which type of injury may not be apparent until later ________
Abdominal injuries.
Saliva consists of Ptyalin and mucus. 3 things that stimulate saliva are _____,_____ and _____
Sight, smell, taste and THOUGHTS
The _______in saliva started breaking down polysaccharides to disaccharides . ______provides lubricant. Salivary glands secretes _____liter of saliva daily
Ptyalin; Mucus; 1 liter
Renal response to alkalosis include
Renal response to acidosis include:
Decreased hydrogen ion secretion
Decreased production of ammonia
increased bicarbonate excretion
Increased in hydrogen ion secretion
increased in bicarbonate secretion
increased in ammonia production
The most common cause of esophageal obstruction in children is
Foreign body
Crohn’s Disease affect the _______side of the colon, while Ulcerative Colitis
affect the ______ side of the colon. In crohn’s disease, bleeding is_____
Right; Left.; rare
Hepatitis A takes ___ to ____weeks to incubate and is ____% curable
Hepatitis B causes 15-25 % of people to develop ______
Hepatitis C causes 20-50% people to develop ________and 20 % develop ______ and same number develop _____ _____
2 to 6; 99
Liver Cancer
Cirrhosis; liver cancer; liver failure.
Medications used to decreased portal pressure by relaxing the ________ vascular smooth muscle is __________; Alternative is a combination of IV _________ and SL or _______ ________
Mesenteric; Octreotide or Sandostatin; Vasopressin; SL or Transdermal Nitroglycerin
If an individual’s pH is >7, it indicates that the individual is at risk for a _______ stone.
If an individual’s pH is < 5, the individual is at risk for developing a ____ _____stone
Struvite
uric acid stone
If an individual’s urine appears orange-pink in color, it is an indication of ___ ___ ____
If it is orange colored only, it may indicate ________
Uric acid crystals
medications
Digestion of carbohydrates started in the ________ and it this breaks down polysaccharides to disaccharides
Mouth
Renal TRAUMA is considered major if there are ______ ______lacerations and _______lacerations
Critical Renal trauma include ______ _______ or a ____ ____ injury
Deep Cortical; CALICEAL laceration
Renal fracture ; Renal Vascular
Medication generally prescribed for trichomonas is _______
Benzathine (bicillin) and doxycycline medictations are usually prescribed for______
Flagyl
Syphillis
What is MITTELSCHMERZ
Middle pain, used to refer to pain around the middle of the menstrual cycle.
What organs does the left gastric branch of the CELIAC ARTERY supply
The Hepatic to right gastric branch of the celiac artery supplies only the ______
The GASTRODUODENAL BRANCH of the celiar artery supplies in the _______ and the _________
The SPLENIC BRANCH of the Celiac artery supplies the ______, the ______ and the _________
Stomach and esophagus
Stomach
Stomach and the Duodenum
Stomach, pancreas and spleen.
Which 2 ribs could cause penetration of the kidney if the become fractured?
The ____kidney is lower than the _____ kidney therefore they _____ kidney is more susceptible to injury than the ____ kidney.
When the left kidney is injured, it is often accompanied by _____injury
When the right kidney is injured, it is often accompanied by _____injury
Ribs 11 and 12
Left; right; right ; left
Spleen
Liver
Fractures of the 1st and 2nd ribs can result in injury to the ______, _____aorta, _____Artery and ______
Lungs, ASCENDING, subclavian, brachial plexus
Normal amylase is ______ and Normal lipase _______and they are both elevated in _________cancer
23-125; ______ 10-180; pancreatic.
During pregnancy , HR ______and CO ______
Oxygen consumption
Abdominal injuries and hemorrhage are masked : T/F
increases; increases
increases
True
HELLP stands for _____ ____ ____ ___ ____ it is an obstetric emergency and varinat of ______ _____
Hemolysis, elevated liver Enzyms and low Platelet.
severe preeclampsia
Ulcerative coltis is characterized by SBLLQ
Severe diarrhea
Bloody stoll
LLQ tenderness
Crohn’s Disease is characterized by abdominal pain ______, weight loss, _______, and _______
Low grade fever
Intestinal obstruction
Anal fissures or abscess
Complications of Gonorrhea are associated with _____ ______ and _____
Vaccinations for HPV is for ages________, and the vaccination is _______
Epididymitis, chronic pelvic pain, fallopian tube damage
13-26; Gardasil
Bladder pain is caused by _______and ______
Ureteral pain is caused by _______ and ______
Overdistention; inflammation.
Obstruction; distention
Diverticulitis is inflammation of the ________
may be the result of ______ by ____ or fecal material
Meckel diverticulum is a small buldge that is located in the _____ intestine that was present at _____
Diverticulosis is multiple ______ that are NOT ______
Diverticula
obstruction ; food
small ; birth
diverticula; inflamed
Testicular Torsion is characterized by twisting of the _________ or the _______ cord and most common occurs in boys between ages ___ and ____
Immediate bedsid______or surgical exploration with ______is performed
testicles; spermatic
12-18
Detorsion; ORCHIDOPEXY
Inflammation of the bladder cause _______ and ____ pain in the _____
Overdistention in the bladder causes pain in the _____area
Renal inflammation causes pain in the _____area
Prostate inflammation causes pain in the _____ ____
burning; sharp; urethra
Suprapubic
FLANK
Lower back
Which male genital organs work together to produce semen?
________ and ________
The testes produces ______ and ________
Secretes alkaline component of semen_____
Seminal vesicles
Prostate gland
Sperm ; testosterone
bulbourethral gland
Blood work not elevated in cirrhosis____
what is normal LDH
WBC
90-200
MANTRELS score
< 5 appendicitis _____
5-6 appendicitis ______
7-8 appendicitis _____
9-10 appendicitis ______
unlikely
likely
possible
highly likely
When a patient is diagnosed with epididymoorchitis, one of the things that should be monitored in case of complication is _______which is _____ in sperm
Hemospermia
blood
Which female genital organ is responsible for protecting a fetus_____
allows passage from fertilization and implantation is ________
Neck of the uterus and leads from the vagina is the _____
UTERUS
Fallopian tube
cervix
Right UPPER QUADRANT painis best asses with _______
Right or left LOWER QUADRANT PAIN is best assessed with
Ultrasound
CT scan
Which type of bladder rupture is generally associated with a PELVIC FRACTURE____
Bladder contusion is type ___ and the most ______
- *INTRAPERITONEAL RUPTURE** generally resulst from _____ _____ trauma and is type ____
- *INTERSTITIAL INJURY** Type ____ is the most ____ type of bladder injury
Type IV: Extraperitoneal
Type I; common
lower abdomen; Type II
III; rare
Which male organ store sperm until they become mature _______
Epididymis
Operation of the large intestine is most likely because the patient is
unable to eliminate dignestive wastes effectively.
Deliver of the placenta following birth of the baby includes____________
Placental separation is the final stage of labor and generally occurs within minutes of birth but may take up to ____ minutes. the process should not be hurried.
Massaging the fundus immediatly after delivery of the placenta.