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First Aid Step 2 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

primary cause third trimester bleeding

A

Placental abruption and placenta previa

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2
Q

Classic US and gross appearance of complete hydatidiform mole

A

Snowstorm on US

Cluster of grapes on gross exam

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3
Q

Chromosomal pattern of complete mole

A

46 XX

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4
Q

Molar pregnancy containing fetal tissue

A

Partial mole

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5
Q

Sx of placental abruption

A

Continuous painful bleeding

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6
Q

Sx of placenta previa

A

Self limited, painless vaginal bleeding

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7
Q

When should a vaginal exam be performed with suspected placenta pre via?

A

Never

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8
Q

Abx with teratogenic effect

A

Tetracycline
Fluoroquinolones
Aminglycosides
Sulfonamides

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9
Q

Most common cause of postpartum hemorrhage

A

Uterine atony

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10
Q

Tx postpartum hemorrhage

A

Uterine massage

If that fails - oxytocin

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11
Q

Abx prophy for GBS

A

IV penicillin or ampicillin

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12
Q

Meds to accelerate fetal lung maturity

A

Bethamethasone or dexamethasone x 48 hrs

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13
Q

Pt fails to lactate after an emergency C section with marked blood loss

A

Sheehan syndrome (postpartum pituitary necrosis)

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14
Q

Uterine bleeding at 18 weeks gestation, no products expelled, cervix open

A

Inevitable abortion

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15
Q

Uterine bleeding at 18 wks gestation, no products expelled, cervical os closed

A

Threatened abortion

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16
Q

Teratogens effect during which weeks

A

2-12 wks

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17
Q

Which is older, gestational age or embryonic/developmental age? by how much

A

Gestational age 2 weeks older than embryonic age because is based on LMP which is 14 d prior to fertilization which occurs at ovulation

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18
Q

Naegele rule

A

EDP = LMP + 7 days - 3 months + 1 year

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19
Q

CV changes in pregnancy

A 
CO increased 40%  with SV and HR increase
Systolic murmur b/c inc CO
Myocardial O2 demand increases
SP and DP decrease
Uterus push heart superiorly
Venous distension increases 
PVR decreases
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20
Q

Respiratory changes in pregnancy

A

Uterus pushes diaphragm up and decreases RV, FRC, ERV
Total O2 consumption increases
TV increases 40% with increase in minute ventilation 2/2 progesterone stimulation
PCO2 decreases = dyspnea
VC does not change

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21
Q

Renal changes in pregnancy

A

Renal plasma flow and GFR increase
BUN and Cr decrease
Inc renal loss bicarb due to compensation for resp alkalosis
Blood and interstitial fluid v increases

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22
Q

Endocrine change in pregnancy

A

Nondiabetic hyperinsulinemia with mild glc intolerance
Production human placental lactogen inc glc intolerance by interfering with insulin activity
Fasting TG inc
Cortisol Inc
TBG and T4 inc, free T4 unchange
TSH decrease but WNL

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23
Q

Hematologic changes in pregnancy

A

Hypercoaguable state
Increased RBC
HCT dec bc inc blood V

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24
Q

GI changes in pregnancy

A

Inc salivation
Dec gastric motility
Increased gastric emptying time
Sphincter tone decreases

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25
Q

Weight gain mom

Calorie intake

A

BMI 26: 15-25 lbs

Calories: 2500

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26
Q

Labs at initial visit

A 
9-14 wks
CBC
Blood ab and Rh
Pap
GC/Chlam
UA-every visit
RPR or VDRL
Rubella titer
Hep B surface antien
HIV
TSH?
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27
Q

Labs 16-18 wks

A

Quadruple screen - trisomies 21, 18, NTD

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28
Q

Labs 18-20 wks

A

US dating and anatomy

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29
Q

Labs 24-28 wks

A

1 hr OGTT

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30
Q

labs 32-37 wks

A

N\GC and chlam, HIV and RPR screen in high risk

GBS screening

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31
Q

4 things tested in Quadruple screen

A

AFP- maternal serum
Estriol
hCG
maternal serum inhibin A

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32
Q

Tested in full integrated test

A

US for nuchal translucency and serum for pregnancy associated plasma protein A - first trimester
Quadruple screen - 2nd semester

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33
Q

Amniocentesis tests

Who gets tested?

A

Amniotic fluid after 16 wks for AFP and karyotype

Tested:

  • Abnormal quadruple
  • Rh sensitized mom to obtain fetal blood type
  • Evaluate fetal lung maturity via L:S >=2.5 or detect PG
  • > 35 yrs
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34
Q

Chorionic villous sampling tests

A

9-12 wks gestation for chromosome abnormalities

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35
Q

Percutaneous umbilical cord sampling tests

A

> 18 wks: chromosome defect, fetal infection, Rh sensitization

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36
Q

Maternal serum AFP

  • When valid
  • If high this means?
  • If low this means
A

Valid only 16-18 wks
High levels: NTD (ancephaly or spina bifida) or multiple gestation, abdominal wall defect (gastroschisis, omphalocele), incorrect dating, fetal death, placental abnormalities (placental abruption)
Low levels: trisomies 21 and 18, fetal demise, inaccurate dating

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37
Q

AFP low, hCG high, Inhibin A high, estriol low (Quad)

Nuchal translucency high, hCG high, PAPP-A high (full integrated)

A

Trisomy 21

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38
Q

AFP low, estriol low, hCG low, Inhibin A WNL/low - quad

Nuchal translucency high , hCG and PAPP-A low - full integrated

A

Trisomy 18

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39
Q

Quad screen WNL

Nuchal translucency inc, hCG dec, PAPPA, dec

A

Trisomy 13

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40
Q

AFP levels

  • when are they valid
  • if low/high
A
  • Valid wks 16-18
  • High: NTD or multiples
  • Low: trisomyy 18 or 21
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41
Q

1 hr OGTT

  • Oral glc load
  • Abnormal
A
  • 50 g

- >=130

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42
Q

3 hr OGTT

  • test setup
  • abnormal
A

3 days carb meals, fasting glc measured , 100 g load, measure glc 1,2,3 hrs

Abnormal with 2 of following

  • FG >=95
  • 1 hr >=180
  • 2 hr > = 150
  • 3 hr >=140
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43
Q

Preeclampsia

Meds ok to use

A

HTN
Proteinuria
Edema

Labetolol, no ACEI or ARB

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44
Q

HELLP

A

Hemolysis
Elevated liver enzymes
Low Platelets

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45
Q

Tx seizures in pregnancy

A

Stay on current meds, Vit K and folate given

Diazepam can be use to break seizures

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46
Q

Warfarin

A

Ok breastfeeding

Not pregnancy

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47
Q

Anticoagulation during pregnancy

A

Stop all during active labor and until 6 hrs after delivery

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48
Q

Marijuana

  • Maternal risk
  • Fetal risks
A

Mom: minimal
Kid: IUGR, prematurity

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49
Q

Cocaine

  • Maternal risk
  • Fetal risks
A

Mom: ARRHYTHMIA, MI, SAH, seizures, stroke, abruptio placentae
Kid: ABRUPTIO PLACENTAE, IUGR, prematurity, facial abnormalities, delayed intellectual development, fetal demise, bowel atresias, congenital malformation heart, limbs, face, GU, microcephaly, cerebral infarctions

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50
Q

Ethanol

  • Maternal risk
  • Fetal risks
A

Mom: minimal
Kid: FETAL ALCOHOL SYNDROME, spontaneous abortion, intrauterine fetal demise

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51
Q

Opiods

  • Maternal risk
  • Fetal risks
A

Mom: INFECTION (needles), withdrawa, PROM
Kid: Prematurity, IUGR, meconium aspiration, neonatal infections, NARCOTIC WITHDRAWAL (may be fatal)`

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52
Q

Stimulants

  • Maternal risk
  • Fetal risks
A

Mom: lack of appetite and malnutrition, arrhythmia, withdrawal depression, HTN
Kid: IUGR, congenital heart defect, cleft palate

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53
Q

Tobacco:

  • Maternal risk
  • Fetal risks
A

Mom: ABRUPTIO PLACENTAE, PLACENTAE PREVIA, PROM
Kid: Spontaneous abortion, prematurity, IUGR, intrauterine fetal demise, impaired intellectual development, higher risk of neonatal respiratory infection

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54
Q

`Hallucinogens:

  • Maternal risk
  • Fetal risks
A

Mom: Personal enlargement (poor decisions making)
Kid: Possible developmental delays

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55
Q

Fetal alcohol syndrome

A 
Mental retardation
IUGR
Sensory and motor neuropathy
Facial abnormalities- midfacial hypoplasia
Growth restriction
Renal and cardiac defects
Drinking >6 drinks per day
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56
Q

ACEI teratogen effects

A

Renal- fetal renal tubular dysplasia and renal failure, oligohydramnios
IUGR
Decreased skull ossification

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57
Q

Aminoglycosides teratogen effects

A

CN VIII damange
Skeletal
Renal

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58
Q

Carbamazepine teratogen effects

A 
Facial
IUGR 
Mental retardation
CV
NTD
Fingernail hypoplasia
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59
Q

Chemo (all classes) teratogen effects

A 
Intrauterine fetal demise
Severe IUGR
Anatomic- Palate, bones, limbs, genitals, etc
Mental retardation
Spontaneous abortion
Secondary neoplasms
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60
Q

Diazepam teratogen effects

A

Cleft palate
Renal
Secondary neoplasms

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61
Q

DES teratogen effects

A

Vaginal and cervical cancer - clear cell adenocarcinoma

Possible infertility

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62
Q

Fluoroquinolones teratogen effects

A

Cartilage

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63
Q

Heparain teratogen effects

A

Prematurity
Intrauteine fetal demise
Safer than warfarain

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64
Q

Lithium teratogen effects

A

Ebstein

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65
Q

OCPS teratogen effects

A

Spontaneous abortion

Ectopic

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66
Q

Phenobarb teratogen effects

A

Neonatal withdrawal

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67
Q

Phenytoin teratogen effects

A 
Facial
IUGR 
Mental retardation
CV
Microcephaly
Dysmorphic face
Fingernail hypoplasia
68
Q

Retinoids teratogen effects

A

CNS
CV
Facial
Spontaneous abortion

69
Q

Sulfonamides teratogen effects

A

Kernicterus

70
Q

Tetracycline teratogen effects

A

Skeletal
Limb
Teeth discoloration- yellow brown
Hyoplasia enamel

71
Q

Thalidomide teratogen effects

A

Limb
Anotia and micronotia
Cards and GI

72
Q

Valproic acid teratogen effects

A

NTD
Facial
CV
Skeletal

73
Q

warfarin teratogen effects

A 
Spontaneous abortion
IUGR
CNS
Faical
Mental retardation
Dandy walker
Nasal hypoplasia and stippled bone epiphyses
Eyes
74
Q

Hydrocephalus, intracranial calcifications, chorioretinis, microcephaly, spontaneous abortion, seizures

  • Dx
  • Tx
A

Toxoplasmosis
DX: amniotic fluid for PCR or serum Ab screening, ring enhancing lesion CT
Tx: pyrimethamine, sulfadizine, add folinic acid
Mother - no gardening, litter box, raw meat, unpastuerized milk

75
Q

Increased risk of spontaneous abortion, skin lesion - BLUEBERRY MUFFIN
Congenital syndrome if transmission: IGUR, deafness, CV, vision, CNS, hepatitis, PDA
DX
TX

A

Rubella

IgG screening

Mother immunized before pregnant
No Tx if during pregnancy
No benefit from immunoglobulin

76
Q

INcreased risk of prematurity, IUGR, spontaneous abortion, HIGH RISK NEONATAL DEATH IF TRANSMISSION
Dz
Tx

A

Rubeola/measles

IgM or IgG after rash develops

Immunize mom before pregnant, immune globulin during pregnancy, VACCINE CI DURING PREGNANCY b/c live

77
Q

Neonatal anemia, deafnes, hepatosplenomegaly, pneumo, hepatitis, osteodystrophy, rash followed by hand and foot desquamation, neonatal mortality 25%
Dx
Tx

A

Syphilis

Early RPR or VDRL, confirm with FTA-ABS

PENICILLIN to mom or baby

78
Q

IUGR, chorioretinitis, CNS, mental retardation ,vision, deafness, hydrocephalus, seizures, hepatosplenomegaly, petechial rash, periventricular calcifications
Dx
Tx

A

CMV

IgM or PCR within first few wks of life

No Tx if develops during pregnancy
Ganciclovir may decrease effects in neonates
GOOD HYGIENE TO REDUCE TRANSMISSION

79
Q

Increased risk prematurity, IUGR< spont abortion, neonatal death or CNS probl if transmission
Dx
Tx

A

HSV

Clinical + viral culture/immunoassay

C-section to avoid transmission if active lesion or primary outbreak
Acyclovir in neonates

80
Q

Increased risk prematurity, IUGR< increased risk of neonatal death if acute disease develops
Dx
Tx

A

Hep B

Prenatal surface antigen

Maternal vaccination, vaccination of neonate and immunoglobulin after birth

81
Q

Viral transmission in utero, RAPID DISEASE PROGRESSION
Dx
Tx

A

HIV
Early prenatal maternal blood screening

AZT to decrease vertical transmission
COntinue antivirals - NO efavirenz, didanosine, stavudine, nevirapine

82
Q

Increased risk spontaneous abortion, neonatal sepsis, conjunctivitis
Dx
Tx

A

GC/chlam

Cervical culture + immunoassay

Erythromycin to mom or neonate

83
Q

Prematurity, ENCEPHALITIS< PNEUMO, IUGR, CNS, limb, blindness, high risk neonatal death if birth during active infection
Dx
Tx

A

VZV

IgG titier if no known history of disease
IgM and IgG to confirm Dx in neonates

Varicella immunoglobulin to nonimmune mom within 96 hr of exposure and to neonate if born during active infection
Vaccine CI during pregnancy b/c live attenuated

84
Q

Respiratory, pneumo, meningitis, sepsis
Dx
Tx

A

GBS

Antigen screening after 34 wks

IV beta lacatams or clindamycin during labor or in infected neonates

85
Q

Decreased RBC production, hemolytic anemia, hydrops fetalis
Dx
Tx

A

Parvovirus B19

IgM or PCR

Monitor fetal Hg by PUBS (umbilical blood), give transfusion if severe anemia

86
Q

TORCH

A 
Toxoplasmosis
Other (VZV, Parvovirus B 19, GBS, chlam/GC)
Rubella/rubeola/RPR (syphilis)
CMV
HSV/Hep B/HIV
87
Q

Abortion type: uterine bleeding + closed cervical os + no uterine contents expelled
US viable fetus

A

Threatened

Bed rest and limit activity

88
Q

Abortion type: uterine bleeding with pain, os closed, no uterine contents expelled, US shows nonviable fetus
Tx

A

Missed

Misoprostol or DandC

89
Q

Abortion type: uterine bleeding and pain, os open, no uterine contents expelled
Tx

A

Incomplete

Tx: Misoprostal and DandC

90
Q

Abortion type: uterine bleeding, open/closed os, all contents expelled

A

Complete

91
Q

Spontaneous abortion/miscarriage - when
1st trimester cause
2nd trimester cause

A

<20 wks, non selective

1st: chromosome
2nd: infection, cervical incompetence, uterine abnormalities, hypercoaguable, poor maternal health, drug use

92
Q

Major risk factor for miscarriage

A

> 35 yrs

93
Q

When: intrauterine fetal demise

A

> 20wks

94
Q

Most common causes vaginal bleeding early pregnancy

A

Ectopic
Threatened or inevitable abortion
Physiologic bleeding (implantation)
Uterine cervical pathology

95
Q

Tx UTI pregnant

A

Amoxicillin
Nitrofurantoin
Cephalexin

96
Q

Beta hCG level for transabdominal vs transvaginal US

A

Transabdominal: 6500
Transvaginal: 1000

97
Q

Most common location ectopic pregnancy

A

Ampulla

98
Q

2 types IUGR

A

Symmetric: overall decrease in body size, early pregnancy
Asymmetric: decrease abdominal
Size only, late in pregnancy

99
Q

Oligohydramnios 1st vs 2nd vs

3rd trimester

A

1: spontaneous abortion
2: fetal renal, maternal cause, placental thrombosis
3: PROM, preeclampsia, abruptio placentae, idiopathic causes

100
Q

Oligohydramnios AFI

A

<5cm

101
Q

Polyhydramnios AFI

A

> 25cm

102
Q

Tests show PROM

A

Not razing paper blue

Ferning

103
Q

Fetal lung maturity: lecithin vs sphingomyelin

A

L:S >2 with presence PG in amniotic fluid suggests fetal lung maturity

104
Q

Preterm labor wks

A

<37wks

105
Q

Cervical length low vs high risk

A

Low: >35mm
High:<15mm

106
Q

Most common causes vaginal bleeding >20wks: painful vs painless

A

Placenta previa: painless

Abruptio placentae: painful

107
Q

Placenta previa: low implantation vs partial vs complete

A 
Placenta near cervical os
Low: placenta in lower uterus but does not infringe on cervical os until
Dilation
Partial: partially covers os
Complete: completely covers os
108
Q

Premature separation of placenta from uterine wall leading to lots of hemorrhage

A

Abruptio placenta

109
Q

Only time conjoined twins occur

A

Monozygotic twinning

110
Q

Umbilical cord for multiple fetuses fused, what happens?

A

Twin-twin transfusion syndrome: one twin inadequately transfused

111
Q

Normal FHR

A

120-180

112
Q

False contractions

A

Braxton Hicks

113
Q

Early decel
Cause
Tx

A

Decelerations begin and end with uterine contractions
Cause: head compression
Tx: not sign of fetal distress

114
Q

Late decel
Cause
Tx

A

Begin after contraction starts and end after contraction finished
Cause: uteroplacental insuff, maternal venous compression,maternal hypotension, abruptio placenta
FETAL HYPOXIA
Tx: determine hypoxia or acidosis; recurrent late decels - prompt delivery

115
Q

Variable decel
Cause
Tx

A

Inconsistent onset, duration, degree
Cause: umbilical cord progression
Tx: change moms position

116
Q

Most common causes uterine atony

A

Multiple gestational
Prolonged labor
Chorioamnionitis
Atony most common

117
Q

High beta hCG

A

Hydatidiform mole and multiple gestation

118
Q

Preeclampsia in first half of pregnancy

A

Suspect molar pregnancy

119
Q

Complete vs incomplete hydatidiform mole

A

Complete 46 XX or XY - all from father with empty egg

Incomplete: 69 XXY or XXX or XYY - 2 sperm

120
Q

Complications hydatidiform mole

A

Malignant gestational trophoblastic neoplasm

Choriocarcinoma

121
Q

GP: Parity means

A

Number of pregnancies led to birth beyond 20 wks or infant >500 g

122
Q

Fundal height at 20 wks

A

Umbilicus

123
Q

When can you hear fetal heart tones on doppler

A

10-12 wks

124
Q

Fetal movements- when

A

17-18 wks

125
Q

When does beta hCG peak, at what number?

A

10 wks, 100,000

Doubles every 48 hrs during early pregnancy

126
Q

When to give RhoGAM

A

If Rh- mom

give 28-30 wks

127
Q

When should moms visit doc’s?

A

Wks 0-28: every 4 wks
Wks 29-35: every 2 wks
Wks: 36-birth: every 1 wks

128
Q

CVS vs amniocentesis

A

CVS: 10-12 wks, placental tissue, earlier than amniocentesis; cannot detect open NTD

Amnio: 15-20 wks, amniotic fluid

129
Q

Lead fetal defects

A

Inc spont abortion rate

Stillbirth

130
Q

Methotrexate fetal defects

A

Inc spont abortion rate

131
Q

Organic mercury fetal defects

A 
Cerebral atrophy
Microcephaly
Dysmorphic craniofacial features
Cardiac defects
Fingernail hypoplasia
132
Q

Radiation fetal defects

A

Microcephaly
Mental retardation
Medical diagnostic radiation delivering <0.05 Gy to the fetus has NO risk

133
Q

Streptomycin and kanamycin fetal defects

A

Hearing loss

CN VIII damage

134
Q

Trimethadione and paramethadione fetal defects

A

Cleft lip or palate
Cardiac defects
Microcepaly
Mental retardation

135
Q

Vitamin A fetal defects

A 
Inc spont abortion
Microtia
Thymic agenesis
CV
Craniofacial
Microphthalmia
Cleft lip or palate
Mental retardation
136
Q

Endometritis leading to septicemia, result sin hypotension, hypothermia, inc WBC

A

Septic

137
Q

Station fetal head position

A

Above ischial spines -

Below ischial spines +

138
Q

Visceral pain from uterine contractions and cervical dilation - levels

A

T10-L1

139
Q

Somatic pain from descent of fetal head and P on vagina and perineum - levels

A

Pudendal n, S2-S4

140
Q

Pneumonic BPP

A 
Test the Baby MAN
Fetal Tone
fetal Breathing
Amniotic fluid V
Nonstress test
141
Q

Gestational HTN develops which wks

A

> 20 wks

142
Q

Rh neg mom, Rh + baby = risk

A

Erythroblastosis fetalis
Hydrops fetalis if Hg <7
Fetal hypoxia and acidosis, kernicterus

143
Q

What to do with shoulder dystocia

A

HELPER

Help reposition
Episiotomy
Leg elevated- McRoberts maneuver
Pressure (suprapubic)
Enter vagina and try to rotate (Wood's screw)
Reach for fetal arm
144
Q

Postpartum endometritis

A

Fever >38C within 36 hrs
Uterine tenderness
Malodorous lochia

145
Q

Pelvic infection leads to infection of vein wall and intimal damage –> thrombogenesis–>clot invaded with microbes
Suppuration w/ liquefaction –> fragmentation –>septic embolization

Picket fence fever curve, abdominal and back pain

Tx: abx, anticoag w/ hepatin 7-10d

A

Septic pelvic thrombophlebitis

146
Q

7 W postpartum fever

A 
Womb - endomyometritis
Wind - atelectasis, pneumo
Water- UT
Wound
Weaning- breast abscess, mastitis
Wonder drug
147
Q

Failure to lactate due to dec prolactin levels

A

Sheehan syndrome- ant pituitary

Tx: replace hormones, may recover

148
Q

Breastfeeding CI

A

HIV
Active hepatitis
Meds- BDZ, barbs, opiates, alcohol, caffeine, tobacco

149
Q

Tx mastitis

A

Continue breastfeeding

Abx: dicloxacillin, cephalexin, amxicillin/clauvulanate, azithromycin, clindamycin

150
Q

Normal lab tests in pregnancy

A 
ESR elevated
TBG increased, free T4 normal
V inc dec H and H
BUN and Cr dec
GFR inc
WBC inc
ALP inc
Mild proteinuria and glucosuria normalx
151
Q

Weeks pregnant when fundus at pubic symphysis

A

12 wks

152
Q

Tx bacteriuia

A

Always Tx even if ASx

Penicillin, cephalosporin, nitrofurantoin

153
Q

Antiphospholipid Ab with previous pregnancies - what may help with subsequent pregnancies

A

NSAID- acetaminophen best (not use ASA or other NSAID)

154
Q

Safe in pregnancy

A 
Acetaminophen, NOT NSAID OR ASA
Penicillin
Cephalosporin
Erythromycin
Nitrofurantoin
H2 blockers
Antacids
Heparin
Hydralazine
Methyldopa
Labetalol
Insulin
Docusate
155
Q

Itching of palms and soles
Abnormal LFT
Jaundice

A

Cholestasis

Tx: delivery, can use ursodeoxycholic acid or cholestyramine

156
Q

Acute fatty liver of pregnancy

A

3rd trimester or after delivery
Usually progresses to hepatic coma
Tx: IVF, IV glc, FFP
Cannot use Vit K - because liver is in temporary failure

157
Q

Toxic effects Mg

A

Hyporeflexia - first sign
Resp depression
CNS depression
Coma death

158
Q

Prolonged rupture of membranes

A

> 18 hrs

Inc risk infection: GBS, E coli, Listeria

159
Q

When is fetal fibronectin most useful

A

Wks 22-34, if test negative indicates very low likelihood of delivery in next 2 weeks

160
Q

If check Rh ab in RH - mom and is positive

A

Dont bother giving RhoGAM, already positive

If test is negative, RhoGAM at 28 wks and after delivery also with any surgery, bleeding, etc.

161
Q

Hemolytic disease of newborn

A

Rh incompatibility

ABO incompatibility- do not need prior sensitization because already have Ab (O mom with A, AB, B kid)

162
Q

Test that quantifies fetal blood in maternal circulation, can be used to determine amt of RhoGAM

A

Kleihauer Betke

163
Q

Cardinal movements of labor

A 
Engagement
Flexion
Descent
IR
Extension
ER/restitution
Expulsion
164
Q

Scalp pH below what indicates immediate C section

A

7.2

165
Q 
SOB
Tachypnea
CP
Hypotension
DIC
A

AF PE

166
Q

Tx chorioamnionitis

A

Ampicillin plus gentamicin while awaiting culture

First Aid Step 2 (22 decks)

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