DOI: 10.1111/tog.

12091

2014;16:1358

The Obstetrician & Gynaecologist

CPD

http://onlinetog.org

CPD questions for volume 16 number 2

CPD credits can be claimed for the following questions
online via the TOG CPD submission system. You must be a
registered CPD participant of the RCOG CPD programme
(available in the UK and worldwide) in order to submit your
answers. Participants will need to log in to the RCOG website
(www.rcog.org.uk) and go to the Our Profession tab.
Participants can claim 2 credits per set of questions if at
least 70% of questions have been answered correctly. At least
50 credits must be obtained in this way over the 5-year cycle.
Please direct all questions or problems to the CPD Office.
Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk
The blue symbol denotes which source the questions refer
to including the RCOG journals, TOG and BJOG, and RCOG
guidance, such as Green-top Guidelines (GTG) and Scientific
Impact Papers (SIPs). All of the above sources are available to
RCOG members and fellows via the RCOG website.
TOG

Medical management of miscarriage

With regard to miscarriage,

1. the incidence of clinically recognised
miscarriage ranges from 510%.
2. most occur before 12 weeks of pregnancy.
3. the risk in second trimester is
approximately 15%.
Regarding medical management of miscarriage,
4. it is currently the gold standard and has
therefore replaced surgical management.
5. the chief pharmacological agents
include prostaglandins.
6. the success rate is higher for missed than for
incomplete miscarriage.
With regard to mifepristone,
7. it is an antiprogestogenic agent.
8. it increases the sensitivity of the myometrium
to prostaglandins that have uterotonic action.
9. the optimal timing of prostaglandin
administration following mifepristone is
4872 hours.
Misoprostol is,
10. a prostaglandin F2a analogue.
11. licensed for the treatment of miscarriage.
12. is cheap, stable at room temperature and does
not require stringent storage conditions.

2014 Royal College of Obstetricians and Gynaecologists

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Regarding the route of misoprostol administration,

13. the vaginal route is more effective when it is
moistened with water or saline.
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14. the sublingual route has fewer gastrointestinal
side effects.
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With regard to various medical regimens for the
management of miscarriage,
15. the risk of uterine rupture in women with a
previous caesarean scar receiving these
regimens in the second trimester is low.
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With regard to pain management,
16. analgesia requirement is higher in older
parous women.
17. non-steroidal anti-inflammatory drugs
decrease the efficacy of misoprostol.

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Regarding psychological sequelae after miscarriage,

18. counselling should be offered as per the
womans preferences.
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With regard to the prescription of medications
in the management of miscarriage;
19. it is illegal for a doctor to prescribe a licensed
drug for unlicensed indication.
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With regard to the medical manageme
nt of miscarriage at home,
20. it carries a risk of heavy bleeding in a small
number of cases.

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Antibiotics for early-onset neonatal

infection: a summary of the NICE guideline
2012
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With regard to early-onset neonatal infection,

1. the consensus definition is infection occurring
within 48 hours of birth.
2. most cases are caused by Gram-positive
micro-organisms.
3. Escherichia coli is the most frequently reported
Gram-negative micro-organism.

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Risk factors for early-onset neonatal infection include:

4. maternal group B streptococcus (GBS)
colonisation in the current pregnancy.
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5. invasive GBS infection in a previous baby.
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6. multiple pregnancy.
7. preterm birth following spontaneous labour
(before 37 weeks of gestation).
8. suspected or confirmed rupture of
membranes for more than 12 hours in a
preterm birth.

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In the management of early-onset neonatal infection,

9. universal screening to detect GBS
colonisation in pregnant women
is recommended.
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10. risk scoring systems are effective for
identifying babies who will develop
an infection.
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Intrapartum antibiotic prophylaxis to prevent early-onset
neonatal infection should be offered to,
11. women in preterm labour if there is prelabour
rupture of membranes (PROM) of any duration. T h F h
12. women in term labour with PROM if the
membranes have been ruptured for more than
24 hours.
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13. women who have had GBS colonisation,
bacteriuria or infection in the
current pregnancy.
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14. women with suspected or
confirmed chorioamnionitis.
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15. women who have had a previous baby with an
invasive GBS infection.
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With regard to the choice of antibiotic used
for intrapartum antibiotic prophylaxis to prevent
early-onset neonatal infection,
16. benzylpenicillin is the first choice.
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17. clindamycin should be used in women who
are allergic to penicillin unless individual
GBS sensitivity results or local
microbiological surveillance data indicate a
different antibiotic.
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18. in women with preterm labour erythromycin
should be used.
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The following statements are correct:
19. Pregnant women who have had GBS
colonisation in a previous pregnancy but
without infection in the baby should be
reassured that this will not affect management
of the birth in the current pregnancy.
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20. At discharge, women who have had GBS
colonisation in the pregnancy but without
infection in the baby should be informed that if
they become pregnant again, they will be offered
intrapartum antibiotic prophylaxis to prevent
an early-onset neonatal infection in the baby.
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136

Idiopathic intracranial hypertension in

pregnancy
TOG

Idiopathic intracranial hypertension (IIH),

1. is a disease of unknown aetiology associated
with increased intracranial pressure.
2. is commonly seen in obese young women.
In making the diagnosis of IIH,
3. the lumbar CSF opening pressure should be
greater than 250 mm of water.
4. the modified Dandy criteria includes tinnitus
and vertigo.
5. CT or MRI demonstrates normal to small
symmetrical ventricles.
In IIH and pregnancy,
6. termination of pregnancy is recommended in
symptomatic women.
7. there is an increased risk of recurrence in
subsequent pregnancies.
8. visual outcome is the same as that for women
with IIH who are not pregnant.

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With regard to the treatment of IIH in pregnancy,

9. diet and weight control play a role in symptom
improvement.
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10. acetazolamide is contra indicated
in pregnancy.
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11. steroids are reserved for the acute phase only. T h F h
Regarding the symptoms of IIH in pregnancy,
12. there is a direct correlation between severe
visual symptoms and the degree
of papilloedema.
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13. severe visual loss is a recognised complication
of up to 50% of cases.
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14. visual obscuration characteristically lasts for a
few minutes to hours.
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With regard to IIH,
15. when it occurs in pregnancy, there is an
increased risk of obstetric complications.
16. the increased in intracranial pressure during
labour means caesarean section is the
preferred method of delivery.
17. when it predates pregnancy, it tends to worsen
in pregnancy.
18. most cases in pregnancy present in the second
half of gestation.
19. epidural anaesthesia carries a potential risk of
increasing intracranial pressure.
20. the progestogen only contraceptive is
recommended only in those in whom a
thrombotic event has been excluded.

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TOG

Pregnancy and spinal cord injury

Following a complete spinal cord injury (SCI) at the level

of T5,
1. pregnancy is contraindicated as it may be
life-threatening.
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2. autonomic dysreflexia and spasms are
complications associated with pregnancy,
labour and delivery.
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The quality of life in women with SCI
3. is improved by having families and children of
their own.
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With regard to autonomic dysreflexia,
4. treatment is by removing the source of
noxious stimulus.
5. if it persists or the cause cannot be identified,
one treatment is with 10 mg of sustained
release nifedipine.

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With regard to epidural analgesia in women with SCI,

6. it is routinely recommended in those with a
history of autonomic dysreflexia, prior to
performing an external cephalic version.
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7. it is advised in early labour in those who
are tetraplegic.
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8. it is contraindicated before artificial rupture of
membranes in a tetraplegic woman.
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The following are true statements about caesarean sections
in women with SCI:
9. A midline skin incision is advised to allow for
better access.
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10. A classical caesarean section is recommended
if bladder care is by a suprapubic catheter.
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11. A suprapubic catheter should be changed
1224 hours before surgery for infection
control measures.
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In women who sustained a SCI during pregnancy,
12. there is a high risk of DVT and PE in the
months following acute spinal cord injury.
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13. the risk of congenital abnormality is
not increased.
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The following statement is true regarding support required
for women with SCI:
14. mood disorders require assessment by a
psychiatrist with experience in caring for
women with disability.
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With regard to pregnancy in women with SCI,
15. the incidence of abnormal presentation is
not increased compared to that in
those without.

2014 Royal College of Obstetricians and Gynaecologists

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16. there are no known measures for the

prediction of the need for ventilation.
17. a rise in systolic blood pressure of 20
40 mmHg above baseline is considered a sign
of autonomic dysreflexia.
18. the incidence of urinary tract infections is not
dissimilar to that in non SCI women.
19. there is robust evidence to support treatment
of those with aysmptomactic bacteriuria.
20. the effectiveness of epidural analgesia is
determined by testing the level of block.

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TOG Providing an obstetric teaching

programme in a resource poor country

With regard to team planning prior to a teaching visit,

1. the Belbin model of team structure states that
including people of similar personality types
would result in a successful team.
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2. a plant is a highly creative personality
type who may find unconventional solutions
to problems.
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3. a shaper is a motivational personality type that
keeps the team focussed and moving forward. T h F h
With regard to budgeting during planning to deliver an
obstetric teaching programme in a low resource country,
4. the RCOG is not a source of travel bursaries or
scholarships.
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Regarding personal safety,
5. routine travel vaccinations are provided free of
charge by most occupational health departments. T h F h
6. post-exposure prophylaxis (PEP) should be
taken in the event of contamination with
blood suspected to be infected with HIV.
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7. visiting obstetricians need not take their own
supplies of PEP as it is freely available in most
host hospitals in resource poor countries.
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When planning delivery of your teaching programme,
8. the best approach is to decide your topics
independently and stick rigidly to your
syllabus, as too much flexibility may mean you
dont get to deliver all the topics.
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During delivery of a teaching programme,
9. a didactic, paternalistic approach is likely to
generate the best results.
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10. As the visiting obstetrician, it is unlikely that you
will learn anything new (as you are the teacher). T h F h
11. contemporaneous post course feedback is easy
to collect and useful when planning
subsequent visits.
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CPD

Regarding follow-up after implementing a

teaching programme,
12. organisation of a reciprocal placement for
some of your host doctors to visit your UK
department would facilitate bi-directional
learning and strengthen the link.
13. the use of Skype sessions and video links
where available will facilitate an ongoing
educational link.
With regard to teaching theories,
14. Maslows theory states that humans are
effective learners in the absence of the meeting
of safety needs.
15. David Kolbs experimental learning model
refers to the fact that people learn in one of
four different ways.
With regard to maternal mortality,
16. there are over 500 000 global maternal deaths
every year.
17. maternal mortality has fallen by about 50%
since 1990.
18. the decline in maternal mortality is on track to
meet millennium development goal number 5
by 2015.
19. in Sub-Saharan Africa there is only 1 health
worker per 100 population.
20. training of health workers in the developing
world improves clinical practice but not
clinical outcomes.

not been shown to improve the prediction of

delivering an SGA neonate.

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GTG Green-top Guideline No. 31.

Small-for-Gestational Age Fetus,
Investigation Management

With regard to the identification of women

of having small for gestational age (SGA)
and their management,
1. second trimester Down syndrome markers
have been shown to improve accuracy for the
delivery of SGA neonates.
2. those with an abnormal uterine artery Doppler
at 2024 weeks which subsequently normalises
are not at increased risk of having an
SGA neonate.
3. echogenic fetal bowel is an indication for serial
ultrasound measurement of fetal size and
assessment of wellbeing with umbilical
artery Doppler.
4. serial measurement of symphysio-fundal
height (SFH) from 24 weeks of gestation has

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at risk
fetuses

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Following the diagnosis of SGA,

5. it is recommended that karyotyping is
discussed and offered to those where
the uterine artery Doppler is normal.
6. serological screening for congenital
cytomegalovirus (CMV) is indicated if the
SGA is severe.

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With regard to interventions in the prevention of SGA,

7. antiplatelet agents such as aspirin have been
shown to be ineffective.
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In cases of diagnosed SGA,
8. it is recommended that when the umbilical
artery Doppler is normal, it should be
repeated at least weekly.
9. in the preterm SGA, Doppler of the
middle cerebral artery is more useful in
timing delivery.
10. the use of biophysical profilometry in the
preterm SGA is not recommended.

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BJOG Maternal and perinatal consequences

of antepartum haemorrhage of unknown
origin

Antepartum bleeding of unknown origin,

1. includes mild cases of placental separation.
2. includes bleeding from vasa praevia.
3. is an uncommon cause of bleeding
in pregnancy.

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Risk factors for antepartum bleeding of unknown

origin include,
4. previous history of bleeding in pregnancy.
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5. lower socio-economic status.
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Compared to those without antepartum bleeding of
unknown origin, pregnancies complicated by this
condition are at a higher risk of:
6. spontaneous preterm delivery.
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7. congenital malformations in the neonate.
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8. delivery by caesarean section.
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9. preterm prelabour rupture of fetal membranes. T h F h
10. postpartum haemorrhage.
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Reference
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Bhandari S, Raja EA, Shetty A, Bhattacharya S. Maternal and perinatal

consequences of antepartum haemorrhage of unknown origin. BJOG
2014;121:4452.

2014 Royal College of Obstetricians and Gynaecologists