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Module 8: Mali: GU > GU pharm lectures > Flashcards

GU pharm lectures Flashcards

1
Q

what are the two supplements used during pregnancy?

A
  1. folic acid

2. B6 pyridoxine

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2
Q

what is the anti nausea drug used in pregnancy?

A

pyridoxine plus doxylamine

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3
Q

what are the two anti hypertensive drugs that are used in pregnancy?

A

methyldopa

labetalol

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4
Q

what are the three tocolytics used in pregnancy?

A
  1. magnesium sulfate
  2. nifedipine
  3. terbutaline
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5
Q

what is considered normal BP in pregnancy?

A

SBP: less than 140
DBP: less than 90

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6
Q

what is considered mild HTN in pregnancy?

A

SBP: 140-160
DBP: 90-100

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7
Q

what is considered moderate HTN in pregnancy?

A

SBP: 160-180
DBP: 100-110

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8
Q

what is considered severe HTN in pregnancy?

A

SBP: greater than 180
DBP: greater than 110

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9
Q

what are the qualifications for chronic/preexisting HTN?

A

before 20 weeks or pre PG

greater than 140/90

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10
Q

what is the goal BP in chronic/preexisting HTN?

A

SBP: less than 140-160
DBP: 90-100

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11
Q

what 4 antihypertensive drugs should you not use in pregnancy? why?

A
  1. ACE
  2. ARB
  3. direct renin inhibitor
  4. atenolol

Don’t use these because fetal tissue has angiotensive II receptors

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12
Q

what are the HTN classifications for preclampsia?

A

SBP: greater than 140
DBP: greater than 90

AND

proteinuria greater than 0.3 in 24 hour urine

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13
Q

what are the HTN classifications for gestational HTN?

A

SBP: greater 140
DBP: greater than 90

and

NO Proteinuria

AFTER 20th week gestation

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14
Q

what are the HTN classifications for postartum HTN? for how long?

A

SBP: greater than 140
DBP: greater than 90
exists beyond 12 weeks

AND

PROTEINURIA greater than 0.3 gm

can persist up to 6 months post partum and reverts

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15
Q

how much folic acid does a woman need? and how much do they typically get from baked goods?

A

a woman needs: 400 mcg/day

a woman gets: 200 mcg day from baked goods.

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16
Q

what is the purpose of supplementing folic acid to a pregnant woman?

A

prevents neural tube defects

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17
Q

what can folic acid obscure?

A

vitamin B12 deficiency

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18
Q

what can folic acid interfere with? what are these used for? 2

A

decrease the effects of pheytoin and phenobarbitol that are used for seizure control

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19
Q

what must you rule out before giving folate supplement to pregnant lady?

A

B12 deficiency

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20
Q

topical azoles do what?

A

weaken latex condoms/diaphrams so keep this in mind!!!

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21
Q

what are the four classifications for HTN in pregant woman?

A

chronic/preexcisting HTN
preeclamptic
gestational
postpartum HTN (preeclamtic HTN that exists 12 weeks post partum)

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22
Q

what is the organ BP for pregant woman?

A

SBP: less 140-160
DBP: 90-100

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23
Q

how do you tx postpartum HTN?

A

the same as you would in a non-pregnant woman!

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24
Q

what antihypertensive med do you use to treat preeclampsia and gestational HTN?

A

labetalol

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25
Q

what antihypertensive meds do you use in postpartum HTN?

A

labetalol

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26
Q

what antihypertensive do you use in chronic or preexisting HTN?

A

labetalol

methyldopa

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27
Q

what is the drug class of methyldopa?

A

cental alpha-adrenergic inhibitor

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28
Q

what is the drug class for labetalol?

A

b1, b2 and alpha 1 blocker

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29
Q

what is a contraindiction for labetalol?

A

bronchial asthma

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30
Q

what is the ration of alpha to beta receptor blockade when given orally or IV for labetalol?

A

1: 3 orally
1: 7 IV

this means stronger when given IV

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31
Q

what does the drug class tocolytics mean?

A

mean they slow down labor

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32
Q

what are the new reccomendations for medication saftey rating for pregnancy?

A
  1. fetal risk summary
  2. clinical considerations
  3. data
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33
Q

what are 4 other medications you need to avoid in pregnancy because they can cause harm to the fetus?

A
  1. opoids-codeine, hydrocodone, oxycodone
  2. antipsychotics-can cause withdrawals in neonate
  3. antidepressants-paxil D, other SSRIs C
  4. antiseizure medications- C
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34
Q

what are the two hormones that are considered for contraceptive methods?

A

estrogen and progestin

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35
Q

what are the two estrogen options used for contraception use? why might his only really be considered one?

A
  1. ethinyl estradiol
  2. metstranol (prodrug that is converted to ethinyl estradiol so really, it appears like there is only 1 estrogen option which is ethinyl estradiol)
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36
Q

how many generations of estrogen based contraceptives are there? what is considered low dose estrogen?

A

there are 3 generations

low dose is considered an estrogen content less than 30 mcg

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37
Q

what is the risk you run when using a low dose estrogen?

A

increased risk of failure and obesity

higher efficacy results outside of US

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38
Q

how many generations of progestins are there? what happens to their affinity for progesterone receptors and androgenic effect as the generations increase?

A

4 generations of progestins

as you go through the generations the affinity for progesterone receptors increase and androgenic activity decreases

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39
Q

what are 6 additional benefits of combined oral contraception (COC) in addition to contraception?

A
  1. reduced risk of endometrial cancer
  2. reduced risk of ovarian cancer
  3. regulation of menstration, reduced dysmenorrhea
  4. fewer breast fibroadenomas, cysts
  5. reduced risk of PID
  6. improved acne control
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40
Q

who are progestin only OC useful in? who would you consider using these in? (8)

A

use when they can’t take COC

  1. tobacco
  2. obesity
  3. age >35
  4. HTN with vascular disease
  5. lupus
  6. migraine with focal aura
  7. VTE
  8. coronary or cerebral vascular disease (stroke)
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41
Q

what are 7 ABSOLUTE contraindications for COC?

A
  1. DVT/PE
  2. CVS/CAD
  3. breast cancer
  4. more than 15 cigs a day and older than 35
  5. hepatic tumor
  6. active liver disease
  7. migraine with aura
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42
Q

what are 6 RELATIVE contraindications for COC?

A
  1. any smoking
  2. migraine disorder
  3. HTN
  4. fibroid tumors of uterus
  5. breast feeding
  6. diabetes
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43
Q

what are 4 common SE of COC?

A
  1. N/V
  2. headaches
  3. weight gain
  4. breakthrough bleeding 30-50% women
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44
Q

when does breakthrough bleeding when using a COC usually resolve?

A

3-4th menstrual cycle

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45
Q

depending on when breakthrough bleeding occurs during menses when using a COC can tell you wnat you need to do to fix it…what do you do in these situations:

  1. bleeding late in active pills?
  2. prolonged menses?
  3. midcycle bleeding?
A
  1. bleeding late in cycle: increase progestin
  2. prolonged menses: increase estrogen dose
  3. midcycle bleeding: increase estrogen AND progestin dosing
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46
Q

if a COC caused a headache…what should you do? when?

A

if they get blurred viision or neuro deficit or increased frequency of migraine, STOP COC and workup!!!

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47
Q

what can progestin in COC cause?

A

decreased libido, depression, dyslipidemia, bloating, constipation

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48
Q

what can estrogen in COC cause? (2)

A

mastalgia

weight gain

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49
Q

when do GI SE of COC resolve?

A

bloating, constipation, and N/V usually resolve within 1-3 months of use

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50
Q

what are four side effects of estrogen excess?

A
  1. bloading
  2. migraine headache
  3. decrease libido
  4. weight gain
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51
Q

what are the 3 SE of estrogen deficiency?

A

spotting
amennorhea
vaginal dryness

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52
Q

what are the 4 SE of progestin excess?

A
  1. acne
  2. increased appetitie
  3. fatigue
  4. dperession
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53
Q

what is the SE of progestin deficiency?

A

amenorrhea

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54
Q

is estrogen a CYP34A substrate? what are five things can make this less effective?

A

YES!!!

  1. anticonvulsants
  2. corticosteroids
  3. penicillins
  4. st. johns wart
  5. rifampin
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55
Q

what is one really important benefit of progestin only OC?

A

less risk of thromboembolytic event

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56
Q

what are the two options for progesterone?

A
  1. norethindrone

2. norgestrel

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57
Q

what is one down side of progestin OC?

A

it must be taken at the same time each day to maintain adequate levels of the drug in patient system

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58
Q

what are the prototype drugs for each of the COC drugs?

A

monophasic: loestrin FE 1/20
norethiadone acetate, ethinyl estradiol

biphasic: lo lostrin FE 1/10
norethiadone acetate, ethinyl estradiol

triphasic: triphasil
levonorgestrel/ethinyl estradiol

quadraphasic: natazia
dionogest/estradiol valerate

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59
Q

what is important to do with both the triphasic and quadriphasic COC?

A

make sure you take it at the same time each day to avoid breakthrough bleeding

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60
Q

what is the progestin only called? what does it do less of when compared with OCP?

A

ovrette
containing norgestrel

inhibits ovulations less than COC

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61
Q

are progestin only BC and COC the same efficacy?

A

progestin only OCP has about the same effiiacy as COC with 20 to 30 mcg of EE

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62
Q

what can progestin only BC cause in a woman who has been taking it long term?

A

can cause breakthrough bleeding and amenorrhea

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63
Q

who are extended cycle OC helpful for?

A

women who have menstrual related sxs like HA, menorrhagia, anemia, endometriosis related pain

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64
Q

what is the name of the extended cycle OC that has a constant amount of leveonorgestrel/EE?

A

Lybrel

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65
Q

what is normal during the first few months of taking an extended cycle OC?

A

breakthrough bleeding in the first few months since the EE content is low

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66
Q

what is the name of the ascending dose levonorgestrel/EE extended cycle OC?

A

Quartette

67
Q

what is the cycel length for Quartette which is the ascending dose extended cycle OC?

A

91 day cycle

68
Q

how long have recent studies shown continuous use of extended cycle OC?

A

up to four years of continuous COC use

69
Q

how long can the levonorgestrel (progestin) only IUD mirena be used for?

A

5 years

70
Q

how long can the copper IUD paraguard be used for?

A

10 years

71
Q

what are the two options for emergency contraception? what time frame must you take them in? are they RX? what are they made of?

A
  1. plan B one step-levonorgestrel
    - progestin only
    - OTC in most states
  2. Ella: progesterone agonist/anatgonist
    - RX only

MUST TAKE BOTH OF THESE WITHIN 120 hours!!!

72
Q

Ammenorhea: 3 goals of tx?

A
  1. preserve bone density
  2. prevent bone loss
  3. restore ovulation and fertility
73
Q

what is the tx for amennohrea in these situations:

  1. CEE
  2. hyperprolactinemia
  3. PCOS
A
  1. CEE: EE, COC
  2. hyperprolactinemia: bromocriptine
  3. PCOS: metformin
74
Q

what do you use to tx secondary ammenorhea?

A

provera

75
Q

what are the three options used to tx menorrhagia? what percents do they decrease bleeding?

A
  1. NSAIDS 20-50% reduction
  2. COC 43-53% reduction
  3. IUD with levonorgestrel 90% reduction
76
Q

what is dysmennohea?

A

crampy pelvic pain with or just prior ot menses

77
Q

what is thought to be the cause of dysmennorhea?

A

prostenoids that induce uterine contrations

78
Q

what are the 4 tx options for dysmennorhea?

A
  1. NSAIDS
  2. OCP
  3. Depro-vera
  4. levonorgestrel-releasing IUD

3 later ones regulate the hormones

79
Q

anovulatory bleeding results from_____ and you should always do ______

A

anovulatory bleeding results from UNOPPOSED ESTROGEN and you should always do PREGNANCY TEST

80
Q

what are the four main causes of anovulatory bleeding?

A
  1. hyperandrogenic anvoluation (70%)
    - PCOS, androgen-producing tumors
  2. hyperprolactinemia 10%
  3. primary pituiatry disease 10%
  4. premature ovarian failure 10%
81
Q

what is the most frequent etiology of anovulatory bleeding?

A

PCOS

82
Q

what are the 3 tx options of anovulatory bleeding in PCOS?

A
  1. COC tx (increases SHBG causing increased androgen binding)
  2. MPA (oral or depot) progestin that supresses pituitary gonadotropins and circulating andrgens
  3. metformine (increases insulin sensitivitiy with increase in SHBG, increases ovulation and glucose intolerance)
83
Q

what is the preferred method of tx for anovulatory adolescent?

A

low dose COC with less thatn 35 mcg of ethinyl estradiol

84
Q

what is the definition of menopause and what is it caused by?

A

amennorhea for 12 months

cause: loss of ovarian follicular development

85
Q

what are two labs you will see elevated in menopause?

A

FSH, LH

86
Q

what are 4 sxs you will see with menopause?

A
  1. hot flashes
  2. vulvovaginal atrophy
  3. mood swings
  4. insomnia
87
Q

WHAT MUST BE TAKEN INTO CONSIDERATION IF YOU ARE TXING SOMEONE WITH HORMONAL THERAPY FOR MENOPAUSE

A

MUST TAKE INTO CONSIDERATION IF THE WOMAN HAS A UTERUS OR NOT

88
Q

IF A WOMAN HAS A UTERUS AND MENOPAUSE….TX WITH…

A

ESTROGEN AND PROGESTERONE! DECREASES RISK OF ENDOMETRIAL CANCER

89
Q

IF A WON’T DOESN’T HAVE A UTERUS AND MENOPAOUSE…..TX WITH….

A

ESTROGEN REPLACEMENT ONLY!!!

90
Q

what are the contraindications for hormonal tx of menopause?

A 
DVT
CAD
Beast cancer
undiagnosed vaginal bleeding
liver disease
91
Q

what are the options estrogen for tx of menopause? 3 options

A
  1. conjugated equine estrogen CEE “premarin” estrogen supplement
  2. transdermal estrogen
  3. topical estrogen for intravaginally
92
Q

what are the progesterone oprions for tx of menopause?

A
  1. MPA (oral)

2. transdermal levonorgestrel

93
Q

what are the combination tx options for menopause?

A
  1. oral conjugate equine estrogen (premarin) + MPA (prempro)
  2. transdermal: estradiol + norethiadrone
94
Q

what are the risks of using hormone therapy to tx menopausal sxs are?

A
  1. CHD
  2. CVA
  3. breast cancer
  4. VTE
95
Q

what are alternatives for the tx of menopause other than hormonal interverntion? 2 options

A

SSRIs (low dose)

clonidine

96
Q

what is the name of the estrogen used to tx menopause?

A

combined equine estrogen

97
Q

what does a person who is taking combined estrogen hormones need to monitor?

A

breast exams for estrogen induced breast masses

98
Q

what is the black box warning for conjugated equine estrogen

A

in CVD, dementia, malignancy

99
Q

what is tenofovir/emtricitabine used for?

A

the prevention of the transmission of HIV-1

100
Q

who should you use tenofovir/emtricitabine in? (only people you use it in)?

A

only use in HIV negative people!!

101
Q

what must be done if takining tenofovir/emtricitabine?

A

q3 months serial HIV testing

102
Q

what are the two black box warnings for tenofovir/emtricitabine?

A
  1. lactic acidosis

2. hepatomegally

103
Q

what might giving someone tenofovir/emtricitabine with a underdetermined HIV status do?

A

increase resistances

104
Q

what is the target receptor for erectile dysfunction?

A

PDE5 enzyme inhibitors

105
Q

what is the target receptor for hypogonadism?

A

testosterone receptor stimulation

106
Q

what is the target receptors for benign prostatic hypertrophy? 2

A

alpha 1 inhibtors

5 alpha reductase inhibitors

107
Q

what receptor is the target for malignant prostate dxs?

A

androgen receptors (anti-androgens)

108
Q

what are the three targeted receptors for urinary incontinence?

A
  1. M3 muscarinic receptor inhibitors
  2. tricyclic antidepressants inhibitors
  3. estrogen receptor (topical stimulation)
109
Q

what are the causes of erectile dysfunction?

A
  1. organic 80%
    - vascular, neurogenic, hormones
  2. psychogenic 30%
110
Q

how is an erection formed?

A
  1. increased testosterone
  2. increased sexual arousal
  3. INCREASED PARASYM, DECREASE SYMPATHETIC ACTIVITY
  4. increase in NO
  5. aterial SM relaxation and trebecular sm relaxation
  6. arterial dilation and expansion of sinussoidal spaces (causing venous occlusion and decreased venous outflow)
  7. increased intracavernous pressure
  8. erection!
111
Q

how is an erection lost?

A

INCREASE SYMPATHETIC ACTIVITY

constricts corproal ateriole smooth muscle and leads to flaccidity

112
Q

what are the three causes of erectile dysfunction?q

A
  1. vascular
  2. neurogenic
  3. hormonal
113
Q

what are 6 potential drugs that can cause erectile dysfunction?

A
  1. antihypertensives
  2. antidepressants
  3. antipsychotiics
  4. anticonvulsants
  5. antiandrogens (5 alpha reductase inhibitors, progesterone and estrogen)
  6. recreational drugs: alcohol, cocaine, MJ, opiates
114
Q

what can Erectile dysfunction sometimes be the presenting feature of sometimes?

A

cardiovascular disease!!! so suspect this if someone presents with ED!!!

115
Q

what are 2 tx options for ED?

A
  1. testosterone ONLY IF DEFICIENT

2. PDE5 inhibitors

116
Q

how do PDE5 inhibitors for ED work?

A

prevent degredation of NO/cGMP (creates dilation in penis) maintaining arteriolar SM relaxation and corporal blood inflow greater than outflow

117
Q

what is the most common tx of ED? two drugs?

A

PDE5 inhibitors

sildenafil
tadalafil

118
Q

what are the SE seen with PDE5 inhibitors? 3

A
  1. headache
  2. hypotension
  3. nasal congestion
119
Q

what are two ABSOLUTE contraindications for the use of PDE5 inhibtors? (sildenafil and tadalafil)

A

hx of CV disease

nitrates ABSOLUTE!

120
Q

what are the contraindications for PDE5 inhibitors? 4

A
  1. CVD
  2. nitrates
  3. hyptertension over 170/110
  4. hypotension less than 90/50
121
Q

what drug class and two drugs is a CYP34A substrate so you should avoid what?

A

PDE5 inhibitors sildenafil and tadalafil for ED

122
Q

when giving a patient either sildenafil or tadalafil what do you need to instruct them to do if this SE occurs?

A

an erection last longer that 4 hours….tell healthcare provider

need to inject epi into the penis to decrease parasynpathetic stimulation and get rid of the erection

123
Q

what is the difference between the half life of sildenafil and tadalafil? what does this influence?

A

sildenafil: 4 hours (short term)
tadalafil: 15-17.5 hours

this explains why tadalafil can be taking low dose on a daily basis

124
Q

what is the differences between the PRN dosing and daily dosing for tadalafil?

A

prn: 10 mg up to once daily
daily: 2.5 mg dose

can do this since the halfilfe is 15-17.5 hours!

125
Q

who should testosterone be used in?

A

only those who are testosterone deficient

126
Q

what forms does testosterone come in? what do you need to be careful and warn partners about?

A

injection, patch, gel, pellet

causes virilization in female sex partners!!! need to warn them not to touch places where the gel or patch is because they can absorb it and get the same effects

127
Q

what is prostate disease? what causes it?

A

starts over age 40 from

coversion of testosterone to dihydrotestosterone from type II 5alpha reductase activates

128
Q

what are the two tissue types that are effected in prostatic hypertrophy?

A
  1. glandular/epithelia=androgens

2. muscle or stroma=contractile via alpha2A receptors

129
Q

explain the static factors contributing to prostate hypertrophy and their sxs?

A

urethral compression secondary to glandular enlargement

OBSTRUCTIVE SIGNS: hesitation dribbling straining

130
Q

explain the dynamic factors contributing to prostate hypertrophy and their sxs?

A

excessive stimulation of a1A adrenergic receptors of the prostate and urethal SM

OBSTRUCTIVE SIGNS: hestiation, driblling, straining

131
Q

explain the detrussor factors contributing to prostate hypertrophy and their sxs?

A

bladder detrussor muscle instability secondary to chronic distention secondary to outlet obstruction (stretches so much that it doesn’t work)

IRRITATIVE SIGNS: urgency and frequency

132
Q

what are the three contributing factors to prostatic hypertrophy?

A
  1. static
  2. dynamic
  3. detrussor
133
Q

what is the breakdown in outcomes for prostatic hypertrophy?

A

1/3 watchfun waiting
1/3 require tx
1/3 require surgery

134
Q

what does a serum PSA over 1.5 mean?

A

implies the gland weighs more than 30 gm

135
Q

how much of a percent reduction in AUA score for prostatic hypertrophy can you expect when using either a alpha-adenrenergic antagonist or 5alpha-reductase inhibitor?

A

30-50% reduction

136
Q

what is the name of the two drugs used to tx BPH and their drug class?

A

5alpha-reductase inhibitor: finasteride

alpha1 adrenergic antagonist: tamullosin

137
Q

what is first line tx for sildenafil?

A

tamulosin

138
Q

what do you need to caution opthalmolagists when taking tamulosin for BPH?

A

that they are on the medication because it can cause floppy iris syndrome so they need to know this BEFORE cataract surgery

139
Q

how long does it take tamulosin to work?

A

1-2 weeks, so works quickly hence why this is first line

140
Q

if a patient is on tamulosin and also takes sildenafil what do you need to instruct them to do? why?

A

make sure they take it at least 4 hours apart

take tamulosin at least four hours after because they are both CYP34A drugs and if taken close together will inhibit each other

141
Q

what is second line tx for BPH?

A

finasteride

142
Q

why does finasteride decrease the size of the prostate?

A

because it induces apoptosis of glandular cells and thus decreasing static factor

143
Q

how long does it take finasteride to work?

A

up to 6 months

144
Q

why should people taking finasteride avoid contact with pregnant females?

A

can cause feminitization of the male fetus

145
Q

how much can finasteride decrease PSA levels?

A

up to 50%

146
Q

can you use both finasteride and tamulosin together?

A

YES

147
Q

what are the 3 tx options for prostate malignancy?

A
  1. leuprolide
  2. flutamide
  3. estrogen
148
Q

what might leuprolide cause when used to treat progstate malignanct?

A

1-2 week flare of tumor causing BONE PAINE, NEUROPATHY) sxs at the initiation of tx secondary to increase in testosterone levels

149
Q

how my does flutamide increase survival in prostatic malignancy when used in conjunction with leuprolide (the other anti-neoplastic agent)?

A

7 month increased survival

150
Q

STRESS INCONTINENCE:
involved anatomy?
sxs? 2

A

urethra spinchter failure

sxs:
1. leakage with increased abdominal stress
2. no nocturia

151
Q

URGE INCONTINENCE:
involved anatomy?
sxs?2

A

bladder detrussor overactivitiy

sxs:

  1. nocturia
  2. enuresis
152
Q

OVERFLOW INCONTINENCE:
involved anatomy?
sxs? 3

A

chronic bladder outlet obstruction or overactivity

sxs

  1. episodic leakage
  2. nocturia
  3. large residual urine volume
153
Q

what are 4 lifestyle modifications that can help tx urinary incontinence?

A
  1. medication management
  2. scheduled voiding
  3. keagles
  4. anti-incontinence devices
154
Q

what is first line tx for urge urinary incontinence (UUI)? class and 3 options. GOAL?

A

goal: control detressor MUSCLE activitiy

M3 antimuscarininc drugs:

  1. tolterodine
  2. oxybutinin
  3. ditropan
155
Q

what are the 2 M3 muscarinic drugs used to control Urge urinary intcontinence?

A
  1. tolterodine
  2. oxybutinin
  3. ditropan
156
Q

what do you use to tx stress urinary incontinence? goal?

A

CONTROL SPHINCTER CONTROL

  1. keagles
  2. vaginal estrogen cream
157
Q

what can you use to tx outflow urinary incontinece WITHOUT BLADDER OUTFLO OBSTRUCTION?

A

alpha-adrenergic antagonis Tamulosin

158
Q

what can you use to relieve ouflow urinary incontinence (OUI) with bladder outflow obstruction

A

remove the obstruction duh

159
Q

what is the name of the tricyclic antidepressant that cab be used to tx urinary incontinence but is NOT a first line drug? why?

A

imipramine

don’t use as much because of dx-dx interaction and Se

160
Q

if a person has heart disease and urge urinary incontinence, which drug would you be more apt to use?

A

use oxybutinin instead of tolterodine because it is LESS LIKELY TO PRODUCE QT prolongation

161
Q

what do you need to be cautious of when txing urge incontience in the eldery?

A

both oxybutinin and tolterodine have increased SE in he eldery

162
Q

what are some of the SE seen with the M3 antimuscarinic drugs used to tx urge urinary incontinence? 4

A
  1. dry mouth
  2. headache
  3. diarreah
  4. confusion
163
Q

of the M3 antimuscarinic drugs, which one is more likely to cause QT prolongation?

A

tolteroine!

Module 8: Mali: GU (6 decks)

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