ASIPP Pregnancy and Nursing Questions Flashcards
1
Q
1600….weakness of the abductor pollicis brevis, the opponens
pollicis, and the fi rst two lumbrical muscles. Sensation
was decreased over the lateral palm and the volar
aspect of the fi rst three digits. Numbness and tingling
were markedly increased over the fi rst three digits and
the lateral palm when the wrist was held in fl exion for
30 s. The symptoms suggest damage to
A. The radial artery
B. The median nerve
C. The ulnar nerve
D. Proper digital nerves
E. The radial nerve
A
- Answer: B
Explanation:
(Moore, Anatomy, 4/e, pp 775, 821-822.)
The patient has a classic case of carpal tunnel syndrome, in
which the median nerve is compressed as it passes through
the carpal tunnel formed by the fl exor retinaculum in the
wrist. Evidence for involvement of the median nerve is
weakness and atrophy of the thenar muscles (abductor
pollicis brevis, opponens pollicis) and lumbricals 1 to 3.
Sensory defi cits also follow the distribution of the median
nerve. The median nerve enters the hand, along with the
tendons of the superfi cial and deep digital fl exors, through
a tunnel framed by the carpal bones and the overlying
fl exor retinaculum. Symptoms are worse in the early
morning and in pregnancy because of fl uid retention,
resulting in swelling that entraps the median nerve. Flexing the wrist for an extended period exaggerates the
paresthesia (“Phelan’s” sign) by increasing pressure on the
median nerve.
Neither the ulnar nerve, radial nerve, nor radial artery
passes through the carpal tunnel. The ulnar nerve supplies
the third and fourth lumbricals and only the short
adductor of the thumb. The radial nerve innervates mostly
long and short extensors of the digits and the dorsal
aspect of the hand. Proper digital nerves lie distal to the
carpal tunnel but are only sensory.
Source: Klein RM and McKenzie JC 2002.
2
Q
1601. What is the most critical period for fetal exposure to a drug? A. 1st week of pregnancy B. 5th week of pregnancy C. 13th week of pregnancy D. 24th week of pregnancy E. 32nd week of pregnancy
A
- Answer: B
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87)
The most critical period is in the fi rst trimester,
specifi cally weeks 4 through 10 during pregnancy.
Source: Shah RV
3
Q
- An infant born at 35 weeks’ gestation to a mother with
no prenatal care is noted to be jittery and irritable, and
is having diffi culty feeding. Child had coarse tremors
on examination. The nurses report a high-pitched cry
and note several episodes of diaarhea and emesis. It is
suspected that the infant is withdrawing from
A. Alcohol
B. Marijuana
C. Heroin
D. Cocaine
E. Tobacco
A
- Answer: C
Explanation:
Reference: Behrman, 16/e, p 530. Rudolph, 21/e, p 2196.
Infants born to narcotic addicts are more likely than other
children to exhibit a variety of problems, including
perinatal complications, prematurity, and low birth
weight. The onset of withdrawal commonly occurs during
an infant’s fi rst 2 days of life and is characterized by
hyperirritability and coarse tremors, along with vomiting,
diarrhea, fever, high-pitched cry, and hyperventilation;
seizures and respiratory depression are less common. The
production of surfactant can be accelerated in the infant of
heroin-addicted mother.
Source: Yetman and Hormann
4
Q
1603. In which stage of pregnancy do major pharmacokinetic changes of lithium metabolism occur? A. Postpartum and during breast-feeding B. At delivery C. Third trimester D. Second trimester E. First trimester
A
- Answer: B
Explanation:
The maternal lithium level must be monitored closely
during pregnancy and especially after delivery because of
the signifi cant change in renal function with massive fl uid
shift that occurs over that time period. Lithium should be
discontinued shortly before delivery, and the drug should
be restarted after an assessment of the usually high risk of
postpartum mood disorder and the mother’s desire to
breast-feed her infant.
Source: Laxmaiah Manchikanti, MD
5
Q
- True statements about addiction during pregnancy is:
A. The prevalence of substance abuse during pregnancy is
signifi cant
B. Women addicted to drugs always have regular menstrual
cycles
C. Women addicted to drugs are unable to conceive
D. A pregnant woman generally fi nds out that she is pregnant
within a few weeks
E. Less than 2% of pregnant women use illegal substances
during pregnancy
A
- Answer: A
Explanation: - The prevalence of substance use during pregnancy is
signifi cant. In a study of women in a city hospital, 59% admitted to consumption of alcohol during pregnancy. - Women addicted to alcohol or other drugs may have
irregular menstrual cycles, but still be able to conceive. - A study found that 11% of pregnant women were using
illegal substances, with cocaine as the drug of choice in
75%. - It may be several months before an addicted woman
realizes that she is pregnant. - Women of low socioeconomic status are perceived to be
at increased risk of perinatal substance abuse and
addiction, but there is little difference in the prevalence of
drug and alcohol use among women enrolling in prenatal
care in public clinics 16% and private offi ces 13%.
Further, rates for black and white women are virtually
identical (14% and 15%).
6
Q
- A newly delivered mother wants to breast-feed her
healthy infant, but that her obstetrician was concerned
about one of the medicines she was taking. Which
of the woman’s medicines, listed below, is clearly
contraindicated in breast-feeding?
A. Ibuprofen as needed for pain or fever
B. Labetolol for her chronic hypertension
C. Lithium for her bipolar disorder
D. Carbamazepine for her seizure disorder
E. Acyclovir for her HSV outbreak
A
- Answer: C
Explanation:
Reference: Behrman, 16/e, p 460. McMillan, 3/e, p477.
Most medications are secreted to some extent in breast
milk. Some lipid-soluble medications may be concentrated
in breast milk. Although the list of contraindicated
medications is short, caution should always be exercised
when giving a medication to a breast-feeding woman.
Medications that are clearly contraindicated include
lithium, cyclosporin, antineoplastic agents, illicit drugs
including cocaine and heroin, ergotamines, and
bromocriptine (which suppresses lactation). Although
some suggest that oral contraceptives may have a negative
impact on milk production, the association has not been
proven conclusively. In general, antibiotics are safe, with
only a few exceptions. While sedatives and narcotic pain
medications are probably safe, the infant must be observed
carefully for sedation. All of the medications listed in the
question are considered safe, except for lithium.
Source: Yetman and Hormann
7
Q
- During pregnancy, treatment of migraine may include:
A. Ergot/caffeine
B. DHE/Reglan
C. Cafergot
D. Amitriptyline
E. Usually not necessary as migraine frequency and severity
is reduced, and the above-listed drugs are contraindicated
A
- Answer: E
Explanation:
Acetaminophen and meperidine can be recommended for
use during pregnancy; however, any drug presents
potential risk during pregnancy. Aspirin may prolong
labor, cause blood loss during pregnancy, and increase risk
of stillbirth. Ergot may cause placental damage due to
vasoconstrictive effect. Fortunately, migraine tends to
remit during pregnancy. New-onset headache during
pregnancy should be evaluated carefully for potential
vascular or structural lesion.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD
8
Q
1607. Which of the following poses the greatest risk of fetal harm? A. multivitamins B. acetaminophen C. prednisone D. metoprolol E. ergotamine
A
- Answer: E
Explanation:
Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87 and
http://www.fda.gov/fdac/features/2001/301_preg.html#cat
egories)
The FDA categories do not necessarily stratify risk, but
actually discuss a risk/benefi t analysis. Note that Category
A and B are probably safe. However, category C and D
drugs may be just as dangerous as category X.
Ergotamines are category X.
Multivitamins are category A.
Acetaminophen, butorphanol, nalbuphine, caffeine,
fentanyl, hydrocodone, methadone, meperidine,
morphine, oxycodone, oxymorphone, ibuprofen,
naproxen, indomethacin, metoprolol, proxetine,
fl uoxetine, prednisolone, prednisone are category B
Aspirin, ketorolac, codeine, propoxyphene, gabapentin,
lidocaine, mexiletene, nifedipine, propanolol, sumatriptan
are category C
Amitriptyline, imipramine, diazepam, phenobarbital,
phenytoin, valproic acid are category D
Source: Shah RV
9
Q
- Anti Infl ammatory medicines are not recommended in:
A. During the process of labor
B. In nursing mothers
C. During pregnancy
D. Those with a history of ulcerative disease
E. All of the Above
A
- Answer: E
Source: Hansen HC, Board Review 2004
10
Q
1609. The most frequent psychiatric disorder of postpartum women is A. An episode of mild schizophrenia B. An episode of mania C. Postpartum “baby blues D. Major depression E. Postpartum psychosis
A
- Answer: C
Explanation:
(Sierles, pp 125-126. Kaplan, pp 27-28,500-501.)
The most frequent (about 50%) postpartum disorder is a
self-limited condition known as postpartum blues, with
rapid swings of mood and irritability, decreased
concentration, and tearing. Next is postpartum major
depression (occasionally mania) in about 10% of
postpartum women, but most severe is postpartum
psychosis (about 1 to 2 per 1000) beginning about 2 to 3
weeks after childbirth. It is still not clear whether
postpartum psychosis is a discrete condition or an affective
or schizophrenia-like condition precipitated by
postpartum stress or endocrine changes. Postpartum
psychiatric disorders respond favorably to treatment and
have a good prognosis, but in all women who experience a
postpartum depression, there is a suicide rate of 5%, an
infanticide rate of 4%, and a recurrence rate of 25% for
postpartum psychosis and depression after subsequent
pregnancies.
Source: Ebert 2004
11
Q
- Studies show that methadone maintenance in the
mother, compared to untreated opioid abusers is
associated with
A. Shorter gestation and increased birth weight
B. Longer gestation and increased birth weight
C. Shorter gestation and decreased birth weight
D. Longer gestation and decreased birth weight
E. All of the above
A
- Answer: B
Source: Raj, Pain Review 2nd Edition
12
Q
- Use of which the following opioids by breast-feeding
mothers via PCA depresses the behavior of the
infant more than the equianalgesic dose of morphine
A. Fentanyl
B. Meperidine
C. Nalbuphin
D. Buprenorphine
E. Tramado
A
- Answer: B
Source: Raj, Pain Review 2nd Edition
13
Q
- This following term describes translating codes from
one system to another (i.e., DSM-IV to ICD-9-CM)
A. encoder
B. prospective payment system
C. crosswalk
D. chargemaster
E. CPT
A
- Answer: C
14
Q
1613. A pregnant patient in the 2nd trimester complains of diabetic peripheral neuropathy. Your drug of choice is: A. Gabapentin B. Mexiletine C. Ibuprofen D. Oxycodone E. Amitripytline
A
- Answer: D
Explanation:
Oxycodone is category B and is considered safe.
Amitriptyline, although generally indicate for diabetic
neuropathy, is category D.
The others are category C.
15
Q
- A 28 African American male presents to the emergency
room agitated and complaining of severe knee pain
and swelling. Urine toxicology screen reveals cocaine.
His mother demands to speak to you and volunteers
that he has sickle cell anemia. Which of the following is
most appropriate for pain management?.
A. Ketorolac 60 mg q6 hours
B. Acetaminophen 650 mg q2-3hours
C. Meperidine 50mg q2hours
D. Codeine 30mg q6 hours
E. Hydromorphone 0.2mg-0.4mg q6-10minutes in a patient
controlled analgesia form
A
- Answer: E
Explanation:
Sickle cell disease represents an alteration in both beta
subunits of hemoglobin from glutamate to valine. It affl ict
about 1 in 500 African American, or 0.15%. Under certain
circumstances the red blood cells sickle in shape and cause
thrombosis in the microcirculation and tissue hypoxia.
Clinically this manifests as a painful vasooclusive crisis in
the chest, abdomen, limbs, bones, penis, kidneys, etc… In
the joints patients may develop a painful, swollen joint.
Predisposing factors include dehydration, hypothermia,
exertion, acidosis, hypoxemia, and, infection. Cocaine is
associated with an increased basal metabolic rate. In this
patient, this may have precipitated a sickle cell crisis.
The question illustrates the ethics of prescribing opioids
to a patient with a severe medical condition and a drug
history. Ketorolac and NSAIDS have a ceiling effect and
have only a modest effect in sickle cell crises. The patient
may be dehydrated given his drug use and may have
underlying renal dysfunction-both of which may preclude
NSAIDs. Acetaminophen at this dose would exceed the
4000 mg limit for short term users and the 3100 mg limit
for chronic users. Its modest analgesic effects would not
benefi t such a painful crisis. Meperidine is a weak opioid
analgesic and at the dose required, may cause a buildup of
normoperidine. This metabolite may cause a seizure.
Codeine is relatively weak as an analgesic. The PCA would
be most appropriate. Hydromorphone may be better than
morphine in some circumstances due to its longer effect,
less emetogenic, and greater potency Other therapies
include oxygen, intravenous fl uids, warm temperatures,
and hydroxyurea..
Source: Shah RV, Board Review 2006
16
Q
- A 32-year-old woman who had epidural analgesia
(bupivacaine and morphine) for vaginal delivery of a 9-
lb, 6-oz baby boy complains of numbness and footdrop
24h after delivery. The most likely cause is
A. transient neurologic defi cit due to compression of the
nerves by the baby during delivery
B. permanent neuropathy from pelvic neural compression
C. herniated intervertebral disk
D. ischemia of the conus medullaris
E. myelopathy due to epidural analgesia
A
- Answer: A
Explanation:
(Bonica)
Maternal obstetric neuropathy after vaginal
delivery is reported to occur in 1 in 2500 deliveries. The
obturator, sciatic, or pudendal plexus can be injured by
continuous pressure of the presenting part during labor or
by forceps. The defi cit is usually unilateral, but may be
bilateral. One to two days after delivery, the patient may complain of burning, aching pain in the distribution of
the injured nerve. There may be some motor impairment.
The neuropathy is usually transient, and complete
recovery often occurs after several weeks.
Source: Kahn and Desio
17
Q
- All of the following are accurate statements with
managing opioid-dependent pregnant patients
experiencing withdrawal symptoms when the drug is
discontinued, EXCEPT:
A. Methadone frequently is used to treat acute withdrawal
from opioids
B. Current federal regulations restrict the use of methadone
for the treatment of opioid addiction to specially registered
clinics
C. Methadone may be used by a physician in a private practice
for temporary maintenance or detoxifi cation when
an addicted patient is admitted to the hospital for an
illness other than opioid addiction
D. Methadone may never be used by a private practitioner
in an outpatient setting when administered daily.
E. Methadone may be used by a private practitioner in an
outpatient setting when administered daily for a maximum
of three days
A
- Answer: D
Explanation:
1.Methadone frequently is used to treat acute withdrawal
from opioids.
2.Current federal regulations restrict the use of methadone
for the treatment of opioid addiction to specially
registered clinics.
3.Methadone may be used by a physician in private
practice for temporary maintenance or detoxifi cation
when an addicted patient is admitted to the hospital for an
illness other than opioid addiction. This includes
evaluation for preterm labor, which can be induced by
acute withdrawal.
4.Methadone may also be used by a private practitioner in
an outpatient setting when administered daily for a
maximum of 3 days while a patient awaits admission to a
licensed methadone treatment program.
18
Q
- Elevated estrogen levels during the menstrual cycle
A. Decreased LH levels
B. Downregulate FSH receptors on granulosa cells
C. Increase FSH cells
D. Increase the ciliation of the epithelial cells of the oviduct
E. Decrease synthesis and storage of glycogen in the vaginal
epithelium
A
- Answer: D
Explanation:
(Junqueira, 9/e, pp 425-430. McKenzie and Klein, pp 344- - Guyton, l0/e, pp 930-933.)
Estrogen levels increase during the maturation of ovarian
follicles, which results in a concomitant increase in
ciliation and height of the oviductal lining cells. Increases
in the number of cilia serve to facilitate movement of the
ovum. Increased estrogen levels also decrease FSH levels
and cause an LH surge. Elevated estrogen levels result in
increased secretion of lytic enzymes, prostaglandins,
plasminogen activator, and collagenase to facilitate the
rupture of the ovarian wall and the release of the ovum
and the attached corona radiata. Following ovulation,
during the luteal phase of the cycle, the theca and
granulosa cells are transformed into the corpus luteum
under the infl uence of LH. Ovulation occurs near the
middle of the menstrual cycle and is associated with an
increase in basal body temperature that appears to be
indirectly regulated by elevated estrogen levels, with IL-I
functioning as the endogenous pyrogen. Estrogen also
upregulates FSH receptors on granulosa cell membranes
and enhances synthesis and storage of glycogen in the
vaginal epithelium.
Source: Klein RM and McKenzie JC 2002.
19
Q
1618. The fetal hydantoin syndrome is characterized by all except: A. Microcephaly B. Mental defi ciency C. Short stature D. Craniofacial deformities E. Variable dimorphic features
A
- Answer: C
Explanation:
The hydanantion syndrome (phenytoin) is associated with
microcephaly, mental defi ciency, craniofacial deformities, and variable dysmorhic features, but not short stature.
Source: Boswell MV, Board Review 2005
20
Q
1619. Which of the following drugs is most compatible with breast feeding? A. Amitritypline, FDA category D B. Imipramine, FDA category D C. Ergotamine, FDA category X D. Diazepam, FDA category D E. Valproic acid, FDA category D
A
- Answer: E
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-87)
The FDA categories are concerned with risk of fetal harm.
The American Academy of Pediatrics has categorized
medications in relation to their safety to the infant
following ingestion by the mother.
Refer to this article:
http://aappolicy.aappublications.org/cgi/content/full/pedia
trics;108/3/776/T5
Source: Shah RV
21
Q
- A full-term male infant displays projectile vomiting 1
h after suckling. There is failure to gain weight during
the fi rst two weeks. The vomitus is not bile-stained
and no respiratory diffi culty is evident. Examination
reveals an abdomen neither tense nor bloated. The
most probable explanation is
A. Congenital hypertrophic pyloric stenosis
B. Duodenal atresia
C. Patent ileal diverticulum
D. Imperforate anus
E. Tracheoesophageal fi stula
A
- Answer: A
Explanation:
(Moore, Developing Human, 6/e, p 276.)
Blockage of the foregut in the newborn produces projectile
vomiting. Congenital hypertrophic pyloric stenosis,
occurring in 0.5 to 1.0% of males and rarely in females,
involves hypertrophy of the circular layer of muscle at the
pylorus. This usually does not regress and must be treated
surgically. During the fi fth and sixth weeks of
development, the lumen of the duodenum is occluded by
muscle proliferation but normally recanalizes during the
eighth week. Failure of recanalization results in duodenal
atresia. Because this occurs distal to the hepatopancreatic
ampulla, the vomitus will occasionally be stained with bile.
Annular pancreas, rare in itself, seldom completely blocks
the duodenum. Imperforate anus results in intestinal
distention with bloating.
Source: Klein RM and McKenzie JC 2002.
22
Q
- A 43-year-old woman as brought to a hospital emergency
room by her brother. Visiting the halfway house in
which she lived, he had found her to be lethargic,
with slurred speech. The patient had a long history
of treatment for psychiatric problems, and the brother
feared that she might have overdosed on one or more
of the several drugs that had been prescribed for
her. Physical examination revealed tachycardia with
irregular heart rate, shallow respirations, decreased
bowel sounds, dilated pupils, and hyperthermia. An
ECG revealed a widened QRS complex with diffuse T
wave changes. If this patient had taken a drug overdose
the most likely causative agent was
A. Clozapine
B. Fluoxetine
C. Lithium
D. Thioridazine
E. Zolpidem
A
- Answer: D
23
Q
1622. In treatment for acute withdrawal from sedativehypnotics in a pregnant women, the following drugs are used, EXCEPT: A. Phenobarbital B. Diazepam C. Chlordiazepoxide D. Lorazepam E. Morphine
A
- Answer: E
Explanation:
In acute withdrawal from sedative-hypnotics in pregnant
women, any medication with cross-dependence can be
used.
An initial dose is given, usually 15 to 90 mg of
phenobarbital or an equivalent dose of another sedativehypnotic
such as diazepam or chlordiazepoxide, and the better to arrow on the side of slightly over- rather than
under-medicating. Reducing the dose by 10% of the total
each day provides a comfortable taper. The taper can be
accomplished more rapidly over 5 days by reducing the
dose by 20% per day if there are no medical or obstetric
complications.
Advanced sedative-hypnotic withdrawal with markedly
abnormal vital signs or delirium should be treated rapidly
and with suffi ciently large doses of medication to suppress
with withdrawal period. Medications with a rapid onset of
action should be used and may be given intravenously for
immediate effect. Lorazepam and diazepam have a rapid
onset of action when given intravenously, although they
have a shorter duration of action than when given orally,
since fi rst past liver metabolism is bypassed. For example,
one may start with Lorazepam, 1 to 4 mg intravenously
every 10 to 30 minutes until the patient’s agitation or
delirium improves, so that the patient is calm but awake
and the heart rate decreases to around 100 per minute.
After stabilization with rapid acting medications, the
patient can be switched to equivalent dose of a long-acting
medication such as phenobarbital, oral diazepam,
clonazepam, or chlordiazepoxide.
Benzodiazepines and barbiturates can adversely affect the
fetus when given during pregnancy, so this should be taken
into account when beginning treatment for acute
withdrawal symptoms.
The risk to both mother and fetus from untreated
sedative-hypnotic withdrawal usually is greater than the
potential risk to the fetus from exposure to these
medications in a controlled setting.
patient is monitored for at least 6 to 8 hours. The
treatment medication is repeated at 1 or 2 hour intervals,
as indicated by the signs of withdrawal the patient exhibits.
After 8 hours, an approximation can be made of the total
dose the patient will require for a 24-hour period. It is
24
Q
- Of those infants born with a congenital malformation,
what percentage will have a clear environmental link?
A.
A
- Answer: B
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87)
Approximately 3% of newborns have a signifi cant
congenital malformation. Of those born with a
malformation, 25% have a known genetic cause. Of those
infants born with a malformation, only 2-3% will have a
clear environmental link. One of the major limitations in
evaluating a medication’s potential for causing harm to a
developing fetus is the degree of species specifi city for
congenital defects. One example is the drug thalidomide.
This drug did not demonstrate any problems in nonprimates,
but was a signifi cant teratogen to human
offspring.
Source: Shah RV
25
Q
1624. The most common cause of pain in buttocks pain in pregnancy is: A. Sacroiliac pathology B. Lumbar radiculopathy C. Urinary tract infections D. Ilioinguinal entrapment E. Lumbar facet arthropathy
A
1624. Answer: A Explanation: Sacroiliac pathology is the most common cause of buttocks pain. Source: Boswell MV, Board Review 2005
26
Q
1625. In general, medicines that are safe for lactating mothers are: A. Highly protein bound B. Fat soluble C. Long acting D. Low molecular weight E. Unionized state
A
1625. Answer: A Explanation: Highly protein bound medications are in general less likely to cross into the breast milk. Source: Boswell MV, Board Review 2005
27
Q
- A nursing mother with a history of severe migraines
prior to her pregnancy, presents to your clinic to
discuss headache prophylaxis. You tell her:
A. there are no appropriate prophylactic medicines for
nursing mothers and she should switch to bottle.
B. beta blockers have been used in nursing mothers with
minimal neonatal effect.
C. the amitriptyline she used before she was pregnant was
fi ne to resume.
D. topiramate has no effects on the baby and she will lose
weight faster.
E. ergotamine should be used at the onset of a headache
A
- Answer: B
Explanation:
Although many of the standard prophylaxis medicines are
contraindicated, beta blockers has been used without
apparent problems. TCAs are not suggested, ergotamines
have been associated with neonatal convulsions, and
topiramate has moderate breast milk excretion. Depakote,
though, might be a reasonable choice.
Source: Boswell MV, Board Review 2005
28
Q
1627. Neural tube defects may occur with which of the following antiseizure drugs? A. Ethosuximide B. Vigabratin C. Phenobarbital D. Valproic acid E. Primidone
A
- Answer: D
Explanation:
Reference: Katzung, pp 411, 1029.
An increased incidence of spina bifi da may occur with the
use of valproic acid during pregnancy. Cardiovascular,
orofacial, and digital abnormalities may also occur.
The main issue with the use of Phenobarbital or
primidone (metabolite is Phenobarbital) for the fetus is
neonatal dependence on barbiturates.
Source: Stern - 2004
29
Q
- In patients with preeclampsia
- therapeutic magnesium levels are between 10 and
15meq/L - decreased levels of thromboxane are thought to be a
possible etiologic factor - the central nervous system shows decreased excitability
- hypotonia in a neonate born to a preeclamptic patient
may be due to high magnesium levels.
A
- Answer: D (4 Only)
Explanation:
The therapeutic magnesium level in treating preeclampsia
is 4 to 6 meq/L. Levels above 10 meq/L are associated with
loss of deep tendon refl exes. High thromboxane levels are
thought to be a possible cause of preeclampsia, and
substances, such as aspirin, which decrease thromboxane
levels also decreases the incidence of preeclampsia. The
central nervous system is hyperexcitable in preeclampsia.
High levels of magnesium in a neonate may cause
hypotonia as well as respiratory depression and apnea.
Source: Miller, 4/e. pp 2061-2063
30
Q
- Opioids recommended for lactating patients include
- Morphine
- Hydromorphone
- Hydrocodone
- Meperidine
A
1629. Answer: A (1, 2, & 3) Explanation: Meperidine is contraindicated for lactation because normeperidine collects in the neonate Source: Boswell MV, Board Review 2005
31
Q
- For a woman with a radiculopathy in early pregnancy,
which the following are appropriate treatments? - Carbamazine
- Epidural steroids
- Amitryptiline
- Ibuprofen
A
- Answer: C (2 & 4)
Explanation:
Anticonvulsants and tricyclics are contraindicated in early
pregnancy. Epidural steroids are safe, and NSAIDs in early
pregnancy are probably OK.
Source: Boswell MV, Board Review 2005
32
Q
- You are treating a pregnant heroin addict who wants
to be sure that her baby is not harmed. Your best
management would be: - Maintain the patient on high-dose methadone
- Withdraw the patient from opioids using clonidine
- Withdraw the patient from heroin using methadone
- Maintain the patient on low-dose methadone
A
- Answer: D (4 Only)
Explanation:
Heroin addicts who are pregnant should be maintained on
low-dose methadone (10-40 mg a day) to prevent
withdrawal and uncontrolled use of narcotics and possible
miscarriage and fetal death.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
33
Q
- Which of the following characterize normal CNS
development in humans - Spinothalamic myelination complete by 1st month after
delivery - Thalamocortical projections complete by 37 weeks post
conception - C-fi ber maturation complete by birth
- Nociceptors are present in newborns
A
- Answer: C (2 & 4)
34
Q
- Signs leading to the diagnosis of preeclampsia include
- proteinuria
- hypertension
- generalized edema
- hyperglycemia
A
- Answer: A (1, 2, & 3)
Explanation:
Preeclampsia is a syndrome that occurs after the 20th week
of pregnancy. Diagnosis is made when the parturient has
the following three signs and symptoms: blood pressure
greater than 140/90, proteinuria with urine protein greater
than 2 g/day, and generalized edema. Hyperglycemia is
not one of the diagnostic signs.
Source: Stoelting, Anesthesia and Co-Existing Disease, 3/e.
35
Q
- Neurologic effects of magnesium sulfate (MgSO4)
include - decreased irritability of the central nervous system
- decreased release of acetylcholine at the motor end
plate - reduced sensitivity to acetylcholine at the motor end
plate - relaxant effect on uterine and vascular smooth muscle
A
- Answer: E (All)
Explanation:
Magnesium sulfate is a CNS depressant and has all the
listed effects in a toxemic parturient. Relaxation of the
uterus may help improve uterine blood fl ow.
Source: Stoelting, Anesthesia and Co-Existing Disease, 3/e.
pp 562-563.)
36
Q
- Which of the following is true of acute pancreatitis?
- auto-digestion of the pancreas by premature release of
proteolytic enzymes is thought to be the pathophysiology - the pain is severe, poorly localized in the epigastrium or
left upper quadrant, dull in quality, constant, and may
linger for 3-7 days - the most common etiology is alcohol abuse and gallstones
- treatment is primarily medical and supportive
A
- Answer: E
Explanation:
Acute pancreatitis has several etiologies (Table 5-3) but
cholelithiasis and alcohol abuse are the most common.
The pain is severe. It peaks in 15-60 minutes and lasts 3-7
days. The pain is poorly localized to the epigastrium or left
upper quadrant, steady, dull or drilling. Radiation may
occur to the back. Pain may be relieved with forward
fl exion.
Diagnosis is clinical and supported by elevated serum
amylase and/or lipase levels. The pathophysiology is that
the pancreas prematurely releases proteolytic enzyme that
induce auto digestion. Therapy is mainly supportive and
medical
Source: Shah RV, Board Review 2006
37
Q
- A nursing mother with a history of migraines presents
with her typical migraine headache. Appropriate
medications include: - Sumatriptan
- Ibuprofen
- Hydrocodone
- Ergotamines
A
- Answer: A ( 1, 2, & 3)
Explanation:
Sumatriptan has no known harmful effects. NSAIDs are
category 3. Opioids do transfer to breast milk but have
minimal effect. Ergotamines are contraindicated because
of
GI effects and possible seizures.
Source: Boswell MV, Board Review 2005
38
Q
- A pregnant woman, 34 weeks gestation, fractures
her pelvis in a motor vehicle accident. Appropriate
treatment options for pain management include: - Meperidine PC
- Epidural infusion of bupvacaine
- Ketoralac parenterally
- Transdermal fentanyl
A
- Answer: E (All)
Explanation:
Meperidine may be associated with fetal and maternal
accumulation of normeperidine; although not the best
choice, the drug is not contraindicated. NSAIDs should be
avoided after 32 weeks. Local anesthetics and fentanyl have
been safely used during late pregnancy.
Source: Boswell MV, Board Review 2005
39
Q
- Pregnant patients should avoid:
- Valproic acid
- Ergotamines
- Benzodiazepines
- Phenyton
A
1638. Answer: E (All) Explanation: All of these medicines are contraindicated in pregnant patients. Source: Boswell MV, Board Review 2005
40
Q
- In a neonate
- the percentage of total body water is greater than in an
adult - the volume of distribution of water-soluble drugs is
greater than in an adult - renal function is diminished, impairing the ability to
handle free water and solutes - drugs redistributed to the fat will have a longer clinical
effect
A
1639. Answer: E (All) Explanation: (Miller, 4/e. pp 2100-2102) All the above are correct. Source: Curry S.
41
Q
- True statement about physical examination fi ndings in
pregnant women with drug abuse are as follows: - Posterior cervical lymphadenopathy is an early sign of
HIV infection. - Finding a new murmur on examination of the heart
may indicate endocarditis - A cough productive of black sputum indicates crack
smoking - Poor dentition may indicate ongoing drug use, with
little concern for dental hygiene
A
- Answer: E (All)
Explanation:
* Pinpoint pupils on examination of the head and neck
indicate opioid intoxication. Atrophy of the nasal mucosa
preparation of the nasal septum indicates snorting of
drugs, most often cocaine or methamphetamine.
* Finding a new murmur on examination of the heart
may indicate endocarditis
* A cough productive of black sputum indicates crack
smoking
* Poor dentition may indicate ongoing drug use, with
little concern for dental hygiene
* Oral pharyngeal candidiasis is more frequent in HIV
positive women, and HIV infection is associated with
addiction
* Posterior cervical lymphadenopathy is an early sign of
HIV infection.
* Palpation of the abdomen may reveal an enlarged or
shrunken liver due to alcohol hepatitis or infectious
hepatitis from transmission by sharing contaminated
needles
* Constipation from opioid abuse may be apparent on
abdominal examination
* Neurological evaluation can reveal altered mental status
due to intoxication or acute alcohol withdrawal
* Hyperrefl exia and tremors may prompt consideration of
acute alcohol withdrawal
42
Q
- Cardiovascular changes that occur in obstetric patients
include - an increase in cardiac output
- an increase in heart rate and stroke volume
- a decrease in systemic vascular resistance
- a decrease in intravascular fl uid volume
A
- Answer: A (1,2, & 3)
Explanation:
Cardiac output increases in obstetric patients by about 40
percent during the fi rst trimester, and this is maintained
throughout pregnancy. The factors that increase cardiac
output include increases in heart rate, contractility, and
stroke volume and a decrease in systemic vascular
resistance. These changes probably are mediated by
ovarian and placental hormones. Intravascular fl uid
volume increases by approximately 35 percent, plasma
volume more so than erythrocyte volume, which leads to
the anemia of pregnancy.
Source: Stoelting, Anesthesia and Co-Existing Disease, 3/e.
pp 539 – 540
43
Q
1642. Disease states associated with airway abnormalities include 1. Pierre Robin syndrome 2. Preeclampsia 3. Treacher Collins syndromes 4. Gastroschisis
A
- Answer: A (1, 2, & 3)
Explanation:
Perre Robin syndrome is characterized by micrognathia
(small mouth) and glossoptosis (protruding tongue). The
primary reason for airway diffi culty in patients with
preeclampsia is laryngeal and oropharyngeal edema.
Mucosal fragility is another feature that may make airway
management diffi cult. Children with Treacher Collins
syndrome have micrognathia and often a cleft palate.
Gastroschisis is rarely associated with other
abnormalities. Omphalocele, by contrast, has a high
association of other abnormalities, including macroglossia.
Source: Stoelting, Anesthesia and Co-Existing Disease, 3/e,
pp 564, 575, 596, 605.)
44
Q
1643. Drug kinetics may be altered in infants, with infants having 1. Increased total body water 2. Smaller volumes of distribution 3. Larger extracellular fl uid space 4. Higher peak blood levels
A
- Answer: B (1 & 3)
Source: Boswell MV, Board Review 2004
45
Q
1644. Which of the following are pain conditions that can occur during pregnancy? 1. Sacro-iliac joint pain 2. iliohypogastric neuralgia 3. transient osteoporosis of the hip 4. migraine
A
- Answer: E (All)
Explanation:
(Shah RV. The management of nonobstetric pains in
pregnancy. Reg Anesth Pain Med. 2003 Jul-
Aug;28(4):362-3 and Rathmell, JP. Mgmt of Nonobstetric
Pain during Pregnancy and Lactation. Anesth
and Analg 1997; 85: 1074-87)
The incidence of iliohypogastric neuralgia in pregnancy is
approximately 1 in 3-5 thousand. Patients are typically
affected in their 2nd or 3rd trimester. Progressive uterine
enlargement may place traction on the iliohypogastric
nerve; this nerve may become entrapped as it traverses the
anterolateral abdominal musculature. Iliohypogastric
neuralgia typically presents as severe pain in the ipsilateral
lower abdominal quadrant, fl ank, inguinal region, and
superolateral hip area. The physical exam may
demonstrate hyper- or hypoesthesia in the distribution of
the nerve. The symptoms of iliohypogastric neuralgia may
be confused with visceral pain: renal colic, diverticulitis,
ovarian cysts, or appendiceal perforation. If the pain is
mistakenly thought of as a surgical abdomen, unnecessary
surgery may be performed. Premature labor may be
induced and both mother and infant could be harmed.
Bone marrow edema syndrome is another condition that
is important to recognize. Like iliohypogastric neuralgia,
pregnant women in their 2nd or 3rd trimester are
affected4; the pain decreases upon delivery. Pain is referred
along the ipsilateral hip and worsens with weight bearing.
The etiology is still unknown, but chemical mediators,
humoral factors, intermittent compression of the
obturator nerve by the infant’s head, and pelvic venous
stasis have all been implicated. Diagnosis can be made
with magnetic resonance imaging. The pain typically
responds to conservative care: restricted weight bearing,
analgesics, and physical therapy. Regional blocks are not
indicated and rarely, core decompression of the femoral
head is required.
Sacroiliac joint pain (due to hormonally induced
ligamentous laxity (relaxin)) and migraines, both have a
high prevalence during pregnancy.
Source: Shah RV
46
Q
- Which of the following measures would reduce the risk
of maternal secretion of drug into the breast milk? - reducing the drugs lipid solubility
- increasing the drug’s molecular weight
- increasing drug polarity
- reducing protein binding
A
- Answer: A (1, 2, & 3)
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87)
Increasing lipid solubility, reducing molecular weight,
reducing protein binding, and reducing drug ionization
(or making a drug unionized) would facilitate drug
secretion into breast milk. Hence, only choices 1,2,3 would
reduce the risk of maternal secretion, but choice 4, would
facilitate maternal secretion into breast milk.
Source: Shah RV
47
Q
- Which of the following conditions is associated with
decreased clearance of ester-type local anesthetics? - Cirrhotic liver disease
- Pregnancy
- Renal insuffi ciency
- Severe chronic obstructive pulmonary disease
A
- Answer: A (1, 2, & 3)
Explanation:
* Pregnancy is associated with decreased
pseudocholinesterase activity; however, this reduction in
activity is minimal such that the rate of hydrolysis of estertype
anesthetics is suffi cient to limit signifi cant placental
transfer to the fetus.
* Severe liver disease is associated with a decreased
concentration of pseudocholinesterase. Likewise, uremic
patients have decreased serum levels of
pseudocholinesterase, which may interfere with the
metabolism of ester local anesthetics.
* Pulmonary disease does not affect the clearance of local
anesthetics, provided blood fl ow to the liver is not lowered
by hypoxia.
48
Q
- True statements about methadone maintenance in a
pregnant woman include the following: - Methadone maintenance is the treatment of choice.
- It is not unusual for the methadone dose requirements
to increase during the third trimester of pregnancy - Women can breastfeed while on methadone maintenance
as long as they are not abusing any drugs - Methadone maintenance patients may require higher
doses of additional opioids due to the development of
tolerance.
A
- Answer: E (All)
Explanation:
* Studies have shown that a daily methadone dose over 60
mg is most effective.
* It is not unusual for the methadone dose requirements
to increase during the third trimester of pregnancy. This is
due to large plasma volume, decreased plasma protein
binding, increased tissue binding, increased methadone
metabolism, and increased methadone clearance in the
mother. As a result, the half-life of methadone is
shortened late in pregnancy and the woman may
experience mild withdrawal symptoms unless her
methadone dose is adjusted. Splitting the total daily
methadone requirement into 2 doses, given in the
morning and evening, is preferred if possible as it provides
a more even blood level throughout the day.
* Breastfeeding should be encouraged to promote
mother infant bonding and to provide optimal nutrition
in passive immunization to the child. The patients may
require higher doses of additional opioids due to the
development of tolerance.
* The medication should be adjusted according to the
patient’s reported level of pain, as assessed through the use
of a pain rating scale.
49
Q
- Opioid neonatal withdrawal syndrome is characterized
by the following: - It occurs in 60% to 80% of infants with intrauterine
exposure to heroin or methadone - Neonatal opioid withdrawal syndrome is treated with a
substitute opioid, such as tincture of opium, paregoric,
or methadone - Neonatal opioid withdrawal syndrome is treated with a
CNS depressant such as phenobarbital - Neonatal opioid withdrawal syndrome occurs in less
than 20% of infants with intrauterine exposure to
heroin or methadone
A
- Answer: A (1, 2, & 3)
Explanation:
Neonatal withdrawal syndrome occurs in 60% to 80% of
infants with intrauterine exposure to heroine or
methadone.
The most comprehensive assessment is the scoring system
proposed by Finnagen and Kaltenbach. This scale assesses
21 symptoms with weighted scores, which are evaluated at
2 hours after birth and then every 4 hours. Scoring is
quantitative; so all symptoms observed during the
intervals should be counted. If the severity score is greater
than 8, the infant should be scored every 2 hours until the
severity score decreases, then scoring should resume every
4 hours.
Pharmacotherapy should be initiated when the total score
is greater than 8 for three consecutive evaluations.
Neonatal opioid withdrawal syndrome is treated with a
substitute opioid, such as tincture of opium, paregoric, or
methadone, or with a CNS depressant such as
phenobarbital.
50
Q
- In the newborn
- Albumen levels are higher than in the adult
- Local anesthetics are more protein bound
- Drugs have increased affi nity for fetal hemoglobin
- Drug free fractions are increased
A
- Answer: D (4 Only)
Source: Boswell MV, Board Review 2004
51
Q
- Which of the following is true
- The neonatal dose of medications in breast milk is only
1-2% of that of the maternal dose - neonatal drug allergy may play a role in adverse reactions
to medications in breast milk - slower neonatal drug metabolism plays an important
role in toxicity to drugs in breast milk - early breast feeding in the fi rst few post-partum days
poses a large risk of adverse drug complications to the fetus from maternal drug consumptions
A
- Answer: A (1, 2, & 3)
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87)
The neonatal dose of most medication obtained through breast feeding is 1-2% of the maternal dose. Even with
such low dose exposures, neonatal drug allergies and
slower drug metabolism must be taken into consideration.
Breast milk in the fi rst few days post- partum is usually a
small amount of colostrums, thus the infant is posed no
signifi cant risk of exposure to drugs used during the
delivery period.
Source: Shah RV
52
Q
1651. Compared to children and adults, drug clearance in neonates may be delayed because of 1. Immature hepatic enzymes 2. Decreased renal blood fl ow 3. Reduce glomerular fi ltration 4. Increased protein binding
A
1651. Answer: A (1, 2, & 3) Explanation: Protein binding is decreased in the newborn compared to the adult Source: Boswell MV, Board Review 2004
53
Q
- True statements about neonatal withdrawal syndrome
from methadone are as follows: - Neonatal withdrawal syndromes are characterized by
hyperactivity, irritability, hypertonia, diffi culty sucking
or excessive sucking, and high pitched cries. - Neonates with intrauterine drug exposure should be followed
in the hospital for 3 to 4 days after the delivery to
monitor for signs of an abstinence syndrome. - Timing of withdrawal onset depends on the time of the
last drug exposure, and metabolism and excretion of
the drug. - If more than 7 days have elapsed between the last
maternal use and delivery, the incidence of neonatal
withdrawal is high.
A
- Answer: A (1, 2, & 3)
Explanation:
If more than 7 days have elapsed between the last maternal
use and delivery, the incidence of neonatal withdrawal is
low.
54
Q
1653. Diabetes mellitus and its effects on the fetus include a greater incidence of 1. pregnancy-induced hypertension 2. respiratory distress of the newborn 3. malpresentations 4. small size for gestational age
A
- Answer: A (1, 2, & 3)
Explanation:
Parturients who are suffering from diabetes mellitus often
have babies who are large for gestational age. This may
lead to malpresentations or other diffi culties during
vaginal deliveries. There is also a greater incidence of
uteroplacental insuffi ciency. For these and other reasons,
these patients often undergo elective and emergency
cesarean sections.
Source: Stoelting, Anesthesia and Co-Existing Disease, 3/e.
pp 564-565
55
Q
- True statements of treatment for acute withdrawal from
sedative-hypnotics in pregnant women including the
following: - This is accomplished in an outpatient setting, which allows
family to interact and provide support - This should be accomplished in an inpatient setting,
which allows for medical supervision in collaboration
with an obstetrician - Treatment is different for withdrawal for each sedative-
hypnotic, such as barbiturates, benzodiazepines,
and alcohol - Uncontrolled withdrawal symptoms may be life-threatening
to both mother and fetus
A
- Answer: C (2 & 4)
Explanation:
* Treatment for acute withdrawal from sedative-hypnotics
in a pregnant woman should be accomplished in an
inpatient setting, which allows for medical supervision in
collaboration with an obstetrician.
* Uncontrolled withdrawal symptoms may be lifethreatening
to both mother and fetus
* Treatment is identical for withdrawal from all sedativehypnotics,
including barbiturates, benzodiazepines, and
alcohol, because all drugs in this class exhibit crossdependence.
