DOI: 10.1111/tog.

12076 2014;16:58–63
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 16 number 1

CPD credits can be claimed for the following questions Concerning factors that affect the achievement of MDG4,
online via the TOG CPD submission system. You must be a
11. a mother being alive reduces by one half the
registered CPD participant of the RCOG CPD programme
chances of her child dying by 5 years. ThFh
(available in the UK and worldwide) in order to submit your
12. training is not a barrier to implementation
answers. Participants will need to log in to the RCOG website
of evidence to reduce under-5 mortality
(www.rcog.org.uk) and go to the ‘Our Profession’ tab.
into practice. ThFh
Participants can claim 2 credits per set of questions if at
13. approximately half of health workers in low
least 70% of questions have been answered correctly. At least
resource settings cannot perform basic
50 credits must be obtained in this way over the 5-year cycle.
neonatal resuscitation. ThFh
Please direct all questions or problems to the CPD Office.
14. women are usually in charge of their own
Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk
access to care in low resource settings. ThFh
The blue symbol denotes which source the questions refer
to including the RCOG journals, TOG and BJOG, and RCOG With regard to the provision/delivery of services that may
guidance, such as Green-top Guidelines (GTG) and Scientific affect the attainment of MDG4 goals,
Impact Papers (SIPs). All of the above sources are available to
15. user fees are the main cost consideration of
RCOG members and fellows via the RCOG website.
accessing care. ThFh
16. poor quality services are poorly attended. ThFh
TOG Millennium Development Goal 4 – 17. inequality and inequity essentially mean the
reducing perinatal and neonatal mortality same thing. ThFh
in low resource settings 18. outcomes have improved most for those easy
to reach. ThFh
With regard to Millennium Development Goals (MDGs),
19. caesarean section rate is approximately 1%
1. they are important for highlighting health issues. T h F h for the poorest fifth of the population in
2. the target is to reduce mortality of those aged some countries. ThFh
≤5 years by 50%. ThFh 20. many of the possible solutions to reach MDG4
3. stillbirth is not addressed by the MDGs. ThFh targets are known. ThFh
With regard to neonatal death, stillbirth and perinatal
mortality, TOG Retinoids and pregnancy: an update
4. the definition of neonatal death is babies who With regard to isotretinoin,
die within 7 days of being born. ThFh
1. its mode of action is to reduce sebum secretion. ThFh
5. the key factor in improving neonatal mortality
2. it is used as a first-line treatment for acne. ThFh
is political commitment. ThFh
3. it has an elimination half-life of less than
6. neonatal training packages for traditional birth
10 hours. ThFh
attendants have been shown to reduce perinatal
4. the dose prescribed is adjusted according to
and neonatal death by more than 20%. ThFh
the patient’s weight. ThFh
7. antenatal corticosteroids for those women in
5. the estimated pregnancy rate while on
preterm labour could save over 300 000
treatment is around 1%. ThFh
babies annually. ThFh
8. kangaroo mother care is less effective than Regarding side effects of retinoids (such as isotretinoin)
nursing in an incubator for stable babies. ThFh including their teratogenicity,
9. birth spacing has no effect on
pregnancy outcomes. ThFh 6. mood disturbance is well documented. ThFh
10. malaria contributes to 100 000 neonatal 7. derivatives of the mesonephric duct are
deaths annually. ThFh recognised malformations. ThFh

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8. limb deformities are common.
9. their use in pregnancy is associated with
ear abnormalities.
With regard to the incidence of teratogenic effects of
isotretinoin,
10. 30% of affected fetuses have been reported to
perform poorly in neuropsychological tests. ThFh
11. approximately half of fetuses exposed to them
suffer from mental retardation. ThFh
12. about a third of fetuses exposed to them have
retinoid specific fetal malformations. ThFh
Concerning the pregnancy prevention programme in those
being placed on isotretinoin;
13. the programme was launched in 2005 in the UK. T h F h
14. contraception should be used for 1 month
prior to and 2 months following treatment. ThFh
15. pregnancy tests should be taken monthly
throughout treatment. ThFh
Isotretinoin,
16. exerts its teratogenic effect through a
mechanism that does not significantly affect
vitamin A levels. ThFh
17. affects the development of the branchial arches
by effecting haemopexin signalling. ThFh
18. is associated with a miscarriage of over 20%
when used in the first trimester. ThFh
Concerning retinoid embryopathy,
19. topical application is not associated with an
increased risk. ThFh
20. the most common malformations are those of
the musculoskeletal system. ThFh
TOG Abdominal incisions and sutures in
obstetrics and gynaecology
ThFh 5. A Joel-Cohen incision is located slightly lower
than a Pfannenstiel incision. ThFh
ThFh 6. The incidence of wound dehiscence is lower with
paramedian compared with median incisions. ThFh
7. A caesarean section through the Joel-Cohen
incision carries less postoperative febrile
morbidity when compared to that through a
Pfannenstiel incision. ThFh
8. A transverse incision is associated with
reduced incidence of wound dehiscence
compared with a vertical incision. ThFh
With regard to skin incisions for laparoscopic surgery,
9. those that are more than 7 mm will need
formal deep sheath closure. ThFh
Which of the following statements is/are true?
10. The primary function of a suture is to
maintain tissue approximation during healing. ThFh
11. Wound infection rate is higher with braided
compared with monofilament sutures. ThFh
12. Non-absorbable sutures are associated with
reduced incidence of wound dehiscence. ThFh
13. PDS (polydiaxanone) is a braided suture with
high tissue reaction. ThFh
14. Polypropylene is a monofilament suture with
least tissue reaction. ThFh
15. Vicryl rapide is absorbed in 60–90 days. ThFh
With regard to use of staples for closure,
16. the non-absorbable variety has the highest
tensile strength of any wound closure device. ThFh
17. contaminated wounds closed with staples have
a lower incidence of infection compared with
those closed with sutures. ThFh
18. the absorbable varieties have a tissue half-life
of 10 weeks. ThFh
With regard to electrosurgery,

With respect to the risk of surgical site infection following 19. it is associated with poor wound healing when
abdominal incisions, used to incise the skin. ThFh
20. the use of a separate scalpel for superficial and
1. it is reduced with preoperative deep incisions is recommended. ThFh
antiseptic showering. ThFh
2. it is reduced if the site is depilated preoperatively. T h F h
3. it is increased approximately seven-fold by TOG Urinary tract injuries in laparoscopic
morbid obesity. ThFh gynaecological surgery; prevention,
Which of the following is/are true about abdominal recognition and management
incisions? With regard to bladder injuries at laparoscopic
4. In a Pfannenstiel incision, the layers of the gynaecological surgery,
abdominal wall are cut transversely, including 1. they are the second most common
the rectus muscle. ThFh visceral injury. ThFh

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2. the commonest site is the bladder’s dome. ThFh 20. trans-uretero-ureterostomy is a repair
3. cancer is a known risk factor. ThFh technique appropriate for major injuries at the
4. the incidence of fistula formation following a upper third of the ureter. ThFh
bladder injury is approximately 0.5%. ThFh
With regard to injuries from electrosurgery in TOGNerve injuries associated with
gynaecological laparoscopy, gynaecological surgery
5. thermal bladder or ureteric injuries are known Regarding the pathophysiology of nerve injury,
to present late due to delayed tissue breakdown. T h F h
1. neuropraxia involves disruption of the axon
6. brief intermittent activation prevents
and Schwann cells. ThFh
unnecessary thermal spread. ThFh
2. neurotmesis has a good prognosis without
7. both the tip and the heel of the active electrode
restorative surgery. ThFh
are recognised to be potential causes of
3. axonotmesis usually resolves with conservative
thermal damage. ThFh
management within months. ThFh
With regard to the identification and management of
The femoral nerve,
bladder injuries,
4. is the nerve most commonly damaged during
8. uroperitoneum is painless. ThFh
gynaecology surgery. ThFh
9. serum creatinine is likely to be elevated in a
5. is compressed against the pelvic side wall from
woman sustaining a bladder injury. ThFh
deeply seated self-retaining retractors. ThFh
10. repair by laparotomy should be the first
option when a bladder injury occurs during a Regarding pelvic nerve neuropathies,
laparoscopic operation. ThFh
6. foot drop is a feature of obturator nerve injury. ThFh
11. post operative bladder drainage reduces the
7. pain relief following the administration of a
risk of fistula formation. ThFh
local anaesthetic is diagnostic of ilioinguinal/
12. conservative management of a small
iliohypogastric neuropathy. ThFh
retropubic bladder injury has been shown to
8. gluteal, perineal and vulval pain following a
be effective in some cases. ThFh
sacrospinous ligament fixation are features of
With regard to ureteric injuries at laparoscopic pudendal nerve neuropathy. ThFh
gynaecological surgery, 9. following a Pfannenstiel incision, about 20%
of patients report ilioinguinal or
13. the commonest site is at the level of the
iliohypogastric related nerve injury. ThFh
ovarian fossa. ThFh
10. the genitofemoral nerve is susceptible to injury
14. the commonest type of injury is ligation. ThFh
during removal of the external iliac nodes. ThFh
15. preoperative stenting has been proven to be of
11. an obturator nerve neuropathy is the likely culprit
benefit in cases of severe endometriosis with
of a patient who reports a burning sensation
ureteric involvement. ThFh
radiating to the mons pubis and thigh following a
16. computed tomography intravenous urogram
retropubic mid urethral tape procedure. ThFh
is an appropriate investigation when
12. meralgia paraesthesia is a feature of
suspecting such an injury. ThFh
genitofemoral nerve neuropathy. ThFh
With regard to the repair of ureteric injuries in
The brachial plexus,
laparoscopic gynaecological surgery,
13. originates from C7–T1 nerve roots. ThFh
17. the type of repair is mainly dependent on the
preference of the individual surgeon. ThFh Ulnar nerve neuropathy,
18. where crush injuries are minor, conservative
14. causes wrist drop. ThFh
management has been shown to be an
15. presents with sensory loss over the lateral 3½
effective option. ThFh
fingers of the hand. ThFh
19. uretero-neocystostomy (with or without psoas
hitch or Boari flap) is the most appropriate With regard to brachial plexus neuropathy,
repair technique for major injuries at the
16. hyper-abduction of the arm greater than 90
lower third of the ureter. ThFh
degrees is associated with an Erb’s palsy. ThFh

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Regarding the prevention and treatment of neuropathy sperm on a regular basis (unexplained or
associated with surgery, mild male factor infertility) do not
benefit from clomiphene citrate. ThFh
17. patient mal-positioning is the most likely
12. surgical reversal of tubal sterilisation is less
cause of intraoperative nerve-related injury. ThFh
successful than IVF. ThFh
18. gamma-aminobutyric acid (GABA)
13. hydrosalpinx is an end stage of distal tubal
antagonists are not effective in treating
disease. ThFh
surgical nerve related neuropathies. ThFh
14. intrauterine insemination has been shown to
19. detailed neurological examination and
benefit couples with unexplained infertility. ThFh
electromyographic (EMG) studies are key in
15. salpingectomy followed by IVF is the
diagnosing neurologic deficit. ThFh
recommended treatment for hydrosalpinx
20. the majority of neuropathies following surgery
associated infertility. ThFh
resolve spontaneously without intervention. ThFh
Regarding factors associated with infertility,
16. Chlamydia is the single largest cause of
TOG The role of tubal patency tests and acquired tubal pathology. ThFh
tubal surgery in the era of assisted 17. proximal tubal disease accounts for
reproductive techniques approximately 25% of causes of tubal
factor infertility. ThFh
Regarding in vitro fertilisation (IVF),
Concerning transvaginal 2-D ultrasound,
1. it was developed primarily as an alternative
to tubal surgery for the treatment of tubal 18. it has a sensitivity of approximately 85% for
factor infertility. ThFh the diagnosis of hydrosalpinx. ThFh
Concerning tubal patency tests, With regard to selective salpingography,
2. laparoscopy is widely considered to be the gold 19. it is associated with lower false positive rates
standard test. ThFh from tubal spasm. ThFh
3. hysterosalpingogram (HSG) has a low 20. it is used primarily to assess tubal patency
sensitivity and high specificity. ThFh where other tests are not recommended. ThFh
4. radiation exposure during an HSG is
significantly lower than from standard
chest X-ray. ThFh TOG Selective progesterone receptor
5. approximately 2% of patients develop pelvic modulators (SPRMs) and their use within
infection following HSG. ThFh gynaecology
6. with hysterosalpingo contrast sonography
With regard to mifepristone,
(HyCoSy) there is a higher likelihood of
uncertainty when reporting (neither patent nor 1. it is a progesterone antagonist. ThFh
occluded) compared with HSG. ThFh 2. it has no effect on glucocorticoids. ThFh
7. with tubal catheterisation, the risk of (tubal)
With regard to ulipristal acetate,
perforation is approximately 4%. ThFh
8. fertiloscopy is an outpatient technique which 3. it is licensed for use as an
combines hysteroscopy, transvaginal hydro emergency contraceptive. ThFh
laparoscopy and salpingoscopy. ThFh 4. in the UK it is licensed for the preoperative
treatment of uterine fibroids. ThFh
With regard to surgery and treatment for infertility,
5. it is not available as an oral preparation. ThFh
9. opportunistic treatment of mild or minimal
With regard to the actions of progesterone,
endometriosis and peri-adnexal adhesions does
not confer any significant therapeutic benefit. ThFh 6. selective progesterone receptor modulators
10. previous pelvic surgery is not a risk factor for (SPRMs) effectively reduce circulating levels
tubo-peritoneal pathology associated with of estrogen. ThFh
tubal factor infertility. ThFh 7. selective progesterone receptor modulators
11. there is strong evidence to suggest that women produce a pure antagonist effect on the
who are otherwise ovulating and exposed to progesterone receptor. ThFh

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 CPD

8. activation of human progesterone receptor B Regarding key cases that influence medico-legal
(hPR-B) counteracts estrogen-induced rulings,
endometrial proliferation. ThFh
6. the Roe ruling states that a defendant can be
9. hPR-Bs are involved in proliferation of
subsequently liable if more recent medical
breast tissue. ThFh
knowledge shows that they should have
With regard to the management of fibroids with SPRMS. acted otherwise. ThFh
7. the Ashcroft ruling states that the burden of
10. they have been shown to reduce fibroid proof lies with the claimant to prove that on
volume by over 10%. ThFh the balance of probabilities the defendant
11. they have been shown to significantly increase was negligent. ThFh
breast tenderness. ThFh 8. according to Hunter, departure from routine
With regard to the mode of action of and uses of SPRMS, practice automatically constitutes negligence. ThFh
9. according to Crawford the standard of
12. they inhibit ovulation by blocking the medical knowledge and its application will
luteinising hormone surge. ThFh be judged on the basis of publication in
13. they have no effect on implantation. ThFh medical journals. ThFh
14. ulipristal acetate is effective emergency 10. according to Bolam the law imposes the duty
contraception when used for up to 120 hours of care; but the standard of care is a matter of
after unprotected intercourse. ThFh medical judgement. ThFh
15. ulipristal acetate can be used more than once 11. Chester states that a patient does not need to
in any menstrual cycle. ThFh be informed of a risk if it would not have
16. amenorrhea rates of over 80% have been changed the claimant’s decision to proceed
observed with asoprisnil. ThFh with the treatment. ThFh
17. they are licensed for use as long-term
contraceptives in the UK. ThFh Regarding overall claims for clinical negligence,
18. the exact mechanisms by which they induce 12. the maximum number of claims are made
amenorrhoea are unknown. ThFh in gynaecology. ThFh
13. the value of claims are highest for obstetrics. ThFh
Concerning the side-effects of SPRMS,
Regarding insurance cover,
19. their use has been linked with pre-malignant and/
or malignant endometrial histological changes. ThFh 14. doctors need either Medical Defence Union
20. they should be used with caution in those (MDU) or Medical Protection Society (MPS)
with hypertension. ThFh cover for NHS work. ThFh
15. the NHS Litigation Authority advises the NHS
on human rights case law. ThFh
TOG Litigation in gynaecology Regarding valid consent,
Within the remit of obstetrics and gynaecology,
16. a patient’s signature on a consent form implies
1. claims should be made within 5 years of valid consent. ThFh
the injury. ThFh 17. research has identified that the best way to
2. children who have suffered an injury are communicate uncertainty about harms
allowed to make a claim any time up to their and benefits of treatment to patients is
21st birthday. ThFh through videos. ThFh
3. it is recommended that claims by those who
Regarding sterilisation,
lack capacity are made within 10 years of
the injury. ThFh 18. medicolegal law states that parents are entitled
to the cost of bringing up a child if it is born as
Of the total claims made,
a result of failed sterilisation. ThFh
4. 5–10% reach court. ThFh
With regard to taking responsibility,
5. there is about a 40% chance that a case will be
defended successfully. ThFh 19. saying sorry equates to admitting liability. ThFh

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 CPD

In gynaecology malpractice suits, considering hysterectomy in a

20. if an adult dies as a result of their medical
treatment, their personal representatives or
dependants are allowed to bring a claim within
3 years of the date of their death. ThFh
BJOG Menstrual and fertility outcomes
following surgical management of
postpartum haemorrhage: A systematic
review
With regard to postpartum haemorrhage (PPH),
1. it is a major cause of maternal morbidity and
mortality, which is responsible for up to 25% of
all maternal deaths worldwide. ThFh
2. approximately 15% of all births are complicated
by loss of greater than 1000 ml. ThFh
In the management of PPH,
3. if bimanual uterine compression and
pharmacological measures fail to control the
haemorrhage, hysterectomy should be
performed immediately. ThFh
4. intrauterine balloon tamponade is an
appropriate first line surgical intervention for
most women where uterine atony is the only or
main cause of haemorrhage. ThFh
5. it has been proposed that a second (or even a
third) uterine sparing procedure be performed
in case of a failed first procedure before
haemodynamically stable patient. ThFh
Following uterine compression sutures in the treatment of
PPH,
6. more than 90% women will have a normal
onset of menstruation. ThFh
7. more than 85% of women who had the desire
of pregnancy, achieved conception following
these procedures. ThFh
With regard to uterine artery embolisation (UAE),
8. the success rates for severe PPH have been
reported to be between 30 to 50%. ThFh
9. only 50% of the women resumed menstruation
within the normal time-frame after delivery
following the procedure. ThFh
10. only 45% of women who desired another
pregnancy achieved conception following UAE
for PPH. ThFh
Reference
Doumouchtsis SK, Nikolopoulos K, Talaulikar VS, Krishna A, Arulkumaran S.
Menstrual and fertility outcomes following surgical management of
postpartum haemorrhage: A systematic review. BJOG 2013; DOI: 10.
1111/1471-0528.12546.

Erratum

Tang T, Abdelrahman A. Website reviews@TOG. The Obstetrician & Gynaecologist 2013;15:283

In the article detailed above, there was an error in the spelling of the first name of the second author. ‘Abdelmagreed’ should
have been spelled ‘Abdelmageed’.
The Publisher and Editors apologise for the error.

DOI: 10.1111/tog.12080

ª 2014 Royal College of Obstetricians and Gynaecologists 63