High risk Neocities V4 Sem10

<h3>Here comes another exciting game of obstetrics.</h3> You will have brainstorming questions to assess your clinical knowledge and problem solving skills. If you answer incorrectly, you can go back and try again until you get it right. Also, you can read the explanation provided with references to improve your understanding. Ready? Welcome to the beautiful world of Ms. Tess. [[START]] <img src="/High risk pregnancy/tesspic.jpg"/>

Oh, that's wrong. Ovarian hyperstimulation syndrome (OHSS) is associated with recent gonadotropin use (with or without IVF); lower abdominal pain, distension, nausea, and vomiting are common; symptoms and signs worse if early onset, late onset indicates pregnancy. ‘Early’ OHSS usually presents within 7 days of the hCG injection and is usually associated with an excessive ovarian response.‘Late’OHSS typically presents 10 or more days after the hCG injection and is usually the result of endogenous hCG derived from an early pregnancy. Remember, your patient had her fertility treatment <b>7 weeks</b> ago, therefore OHSS is unlikely. Read <a href="/High risk pregnancy/BMJ Assessment of abdominal pain in pregnancy.pdf" target="_blank">Assessment of abdominal pain in pregnancy (BMJ)</a> <img src="/High risk pregnancy/OHSS.jpg"/> (track: 'uh oh', 'play')

Ms. Tess, 35-year-old primigravida, is admitted with severe nausea and vomiting for the past few days. She has been married for 5 years. Her last menstrual period (LMP) was 9 weeks ago. She has had difficulty conceiving, but was finally successful following fertility treatment, which she underwent 7 weeks ago. What is your diagnosis? a. [[Hyperemesis gravidarum->Option 1]] b. [[Ovarian hyperstimulation syndrome->Option 2]] c. [[Peptic ulcer->Option 3]]

That's right! Hyperemesis gravidarum is the most severe form of NVP and is characterised by persistent vomiting, volume depletion, ketosis, electrolyte disturbances, and weight loss. [[CONTINUE->PART 1]] Read <a href="/High risk pregnancy/BMJ Nausea and vomiting in pregnancy.pdf" target="_blank">Nausea and vomiting in pregnancy (BMJ)</a> (track: 'yess', 'play') (track: 'yess', 'volume', 0.07)

That's wrong. Try again. Peptic ulceration is less common in pregnancy and pre-existing ulceration tends to improve, probably due to altered oestrogen levels and the improved maternal diet in pregnancy. Reference: Textbook of Obstetrics by ten teachers, 20th edition page no.312 (track: 'uh oh', 'play')

Ms. Tess undergoes a pelvic ultrasound scan and is diagnosed with dichorionic diamniotic twins, viable and corresponding to dates. She is treated with IV hydration and antiemetics and is discharged after 5 days. The following are helpful in the diagnosis of twins EXCEPT a. [[Exaggeration of pregnancy symptoms->Option 4]] b. [[Anasarca->Option 5]] c. [[Uterus larger than dates->Option 6]] d. [[Ultrasound scan->Option 7]]

That's incorrect. Try again. All the physiological changes of pregnancy, including increased cardiac output,volume expansion, relative haemodilution, diaphragmatic splinting, weight gain and lordosis, are exaggerated in multiple gestations. This results in much greater stresses being placed on maternal reserves. The ‘minor’ symptoms of pregnancy may be exaggerated, such as nausea and vomiting and heartburn. Reference: Textbook of Obstetrics by ten teachers, 20th edition page no.203 (track: 'sad', 'play') (track: 'sad', 'volume', 0.05)

That's correct! Anasarca is generalised oedema. It is pathological and suggestive of haematological, cardiac, and renal disorders. It is NOT useful for diagnosis of twin pregnancy. [[CONTINUE->PART 2]] <img src="/High risk pregnancy/Anasarca.jpg"/> (track: 'Success', 'play') (track: 'Success', 'volume', 0.05)

That's incorrect. Try again. There are several signs and symptoms associated with multiple pregnancy including: • Hyperemesis gravidarum. • Uterus is larger than expected for dates. • Three or more fetal poles may be palpable at >24wks. • Two fetal hearts may be heard on auscultation. However, the <b>vast majority</b> are diagnosed on ultrasound in the first trimester (at a dating or nuchal translucency scan). Reference: Oxford handbook of obstetrics and gynaecology, 3rd edition page No.74 (track: 'sad', 'play') (track: 'sad', 'volume', 0.05)

Ms. Tess attends antenatal clinic at 20 weeks’ of gestation for a routine check-up. The following are the clinical assessments performed routinely at 20 weeks' EXCEPT a. [[General examination->Option 8]] b. [[Abdominal examination->Option 9]] c. [[Anomaly scan->Option 10]] d. [[Pelvic examination->Option 11]]

That's wrong. Try again. Anomaly scan is routinely done at 20 weeks' to rule out structural abnormalities in the fetuses. Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'Oh no', 'play') (track: 'Oh no', 'volume', 0.05)

That's right! Pelvic examination is not routinely recommended unless patient presents with vaginal loss. [[CONTINUE->PART 3]] Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'short success', 'play') (track: 'short success', 'volume', 0.2)

At 20 weeks POG, Ms.Tess has mild conjunctival pallor with normal vital signs and BMI. Abdominal examination: uterus corresponds to 24 weeks and multiple fetal parts felt. Urine dipstick is negative for protein and sugar. Obstetric ultrasound scan reveals two viable foetuses corresponding to the dates with no obvious congenital anomalies. Which of the following is recommended to assess fetal growth in Mrs. Tess? a. [[Symphysis fundal height->Option 12]] b. [[Obstetric ultrasound scan->Option 13]]

That's wrong. Try again. Do not use abdominal palpation or symphysis–fundal height measurements to monitor for fetal growth restriction in a dichorionic twin. Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'oh', 'play') (track: 'oh', 'volume', 0.05)

That's right! Serial scanning is indicated to monitor fetal growth. A common policy to detect IUGR in dichorionic twins is four-weekly scanning from 24 weeks,with further scans and/or Doppler measurements as indicated. [[CONTINUE->PART 4]] Read <a href="/High risk pregnancy/Taylor TOAG 2000.pdf" target="_blank">Multiple Pregnancy, MJO Taylor and NM Fisk, The Obstetrician & Gynecologist, October 2000</a> (track: 'music box', 'play') (track: 'music box', 'volume', 0.05)

Ms. Tess presents to PAC at 29 weeks’ gestation with lower abdominal pain for the past 3 to 4 hours. There is no history of vaginal loss. On examination of her abdomen, the uterus corresponds to 32 weeks, uterine contractions are felt, and fetal hearts are normal. Speculum examination findings: cervix appears normal with closed os. No vaginal bleeding or leaking. What is your provisional diagnosis? a. [[Placental abruption->Option 14]] b. [[Threatened preterm labour->Option 15]] c. [[Symphysis pubis dysfunction->Option 16]]

That's wrong. Try again. General examination is done to assess pallor, blood pressure and BMI, which are important at this stage. Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'Oh no', 'play') (track: 'Oh no', 'volume', 0.05)

That's wrong. Try again. Placental abruption usually presents with constant abdominal pain and vaginal bleeding. (track: 'evil laugh', 'play') (track: 'evil laugh', 'volume', 0.05)

That's correct! She is having preterm contractions with no cervical changes. [[CONTINUE->PART 5]] (track: 'one cheer', 'play') (track: 'one cheer', 'volume', 0.05)

That's incorrect. Try again. Symphysis pubis dysfunction presents with pain in symphysis pubis and difficulty in walking. (track: 'error', 'play') (track: 'error', 'volume', 0.05)

That's wrong. Try again. Ultrasound is used to confirm chorionicity, number of fetuses, location, gestational age and structural abnormalities. <img src="/High risk pregnancy/USStwins.jpg"> Reference: Oxford handbook of obstetrics and gynaecology 3rd edition page No.74 (track: 'sad', 'play') (track: 'sad', 'volume', 0.05)

That's wrong. Try again. Abdominal examination is needed to assess clinical fundal height, fetal poles, fetal parts, liquour status, and fetal hearts. (track: 'Oh no', 'play') (track: 'Oh no', 'volume', 0.05)

Ms. Tess is diagnosed with threatened preterm labour without rupture of membranes. The following are done to assess preterm labour EXCEPT a. [[FBC, CRP, Urine dipstick for nitrites->Option 17]] b. [[High vaginal swab, fetal fibronectin->Option 18]] c. [[Digital/vaginal examination->Option 19]] d. [[Cervical ultrasound->Option 20]] e. [[Cardiotocograph->Option 21]]

That's incorrect. Try again. FBC, CRP and nitrites are necessary to look for signs of infection. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.05)

That's incorrect. Try again. High vaginal swab and fetal fibronection in vaginal swab are done to look for an infection and to assess if the patient will progress to preterm labour. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.05)

That's correct! Digital/ vaginal examination is not necessary if speculum examination shows that the os appears closed. But.....if you suspect your patient is having regular uterine contractions and the os appears open on speculum examination, vaginal examination is required to assess bishop's score to know how advanced her labour is. If your patient is having leaking but no contraction pain (Preterm prelabour rupture of membrane without preterm labour), then vaginal examination is contraindicated due to the risk of ascending infection. After undergoing the appropriate assessments and two days of observation on the ward, Ms Tess' condition remains stable and she is allowed to go home. [[CONTINUE->PART 6]] Reference: Oxford handbook of obstetrics and gynaecology, 3rd edition (track: 'Bingo', 'play') (track: 'Bingo', 'volume', 0.05)

That's wrong. Try again. CTG is used to assess fetal well being as well as uterine contractions. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.05)

A few weeks later, Ms. Tess is admitted with preterm contractions again. She is now at 33 weeks period of gestation. This time, her cervix is 2 cm dilated with intact membranes. Which one of the following is the BEST management option for her? a. [[Counselling, steroids for fetal lung maturity, magnesium sulfate for cerebral protection->Option 22]] b. [[Progestogens, cervical cerclage, steroids for fetal lung maturity, tocolytics->Option 23]]

That's wrong. Try again. Cervical ultrasound is used to assess cervical length, which if measures < 25mm, increases the risk of preterm labour. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.05)

That's correct! Ms Tess is experiencing preterm labour at 33 weeks period of gestation. Therefore, you need to counsel her for the likelihood of preterm delivery and the consequences of a preterm baby. You also need to administer corticosteroids for fetal lung maturity, give IV magnesium sulfate for cerebral protection for the fetus, and tocolyse for completion of dexamethasone. Fortunately for Ms Tess, the contractions stop and her membranes remain intact. However, she is kept in hospital for bed-rest and continued monitoring for any further contractions. [[CONTINUE->PART 7]] (track: 'Basic rock 135', 'play') (track: 'Basic rock 135', 'volume', 0.05)

That's incorrect. Try again. You are right in the sense that Ms Tess is experiencing preterm labour. However, emergency cervical cerclage not recommended at 33 weeks as the perinatal outcome is not improved. Furthermore, Progesterone does not have any benefit when prescribed in the case of twins, and may increase adverse effects. Read <a href="/High risk pregnancy/BMJ Premature labour - Emerging Rx.pdf#page=30" target="_blank" >Premature labour - Emerging treatments (BMJ)</a> (track: 'Baby Giggle 1', 'play') (track: 'Baby Giggle 1', 'volume', 0.05)

At 34 weeks’ gestation Ms. Tess’s blood pressure is found to be 146/100 mmHg on two occasions. She is asymptomatic and fetal movements are good. Which of the following is the appropriate next step in management? a. [[BP monitoring, antihypertensives, Urine protein, ultrasound and thromboprophylaxis->Option 24]] b. [[Antihypertensives, steroid, CTG and scan->Option 25]] c. [[Plan for emergency caesarean section and thromboprophylaxis->Option 26]]

That's correct! Ms Tess has developed pregnancy-induced hypertension as her blood pressure is more than 140/90 mmHg. Therefore, you need to consider starting an antihypertensive, check urine dipstix for protein to exclude pre-eclampsia (Pregnancy-induced hypertension without proteinuria), perform ultrasound examination to assess twin presentation and fetal well-being, and give thromboprophylaxis (TED stockings). [[CONTINUE->PART 8]] (track: 'lightapplause', 'play') (track: 'lightapplause', 'volume', 0.05)

That's incorrect. Try again. Ms Tess now has pregnancy-induced hypertension as her blood pressure is above 140/90 mmHg. Antihypertensives are used if the patient is symptomatic or if the BP is >140/100 mmHg. However, she was previously given steroids at 33 weeks gestation. Repeat course of steroids is NOT recommended. Read <a href="/High risk pregnancy/NICE preterm-labour-and-birth.pdf#page=13" target="_blank">NICE guidelines on materal steroids in pre-term labour (page 13)</a> Read <a href="/High risk pregnancy/NICE hypertension-in-pregnancy-diagnosis-and-management.pdf" target="_blank">NICE guidelines on hypertension in pregnancy</a> (track: 'Game over', 'play') (track: 'Game over', 'volume', 0.05)

That's wrong. Try again. Ms Tess has developed pregnancy-induced hypertension as her blood pressure is above 140/90 mmHg. However she is asymptomatic and she is still only at 34 weeks period of gestation. Emergency caesarean section is planned if there is maternal or fetal compromise. Emergency LSCS is indicated if BP is high despite antihypertensives, or if there is deterioration in biochemical or haematological parameters or doppler abnormalities. (track: 'Game over', 'play') (track: 'Game over', 'volume', 0.05)

Ms. Tess' BP is now well-controlled with methyl dopa and her urine protein is nil. Which one of the following is <b>NOT</b> recommended in the monitoring of fetal well-being in twin pregnancy? a. [[Fetal kick chart->Option 27]] b. [[CTG->Option 28]] c. [[Biophysical profile->Option 29]] d. [[Doppler ultrasound->Option 30]]

That's correct! Fetal kick chart is not recommended to monitor fetal well-being in twin pregnancy. [[CONTINUE->PART 9]] (track: 'one cheer', 'play') (track: 'one cheer', 'volume', 0.05)

That's wrong. Try again. The cardiotocograph (CTG) is a continuous tracing of the fetal heart rate used to assess fetal wellbeing, together with an assessment of uterine activity. Reference: Textbook of Obstetrics by ten teachers, 20th edition page No. 99 (track: 'Punch 2', 'play') (track: 'Punch 2', 'volume', 0.05)

That's wrong. Try again. Ultrasound can be used to assess fetal wellbeing by evaluating fetal movements,tone and breathing in the biophysical profile. Reference: Textbook of Obstetrics by ten teachers 20th edition, page no. 97 (track: 'Punch 2', 'play') (track: 'Punch 2', 'volume', 0.05)

That's incorrect. Try again. Doppler ultrasound can be used to assess placental function and identify evidence of blood flow redistribution in the fetuses, which is a sign of hypoxia. Doppler of umbilical and middle cerebral arteries and ductus venosus are helpful. Reference: Textbook of Obstetrics by ten teachers, 20th edition page No. 97 (track: 'Punch 2', 'play') (track: 'Punch 2', 'volume', 0.05)

Ms. Tess undergoes an ultrasound scan. The pictorial illustration of the twin fetuses is shown below. <br> <img src="/High risk pregnancy/Twin_breech.jpg"> <br> What is the presentation of the twins? a. [[Breech,vertex->Option 31]] b. [[Vertex,vertex->Option 32]] c. [[Vertex,breech->Option 33]]

That's correct! First twin is the one which is lowest in the pelvis. [[CONTINUE->PART 10]] (track: 'yess', 'play') (track: 'yess', 'volume', 0.05)

That's incorrect. Try again. Lowest in pelvis is first twin which is breech. (track: 'no', 'play') (track: 'no', 'volume', 0.05)

Ms Tess's antenatal period was quite eventful. Fortunately, under your excellent care, she has now progressed well to 35 weeks plus 3 days period of gestation. Her blood pressure is well-controlled and she is asymptomatic. In addition, she is stable biochemically. Both twins are growing well along the 50th centile. Choose the optimal timing and mode of delivery for Ms. Tess. a. [[36-37 weeks, induction of labour->Option 34]] b. [[35-36 weeks, caesarean section->Option 35]] c. [[37-38 weeks, elective caesarean section->Option 36]] d. [[Wait for spontaneous labor until 38 weeks->Option 37]]

That's incorrect. Try again. Elective caesarean section is recommended for malpresentation of first twin. Therefore induction of labour and attempting vaginal delivery is not the best option for Ms Tess's fetuses (Her leading/first twin is breech). Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'attack', 'play') (track: 'attack', 'volume', 0.05)

That's wrong. Try again. 35-36 weeks is still very early for Ms Tess. Since there is no fetal or maternal compromise, we don't need to deliver at this period of gestation yet. Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'attack', 'play') (track: 'attack', 'volume', 0.05)

That's correct! Elective caesarean section is recommended in dichorionic twins with malpresentation of first twin by 38 weeks of gestation. However, you need to bear in mind that Ms Tess has pregnancy-induced hypertension. Therefore, you can consider delivery at around 37-38 weeks period of gestation. [[CONTINUE->PART 11]] Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> Read <a href="/High risk pregnancy/HYPITAT II abstract.pdf" target="_blank">(Abstract) Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial</a> (track: 'short success', 'play') (track: 'short success', 'volume', 0.20)

That's wrong. Try again. Elective caesarean section is recommended for malpresentation of first twin. Therefore vaginal delivery is not the best option for Ms Tess's fetuses because her first twin/leading twin is non-cephalic. Read <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> (track: 'attack', 'play') (track: 'attack', 'volume', 0.05)

Ms. Tess safely delivers her twins by elective caesarean section at 38 weeks of gestation. The twins' APGAR scores are 8/10 and 9/10, and they weigh 2.5 and 2.6kg respectively. Intraoperative and postoperative periods are unevenful and she is discharged after 3 days. <h4>Congratulations on your effective management and safe confinement of twins!</h4> For full list of recommended reading [[click here|reading materials]] <img src="/High risk pregnancy/twinsbaby.jpg"> (track: 'football', 'play') (track: 'football', 'volume', 0.05)

<b>Recommended reading:</b> 1. <a href="/High risk pregnancy/BMJ Assessment of abdominal pain in pregnancy.pdf" target="_blank">Assessment of abdominal pain in pregnancy (BMJ)</a> 2. <a href="/High risk pregnancy/BMJ Nausea and vomiting in pregnancy.pdf" target="_blank">Nausea and vomiting in pregnancy (BMJ)</a> 3. <a href="/High risk pregnancy/NICE twin-and-triplet-pregnancy.pdf" target="_blank">NICE guidelines on Twin and Triplet pregnancy</a> 4. <a href="/High risk pregnancy/Taylor TOAG 2000.pdf" target="_blank">Multiple Pregnancy, MJO Taylor and NM Fisk, The Obstetrician & Gynecologist, October 2000</a> 5. <a href="/High risk pregnancy/BMJ Premature labour - Emerging Rx.pdf#page=30" target="_blank" >Premature labour - Emerging treatments (BMJ)</a> 6. <a href="/High risk pregnancy/NICE preterm-labour-and-birth.pdf#page=13" target="_blank">NICE guidelines on materal steroids in pre-term labour (page 13)</a> 7. <a href="/High risk pregnancy/NICE hypertension-in-pregnancy-diagnosis-and-management.pdf" target="_blank">NICE guidelines on hypertension in pregnancy</a> 8. <a href="/High risk pregnancy/HYPITAT II paper.pdf" target="_blank">HYPITAT-II trial (Full paper)</a> <b>Recommended textbooks:</b> 1. Collins, S. et al. Oxford Handbook of Obstetrics and Gynaecology. Oxford University Press, 2016. 2. Kenny, L. (Ed.), Myers, J. (Ed.). Obstetrics by Ten Teachers. Boca Raton: CRC Press, 2017 <p>Back to <a href="https://medventure.neocities.org/Semester10/index.html">Home</a> (link: "Restart Game")[(reload:)]

firstbeat: http://nck.yolasite.com/resources/first_beat.mp3 witch: http://nck.yolasite.com/resources/wickedwitchlaugh.mp3 happykids: http://nck.yolasite.com/resources/happykids.mp3 lightapplause: http://nck.yolasite.com/resources/lightapplause.mp3 AAAGH1: http://nck.yolasite.com/resources/AAAGH1.mp3 lidcreak: http://nck.yolasite.com/resources/lidcreak.mp3 smirk: http://nck.yolasite.com/resources/Smirk%2B1.mp3 creakydoor: http://nck.yolasite.com/resources/creaky_door_4.mp3 attack: http://nck.yolasite.com/resources/attack.mp3 cheer: http://nck.yolasite.com/resources/cheer.mp3 clapping: http://nck.yolasite.com/resources/Clapping.mp3 yell: http://nck.yolasite.com/resources/Yell%2BMale%2BWahhh.mp3 Basic rock 135: http://nck.yolasite.com/resources/Basic_Rock_135.mp3 Success: http://nck.yolasite.com/resources/Collect-chimes-sound-effect.mp3 Baby Giggle 1: http://nck.yolasite.com/resources/Baby%2BGiggle%2B1.mp3 Bingo: http://nck.yolasite.com/resources/Bingo.mp3 Oh no: http://nck.yolasite.com/resources/Oh-no-sound-effect.mp3 Game over: http://nck.yolasite.com/resources/Game-over-ident.mp3 Punch 2: http://nck.yolasite.com/resources/punch2.mp3 Smirk 1: http://nck.yolasite.com/resources/Smirk%2B1.mp3 uh oh: http://nck.yolasite.com/resources/Uh%20Oh%20Baby-SoundBible.com-1858856676.mp3 sad: http://nck.yolasite.com/resources/Sad_Trombone-Joe_Lamb-665429450.mp3 bye bye: http://nck.yolasite.com/resources/bye_bye_son-Mike_Koenig-1260922981.mp3 oh no: http://nck.yolasite.com/resources/Oh-no-sound-effect.mp3 yess: http://nck.yolasite.com/resources/Yess-Fabio_Farinelli-187689388.mp3 wakeup: http://nck.yolasite.com/resources/Wake%20Up%20Call-SoundBible.com-1842390350.mp3 short success: http://nck.yolasite.com/resources/Short_triumphal_fanfare-John_Stracke-815794903.mp3 oh: http://nck.yolasite.com/resources/Oh-SoundBible.com-1138238845.mp3 no: http://nck.yolasite.com/resources/No-SoundBible.com-402355541.mp3 no dear: http://nck.yolasite.com/resources/No%20Dear-SoundBible.com-223285016.mp3 football: http://nck.yolasite.com/resources/Football_Crowd-GoGo-1730947850.mp3 music box: http://nck.yolasite.com/resources/Music_Box-Big_Daddy-1389738694.mp3 evil laugh: http://nck.yolasite.com/resources/Evil_Laugh_Male_6-Himan-1359990674.mp3 error: http://nck.yolasite.com/resources/Computer%20Error-SoundBible.com-1655839472.mp3 one cheer: http://nck.yolasite.com/resources/1_person_cheering-Jett_Rifkin-1851518140.mp3 where is mummy: http://nck.yolasite.com/resources/Wheres_My_Mummy-KillahChipmunl-717920453.mp3 wake up: http://nck.yolasite.com/resources/Wake%20Up%20Call-SoundBible.com-1842390350.mp3 goodbye: http://nck.yolasite.com/resources/Good%20Bye%20Female-SoundBible.com-894885957.mp3