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obstetrics Flashcards

1
Q

Placenta accreta

A
  • Low lying placenta
  • thin overlying myometrium
  • vessels extend into bladder

MANAGEMENT

  • Ask for growth charts
  • need caesarian hysterectomy
  • MRI pelvis to charactrise extent
  • Delivery at tertiary referral
  • Input from intervetional radiology
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2
Q

Retroverted utereus with caesarian scar ectopic

A

Spiel

  • Transabdominal and TV images
  • Uterus is retroverted
  • Normal endometrium

KILLER

  • Intrauterine pregnancy
  • Inferior aspect of uterus
  • above cervix
  • Abnormal location
  • corpus luteum cyst

MANAGEMENT

  • Urgent referral to tertiary referral
  • Gynaecology referral
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3
Q

Haemorrhagic cyst

Clinical history

  • Acute abdominal pain, presented to accident and emergency
A
  • TVUS
  • Uterus is anteverte

KILLER

  • Correlate endometrial stripe with gestation
    • Likely secretory phase
  • Cystic adnexal structure
  • lace like fish net pattern
  • Absent colour flow
  • Thickened tissue around- ovarian torsion!!!!

MANAGEMENT

  • Referral to tertiary centre for detorsion
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4
Q

Sequestration

A
  • Hyperechoic mass
  • SIDE
  • SITE
  • SIZE
  • dipslaces heart
  • compresses contralateral lung
  • STOMACH BUBBLE LOCATION
  • arterial thoracic vessel

DIFFERENTIAL

  • CPAM
  • sequestration
  • diapragmatic hernia
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5
Q

Encephalocele

A
  • Cystic structure in continuation with the posterior skull
  • Disruption of posterior skull
  • herniation of contents posteriorly

LOOK FOR

  • ARPKD
  • poyldactyly
    *
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6
Q

Multicystic dysplastic kidneys

A
  • Cystic dilatations in the kidney
  • Do not appear to communicate
  • Kidney is enlarged

Differential

  • Hydronephrosis
  • PUJ

Management

  • Referral to Tertiary
  • nephrectomy
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7
Q

Meckel Gruber

A
  • Enecephalocele-
    • cystic structure at posterior aspect of cranium
    • Absent posterior skull
  • ARPKD
    • Bilateral enlarged
    • hyperechoic
  • Polydactyly

Management

  • 1/4 recurrence
  • autosomal recessive
  • POLYDACTYLY
  • Look at hands
  • look at kidneys
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8
Q

Omphalocele

A
  • Well defined
  • Anterior abdomen
  • ? cord insertion
  • Contents
    • liver
    • bowel

Management

  • Tertiary referral
  • karyotyping
    *
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9
Q

Cervical incompetence

A
  • <25mm
  • Bulging pattern T→Y→V→U→bulging

Management

  • Cerclarge
  • Progesterone pessary
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10
Q

Placenta Previa/low lying

A
  • <25 mm from internal os

DO

  • TV scan with empty bladder
  • Vasa previa – Doppler on internal os

Management

  • F/U 32 weeks
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11
Q

vasa praevia

A
  • Vessels crossing the internal os

Look for

  • Low lying placenta
  • Velamentous insertion
  • Succenturiate lobe

Management

  • C-section delivery before onset of labour.
  • Anterior previa important as CS will cross
  • Velamentous – 90%
  • Succenturiate – 10%
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12
Q

Placental sonolucencies

extensive >3

A
  • > 3 lucencies in placenta

Looking for

  • IUGR
  • Oligohydramnios
  • Vascular flow
  • consider placenta accreta

Management

  • F/U scans for IUGR/oligo
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13
Q

Placental chorioangioma

A
  • Low echogenic placental lesion
  • well defined
  • internal doppler flow
  • >5cm or multiple ↑complication

Follow up

HIP

  • Hydrops
  • IUGR
  • Polyhydramnios
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14
Q

Single umbilical cord

A

Look for

  • Other signs aneuploidy
  • Cardiac/renal anomaly
  • IUGR

Management

  • Isolated 3rd trimester USS for IUGR
  • Non-isolated 3° referral & karyotyping
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15
Q

POLYHYDRAMNIOS

A

DEFINITION

  • AFI > 24 cm
  • MVP > 8 cm
  • MVP > 7 cm twins

CAUSES

  1. Idiopathic
  2. ​Maternal
    • GDM
    • HTN/preeclampsia
    • CCF
  3. Fetal
    • CNS – can’t drink
    • Obs to GI tract
    • Cardiac anomaly
    • Skeletal dysplasia
  • LOOK FOR
    1. IUGR = bad outcome
    2. Face anomalies
    3. GI obstruction
  • Presence of stomach
    1. CHD
    2. Limbs
    3. ↑AC for diabetic baby
  • Management
    • Tertiary referral
    • amnioreduction
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16
Q

OLIGOHYDRAMNIOS

Spiel- The Paucity of amniotic fluid makes interpretation difficult.

A

DEFINTION

  • AFI < 5 cm
  • MVP < 2 cm
  • MVP < 3 cm twins

CAUSE

  • -Demise
  • -Renal abnormality
  • -IUGR
  • -PROM – most common
  • -Post-dates
  • -Chromosomal
  • -Placental insufficiency

LOOK FOR

  • -Ask about any PV d/c
  • -Aneuploidy markers
  • -Renal tract obstruction -Renal agenesis

MANAGEMENT

  • Tertiary referral ±karyotype
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17
Q

HYDROPHS

There is fluid in 1 cavity and I am looking for fluid in other compartments for evidence of hydrops

A
  • Hydrop
  • ≥2 cavities
    • pericardial
    • pleural
    • ascites
    • skin oedema

CAUSES

  • Immune hydrops
    • Rh
  • Non-immune hydrops
    • Mass – chest most commonneu
    • Aploidy
    • Anaemia
    • AVM
    • Cardiac anomaly
    • TORCH

LOOK FOR CAUSE

  • MCA PSV

MANAGEMENT

  • Tertiary referral
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18
Q
  • Exencephaly (brain left)
  • Anencephaly (no brain)
  • Acrania (entire cranium absent)

spiel-

  • Genetic counselling
  • MEGA FOLATE
    • next pregnancy as at ↑risk of all neural tube defects.
A

ASSOCIATIONS

Neural tube defects

LOOK FOR

  • Other neural tube defects
  • Clenched hands

MANAGEMENT

  • Incompatible with life
  • Offer termination.
  • Genetic counselling
  • MEGA FOLATE in next pregnancy
    • ↑risk of all neural tube defects.
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19
Q

Holoprosencephaly

alobar/semilobar /lobar

A

CAUSE

  • T13
  • Multiple facial anomalies

LOOK FOR

  • Proboscis
  • Cyclops
  • Hypoplastic L heart
  • Other anomalies
    • rockerbottom feet

MANAGEMENT

  • Tertiary referral ±karyotyping
  • Usually lethal

SPIEL

Genetic counselling and MEGA FOLATE in next pregnancy as at ↑risk of all neural tube defects.

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20
Q

HYDRANCEPHALY

Falx present cf holoprosencephaly

No rind of brain cf aqueduct stenosis

A

FINDINGS

  • Falx present cf holoprosencephaly
  • No rind of brain cf aqueduct stenosis

ASSOCIATIONS

  • TORCH

MANAGEMENT

  • Tertiary referral
  • -TORCH screen
  • ±karyotyping
  • Poor prognosis
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21
Q

AQUEDUCT STENOSIS

A

CAUSES

  • X-linked hydrocephalus
  • -TORCH
  • -Dandy-Walker
  • -Chiari II
  • -Agenesis CC
  • -VACTERL

LOOK FOR

  • Clenched hands for X-linked

MANAGEMENT

  • Tertiary referral
  • TORCH screen ±karyotyping
  • Poor prognosis

COMPLICATIONS

  • Birth issues due to dystocia of the head ↑HC
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22
Q

Abnormal cavum septum pellucidum

  • Holoprosencephaly
  • Agenesis of SP
  • Agenesis of CC
A

LOOK FOR

  • -Schizencephaly
  • -Other neuro defects

MANAGEMENT

  • Tertiary referral
  • Variable outcome
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23
Q

VENTRICULOMEGALY

SPIEL

  • Scan in real-time for intracranial abnormalities.
  • In particular cerebellum shape and absent CC.
  • Review 1st trimester screening results for aneuploidy risk and TORCH infections.
A

DEFINITION

  • Mild > 10 mm
  • Severe > 15 mm

ASS./CAUSE

  1. -Isolated
  2. -Aneuploidy
  3. -Agenesis of CC
  4. -Chiari II
  5. -Encephalomalacia

LOOK FOR

  1. Other signs of aneuploidy
  2. lemon shaped skull
  3. banana cerebellum
  4. Absent CC
  5. Myelomeningocele

MANAGEMENT

  • -Tertiary referral
  • ±Karyotype
  • -TORCH screen
  • ±MRI

SPIEL

Scan in real-time for intracranial abnormalities. In particular cerebellum shape and absent CC. Review 1st trimester screening results for aneuploidy risk and TORCH infections.

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24
Q

CHOROID PLEXUS CYST

SPIEL

  • May be seen in isolation.
  • Correlate with FTS results.
  • Careful examination for other signs of aneuploidy in particular T18;
    • clenched hands
    • IUGR.
  • If isolated nil further.
A
  • Aneuploidy
  • -T18 in particular
  • -T21 with other soft signs

LOOKING FOR

  • IUGR
  • strawberry head
  • cardiac defects
  • Clenched hands
  • Other signs of aneuploidy

MANAGEMENT

  • Isolated – nil
  • Associated – tertiary referral with view to karyotyping
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25
CEPHALOCELE SPIEL Counselling and will need MEGA FOLATE in next pregnancy as at ↑risk of all neural tube
Associations 1. Other CNS abnormalities 2. Meckel-Gruber 3. Aneuploidy LOOK FOR 1. Meckel Gruber 1. Renal cystic dysplasia 2. polydactyl 2. Aneuploidy markers 3. DDx – cystic hygroma MANAGEMENT 1. -Tertiary referral 2. -Offer karyotyping if other signs of aneuploidy, if not then no need. 3. *Counselling and will need MEGA FOLATE in next pregnancy as at ↑risk of all neural tube*
26
VEIN OF GALEN
ASSOCIATIONS 1. Coarctation of the aorta 2. Transposition of great arteries 3. Heart failure LOOK FOR 1. CHD 2. Cardiomegaly 3. Hydrops MANAGEMENT * Tertiary referral
27
CHIARI
DESCRIPTION * Frontal scalloping * Banana cerebellum * Cisterna magna \<2mm ASSOCIATIONS * Open neural tube defect (may be occult) ie myelomeingocele * Ventriculomegaly * Triangular post ventricles * Myelomeningocele * Aneuploidy markers (T13/18) MANAGMENT * Tertiary referral * Offer karyotyping if other signs of aneuploidy, if not then no need. * Counselling * Need MEGA FOLATE in next pregnancy as at ↑risk of all neural tube
28
**Cystic posterior fossa mass** DDx 1. -Blake’s pouch cyst 2. -Dandy-Walker Complex 3. -Vermian hypoplasia 4. -Megacisterna magna (\>10 mm)
**Associations** 1. -Other CNS abnormalities 2. -Aneuploidy (T18) 3. -Meckel-Gruber 4. -Multiple syndromes 5. -Isolated cases have good outcome **Look for** 1. -CNS abnormalities 2. -Other signs of aneuploidy 3. -Cephalocele 4. renal cystic dysplasia 5. polydactyl **Management** 1. -Tertiary referral 2. ±karyotyping **Spiel** for ↑CM * *Tertiary referral for confirmation of isolated cisterna magna and consideration of karyotyping*
29
NUCHAL THICKNESS AND TRANSLUCENCY 1st Trimester- **\>3mm** 2nd Trimester - **\>6 mm**
ASSOCIATIONS 1. Aneuploidy 2. -Many conditions 3. -Cystic hygroma consider Turners ( LOOK FOR SEPTATIONS) 4. -CHD 5. -Skeletal dysplasia LOOK FOR 1. Other signs of aneuploidy 2. -↑↑NT±septations for cystic hygroma 3. -Skeletal dysplasia MANAGEMENT 1. -Tertiary referral 2. -Correlate with FTS background risk and bloods. 3. -Offer karyotyping if at high risk. 4. -Position of placenta for CVS if \<16 weeks SPIEL * *Patient requires genetic counselling with a view to karyotyping.* * *I am looking at the placenta position for potential CVS.*
30
**Cystic hygroma** “spoke wheel” septations
ASSOCIATIONS 1. -Turner (XO) 2. -T21 3. -Other aneuploidy 4. -CHD 5. -Hydrops LOOK FOR 1. -Other anomalies 2. -Hydrops 3. -CHD 4. -Skull defect to suggest DDx 1. cephalocele, other neck mass MANAGEMENT 1. -Tertiary referral 2. -Correlate with FTS background risk and bloods. 3. *Patient requires genetic counselling with a view to karyotyping.*
31
**Absent / hypoplastic** **nasal bone** 1st – absent 2nd - \< 3mm
ASSOCIATIONS 1. -T21 – 60% 2. -T18 3. -T13 4. -Normal variant Afro-Caribbean, Asians LOOK FOR 1. Other signs of aneuploidy 2. -↑NT 3. -Tricuspid regurg 4. -Deep A waves in DV 5. -Position of placenta for CVS MANAGMENT 1. Correlate with FTS 2. background risk and bloods. 3. Offer karyotyping if at high risk.
32
Cleft lip Cleft lip/palate
ASSOCIATION 1. -Aneuploidy 2. -\>200 syndromes CHECK FOR * Cleft palate MANAGMENT 1. Tertiary referral 2. -Delivery in paediatric centre as will have issues with feeding
33
**Pericardial effusion** \>2mm There is fluid in 1 cavity and I am looking for fluid in other compartments for evidence of hydrops
ASSOCIATIONS 1. -CHD 2. -TORCH 3. -Hydrops LOOK FOR 1. -Hydrops 2. -Brian/liver calcs for TORCH MANAGEMENT 1. -Tertiary referral for review 2. -TORCH screen
34
ECHOGENIC CARDIAC FOCUS I am looking carefully for other markers of aneuploidy. In isolation this is considered a normal variant.
ASSOCIATIONS 1. Isolated = normal variant 2. -Aneuploidy T21/T13 3. -Large DDx - rhabdomyoma LOOK FOR 1. -Other signs of aneuploidy 2. -Heart defects MANAGEMENT 1. Review FTS 2. Isolated – Nil Mx 3. ↑FTS or associated abnormalities – genetic counselling
35
VSD
ASSOCIATIONS 1. -CHD 2. -Aneuploidy LOOK FOR 1. CHD – look thoroughly 2. -Review whole fetus for T21 markers MANAGMENT 1. Tertiary referral with view to karyotyping 2. -Review FTS results
36
**AVSD** Endocardial cushion defect
ASSOCIATIONS 1. -T21 – 40% 2. -Heterotaxia syndromes LOOK FOR 1. -Aneuploidy markers MANAGEMENT 1. -Tertiary referral 2. ±karyotyping
37
**Transposition of great arteries** -Parallel outflow tracts
ASSOCATIONS 1. -Rarely associated with aneuploidy LOOK FOR 1. Other heart defects MANAGEMENT 1. Foetal echo for confirmation 2. Correctable condition postnatal. Delivery in specialised paediatric centre eg Royal Children’s
38
**Tetralogy of Fallot** 1. -RV outflow obs 2. -RV hypertrophy 3. -Overriding aorta 4. -VSD
ASSOCIATIONS * 45% aneuploidy LOOK FOR 1. Other heart defects 2. Aneuploidy markers MANAGEMENT 1. Karyotyping 2. Good prognosis if isolated. 3° delivery & surgery
39
**Sequestration** - ↑echo mass - Supply from aorta
ASSOCIATIONS 1. -CDH 2. -Cardiac 3. -Pulmonary – CPAM 4. -GI anomalies 5. -?Aneuploidy LOOK FOR 1. Systemic arterial supply 2. -DDx – CPAM, neuroblastoma, liver CDH MANAGMENT 1. -Tertiary referral 2. -**Serial USS for hydrops and polyhydramnio**s 3. **-Post natal CT** 4. -No karyotyping - Kristy
40
**CPAM** - Cystic, solid or mixed - No systemic arterial supply
**Look for** 1. -Hydrops 2. -Polyhydramnios 1. Bad prognosis 3. **-Normal stomach bubble** DDx CDH 4. -Renal anomalies **Association/Cause** 1. -Not associated with aneuploidy 2. -Other lung anomalies 3. -Renal anomalies 4. -DDX 1. --CDH 2. --Sequestration 3. --Bronchial atresia **Management** 1. -Serial USS for hydrops and polyhydramnios 2. -Post natal CT
41
DIAPHRAGMATIC HERNIA
1. CNS, cardiac, renal & spinal anomalies 2. -Aneuploidy 3. -Syndromes LOOK FOR 1. -Lung to head ratio 2. -Other signs of aneuploidy and anomalies MANAGMENT 1. -Genetic counselling with view to karyotype. 2. -Consideration of foetal MRI. 3. Delivery in tertiary paediatric centre for surgical intervention
42
OMPHALOCELE
SPIEL 1. There is an anterior abdominal wall defect; 2. I am trying to determine if it is an omphalocele or gastroschisis. 3. I am looking for features such: * insertion of the cord, * covering membranes * cauliflower appearance. LOOKING FOR 1. -Polyhydramnios 2. -Other signs of aneuploidy and anomalies 3. -Bowel containing only – worse prognosis ASSOCIATIONS 1. -Aneuploidy 2. -Cardiac & GI abnormalities 3. -Beckwith-Wiedemann MANAGEMENT 1. Tertiary referral 2. -Karyotype 3. -Delivery tertiary paeds surgical centre
43
GASTROSCHISIS
SPIEL * There is an anterior abdominal wall defect; * I am trying to determine if it is an omphalocele or gastroschisis. * I am looking for features such * insertion of the cord * covering membranes * cauliflower appearance. ASSOCIATIONS * -Maternal drug use * -\<25 yo mother * -IUGR * -Congenital heart disease * -No aneuploidy LOOK FOR * heart anomalies MANAGEMENT 1. 3rd trimester F/U * IUGR * bowel problems (ileus, atresia, obstruction) 2. Delivery tertiary paeds surgical centre
44
ECHOGENIC BOWEL
DESCRIPTION 1. bright as bone 2. -mass like 3. -no shadowing ASSOCIATIONS 1. Normal variant 2. -Aneuploidy T21 3. -Infection – TORCH 4. -Ingested blood (abruption or prior amniocentesis) 5. -Cystic fibrosis 6. -Bowel ischemia/atresia MANAGEMENT 1. FTS consider karyotyping 2. -TORCH screen 3. -CF screen 4. -3rd trim USS for IUGR
45
**Absent stomach bubble** Shown with polyhydramnios in image
CAUSES 1. -Potential causes 2. -Chest mass 3. -CDH 4. -VACTERL ASSOCIATIONS 1. Obstruction – with poly 2. mechanical due to mass 3. atresia oesophagus (VACTERL) 4. Abnormal swallowing mechanism 5. Oligohydramnios MANAGMENT 1. Tertiary referral 2. Karyotyping
46
Duodenal atresia
ASSOCIATIONS 1. -Aneuploidy T21 2. -Cardiac anomalies 3. -GI anomalies 4. -IUGR REFERRAL 1. -Tertiary referral 2. -Karyotyping
47
**Dilated bowel** - SB \> 7 mm - LB \> 18 mm Often eyeball
SPIEL “Look in real time for peristalsis to confirm the tubular cystic structure is bowel” ASSOCIATIONS 1. -Aneuploidy T21 2. -Cystic fibrosis 3. -Jejunal/ileal atresia 4. -VACTERL MANAGEMENT 1. -F/U 2. -Tertiary referral if other anomalies
48
**Meconium Peritonitis** 1. -Calcifications 2. -Ascites 3. ±Meconium pseudocyst 4. ±dilated bowel 5. ±Polyhydramnios
**findings** 1. -Calcifications 2. -Ascites 3. ±Meconium pseudocyst 4. ±dilated bowel 5. ±Polyhydramnios Causes 1. -Bowel atresia 2. -Cystic fibrosis 3. -**Ischemia** 4. Intussusception 5. Volvulus Management 1. Tertiary referral 2. -Post natal Ix
49
Umbilical vein varix
Cause 1. -Renal tract mostly 2. -Can cause anaemia 3. -May rupture Look for 1. -Doppler to confirm Dx and to exclude thrombosis 2. -MCA PSV Managment 1. Tertiary referral 2. -Monitor to ensure no thrombosis 3. -Anaemia
50
**Megacystis** \>7 mm – **1st** \>20 mm – **2nd** Eyeball – **3rd**
- 1st trim – think aneuploidy - 2nd trim – think obstruction - Fluid & kidney anomalies ASSOCIATIONS 1. -Aneuploidy T13/18 2. -Urethral obstruction MANAGEMENT 1. Tertiary referral with a view to karyotyping
51
**Pyelectasis** \>4 mm **\<**23 wks \>7mm **\>**23 wks
CAUSE 1. T21 – soft marker 2. -Isolated 3. -Renal tract obstruction 4. -Duplex LOOK FOR - Correlate with FTS and other aneuploidy anomalies - Renal tract obstruction MANAGEMENT 1. -3rd trimester scan for progression 2. -Neonatal renal tract USS (even if resolves in 2/3rd)
52
HYDRONEPHROSIS AND HYDROURETER ## Footnote *Looking at bladder for a ureterocele to exclude a duplex kidney with obstruction as cause of appearances*
CAUSES 1. -PUJ obstruction 2. -VUJ obstruction 3. -Post urethral valve 4. -Reflux 5. -1° mega ureter 6. -Prune belly 7. -Duplex system LOOK FOR 1. Polyhydramnios Management 1. Tertiary referral 2.
53
**Multicystic dysplastic kidney** - Multiple non-communicating cysts * Looking at bladder for a ureterocele to exclude a duplex kidney with obstruction as cause of appearances*
LOOKING FOR 1. Oligohydramnios 2. -Other anomalies ASSOCIATIONS 1. -Non-renal anomalies 5% 2. -Meckel-Gruber 3. -T13/18 MANAGEMENT 1. Consider karyotyping 2. -F/U for size of both kidneys and fluid volume 3. -Maternal renal USS
54
**Autosomal Recessive Polycystic Kidneys** -↑echo large kidneys
_Looking for_ Oligohydramnios _Managment_ Tertiary referral
55
Renal agenesis * Renal arteries are angle dependent and I would scan in real time.* * Bilateral renal agenesis is incompatible with life due to pulmonary hypoplasia and Potter sequence.*
LOOK FOR * -Bladder size * -Oligohydrmanios * -Bilateral incompatible with life ASSOCCIATIONS * VACTERL * -Single umbilical artery MANAGEMENT 1. Tertiary referral 2. -Maternal renal USS 3. -3rd trimester USS for AFI
56
TALIPES -Long axis of foot and leg in same view
LOOK FOR 1. Other anomalies 2. -Aneuploidy markers 3. -Myelomenigocele ASSOCIATIONS 1. Spina bifida 2. -Any cause of oligo 3. -Aneuploidy (esp T18) 4. -Skeletal dysplasia MANAGEMENT 1. Isolated – nil obstetric 2. -Paeds follow-up for possible bracing 3. **_If isolated counsel the parents that this is not normal but is a correctable condition._**
57
**Rockerbottom foot** -convex sole of foot with hyperextended toes
LOOK FOR 1. Other anomalies 2. -Aneuploidy markers 3. -Myelomenigocele ASSOCIATIONS 1. Spina bifida 2. -Any cause of oligo 3. -Aneuploidy (esp T18) 4. -Myotonic dystrophy MANAGEMENT 1. Rarely seen in isolation, go by other anomalies
58
**Thanatophoric dysplasia** -Limb shortening **-Type I** – telephone receiver femurs **-Type II** – cloverleaf skull -**Platyspondyly** – flat vert bodies
LOOK FOR Chest size for pulmonary hypoplasia
59
OSTEOGENESIS IMPERFECTA - Fractures - Short limbs - ↓mineralisation – see brain too well --skull deformable by transducer pressure
ASSOCIATIONS * Type II and III normally diagnosed in utero LOOK FOR * Chest size for pulmonary hypoplasia MANAGEMENT -Tertiary referral
60
**Achondrogenesis** - Absent vertebral body ossification - Small thorax with flared ribs - Severe micromelia
ASSOCIATIONS * Cystic hygroma MANAGEMENT * Tertiary referral
61
**Sacrococcygeal Teratoma** - Exophytic solid/cystic mass - May have sig internal component
LOOK FOR * AV shunting in lesion (↑solid = ↑risk) for risk of hydrops * -Local mass effect ASSOCIATIONS 1. Hydrops 2. -Polyhydramnios 3. -Renal tract obstruction 4. -Structural defects due to mass effect REFERRAL Tertiary referral

3 differentials (8 decks)

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