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Midwifery Comprehensive Exam
Two products of impaired blood flow to the legs are thought to be linked to cramps?
- correct answer Pyruvic acid Lactic acid Name two prevention techniques for nocturnal leg cramps - correct answer Hydration, stretching, avoid long periods of sitting or standing, warm baths, exercise What is the most important differential diagnosis to rule out when a pregnant patient comes in with complaints of leg cramping? - correct answer Deep Vein Thrombosis: Look for warm red tender swollen leg. Conflicting evidence supports taking which supplement for leg cramps? - correct answer Magnesium True or false. Women with NVP have lower rates of preterm births, low birth weight babies, congenital anomalies, and stillbirths. - correct answer True How does progesterone contribute to NVP? - correct answer Slows peristalsis and gastric emptying If dietary measures, lifestyle changes, and OTC remedies do not help with NVP, what medicine has shown to be effective with NVP? - correct answer Antiemetics such Zofran (Ondansetron). Note: Not mentioned in Varney's True of False. Effective therapy for NVP will always remain the same for a woman throughout her pregnancy and subsequent pregnancies. - correct answer False. Effectiveness of therapy may fluctuate over the course of pregnancy and varies greatly from pregnancy to pregnancy.
True or False. To combat nausea during pregnancy, one should brush their teeth immediately after they eat. - correct answer False. Brushing your teeth can stimulate the gag reflex, aggravating nausea and vomiting. What pre-existing conditions can contribute to NVP? - correct answer H. pylori and GERD What is the most important differential diagnosis to rule out with leg cramps during pregnancy? - correct answer Deep vein thrombosis True/false: Leg cramps during pregnancy are not normal and should be reported immediately to provider. - correct answer False. Leg cramps are completely normal during pregnancy and occur more frequently during the 2nd and 3rd trimesters. How can your pregnant patient prevent leg cramps (select all that apply)? a. Walking or other exercise b. Drink plenty of water c. Stretch before bed d. Taking a warm bath e. Sitting for long periods of time - correct answer A, B, C, D True/false: Dorsiflexion of the affected foot when a cramp begins helps to alleviate the pain. - correct answer True True/false: Magnesium supplements have been found to help with leg cramps. - correct answer False. Research is mixed and taking magnesium supplements seem to have little effect on preventing leg cramps in pregnant women. True or False: Back pain may be a sign of preterm labor only if cramping is present. - correct answer False: Cramping may or may not accompany preterm labor. What are some of the contributing factors causing back pain during pregnancy?
Round Ligament pains lasting for more than 1 minute is normal. - correct answer False: Round Ligament pain should only last for a few seconds. See your health care provider for pains lasting longer or not alleviate after a short rest. What are "dermatoses of pregnancy"? - correct answer Dermatoses of pregnancy are rare severe pruritic inflammatory skin diseases that are specific to women during pregnant or postpartum period. MATCH the dermatoses of pregnancy with its clinical presentation.
- Pruritic Urticarial papules and plaques of preganancy
- Pemphigiod gastationis
- Intrahepatic cholestasis of pregnancy
- Atopic eruption of pregnancy A. Red painful itchy rash that begins as erythematous papules within the striae B. Eczematous type on face, neck and flexure surfaces C. Papules that begins around the umbilicus and spreads centrifugally. D. Intense pruritus on palms of hands and soles of feet, but with an absence of lesions. - correct answer 1. Pruritic Urticarial papules and plaques of preganancy= A
- Pemphigiod gastationis=C
- Intrahepatic cholestasis of pregnancy=D
- Atopic eruption of pregnancy=B Pemphigoid gestationis, which begins as plaques or papules around the womans's umbilicus and spreads centrifugally. TRUE or FALSE. The plaques and papules usually spreads to the face, scalp and mucus membrane also. - correct answer FALSE. In pemphigoid gestationis, the face, scalp and mucus membrane are UNAFFECTED. Your patient Ms G is in her third trimester and is complaining of intense itching, dark colored urine and clay colored stools. You suspect which dermatoses of pregnancy? A. Pruritic Urticarial papules and plaques of preganancy B. Pemphigiod gastationis
C. Intrahepatic cholestasis of pregnancy D. Atopic eruption of pregnancy - correct answer C. Intrahepatic cholestasis of pregnancy Pruritic Urticarial papules and plaques of pregnancy usually presents: A. Before 12 weeks gestation B. Early in the second trimester C. Late in the third trimester - correct answer C. Late in the third trimester True/False: Although it often appears during the first trimester, pregnancy rhinitis can occur at any point during pregnancy. - correct answer True. What is the believed etiology of pregnancy rhinitis? - correct answer Increased hormone levels. Increased blood flow. True/False: Caffeinated fluids help relieve the symptoms of pregnancy rhinitis. - correct answer False. When does pregnancy rhinitis typically resolve? - correct answer After delivery- typically disappears within 2 weeks after delivery. What common discomfort occurs in about 30% of pregnancies and involves the swelling of the nasal mucosa? - correct answer Pregnancy rhinitis True/False Patients have found great long term success with using intranasal decongestants for pregnancy rhinitis. - correct answer False Which aspect of health is most affected by the breathing issues of pregnancy rhinitis? - correct answer Sleep Which two differential diagnoses must be carefully assessed with pregnancy rhinitis? - correct answer Allergic rhinitis and sinusitis
What helps the the absorption of iron to decrease constipation? - correct answer Taking iron with orange juice. When does round ligament pain usually occur? - correct answer Second trimester What is the etiology of Round ligament pain? - correct answer Round ligament pain probably results from this stretching and possibly from the pressure of the increasingly heavy uterus on the ligaments Where is round ligament pain felt? - correct answer Hips and Groin What are some relief measures for round ligament pain? - correct answer - Acetaminophen 325-650 q4-6 or paracetamol. -Pelvic tilt exercises, re-positioning into positions that place less stress on the ligaments, and wearing a maternity support or girdle. -Slow position changes. -Walk daily - 30 min. -Stretching- Downward Dog, Bring knees to chest. -Lie on side - one pillow under belly for support, one pillow between legs -Heat, warm bath What are some differential diagnoses for round ligament pain? - correct answer - Appendicitis -Constipation -Muscle strain or pain -Symphysis Pubis Diathesis -Ectopic pregnancy -Kidney / UTI Infection -Placental abruption -Chorioamnionitis -Preterm Labor
What causes heartburn in pregnancy? - correct answer The relaxation of the lower esophageal sphincter (s/t high levels of estrogen/progesterone), and the upward pressure of the uterus on stomach/intestines. Digested food is pushed from the stomach into the lower esophagus, causing an uncomfortable burning Approximately what percentage of women are affected by heartburn in the third trimester of pregnancy? - correct answer 72% Approximately what percentage of women are affected by heartburn in the second trimester of pregnancy? - correct answer 39% Approximately what percentage of women are affected by heartburn in the first trimester of pregnancy? - correct answer 22% What medications are safe to use to treat or prevent heartburn? - correct answer First try using antacids containing magnesium, calcium, aluminum based (Maalox, mylanta, tums...) If not effective, move onto H2 receptor antagonists (Ranitidine (Zantac), cimetidine (Tagamet)). Sodium bicarbonate antacids (Alka-Seltzer) should be avoided. What are behavior modifications that can help relieve or prevent heartburn? - correct answer smaller meals avoid drinking large amounts of liquid with meals avoid laying down right after eating wear nonrestrictive clothing around the waist especially. What is important to rule out when a pregnant woman complains of chest pain? - correct answer Myocardial infarction! Also: pulmonary embolism and asthma attack. What are differential diagnoses for heartburn? - correct answer hiatal hernia (need endoscopy to confirm)
What condition presents with clue cells? - correct answer BV What conditions present with WBCs on wet-mount? - correct answer Trich (many), candidiasis (few), BV (very few, may not be present) What is hyperemesis? - correct answer N/V that persists beyond the first trimester of pregnancy. May result in >5% weight loss, and/or fluid/electrolyte imbalance What are the risk factors for hyperemesis? - correct answer History of hyperemesis, pre-existing GI disorders (GERD, PUD, cholecystitis, gastroenteritis), pre-existing psychiatric disorders, hyperthyroidism, high HCG (due to molar pregnancy or multiple gestation) What pregnancy category is Zofran? - correct answer Category B What pregnancy category is Phenergan? - correct answer Category C What pregnancy category is Reglan? - correct answer Category B What is the recommended dosage for zofran? - correct answer 4-8 mg IV or PO What is the recommended dosage for phenergan? - correct answer 12.5-25 mg PO/IM What is the recommended dosage for reglan? - correct answer 5-10 mg PO/IV What are risk factors for thyroid disorders in pregnancy? - correct answer Family/personal history, history of HEENT radiation, iodine insufficiency/malnutrition, Type I DM, morbid obesity, age > 30, history of recurrent miscarriage How would you screen a patient with risk factors for thyroid disease? - correct answer Get a TSH in the first trimester--if greater than 2.5, draw a free T
What is the dosage for iodine supplementation? - correct answer 250 mcg/day in pregnancy and when BF (150 mcg if not) What is a normal TSH level in the first trimester? - correct answer .1-2. What is a normal TSH level in the second trimester? - correct answer .2- What is a normal TSH level in the third trimester? - correct answer .3- How are free T3/T4 values altered in pregnancy - correct answer They're not, at any gestation--refer to normal lab values How are total T4 values altered in pregnancy? - correct answer They are normally elevated in the first and second trimester, and normalize in the third How are total T3 values altered in pregnancy? - correct answer They are normally elevated in all trimesters How does hyperthyroidism occur in pregnant women? - correct answer 1. Graves Disease (antibodies stimulate the thyroid cells to produce more thyroid hormone)
- hCG mimics TSH and causes transient hyperthyroidism (should resolve by 18- weeks) What are s/s of hyperthyroidism? - correct answer Weight loss, nervousness, tachycardia, tremors, brittle hair May be missed/covered with an anxiety diagnosis--if you ever put someone on an SSRI, draw a TSH What complications are associated with maternal hyperthyroidism? - correct answer Increased SAB, LBW, PTL, IUFD, IUGR, increased incidence of PIH, maternal thyroid storm, neonatal hyperthyroidism, maternal HF
Retest at 6-week f/u What is postpartum thyroiditis? - correct answer Abnormal TSH level in the first 12 months without nodules or TRA antibodies. Mimics normal postpartum s/s, but with more pronounced fatigue and depression (may also occur post-AB) What are risk factors for diabetes in pregnancy? - correct answer Morbid obesity, personal history, PCOS, family history, glycosuria > +1 twice Describe normal diabetes screening in pregnant women? - correct answer Screened at 24-28 weeks (1 hour screen + 3 hours test PRN, or a single 2-hour test) May also screen early if history or s/s is suspicious Repeat testing in 4 weeks for women who pass OGTT before 26 weeks but have a previous abnormal value How would you teach a mom with GDM to monitor her glucose? - correct answer She will keep a daily glucose log, measuring glucose 4x/day until stable (fasting, 2 h post-prandial, HS) After stable, may check 4x/day twice a week, unless on meds In third trimester: needs weekly NST/BPP How would you monitor a mom with pre-existing diabetes though her pregnancy? - correct answer 1st trimester: A1C, evaluate kidney and thyroid function 2nd trimester: A1C, evaluate kidney function, fetal anatomy scan (fetal echo if A1C was elevated in first trimester) What lab values would necessitate initiating insulin therapy? - correct answer If >20% of a woman's post-prandial readings are greater than 120
When can glyburide be given to pregnant women? - correct answer In the 2nd and 3rd trimesters Is considered pregnancy category B What is the recommended mode of delivery for a woman with GDM? - correct answer medicated/non-diet controlled: Induce @ 40 w All others, induce only if concerned about very poor management or non-reassuring fetal status How is blood sugar monitored postpartum? - correct answer If glucose was poorly- controlled in pregnancy, keep daily log for 1 week postpartum Otherwise, screen at 6w checkup (fasting or OGTT) What is the dosing regimen for terbutaline? - correct answer .25 mg SubQ x3 doses (q 20 min, if indicated) Hold for clinical tachycardia What is the dosing regimen for Nifedipine? - correct answer 10-30 mg PO Q8h What is the dosing regimen for Indomethacin? - correct answer 25-50 mg PO Q8h What is the dosing regimen for Dexamethasone? - correct answer 6mg IM Q 12 hours x 4 doses What is the dosing regimen for Betamethasone? - correct answer 12 mg IM q 24 hours (2 doses)
PO: 50-100 mcg every 3-6 hours x 5 doses What is dosage protocol for cervidil? - correct answer PV: 10 mg suppository, removed after 12 hours When is amniotomy recommended? - correct answer Never, really. But if the woman is dilated more than 4 cm, early amniotomy is not associated with adverse outcomes and may shorten overall labor time by about 2 hours (parity- dependent) Your patient wants to use blue cohosh to induce labor. What do you tell her? - correct answer Bad idea (associated with perinatal stroke and acute MI)--she probably wants black cohosh. Other non-pharmacological options: Castor oil, evening primrose, raspberry leaf tea, nipple stimulation, sex What is the pH of amniotic fluid? - correct answer 7-7. What narcotics are used in therapeutic rest medication regimens? - correct answer Morphine (5-10 mg IM hs x1) Nubain (10 mg IM hs x1) Demerol (50-100 mg IM hs x1) What potentiators are used in therapeutic rest medication regimens? - correct answer Phenergan 25 mg IM hs x Vistaril 25 mg IM hs x What sleep aids are used in therapeutic rest medication regimens? - correct answer Ambien 5 mg PO hs x Benadryl 50 mg PO hs x
When is therapeutic rest indicated? - correct answer In protracted prodromal labor, before 6 cm When is amnioinfusion indicated? - correct answer In the presence of variable decels (ONLY) What is dosage protocol for amnioinfusion? - correct answer 500-800 mL NS or LR over 30-60 minutes, then 100-200 mL/hr What antibiotics are routinely used for chorioamniotitis treatment? - correct answer Ampicillin (2 g IV loading dose, then 1-2 grams IV Q4h) Gentamycin (80 mg IV Q8h) Clindamycin (900 mg IV Q8h) What is the incidence of SAB? - correct answer 15-20% of pregnancies are lost in the first 20 weeks (80% of these occur in the first trimester) What is "threatened abortion"? How is it diagnosed and treated? - correct answer Uterine bleeding and cramping not associated with cervical changes Diagnosed by quantitative hCG and U/S Treated by pelvic rest x2-3 weeks. Bed rest not evidence-supported, but commonly recommended. What are common causes of first-trimester bleeding? - correct answer 1. Pregnancy abnormalities: ectopic placement or molar pregnancy
- Cervical abnormalities: polyps (most commonly presents with post-coital bleeding) or cervicitis
What conditions are considered contraindications to prostaglandin use? - correct answer Asthma, glaucoma, HTN, epilepsy What are possible contraindications to therapeutic abortion? - correct answer Severe anemia, known bleeding disorders, severe asthma, heart disease, epilepsy How late in pregnancy may medical abortion be offered? - correct answer Up to 9 weeks gestation What dosage of medications are used in a medical abortion (with mifepristone)? - correct answer 600 mg mifepristone PO, then 400 mcg cytotec PO (alternative protocol: 200 mg mifepristone PO, then 800 mcg cytotec PV) What are contraindications to mifepristone? - correct answer Suspected ectopic pregnancy, current IUD, concurrent long-term corticosteroid use, coagulation disorders or anticoagulant therapy What dosages of medications are used in a medical abortion (methotrexate)? - correct answer 50 mg methotrexate IM or PO, then 800 mcg cytotec PO in 3-7 days How long is pelvic rest recommended post-EAB? - correct answer 2 weeks How long must a back-up method be used after an Essure procedure? - correct answer 3 months How long does a vastectomy take to become effective? - correct answer 12 weeks (recommended semen analysis after 12 weeks/20 ejaculations) Describe 3 contraindications to VBAC - correct answer 1. Previous classical/T-shaped incision
- Extensive transfundal surgery (like a myomectomy)
- Previous uterine rupture What are s/s of intrapartum uterine rupture? - correct answer 1. Sudden nonreassuring FHTs, acute ctx changes
- Loss of fetal station, or fetal parts easily palpated
- Increased vaginal bleeding
- Severe abdominal/back pain How should a woman's cervix be ripened, if she has a history of cesarean section? - correct answer Mechanically ONLY. NO PROSTAGLANDINS. What is the lifetime prevalence of breast cancer? - correct answer 1 in 8 Describe risk factors for breast cancer: - correct answer 1. Increased age
- BRCA 1/BRCA2 mutations
- Family hx (1st degree relative)
- Early menarche
- Delayed first childbearing
- Recent use of postmenopausal estrogens and progestins What is the MOA of Tamoxifen? - correct answer This is a SERM, given to compete with estradiol on estrogen receptors. What is the MOA of Raloxifene? - correct answer This is a SERM, given to compete with estradiol on estrogen receptors. What are the differences between Raloxifene and Tamoxifen? - correct answer Raloxifene is approved by the FDA for reducing vertebral fractures and breast cancer risk
