Postpartum Questions

1. When assessing your patient for postpartum depression you note that all of the following signs/symptoms are “red flags” except?
a. A previous psychotic break.
b. Personal or family history of bipolar disorder
d. Thoughts of harming self or newborn.
c. * Inability to sleep more than 4 hours per night.

All of the following are “red flags” and should elicit a more detailed interview/examination except an inability to sleep more than 4 hours per night. One should become worried if the postpartum female is unable to sleep more than 2 hours per night. Having a previous psychotic break or a personal/family hx of bipolar disorder are both risk factors for developing postpartum depression or psychosis. Thoughts of harming oneself or a newborn can be ominous and must be explored further.


2. A quick postpartum depression screen at a well-child visit can consist of what?
a. Asking if the postpartum patient feels depressed or “mulligrubby”
b. Performing the Edinburgh Postnatal Depression Scale Test
c. *Asking the first two questions of the PHQ-9 Test
d. Performing the Post Partum Depression Screening Scale Test

Asking if the patient feels depressed is a good start, but it is not recognized as a sensitive/specific tool to use for screening. Performing the Edinburgh or Post Partum Depression Tests will certainly help you to determine if the patient is at risk/suffering from PPD, but they are not as quick as asking the first two questions from the 9 question Patient Health Questionnaire test (PHQ-9). Using the first two questions from the PHQ-9 affords a 96% sensitivity and up to 94% specificity in detecting PPD if the provider also asks the patient “is this something you would like help with.”


3. What medication is considered first line for managing depression while a patient is breastfeeding?

a. * Zoloft
b. Buproprion
c. Fluoxetine
d. Lithium

Zoloft is a pregnancy category C-drug. However, zoloft is not orally bioavailable to infant through breastmilk. Reports state that Buproprion is associated with infant seizures. Fluoxetine may be associated with somnolence, fever, and hypotonia. Lithium is associated with hypotonia, hypothermia, and infant cyanosis.


4. All of the following are risk factors associated with postpartum depression except?

a. Lack of social support
b. Depression during pregnancy
c. Rapid hormone changes
d. Infant temperament
e. * None of the above

All of the above are considered risk factors for developing postpartum depression.


5. True or False? The “baby blues” is a normal phenomenon that affects 70% of all postpartum women and as such, it does not require a follow-up visit.

False—Up to 20% of women experiencing the baby blues can develop postpartum depression. Hence, they need to be followed.

Transplant Questions

Exam questions

1. Which of the following maternal-fetal complication is not generally associated with pregnancy after organ transplantation?

a. hypertension
b. prematurity,
c. macrasomia
d. low birth weight.

Rational: hypertension, prematurity and low birth weight is each a known complication of post transplant pregnancy. Macrasomia is often associated with diabetes mellitus and gestational diabetes, low birth weight is more likely to occur in the post transplant setting.

2. Organ transplant may result in a change in which sperm characteristic?

a. sperm ph
b. sperm counts
c. sperm morphology
d. sperm motility

Rational Transplantation restores the balance in the hypothalamic-pituitary axis is associated with improvements in sperm motility but not in sperm counts or morphology, there is no effect on sperm ph.

3. Chances of successful pregnancy are increased all of the following except…

a. hematocrit levels > 42%
b. immunosuppressive medications at maintenance levels,
c. serum creatinine levels less than 1.3 mg/dL
d. absence of graft rejection for at least a year,

Rational: absence of graft rejection, stable immunosuppression and serum creatinine <1.3mg/dl all increase chances of successful pregnancy. A hematocrit of 42%t is s normal and supportive of pregnancy but not specifically cited as contributing to post transplant success.

4. Barrier methods of contraception are the method of choice for post transplant patents.

a. True
b. False

Rational: Due to high levels of immunosuppressive therapy, pregnancy in the immediate post implantation period can lead to unacceptable fetal risks and/or anomalies. The potential for barrier failure to too high to rely upon barrier contraception alone.

5. In counseling post transplantation patients about the importance of contraception the clinician should explain that…

a. Contraception is unnecessary because it takes a year for fertility to return
b. The post implantation period involves use of potentially fetotoxic or teratogenic medications which present a risk to the developing embryo so it is important to avoid unintended pregnancy
c. Oral Contraceptives have the potential to interfere with immunosuppressive therapy and should be avoided.
d. IUDs are the female contraceptive of choice

Rational: Fertility can return as early as one month post transplant. Oral contraceptives have not been generally shown to interfere with immunosuppression, and IUDs carry a higher risk for infection due to immunotherapy. A significant risk is posed by fetotoxic and teratogenic immunosuppressive drugs.

Renal Disease & Pregnancy Exam Questions

1. You are counseling Ms. Smith on contraception. Her creatinine levels are 1 mg/dl, her BUN is WNL. Her urine shows no proteinuria, no glycosuria. Her VS this visit are, ht 5’6”, wt 130#, BP 120/80, RR20, HR 72. When advising her about her contraceptive options you state:

a. Kidney disease is a contraindication for Mirena. You should consider other methods. (Transplant pts should consider this, not those with kidney disease.)
b. Yaz is an option for you, and might be a good choice in helping control your acne also. (Yaz is contraindicated in renal disease.)
c. I know you like the combined oral contraceptive you’ve used in the past. By ensuring you have no other risk factors, using the lowest dose estrogen, and monitoring your blood pressure carefully you can still use them.
d. Your chances of getting pregnant are remote—renal insufficiency causes infertility. You do not need contraception. (Pt has mild presentation, fertility not likely affected.)

2. Ms Smith returns to you several years later and wants to discuss getting pregnant. Her creatinine levels are now 1.5 mg/dl, her BUN is still WNL, and she is showing no proteinuria. She has gained 20 pounds and her VS are BP 135/85, RR 20, HR 74. As her provider, it is essential that you notify her of all of the following issues with her planned pregnancy EXCEPT:
a. Once pregnant she will need to be seen every 2 weeks until 28 wks GA, then weekly, with early referral to Obstetrics and Nephrology.
b. Even if her disease remains under control, she will have HEELP and preterm labor. (Rationale—with mild disease she is more likely to have close to normal pregnancy outcomes and complications may be avoided still. She is high risk, even though she is in the mild range. Her indices are going up)
c. You will need to carefully monitor her blood pressure, creatinine levels, blood urea levels, protein levels, cholesterol and urine.
d. Women with renal disease are at an increased risk of preeclampsia, especially in the third trimester.

3. Elevated risk in pregnancy with associated renal disease includes all of the following except:
a. Preterm labor
b. Hypertension
c. Macrosomia (Babies in this scenario would be smaller not larger)
d. Intrauterine growth retardation

4. Mrs. Smith has now had a kidney transplant. She would like to try getting pregnant again. Which of the following statements is not true regarding transplant patients?
a. There is no risk to subsequent pregnancies once her renal function has normalized. (Medications used to maintain transplant may affect the formation of the fetus at the higher doses used immediately post surgery and for 1-2 years after, also risks to the graft and UTIs are reported.)
b. It is recommended that she wait 1-2 years after the transplant before trying to conceive.
c. The medications used to retain her transplant may interfere with certain methods of birth control.
d. Fertility that was adversely affected by her renal failure may rebound as early as 1 month after transplantation.

5. True or False—Renal disease in men only affects their ability to have an erection and does not affect sperm formation or production.

Scoliosis Questions

1. Which of these is not an effective treatment for scoliosis?

a. Physical therapy
b. Electrical muscle stimulation
c. Milwaukee brace
d. Anterior fusion of lumbar spine

Electrical muscle stimulation is not a suggested treatment for scoliosis. Mild to moderate curvature may be treated with physical therapy, if the angle is 35 degrees a Milwaukee brace should be worn, if curvature is greater than 45 degrees surgical intervention such as the anterior fusion of the lumbar spine may be performed.

2. Which of these is not a potential cause for scoliosis?

a. Idiopathic
b. Congenital
c. Neurofibromatosis
d. Systemic lupus erythematous

There are many causes of scoliosis to include congenital, secondary to traumatic injury, spinal tuberculosis, infantile poliomyelitis and others but the most common is idiopathic. Scoliosis can also present as a component to other genetic disorders such as neurofibromatosis.

3. Mrs. Burns is a 24 year old newly married patient here for her first clinic appointment today. She informs you that she has a history of scoliosis that was corrected by spinal surgery with rodding years ago but is now considering starting a family. Which of these statements would be the correct information for this patient?

a. Because you know that this type of surgery is done for curvatures greater than 30 degrees you reply “ This surgical correction increases the risk of miscarriage, it may be necessary to discuss alternative options”
b. You are aware that this surgery increases her likelihood of infertility so you reply “ It might to be best to begin with infertility testing as well as discuss alternative family planning options”
c. “Research has shown that women who have received treatment via brace or surgery for scoliosis tend to experience normal pregnancy and deliveries with proper management, we can begin with preconception counseling”
d. “The stress of pregnancy and delivery causes progression of the spinal curvature which will require further surgical correction after delivery”

At present, research reflects that normal pregnancy and delivery is obtainable through proper management. Scoliosis treatment via surgery or brace does not predispose to miscarriage or been linked to infertility at present. Although there may be a slight progression of curvature in pregnancy, it is not significant enough to require further surgical intervention.

4. Which of these statements is correct involving the administration of epidural anesthesia of a parturient with scoliosis that has undergone surgical correction?

a. Having rods in place does not increase the risk of complications while providing adequate pain control
b. Having rods in place moderately increases the risk of delivery complications while providing adequate pain control
c. Having rods in place severely increases the risk of delivery complications, it is necessary to weigh the risks against the benefit
d. Having rods in place does not increase the risk of complications but may not provide adequate pain control

Research suggests that having rods in place does not increase the risk of delivery complications and epidural anesthesia can provide safe and adequate pain control

5. Which contraception method would be contraindicated for a female patient with severe scoliosis?

a. Abstinence
b. Combined oral contraceptive
c. Rhythm method
d. Female barrier protectors

The use of combined oral contraceptives is useful for young women with mild to moderate scoliosis without mobility issues, patients with severe disorder are at an increased risk of thromboembolisms. All of the other above listed methods are acceptable choices for severe scoliosis

Cerebral Palsy

1. A mother brings her 13 year old daughter with cerebral palsy in to see you because she is concerned that her daughter has not started her menstrual cycle yet. You tell her the following:

a. We will start her on oral estrogen therapy because I am concerned about her delayed puberty

b. Research has shown that patients with cerebral palsy often have delayed menarche, with the median age of menarche at 14. If she has not started her cycle by 14, please return for re-evaluation.

c. We will start her on a gonadotropin releasing hormone agonist (GNRH).

d. We will start her on continuous oral contraceptives to manage her menstrual cycle.

(B is the correct answer. Since many patients with CP have delayed menarche, this may be normal for this patient, so estrogen therapy is not warranted at this time. C is incorrect because GNRH is a treatment option for girls with early puberty, not late. D is incorrect because she hasn’t had a menstrual cycle so she doesn’t need contraception yet. A good article to read for further clarification is the one by Zacharin.)

2. A couple comes to see you for preconception counseling. The wife has cerebral palsy and the couple wants to know what is the likelihood of passing cerebral palsy on to their child. You respond with the following:

a. Cerebral palsy is an autosomal dominant condition and each of your children have a 50% chance of inheriting it.

b. Cerebral palsy is curable, so let’s work on getting you better first and then we can worry about you getting pregnant.

c. Cerebral palsy is caused by an insult to the brain usually occurring during fetal development or infancy. We are not always certain what causes the insult to the brain but we know that it is not passed on like a genetic condition.

d. Due to your disability, I do not recommend that you get pregnant. Let’s talk about some contraceptive methods and possibly adoption.

(C is the correct answer. A is incorrect because cerebral palsy is not a genetic condition, therefore it cannot be autosomal dominant. B is incorrect because CP is a chronic condition that is not curable. The goal of treatment is to get the patient to their maximum level of independence. D is incorrect because CP does not prevent someone from getting pregnant and many CP patients have delivered babies with no complications.)

3. Sandy is a 23 year old female with cerebral palsy. She is confined to her wheelchair and has spasticity of arms and hands but has no cognitive impairment. She is obese. She lives alone with the help of a twice daily nurse visit. She works outside of her home so menses control is important to her. She would like to discuss contraception options with you. Which of the following would be the best option for her?

a. Depo-Provera shot every three months

b. Combined oral contraceptive pills

c. Transdermal patch

d. Levonorgestrel IUD

(D is the correct answer. The IUD is a long-term, reversible option that may induce amenorrhea for Sandy, which is something she desires. It also does not contain estrogen, so there is not an increased risk for DVTs like with the combined OCPs. Also, remember to teach Sandy about the signs and symptoms of an infection after IUD placement. A is not the best option because Depo has been shown to increase loss of bone density and since Sandy is immobile she is already at increased risk for that. B is not the best because of the increased risk for DVTs with estrogen containing contraception. C is not the best because the patch is not as effective in obese women.)

4. Amy is 20 years old and has cerebral palsy. She is here today for preconceptual counseling. During your history and physical, you learn that Amy also has epilepsy and is on Phenytoin. Which of the following drugs might you consider switching Amy to?

a. Lamotrigine

b. Valproate

c. Carbamezipine

d. Phenobarbital

(A is correct. Lamotrigine is the only class C anticonvulsant drug in this list. All the other drugs listed (B, C, and D) are class D drugs. Lamotrigine is the most widely used second generation antiepileptic and is a potential option for pregnant women with seizure disorders. Lamotrigine has anti-folate properties, so folate supplementation 1-4 mg is recommended. Obviously, a class C drug is not great, but remember that a seizing mother is really bad too.)

5. You have a 20 week G1P0 with cerebral palsy in your office. She has limited mobility and uses a walker for ambulation. Which of the following complications in pregnancy would you be least likely to see in this patient?

a. Deep vein thrombosis

b. Urinary tract infection

c. Fracture from falls

d. Autonomic dysreflexia

(D is the correct answer. Autonomic dysreflexia is an over activation of the sympathetic nervous system that occurs in patients with spinal cord injuries. It can be triggered in spinal cord injury patients during pregnancy. Answers A, B, and C are all things that you would be concerned about for your CP patient. Providers should be sure to give this patient information to prevent these complications along with information about the signs and symptoms of them. A great article to read about complications in pregnancy for women with disabilities is the one by Smeltzer.)

Vulvar Disorders- MAJ Racine

1. Common etiologies of acute vulvar pruritis include(s):

a. candidiasis

b. contact dermatitis

c. lichen sclerosus

d. choices a and b

e. all of the above

a. Candidiasis by itself is a common etiology of vulvar pruritis, but so is contact dermatitis.

b. Contact dermatitis by itself is a common etiology of vulvar pruritis, but so is candidiasis.

c. Lichen sclerosus is a cause of severe itching, but it is not as common as candidiasis or contact dermatitis and should be suspected in cases of chronic vulvar pruritis.

d. In cases of acute vulvar pruritis, common etiologies include both vulvovaginal candidiasis and contact dermatitis (ACOG, 2008).

e. Although both candidiasis and contact dermatitis are common causes of acute vulvar pruritis, LS is not.

2. You see an 89 y/o woman for a follow-up appointment with continued severe vulvar pruritis that wakes her at night; she has been unresponsive to clotrimazole and estrogen. Your PE reveals white plaques with areas of purpura and excoriation. You suspect this is:

a. allergic vulvar dermatitis and refer her to derm for biopsy and patch testing

b. lichen sclerosus and refer her to derm for vulvar biopsy

c. streptococcal vulvovaginitis and prescribe penicillin

d. iron deficiency and prescribe Fe supplementation

a. Allergic dermatitis does not typically present as white plaques with areas of purpura/excoriation- erythema and scaling are usual signs of allergic dermatitis.

b. This is a classic presentation of LS: intense pruritis and white plaques w/areas of purpura and excoriation in the vulva, in a post-menopausal woman (Dalziel, 2010). Also, LS can mimic many other conditions, including vulvar carcinoma (and she is at increased risk for this as she is over the age of 70), so a biopsy is needed to confirm the diagnosis (ACOG, 2008).

c. Streptococcal vulvovaginitis does not present as white plaques with areas of purpura/excoriation- edema and erythema are typical signs. This condition is also seen mostly in prepubertal females.

d. Iron deficiency could be a cause of intractable pruritis, but by itself would not cause the white plaques with areas of purpura and excoriation.

3. Systemic estrogen therapy is the mainstay treatment for vulvar atrophy:

a. True

b. False

a. Systemic estrogen therapy is not the mainstay treatment for vulvar atrophy- a topical estrogen preparation is a more appropriate treatment strategy.

b. Management options for vulvar atrophy include lifestyle modifications, OTC vaginal moisturizers, and topical low-dose estradiol preparations (ACOG, 2008).

4. Educating patients to decrease risk factors for vulvar cancer- such as avoiding smoking and limiting the number of sexual partners- is an integral part of managing vulvar cancers:

a. True

b. False

a. Smoking and HPV are significant risk factors for vulvar cancer and can help prevent the occurrence of vulvar cancers in patients (Wallace & Sanford, 2006).

b. Prevention of vulvar cancers is an important strategy in the fight against this rare gynecological cancer.

5. The treatment plan for generalized vulvodynia includes all of the following, except:

a. psychotherapy

b. topical compounded preparations

c. surgery

d. pelvic floor therapy

a. Psychotherapy is an appropriate adjunct in the care of a woman with any type of vulvodynia.

b. Topical compound preparations are an appropriate management strategy for women with both types of vulvodynia.

c. Surgery is contraindicated in women with generalized vulvodynia; it is a management strategy for women suffering from localized vulvodynia (vestibulodynia) only (NVA, 2010).

d. Pelvic floor therapy is an appropriate adjunct for therapy in women with vulvodynia.

Congenital Heart Disease

1. The safest and most efficacious contraception choice for the female patient with severe congenital heart disease (CHD) is…

a. Mirena IUS

b. Barrier contraception

c. Implanon

d. Sterilization

i. The risk of vasovagal response during insertion makes Implanon a safer choice for females with severe CHD. Although there is no additional cardiac risk, barrier contraception is not a reliable method for efficacy for patients with severe CHD. Aside from the higher failure rates in young women and that Implanon and Mirena IUS are more efficacious, the surgery itself requires long-term head-tilts and filling of the abdomen with carbon dioxide, both of which stand to compromise the stability of the patient with CHD.

2. Which of the following is NOT a risk for the fetus of a woman with CHD?

a. Fetal loss

b. Macrosomia

c. Premature birth

d. Intracranial hemorrhage

i. Fetal loss, premature birth, and intracranial hemorrhage are all risks to the fetus for a woman with CHD. Macrosomia is not a risk.

3. Sexual activity is not contraindicated in mild-moderate CHD.

a. True

b. False

i. Sexual activity is allowed in CHD as long as the patient can tolerate the activity.

4. The main reason estrogen-progesterone methods of birth control are not recommended for women with CHD is...

a. The risk of ectopic pregnancy is higher with this type of birth control.

b. Weight gain is higher with this type of method and should be avoided in women with CHD.

c. Pregnancy in a woman with CHD is contraindicated so more permanent methods should be taken to prevent it.

d. They have the potential to form more clots than other methods.

i. The risk of ectopic pregnancy is higher with sterilization and IUS, not with estrogen-progesterone methods. Weight gain is not a contraindication for this type of method. Pregnancy is contraindicated only in the most severe form of CHD where it would be life threatening. Most women with CHD can become pregnant and deliver while being followed by a multi-disciplinary team.

5. Sterilization is the safest and most efficacious method of birth control for women with CHD.

a. True

b. False

i. IUS and Implanon are more efficacious than sterilization. Also, the sterilization procedures have inherent risks to women with CHD.