DOI: 10.1111/tog.

12540 2019;21:59–63
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 21 number 1

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TOG Evolution in screening
for Down syndrome
The serum levels of the following fetoplacental products
are raised in pregnancies with fetal trisomy 21,
1. alphafetoprotein. ThFh
2. unconjugated estriol. ThFh
3. free ß-human chorionic gonadotrophin. ThFh
4. inhibin A. ThFh
5. pregnancy-associated plasma protein A. ThFh
With regard to Down syndrome screening tests,
6. the detection rate is the ability of a test to give a
positive result in individuals who have the
condition being screened for. ThFh
7. the screen-positive rate is the proportion of
affected and unaffected individuals yielding a
positive result. ThFh
8. the false positive rate is the proportion of
unaffected individuals yielding a positive result. T h F h
In relation to screening tests for the detection of a fetus with
Down syndrome,
9. using a maternal age of >35 years has a
detection rate of 70% for a false positive rate
of 5%. ThFh
10. using second trimester biochemistry (quadruple
test) has a detection rate of 75% for a false
positive rate of 5%. ThFh
11. using the combination of nuchal translucency
and serum biochemistry in the first trimester
has a detection rate of 90% for a false positive
rate of 5%. ThFh
12. the cell-free DNA test detects >99% of fetuses
with Down syndrome for a false positive rate
of <0.1%. ThFh
Regarding Down syndrome screening in twin pregnancies,
13. the detection rate of Down syndrome in twins
using the first trimester combined test is the
same as it is in singletons. ThFh
14. the first trimester combined test has a higher
false positive rate in the monochorionic than
in dichorionic type. ThFh
15. the risk of Down syndrome in monochorionic
twins is the average of the individual risks of
each twin obtained from a first trimester
combined test. ThFh
16. the rate of failure to obtain a result in the cell-
free DNA test is higher in monochorionic than
in dichorionic types. ThFh
With regard to cell-free DNA testing on maternal blood,
17. its performance in screening for trisomies is
dependent on the fetal DNA fraction. ThFh
18. its use to screen for sex chromosome
aneuploidies is advisable. ThFh
19. the recommendation of the National
Screening Committee for implementation of
the cell-free DNA test in the NHS is dependent
on available funding. ThFh
20. offering this, rather than invasive testing, to
women identified by the first-trimester
combined test as being at high risk for trisomy
increases the detection rate. ThFh

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 CPD
TOG The transgender population:
improving awareness for gynaecologists
and their role within the provision of care
Regarding gender variance,
1. a 2012 survey of 10 000 people by the Equality
and Human Rights Commission found an
incidence of 1% in the survey population. ThFh
2. the Tavistock and Portman NHS Foundation
Trust, which provides a Gender Identity
Development Service for children and
adolescents, had 2018 new referrals in
2016–2017. ThFh
Regarding access to services for transgender patients,
3. the current waiting time from GP referral to
being seen in a Gender Identity Clinic in the
Tavistock and Portman Trust is 14 months. ThFh
Regarding Gender Identity Clinics,
4. they provide a service led by specialists in
adult gender dysphoria medicine. ThFh
Regarding hormone treatment,
5. gonadotrophin-releasing hormone analogues
are an option for use as ‘hormone blockers’ in
adolescents to delay puberty. ThFh
6. weekly monitoring of bloods is required when
a patient has commenced hormone therapy. ThFh
7. estrogen therapy leads to a reduction in libido. ThFh
8. if polycythaemia occurs with testosterone
treatment, it should be stopped
immediately. ThFh
9. transwomen who are at high risk of venous
thromboembolism should be prescribed
transdermal estrogen as opposed to oral
estrogen because it passes through the liver
and confers a lower thromboembolic risk. ThFh
With regard to gender reconstructive surgery,
10. patients should have lived in the gender role
that is congruent to their gender identity
before the surgery. ThFh
11. five units in the UK offer this type of surgery. ThFh
12. body contouring surgery is available on
the NHS. ThFh
13. transition at an early age is associated with a
low regret rate following this type of surgery. ThFh
With regard to the gynaecologist’s role in treating
transgender patients,
14. testosterone is recognised to be teratogenic. ThFh
60
15. ovarian tissue cryopreservation is a technique
that is widely used in fertility preservation
for transmen. ThFh
16. transgender individuals are allowed to store
their gametes for up to 55 years. ThFh
17. a hysterectomy is advised in transmen after
4–5 years of testosterone treatment. ThFh
18. the preferred surgical approach for
hysterectomy is the abdominal route. ThFh
Regarding equality in health care,
19. in 2015, the World Health Organization
reported that one in five transmen refused
health care because doctors call them by the
wrong gender. ThFh
20. the General Medical Council has published
advice for doctors who treat trans patients. ThFh
TOG Continence surgery at the time of
pelvic organ prolapse repair: a review
of the literature
Pelvic floor muscle training,
1. increases the chance of improving prolapse
stage by more than 30% compared with
no treatment. ThFh
2. is associated with less improvement in
symptoms compared with synthetic
midurethral sling (SMUS) in women with
stress urinary incontinence (SUI). ThFh
Pelvic organ prolapse,
3. at or beyond stage 2 has been observed in up
to one in four women 12 years after
their first delivery. ThFh
4. affects an estimated one in five women. ThFh
5. and SUI coexist in up to 80% of women. ThFh
Urinary incontinence,
6. has been shown to be cured in 20–30% of
women who have had transvaginal prolapse
repair alone. ThFh
7. occurs in more than 50% of women over the
age of 40 years. ThFh
8. in women is most commonly the mixed type. ThFh
9. has been demonstrated preoperatively in
more than 50% of women after reduction
of prolapse. ThFh
Surgical treatment,
10. for SUI is required for approximately 10% of
parous women over a lifetime. ThFh
ª 2019 Royal College of Obstetricians and Gynaecologists
 CPD

11. for SUI is required for less than 50% of In the treatment of symptoms of vaginal estrogen deficiency,
women with symptomatic incontinence before
6. caution should be exercised when prescribing
and after vaginal prolapse repair. ThFh
phytoestrogens to those with a history of
Abdominal sacrocolpopexy, breast cancer. ThFh
7. systemic hormone replacement therapy (HRT)
12. was shown to result in significantly greater SUI should be used when symptoms are
in the CARE trial when combined with predominantly vaginal. ThFh
concomitant Burch colposuspension. ThFh 8. vaginal estrogen therapy is known to improve
13. when combined with Burch colposuspension, sexual function. ThFh
has been shown to have no significant increase 9. lasofoxifene is effective. ThFh
in serious adverse events compared 10. oral preparations of dehydroepiandrosterone
with sacrocolpopexy alone. ThFh are ineffective. ThFh
11. tissue-selective estrogen complexes have been
Regarding SMUS at the time of vaginal prolapse repair, shown to prevent bone loss. ThFh
14. in continent women with stage 3 or With regard to the treatment of vulvovaginal atrophy,
4 prolapse, retropubic tension-free vaginal
tape has been shown to reduce the rate 12. raloxifene is effective. ThFh
of postoperative SUI. ThFh 13. androgens are not implicated in female
15. a rate of bladder injury of up to 8.7% has sexual function. ThFh
been reported. ThFh 14. the various intravaginal estrogenic
preparations show different efficacy when
Occult SUI, compared with each other. ThFh
15. monitoring endometrial thickness in
16. has no standardised diagnostic test. ThFh
asymptomatic, low-risk women receiving low-
17. has a ten-fold higher detection rate with
dose vaginal estrogen is not indicated. ThFh
speculum testing compared with
16. the effect of moisturisers is longer lasting
ring pessary use. ThFh
compared with lubricants. ThFh
18. was detected in approximately one-third of
17. erbium laser is not an effective treatment in
women in the CARE and OPUS trials. ThFh
breast cancer survivors. ThFh
18. vaginal testosterone is an effective option. ThFh
Asymptomatic prolapse,
19. vaginal moisturisers imitate natural
19. of stage 2 has been reported in more than one- vaginal secretions. ThFh
third of women presenting 20. systematic HRT is best used in the presence of
with SUI symptoms. ThFh osteoporosis and/or vasomotor symptoms. ThFh
20. is unlikely to progress at up to 3 years of
follow-up. ThFh
TOG Routes to parenthood for women with
Turner syndrome
TOG Vaginal estrogen deficiency
With regard to the epidemiology of Turner syndrome (TS),
Concerning the vagina,
1. it is the second most common chromosomal
1. superficial to parabasal cell proportion aneuploidy in humans. ThFh
increases with age. ThFh 2. its incidence increases with
2. the bacterial population remains unchanged increasing maternal age. ThFh
after menopause. ThFh 3. approximately 1 in 100 affected fetuses
3. atrophy is underdiagnosed worldwide. ThFh are born alive. ThFh
With regard to vaginal estrogen deficiency, With regard to the clinical features of TS,
4. dyspareunia is the second most 4. most affected women have
common symptom. ThFh spontaneous menarche. ThFh
5. recurrent urinary tract infections occur in up to 5. those presenting with primary amenorrhea are
20% of postmenopausal women. ThFh likely to have suboptimal uterine development. T h F h

ª 2019 Royal College of Obstetricians and Gynaecologists 61

 CPD

Concerning the pathogenesis of TS, Regarding acute appendicitis in pregnancy,

6. there is accelerated atresia of primordial 4. the gravid uterus displaces the appendix,
follicles in the ovary. ThFh causing right upper-quadrant pain. ThFh
7. those who have spontaneous menarche are 5. erythrocyte sedimentation rate is a useful
likely to be mosaic. ThFh marker of underlying infection and
8. serum anti-m€ ullerian hormone does not inflammation in pregnancy. ThFh
correlate with karyotype. ThFh 6. it occurs most commonly in the third trimester. ThFh
7. diagnosis by ultrasound has a high specificity. ThFh
With regard to treatment of women with TS,
When investigating the causes of abdominal
9. estrogen replacement should be started at
pain in pregnancy,
15 years of age. ThFh
10. estrogen needs to be started at half the 8. if the patient is unstable, treatment should be
normal adult dose. ThFh delayed until appropriate imaging
11. when childbearing is complete, it is advisable has been organised. ThFh
to stop HRT. ThFh 9. magnetic resonance imaging is the most
sensitive imaging modality. ThFh
Regarding pregnancy in women with TS,
Regarding assessment of abdominal pain in pregnancy,
12. the most dramatic risk during pregnancy
is aortic dissection. ThFh 10. focal right upper-quadrant pain is more
13. the risk of maternal mortality is around 2%. ThFh common as biliary colic progresses
14. a history of aortic dissection is a definite to cholecystitis. ThFh
contraindication to pregnancy. ThFh 11. absolute constipation is a common feature of
small-bowel obstruction. ThFh
Concerning fertility in women with TS,
12. displacing the uterus during examination may
15. approximately 8% conceive naturally. ThFh help to differentiate uterine from extrauterine
16. there is an increased risk of miscarriage. ThFh causes of pain. ThFh
With regard to assisted reproductive technology in Regarding investigating abdominal pain in pregnancy,
women with TS,
13. cardiotocographic abnormalities are helpful to
17. in gestational surrogacy, the surrogate is differentiate obstetric from non-obstetric
genetically unrelated to the baby. ThFh causes of pain. ThFh
18. there are reliable data on outcomes after 14. teratogenesis is the most common fetal risk of
oocyte freezing and embryo freezing. ThFh exposure to ionising radiation. ThFh
19. ovarian tissue freezing is an option for fertility 15. lactate values are typically higher in pregnant
preservation, even before the onset of women compared to nonpregnant women. ThFh
puberty. ThFh 16. tests for serum lipase levels are more sensitive
20. preserved embryos are allowed to be used for and specific than those for serum amylase
treatment even if there is a relationship levels for the diagnosis of pancreatitis. ThFh
breakdown and the male partner withdraws
Regarding the treatment of non-obstetric abdominal
consent for the use of embryos created using
pathology,
his sperm. ThFh
17. the risks of surgery during pregnancy mean it
is usually best to defer surgery
TOG Surgical causes of acute abdominal until after delivery. ThFh
pain in pregnancy 18. anti-D prophylaxis is not required as long as
the uterus is not entered. ThFh
Concerning physiological changes during pregnancy,
With regard to visceral artery aneurysms,
1. total blood volume increases
by approximately 30%. ThFh 19. dissecting aortic aneurysms are the most
2. respiratory rate remains unchanged. ThFh common type in pregnancy. ThFh
3. oxygen consumption increases 20. less than 20% of splenic aneurysm ruptures
by approximately 20%. ThFh occur during pregnancy. ThFh

62 ª 2019 Royal College of Obstetricians and Gynaecologists

 CPD

2. the risk of urinary stress incontinence among

BJOG Neurological outcomes by mode of women with twin pregnancy and a prior history
delivery for fetuses with open neural tube of urinary stress incontinence is modified by
defects: a systematic review mode of birth. ThFh
and meta-analysis 3. planned caesarean section compared with
With regard to neural tube defects (NTDs), planned vaginal birth reduces the risk of
problematic urinary stress incontinence
1. they are most commonly associated with at 2 years among women with twin pregnancy. T h F h
structural anomalies of the musculoskeletal 4. planned caesarean section compared with
system/extremities. ThFh planned vaginal birth reduces the risk of
2. the absence of the sac differentiates myeloschisis flatal incontinence in women with
from meningocele and myelomeningocele. ThFh twin pregnancy. ThFh
3. the most common location is sacral. ThFh
4. the incidence varies by region. ThFh In this randomised controlled trial,
5. multifetal gestation is a risk factor. ThFh 5. a power calculation was performed assuming a
6. the recommended dose of folic acid for 10% rate of loss to follow-up. ThFh
pregnancies at low risk for their occurrence is 4 mg. ThFh 6. data were analysed according to the group to
Regarding open NTDs, which the participants were assigned (i.e.
planned caesarean section or planned vaginal
7. the most commonly associated brain birth), regardless of the ultimate mode of birth. T h F h
abnormality is Chiari malformation type II. ThFh
8. there have been prospective randomised trials Regarding randomised controlled trials,
evaluating mode of delivery. ThFh 7. Allocation concealment is a technique used to
Regarding the MOMS trial, prevent selection bias. ThFh
8. Blinding ensures that the person randomising
9. the primary outcome was ambulation at 2 years. T h F h the patient does not know what the next
10. shunt requirement was found to be significantly treatment allocation will be. ThFh
reduced in the prenatal repair group. ThFh 9. The CONSORT statement sets out
recommendations for reporting randomised
controlled trials. ThFh
Reference 10. A core outcome set is an agreed minimum set
1 Tolcher MC, Shazly SA, Shamshirsaz AA, Whitehead WE, Espinoza J, Vidaeff AC, of standardised outcomes that should be
Belfort MA, Nassr AA. Neurological outcomes by mode of delivery for fetuses measured and reported in all clinical trials of a
with open neural tube defects: a systematic review and meta-analysis. BJOG
2018; https://doi.org/10.1111/1471-0528.15342. [Epub ahead of print].
specific condition. ThFh

BJOGUrinary stress incontinence and other Reference

maternal outcomes 2 years after caesarean 1 Hutton EK, Hannah ME, Willan AR, Ross S, Allen AC, Armson BA, Gafni
or vaginal birth for twin pregnancy: a A, Joseph KS, Mangoff K, Ohlsson A, Sanchez JJ, Asztalos EV, Barrett
JFR, for the Twin Birth Study Collaborative Group. Urinary stress
multicentre randomised trial incontinence and other maternal outcomes 2 years after caesarean or
vaginal birth for twin pregnancy: a multicentre randomised trial. BJOG
This study demonstrates that, 2018; 125:1682–90.

1. planned caesarean section compared with

planned vaginal birth reduces the prevalence
and severity of urinary stress incontinence at 2
years in women with twin pregnancy. ThFh

ª 2019 Royal College of Obstetricians and Gynaecologists 63