DOI: 10.1111/tog.

12091 2014;16:135–8
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 16 number 2

CPD credits can be claimed for the following questions Regarding the route of misoprostol administration,
online via the TOG CPD submission system. You must be a 13. the vaginal route is more effective when it is
registered CPD participant of the RCOG CPD programme moistened with water or saline. ThFh
(available in the UK and worldwide) in order to submit your 14. the sublingual route has fewer gastrointestinal
answers. Participants will need to log in to the RCOG website side effects. ThFh
(www.rcog.org.uk) and go to the ‘Our Profession’ tab.
With regard to various medical regimens for the
Participants can claim 2 credits per set of questions if at
management of miscarriage,
least 70% of questions have been answered correctly. At least
15. the risk of uterine rupture in women with a
50 credits must be obtained in this way over the 5-year cycle.
previous caesarean scar receiving these
Please direct all questions or problems to the CPD Office.
regimens in the second trimester is low. ThFh
Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk
The blue symbol denotes which source the questions refer With regard to pain management,
to including the RCOG journals, TOG and BJOG, and RCOG 16. analgesia requirement is higher in older
guidance, such as Green-top Guidelines (GTG) and Scientific parous women. ThFh
Impact Papers (SIPs). All of the above sources are available to 17. non-steroidal anti-inflammatory drugs
RCOG members and fellows via the RCOG website. decrease the efficacy of misoprostol. ThFh
Regarding psychological sequelae after miscarriage,
TOG Medical management of miscarriage 18. counselling should be offered as per the
woman’s preferences. ThFh
With regard to miscarriage,
1. the incidence of clinically recognised With regard to the prescription of medications
miscarriage ranges from 5–10%. ThFh in the management of miscarriage;
2. most occur before 12 weeks of pregnancy. ThFh 19. it is illegal for a doctor to prescribe a licensed
3. the risk in second trimester is drug for unlicensed indication. ThFh
approximately 15%. ThFh
With regard to the medical manageme
Regarding medical management of miscarriage, nt of miscarriage at home,
4. it is currently the gold standard and has 20. it carries a risk of heavy bleeding in a small
therefore replaced surgical management. ThFh number of cases. ThFh
5. the chief pharmacological agents
include prostaglandins. ThFh
6. the success rate is higher for missed than for TOG Antibiotics for early-onset neonatal
incomplete miscarriage. ThFh infection: a summary of the NICE guideline
2012
With regard to mifepristone,
7. it is an antiprogestogenic agent. ThFh With regard to early-onset neonatal infection,
8. it increases the sensitivity of the myometrium 1. the consensus definition is infection occurring
to prostaglandins that have uterotonic action. ThFh within 48 hours of birth. ThFh
9. the optimal timing of prostaglandin 2. most cases are caused by Gram-positive
administration following mifepristone is micro-organisms. ThFh
48–72 hours. ThFh 3. Escherichia coli is the most frequently reported
Gram-negative micro-organism. ThFh
Misoprostol is,
10. a prostaglandin F2a analogue. ThFh Risk factors for early-onset neonatal infection include:
11. licensed for the treatment of miscarriage. ThFh 4. maternal group B streptococcus (GBS)
12. is cheap, stable at room temperature and does colonisation in the current pregnancy. ThFh
not require stringent storage conditions. ThFh 5. invasive GBS infection in a previous baby. ThFh

ª 2014 Royal College of Obstetricians and Gynaecologists 135

 CPD
6. multiple pregnancy. ThFh
7. preterm birth following spontaneous labour
(before 37 weeks of gestation). ThFh
8. suspected or confirmed rupture of
membranes for more than 12 hours in a
preterm birth. ThFh
In the management of early-onset neonatal infection,
9. universal screening to detect GBS
colonisation in pregnant women
is recommended. ThFh
10. risk scoring systems are effective for
identifying babies who will develop
an infection. ThFh
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. ThFh
13. women who have had GBS colonisation,
bacteriuria or infection in the
current pregnancy. ThFh
14. women with suspected or
confirmed chorioamnionitis. ThFh
15. women who have had a previous baby with an
invasive GBS infection. ThFh
With regard to the choice of antibiotic used
for intrapartum antibiotic prophylaxis to prevent
early-onset neonatal infection,
16. benzylpenicillin is the first choice. ThFh
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. ThFh
18. in women with preterm labour erythromycin
should be used. ThFh
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. ThFh
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. ThFh
136
TOGIdiopathic intracranial hypertension in
pregnancy
Idiopathic intracranial hypertension (IIH),
1. is a disease of unknown aetiology associated
with increased intracranial pressure. ThFh
2. is commonly seen in obese young women. ThFh
In making the diagnosis of IIH,
3. the lumbar CSF opening pressure should be
greater than 250 mm of water. ThFh
4. the modified Dandy criteria includes tinnitus
and vertigo. ThFh
5. CT or MRI demonstrates normal to small
symmetrical ventricles. ThFh
In IIH and pregnancy,
6. termination of pregnancy is recommended in
symptomatic women. ThFh
7. there is an increased risk of recurrence in
subsequent pregnancies. ThFh
8. visual outcome is the same as that for women
with IIH who are not pregnant. ThFh
With regard to the treatment of IIH in pregnancy,
9. diet and weight control play a role in symptom
improvement. ThFh
10. acetazolamide is contra indicated
in pregnancy. ThFh
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. ThFh
13. severe visual loss is a recognised complication
of up to 50% of cases. ThFh
14. visual obscuration characteristically lasts for a
few minutes to hours. ThFh
With regard to IIH,
15. when it occurs in pregnancy, there is an
increased risk of obstetric complications. ThFh
16. the increased in intracranial pressure during
labour means caesarean section is the
preferred method of delivery. ThFh
17. when it predates pregnancy, it tends to worsen
in pregnancy. ThFh
18. most cases in pregnancy present in the second
half of gestation. ThFh
19. epidural anaesthesia carries a potential risk of
increasing intracranial pressure. ThFh
20. the progestogen only contraceptive is
recommended only in those in whom a
thrombotic event has been excluded. ThFh
ª 2014 Royal College of Obstetricians and Gynaecologists

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. ThFh
2. autonomic dysreflexia and spasms are
complications associated with pregnancy,
labour and delivery. ThFh
The quality of life in women with SCI
3. is improved by having families and children of
their own. ThFh
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.
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. ThFh
7. it is advised in early labour in those who
are tetraplegic. ThFh
8. it is contraindicated before artificial rupture of
membranes in a tetraplegic woman. ThFh
The following are true statements about caesarean sections
in women with SCI:
9. A midline skin incision is advised to allow for
better access. ThFh
10. A classical caesarean section is recommended
if bladder care is by a suprapubic catheter. ThFh
11. A suprapubic catheter should be changed
12–24 hours before surgery for infection
control measures. ThFh
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. ThFh
13. the risk of congenital abnormality is
not increased. ThFh
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. ThFh
With regard to pregnancy in women with SCI,
15. the incidence of abnormal presentation is
not increased compared to that in
those without.
ª 2014 Royal College of Obstetricians and Gynaecologists
CPD
16. there are no known measures for the
prediction of the need for ventilation. ThFh
17. a rise in systolic blood pressure of 20–
40 mmHg above baseline is considered a sign
of autonomic dysreflexia. ThFh
18. the incidence of urinary tract infections is not
dissimilar to that in non SCI women. ThFh
19. there is robust evidence to support treatment
of those with aysmptomactic bacteriuria. ThFh
20. the effectiveness of epidural analgesia is
determined by testing the level of block. ThFh
TOG Providing an obstetric teaching
programme in a resource poor country
ThFh
With regard to team planning prior to a teaching visit,
1. the Belbin model of team structure states that
ThFh including people of similar personality types
would result in a successful team. ThFh
2. a ‘plant’ is a highly creative personality
type who may find unconventional solutions
to problems. ThFh
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. ThFh
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. ThFh
7. visiting obstetricians need not take their own
supplies of PEP as it is freely available in most
host hospitals in resource poor countries. ThFh
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
don’t get to deliver all the topics. ThFh
During delivery of a teaching programme,
9. a didactic, paternalistic approach is likely to
generate the best results. ThFh
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
ThFh subsequent visits. ThFh
137
 CPD

Regarding follow-up after implementing a not been shown to improve the prediction of
teaching programme, delivering an SGA neonate. ThFh
12. organisation of a reciprocal placement for
Following the diagnosis of SGA,
some of your host doctors to visit your UK
5. it is recommended that karyotyping is
department would facilitate bi-directional
discussed and offered to those where
learning and strengthen the link. ThFh
the uterine artery Doppler is normal. ThFh
13. the use of Skype sessions and video links
6. serological screening for congenital
where available will facilitate an ongoing
cytomegalovirus (CMV) is indicated if the
educational link. ThFh
SGA is severe. ThFh
With regard to teaching theories,
With regard to interventions in the prevention of SGA,
14. Maslow’s theory states that humans are
7. antiplatelet agents such as aspirin have been
effective learners in the absence of the meeting
shown to be ineffective. ThFh
of ‘safety needs’. ThFh
15. David Kolb’s experimental learning model In cases of diagnosed SGA,
refers to the fact that people learn in one of 8. it is recommended that when the umbilical
four different ways. ThFh artery Doppler is normal, it should be
repeated at least weekly. ThFh
With regard to maternal mortality,
9. in the preterm SGA, Doppler of the
16. there are over 500 000 global maternal deaths
middle cerebral artery is more useful in
every year. ThFh
timing delivery. ThFh
17. maternal mortality has fallen by about 50%
10. the use of biophysical profilometry in the
since 1990. ThFh
preterm SGA is not recommended. ThFh
18. the decline in maternal mortality is on track to
meet millennium development goal number 5
by 2015. ThFh
BJOG Maternal and perinatal consequences
19. in Sub-Saharan Africa there is only 1 health
of antepartum haemorrhage of unknown
worker per 100 population. ThFh
origin
20. training of health workers in the developing
world improves clinical practice but not Antepartum bleeding of unknown origin,
clinical outcomes. ThFh 1. includes mild cases of placental separation. ThFh
2. includes bleeding from vasa praevia. ThFh
3. is an uncommon cause of bleeding
GTG Green-top Guideline No. 31. in pregnancy. ThFh
Small-for-Gestational Age Fetus,
Risk factors for antepartum bleeding of unknown
Investigation Management
origin include,
With regard to the identification of women at risk 4. previous history of bleeding in pregnancy. ThFh
of having small for gestational age (SGA) fetuses 5. lower socio-economic status. ThFh
and their management,
Compared to those without antepartum bleeding of
1. second trimester Down syndrome markers
unknown origin, pregnancies complicated by this
have been shown to improve accuracy for the
condition are at a higher risk of:
delivery of SGA neonates. ThFh
6. spontaneous preterm delivery. ThFh
2. those with an abnormal uterine artery Doppler
7. congenital malformations in the neonate. ThFh
at 20–24 weeks which subsequently normalises
8. delivery by caesarean section. ThFh
are not at increased risk of having an
9. preterm prelabour rupture of fetal membranes. T h F h
SGA neonate. ThFh
10. postpartum haemorrhage. ThFh
3. echogenic fetal bowel is an indication for serial
ultrasound measurement of fetal size and
assessment of wellbeing with umbilical Reference
artery Doppler. ThFh
Bhandari S, Raja EA, Shetty A, Bhattacharya S. Maternal and perinatal
4. serial measurement of symphysio-fundal consequences of antepartum haemorrhage of unknown origin. BJOG
height (SFH) from 24 weeks of gestation has 2014;121:44–52.

138 ª 2014 Royal College of Obstetricians and Gynaecologists