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4500 Gender & reproductive health > Class 3 - pregnancy complicated > Flashcards

Class 3 - pregnancy complicated Flashcards

1
Q

What are 2 leading causes of newborn morbidity and mortality?

A
  1. Preterm
  2. multiple births
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2
Q

What helps a new born achieve good mortality?

A

fetal wellbeing

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3
Q

What is an important factor in fetal well being (the foundational organ)

A

utero-placental function
ie) the placenta

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4
Q

What occurrences put a pregnant person and fetus at risk?

A
  1. hypertension in pregnancy
  2. Gestational DM
  3. Hyperemesis gravidarum
  4. hemorrhagic complications
  5. surgery during pregnancy
  6. trauma
  7. Infections during pregnancy
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5
Q

What morbidity issues do Hypertensive disorders in pregnancy cause in the maternal person?

A

Stroke
acute renal failure
pulmonary edema
HELLP syndrome
cerebral edema w/seizures

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6
Q

What does HELLP stand for?

A

Hemolysis (break down of RBC) - they get stuck on the thrombosis/platelets and tear

elevated liver enzymes - liver not being perfused

low platelets- thombosis collects platelets

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7
Q

What maternal mortality issues can hypertensive disorders cause in pregnancy?

A

hepatic rupture
placental abruption
eclampsia - seizures

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8
Q

What is the fetus of the pre-eclamptic patient at increased risk from?

A

Placental abruption

preterm birth

IUGR (intrauterine growth restriction)

acute hypoxia

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9
Q

what is IUGR

A

intrauterine growth restriction

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10
Q

what is considered non-severe hypertension in pregnancy?

A

> or = 140 sytolic
or = 90 diastolic

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11
Q

how many measurements of an abnormal BP are needed to diagnose non-severe hypertension?

A

at least 2 measurments

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12
Q

how many min should we wait before taking a second BP?

A

15 min apart
AFTER 5 min of rest

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13
Q

What is considered severe hypertension?

A

> or = 160 systolic
or = 110 diastolic

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14
Q

Which is an emergency, severe hypertension or non-severe hypertension and how quickly do we need to act?

A

severe hypertension
treat within 30-60 min (goal is ASAP)

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15
Q

Hypertensive disorders of pregnancy can cause death of the pregnant person by causing the following issues:

A

intracranial hemorrhage

eclampsia or cerebra edema

pulmonary edema

hepatic rupture

hepatic necrosis/HELLP

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16
Q

which BP number do we record if BP is consistently higher in one arm? The lower or higher arm?

A

go with the higher BP

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17
Q

should we use automated BP machine or manual for someone with pre-eclampsia?

A

manual
unless automated has been approved

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18
Q

What are the 3 types of hypertension in pregnancy?

A
  1. chronic hypertension <20 weeks
  2. gestational hypertension >20 weeks
  3. Pre-eclampsia - hypertension & proteinuria
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19
Q

How do we identify chronic hypertension?

A

<20 weeks gestation
no s/s of organ damage
high BP

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20
Q

How do we identify pre-eclampsia?

A
  1. High BP with complications
  2. > 20 weeks gestation
  3. Proteinuria
  4. organ damage s/s
  5. 3x hypertension treatment failure
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21
Q

Why are we worried if someone has chronic hypertension?

A

increased risk of:
1. poor fetal growth
2. fetal still birth

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22
Q

What is gestational hypertension?

A
  • detected at or after 20 weeks in previous normotensive peeps
  • hypertension but no pre-eclampsia (no complications)
  • Systolic is > or = 140
  • Diastolic > or = to 90
  • no proteinuria
  • no s/s of organ damage

25% go on to develop pre-eclampsia

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23
Q

What is pre-eclampsia defined as?

A

multisystem
vasospastic disease procress

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24
Q

What is the main pathogenic factor of pre-eclampsia and why?

A

poor perfusion d/t vasospasm

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25
Q

Is pre-eclampsia from high BP or vasospastic disease process, or both?

A

Vasospastic disease process
- the placenta impants funny and sends out inflammatory factors that cause endothelial cells to go wacko and increase BP to help with perfusion

Results in:
-reduced tissue perfusion to major organs
- increases blood pressure

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26
Q

What are the risks for developing pre-eclampsia?

A
  1. nullipartiy
  2. age >40 (35+)
  3. IVF
  4. 7 years between preggers
  5. family history
  6. pre preg BMI >30
  7. Gest. DM
  8. multifetal gestation
  9. pre-eclampsia in previous preggs
  10. previous pregs poor outcome
  11. PMHX/genetic conditions
  12. chronic HTN
    13 . renal disease
  13. DM 1
  14. antiphospholipid antibody syndrome
  15. factor V Leiden mutation
  16. OSA obstructive sleep apnea
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27
Q

what is the theory etiology of pre-eclampsia?

A
  1. something wrong with placenta
  2. signals to preggers person to increase perfusion
  3. endothelial cells control vasoconstriction/dilation but they get confused
  4. vessels leak out more protien and fluid causing edema
  5. edema in brain = seizures = eclampsia
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28
Q

How do we check for proteinuria?

A

pee dip stick
min 2 random samples <6hrs apart.
should not have UTI

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29
Q

how often do we check for proteinuria?

A

during an apt or if pesron has hypertension.

test 1 - pass - stop
test 1 - fail - 2nd test at least 6 hrs apart (no UTI)

24 hour urine test

If fail = has proteinuria = stop testing

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30
Q

What CNS symptoms in preesclampsia require close monitoring?

A
  1. headache 8/10
  2. visual distrubances - aura sightings/ flashing lights
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31
Q

what are the signs & symptoms for eclampsia?

A
  1. headache
  2. severe epigastric pain
  3. Hyperreflexia (hammer to test. If you don’t need hammer , +3,+4 = not good
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32
Q

What is the worry during an eclampsia episode?

A

during the seizure, the pregnant person and fetus are not getting enough oxygen

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33
Q

Can someone with a history of seizures be diagnosed with eclampsia?

A

No. because eclampsia by definition is only when they have seizures but no other history to explain it

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34
Q

What cardiorespiratory symptoms in preesclampsia require close monitoring?

A

Chest pain/dyspnea = pulmonary edema

Oxygen saturation <97%

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35
Q

What adverse CNS conditions of preeclampsia require delivery regardless of gestational age?

A
  1. Eclampsia
  2. PRES - edema in the back of the brain
  3. cortical blindness (reversable) / retinal detatchment
  4. Stroke or TIA
  5. GCS <13
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36
Q

What adverse Cardiorespiratory conditions of preeclampsia require delivery regardless of gestational age?

A
  1. uncontrolled severe HTN >12 hours + fail 3 antihypertensives
  2. O2 sat <90%, need 50% O2 for >1 hr, intubation, pulmonary edema
  3. positive inotropic meds (ie: DIG)
  4. MI
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37
Q

What adverse Hematological conditions of preeclampsia require delivery regardless of gestational age?

A
  1. platelets <50
  2. transfusion of ANY blood product
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38
Q

What hematological symptoms in preesclampsia require close monitoring?

A

Low platelet count <100

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39
Q

What Renal symptoms in preesclampsia require close monitoring?

A

elevated serum creatinine

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40
Q

What adverse renal conditions of preeclampsia require delivery regardless of gestational age?

A
  1. AKI
  2. new indication for dialysis
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41
Q

What adverse Uteroplacental dysfunction
of preeclampsia require delivery regardless of gestational age?

A
  1. Abruption w/evidence of maternal or fetal compromise
  2. Absent or revered ductus venous A wave by doppler velocimetry
  3. Intrauterine fetal death
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42
Q

What Uteroplacental dysfunction
in preesclampsia require close monitoring?

A

1.Abnormal or atypical Fetal Heart Rate (FHR) – NST​
2. Fetal growth restriction​
3. Oligohydramnios​
4. Absent or reversed end diastolic flow by umbilical artery Doppler velocimetry – we want continuous flow in ONE direction ​
5. Angiogenic imbalance​ - measure blood levels

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43
Q

What is HELLP syndrome considered a variant or complication of?

A

pre-eclampsia

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44
Q

How is HELLP diagnosed?

A

platelet count <100
AST, ALT elevated

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45
Q

HELLP syndrome can occur without what two complications?

A
  1. hypertension HTN
  2. proteinuria
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46
Q

What causes low platelets?

A

damaged endothelial cells (confused hall monitors) use them up

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47
Q

how long is postpartum surveillance after birth?

A

up to 6 weeks

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48
Q

What 3 things do we test in pre-eclampsia that we don’t test in gestational/chronic HTN?

A
  1. platelets
  2. serum creatinine
  3. AST or ALT
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49
Q

What antihypertensives can we NOT give because they are teratogenic?

A

ACEs & ARBS

50
Q

What meds can be given to control HTN?

A

Labetolol – B-Blocking agent​
Hydralazine​
Nifedipine​
Methyldopa (Aldomet)

51
Q

what is the goal diastolic BP of a preggers person with chronic/gestational/preeclampsia?

A

diastolic = 85mm Hg

52
Q

What med is given for seizure prevention?

A

Magnesium Sulphate IV

53
Q

When would someone become an inpatient ?

A

severe hypertension or preclampsia with 1 or more maternal adverse conditions

54
Q

When is magneisum sulphate indicated?

A

pre-eclampsia with severe features & severe gestational hypertension

all cases of severe >160/110, 15+ min, regardless of classification

55
Q

What is really important to remember about magnesium sulphate ?

A

the person should not be left alone!
toxicity risk

56
Q

What is the MOA of magnesium sulfate?

A

CNS depression

not antihypertensive

57
Q

What do we montior for peopel with magnesium sulphate?

A
  1. test reflexes for big changes
  2. monitor FHR
58
Q

What is the antidote for magnesium sulphate?

A

calcium gluconate

59
Q

how do we know someone has magnesium toxicity?

A
  • decreased/absent reflexes
  • lower BP, HR,
  • RR (<12 for 15 min)
  • lower O2 (94% for 15 min)
  • Urine output <30ml/hr for 4 hr
60
Q

When someone is on magnesium sulphate how often do we measure mom & fetal vitals?

A

mom- q 30 min
fetus >26 weeks continuous HR

61
Q

how do we know that someone is having CNS symptoms from magnesium sulphate?

A

reflexes absent or slow

foot will continue to shake

62
Q

what are our 2 greatest maternal concerns if someone is having eclampsia?

A

airway
patient safety

63
Q

What placenta issues is someone at risk for who has eclampsia?

A

placental abruption

64
Q

what is a risk of using magnesium sulphate?

A

hemorrhage because the uterus can’t contract the way it normally would to stop bleeding after delivery

65
Q

What is Gestational diabetes mellitus?

A

any degree of glucose intolerance with onset during pregnancy

66
Q

What are the risks if someone has either pre-existing DM or gestational DM?

A

-Fetal macrosomia
-Large for gestational age
-Fetal Hypoglycemia, IUGR (interurerine growth restriction) , intrauterine fetal death, fetal lung immaturity
-Neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia
-2x risk of hypertensive disorders (pre-eclampsia)
-Infection
-Trauma and injuries during birth
-Caesarean birth
-Shoulder dystocia and nerve injury
-Preterm delivery

67
Q

Why does diabetes cause big babies?

A

high glucose causes the fetus to release insulin.
Insulin lets glucose into the cells
1. Stimulates fat storage
2. causes organs to grow

68
Q

What are the 4 MAIN things that someone is at risk for with diabetes?

A
  1. c-section
  2. shoulder dystocia
  3. trauma
  4. pre-term birth
69
Q

What medication makes someone at risk for developing GDM?

A

corticosteroid meds

70
Q

how many weeks do we screen people for GDM?

A

24-28 weeks

71
Q

When do we screen people who have type 2 diabetes ?

A

at initial prenatal visit
take A1C
If normal = <6.5 screen again at 24-28 weeks with 50g OGTT

72
Q

What is the two step approach for screening GDM?

A
  1. Step 1= Random non-fasting 50g OGTT
    - 1 hour Plasmas glucose <7.8mmol
    STOP
  2. Step 2 = 75g OGTT
    - 1 hr plasma glucose >or = to 11.1 mmol/L
    diagnosed GDM
    STOP
  3. Step 1 >11.1 stop
    Automatic GDM
73
Q

After 50g glucose challenge test how long do we wait to test plasma glucose?

A

1 hour

74
Q

When someone has GDM how long do we wait for activity and lifestyle modification before starting pharmacology therapy?

A

1-2 weeks trial

75
Q

What is the recommended weight gain for “normal weight?”

A

11.5-18 kg (25-35 lb)

76
Q

What do we check for in urine of people with GDM?

A

leukocytes or nitrates
glucose
protein

77
Q

What is very important for people with Diabetes to monitor with their fetus?

A

Kick counts

78
Q

How many weeks should someone be induced who has diabetes?

A

consider induction 38-40 weeks
*reduces stillbirth & c-section

79
Q

What is considered polyhydramnios?

A

Amniotic fluid >2000 ml

80
Q

What is Oligohydramnios?

A

Amniotic fluid less than expected amount

81
Q

What is polyhydramnios more common with?

A

Gestational diabetes

82
Q

according to the AMI (amniotic fluid index), what is considered nomral, oligohydramnios, polyhydramnios?

A
  1. 10-25 cm normal
  2. <5 cm= oligohydramnios
  3. > 25cm = polyhydramnios
83
Q

What are some signs and symptoms of polyhydramnios?

A
  1. vericose veins in legs
  2. swelling/edema
  3. stretched skin
  4. hard to find fetal heart - polyhydramnios
  5. polyuria
84
Q

What are 4 things to measure in people with GDM intrapartum?

A

1.Monitor glucose closely, keep glucose between 4-7 mmol/L​
2.Hydration (may require IV fluids)​
3.Insulin may be required ​
4. Monitoring of uterine activity & FHR

85
Q

How long does someone with GDM take insulin post partum and why?

A

Stop insulin and Diabetic diet immediately post partum

why? - cuz the placenta is out

86
Q

What are we worried about with DMII and pregnancy in the 1st trimester and early 2nd trimester?

A

Metabolic changes = risk of hypoglycemia

  1. increased insulin production
  2. increased tissue glycogen storage (less in the serum)
  3. decreased hepatic production of glucose
87
Q

What are we worried about with DMII and pregnancy in the later part of 2nd trimester and 3rd trimester?

A

hyperglycemia

  1. decreased glucose tolerance
  2. increased insulin resistance
  3. decreased glycogen stores
  4. increased hepatic production of glucose
  5. increase insulin - more is required
  • increased glucose is normal for non DM preggs peeps too
88
Q

What should we teach those who are DMII in the preconception phase?

A
  1. healthy weight goal
  2. folic acid (1 mg OD X 3 months before preggers and 1st trimester. then 0.4 mg for rest of pregnancy
  3. A1C </= 7.0 %
  4. review meds if any are teratogenic
89
Q

what type of prenatal care do we do for someone with DMII?

A
  1. control blood glucose
  2. usually switch to insulin
  3. frequent prenatal visits
  4. more lab tests
  5. fetal health surveillance (FHS)
90
Q

What is important to monitor for pregs peeps during intrapartum care?

A
  1. BG level
  2. Ketones in urine
  3. Hydration
  4. shoulder dystocia
  5. continuous fetal HR montitor if birther has insulin
91
Q

What do we monitor in someone with DMII during post partum care?

A
  1. Blood glucose levels
  2. preeclampsia/eclampsia
    3.hemorrhage
  3. infection
  4. breast feeding
  5. family planning
92
Q

What is bleeding in pregnancy to be treated as?

A

a medical emergency

93
Q

In the first trimester what is most bleeding a result of?

A

Spontaneous abortion
ectopic pregnancy

94
Q

What is 50% of bleeding in the 3rd trimester from?

A

placenta previa
placenta abruption

95
Q

why is checking for disruption of vascular integrity so important in pregnant people?

A

because they can bleed out within 8-10 min d/t increased fluid volume

96
Q

How many weeks is considered a miscarriage or spontaneous abortion?

A

a loss less than 20 weeks

97
Q

What are the 5 types of miscarriage?

A
  1. threatened pre loss (cramping)
  2. inevitable loss
  3. incomplete loss
  4. complete loss
  5. missed abortion
98
Q

What are the symptoms of inevitable loss?

A

moderate bleeding, cramping mild. cervix is dilated. stuff is coming out and they are losing the fetus

99
Q

What are the s/s of incomplete loss?

A

heavy bleeding, severe cramping. no more fetal parts inside but it’s ongoing heavy bleeding . sometimes D&C needed

100
Q

What are the s/s of a complete miscarriage?

A

everything is out of the cervix and the cervix closes

101
Q

What are the s/s of a missed abortion?

A

no heart beat but everything is in the urterus still . no cramping. >5 weeks there’s a risk for the person. risk of infection

102
Q

if someone is bleeing, what test should we order or have ready?

A

Usually check serum BhCG 2x over 48 hours. should double in a normal pregnancy
Other tests will depend on symptoms and history (i.e. CBC)
Blood type and RhD antigen screening

103
Q

what are two things that can happen if we don’t know the Rh status of the mother?

A
  1. placental abruption
  2. placental previa
    (if fetus is Rh+ and mom is Rh -)
104
Q

What is premature dilation of the cervix (cervical insufficiency)?

A
  • passive and painless dilation of cervix
  • can cause late miscarriages
  • can lead to recurrent preterm births
105
Q

what is cerclage?

A

closing the cervix to prevent premature birth
- until 35-37 weeks or active labour

106
Q

What are the 3 causes of late pregnancy bleeding?

A
  1. placenta previa
  2. placental abruption
  3. variations in cord insertion on the placenta (should be center)
107
Q

What are the risk factors for placenta previa?

A
  1. previous one
  2. previous c-section
  3. D&D
  4. multiples
  5. age >35+
  6. smoking
  7. higher altitude
108
Q

What are the clinical manifestations of placenta previa?

A
  1. painless
  2. bright red vaginal bleeding
  3. 2nd and 3rd trimester
  4. uterus is soft, relaxed and nontender with normal tone
109
Q

What are the risks of placenta previa to the fetus?

A
  1. preterm birth
  2. still birth
  3. breech etc
  4. fetal anemia
  5. IUGR
110
Q

What should we never examine with placenta previa?

A

NO PELVIC/VAGINAL exam

111
Q

how often do we monitor fetus in placenta previa?

A

1-2x per week
NST or BPP

112
Q

what do we do (assessments/interventions) for placenta previa peeps?

A
  1. NST or BPP
  2. regular labs (bleeding factors)
  3. IV sometimes
  4. Winrho to help develop lungs (24-46+6 weeks)
113
Q

What is a velamentous cord insertion problem?

A

cord gets bumped and bleeds cuz its not nice and strong

114
Q

What is a battledore cord insertion problem?

A

cord isn’t central

115
Q

What is responsible for 1/3 of all antepartum bleeding?

A

Placental abruption

116
Q

what are the risk factors for placental abruption?

A
  1. HTN disorders with pregnancy
  2. cocaine use
  3. MVA/blunt trauma
  4. smoking
  5. previous history of one
  6. preterm/premature rupture of membranes
  7. thrombophilia
117
Q

What are the S/S of placental abruption?

A
  1. sudden onset of intense pain (usually localized)
  2. with or without bleeding
  3. dark nonclotting bleeding
  4. hard abdomen
118
Q

What is different between previa and abruption?

A

previa :
painless
bright red blood
soft abdomen

abruption:
painful
dark red blood - not clotting
very hard abdomen

119
Q

what are maternal complications of placental abruption?

A

1.Hemorrhage
2.Hypovolemic Shock
3.Couvelaire Uterus (purple)
4.Infection
5. DIC - more likely with moderate or severe separation
6. Hypofibrinogenemia
7.Thrombocytopenia- low platelets
8.Organ damage
9. Rh sensitization

120
Q

what are the fetal complications of an abruption?

A
  1. IUGR (intrauterine growth restriction)
  2. Oligohydramnios
  3. preterm birth
  4. fetal hypoxemia
  5. still birth
121
Q

What are newborn complications of placental abruption?

A
  1. neurological defects
  2. cerebral palsy
  3. newborn death
122
Q

When should someone with placental abruption not have a c-section?

A

if coagulopathy is severe and uncorrected

4500 Gender & reproductive health (11 decks)

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