DOI: 10.1111/tog.
12757 2021;23:220–3
The Obstetrician & Gynaecologist
http://onlinetog.org
CPD questions for volume 23 issue 3
CPD credits can be claimed for the following questions
online via the TOG CPD submission system in the RCOG
CPD ePortfolio. 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 can claim 2 credits per set of questions if at
least 70% of questions have been answered correctly. CPD
participants are advised to consider whether the articles are
still relevant for their CPD, in particular if there are more
recent articles on the same topic available and if clinical
guidelines have been updated since publication.
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 (GTGs) and
Scientific Impact Papers (SIPs). All of the above sources are
available to RCOG Members and Fellows via the RCOG
website. RCOG Members, Fellows and Associates have full
access to TOG content via the TOG app (available for iOS
and Android).
TOGFertility on ice: an overview of fertility
preservation options for children and
young adults with cancer
Regarding childhood cancer,
1. overall survival is now greater than 80%. ThFh
2. chemotherapy received prepubertally should
not affect future fertility. ThFh
3. the effects of chemotherapy are related to the
type of agent used as well as the cumulative
dose received. ThFh
Regarding fertility preservation for postpubertal females,
4. ovarian tissue cryopreservation is considered
first-line. ThFh
5. vitrification is a process of cryopreservation
using high concentrations of cryoprotectants
and rapid cooling. ThFh
6. oocyte vitrification was re-classified from
experimental to nonexperimental by the
American Society of Reproductive Medicine
220
CPD
(ASRM) and the European Society for Human
Reproduction and Embryology (ESHRE). ThFh
7. the process of ovarian stimulation is usually of
2 weeks duration and involves self-
administration of follicle-stimulating
hormone injections. ThFh
Regarding ovarian tissue cryopreservation,
8. it involves laparoscopic surgery to remove all
or part of the ovary, followed by
cryopreservation of the excised tissue with a
view to autotransplantation in the future. ThFh
9. from a restoration of fertility perspective,
heterotopic transplantation is the preferred
method compared with
orthotopic transplantation. ThFh
10. it usually will delay commencement of cancer
treatment by 2–3 weeks. ThFh
11. there have been less than 50 live births
reported worldwide from this. ThFh
Regarding in-vitro maturation (IVM) of oocytes,
12. it avoids the need for ovarian stimulation. ThFh
13. it usually results in a delay in cancer treatment
of 2–3 weeks. ThFh
14. there have been more than 100 live births
reported following IVM for cancer patients. ThFh
15. a concern with this is that it carries the
potential risk of malignant contamination. ThFh
Regarding fertility preservation for patients with cancer,
16. testicular tissue cryopreservation is
considered experimental. ThFh
17. ovarian transposition is an effective method
of fertility preservation for both pre- and
postpubertal girls requiring pelvic radiation
for non-ovarian tumours. ThFh
18. the overall efficacy of ovarian transposition is
reported to be greater than 90%. ThFh
19. research suggests that patients and their
parents often do not recall discussions
regarding fertility around the time of a
cancer diagnosis. ThFh
ª 2021 Royal College of Obstetricians and Gynaecologists
 CPD

20. research suggests that cancer survivors prognosis according to the the International
(including adults) are approximately 40% less Germ Cell Consensus Group classification. ThFh
likely to achieve pregnancy. ThFh
When counselling women undergoing fertility conserving
surgery, they should be informed that,
TOG Nonepithelial ovarian cancers 19. following a unilateral salpingo-
Malignant germ cell tumours, oophorectomy, they will enter menopause on
average 2 years earlier than women with both
1. represent approximately 90% of pre-adolescent ovaries intact. ThFh
ovarian malignancies. ThFh 20. following unilateral salpingo-ophorectomy,
2. have a 5-year relative survival rate greater than the rate of successful pregnancy is lower than
95% for all stages combined. ThFh for women with both tubes and ovaries intact. T h F h
3. are commonly managed with a bleomycin,
etoposide and cisplatin chemotherapy regimen
in women under the age of 40 years old. ThFh TOG Intrauterine contraception
With regard to intrauterine contraceptive devices,
Sex cord-stromal tumours,
1. Jaydess contains 52 mg of levonorgestrel. ThFh
4. arise from a wide range of cells including theca 2. Levosert has a licence for 5 years for the
cells, fibroblasts and Sertoli cells. ThFh treatment of heavy menstrual
5. have better 5-year relative survival rates than bleeding (HMB). ThFh
germ cell tumours for similar stages of disease. T h F h 3. Jaydess has a licence for 5 years for the
6. require regular follow-up starting 5 years treatment of HMB. ThFh
post-treatment. ThFh 4. the copper ball is licensed for 10 years for
contraceptive use. ThFh
Granulosa cell tumours are, 5. the levonorgestrel-containing intrauterine
7. associated with mutations in the DICER1 gene. T h F h system (LNG-IUS) is the most effective at
8. recognised to present with abnormal preventing pregnancy. ThFh
uterine bleeding. ThFh 6. there is a delay in return of fertility for 6
9. associated with endometrial hyperplasia. ThFh months post-removal. ThFh
7. the copper intrauterine device (IUD) is the
With regard to small cell carcinoma of the ovary, most effective form of
hypercalcaemic type, emergency contraception. ThFh
8. if a patient who attends to have one fitted has a
10. approximately 50% of tumours have extra-
negative pregnancy test, insertion should
ovarian spread at diagnosis. ThFh
proceed without the need to ask about
11. the 5-year survival is approximately 10%. ThFh
prior contraception. ThFh
12. most are unilateral. ThFh

With regard to ovarian sarcomas, With regard to the safety of IUDs,

13. approximately 50% occur in 9. the perforation rate is about 2 per 1000. ThFh
postmenopausal women. ThFh 10. they increase ectopic pregnancy rates
14. the mean age at diagnosis is in the fifth decade when compared with non-users
of life. ThFh of contraception. ThFh
15. carcinosarcoma is the most common subtype. ThFh 11. the most commonly reported side-effect with
16. most women at presentation have the LNG-IUS use is problematic bleeding. ThFh
distant metastases. ThFh 12. treatment for vasovagal attack during
insertion is with sc adrenaline. ThFh
With regard to tumour markers,
With regard to the noncontraceptive benefits of IUDs,
17. inhibin B is secreted by granulosa
cell tumours. ThFh 13. a woman using Mirena for HMB only can
18. a serum human chorionic gonadotrophin level only use it for 5 years if it is controlling
over 5000 mIU/mL is associated with poor her symptoms. ThFh

ª 2021 Royal College of Obstetricians and Gynaecologists 221

 CPD

14. Mirena is the first-line treatment for women 9. placentae in Barts Hydrops cases have a classic
with a fibroid of 4 cm in diameter. ThFh ‘thinned-out’ appearance. ThFh
15. when Mirena is being used as the
progestogenic component of menopausal In the UK there is an established antenatal screening
hormone therapy, it is recommended to be programme for,
changed after 5 years. ThFh 10. red cell alloimmunisation. ThFh
16. if a woman has Mirena inserted at the age of 11. cytomegalovirus. ThFh
46 for the management of HMB it is an 12. haemoglobinopathies. ThFh
effective contraceptive even if she
is amenorrhoeic. ThFh In monochorionic twins,
17. Mirena is an effective option for the 13. twin anaemia polycythaemia sequence (TAPS)
treatment of premenstrual is more common after fetoscopic laser
syndrome symptoms. ThFh ablation for feto-fetal transfusion syndrome. T h F h
18. Mirena is the treatment of choice for women 14. there is no significant liquor volume
with endometrial hyperplasia with atypia discordance in TAPS. ThFh
desiring fertility preservation. ThFh 15. death of one fetus in utero will not
increase perinatal morbidity in the surviving
In the follow-up of women who have had an IUD fitted,
co-twin. ThFh
19. expulsion rates are highest in the first 3
months post-insertion. ThFh With regard to ultrasound assessment in fetal anaemia,
20. the diagnosis of pelvic inflammatory disease is 16. umbilical artery Doppler velocimetry is a
an indication for removal of the device. ThFh sensitive screening test. ThFh
17. middle cerebral artery peak systolic velocity
TOG Identification and management of has a better sensitivity than magnetic
fetal anaemia: a practical guide resonance imaging in diagnosis. ThFh

Regarding red cell alloimmunisation, Neonates with haemolytic disease of the newborn,
1. blood transfusion is the leading cause 18. are less likely to need a blood transfusion if
in women. ThFh deferred cord clamping is practiced. ThFh
2. cell-free fetal DNA testing has eliminated the 19. will clear maternal antibodies in their
need for invasive testing for red cell circulation within the first month of life. ThFh
antigen genotypes. ThFh 20. are at an increased risk of developing
3. pregnant women with anti-Kell antibodies cholestatic jaundice it they have had
should be referred to a fetal medicine specialist intrauterine transfusion. ThFh
regardless of titre. ThFh
TOG Antenatal venous thromboembolism
Parvovirus B19,
Regarding venous thromboembolism (VTE) in pregnancy,
4. causes more obvious symptoms in children
than in adults. ThFh 1. there has been a reduction in the incidence of
5. is more likely to result in fetal loss if infection maternal mortality from pulmonary
occurs in the first half of pregnancy. ThFh embolism (PE). ThFh
6. causes fetal anaemia predominantly through 2. deep venous thrombosis (DVT) is the most
red blood cell haemolysis. ThFh common manifestation. ThFh
3. less than 50% of women who develop PE have
identifiable risk factors. ThFh
Regarding inherited anaemias, 4. over 50% of women who have an untreated
7. beta thalassaemia is the commonest DVT will develop PE. ThFh
inherited anaemia. ThFh
8. parents with with alpha thalassaemia trait have Regarding the diagnosis of VTE in pregnancy,
a 1:2 chance of having a child with 5. most women who present with this
the condition. ThFh complication are symptomatic. ThFh

222 ª 2021 Royal College of Obstetricians and Gynaecologists

 CPD

6. computerised tomography pulmonary 14. LMWH is associated with greater than 20%
angiogram (CTPA) is associated with a higher rates of antepartum and
risk of maternal breast cancer than ventilation/ postpartum haemorrhage. ThFh
perfusion (V/Q) scanning. ThFh
7. D-Dimer is a well-established diagnostic tool. ThFh Regarding the use of inferior vena cava filters,
8. V/Q scanning is known to carry an increased
15. when indicated, insertion via the internal
risk of childhood cancer in the offspring when
jugular vein is preferable. ThFh
compared with CTPA. ThFh
16. there is a risk of renal vein thrombosis with
9. scoring systems are of no value in the diagnosis
supra-renal placement. ThFh
of VTE in pregnancy. ThFh
Regarding follow-up of women diagnosed with VTE
Regarding the management of VTE in pregnancy,
in pregnancy,
10. vitamin K antagonists are contraindicated in
17. LMWH should be continued for a minimum
the antenatal period. ThFh
of 6 weeks postnatally and until at least 3
11. low-molecular-weight heparin (LMWH) is
months of treatment has been given. ThFh
preferred over unfractionated heparin as first-
18. warfarin is contraindicated in breastfeeding. ThFh
line management antenatally. ThFh
19. newer agents (such as rivaroxaban, dabigatran
12. heparin-induced thrombocytopenia is a
and apixaban) can be safely used postnatally
common side effect of LMWH. ThFh
in women who are breastfeeding. ThFh
13. anti-Xa assays are recommended to monitor
20. routine thrombophilia testing is
LMWH dosing. ThFh
not recommended. ThFh

ª 2021 Royal College of Obstetricians and Gynaecologists 223