DOI: 10.1111/tog.
12022 2013;15:128–32
The Obstetrician & Gynaecologist
http://onlinetog.org
CPD questions for volume 15, number 2
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guidance, such as Green-top Guidelines (GTG) and Scientific
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RCOG members and fellows via the RCOG website.
TOG Surrogate pregnancy: ethical and
medico-legal issues in modern obstetrics
With regard to different types of surrogacy,
1. the practice of ‘straight surrogacy’ produces a
child who has no genetic link to the surrogate
mother. ThFh
When medical interventions in pregnancy (such as
amniocentesis) are recommended,
2. a doctor should obtain consent from both the
commissioning parents and the surrogate if
the baby is the genetic child of the
commissioning mother. ThFh
3. In 2013, professional medical bodies are totally
opposed to surrogacy arrangements in the UK. T h F h
After delivery,
4. the community healthcare visitor should only
visit a baby if it resides with the surrogate
mother. ThFh
If the surrogate mother has a miscarriage,
5. the doctor may be asked to provide evidence
to support this. ThFh
Commissioning parents,
6. previously knew the surrogate mother in
about 10% of cases. ThFh
128
CPD
7. are free to consent to medical treatment for
the baby while waiting for parental
responsibility to be granted, provided that the
child resides with them. ThFh
With regard to the surrogacy contract,
8. it is legally enforceable and therefore the
involvement of the Trust’s legal team is
unnecessary. ThFh
With regard to current legislation surrounding
the practice of surrogacy in the UK,
9. the introduction of The Human Fertilisation
and Embryology Act 1990 makes it likely that
there will be more cases of surrogacy in the
future. ThFh
10. if the surrogate or a foreign commissioning
parent domiciles in the UK, then UK laws
apply regardless of where conception
occurred. ThFh
11. organisations and agencies involved are legally
allowed to operate in the UK, and can charge
membership fees provided that they operate
on a non-profit basis. ThFh
12. if a surrogate mother feels emotional and unsure
about handing over the baby to the intended
parents after birth, since she has already
accepted payment from the intended parents
she is bound by the terms of her contract and
must continue with the arrangement. ThFh
13. advertising the availability of surrogate service
is illegal in the UK. ThFh
Regarding parental responsibility,
14. the court will grant a parental order if the
commissioning couple are either married or
cohabitees and both are >16 years old. ThFh
15. a parental order can only be granted to a same
sex couple if they have been together for at
least 10 years. ThFh
16. the commissioning couple should apply for
parental responsibility within 6 months after
the birth of the child. ThFh
With regard to the surrogate mother,
17. if she changes her mind about handing over
the baby after birth, it is possible that she may
ª 2013 Royal College of Obstetricians and Gynaecologists
 CPD

be able to retain legal custody of the child if In the context of the complications of haemosiderosis,
she has a genetic link to the child. ThFh seen in transfusion-dependent young adults with
18. if her husband was unaware that his wife b-thalassaemia,
underwent artificial insemination and became 17. diabetes is the commonest endocrine
pregnant as a surrogate, he is still the legal complication. ThFh
father of the child. ThFh 18. osteoporosis correlates directly with the
occurrence of hypogonadotrophic
If a woman has donated an egg,
hypogonadism. ThFh
19. she is legally considered to be the mother of
the child. ThFh The following are among the most significant
(i.e. most frequent) complications of pregnancy in
The commissioning mother,
women with b-thalassaemia major:
20. will be entitled to normal maternity rights with
19. cardiomyopathy. ThFh
her employer if she has a genetic link to the child. T h F h
20. obstructed labour. ThFh

TOG Sickle cell disease and b-thalassaemia

major in pregnancy TOG Role of surgery to optimise outcome of
assisted conception treatments
With regard to pregnancies in women with sickle cell
disease in the UK, Regarding salpingectomy for the management
1. the perinatal mortality rate is about double the of hydrosalpinx,
overall national rate. ThFh 1. although the detrimental effect of
2. the maternal mortality rate is about 220 times hydrosalpinx on the outcome of in vitro
higher than the overall national rate. ThFh fertilisation (IVF) is now well documented,
the underlying reasons are still not very clear. ThFh
The following complications occur with increased 2. there is very little evidence to suggest that
frequency in pregnancies in women with sickle cell salpingectomy for hydrosalpinx, prior to IVF,
disease: improves outcomes. ThFh
3. severe pre-eclampsia. ThFh 3. a larger treatment effect has been observed (up
4. placental abruption. ThFh to 3.5-fold increase in delivery rate) for
5. pyelonephritis. ThFh women with more severe disease. ThFh
The following medication should be stopped in a 4. patients who refuse primary surgery should
woman with sickle cell disease who is trying to conceive: not be counselled regarding benefits of interval
6. vitamin C. ThFh salpingectomy after a failed IVF treatment
7. hydroxycarbamide. ThFh cycle. ThFh
8. desferrioxamine. ThFh 5. there is good evidence to offer salpingectomy
for communicating hydrosalpinx only. ThFh
With regard to the national antenatal and newborn
screening programme for haemoglobinopathies in the UK, With regard to uterine fibroids in women with infertility,
9. one in 35 pregnant women carries a 6. they are associated with decreased pregnancy
haemoglobinopathy. ThFh rates following IVF treatment. ThFh
10. about 300 babies are born annually with sickle 7. most experts recommend removal of cavity-
cell disease. ThFh distorting intramural fibroids before IVF,
11. about 200 babies are born annually with although there is no strong evidence that
b-thalassaemia major. ThFh their removal improves outcomes. ThFh
Treatment of a patient with an acute sickling crisis requiring With regard to polyps,
hospital admission in pregnancy should usually include: 8. despite lack of clinical evidence, most
12. low molecular weight heparin injections. ThFh clinicians would recommend hysteroscopic
13. blood transfusion. ThFh removal of endometrial polyps prior to IVF. ThFh
14. intramuscular injection of pethidine for Regarding uterine septum and other uterine anomalies,
analgesia. ThFh 9. a review of non-controlled trials reported
Complications seen with increased frequency a 74% reduction in miscarriage risk
during pregnancy in women with sickle cell trait include: following hysteroscopic division
15. chest syndrome. ThFh (septoplasty) in patients with recurrent
16. acute pyelonephritis. ThFh miscarriage. ThFh

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10. the presence of a septum represents an 3. the Trust research and development ethics
important hysteroscopically preventable risk committee. ThFh
factor for lower implantation rates in patients
The data on the BSUG database is useful for:
undergoing IVF treatment. ThFh
4. personal development and appraisal. ThFh
11. available evidence suggests poor outcomes for
5. clinical governance purposes. ThFh
women with arcuate uterus; however, there is
6. identifying the training offered to trainees by a
no agreement whether this anomaly should be
given clinician. ThFh
treated even in patients with recurrent
miscarriage. ThFh With regard to the BSUG database,
7. patient identifiable data (PID) are only visible
Regarding endometriosis,
to the patient’s clinician. ThFh
12. it affects 20–40% of women who complain of
8. the management of the patient identifiable
subfertility. ThFh
data within the BSUG database has to fulfil the
13. possible reasons for subfertility in women
Caldicott Guardian principles. ThFh
with this conditon include interference
9. in patients who are already in the system
with embryo development and
(having had previous surgery) their
implantation. ThFh
identifiable data need to be re-entered for each
14. IVF success is similar if not better in
surgical episode. ThFh
patients with this condition than in those
10. a patient’s verbal consent is adequate for
with other aetiologies such as tubal factor
use of their personal data on the
infertility (despite reduced responsiveness to
database. ThFh
ovarian stimulation). ThFh
15. medical treatment, although useful for The following questionnaires form part of the objective
management of pain symptoms and limiting measures of outcome in the BSUG database:
progression of disease, is very much 11. ICIQ-VS. ThFh
compatible with fertility. ThFh 12. ICIQ-SM. ThFh
16. surgical treatment of the condition aims to 13. ICIQ-OAB. ThFh
remove all areas of endometriosis (optimal 14. ICIQ-FLUTS. ThFh
debulking) and restore anatomy by the 15. EPAQ. ThFh
division of adhesions. ThFh
17. the ENDOCAN multicentre RCT showed a With regard to the BSUG database,
two-fold increase in conception rate following 16. it is still awaiting recognition by the National
laparoscopy and treatment of superficial Institute for Health and Clinical Excellence
condition compared with diagnostic (NICE). ThFh
laparoscopy alone. ThFh 17. tertiary hospitals comprise at least half
18. a Cochrane review of three RCTs found that of the active centres on the
the administration of GnRH agonists for a database. ThFh
period of 3–6 months prior to IVF in women 18. BSUG currently allows any consultant
increases the odds of clinical pregnancy four- or associate specialist/subspecialty trainee
fold. ThFh who performs anti-incontinence and/or
19. the evidence for increased spontaneous prolapse surgery to gain access to the
conception rates following treatment of database. ThFh
endometrioma is based on a review of 19. the majority of the registered centres
observational uncontrolled trials. ThFh in the UK actively submit data to the
20. international (ESHRE) guidelines recommend database. ThFh
treatment of endometrioma larger than 20. Approximately 150–200 cases are entered onto
40 mm prior to IVF. ThFh the BSUG database per week. ThFh

TOG The use of chromosomal microarray in

TOG The BSUG national database: concept,
design, implementation and beyond prenatal diagnosis
It is recommended by the British Society of With regard to the history of prenatal
Urogynaecology (BSUG) that prior to using the database chromosomal testing,
within the Trust one should inform the following: 1. DNA extracted from chorionic villus
1. the local Caldicott Guardian. ThFh sampling was the first method of fetal DNA
2. the clinical director. ThFh extraction. ThFh

130 ª 2013 Royal College of Obstetricians and Gynaecologists

 CPD

2. many laboratories are now only performing
quantitative fluorescent polymerase chain
reaction (QFPCR) testing for ‘high risk
screening results’. ThFh
With regard to the timeframe of prenatal
chromosome testing,
3. QFPCR can be turned around in less than
24 hours. ThFh
4. cell culture can take up to 3 weeks. ThFh
With regard to the differences between
G-band karyotyping and chromosomal microarray (CMA),
5. conventional karyotyping can look at the fetal
chromosome at a resolution of 5–10 Mb. ThFh
6. CMA has a quicker ‘turnaround time’ than
G-band karyotyping as it can be used on
uncultured cells. ThFh
With regard to CMA limitations,
7. triploidy undetected by CMA is likely to be
detected by QF-PCR. ThFh
With regard to the prenatal detection rates of
chromosomal abnormalities,
8. the rates by CMA performed for a structural
abnormality on ultrasound scans are higher
than when performed for other indications
(e.g. advanced maternal age, high risk
screening result or parental anxiety). ThFh
Counselling for CMA should include the
following information:
9. incidental or unsolicited findings are likely to
occur in 10–20% of cases. ThFh
10. variants of unknown significance (VOUS) are
likely to occur in 15% of cases. ThFh
11. when performed for abnormal ultrasound
scan findings, CMA detects chromosomal
abnormalities in 15% more cases then
conventional karyotyping. ThFh
When counselling for prenatal CMA,
12. chromosomal differences of unknown
significance must be discussed. ThFh
With regard to the cost-effectiveness,
13. CMA has already been shown to be
cost-effective in postnatal settings when
testing children with idiopathic learning
disability. ThFh
With regard to the processing of microarrays,
14. Cot-1 DNA is used to suppress repetitive
sequences when processing the microarray. ThFh
15. array platforms in common clinical use have a
typical resolution of 10 kb in targeted disease
specific regions of the genome and 200 kb in
the genome backbone. ThFh
With regard to limiting the chromosomal results
of unknown significance
16. a highly targeted CMA test would limit
detection of novel microdeletion or
microduplication syndromes. ThFh
17. databases of genetic variation will increase the
chromosomal variants of unknown
significance. ThFh
With regard to the international current recommendations
for prenatal CMA use,
18. the American College of Obstetricians and
Gynecologists recommend the use of CMA for
advanced maternal age. ThFh
19. Canadian recommendations are to use CMA
in lieu of karyotyping when the indication is
ultrasound scan abnormalities. ThFh
20. Italian recommendations are to use CMA in
lieu of karyotyping in all cases. ThFh
TOG Management of menstrual problems in
adolescents with learning and physical
disabilities
With regard to the management of menstrual problems in
women with disabilities, studies have shown that:
1. these women have fewer problems with
premenstrual syndrome than the general
population. ThFh
2. one particular reason for a parent or caregiver
to access paediatric and adolescent
gynaecology services is concern over cyclical
behavioural changes. ThFh
With regard to epilepsy,
3. epileptic exacerbations at the time of
menstruation are called catamenial
seizures. ThFh
4. Sodium valproate has been linked with
hyperprolactinaemia. ThFh
With regard to the combined oral contraceptive pill,
5. it is contra-indicated in girls with cyanotic
congenital heart disease. ThFh
6. using it continuously until breakthrough
bleeding occurs and then having 7 pill-free
days is not safe. ThFh
7. a thrombophilia screen is recommended
before prescribing it. ThFh
With regard to the transdermal combined
hormonal contraceptive patch,
8. it is safer than the combined oral
contraceptive pill. ThFh
9. there is no need to have a bleed every 21 days
when using the transdermal patch. ThFh

ª 2013 Royal College of Obstetricians and Gynaecologists 131

 CPD
In girls with learning disabilities and physical
disabilities on the progestogen only contraception,
10. unopposed intramuscular preparation is
associated with a lower final bone mineral
density. ThFh
11. initial breakthrough bleeding occurs in
approximately 50% of those using depot
medroxyprogesterone acetate. ThFh
12. a uterine length of approximately 5 cm (adult
length) is required for the successful insertion
of the levonorgestrel intrauterine system
(LNG-IUS). ThFh
13. heavy bleeding is common in those who use
Nexplanon (Merck Sharp & Dohme Limited,
Hoddesdon, Herts). ThFh
14. the LNG-IUS causes fewer widespread side
effects than the combined oral contraceptive
pill. ThFh
With regard to menstrual problems in those with
learning and physical disabilities;
15. in most circumstances, medical treatment is
successful and therefore the request for
permanent surgical procedures is approved
only in exceptional circumstances. ThFh
16. surgical options, including endometrial
ablation or hysterectomy, should only be used
as a last resort in adolescents with seriously
distressing symptoms. ThFh
With regard to the Mental Capacity Act 2005:
17. under this Act, doctors have a legal duty to
consult a range of people when determining
the best interests of a person who lacks
capacity.
18. the Act does not cover children under 16 years
old.
With regard to consent to treatment,
19. the requirement for interventions should be the
least restrictive of basic rights and freedom. ThFh
20. under UK law, approval from the magistrate
court is necessary before surgery can be carried
out. ThFh
BJOG Timing of administration of
prophylactic antibiotics for caesarean
section: a systematic review and meta-
analysis
Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics
for caesarean section: a systematic review and meta-analysis. BJOG 2012;
DOI: http://dx.doi.org/10.1111/1471-0528.12036.
132
Regarding infectious morbidities after caesarean section:
1. the rate is greater than four-fold compared
with vaginal delivery. ThFh
2. women undergoing elective caesarean section
are roughly at equal risk. ThFh
3. the risk of developing infection is modified by
the composition of the vaginal microbial flora. ThFh
4. greater than 50% of the infections are clinically
manifest by the fourth postoperative day. ThFh
5. the term surgical site infection (SSI) refers to
infections confined to the skin, subcutaneous
tissues, fascia or muscles. ThFh
The following are true statements about principles
of antibiotic prophylaxis in surgical procedures:
6. to reduce the inoculum of microbial
contamination to a level that can be handled
by the host defenses. ThFh
7. an ideal agent should be safe, inexpensive, and
bacteriostatic. ThFh
8. to maintain therapeutic levels of the agent in
serum and tissues at incision and throughout
the operation. ThFh
9. a single agent is as effective as multiple agents. T h F h
Interventions known to reduce the risk of post
caesarean section infectious morbidities include:
10. showering with 4% chlorhexidine gluconate
the night before elective surgery. ThFh
11. shaving pubic hair immediately
preoperatively. ThFh
12. exteriorization of the uterus for repair. ThFh
13. avoidance of manual removal of the placenta
and fetal membranes. ThFh
ThFh 14. closure of the skin with staples rather than
subcuticular stitch. ThFh
ThFh 15. preoperative vaginal cleansing with povidone
iodine. ThFh
16. closure of the pelvic peritoneum. ThFh
With use of prophylactic antibiotics at caesarean section:
17. the risk of maternal adverse effects (allergic
reactions, nausea, vomiting, diarrhoea, skin
rashes, thrush) compared to none use, can be
as high as 400%. ThFh
18. pre-incision administration is associated with
excessive neonatal septic work up. ThFh
19. there is a shift from group B streptococcal
(GBS) early neonatal sepsis into none GBS
early neonatal sepsis. ThFh
20. fetal exposure to antibiotics is an important
risk factor in the development of allergic
disease in infancy. ThFh
ª 2013 Royal College of Obstetricians and Gynaecologists