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Obs Gyne > General Obs and Gyne > Flashcards

General Obs and Gyne Flashcards

1
Q

What is the risk of developing DMII if you have GDM?

A

50% risk of developing DMII in the next 20 years if you have GDM

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2
Q

Is GDM related to the same risk of spontaneous abortion, and physical anomalies as DM 1/II?

A

No, GDM develops usually in the second trimester due to anti insulin factors and higher cortisol levels DM I/II are related to higher anomalies and spontaneous abortion because of first trimester hyperglycemia (important for anomalies) and the pre- conception glycemic control (important for spontaneous abortion)

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3
Q

What is the definition of preterm labour?

A

Preterm birth is a birth that occurs between 20 weeks and 37 weeks of gestation with preterm labor being labour that occurs during these gestational ages. Labour is defined a regular contractions with cervical change (effacement, dilation).

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4
Q

What is the definition of threatened preterm labour?

A

regular contractions that do not dilate the cervix OR preterm labour that stops (eg. person dilates to 2cm, then has no further change, they are now “threatened” preterm labour).

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5
Q

What is the definition of cervical insufficiency?

A

ervical effacement and or dilation with NO contractions /pain.

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6
Q

What are the definitions of braxton hicks contractions?

A

irregular contractions, usually not painful, producing no cervical changes. Usually improve with rest and hydration.

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7
Q

What are the risk factors for preterm labour?

A

Risk factors : previous preterm birth, multiple gestations, short cervix on ultrasound (asymptomatic), complicated pregnancies (abruptions, PPROM, chorioamnionitis, polyhydramnios)

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8
Q

How do you diagnose preterm labour?

A

1)risk factors: previous preterm birth, multiple gestations, short cervix on ultrasound (asymptomatic), complicated pregnancies (abruptions, PPROM, chorioamnionitis, polyhydramnios) 2)Regular painful contractions 3)Fetal fibronectin–> high negative predictive value 4)Cervical exam for dilatation and effacement 5)ultrasound for cervical length

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9
Q

What is the DDX for cramping?

A

Pregnancy related :  True preterm labour ** lots of causes (eg. chorio, abruption etc)  Threatened preterm labour  Abruption Gynecology related:  Fibroid degeneration or ovarian cyst (rupture / torsion) Other systems :  Pyelonephritis / UTI  dehydration  Appendicitis / bowel infections  MSK : not usually regular cramping

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10
Q

What are the TORCH infections

A

Toxoplasmosis Other (Syphilis, varicella-zoster, , parovirus B-19) Rubella CMV Herpes

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11
Q

What populations do you do a fetal fibronectin for?

A

threatened preterm labour from 24-34 weeks This can direct whether you would give steroids or not

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12
Q

What are the changes to the cervix in labour?

A

Shortens Dilates Softens Moves more anteriorly

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13
Q

What are the components of Bishops Score? What is this score useful for?

A

Bishops score is useful in predicting a successful vaginal delivery

If the Bishop score is high, the likelihood of vaginal delivery is similar whether labor is spontaneous or induced [23,46]. In contrast, a low Bishop score increases the likelihood that induction will fail to result in vaginal delivery. The thresholds for high and low scores vary among trials, but a score ≥8 generally predicts a low rate of failed induction and a score of ≤6 generally defines an unfavorable cervix [5].

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14
Q

What are the GBS prophylaxis guidelines?

A

GBS prophylaxis : if unknown, treat as < 37 weeks (as per SOGC GBS guideline)  First line : Penicillin G 5 million U then 2.5Mill U q4h

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15
Q

What are the treatment of preterm labour?

A
  • 1)IV fluids and analgesia
    2) Mother and fetal monitoring
    3) GBS prophylaxisif unknown, treat as < 37 weeks (as per SOGC GBS guideline)  First line : Penicillin G 5 million U then 2.5Mill U q4h
    4) Steroids Betamethasone 12mg q24h x2 IM OR Dexamethasone 6mg IM q12 hour x4
  • do not use prednisone as it is destroyed by the placenta
  • they can be given twice between 24 and 34 weeks
    5) Consider tocolysis
    a) Indocid (indomethacin)
    b) adalat (nifedipine)
  • the purpose of tocolysis is to allow time for steroids
    6) Can’t do Breech delivery before 29 weeks because the head is bigger than the body, so it will get stuck
    7) Tertiary care (has 24 hour care < 32 weeks)
    8) Obs-gyne care +neonatology
    9) Consider MgSO4 for fetal neuroprotection (NMDA receptor blockade)
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16
Q

What is PPROM and how is it confirmed?

A

Rupture of membranes before 37 weeks

confirmed by

1) Fernings test (Gold standard)
2) Nitrazine

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17
Q

How long is the GBS swab acurate for?

A

5 weeks

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18
Q

What is the treatment of PPROM?

A

PPROM IS NOT LABOUR, DON’T TREAT IT AS SUCH

1) IV, CBC, type and screen
2) Fetal monitoring
3) Monitor maternal vital signs for fevers
4) Ultrasound: BPP, presentation, AFI, EFW
5) Steroids

24-34 weeks–> Tocolysis and subsequent steroids to get to 34 weeks

After 34 weeks- tocolysis in this area is a grey zone

6) Tocolysis is not used in PPROM–> higher risk of infection–> higher risk of IVH–> bad outcomes
7) Antibiotics
a) PPROM Antibiotics –> erythromycin +/- ampicillin q 7days
b) Preterm labour antibiotics–> Pen G ( if in labour with PPROM and unknown GBS)
c) if PPROM and then some preterm labour which stops and then goes back to just PPROM

–> erythromycin +/- ampicllin–> PENG–> erthromycin +/- ampicillin

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19
Q

What are the complications of PPROM?

A

 Chorioamnionitis
 Abruption
 Cord prolapse (esp if not cephalic)

 Preterm Labour

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20
Q

When do you deliver with PPROM?

A

 If everything is reassuring : fetal growth, no signs infection or other OB complications

 <34 weeks : try to prolong pregnancy (latency Abx)  >37 weeks Deliver.

          Cephalic : oxytocin induction               

          Breech / other : cesarean section  34-37 weeks : controversial. Not clinical clerk level.

 Calgary : most times you will see delivery with PPROM >34 weeks but cases where pregnancy is prolonged.

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21
Q

What are the treatment for GBS?

A

First Line–> Pen G 5 000 000 u IV, the 2 500 00 u IV q4h until delivery

IF PEN ALLERGIC (NON ANAPHYLAXIS)

Ancef 2 g IV, then 1 g IV q8h until delivery

IF PEN ANAPHYLAXIS

Clindamycin 900mg IV q8h until del (pen anaphylaxis) – be sure to check sensitivities!

Vancomycin 1 g IV q12h until del (Pen anaphylaxis and clinda resistant!)

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22
Q

When do you treat for GBS?

A

1) Positive GBS swab
2) Previous infant with GBS disease (sepsis, meningitis, pneumonia, death)
3) GBS bacteria in urine during pregnancy at any time
4) GBS unknown if:
a) preterm < 37 weeks, any reason for labour ( PTL, PPROM, iatrogenic)
b) intrapartum temperature > 38.5
c) ruptured membranes > 18 hours and unknown GBS (takes a week to get swab back)

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23
Q

What is the treatment for term ROM and GBS positive?

A

induce labour

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24
Q

What defines PPH?

A

Vaginal delivery blood loss > 500ml

C/S blood loss > 1000ml

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25
Q

Is clotting affected in pregnancy?

A

Clotting factors are not affected by pregnancy

Fibrinogen becomes higher in pregnancy (goes up to 4) so if you check for DIC and it is 2, then you are actually low

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26
Q

What are the four causes of PPH?

A

Tone

Tissue

Truama

Thrombin

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27
Q

What are the drug therapies for Uterine Atony?

A
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28
Q

What are the non medical therapies for uterine atony?

A

Tamponading –> Bakri baloon, folley, packing with gauze

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29
Q

What are the surgical therapies for uterine atony?

A

1)Suture the uterus–>B-Lynch sutures

30
Q

What are the common causes of retained tissue for PPH?

A
31
Q

How does C/S affect placental development?

A

C/S increases your risk of placental acreta, increta…

32
Q

What are the causes and risk factors for trauma for PPH?

A
33
Q

What are the causes of thrombin related PPH?

A
34
Q

What are the blood supply to the uterus and ovaries?

A
35
Q

What is the treatment of PPH?

A
36
Q

What is antepartum hemorrhage?

A

Bleeding from or into the genital tract occuring from 24+0 to prior to the birth

includes labour

Leading cause of perinatal and maternal mortality

Previa and uterine rupture are rare and bad

post coital bleeding, cervical polyps, cervical dysplasia, urinary tract and rectal are common and no bad

37
Q

Are speculum exams or vaginal exams contraindicated in placenta previa?

A

Vaginal exams are contraindicated in previa

Speculum exams are not contraindicated in previa

38
Q

What is the APT test, and why is it important?

A

The APT test tests for fetal blood from vagina, it is the same as the Klienhauer-Betke test

39
Q

What is placental abruption?

A

Premature separation of a normal implanted placenta

4 classes

1) revealed
2) concealed
3) Total
4) Partial/marginal

Risks of placental abruption–> spontaneous preterm birth, iatrogenic preterm delivery

Risk factors for placental abruption

  • Abruption in a previous pregnancy
  • 4.4% incidence of recurrent abruption (OR 8.7)
  • If 2 previous pregnancies with abruption: 19-25% recurrence
  • Preeclampsia
  • Multiparity
  • Low BMI
  • Pregnancy following ART • Intrauterine infection
  • PPROM
  • Thrombophilia (FVL and Prothrombin gene defect) • Abdominal trauma
  • Smoking
  • Cocaine / amphetamines
40
Q

What is the most important tests to order if suspect abrubtion?

A

1) Ultrasound looking for jello sign (thickened heterogenous placenta)
2) Kliehauer-Betke test –> tests for maternal fetal hemorrhage

gives you an idea of appropriate Rhogam dosing ( for every 30 ml of fetal blood in maternal blood-> give 300 ul of rhogam

–> you must always order if RH negative, or if want to document FMH in APH

41
Q

What is the management of a stable placental abruption?

A

If spotting and not previa: home

If heavier than spotting and/or ongoing: remain inpatient until bleeding stopped

• No data regarding duration of hospital stay

No tocolysis
• Should not delay delivery in an unstable patient • Generally contraindicated

ObGyn care

RhIg with each bleed

Serial ultrasound assessment of fetal growth and well-being (risk of IUGR, oligohydramnios, PPROM, PTL)

Increased surveillance for remainder of pregnancy

Likely delivery at or after 37+0 GA

42
Q

What is a placenta previa?

A

Placenta implanted in the lower segment of the uterus presenting ahead of the leading pole of the fetus

2.8-4/ 1000 ( greater risk with twins)

Increased risk of maternal mortality, PPH and hysterectomy

Location of placenta previa

a) complete–> completely covers interal os
b) partial- partially covers the internal os
c) marginal-reaches internal os (0mm away)
d) low lying (1-29mm)

Management

There is a relative upward shift due to differential growth of the lower seqment in the third trimester–> most previas self resolve

** the previa is very unlikely to persist past the first trimester unless the overlap is > 10mm**

  • between 18-24 weeks the placenta reaches or overlaps the internal os on TVS–> mandatory follow up in third trimester
  • if between 18-24 weeks 1mm or more away from internal os–> no follow up required
  • at >26 weeks if < 20mm from cervical os–> further follow up needed + higher risk of C section
  • check again at 35 weeks when
    a) > 20mm away from os–> high likelihood VD
    b) 0-20mm away from os 40-90% c/s rate with closer to os= higher c/s
    c) 0mm from os–> C/S

It is very important to document the location of the chord insertion if low lying or previa to assess risk of chord prolapse

43
Q

What are the risk factors for vasa previa?

A

Previous Previa

Previous C/S

Multiparity

Previous termination of pregnancy

Advanced maternal age

Smoking

Assisted conception

44
Q

What is the difference between placenta previa and vasa previa?

A

Placenta previa is a normal placenta in an abnormal position in the uterus ( close to the cervical os)

vasa previa is an abnormal placenta with umbilical vessels that are unsupported by the umbilical chord or placental tissue that traverse the fetal membranes above the cervix ( so a placenta previa with an abnormal placenta )

  • it is usually associated with an abnormal placenta
    a) velementous insertion (chord and vessels attach to membranes and then travel to placent)
    b) bi-lobed placenta
    c) succinturiate lobe (an accessory lobe)

Risk factors for Vasa Previa are

1) IVF
2) 2nd trimester placenta previa
3) abnormal placental morphology
4) Associations with APH, IUGR, prematurity

Diagnosis in first or second trimester is very important and saves lives

People who should be screened for vasa previa at 18-20 week ultrasound

1)all low lying placentas (0-20mmm

Consider trans-vaginal ultrasound in people who are high risk

1) IVF
2) 2nd trimester previa
3) abnormal placental morphology
4) patients with vaginal bleeding

Management

1) serial ultrasounds
2) Neonatal consult + betamethasone if neccessary
3) Admission to tertiary care

45
Q
A
46
Q

What are the indications for Rhogam and when do you give it?

A

Give to a Rh- mother

Don’t give to Rh+ mother

if she is anti-body positive

  • still give if anti-kell
  • don’t give if anti-d
47
Q

Who should be screened for GDM and how?

A

Should do routine screening between 24-28 weeks with OGCT (50g)

for all women except

< 25 years old

caucasian or low prevalence of diabetes ethnicity

pregnant BMI= 27

No previous hx GDM or glucose intolerance

No first degree family hisotory

No history of adverse GDM related outcomes

If GDM is diagnosed –> use 75g OGTT

48
Q

What is the diagnostic criteria for post partum depression?

A

The diagnostic criteria for post-partum depression are the same as for non-peurpural major depression

Must occur within 4 weeks of birth to be given the diagnosis of MDD with peripartum onset

for 2 weeks in the last month meet the criteria of

1) mood
2) sleep
3) interests
4) guilt
5) energy
6) concentration
7) appearance
8) psychomotor agitation or depression
9) suicidality

49
Q

What is the jello sign, and what is its importance?

A

The sonographic presence of thick heterogeneous placenta is strongly associated with an adverse pregnancy outcome and often with perinatal death.

Jello sign is the name for this

It is important to asess the placenta in all types of antepartum hemmorhage

50
Q

What are the indications for administration and dosage of Rho-GAM?

A

1) A woman who is Rh negative, and who has negative anti-d titres
2) Routinely give at 28 weeks if antibody titire is still negative
3) Rh negative with antibodies other than anti-D
4) antipartum bleeding ( spontaneous or induced abortion, treatment of ectopic, significant vaginal bleeding, amniocentesis, abdominal trauma, ECV)
5) Give to all Rh negative, anti-D negative women who deliver an Rh-positive infant within 72 hours of delivery

Dosage of Rho-GAM

1) for < 30ml of transplacental hemorrhage 300ug of anti-D is sufficient
2) Additional Rho-GAM can be given at a dose of 10 ug for every 1m of transplacental hemorrage as determined on Kleinhauer Betke test

51
Q

What is the difference between an APT test a Kleihauer Betke and a Wright stain?q

A

APT test–> qualitative done on a slide with blood from antepartum hemorrhage and mixed with NaOH. If supernatant turns pink= fetal, yellow= maternal

Kleihauer betke–> quantitative test to determine how much fetal blood is in maternal circulation at time of transplacental hemorrhage

Wright stain–> qualitative test to look for nucleated red blood cells ( fetal)

52
Q

What are the components of the first trimester screen, and what is their importance?

A

The first trimester screen is composed of

1) nuchal transulscency on US and is done at 11-14 weeks
2) PAPP-A PAPP-A is a complex, high molecular weight glycoprotein. Its levels, on average, are lower in pregnancies affected with fetal Down syndrome. In contrast to beta-hCG, PAPP-A performance as a screening marker decreases with increasing gestational age between 9 and 13 weeks
3) B-HCG

Beta-HCG levels are, on average, twice as high in pregnancies affected with fetal Down syndrome than in euploid pregnancies. Beta-hCG can be assayed in its free or total form.

Free beta-hCG is effective at 90/7ths to 136/7ths weeks, and the performance improves as gestational age advances within this interval [21].

Total beta-hCG is effective at 110/7ths to 136/7ths weeks, and the performance improves as gestational age advances within this interval [7,8,17].

Between 110/7ths and 136/7ths weeks, there is no consensus as to whether free beta-hCG performs significantly better than total beta-hCG for Down syndrome screening when interpreted in conjunction with measurement of PAPP-A and nuchal translucency [7,8,21].

53
Q

What are the timing of the fetal ultrasounds, and what is their acuracy?

A

1)dating ultrasound –> 8-12 weeks gestation (crown rump length)

+/- 3 days

  • change to this date if > 1 week difference from Naegeles rule
    2) Nuchal Translucency Ultrasound (11-14 weeks gestation)
    3) fetal growth and anomaly ultrasound (18-20 weeks)

+/- 7 days acuracy

54
Q

What are the exclusion criteria for the use of misoprostol?

A

confirmed or suspected ectopic

Presence of an IUD

IBD

breastfeeding

haemorrhagic disorder, or on anti-coagulation

known or suspected ischemic heart disease or myocardial infarction

severe asthma on long term corticosteroids

identified non-compliance potential

55
Q

What are the criteria for the use of misoprostol to terminate a pregnancy?

A

Transvaginal (TV) is always smaller

Embryo no cardiac activity > 7mm TV, > 9mm TA

Gestational sac, no yolk sac, no embryo >8mm TV, > 20mm TA

Gestational sac with yolk sac, no embryo > 25mm TV, > 25mm TA

56
Q

What are the important guidelines about ovarian cancer?

A

The RMI or risk of malignancy index is an important metric used to calculate the risk a patient has of having a malignant ovarian cancer

RMI=ultrasound scoreX menopausal score x CA125 level in U/ml

an RMI> 200 neccesitates referral to gynechology oncology

Ovarian cancer should be on the differential for persistent pelvic pain/ abdominal pain, urinary urgency/frequency, increased abdominal size/bloading, difficulty eating

CA125 is a useful test in this case

57
Q

What are the absolute and relative contraindications to estrogen OCP?

A

Absolute contraindications

  • smoking > age 35
  • migraine with neurological symptoms including aura
  • congenital hypertriglyceridemia
  • impaired liver function assocaited with acute liver disease
  • known or suspected pregnancy
  • vaginal bleeding of unknown origin
  • estrogen dependant cancer (breast or ovarian)
  • past thromboembolic events or thromboembolic disease (factor V lieden, protein C or protein S deficiency, hemophillia)
  • coronary artery disease
  • cerebrovascular disease
  • uncontrolled hypertension

relative contraindications to estrogen based OCP

  • migraines- non focal with aura< 1h
  • diabetes mellitus complicated by vascular disease
  • SLE
  • controlled hypertension
  • hyperlipidemia
  • sickle cell anemia
  • gallbladder disease
58
Q

What are the options for emergency contraception (postcoital)?

A

levonestrogel ( plan B)

750 ug q12 mette 2 doses (75-95% effective)

Yupzee method

OVRAL (ethinyl estradiol 100 ug/ levonestrogel 500ug)

2 tabs po q12 x 2

Copper IUD (can be done up to 7 days postcoitus, and has a 1% failure rate

59
Q

What is the normal endometrial thickness in postmenopause, and when do you refer?

A

< 5mm is normal in an asymptomatic woman

> 4-5 mm in a bleeding postmenopausal woman is grounds for endometrial biopsy

>11 mm or other positive findings on U/S such as increased vascularity, inhomegineity of the endometrium, particulate fluid are grounds for referral to a gynechologist

60
Q

What are the risk factors for a placental abrubtion?

A

Hypertension

Cocaine use

Short umbilical chord

Trauma

Uterplacental insufficiency

Submucous leiomyomata

Sudden uterine decompression (hydramnios)

Cigarette smoking

Preterm premature rupture of membranes

61
Q

What are the risk factors for cervical cancer?

A

HPV infection (serotypes 16,18)

smoking

high risk behaviours (multiple partners, other STI’s, early age at first intercourse, high risk male partner)

poor screening uptake is the most important risk factor for cervical cancer in Canda

62
Q

How does hypothyroidism induce galactorhea?

A

TRH stimulates both TSH and prolcatin relase.

63
Q

What is the differential diagnosis for urticaria in pregnancy

A

cholestasis (pruritis) of pregnancy

  • associated with a high level of circulating bile acids, increased ethnic propensity
  • commonly no elevation in liver enzymes
  • cholestasis in pregnancy particularly when associated with jaundice is associated with a higher degree of prematurity, fetal distress, fetal loss

puritic urticarial papules and plaques of preganncy (PUPPP)

  • lesions begin on abdomen and spread to thighs and sometimes buttocks and arms
  • lesions are erythematous urticarial plaques and small papules surrounded by a narrow, pale halo
  • 1% incedence
  • histologically is related to perivascular infiltrate of lymphocytes and histocytes associated with edema of the papillary dermis
  • there is no known effect on fetal and maternal outcomes
  • treatment includes topical steroid and antihistamines

Herpes gestationis

  • thought to be compliment mediated, IgG triggered reaction to antibodies in the basement membrane.
  • clinically is intense pruritis followed by extensive patches of cutaneous ethythema and subsequent formation of small vessicles and tense bullae
  • limbs are affected more than the trunk
  • biopsy is the only true diagnosis
  • treatment is corticosteroids
  • there is an increase in growth retardation and stillbirths
  • if untreated and in labour, likely will be neonatal lesions, but they will heal
64
Q

What are the diagnostic criteria and common causes of PID (synonymous with acute salpingitis)?

A

Caused usualy by chlamydia, gonorrhea, some anaerobic bacteria, and other agents

  • common presentation is young, dysparunia, vaginal discharge, lower abdominal pain
  • diagnosis of PID is made clinically with abdominal tenderness, cervical motion tenderness, adnexal tenderness

+/- fever, pelvic mass

common sequelae- tubo ovarian abscess

treatment

1) outpatient- must have low fever, no peritonitis, and be a candidate for oral therapy
- ceftriaxone IM once + oral doxycycline BID for 10-14 days

65
Q

What are the risk factors for PID, what are the clinical features and diagnostic criteria and what are the treatments?

A

Multiple organisms causitive

  • Chlamydia
  • Neiserria
  • endogenous flora, anaerobic, aerobic or both
  • E.coli, staphylococcus, streptococcus, entercoccus, bacteriodes, peptostreptococcus, H. Influenza, G. vaginalis
  • Actinomyces israeli

risk factors

  • age< 30
  • douching
  • IUD
  • invasive gynechological procedures
66
Q

What are moliminal symptoms?

A

They are symptoms around ovulation

  • mood changes
  • breast tenderness
  • abdominal pain
67
Q

Who should you do an endometrial biopsy?

A

over 35-40 with abnormal uterine bleeding

Under 35-40 with AUB and risk factors

Persistent AUB

Presence of atypical glandular cells on cervical cytology

Presence of glandular cells on cervical cytology in a woman>/= 40 years old

woman with hereditary nonpolyposis colorectal cancer

guidelines for postmenopausal women are

biopsy if > 11mm

biopsy is between 5-11mm ( SOGC says to biopsy)

< 5mm DO NOT BIOPSY

68
Q

What is the difference between an indirect and direct coombs test, and what the bad antibodies that can be found, and what is the dangerous level they can be found at?

A

Both the direct and indirect coombs test are looking at the recipients blood products to look for antigens and antibodies

The direct coombs test looks at the recipients RBC’s and are incubated with antihuman antibodies–> if there are antigens and antibodies on the RBC surface then there is coagulation

The indirect only looks at antibodies in the serum of the recipient. Donor RBC’s are mixed with recipient serum. That combination is then mixed with anti-human IgG’s (coombs reagent) and if there is aglutination, then the test is positive

The important antibodies are

anti-lewis- OK

anti-kell-Bad

anti-duffy-Bad

The mneumonic is “Lewis Lives, Kell Kills, Duffy Dies”

The antibodies are not important until they get to more than a 1:8 dilution factor ( can be detected past that)

69
Q

What is the management of placenta acreta, increta and percreta?

A

cesarean sectionand hysterectomy in people known to have placenta acreta or greater

internal illiac balloon catheterization can be done to reduce the intraoperative bleeding

70
Q

1

What are the absolute and relative contraindications to OCP?

A

`<6 weeks postpartum if breastfeeding

smoker > 35 years (≥ 15 cigarettes per day)

hypertension ( systolic ≥ 160mm Hg or diastolic ≥100 mm Hg)

Current or past VTE

CAD

past CVA

Complicated valvular disease (pulmonary hypertension, atrial fibrilation, history of subacute bacterial endocarditis)

migraine headaches with focal neurological symptoms

Current breast cancer

Diabetes with retinopathy/ nephropathy/ neuropathy

Severe cirrhosis

Liver tumor (adenoma or hepatoma)

71
Q

What are the absolute contraindications of progestin only contraception?

A

pregnancy(known or suspected)

unexplained vaginal bleeding

current diagnosis of breast cancer

Obs Gyne (1 decks)

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