Obstetrics Flashcards
What is meant by gravidity?
No. of pregnancies a woman has had
What is meant by parity?
No. of pregnancies that went beyond 28 weeks’ gestation that resulted in delivery
What is meant by “para 2+1”?
Woman has had 2 pregnancies beyond 28 weeks and 1 pregnancy terminated/miscarried before 28 weeks
How do you calculate an estimated date of delivery (EDD) of a baby?
1 year + 7 days after LMP, minus 3 months
What happens to red cell volume during pregnancy and what is the consequence of this?
Red cell volume increases, causing dilution of Hb and a physiological anaemia
Treat with iron supplements
What happens to blood pressure during pregnancy?
High in 1st trimester
Falls in 2nd trimester until about 22 weeks
Steady rise to normal by end of term
High blood pressure should normalise within 6 weeks post-partum
When is a pregnancy test +ve?
9 days post-conception until 20 weeks gestation
Can be positive up to 5 days after miscarriage
When is the booking antenatal visit?
8-12 weeks
When is the dating USS done?
Around 10 weeks
When is the Down’s syndrome nuchal thickness test done?
Can be done with dating scan around 10-11 weeks
When is the anomaly scan done?
18 weeks
When is the first routine check-up antenatal visit?
25 weeks
When may a woman receive anti-D prophylaxis?
28 and 34 weeks’ gestation
When is the triple assessment for Down’s syndrome carried out and what does it measure?
11-13 weeks
Nuchal thickness, bHCG and PAPPA levels
Tricyclics are usually OK to prescribe in pregnancy. True/False?
True
but may have withdrawal effects in the foetus
Which SSRI has the lowest risk for use in pregnancy?
Fluoxetine
Avoid paroxetine
Breastfeeding is contraindicated in those taking psychiatric drugs. True/False?
Generally true, especially citalopram and fluoxetine
Consult psychiatrist for specialist advice
When is lithium most teratogenic in pregnancy?
First trimester
BZD use is contraindicated in pregnancy. True/False?
True
How much folic acid is recommended during pregnancy?
0.4mg until 12th week at least
5mg if increased risk of NTD’s (diabetes, epilepsy, obese)
Radioiodine and carbamazepine are safe in pregnancy. True/False?
False
Contraindicated - use propylthiouracil instead
When should trimethoprim and nitrofurantoin be avoided in pregnancy?
Avoid trimethoprim in the first trimester
Avoid nitrofurantoin in the third trimester
In which trimester is there an increased risk of seizures?
First trimester
Which anti-epileptic drug has the lowest risk in pregnancy?
Lamotrigine
Breastfeeding is safe in those taking anti-epileptics. True/False?
True
Except barbiturates
When should methotrexate be stopped with regards to pregnancy?
3 months before trying to conceive
Why should NSAID’s be avoided in the 3rd trimester?
Can cause premature closure of the ductus arteriosus
Which rheumatological antibodies can cross the placenta and cause congenital heart block?
Anti Ro
Anti La
What should patients with antiphospholipid syndrome take in pregnancy?
Aspirin and enoxaparin from 6-34 weeks’ gestation
When can the uterus typically be first felt in pregnancy?
Around 12 weeks
How is gestation estimated according to symphiseal-fundal height?
Gestation = SFH +/- 2cm
Describe foetal movements during labour
Increased flexion and descent as head enters pelvic cavity
Internal rotation at ischial spines, increased head flexion
Head extension to reach out of vulva
Restitution: shoulders rotate and head externally rotates the opposite way
Lateral flexion to deliver shoulders
Deliver buttocks and legs
Describe the basics of a normal CTG trace
Heart rate 110-160 beats/min
Variability greater than 5 beats/min
2 or more accelerations
What might cause reduced variability on a CTG?
Preterm
Sleeping foetus
Drug effects (BZD, opioids)
Hypoxia
What might cause tachycardia on a CTG?
Maternal fever B-agonists Chorioamnionitis Hypoxia Arrhythmia
What might cause bradycardia on a CTG?
Increased vagal tone of foetus
Heart block
Cord compression
What are late decelerations on a CTG a sign of?
Foetal hypoxia
What does DR C BRAVaDO stand for with regards to a CTG?
Determine Risk Contractions Baseline Rate Accelerations Variability Decelerations Overall impression
Blood pressure should normalise within 6 weeks postpartum. True/False?
True
If not, may indicate chronic hypertension
What is pre-eclampsia?
Triad of pregnancy-induced hypertension, proteinuria and oedema
Occurs after 20 weeks gestation, typically resolves within 10 days postpartum
Describe the pathophysiology of pre-eclampsia
Failure of trophoblastic invasion causes failure of normal vascular remodelling: spiral arteries remain high-resistance low-capacitance vessels, causing endothelial damage and dysfunction
List aetiology/risk factors for pre-eclampsia
Maternal/family history Primiparity Twin/multiple pregnancy IVF, ICSI Short stature Obesity Migraine history Hypertension, renal disease Hydatidiform mole
List clinical features of pre-eclampsia
Headaches Visual disturbance Epigastric/RUQ pain Nausea, vomiting Sudden oedema and weight gain Generalised seizure (eclampsia) HELLP syndrome
What investigations would you do for pre-eclampsia?
Bloods: FBC, U+E, LFT's, urate, coag screen Foetal CTG USS, uterine artery Doppler Urinalysis Regular BP checks
Outline management of pre-eclampsia
Admit if BP rises 30/20 from booking BP, or if 140/90 + proteinuria
Treat if systolic over 160: labetolol, methyldopa, nifedipine, hydralazine
Steroids to promote foetal lung development
MgSO4 if eclampsia (prophylactically can half the risk of eclampsia)
Definitive management: delivery the baby!
If a woman is at increased risk of pre-eclampsia, what can she take during pregnancy?
Aspirin from 12 weeks until birth
List aetiology/risk factors for foetal distress
Prolonged pregnancy or labour
Small foetus
Antepartum haemorrhage
Hypertension, pre-eclampsia
List clinical features of foetal distress
Meconium passage in labour
Foetal tachycardia persistently above 160bpm
Loss of variability, late decelerations on CTG
Outline management of foetal distress
Change maternal position IV fluids Stop syntocinon/tocolytics Foetal blood sample Deliver promptly!
Antepartum haemorrhage is defined as bleeding that occurs when?
After 24 weeks’ gestation
What is placental abruption?
Separation of a normally implanted placenta from the uterus
List aetiology/risk factors for placental abruption
Subsequent pregnancies Pre-eclampsia Smokers Previous C-sections Thrombophilia Cocaine use Trauma Polyhydramnios
List clinical features of placental abruption
Bloody cervix
Painful, tender uterus
Backache
Placental insufficiency leads to foetal anoxia/death
How would you diagnose placental abruption?
Clinical diagnosis
Can do transvaginal USS
Outline management of placental abruption
Deliver - C-section if unstable, NVD if stable
What is placenta praevia?
Implantation of placenta in the lower uterine segment, over or near to the cervical os
Describe minor and major placenta praevia
Minor: not covering os but near it
Major: partially or completely covering os
List aetiology/risk factors for placenta praevia
Multiple pregnancy Prior C-sections Uterine abnormalities (fibroids) Smoking Older mum Twin pregnancy IVF
List clinical features of placenta praevia
Painless bleeding
Non-tender uterus
High presenting part
Outline management of placenta praevia
If less than 2cm from os, do C-section
If more than 2cm from os, consider NVD
Do not examine vagina!
What is placenta accreta?
Placenta invades and adheres to myometrium
Associated with previous C-sections
List clinical features of placenta accreta
Massive bleeding
Pain
Outline management of placenta accreta
C-section delivery
May need to do hysterectomy
What is vasa praevia?
Foetal blood vessels overlie internal cervical os, causing increased risk of tearing of vessels and foetal hypoxia
How would you diagnose vasa praevia?
Colour Doppler USS
What is the most common liver disease of pregnancy?
Obstetric cholestasis
List clinical features of obstetric cholestasis
Pruritis in 2nd half of pregnancy
Usually affecting palms and soles
No rash
Outline management of obstetric cholestasis
Vitamin K to mother and baby
Orsodeoxycholic acid
Induce labour at 37 weeks
What is HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelets
Complication of pregnancy
List clinical features of HELLP syndrome
Upper abdo pain Jaundice Malaise Vomiting Headache
Describe stage 1 of labour
Period from the onset of regular contractions to full dilation of the cervix
Latent phase: 0-3cm dilation, takes ~6h
Active phase: 3-10cm dilation, takes ~1cm/h
3-4 contractions every 10 mins
Describe stage 2 of labour
Period from complete cervical dilation to delivery of baby
Generally lasts 45m-2h in primip, 15-45m in multip
Mother has urge to push, uses abdo muscles, Valsalva maneuvre
Why is cord clamping delayed after delivery?
Delayed for 60s to increase perfusion and O2 to baby
Describe stage 3 of labour
Delivery of placenta and membranes
Generally 30 mins with oxytocin/ergometrine support
How often is foetal heart rate, contractions, maternal pulse, maternal BP + temp, vaginal exam and urine analysis done during labour?
Foetal heart rate (CTG): every 15 mins Contractions: every 30 mins Maternal pulse: every 60 mins Maternal BP + temp: every 4h Vaginal exam: every 4h Urinalysis: every 4h
List contraindications to induction of labour
Cephalopelvic disproportion Malpresentation other than breech/facial presentation Foetal distress Placenta praevia Cord prolapse Vasa praevia Pelvic tumour
What is measured on the Bishops score?
Measure of cervical ripeness to estimate likelihood of spontaneous labour Cervical dilation Cervical consistency Cervical position Cervical length Station of head
Describe factors on Bishops score that would score a point of 0
Cervical dilation: 0cm Cervical consistency: firm Cervical position: posterior Cervical length: more than 2cm Station of head: -3
Describe factors on Bishops score that would score a point of 1
Cervical dilation: 1-2cm Cervical consistency: medium Cervical position: middle Cervical length: 1-2cm Station of head: -2
Describe factors on Bishops score that would score a point of 2
Cervical dilation: 3-4cm Cervical consistency: soft Cervical position: anterior Cervical length: less than 1cm Station of head: -1
What Bishops score indicates that labour is unlikely to occur spontaneously?
Score of 9 indicates likely spontaneous labour
Score of less than 5 indicates labour is unlikely to occur spontaneously
Outline the stepwise approach to induction of labour
Membrane sweep
Vaginal prostaglandin
Amniotomy + start foetal heart rate monitoring/pulse oximetry through scalp clip
Syntocinon
What pain relief can be used during labour?
Supportive, massage, relaxation Entonox Water immersion TENS electrode placed on back Pudendal block (S2,3,4) inject below and medial to ischial spine IM diamorphine IV remifentanyl Epidural block (T11-S5)
Define failure to progress in stage 1 of labour
Less than 2cm dilation in 4h in a primip
Less than 2cm dilation in 4h or slowing progress in a multip
Define failure to progress in stage 2 labour
No delivery in 2h (no epidural) or 3h (epidural)
No delivery in 1h (no epidural) or 2h (epidural)
List aetiology/risk factors for failure to progress in labour
Power: inadequate contractions, low strength +/- frequency of contractions
Passage: narrow pelvis, short stature, pelvic trauma)
Passenger: macrosomia, malposition, malpresentation
What is assessed on a partogram?
Assesses progression of labour Foetal heart rate Amniotic fluid Cervical dilation Foetal descent Contractions Obstruction (moulding, caput) Maternal observations
What is cord prolapse?
Umbilical cord descends ahead of presenting part of foetus, potentially causing foetal asphyxia and death
List aetiology/risk factors for cord prolapse
Prematurity Nulliparity Polyhydramnios Twins Cephalopelvic disproportion Malpresentation Placenta praevia High foetal station
List clinical features of cord prolapse
Foetal bradycardia
Variable decelerations
Palpable cord in vagina
Outline management of cord prolapse
Keep cord in vagina (do not push it back)
Presenting part may be pushed back
Mother on all fours position (use gravity to assist)
Instrument delivery may be possible if cervix fully dilated and head is low
Tocolytics help bradycardia + reduce contractions
Plan C-section
What are dizygotic and monozygotic twins?
Dizygotic: non-identical, 2 separate ova fertilised at same time
Monozygotic: identical, 1 fertilised ova divides into 2 embyros
List aetiology/risk factors for multiple pregnancy
Previous twins Family history of twins Increased maternal age IVF Induced ovulation Race (Afro-Caribbeans)
List clinical features of multiple pregnancy
Uterus larger for dates
Polyhydramnios
More than 2 foetal poles felt
Spontaneous miscarriage/perinatal mortality
Malformations
IUGR
Twin-twin transfusion (one twin born plethoric, the other anaemic)
Pregnancy-induced hypertension, pre-eclampsia
Prematurity
Malpresentation
What is the commonest malpresentation of a foetus?
Breech (buttocks) where caudal end occupies lower uterus
List aetiology/risk factors for breech presentation
Contracted pelvis Bicornuate uterus Uterine malformations, fibroids Placenta praevia Prematurity Foetal abnormality
Outline management of breech presentation
If less than 36 weeks most will turn spontaneously
External cephalic version if 36w (primip) or 37w (multip)
Planned C-section or NVD
List some contraindications to external cephalic version
Placenta praevia Twins Antepartum haemorrhage in last 7 days Ruptured membranes Growth restricted babies Abnormal CTG Uterine abnormality
A woman with a long anthropoid pelvis is at particular risk of which foetal malpresentation?
Occipitoposterior
A foetus with anencephaly and/or short neck muscles is at risk of which malpresentation?
Facial presentation
Which malpresentation typically are always delivered by C-section?
Brow presentation
Transverse lie
What is shoulder dystocia?
Inability to deliver shoulders after head, requiring additional maneuvers to release the shoulders after downwards traction fails
List aetiology/risk factors for shoulder dystocia
Large/postmature foetus Maternal BMI over 30 Induced labour, oxytocin Prolonged labour Assisted vaginal delivery Previous shoulder dystocia
List clinical features of shoulder dystocia
Maternal + foetal morbidity
Postpartum haemorrhage
Brachial plexus injury
Perineal tear
Outline management of shoulder dystocia
McRobert’s maneuver (hyperflexed lithotomy position): flex and abduct maternal hips, thighs towards abdomen, apply suprapubic pressure
Episiotomy can allow better access for internal manoeuvres
What is hyperemesis gravidarum?
Persistent vomiting in pregnancy which causes weight loss and ketosis, related to high bHCG levels
Usually occurs 8-12 weeks but may persist up to and beyond 20 weeks
List aetiology/risk factors for hyperemesis gravidarum
Young, primiparous Non-smokers Eating disorder Multiple pregnancy Molar pregnancy Hyperthyroidism Obesity
Outline management of hyperemesis gravidarum
Admit to hospital
IV rehydration
Antihistamine, antiemetic (promethazine, cyclizine)
Thiamine supplementation
List indications for forceps delivery
Delayed stage 2 of labour
Foetal or maternal distress in stage 2 of labour
Control head in breech delivery
Dense epidural block with reduced urge to push
Assisted delivery for malpresentation
Prolapsed cord
Ventouse vacuum extraction delivery causes less maternal trauma than forceps delivery. True/False?
True
What are the 2 types of C-section?
Lower segment CS (most common): horizontal incision 3cm above symphysis pubis with subsequent blunt dissection
Classical CS: vertical incision
What layers are cut/separated and then stitched in a lower segment CS?
Skin + fascia Anterior rectus sheath Separation of recti (not cut) Fascia + peritoneum Retract bladder Uterine wall Amniotic sac Stitch uterine wall with visceral peritoneum, close rectus sheath, fascia and skin
List complications of C-section
Need for further surgery/hysterectomy VTE Bladder/ureteric injury Increased uterine rupture in future pregnancies Increased risk of stillbirth Wound infections, abdo discomfort Need for repeat C-sections
List indications for C-section
Known cephalo-pelvic disproportion Placenta praevia Breech presentation Twin pregnancies Malpresentation Pre-eclampsia IUGR Foetal distress Failure to progress in labour
What is primary postpartum haemorrhage?
Loss of greater than 500ml blood during first 24h after delivery
List aetiology/risk factors for primary PPH
Uterine atony Genital tract trauma Clotting disorder Retained placenta Halothane anaesthesia Large placental site (twins, macrosomia) Prolonged labour Poor 2nd stage contractions Older mum Uterine malformation
Outline management of primary PPH
IV oxytocin
High-flow O2
Blood transfusion if shocked
If placenta not delivered, attempt by cord traction
What is secondary postpartum haemorrhage?
Excess blood loss after 24h from delivery, usually between 5-12 days
List aetiology/risk factors for secondary PPH
Retained placental tissue
Clot
Secondary infection
Outline management of secondary PPH
Uterine exploration if heavy
Crossmatch blood
Ampicillin/metronidazole if infection
Uterine curette for histology
When is a placenta defined as being “retained”?
If not delivered by 30 mins
Describe a 1st degree perineal tear
Superficial tear
No muscle damage
Describe a 2nd degree perineal tear
Laceration involves perineal muscle
Describe a 3rd degree perineal tear
Damage involves anal sphincter muscle
3a: less than 50% of EAS
3b: more than 50% of EAS
3c: tear of EAS and IAS
Describe a 4th degree perineal tear
Tear to anal sphincter and rectal mucosa
What is cut in an episiotomy and why is it done?
Incise vaginal epithelium, perianal skin, bulbocavernosus, superficial and deep transverse perineal muscles
Done to enlarge pelvic outlet to hasten birth of distressed baby, for breech and to prevent 3rd degree perineal tear
Outline management of preterm rupture of membranes
Oral erythromycin for 10 days
Antenatal steroid
Tocolysis (nifedipine) to reduce contractions
What is baby blues and how long does it last?
Depressive/anxiety -like symptoms seen around 3-7 days after birth, usually lasts no more than 72h
Give reassurance and health visitor support
What is postnatal depression and how long does it last?
Depression symptoms starting within 1 month of pregnancy, peaking at 3 months, resolving by 6 months
Outline management of postnatal depression
Reassurance and support
CBT
SSRI (sertraline, paroxetine)
Lithium/ECT may be tried
What is puerperal psychosis and when does it start?
Severe mood swings (similar to BPD) and altered perception and delusions, occurring 2-3 weeks after birth
Mums can have delusions regarding child and suicidal ideation
Outline management of puerperal psychosis
Admit to hospital/mother-baby unit
What is puerperal pyrexia?
Temperature greater than 38’C in first 14 days after delivery
List aetiology/risk factors for puerperal pyrexia
Endometritis UTI Wound infection (perineal tear, C-section) Mastitis VTE
List clinical features of puerperal pyrexia
Lower abdo pain
Tender uterus
Lochia (endometrial slough passed per vaginum)
What does “triple assessment” of a breast lump entail?
Clinical examination
Imaging (USS if under 40, mammogram if over 40)
Biopsy (core/vacuum/FNA)
List aetiology/risk factors for mastaglia
Low progesterone
High oestrogen, prolactin, fatty acids
Caffeine excess
Poor diet
List clinical features of mastalgia
Cyclical: pre-menopausal, outer 1/2 of breast, may be unilateral
Non-cyclical: older women, continuous/random distribution
Breast discomfort
Fullness, heaviness
Burning pain
Outline management of mastalgia
Mild-mod: reassurance, well-fitting bra, topical NSAID
Severe: danazol, gamolenic acid, bromocriptine, tamoxifen, evening primrose oil
List aetiology/risk factors for nipple discharge
Duct ectasia
Intraductal papilloma
Carcinoma
Lactation
What is gynaecomastia?
Breast development in a male, with ductal growth but without lobular development
List aetiology/risk factors for gynaecomastia
Hypogonadism Puberty Drugs (spironolactone, cannabis) Cirrhosis Testicular tumours
Outline management of gynaecomastia
Resolve spontaneously after 2 years
Surgery
Stop drugs
Tamoxifen, danazol
Which breast condition is common in postpartum lactating women?
Breast abscess
Which organisms are associated with breast abscess?
Staph aureus
Strep pyogenes
List clinical features of breast abscess
Pain Swelling Tenderness Mobile mass Overlying skin necrosis
Outline management of breast abscess
Continue breastfeeding
Flucloxacillin +/- aspiration
What is duct ectasia?
Dilation of sub-areolar ducts
List aetiology/risk factors for duct ectasia
Smokers
Elderly parous women
List clinical features of duct ectasia
Coloured (thick green) discharge
Acute/episodic
Nipple changes
Reduced milk production
Outline management of duct ectasia
Treat infection
Exclude malignancy
Stop smoking
Duct excision
Periductal mastitis presents in an older age group compared to duct ectasia. True/False?
False
Typically presents in younger women
List clinical features of periductal mastitis
Pain Abscess Duct fistula Pus discharge Redness
Outline management of periductal mastitis
Co-amoxiclav
Drain abscess
List aetiology/risk factors of fat necrosis of breast
Post-trauma
Obesity
Large breasts
List clinical features of fat necrosis of breast
Hard, firm lesion/lump
Scarring
Foamy macrophages and damaged adipocytes on histology
Which benign breast tumour is best described as a painless, firm, discrete mobile mass?
Fibroadenoma
Describe the pathology of fibroadenoma
Develop from whole lobule
Circumscribed, rubbery
Grey-white biphasic tumour (consists of epithelium and stroma)
Which benign breast tumour is best described as a slow-growing unilateral mass?
Phyllodes tumour
Describe the pathology of Phyllodes tumour
Occur in older people
Malignant potential
Stromal overgrowth +/- infiltration
Outline management of Phyllodes tumour
Wide local excision
Mastectomy if large
Which benign breast tumour is best described as a smooth discrete lump associated with cyclical pain?
Fibrocystic change
Describe the pathology of fibrocystic change
Occur in middle-aged
Several 1mm cysts
Blue-domed with pale fluid
Which benign breast tumour is best described as having blood-stained discharge, a central solitary nodule or multiple peripheral nodules?
Intraductal papilloma
Describe the pathology of intraductal papilloma
Occur in middle-aged
Local epithelial proliferation in sub-areolar ducts
Fibrovascular core
Outline management of intraductal papilloma
Microdochectomy or total duct excisionm
Describe the pathology of sclerosing adenosis/radial scars
Extra tissue growth in lobules as part of ageing
Epithelial proliferation, stromal fibrosis and sclerosis
Radial scar: stellate architecture, central puckering, radiating fibrosis
List clinical features of sclerosing adenosis
Recurring pain
Firmness
Small lump
List aetiology/risk factors for malignant breast cancer
Increasing age Familial history BRCA mutation Early menarche, late menopause Nulliparity HRT, COCP Alcoholism Obesity Not breastfeeding
List clinical features of malignant breast cancer
Asymptomatic Lump Mastalgia Nipple discharge Skin changes, dimpling Lymphoedema
What is ductal carcinoma in situ (DCIS)?
Precursor to invasive carcinoma involving malignant epithelial cells confined within the basement membrane of the duct
Precursors: atypical duct hyperplasia, epithelial hyperplasia
What would a mammogram of DCIS show?
Microcalcifications
Outline management of DCIS
If less than 4cm, wide local excision + SN biopsy
If more than 4cm, mastectomy + SN biopsy
+/- adjuvant radiotherapy
What is lobular carcinoma in situ?
Precursor to invasive carcinoma involving intralobular proliferation
Usually multifocal + bilateral, not visible or palpable grossly
Precursor: atypical lobular hyperplasia
What is the screening schedule for breast cancer?
47-73 year-olds get 3-yearly mammograms
If increased risk, can screen earlier
e.g. if age less than 40, bilateral, ovarian Ca history, first-degree family/relative
Where does invasive breast carcinoma arise from?
Epithelial cells in terminal duct lobular unit
What is the most common form of invasive breast carcinoma?
Ductal carcinoma (adenocarcinoma)
Describe staging of breast carcinoma
1: confined to breast
2: confined to breast + axillary LN involved
3: fixed to muscle + axillary LN involved
4: fixed to chest wall
Describe T1-T4 staging of breast carcinoma
T1: less than 2cm
T2: 2-5cm
T3: more than 5cm
T4: fixed to chest wall
What is the Nottingham Prognostic Index for breast carcinoma?
NPI = (tumour size x 0.2) + LN score + grade score
Grade 1 = 0 lymph nodes
Grade 2 = 1-3 lymph nodes
Grade 3 = 4+ lymph nodes
Which circumstances would favour wide local excision of breast carcinoma?
Solitary
Peripheral
Small lesion on big breast
DCIS less than 4cm
Which circumstances would favour mastectomy of breast carcinoma?
Multifocal
Central
Large lesion on big breast
DCIS more than 4cm
Which drugs are given for HER2 and ER +ve cancers?
HER2: Trastizumab (Herceptin)
ER: tamoxifen
What types of breast reconstruction may be done following mastectomy?
Implants Flaps (latissimus dorsi, transverse rectus abdominis musculocutaneous)
