The Obstetrician & Gynaecologist 10.1576/toag.8.1.055.27210 www.rcog.org.

uk/togonline CPD

CPD Questions for

volume 8, number 1
If you intend to claim CPD credits you should submit your 12 one in 6 stillbirths occurs in women with
answers online. Please refer to the box at the end of the hypertension. Th Fh
questions section explaining how to find the online CPD 13 pre-eclampsia is estimated to account for 35% of
submission system. preterm births. Th Fh

Please note that the maximum number of CPD credits you can The following are possible mechanisms involved in the
claim for each issue of The Obstetrician & Gynaecologist is five. pathogenesis of pre-eclampsia:
Please be selective when undertaking the questions and ensure that 14 abnormal placentation. Th Fh
you submit answers to no more than five topics. 15 maternal microvascular disease. Th Fh
16 an exaggerated inflammatory reaction. Th Fh
The deadline for submitting your answers to the questions in
volume 8 number 1 is 17 July 2006 Regarding placentation,
17 in normal pregnancy there is extravillous
Twin-to-twin transfusion syndrome trophoblast invasion of the interstitium and the
endothelium. Th Fh
Regarding twin-to-twin transfusion syndrome (TTTS), 18 in pre-eclampsia, endovascular invasion of the
1 it occurs in 15% of dichorionic, diamniotic twins. T h F h spiral arteries continues to the adventitia (deep
2 the diagnosis is usually made between 15 and portions of the blood vessels). Th Fh
25 weeks of gestation. Th Fh 19 the cytotrophobastic expression of adhesion
molecules influencing invasion is altered in
Regarding diagnosis of TTTS, women with pre-eclampsia. Th Fh
3 once there are Doppler abnormalities the risk of
at least one twin surviving is only 33%. Th Fh The following statements about serum from women with
4 up to 10% of recipients have chronic cardiac pre-eclampsia are true:
problems. Th Fh 20 It is cytotoxic to human umbilical vein
endothelial cells. Th Fh
Arterio-arterial anastamoses,
21 It has no effect on the endothelium-dependent
5 have a protective effect against TTTS. Th Fh relaxation of vessels from normal pregnant
6 result in net transfusional flow in either direction. Th Fh women. Th Fh
The following statements regarding treatment of TTTS are true:
7 Approximately 25% of survivors after The following statements about circulating factors that may
amnioreduction have abnormalities on neonatal influence the endothelial cells in pre-eclamptic pregnancies are
cranial ultrasound. Th Fh correct:
8 Selective laser treatment results in at least one 22 Vascular endothelial growth factor (VEGF) has
survivor in more than 80% of cases. Th Fh been suggested as one such factor. Th Fh
9 Cord occlusion using bipolar diathermy is not 23 The levels of VEGF increase at the onset of the
recommended after approximately 26 weeks of clinical symptoms of the condition. Th Fh
gestation because the umbilical cord becomes too 24 The rate of apoptosis is decreased in pregnancies
large. Th Fh with this complication. Th Fh

Septostomy Which of the following are true:

10 is more likely to need repeating than 25 The levels of antioxidants dominate over those
amnioreduction. Th Fh of pre-oxidants when there is oxidative stress. Th Fh
26 In women with pre-eclampsia, markers of
Current thoughts on the pathogenesis oxidative stress are higher in the subcutaneous
of pre-eclampsia vessels than in those of normal pregnancies. Th Fh

With regard to hypertensive diseases in pregnancy, With regard to oxygenation in pregnancies complicated by
11 they are the leading cause of maternal death in pre-eclampsia,
the UK. Th Fh 27 the degree fluctuates within the placenta. Th Fh

’ 2006 Royal College of Obstetricians and Gynaecologists 55

CPD Questions for volume 8, number 1 The Obstetrician & Gynaecologist

28 there is an increase in apoptosis in placentas 49 requires maternal sedation to prevent artefactual

exposed to hypoxia–reoxygenation. Th Fh images due to excessive fetal movement. Th Fh
50 is useful in distinguishing dermoid cysts from
Regarding endothelial cell activation and injury, endometriomas. Th Fh
29 biochemical markers of endothelial cell injury
and activation are raised in the blood of women
with pre-eclampsia. Th Fh
Management of women with epilepsy
30 the endothelium-dependent relaxation of during pregnancy
myometrial vessels in women with pre-
eclampsia is caused by endothelium-derived The following statements about antiepileptic drugs (AEDs) in
hyperpolarising factor (EDHF). Th Fh pregnancy are true:
51 Approximately 0.5% of pregnancies are exposed
to AEDs. Th Fh
Management of adnexal masses in 52 The adverse outcomes reported in pregnant
pregnancy women with epilepsy are mainly attributable to
AEDs. Th Fh
Concerning ovarian cysts in pregnancy, 53 No long-term adverse effects have been
31 the commonest variety found at surgery is a described following AED exposure in utero. Th Fh
benign cystic teratoma. Th Fh
32 dermoids grow rapidly in pregnancy due to the Maternal risks during pregnancy in women with epilepsy include
presence of hormone-dependent sebum. Th Fh 54 an increase in the seizure frequency in over 40%
33 approximately 75% of those persisting are of women. Th Fh
complex in nature. Th Fh 55 an increased caesarean section rate. Th Fh
34 those detected at routine early ultrasound are 56 a fall in total serum AED levels. Th Fh
generally asyptomatic. Th Fh
35 Doppler ultrasound studies are useful in Risks to the fetus in women with epilepsy taking AEDs
distinguishing benign from malignant include
neoplasms. Th Fh 57 a 10-fold increase in fetal loss. T h F h
36 most will resolve spontaneously. Th Fh 58 a 2 to 3-fold increase in major malformations. T h F h
37 the incidence of adnexal pathology detected at 59 a lower birth weight. T h F h
caesarean section is approximately 5%. Th Fh 60 developmental delay in the first two years of life. T h F h
38 transabdominal needle aspiration of the simple
type is contraindicated where there is fetal The following statements about risks to the fetus in women with
malpresentation. Th Fh epilepsy taking AEDs are true:
61 The risks are equal in all three trimesters. Th Fh
With regard to ovarian cancer in pregnancy, 62 There is an increased risk from convulsive
39 the incidence is approximately 0.5%. Th Fh compared with non-convulsive seizures. Th Fh
40 it is the most common malignancy diagnosed in
pregnancy. Th Fh The following statements regarding major fetal malformations are
41 most tumours are of the borderline type. Th Fh correct:
42 measurement of serum CA125 levels is unhelpful 63 They are not increased through polytherapy
because of increased synthesis in normal exposure in utero. Th Fh
pregnancy. Th Fh 64 The risk is highest with phenytoin exposure. Th Fh
65 They are significantly reduced in women taking
With regard to surgery for ovarian cysts in pregnancy, 0.4 mg folic acid in the first trimester. Th Fh
43 it should be performed laparoscopically in the 66 Orofacial clefts are more likely to be associated
majority of cases. Th Fh with valproate. Th Fh
44 it should be performed in the second trimester if
possible. Th Fh The following statements about the dosage of AEDs in pregnancy
45 if done laparoscopically, the Hasson technique are true:
should be used. Th Fh 67 Lower doses of AEDs are associated with lower
risks. Th Fh
Magnetic resonance imaging (MRI) in pregnancy, 68 Withdrawal of medication is best planned
46 is safer than conventional computed several months before conception. Th Fh
tomography (CT) scan. Th Fh
47 provides more accurate information than With regard to neonatal care and delivery,
ultrasound. Th Fh 69 approximately 40% of women with epilepsy will
48 can be used with gadolinium contrast experience a tonic-clonic seizure during delivery
enhancement. Th Fh and the first 24 hours after delivery. Th Fh

56 ’ 2006 Royal College of Obstetricians and Gynaecologists

The Obstetrician & Gynaecologist Questions for volume 8, number 1 CPD

70 breastfeeding is not recommended in women 88 estrogen–progestogen HRT is associated with a

who continue to take AEDs. Th Fh higher risk of VTE compared with estrogen-only
HRT. Th Fh
Obesity and female hormones 89 women taking conjugated equine estrogens have
a reduced risk of VTE compared with those
Regarding contraceptive efficacy, taking esterified estrogens. Th Fh
71 there is a significant decrease in contraceptive 90 transdermal HRT users show a significant
efficacy in overweight women taking combined increase in body weight compared to oral HRT
oral contraceptives. Th Fh users. Th Fh
72 the efficacy of the combined contraceptive
transdermal patch is significantly reduced in
women weighing over 90 kg. Th Fh Management of chronic pelvic pain:
73 contraceptive efficacy is significantly affected in
overweight Depo-ProveraH users. Th Fh
evidence from randomised controlled
trials
Regarding hormonal contraceptives,
74 the Cochrane reviews (Gallo et al., 2003) found a With regard to the surgical treatment of CPP,
significant weight gain in combined oral 91 presacral neurectomy (PSN) and laparoscopic
contraceptive pill users. Th Fh uterine nerve ablation (LUNA) both involve the
75 drospirenone is an anti-mineral corticoid disruption of sensory nerve afferents that carry
progestogen. Th Fh pain stimuli from the pelvis. Th Fh
76 there is robust evidence of weight gain in 92 serious complications are more common with
women using the levonorgestrel intrauterine LUNA than with PSN. Th Fh
system. Th Fh 93 a large placebo effect may be associated with
77 baseline body mass index (BMI) is a good surgical trials for chronic pelvic pain. Th Fh
predictor of weight gain with Depo-Provera use. Th Fh
78 Depo-Provera related bone mineral density loss With regard to chronic pelvic pain (CPP),
is increased in overweight women. Th Fh 94 current US and British data suggest that it
occurs in about 15–25% of women between the
With regard to obesity, venous thromboembolism (VTE) and ages of 18 to 50 years. Th Fh
arterial disease, 95 consulting rates are higher in the
79 obesity is an independent risk factor for VTE. Th Fh postmenopausal age group. Th Fh
80 users of transdermal contraceptive patches have 96 about 50% of women with CPP who consult a
a significantly reduced risk of venous physician will be referred on to tertiary centres. Th Fh
thromboembolism compared with combined
97 about 35% of women with CPP do not have
oral contraceptive users. Th Fh
identifiable pathology at laparoscopy. Th Fh
81 recent studies show no significant difference in
98 most studies define it as pelvic pain of at least
cardiovascular events in users of various
6 months’ duration. Th Fh
formulations of oral contraceptives. Th Fh
82 obese oral contraceptive users have a higher risk
of haemorrhagic stroke. Th Fh In randomised controlled trials of medical treatment of CPP,
99 no improvement in pain scores was seen in
Regarding the menopause, women taking sertraline compared to placebo. Th Fh
83 BMI increases as a function of age at the 100 lofexidine has been shown to improve pain
menopause. Th Fh scores. Th Fh
84 in postmenopausal hormone therapy users, a 101 progestogen (medroxyprogesterone acetate)
gynoid fat distribution is promoted. Th Fh with psychotherapy have been shown to
85 there is a statistically significant increase in body improve pain scores. Th Fh
weight in users of unopposed estrogen 102 goserelin is more effective than progestogen
replacement therapy compared with non alone. Th Fh
users. Th Fh
With regard to the multidisciplinary management of CPP,
Regarding hormone replacement therapy: 103 it is widely used in the UK. Th Fh
86 HRT is associated with a 3-fold increase in risk 104 evidence strongly suggests that it improves the
of VTE. Th Fh McGill pain score. Th Fh
87 there is a 3–6 fold increase in risk of VTE in 105 a combination of counselling and
obese compared with women of normal weight ultrasound scanning is effective in terms of
taking combined hormone therapy. Th Fh pain scores. Th Fh

’ 2006 Royal College of Obstetricians and Gynaecologists 57

CPD Questions for volume 8, number 1 The Obstetrician & Gynaecologist

With regard to CPP,

106 research has shown improvement following
two weeks of treatment in women who had Instructions for CPD Questions
static magnetic therapy compared with those
on placebo. Th Fh Please submit your answers online using the CPD submission
107 photographic reinforcement after surgery does system, which can be found on the RCOG website
not appear to have any beneficial effect. Th Fh (www.rcog.org.uk). Please sign in as a registered user, then
108 interventions that involved women identifying from the menu on the left choose ‘Fellows and Members’,
and expressing the thoughts and feelings proceed to ‘TOG Online’ and then select ‘CPD submission’.
associated with their pain have been shown to
be useful in one subgroup of women. Th Fh Further instructions are available online. Please note that
109 laparoscopy is the ‘gold standard’ in the the CPD answer cards have been withdrawn and all
diagnosis of CPP. Th Fh responses must now be submitted online.
110 in some women, normal sensation from the
ovaries can be perceived as painful. Th Fh The CPD Committee has decided that an appropriate
achievement mark for these tests is 70%. On completion of
The changing face of consent: past and this exercise you should print and retain a CPD certificate
present indicating the number of credits achieved. The College will
not keep a record of individual performances.
Consent is valid as long as
111 the person giving consent is over the age of You will be able to determine your percentage mark by
18 years. Th Fh referring to the test answers, which will be printed in the
112 a consent form has been signed. Th Fh second following issue of the journal. Please note that all tests
are valid for CPD purposes for a maximum of six months.
Regarding consent, The closing date for submitting your answers for this issue is
113 operating on a patient without consent is shown above the questions. It will not normally be possible to
negligent. Th Fh re-attempt tests.
114 if given verbally it is not legally binding. Th Fh
115 it cannot be withdrawn. Th Fh You must be a registered CPD participant in order to submit
your answers. Those readers who are not registered for CPD
Regarding disclosure of information, at the College are encouraged to participate in this CPD
116 patients must be given the known ‘material’ exercise but cannot submit their answers online. You can
risks. Th Fh assess yourself when the answers are published.
117 the standard of disclosure is no longer based on
the Bolam principle. Th Fh Please direct all questions or problems to the CPD Office,
Clinical Governance and Standards Department, Royal
Concerning capacity in a competent adult patient, the following College of Obstetricians and Gynaecologists, 27 Sussex Place,
statements are true: Regent’s Park, London NW1 4RG. Tel +44(0)20 7772 6307 or
118 The patient’s relatives can give consent. Th Fh email: cpd@rcog.org.uk
119 In an emergency the doctor can proceed with a
treatment as long as it is in the patient’s best
interests. Th Fh
120 It is lawful to discuss with relatives the
treatment of a patient who is unconscious and
has previously stipulated whilst competent that
no such discussion should take place. Th Fh

58 ’ 2006 Royal College of Obstetricians and Gynaecologists