DOI: 10.1111/tog.
12170 2015;17:62–7
The Obstetrician & Gynaecologist
http://onlinetog.org
CPD questions for volume 17 number 1
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guidance, such as Green-top Guidelines (GTG) and Scientific
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ST analysis for intrapartum fetal
TOG
monitoring
With regard to use of cardiotocography (CTG) and ST
analysis (STAN),
1. the principle of STAN relies on the release of
potassium ions during glycogen breakdown in
anaerobic metabolism within fetal
myocardium following oxygen deficiency,
resulting in electrocardiogram (ECG) changes,
which are picked up as STAN events. ThFh
2. STAN monitoring looks for changes in fetal
ECG and compares them with the baseline
ECG at the start of the monitoring. ThFh
3. the use of STAN monitoring does not
significantly reduce the rate of emergency
caesarean section. ThFh
4. operative vaginal delivery rate is reduced by
approximately 11% with the use of STAN
monitoring in comparison to CTG. ThFh
With regard to starting STAN,
5. it cannot be started in labour where the
woman has already been on CTG monitoring. ThFh
6. where atypical decelerations are present on
prior CTG for 40–60 minutes, commencing
STAN is not advised. ThFh
62
CPD
7. where normal baseline fetal heart rate and
variability are maintained on a prior CTG,
commencing STAN is appropriate. ThFh
8. where a normal baseline fetal heart rate is
maintained but variability is reduced on a
prior CTG for more than 40 minutes,
performing fetal blood sampling before
commencing STAN is a reasonable option. ThFh
9. STAN in combination with CTG has been
shown to significantly reduce the incidence of
hypoxic ischaemic encephalopathy. ThFh
With regard to interpreting STAN,
10. if the ST analysis as displayed by the crosses on
the bottom of the screen is not picked up for
more than 4 minutes the interpretation on
STAN monitoring becomes invalid. ThFh
With regard to ST events in STAN,
11. an episodic T/QRS rise in fetal ECG is an
increase in T:QRS ratio that lasts less than
10 minutes and represents a period during
which the fetus has utilised anaerobic
metabolism but recovered back to
aerobic metabolism. ThFh
12. a baseline T/QRS rise in fetal ECG is an
increase in T:QRS ratio that lasts more than
10 minutes and represents a fetus utilising
anaerobic metabolism for an extended period
of time. ThFh
13. the greater magnitude of T/QRS rise with an
intermediary CTG is as significant as lesser
magnitude T/QRS rise with abnormal CTG. ThFh
14. a biphasic ST event is the ST depression of
fetal ECG and usually indicates a situation
where the fetus is suffering from hypoxia and
either has not had time to respond by
switching to anaerobic metabolism or lacks
the capacity to respond. ThFh
15. an ST event during the second stage of labour
should prompt delivery unless the delivery is
quite imminent. ThFh
16. a new ST event will be recorded if STAN is
commenced on a fetus suspected of
possible hypoxia. ThFh
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17. if the CTG becomes abnormal while on STAN The middle cerebral artery Doppler,
without any ST events, delivery is indicated. ThFh
12. should be used to assist clinicians in the
With regard to the limitations of STAN, timing of delivery in the preterm growth
restricted fetus. ThFh
18. when the STAN electrode is connected to the
13. typically has a reduced impedance in advanced
breech a false biphasic event is likely to
fetal growth restriction. ThFh
be recorded. ThFh
14. does not require angle correction for
19. STAN is recommended in fetal conditions
interpretation of the peak systolic
such as cardiac malformations
velocity fetus. ThFh
or dysrhythmias. ThFh
20. the absence of a P wave on the ECG and a In relation to the application of Doppler in
normal fetal heart rate on CTG is highly twin pregnancy,
suggestive of a misplaced STAN electrode. ThFh
15. abnormalities in Doppler waveform
correspond to Quintero II staging in
twin-to-twin transfusion syndrome. ThFh
TOG The clinical application of Doppler
16. tricuspid regurgitation is a recognised marker
ultrasound in obstetrics
of cardiac failure in the recipient fetus in
In the surveillance and management of the pregnancies affected by twin-to-twin
small-for-gestational-age fetus, transfusion syndrome. ThFh
17. ductus venosus Doppler has no role in the
1. use of the umbilical artery Doppler has been
assessment of fetal growth discordance
shown to improve perinatal outcome. ThFh
in twins. ThFh
2. the ductus venosus Doppler has a low
18. the middle cerebral artery Doppler is useful in
predictive accuracy for perinatal outcome. ThFh
the assessment of complications of twin-twin
3. there is robust evidence from randomised
transfusion therapy. ThFh
controlled trials to support use of the
ductus venosus. ThFh Which of the following factors is known to affect the
umbilical artery Doppler measurement or waveform?
In relation to venous Dopplers,
19. Fetal breathing. ThFh
4. a reversed A-wave develops in the ductus
20. The site where the umbilical cord
venosus waveform in severe fetal
is insonnated. ThFh
growth restriction. ThFh
5. they serve as an indirect marker of fetal
cardiac function. ThFh
6. they are mild predictors of fetal acidaemia TOG Latest evidence on using hormone
and outcome. ThFh replacement therapy in the menopause
7. they are used commonly in general
Women with premature ovarian insufficiency or failure
obstetric practice. ThFh
(POI/POF),
In terms of the role of Doppler sonography in
1. have been shown to have an earlier onset of
screening,
cardiovascular disease episodes. ThFh
8. second trimester uterine artery Dopplers are 2. have no greater risk of breast cancer (if treated
useful in screening for pre-eclampsia in a low with HRT) than the population risk for
risk population. ThFh their age. ThFh
9. second trimester uterine artery Dopplers 3. are advised to consider taking hormone
should be performed at 30 weeks. ThFh replacement therapy (HRT) at least until the
10. the presence of an abnormal waveform in the natural age of menopause. ThFh
ductus venosus from the first trimester of
Common side effects of HRT include,
pregnancy is a marker of fetal aneuploidy. ThFh
11. the umbilical artery Doppler should be used to 4. breast tenderness. ThFh
assess for fetal compromise in small for 5. muscle cramps. ThFh
gestational age pregnancies. ThFh

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With regard to morbidity with HRT, 2. the risk of uterine perforation at hysteroscopic
removal outweighs the risk of malignancy in
6. transdermal HRT is associated with a lower
those with asymptomatic polyps. ThFh
risk of venous thromboembolism (VTE)
compared to oral. ThFh In the postmenopausal endometrium,
7. previous VTE is a contraindication to HRT. ThFh
3. the histological appearance of a biopsy
8. HRT (estrogen plus progesterone) increases
specimen is dependent on the last hormonal
the risk of VTE four-fold over 5 years. ThFh
pattern before the menopause. ThFh
9. HRT is absolutely contraindicated in women
with a family history of early onset breast cancer. ThFh With regard to endometrial hyperplasia,
10. oral estrogen can be used in women
4. those without atypia have a 2% risk of
on tamoxifen. ThFh
progression to endometrial carcinoma. ThFh
The re-analysis of the WHI study in 2007 showed that 5. where there is atypia, endometrial cancer
giving HRT to women within 10 years of menopause was coexists in less than 10% of cases. ThFh
associated with,
In women on selective estrogen receptor
11. fewer risks. ThFh modulators (SERMs),
12. an increase in cardiovascular events. ThFh
6. there is no increased risk of endometrial
In women with (POI/POF), hyperplasia in those taking raloxifene. ThFh
7. routine screening for endometrial hyperplasia
13. bisphosphonates are an acceptable first line for
with transvaginal ultrasound in asymptomatic
the prevention of osteoporosis. ThFh
women on tamoxifen is recommended. ThFh
Concerning HRT in low risk women, 8. women on tamoxifen with symptoms and a
thickened endometrium should be
14. the risk from taking HRT is greater than that
investigated with a hysteroscopy and
from obesity. ThFh
targeted biopsy. ThFh
15. the increased risk of breast cancer reverts to
9. the levonorgestrel-releasing intrauterine system
population risk 5 years after stopping. ThFh
has been shown to reduce the risk of
16. mortality from breast cancer developed while
endometrial hyperplasia in those on tamoxifen. ThFh
on the HRT is much greater than that in those
with cancer not on HRT. ThFh With regard to screening for endometrial pathology,
17. prior to initiating HRT it is recommended
10. routine transvaginal ultrasonography is of
that a breast examination is performed. ThFh
proven benefit in asymptomatic
18. the risk of VTE is increased significantly after
postmenopausal women. ThFh
12 months of use compared to soon
11. a threshold endometrial thickness of 5 mm has
after initiation. ThFh
higher positive predictive value (PPV) than
19. the risk of VTE is greater with the oral
4 mm. ThFh
compared to the transdermal route
of administration. ThFh With regard to the aetiology and epidemiology of
endometrial polyps,
With regard to pathology in women on HRT,
12. the use of tamoxifen increases the prevalence
20. the risk of endometrial hyperplasia in those on
by up to 60%. ThFh
sequential HRT is similar to that in those on
13. in obese women, increasing circulating
continuous combined HRT. ThFh
estradiol levels are thought to be the likely
cause of their development and growth. ThFh
14. the increase in prevalence in women on
TOGEndometrial pathology in the anti-hypertensives is independent of their drugs. T h F h
postmenopausal woman – an evidence
In a woman presenting with PMB,
based approach to management
15. the most common cause is atrophic cervicitis. T h F h
With regard to endometrial polyps,
16. if she has a polyp, the risk of it being
1. they account for approximately 10% of all malignant is twice that of a woman who has an
causes of postmenopausal vaginal bleeding. ThFh asymptomatic polyp. ThFh

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Hysteroscopy, 14. the mechanism of association between

autoimmune thyroid disease and
17. has a specificity of 100% in diagnosing
adverse reproductive outcomes is
uterine polyps. ThFh
well established. ThFh
18. carries a higher risk of uterine perforation in
15. autoimmune thyroid disease is
women with symptomatic polyps. ThFh
associated with poorer outcomes in
19. has an accuracy of 100% in
fertility treatment. ThFh
diagnosing polyps. ThFh
20. is the gold standard for diagnosing fibroids. ThFh With regard to the treatment of thyroid disorders
in pregnancy,
16. there is strong evidence to suggest that treating
TOGThyroid dysfunction and
those who are euthyroid with thyroxine
reproductive health
improves outcomes. ThFh
In women with thyroid disorders, 17. there is evidence to suggest that treatment of
autoantibody negative women with subclinical
1. anovulation is common in those
hypothyroidism with thyroxine reduces
with hyperthyroidism. ThFh
miscarriage rates. ThFh
2. pregnancy should be postponed for at least 3
18. euthyroid women with thyroid autoimmunity
months after radioactive iodine therapy. ThFh
have higher rates of miscarriage. ThFh
3. overt hypothyroidism affects 0.5% of those
19. there is strong evidence to suggest that
of reproductive age. ThFh
levothyroxine therapy in women with
4. treatment of those with subclinical
thyroid autoimmunity reduces
hypothyroidism with levothyroxine is
miscarriage rates. ThFh
associated with higher rates of implantation. ThFh
20. there is insufficient evidence to recommend
5. the presence of thyroid stimulating hormone
the treatment of thyroid-autoantibody
receptor antibodies can be used to distinguish
positive euthyroid women with levothyroxine
Grave’s disease from gestational hyperthyroidism. ThFh
in pregnancy. ThFh
With regard to the physiology of the thyroid system
and reproduction,
TOG Management of common disorders
6. ovarian granulosa cells express thyroid in psychosexual medicine
hormone receptors. ThFh
7. the American Thyroid Association now Concerning chronic pelvic pain (CPP),
recommends that TSH should remain at or 1. a diagnostic laparoscopy is the
below 2.5 mU/l first-line treatment. ThFh
pre-conceptually. ThFh 2. it is defined as intermittent or constant pain in
8. subclinical hypothyroidism has a prevalence of the lower abdomen or pelvis of at least 12
5–10% in women of reproductive age. ThFh months’ duration. ThFh
Concerning the physiological changes and functions of the 3. women with CPP are significantly more likely
thyroid system in early pregnancy, to have a history of somatisation. ThFh
4. one third to one half of diagnostic
9. fetal production of thyroxine begins at laparoscopies will be negative. ThFh
approximately 10 weeks of gestation. ThFh 5. the intensity of CPP inversely correlates with
10. thyroid hormones have been shown to play a the extent and duration of past physical or
role in placental development. ThFh sexual abuse. ThFh
11. there is a rise in TSH levels in the early
pregnancy accompanying a rise in b-hCG. ThFh With regard to vulvodynia,
6. it is vulval discomfort occurring in the absence
With regard to thyroid autoimmunity,
of relevant visible findings or a specific,
12. thyroid autoantibodies are present in a third clinically identifiable, neurological disorder. ThFh
of those with Hashimoto’s thyroiditis. ThFh 7. the diagnosis is clinical. ThFh
13. PCOS is a risk factor. ThFh 8. amitriptyline is contraindicated. ThFh

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Concerning hypoactive sexual desire disorder (HSDD), The National Institute of Health Research (NIHR) definition
of ‘authorised healthcare professional responsible for
9. the prognosis is worse in cases where the
conducting a trial at the trial site’ refers to the
woman presents with the initial issue. ThFh
10. a reduction in libido of 70% has been found to 8. principal investigator. ThFh
occur following bilateral salpingo oophorectomy. ThFh 9. trial coordinator. ThFh
11. transdermal testosterone therapy has been
The ultimate responsibility of ensuring that all members of
found to increase sexual activity and
the team are adequately trained in carrying out clinical
satisfaction in at least 51% of women. ThFh
research, including consent and data collection, lies with the
12. the majority of the women with this condition
will respond to psychotherapy. ThFh 10. research midwife/nurse. ThFh
11. trial coordinator. ThFh
Concerning patients with tokophobia,
12. principal investigator. ThFh
13. the primary type has been shown to originate
Studies are able to seek support from Clinical Research
from childhood or adolescence. ThFh
Network (CRN) if,
14. it has a cultural association in some cases. ThFh
15. the secondary type is known to be associated 13. funded by the NIHR. ThFh
with termination of pregnancy. ThFh 14. the clinical question evaluated by the study is
16. a plan of birthing care is detrimental to relevant to practice. ThFh
such patients. ThFh
Costs incurred to support research activity or driven by
17. some women avoid pregnancy. ThFh
NHS duty of care are categorised as,
With regard to psychosexual consultations,
15. research costs. ThFh
18. open questions are not recommended. ThFh 16. service support costs. ThFh
19. ‘transference’ is the conscious redirection of 17. excess treatment costs. ThFh
feelings from the patient to the doctor. ThFh
The contribution of the principal investigator to
20. basic seminar training with the Institute of
research is:
Psychosexual Medicine (IPM) for a
Pyschosexual Medicine Diploma takes 2 years. ThFh 18. a recognised professional development activity. T h F h
The role of a principal investigator is linked to the
Participation in research as a means of
TOG following domains of Good Clinical Practice (GCP):
improving care quality
19. providing a good standard of care for patients. ThFh
The main challenges faced by clinicians undertaking 20. adequate communication. ThFh
clinical trials include,
1. difficulty in obtaining ethics approval. ThFh
GTG Long-term consequences of polycystic
2. recruitment to target in the planned time. ThFh
ovary syndrome
3. limited collaboration between the centres. ThFh
With regard to the risk of cancer in women with PCOS,
Concerning research participation,
1. those with oligoamenorrhoea are less likely to
4. it improves patient outcomes irrespective of
develop cancer than those having
the study findings. ThFh
regular periods. ThFh
5. participants have improved outcomes if the
2. there is an increased risk of estrogen
treatment that is evaluated is found to be effective. T h F h
dependent breast cancer. ThFh
Failure to recruit to target in a clinical trial has been shown 3. an endometrial thickness of 6 mm in a 36 year
to lead to, old woman with oligoamenorrhoea is an
indication for hysteroscopy. ThFh
6. an increased risk of reporting falsely that the
observed clinically relevant differences are not With regard to strategies for reducing the long-term health
significant due to lack of adequate power. ThFh risk of PCOS,
7. delay in the deployment of potentially useful
4. the use of insulin-sensitising agents has been
interventions that have the ability to improve
associated with significant side effects. ThFh
the health of women. ThFh

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5. where there is associated obesity and
hyperandrogenism, weight reduction drugs
have been shown to be useful. ThFh
6. electrocautery of the ovaries is associated with
weight loss. ThFh
7. bariatric surgery is recommended for those
with a BMI of more than 30 kg/m2 with a
high-risk of obesity related conditions. ThFh
With regard to the metabolic consequences of PCOS,
8. the prevalence of gestational diabetes mellitus
is 3–4 times as high as in women with PCOS
compared to women without.
9. insulin resistance is present in approximately
60–89% of women with PCOS independent
of obesity.
10. continuous positive airway pressure (CPAP)
therapy has been shown to improve insulin
sensitivity in women with PCOS and
obstructive sleep apnoea.
GTG Umbilical cord prolapse
Which of the following statement(s) about cord prolapse is
(are) correct?
1. Routine ultrasound examination is sensitive
enough to diagnose cord presentation.
2. When cord prolapse is suspected a digital
examination should be performed.
Following the diagnosis of a cord prolapse,
3. attempts should be made to manually replace
it and allow labour to progress.
4. filling the bladder with normal saline has been
shown to be associated with a better outcome
than manually elevating the presenting part.
5. the use of tocolytics has not been shown to
improve outcome.
6. the patient should be managed in the
knee-chest position during transfer from the
community to the hospital.
Concerning the management of cord prolapse,
7. immediate delivery by CS is the recommended
option in those diagnosed in late first stage.
8. the use of regional anaesthesia for delivery is
associated with a poor outcome.
9. the diagnosis is commonly made when there is
a fetal heart rate abnormality
following amniorrhexis. ThFh
10. when it occurs at the threshold of viability, it
should be replaced and the pregnancy allowed
to continue. ThFh
BJOG Acute kidney injury in major
gynaecological surgery: an observational
study
With regard to acute kidney injury in major
ThFh
gynaecological surgery,
1. changes in serum creatinine concentration
ThFh during hospitalisation as small as 0.3 mg/dl are
associated with longterm mortality. ThFh
2. the American College of Surgeons National
Surgical Quality Improvement Program
ThFh (NSQIP) defines acute kidney injury as a rise
in serum creatinine of greater than 2 mg/dl
from the preoperative value, or an acute need
for renal replacement therapy. ThFh
3. most patients with acute kidney injury in this
study had mild to moderate severity AKI. ThFh
4. most episodes of acute kidney injury occurred
after 72 hours of admission. ThFh
ThFh 5. AKI was more likely to occur among patients
undergoing surgery for malignant disease. ThFh
ThFh 6. most cases with increase in serum creatinine
were found to be secondary to mechanical
urologic injury in this study. ThFh
7. among gynaecology patients, AKI is more
ThFh common than post-operative ileus. ThFh
8. fewer than 5% of the participants in this
cohort had only partial or no renal recovery. ThFh
ThFh 9. a major strength of this study is that AKI was
used measuring longitudinal changes in
ThFh serum creatinine. ThFh
10. a practitioner can prevent AKI by
implementing kidney-sparing
ThFh interventions postoperatively. ThFh
Reference
ThFh
1 Vaught AJ, Ozrazgat-Baslanti T, Javed A, Morgan L, Hobson CE, Bihorac A.
Acute kidney injury in major gynaecological surgery: an observational study.
ThFh BJOG 2014 19 August. DOI: 10.1111/1471-0528.13026. [Epub ahead of print]

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