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Year 5 😊✌🏼 > O&G 2 > Flashcards

O&G 2 Flashcards

1
Q

Combined screening test (test + timing)

A
  • US
  • nuchal translucency
  • serum tests (bhCG, PAPP-A) Not: AFP (used for neural tube defects)

done at 11-12 weeks

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2
Q

Terminology with screening

A

there is a CHANCE of something happening -> do not say risk

based on Down syndrome Society

people have different tolerances of what chance they are

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3
Q

Diagnostic tests for foetal abnormalities (invasive)

A

CVS and amniocentesis

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4
Q

When are CVS and amniocentesis done

A

CVS: (early) - 11-14w

amnio: 15w-18w (fetal cells shed into the amniotic fluid)

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5
Q

CVS issues

A
  • 0.5 - 2% risk of miscarriage
  • moscaiicm - may have patches of maternal tissue, normal tissue
  • insufficient sample
  • Infection 0.1%
  • local reaction: pain and bleeding

full karyoteyp takes 2 w
prelim results are PCR

more spontaneous miscarriages in early pregnancy so CVS > amanio ? check if the procedure risk is the one that a os stated

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6
Q
A

only people with risk of trisomies >150 chance will be offered CVS aaamnio

or if the couple had aa previous pregnancy affected

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7
Q

anomaly scan - when?

A

around 20w

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8
Q

what anomalies does the 20w scan look for?

A
  • neural tube defects
  • cleft lip/palate
  • cystic lesions in neck and lungs
  • pulmonary malformations
  • renal agenesis
  • hydronephrosis
  • hyperechogenic bowel can be associated with CF or the baby having swallowed some blood
  • limbs: any signs of short limbs
  • cord too check if there are 2 or 3 vessels in it

Not:
- hand digits

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9
Q

What is the next step if an anomaly is detected during the anomaly scan?

A

Referral to foetal medicine unit

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10
Q

What should you offer to calculate in PACES questions on IUGR/SGA?

A

GA based on mums EDD from USS

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11
Q

Late foetal loss

A

22-24w

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12
Q

immediate postpartum death within 7 days

A

early neonatal death

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13
Q

neonatal death 7d-1y post birth

A

late neonatal death

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14
Q

is the definition of neonatal death GA dependant?

A

no - can be termed this regardless of GA

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15
Q

IUD - what form of delivery is recommended?

A

vaginal

  • helps with the grief, to allow time for the grief to develop and it might feel surreal if the pregnancy ends with an operation
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16
Q

Steps after miscarriage?

A

stop smoking
normalise BMI
genetic testing? counselling?
optimise any health conditions

offer early pregnancy scan at 6-7 weeks
not earlier because many not be seen and can cause a lot of stress

Breaking bad news

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17
Q

Mx of chronic hypertension in pregnancy

A
  • additional antenatal appts (weekly, 2- or 4-weekly based on pts needs)
  • stop ACEi and ARBs within 2 working days of notification of pregnancy and offer alternatives
  • start aspirin 75-150 mg OD from 12w for PE prophylaxis
  • offer anti-HTN treatment if BP > or = 140/90 mmHg

use LABETOLOL, NIFEDIPINE or METHYLDOPA

aim BP < or = 135/85 mmHg

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18
Q

fetal monitoring in chronic HTN in pregnancy

A

at 28, 32 and 36w carry out
- USS fetal growth and amniotic fluid
- umbilical artery doppler velocimetry

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19
Q

blood vessels inspected on fetal USS

A
  • MCA
  • umbilical A
  • ductus venosus
  • ???
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20
Q

When should aspirin be started in pregnant women with chronic HTM and what is the purpose?

A

at 12 w

to prevent pre-ecclampsia from developing

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21
Q

What dose of aspirin should be given to pregnant women with chronic HTN to prevent pre-ecclapmsia?

A

75-150 mg OD

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22
Q

Which anti-HTM meds are given to women with chronic HTN in pregnancy?

A

Labetalol
Nifedipine
Methyldopa

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23
Q

MoA Labetalol?

A

dual a1 and b1/b2 adrenergic receptor antagonist

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24
Q

Which meds can be prescribed for gestational HTN?

A

labetalol
nifedipine
methyldopa

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25
Q

aim BP in gestational HTN

A

</= 135/85

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26
Q

Blood tests in gestational HTN

A

FBC
LFTs
Renal function

at presentation and then weekly

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27
Q

What anti-HTN medication in pregnancy is contraindicated if the patient has asthma?

A

Labetalol

therefore use nifedipine instead

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28
Q

What anti-HTN for gestational HTN is contraindicated in a PMH of depression?

A

methyldopa

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29
Q

Define gestational HTN

A

BP >140/90 mmHg in pregnancy with no hx of HTN when not pregnant.

without proteinuria

should resolve within 6w PP

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30
Q

What are the main risks associated with untreated gestational HTN?

A
  • IUGR
  • pre-eclampsia
  • placental abruption
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31
Q

What is vasa praevia?

A

Condition where foetal blood vessels run across the internal os of the cervix

presents typically with heavy, painless PV bleeding during labour -> Obs emergency b/c foetus loses O2 supply and CTG trace deteriorates -> em CS

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32
Q

What are risk factors for vasa praevia?

A
  • IVF
  • multiple pregnancy
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33
Q

Most common benign cause of postmenopausal PV bleeding

A

atrophic vaginitis

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34
Q

investigations in postmenopausal PB bleeding

A
  • TVUS!!!! measure the thickness of the endometrium (>4mm would be abnormal and warrants endometrial biopsy)
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35
Q

What underlying conditions can increase the endometrial thickness in postmenopausal women and should be addressed?

A

obesity
T2DM

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36
Q

sx of obstetric choleostasis

A

itching of palms and soles, worse at night with no rash

deposition of bile salts in the skin causes itching

jaundice
pale stools
dark urine

in severe cases the lack of bile in the intestine can cause malabsorption of vitamin K and bleeding therefore.

supported by deranged LFTs and raised bile acids in blood

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37
Q

Risks associated with obstetric cholestasis

A
  • premature birth
  • stillbirth
  • meconium passage

-> therefore close monitoring

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38
Q

Mangement of PID

A

Abx:

ceftriaxone (1g IM stat), doxycycline (100 mg PO BD for 14d), metronidazole (400 mg PO BD for 14d) -> given right away

review after 72h

consider removing copper IUD/IUS if in situ sx still present after 72h

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39
Q

What glucose measurement should be done for pts with a hx of gdm?

A

2h OGTT

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40
Q

risk factors for stress incontinence

A
  • increased age
  • multiparity
  • traumatic delivery
  • obesity
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41
Q

Mx of stress incontinence

A

1st line: 3 months of pelvic floor physiotherapy/exercises

Duloxetine (SNRI) 40 mg BD is used for depression but can also be used as an adjunct to pelvic floor exercises as it increases the activity of the urethral sphincter

if exercises +/- duloxetine is ineffective/unacceptable -> surgery (urethral bulking agents, autologous fascial slings, Burch colposuspension)

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42
Q

Considerations for pregnant women to avoid toxoplasmosis

A
  • wash fruit and vegetables thoroughly!!
  • do not handle cat faeces
  • avoid unpasteurised milk (products)
  • avoid raw or undercooked meat
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43
Q

mnemonic for congenital infections associated with morbidity and mortality

A

TORCH

Toxoplasmosis
Others (Varicella, listeria)
Rubella
Cytomegalovirus
Herpes simplex virus

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44
Q

What does toxoplasmosis in pregnancy cause?

A
  • most babies will have no gross congenital abnormalities but have delayed neurological developmental sequelae (e.g. developmental delay, epilepsy. blindness, deafness)
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45
Q

Surgical ToP methods

A
  • MVA: used up to 14w (cervix may be ripened with misoprostol; vacuum, suction used to evacuate the uterine cavity)
  • dilatation and evacuation: over 14 w (the cervix has to be dilated more in order to remove larger foetal parts; contents of uterus are evacuated sing forceps and vacuum) USS used to confirm complete evacuation
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46
Q

What is symphysis pubis dysfunction?

A

pelvic girdle pain

pain associated with excessive movement of the pubic symphysis due to laxity of the pelvic ligaments

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47
Q

Mx of pelvic girdle pain in pregnancy

A

conservative: exercise to strengthen the surrounding muscles, warm baths, support belts.

Medical: paracetamol

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48
Q

Why should ibuprofen be avoided in pregnancy?

A

because it is associated with an increased risk of miscarriage; before 30w it may be considered in rare cases where the benefits outweigh the risks.

after 30w it should be avoided because NSAIDs may cause premature closure of the ductus arteriosus, persistent pulmonary hypertension of the newborn and oligohydramnios

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49
Q

What can codeine in the 3rd trimester cause?

A

neonatal withdrawal syndrome
neonatal respiratory distress

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50
Q

What are the components of the risk malignancy index in ovarian cancer?

A

Ca-125
menopause status
USS findings

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51
Q

Which USS findings contribute to a higher risk of ovarian cancer?

A
  • multioculated cysts
  • solid areas
  • bilateral lesions
  • ascites
  • intra-abdominal metastases
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52
Q

Mx of ovarian cacner

A
  • depends on stage

mainstay is a total hysterectomy +bilateral sapling-oophrectomy with or without platinum based chemotherapy

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53
Q

Are biopsies performed in ?ovarian cancer?

A

No

because disrupting the surface of the mass may increase the risk of metastasis

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54
Q

Which ovarian cancer subtype would cause changes in a blood hormone profile and what change?

A

granulose cell tumours may cause a high oestrogen level

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55
Q

What does HRT increase the risks of?

A

VTE
Breast cancer
endometrial cancer
gallbladder disease

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56
Q

What conditions does HRT decreases the risks of?

A

colorectal cancer
osteoporosis

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57
Q

what does baseline bradycardia on CTG indicate?

A

cord prolapse, epidural/spinal anaesthesia, rapid foetal descent

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58
Q

what does baseline tachycardia on CTG indicate?

A

maternal pyrexia, hypoxia, prematurity

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59
Q

what does reduced baseline variability on CTG indicate?

A

hypoxia, prematurity

60
Q

What do early decelerations on CTG indicate?

A

usually they are a benign feature caused by head compression during descent

61
Q

what do late decelerations on CTG indicate?

A

foetal distress

62
Q

What do variabel decelerations on CTG indicate?

A

sometimes due to cord compression

63
Q

What is cervical ectropion?

A

physiological process
glandular columnar epithelium (usually present on the endocervix) extends into the ectocervix (which usually consists of stratified squamous epithelium).

this is due to increased exposure to oestrogen (e.g. puberty, pregnancy, OCP)

63
Q

What is cervical ectropion?

A

physiological process
glandular columnar epithelium (usually present on the endocervix) extends into the ectocervix (which usually consists of stratified squamous epithelium).

CTZ shifts (cervical transformation zone; also SC junction)

this is due to increased exposure to oestrogen (e.g. puberty, pregnancy, OCP)

64
Q

Type of epithelium in endocervix and ectocervix

A

Endocervix: glandular columnar epithelium

ectocervix: stratified squamous epithelium

65
Q

Steps (ladder) if major PPH management

A

MOH call; A-E including insertion of wide bore cannulas, supplementing oxygen etc.

  1. IV or IM syntocinon (alternatively IM ergometrine or syntometrine)
  2. IM carbprost
  3. balloon tamponade
  4. B-Lynch suture
  5. hysterectomy
66
Q

What is carboprost?

A

Prostaglandin F2alpha analogue

careful in asthma, may precipitate bronchoconstriction

67
Q

Risk factors for PID

A
  • unprotected sex
  • multiple sexual partners
  • immunocompromised (e.g. HIV)
  • Iatrogenic (IUS/IUD insertion within 21d, Hysteroscopy, SMM/STOP)
68
Q

Complications of PID

A

early:
- tubo-ovarian abscess
- sepsis
- fitz-hugh-syndrome (perihepatic adhesions)

late
- chronic pelvic pain
- ectopic pregnancy
- tubal infertility

69
Q

PID DDx

A
  • appendicitis
  • cervicitis
  • UTI
  • endometriosis
  • adnexal tumours
70
Q

Ix for PID

A
  • FBC, CRP, HVS/urine, USS
  • examination (obs, abdo tenderness, adnexal tenderness, cervical excitation tenderness, mass, speculum, discharge)
  • hx
71
Q

Mx of PID

A

Triple Therapy

Ceph
Doxycycline
Metronidazole

for 2 w

72
Q

Mx of pelvic abscesses in the context of PID

A
  • may need drainage
  • if diameter more than 3 cm unlikely to resolve without surgical intervention
73
Q

Hydrosalpinx

A
  • usually late complication of PID
  • non-functional distended tube
  • incomplete separations on USS
  • beads on string appearance if zoomed our
  • beware in postmenopausal women because they are less likely to have PID, ?malignancy
74
Q

Infected endometrioma

A
  • ‘chocolate cysts’
  • looks like endometriosis
  • symptoms of PID
75
Q

What other conditions is PID associated with

A

MI
Stroke
Ovarian Cancer

76
Q

Are oral abx recommended in asymptomatic bacteriuria in pregnancy?

A

yes - because it reduces the risk of spontaneous miscarriage and preterm labour

(nitrofurantoin or cefalexin)

77
Q

Causes for oligohydramnios?

A

bilateral renal agenesis (can be potter sequence)
pre-ecclampsia
IUGR
post term gestation
PROM

78
Q

How does renal agenesis lead to oligohydramnios?

A

state in which the kidneys do not form
this can result in underproduction of amniotic fluid

79
Q

Which anti-HTN med for pregnancy is contraindicated in asthma?

What should you give instead?

A

Labetalol

Give nifedipine instead

80
Q

Which anti-HTN med for pregnancy is contraindicated in depresssion?

A

methyldopa

81
Q

Name some tocolytics used

A

Salbutamol
Indomethiacin

82
Q

Indications for tocolytic Medication

A

to delay delivery of the baby in a woman presenting with preterm contractions

83
Q

RCOG guideline for 1st line management of PPH due to uterine atony

A

5U of IV Syntocinon (oxytocin)
followed by 0.5 mg of ergometrine (i.m., or can also be given by slow IV injection)

(Green-top Guideline No.52)

84
Q

When should you rescan a patient with a low-lying placenta on the 20w scan?

A

32 w

85
Q

Sx of OHSS

A
  • nausea
  • vomiting
  • abdo pain
  • bloating
  • diaarrhoea
  • SoB
  • fever
  • oliguria
  • peripheral oedema
86
Q

Complications of AKI

A
  • thromboembolism
  • dehydration
  • pulmonary oedema
  • AKI
87
Q

PAPPA and beat hCG in Down syndrome?

A

beta HCG is high

PAPPA is low

88
Q

Complications associated with shoulder dystocia

A

maternal
- postpartum haemorrhage
- perineal tears

fetal
- brachial plexus injury
- neonatal death

89
Q

Risk Factors for cord prolapse

A

prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie

90
Q

What are risk factors for GDM?

A

BMI >30
Previous macrosomic baby 4.5 kg or more
Previous GDM
FH of diabetes (1st degree relative)
Ethnicity with high prevalence of diabetes

Ref: NICE ng3 recommendation GDM

91
Q

What are indication for immediate treatment with insulin for women with GDM?

A

fasting glucose > or = 7.0 mmol/L

or fasting glucose 6.0 - 6.9 mmol/L with complications like macrosomia or hydramnios.

92
Q

What should women with pre-existing diabetes aim for good glucose control pre-conception and throughout pregnancy?

A

to reduce risks of:
- miscarriage
- congenital malformation
- stillbirth
- neonatal death

Risks can be reduced but not eliminated!

93
Q

What should you inform women with diabetes regarding how pregnancy will affect diabetes and vice versa who are planning to get pregnant?

A
  • role of diet, weight and exercise
  • risks of hypoglycaemia and impaired awareness of hypoglycaemia in pregnancy
  • how N&V in pregnancy can affect blood glucose.
  • increased risks of baby being LGA, increasing the risk of birth trauma, IoL, instrumental delivery and C/S
  • diabetic retinopathy assessment before and during pregnancy
  • diabetic nephropathy assessment before pregnancy
  • importance of maternal blood glucose control during labour and birth and need for easily feeding of the baby to reduce the risk of neonatal hypoglycaemia a
  • possibility that the baby may have health problems in the first 28d and possibility of NICU admission
  • risk of diabetes/obesity and/or other health problems later in life.
94
Q

What does UKMEC stand for?

A

UK medical eligibility criteria

95
Q

Folic acid dose for women with diabetes who want to conceive? For how long?

A

5 mg / day

to be taken until 12 w of gestation

96
Q

plasma glucose targets in women with T1DM pre-pregnancy

A

fasting: 5 mmol/L - 7 mmol/L on waking

4 mmol/L - 7 mmol/L before meals at other times of the day

97
Q

HbA1c target for women with diabetes wanting to get pregnant

A

below 48 mmol/mol (6.5%)

if this is achievable without causing problematic hypoglycaemia

98
Q

With what HbA1c levels should you strongly advice women not to get pregnant?

A

> 86 mmol/mol (10%)

this is because of the associated risks

99
Q

which common medications should be stopped immediately when pregnant?

A

ACEi
ARBs
statins

100
Q

Should all women with pre-existing diabetes be offered retinal assessment at their first appt?

A

yes - unless they had one in the last ?3 or ?6 months

101
Q

What results indicate that you should refer to nephrology before stopping contraception to get pregnant?

A
  • serum creatinine 120 micromol/L or more
  • urinary albumin:creatinine ratio is 30 mg/mmol
  • eGFR is less than 45 ml/min/1.73m2
102
Q

Should all women with diabetes have a renal assessment before stopping contraception to get pregnant?

A

yes

(incl. a measure of albuminuria)

103
Q

Role of HbA1c in diabetes in pregnact

A
  • should be measure at booking in women with pre-existing diabetes to assess the risk for the pregnancy.
  • also consider measuring in 2nd and 3rd trimester in women with diabetes.
  • measure in women diagnosed with GDM to identify women who may have pre-existing T2DM.
  • do not routinely use to assess a woman’s blood glucose control in 2nd and 3rd TM
104
Q

When would you offer CSII (insulin pump therapy) in pregnancy?

A

In women with insulin-treated diabetes who
- are using multiple daily injections of insulin
- AND do not achieve blood glucose control without significant disabling hypoglycaemia.

105
Q

What is CSII?

A

continuous subcutaneous insulin infusion

aka insulin pump therapy

106
Q

How often should women with diabetes in pregnancy check their plasma glucose?

A

T1DM and T2DM/GDM managed with multiple daily insulin injections
- fasting
- pre-meal
- 1h post-meal
- bedtime

T2DM/GDM with diet and exercise or oral therapy:
- fasting
- 1h post meal

107
Q

target blood levels in diabetes in pregnancy (fasting, 1h and 2h post-meal)

A

fasting: below 5.3 mmol/L

1h: below 7.8 mmol/L

2h: below 6.4 mmol/L

108
Q

Above which value should pregnant women taking insulin keep their capillary plasma glucose?

A

above 4 mmol/L

109
Q

is diabetic retinopathy a contraindication to vaginal birth?

A

yes

110
Q

Retinopathy assessments during pregnancy

A
  • offer at booking (unless had in the last 3 months)
  • additional retinal assessment at 16-20w (if have retinopathy)
  • additional retinal assessment at 28w
111
Q

What kind of retinal assessment should be offered at booking for women with diabetes?

A

digital imaging with mydriasis using tropicamide

112
Q

should you use eGFR to measure kidney function in pregnancy women?

A

no

113
Q

When should you consider referring a pregnant woman with diabetes to a nephrologist?

A
  • serum Cr > 120 micromol/L or moren
    OR
  • urinary Alb:Cr ratio > 30mg/mmol
    OR
  • total protein excretion > 0.5 g/day
114
Q

what kidney finding would make you consider thromboprophylaxis for pregnant women?

A

proteinuria 5g/day or higher
(alb:Cr ratio greater than 220 mg/mmol)

115
Q

Detecting congenital malformations in diabetes in pregnancy - what scan should be offered?

A

USS @ 20w to detect feral structural abnormalities incl examination of foetal heart (4 chambers. outflow tracts and 3 vessels)

116
Q

What additional monitoring of foetal growth is offered for women with diabetes in pregnancy?

A

USS of foetal growth and amniotic fluid volume every 4w from 28 - 36 w

117
Q

How often should pregnant women with diabetes be reviewed in an antenatal/obs med/endo clinic?

A

every 1-2 the clinic should be in contact with the woman for blood glucose control assessment

118
Q

What should you offer women with previous GDM ?

A
  • 75g 2h OGTT asap (if booking in 1stt or 2nd TM)
  • offer self monitoring
119
Q

What is the upper limit of when women with uncomplicated GDM should give birth?

A

40+6

120
Q

What type of OGTT should be offered to pregnant women?

A

75g 2h OGTT

121
Q

When do we test for GDM?

A

24-28w

with OGTT

122
Q

Summary of additional appts for women with GDM

A
  • 10w: offer OGTT for women with previous GDM who book in 1st TM
  • 16w: offer OGTT or monitoring to women with PMH of GDM
  • 24-28w OGTT shows DM
  • 28 w growth scan + AFV
  • 32w growth scan + AFV
  • 36w growth scan + AFV + discussion re delivery
  • 38w offer tests of fetal wellbeing
  • 39w offer tests of fetal wellbeing

ANC contact evert 1-2 w re glucose levels

advise women with uncomplicated GDM to give birth no later than 40+6 weeks

123
Q

Summary of additional appts for pregnant women with T1/T2DM

A
  • 10w: asses diabetes control and complications; risk; HbA1c; offer retinopathy/nephropathy screening. arrange ANC.
  • 16-20w retinal assessment for women with retinopathy
  • 20w scan for foetal abnormalities
  • 28 w growth scan + AFV; retinal assessment.
  • 32w growth scan + AFV
  • 36w growth scan + AFV + discussion re delivery
  • 37-38 weeks: offer IoL or C/S if appropriate
124
Q

Is diabetes in pregnancy a CI to tocolysis or antenatal steroids for lung maturation?

A

no

(give women on steroids additional insulin according to agreed protocol and monitor closely)

125
Q

What tocolytic medication should not be used in pregnant women with diabetes?

A

betamimetic medicines

126
Q

when should women with pre-existing diabetes deliver?

A

37+0 to 38+6

127
Q

How often should you monitor blood glucose in women with diabetes giving birth? What is the aim?

A

every hour

aim 4 - 7 mmol/L

128
Q

is diabetes a CI for VBAC?

A

no

129
Q

When can you discharge a baby born to aa diabetic mum to community care

A
  • once 2h old
    AND
  • maintaining blood glucose levels and feeding well
130
Q

Considerations for the baby following birth in maternal diabetes

A
  • give birth in a hospital with 24h advanced neonatal care.
  • measure blood glucose every 2-4 hours
  • mum should feed the baby asap after birth (within 30 minutes) and then every 2-3h until feeding maintains their pre-fed capillary levels at a minimum of 2.0 mmol/L
131
Q

How soon should babies of diabetic mums be fed?

A
  • mum should feed the baby asap after birth (within 30 minutes) and then every 2-3h until feeding maintains their pre-fed capillary levels at a minimum of 2.0 mmol/L
132
Q

Indications for tube feeding/IV dextrose in babies born to diabetic mothers

A
  • capillary plasma glucose below 2.0 mmol/L on 2 consecutive readings despite maximal support feeding
  • abnormal clinical signs
  • baby will not efefctively feed orally
133
Q

How can you maintain babies blood glucose levels if they are not feeding and born to diabetic mum?

A

tube feeding

or

IV dextrose

134
Q

Mx of hypoglycaemia in neonates

A

dextrose

135
Q

When should you consider giving IV dextrose and insulin intrapartum?

A

in women with t1dm

in women with diabetes that are not maintaining plasma glucose at 4-7 mmol/L

136
Q

Following birth, should women reduce or increase their insulin?

A

reduce

then monitor blood glucose levels to find the appropriate dose.

137
Q

When should women with GDM stop glucose lowering therapy?

A

immediately after birth

however test for persisting hyperglycaemia before transferring too community care

138
Q

When should women with GDM stop glucose lowering therapy?

A

immediately after birth

however test for persisting hyperglycaemia before transferring too community care

139
Q

When should women who had GDM be offered fasting plasma glucose test following birth?

A

6-13w after birth to exclude diabetes

after 13w can also offer HbA1c

offer annual HbA1c test to women with GDM who have a negative postnatal test for diabetes.

140
Q

How many UKMEC categories are there?

A

1-4

141
Q

UKMEC 1- definition

A

a condition for which there is no restriction for the uses of the method

142
Q

UKMEC 2 - definition

A

a condition where advantages > theoretical/proven risks

143
Q

UKMEC 3 - definition

A

theoretical/proven risks > advantages

the provision of aa method requires expert clinical judgement and/or referral to a specialist contraceptive provider

144
Q

UKMEC 4 - definition

A

unacceptable health risk

Year 5 😊✌🏼 (53 decks)

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