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MIDWIFERY COMPREHENSIVE EXAM
Two products of impaired blood flow to the legs are thought to be linked to cramps? - Answers - Pyruvic acid Lactic acid Name two prevention techniques for nocturnal leg cramps - Answers - 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? - Answers - Deep Vein Thrombosis: Look for warm red tender swollen leg. Conflicting evidence supports taking which supplement for leg cramps? - Answers - Magnesium True or false. Women with NVP have lower rates of preterm births, low birth weight babies, congenital anomalies, and stillbirths. - Answers - True How does progesterone contribute to NVP? - Answers - Slows peristalsis and gastric emptying True/false: Leg cramps during pregnancy are not normal and should be reported immediately to provider. - Answers - 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 - Answers - A, B, C, D True/false: Dorsiflexion of the affected foot when a cramp begins helps to alleviate the pain. - Answers - True True/false: Magnesium supplements have been found to help with leg cramps. - Answers - 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. - Answers - False: Cramping may or may not accompany preterm labor. What are some of the contributing factors causing back pain during pregnancy?
A. The weight of a growing uterus B. A shift in her center of gravity C. Relaxation of sacroiliac ligaments D. All of the above - Answers - D True or False: Acupuncture is a holistic method that has not been correlated with effective pain relief. - Answers - False: One study found that 60% of women reported a decrease in back pain after receiving acupuncture. True or False: It is safe to receive chiropractic manipulation during pregnancy. - Answers - True: As long as a patient sees a licensed chiropractor, studies have shown manual manipulation to be effective. If dietary measures, lifestyle changes, and OTC remedies do not help with NVP, what medicine has shown to be effective with NVP? - Answers - 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. - Answers - 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. - Answers - False. Brushing your teeth can stimulate the gag reflex, aggravating nausea and vomiting. What pre-existing conditions can contribute to NVP? - Answers - H. pylori and GERD What is the most important differential diagnosis to rule out with leg cramps during pregnancy? - Answers - Deep vein thrombosis Why does Round Ligament pain occur? - Answers - As the uterus grows during pregnancy the ligaments stretch and thicken to accommodate and support it. These changes can occasionally cause pains. Where are Round Ligament pains felt? - Answers - Round Ligament pain is a sharp pain or jabbing feeling often felt in the lower belly or groin area on one or both sides. What are some of the triggers of Round Ligament pains? - Answers - Round Ligament pains can occur with position changes, getting up from a sitting, lying down, coughing, sneezing, and laughing. What non-pharmacological methods can be used to alleviate Round Ligament pains? - Answers - Avoid sudden movements Side lying relaxation positions Flex hips: Bend and flex before coughing, sneezing, or laughing.
What is the believed etiology of pregnancy rhinitis? - Answers - Increased hormone levels. Increased blood flow. True/False: Caffeinated fluids help relieve the symptoms of pregnancy rhinitis. - Answers - False. When does pregnancy rhinitis typically resolve? - Answers - 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? - Answers - Pregnancy rhinitis True/False Patients have found great long term success with using intranasal decongestants for pregnancy rhinitis. - Answers - False Which aspect of health is most affected by the breathing issues of pregnancy rhinitis? - Answers - Sleep Which two differential diagnoses must be carefully assessed with pregnancy rhinitis? - Answers - Allergic rhinitis and sinusitis True/False: Moderate levels of exercise worsen the swelling of the nasal mucosa during pregnancy rhinitis. - Answers - False At how many weeks does the NVP tend to disappear? - Answers - 20 weeks True or False. Sucking on hard candy in-between meals can improve nausea and vomiting? - Answers - True True or False. Eating a high protein meal before bed can decrease NVP? - Answers - True True or false. Acupressure is a CAM treatment for NVP that has been helpful for some women. - Answers - True Is it better for women with NVP to eat 3 large meals a day or several smaller meals? - Answers - Several smaller meals What is an important differential that a woman with NVP could experience that would require hospitalization? How would you differentiate between the two? - Answers - Hyperemesis Gravidarum; make sure the woman is not dehydrated and not losing excessive amounts of weight. Check lab values such as CMP, CBC, AST & ALT, UA. Monitor fetal wellbeing as well.
What is constipation? - Answers - Relaxation of the smooth muscle of the large bowel: Decreased peristalsis/motility Classified: <1 bowel movement in 3 days, and straining with painful defecation What hormone is causes constipation by slowing down muscle contractions, intestinal muscles, and bowel activity in pregnancy? - Answers - Progesterone What are three risk factors for constipation in pregnancy? - Answers - low fiber diet, lack of physical activity, and decreased intake of water. What helps the the absorption of iron to decrease constipation? - Answers - Taking iron with orange juice. When does round ligament pain usually occur? - Answers - Second trimester What is the etiology of Round ligament pain? - Answers - 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? - Answers - Hips and Groin What are some relief measures for round ligament pain? - Answers - - 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? - Answers - - Appendicitis
- Constipation
- Muscle strain or pain
- Symphysis Pubis Diathesis
- Ectopic pregnancy
- Kidney / UTI Infection
- Placental abruption
- Chorioamnionitis
- Preterm Labor What causes heartburn in pregnancy? - Answers - 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
Your patient has bacterial vaginosis. What might you expect in her exam? - Answers - May c/o odor, discharge, itching. Discharge, thin, malodorous, milky white, homogenous, adherent. pH greater than 4.5, positive whiff test, clue cells, no/few WBCs What is the normal vaginal pH? - Answers - 3.8-4. What conditions can cause the vaginal pH to rise above 4.5? - Answers - Trichomoniasis, Bacterial Vaginosis What condition can cause "strawberry cervix"? - Answers - Trichomoniasis, though candidiasis can cause inflammation/erythema What conditions can cause a positive whiff test? - Answers - Trichomoniasis, Bacterial vaginosis What condition presents with clue cells? - Answers - BV What conditions present with WBCs on wet-mount? - Answers - Trich (many), candidiasis (few), BV (very few, may not be present) What is hyperemesis? - Answers - 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? - Answers - 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? - Answers - Category B What pregnancy category is Phenergan? - Answers - Category C What pregnancy category is Reglan? - Answers - Category B What is the recommended dosage for zofran? - Answers - 4 - 8 mg IV or PO What is the recommended dosage for phenergan? - Answers - 12.5-25 mg PO/IM What is the recommended dosage for reglan? - Answers - 5 - 10 mg PO/IV What are risk factors for thyroid disorders in pregnancy? - Answers - 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? - Answers - Get a TSH in the first trimester--if greater than 2.5, draw a free T
What is the dosage for iodine supplementation? - Answers - 250 mcg/day in pregnancy and when BF (150 mcg if not) What is a normal TSH level in the first trimester? - Answers - .1-2. What is a normal TSH level in the second trimester? - Answers - .2- 3 What is a normal TSH level in the third trimester? - Answers - .3- 3 How are free T3/T4 values altered in pregnancy - Answers - They're not, at any gestation--refer to normal lab values How are total T4 values altered in pregnancy? - Answers - They are normally elevated in the first and second trimester, and normalize in the third How are total T3 values altered in pregnancy? - Answers - They are normally elevated in all trimesters How does hyperthyroidism occur in pregnant women? - Answers - 1. Graves Disease (antibodies stimulate the thyroid cells to produce more thyroid hormone)
- hCG mimics TSH and causes transient hyperthyroidism (should resolve by 18- 20 weeks) What are s/s of hyperthyroidism? - Answers - 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? - Answers - Increased SAB, LBW, PTL, IUFD, IUGR, increased incidence of PIH, maternal thyroid storm, neonatal hyperthyroidism, maternal HF What lab values would you expect to find in a patient with hyperthyroidism? - Answers - Low TSH, elevated free T4, T If due to Graves, positive thyroid receptor antibodies What causes hypothyroidism? - Answers - Hashimoto's (chronic autoimmune disease), ablation therapy, iodine deficiency What are s/s of hypothyroidism? - Answers - fatigue, depression, cold intolerance, dry skin/hair, hair loss, constipation, muscle cramps, weight gain, bradycardia
How would you monitor a mom with pre-existing diabetes though her pregnancy? - Answers - 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? - Answers - If >20% of a woman's post-prandial readings are greater than 120 When can glyburide be given to pregnant women? - Answers - In the 2nd and 3rd trimesters Is considered pregnancy category B What is the recommended mode of delivery for a woman with GDM? - Answers - 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? - Answers - 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? - Answers - .25 mg SubQ x3 doses (q 20 min, if indicated) Hold for clinical tachycardia What is the dosing regimen for Nifedipine? - Answers - 10 - 30 mg PO Q8h What is the dosing regimen for Indomethacin? - Answers - 25 - 50 mg PO Q8h What is the dosing regimen for Dexamethasone? - Answers - 6mg IM Q 12 hours x 4 doses What is the dosing regimen for Betamethasone? - Answers - 12 mg IM q 24 hours ( doses) What is the dosing regimen for 17-hydroxyprogesterone? - Answers - 250 mg IM weekly, starting at 16-20 weeks, ending at 36-37 weeks. Contraindicated with uncontrolled HTN, hx thromboembolism, BrCa, liver disease When is FFN testing done? - Answers - Between 24-34 weeks when suspicious of PTL
Test only valid if pelvic rest for previous 24 hours What is the ToC in a patient with a PCN allergy who has unknown or positive GBS status? - Answers - Clindamycin (900 mg IV Q8h) or erythromycin (500 mg IV Q6h) If GBS susceptibility testing is unavailable, and the patient has a confirmed PCN allergy, what is ToC? - Answers - Vancomycin (1 gram IV Q12H) What is the PCN dosing protocol for GBS prophylaxis? - Answers - 5 million units IV (loading dose) 2.5 million units IV every 4 hours until delivery What is the ampicillin dosing protocol for GBS prophylaxis? - Answers - 2 gram IV (loading dose) 1 gram IV every 4 hours until delivery How is post-dates pregnancy monitored? - Answers - Daily: fetal kick counts Twice weekly: NST/BPP, AFI Weekly: CST What is dosage protocol for cytotec? - Answers - PV: 25 mcg every 3-6 hours x 5 doses PO: 50-100 mcg every 3-6 hours x 5 doses What is dosage protocol for cervidil? - Answers - PV: 10 mg suppository, removed after 12 hours When is amniotomy recommended? - Answers - 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? - Answers
- 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? - Answers - 7 - 7.
Treated with D&C or cytotec as appropriate What is incomplete abortion? How is it treated? - Answers - Uterine contents are only partially expulsed, results in pain and bleeding Treated with complete uterine evacuation (D&C or cytotec), antibiotics (if fever present), and oral methergine (if bleeding persistent) What is complete abortion? How is it treated? - Answers - The uterus is completely emptied of products of conception Requires no treatment in the absence of complications--observe carefully What is a missed abortion? How is it treated? - Answers - An IUFD that has not yet been expulsed (cervix remains firm and closed) Treated by uterine evacuation: D&C, D&E, cytotec, or observation What is septic abortion? How is it treated? - Answers - An IUFD that results in endometritis Treated with uterine evacuation and IV antibiotics (broad-specturm, but may be targeted for bowel or vaginal flora) What constitutes "recurrent abortion"? - Answers - 3 or more SABs What is the "work-up" for a patient with recurrent abortion? - Answers - 1. US for uterine anomalies
- Karotyping of both parents, for chromosomal abnormalities
- Immunologic factor testing What conditions are considered contraindications to prostaglandin use? - Answers - Asthma, glaucoma, HTN, epilepsy What are possible contraindications to therapeutic abortion? - Answers - Severe anemia, known bleeding disorders, severe asthma, heart disease, epilepsy How late in pregnancy may medical abortion be offered? - Answers - Up to 9 weeks gestation What dosage of medications are used in a medical abortion (with mifepristone)? - Answers - 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? - Answers - 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)? - Answers
- 50 mg methotrexate IM or PO, then 800 mcg cytotec PO in 3-7 days How long is pelvic rest recommended post-EAB? - Answers - 2 weeks How long must a back-up method be used after an Essure procedure? - Answers - 3 months How long does a vastectomy take to become effective? - Answers - 12 weeks (recommended semen analysis after 12 weeks/20 ejaculations) Describe 3 contraindications to VBAC - Answers - 1. Previous classical/T-shaped incision
- Extensive transfundal surgery (like a myomectomy)
- Previous uterine rupture What are s/s of intrapartum uterine rupture? - Answers - 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? - Answers - Mechanically ONLY. NO PROSTAGLANDINS. What is the lifetime prevalence of breast cancer? - Answers - 1 in 8 Describe risk factors for breast cancer: - Answers - 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? - Answers - This is a SERM, given to compete with estradiol on estrogen receptors. What is the MOA of Raloxifene? - Answers - This is a SERM, given to compete with estradiol on estrogen receptors.
- The ductus venosus moves that oxygenated blood past the liver and into the fetal heart via the inferior vena cava
- Blood is shunted from the IVC to the right atrium, then the left atrium via the PFO.
- Ventricular contractions pump blood to the pulmonary artery, which is connected via the ductus arteriosus to the descending aorta. 4a. The ventricular contractions also pump blood into the aortic arch--this blood came from the vein via the PFO, is going to the brain, and will return to the heart via the SVC.
- The descending aorta supplies the kidney and intestines, and returns blood to the placenta via the umbilical arteries. When is surfactant initially secreted by the fetal lungs? - Answers - 20 weeks gestation When are in-utero breathing movements detected? - Answers - 11 weeks Fetal hemoglobin has a higher affinity for oxygen molecules than adult hemoglobin (any type). Why is this advantageous? - Answers - Fetal circulation is purple. Adult circulation is defined by hard lines of oxygenated/deoxygenated capillary beds and tissues (like alveolar lung fields), with little mixing of oxygenated/deoxygenated blood. Fetal circulation is largely mixed, and at any given time fetal blood is tasked with delivering the same oxygen saturation to tissues in an environment with lower oxygen partial pressure. And you have to be better at hanging on to it if you're doing that. What is the driving force behind circulation changes associated with birth? - Answers - the removal of the placenta (a low-pressure oxygenation organ) from the fetal system. This causes an increase in systemic blood pressure s/t a lack of arterial return, which increases pulmonic vascular resistance (which has been building throughout gestation). The increase in BP causes the ductus arteriosis to close--so blood pumped through the pulmonary artery from the right ventricle can now only go to the lungs, and blood pumped from the left ventricle can now only go to the brain/body. ...which means the left ventricle's CO increases by 200% in less than a minute. What fetal shunts close with birth? - Answers - Ductus venosus, ductus arteriosis, foramen ovale DV--means the fetus gets no oxygenated blood from the placenta (stimuli: cord clamping)
DA--means ventricles now have separate functions (stimuli: Increased systemic BP) FO--means the atria no longer communicate with mixed blood supply (stimuli: pulmonary venus return from newly-perfused lungs) Approximately what percentage of fluid is removed from the lungs in an SVD? - Answers - 25 - 33% of fluid in the lungs at birth is immediately replaced by air, through respiration The rest is absorbed over the next 24 hours across the lung epithelium Approximately what percentage of newborns require breathing assistance at birth? - Answers - Approximately 10%, with 1% requiring extensive resuscitation. The goal, always, is to intervene within the period of primary apnea, if applicable. When should a baby be suctioned post-birth? - Answers - If they are apneic, cyanotic, or have an airway obstruction. Otherwise decreases initial oxygenation, esp if co-occuring with placental removal. Sit on the bulb. You are resuscitating an infant who is gasping, with heart rate greater than 100. What is your initial step? - Answers - PPV and re-eval in 30 seconds. You are resuscitating an infant with a heart rate less than 60 beats per minute. What is your initial step? - Answers - Chest compressions with associated PPV, while considering intubation When is neonatal intubation indicatedd? - Answers - For initial suction of non-vigorous meconium-stained newborns (...maybe) if bag-mask ventilation ineffective or prolonged/will become ineffective In the event of chest compressions for extended period In "special circumstances" (VLBW, DH) When is NRP discontinued? - Answers - After 10 minutes of no cardiac activity. Do not screw this up. In the event of extreme prematurity. In the face of abnormalities grossly incompatible with life.
- Evidence of metabolic acisosis (pH less than 7, BD greater than 12)
- Early onset of severe or moderate neonatal encephalopathy (infants greater than 34 weeks)
- CP of spastic quadriplegic or dyskinetic classification
- Exclusion of other explainable etiology (trauma, infection, coagulation disorder, genetics) Describe the "transition stages" in the first 8 hours of life. - Answers - 1. "first reactive period"--minutes 0-30, characterized by alertness, immediate tachycardia, irregular respirations, and absent bowel sounds.
- "decreased responsiveness"--minutes 30-120, characterized by bowel sounds, stabilizing heart rate and slowing respirations
- "second reactive period"--hours 2-8, characterized by gagging, exaggerated responses, crying, start of cluster-feeding cycles What are the 4 cardinal signs of respiratory distress? - Answers - Grunting Nasal flaring Retractions Tachypnea What is TTN? - Answers - Transient tachypnea of the newborn--occurs when fetal fluid is retained in the lungs, often noted when infant remains tachypnic (100 or more breaths per minute) with 1 or more additional signs of respiratory distress most common in LTCS infants Treated with short-term oxygen therapy What is the "safe range" for infant temperature? - Answers - 97.7-99.5 degrees Fahrenheit 36.5-37.5 degrees Celcius There are 4 major ways heat is lost. How do these relate to routine infant care (in most delivery spaces)? - Answers - Convection heat loss--air is circulated around the baby Radiation--cold or room-temperature items are frequently used to touch the baby Conduction--the baby is placed on a cold scale
Evaporation--the baby is bathed early (NOTE: the fetal fluid in utero is about 0. degrees celcius higher than maternal temperature, and the post-birth drop is precipitous) In most cases, the best thermoregulatory option is to keep the infant dry and on top of mom. You are caring for an infant who has not yet passed meconium. At what point is a full work-up indicated? - Answers - At 36 hours, though 95% of infants prove patency at 24 hours You are caring for an infant who has not yet voided. At what point is a full work-up indicated? - Answers - At 24 hours Early urination is not dependent on fluid intake When is a frenotomy indicated? - Answers - When a lingual frenulum is causing consistently poor latch, as evidenced by sore maternal nipples, visual evidence of poor feeding, and decreased voids/stooling/weight gain You are caring for an infant who's mother has tested positive for HBsAG. How do you treat? - Answers - Treat the infant with HepB and HBIG within 12 hours of birth Many hospitals recommend "eyes and thighs" to newborns following birth. What does this refer to? - Answers - 3 things:
- 0.5% erythromycin in each eye (1 cm ribbon) 2 hours after birth
- 1.o mg of vitamin K IM (if birth weight over 1500 grams) within 6 hours of birth
- HepB vaccination (within 12 hours if maternal status unknown, before discharge if negative) You are preparing to give a vitamin K injection to a 4-hour old neonate, when the mother asks about the relative efficacy of oral vs. parenteral Vitamin K. What can you tell her? - Answers - Oral vitamin K is less effective at preventing VKDB from 2- 12 weeks, but has never been associated with childhood cancer incidence When is the newborn metabolic screen (PKU) done? - Answers - At 24-72 hours of life (preferably after first feeding) When are newborn hearing screens done? - Answers - Prior to hospital discharge, OR within the first month of life. In the event of an abnormal screen, infant MUST be re-screened in an office setting prior to 1 month of life.
