DOI: 10.1111/tog.

12189 2015;17:130–5
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 17 number 2

CPD credits can be claimed for the following questions With regard to monitor position during laparoscopic
online via the TOG CPD submission system in the RCOG surgery,
CPD ePortfolio. You must be a registered CPD participant of
7. it has been shown to have no effect on
the RCOG CPD programme (available in the UK and
task performance. ThFh
worldwide) in order to submit your answers. Please log in to
8. optimal placement is directly in front of
the RCOG website (www.rcog.org.uk) to access your
the surgeon. ThFh
CPD ePortfolio.
9. the monitor should be between eye
Participants can claim 2 credits per set of questions if at
level and 15 degrees above the horizontal plane
least 70% of questions have been answered correctly. At
of vision. ThFh
least 50 credits must be obtained in this way over the
10. downward viewing is the most
5-year cycle.
neutral viewing direction for
Please direct all questions or problems to the CPD Office.
extraocular muscles. 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 screen distance from the surgeon,
to including the RCOG journals, TOG and BJOG, and
11. working close up avoids excessive
RCOG guidance, such as Green-top Guidelines (GTG) and
accommodation and staring. ThFh
Scientific Impact Papers (SIPs). All of the above sources
12. as the monitor size increases so too does the
are available to RCOG members and fellows via the
maximum view distance. ThFh
RCOG website.
13. the minimum view distance is 90 cm
irrespective of monitor size. ThFh
TOGOptimal laparoscopic ergonomics in
Regarding laparoscopic instruments,
gynaecology
14. they require less muscle contraction force than
With regard to the surgeon’s posture during surgery,
open instruments. ThFh
1. it is characterised by a straight 15. the use of instruments with a shorter
neck and back where the surgery (250 mm) shaft length results in a shorter
is open. ThFh execution time than when the same task is
2. laparoscopy causes excessive adduction of the performed with standard (330 mm)
upper limbs. ThFh length instruments. ThFh
3. there is less body movement and weight 16. conventional instruments have 4 degrees of
shifting in laparoscopic surgery. ThFh freedom of movement. ThFh
Regarding a surgeon’s footwear, With regard to support during surgery,
4. placing a gel mat beneath the surgeon’s feet 17. armrests have been shown to
causes less pain. ThFh increase oxygen consumption in
the surgeon. ThFh
When setting up the laparoscopic theatre,
With regard to the physical fitness of the surgeon,
5. the table height should be 50%
less than ground to elbow height of 18. trunk endurance programs reduce error rates
the surgeon. ThFh on simulated laparoscopic tasks. ThFh
6. it is possible to lower most older
In robotic surgery,
operating tables to a sufficient
height to ensure optimal 19. a binocular laparoscope is used to convert a
ergonomic positioning. ThFh 2D image into a 3D image. ThFh

130 ª 2015 Royal College of Obstetricians and Gynaecologists

 CPD

20. the surgeon employs a gaze up approach 10. it is mandatory that parents have two
when operating. ThFh counselling sessions prior to opting
for surrogacy. ThFh
With respect to the Human Fertilisation and Embryology
TOGThe role of counselling in the
Authority 2012 Code of Practice, practitioners engaged in
management of patients with infertility
infertility counselling,
With regard to the management of patients with infertility
11. have to belong to a regulated professional
in the UK,
body such as the British Psychological Society
1. the Human Fertilisation and Embryology Act or the British Association for Counselling
of 2008 was highly significant as it made and Psychotherapy. ThFh
counselling a legal requirement in licensed 12. should have or be working towards a
Assisted Reproduction Clinics. ThFh specialised accreditation in infertility. ThFh
2. it is mandatory that couples are seen and
With respect to accessing psychological infertility
offered independent counselling prior to
counselling,
gamete or embryo donation. ThFh
13. the degree of distress in couples has been
With regard to infertility counselling, shown to significantly influence
3. a key way in which clinics are assured that the acceptance rates. ThFh
consent that patients are given to their 14. the level of education of couples does not
treatment choice is truly informed is by influence acceptance. ThFh
implications counselling. ThFh The aim of infertility counselling is to,
4. fertility-related standardised psychological
questionnaires are utilised to enhance/ 15. offer couples an opportunity to understand
improve further understanding of relevant the various options of treatment. ThFh
psychosocial factors presented in 16. help couples accommodate their feelings
therapeutic counselling. ThFh about the outcome of any treatment. ThFh
17. provide couples with solutions to their
Counselling practitioners, psychological problems. ThFh
5. offer counselling related to the implications of 18. facilitate couples’ decision making
adoption alongside fertility counselling. ThFh about continuation or termination
6. rather than the treating clinician, must of treatment. ThFh
undertake an assessment of the ‘welfare of 19. direct couples to where information
the child’. ThFh can be found about alternatives
to parenthood. ThFh
With regard to counselling, 20. offer support primarily to help manage the
7. the European Society of Human Reproduction psychological distress of failed treatment. ThFh
and Embryology offers a comprehensive set of
guidelines and examples on the integration of
psychological care into the daily clinical TOG Blood pressure measurement in
activities of the medical team. ThFh pregnancy
8. it is an expectation of the British Infertility
Counselling Association that all mental health The following errors usually result in an overestimation of
practitioners offering an infertility counselling diastolic blood pressure (BP) in pregnancy:
service successfully complete an annual 1. Oscillometric measurement in women with
minimum of 20 CPD hours. ThFh pre-eclampsia. ThFh
2. Using a large cuff in a woman with a normal-
Regarding surrogacy treatment,
sized arm. ThFh
9. the Human Fertilisation and Embryology Act 3. Using Korotkoff phase 4 to estimate
2008 indicates that legal parenthood and diastolic BP. ThFh
parent responsibility can be interpreted/ 4. Deflating at greater than 3 mmHg
understood as similar. ThFh per second. ThFh

ª 2015 Royal College of Obstetricians and Gynaecologists 131

 CPD

When treating hypertension in pregnancy, TOGAppendicitis in pregnancy: how to

5. systolic BP is more important to target than
diastolic BP.
6. the target systolic BP should be
under 150 mmHg.
7. the target diastolic BP should be kept
above 70 mmHg.
8. ‘tight’ control is associated with fewer
episodes of severe systolic hypertension
in the mother as suggested by the
results from the recent
CHIPS trial.
With regard to maternal mortality and morbidity secondary
to hypertension in pregnancy,
manage and whether to deliver?
ThFh Appendicitis is a likely diagnosis in pregnancy when,
ThFh 1. ultrasound shows a non-compressible
blind-ending tube in the right iliac fossa
ThFh measuring 10 mm in diameter. ThFh
2. a patient presents with right-sided
abdominal pain, constipation and malaise. ThFh
In the diagnosis of appendicitis in pregnancy,
3. ultrasound is the best method for imaging in a
ThFh
morbidly obese patient. ThFh
4. MRI has the greatest specificity of all
imaging modalities. ThFh

9. it is often associated with With regard to the management of a pregnant patient

substandard care in recognising and with appendicitis,
treating hypertension. ThFh 5. it should be operative if the diagnosis
10. it is more common than from haemorrhage, is certain. ThFh
sepsis and unsafe termination of 6. it should primarily aim to reduce any delay in
pregnancy together. ThFh surgical intervention. ThFh
The following are recommended during routine antenatal 7. it should not involve appendicectomy if the
BP assessment: appendix appears normal at the time of surgery. ThFh
8. it should include delivery of the fetus
11. Rounding BP values to the regardless of gestation if the patient is
nearest 5 mmHg. ThFh critically ill. ThFh
12. Avoiding aneroid 9. some cases may be treated with
sphygmomanometry measurement. ThFh antibiotics alone. ThFh
13. Preferential use of the left arm
when possible. ThFh General anaesthesia for pregnant women undergoing
14. Ignoring the first reading if multiple appendicetomy,
measurements are taken. ThFh 10. carries an approximately 25-fold increased risk
15. Inflating the cuff to 20–30 mmHg above of complications than regional anaesthesia. ThFh
palpable systolic BP. ThFh 11. has temporary effects on the fetus as all
16. Deflating at 10 mmHg per second between induction and maintenance agents cross
Korotkoff 1 and 5. ThFh the placenta. ThFh
Concerning automated BP devices, 12. has a uterotonic effect. ThFh

17. they are not recommended in pre-eclampsia
unless specifically validated. ThFh
18. they eliminate observer errors related to
terminal digit preference. ThFh
With regard to guidelines for the management of
hypertension in pregnancy,
19. they recommend using mean arterial pressure
to guide treatment. ThFh
20. they recommend instituting
antihypertensives when there is an
incremental rise of 30 mmHg systolic BP/
15 mmHg diastolic BP, regardless of
absolute values. ThFh
Surgery for appendicetomy in pregnancy,
13. increases the rate of miscarriage. ThFh
14. has the lowest risk to the fetus when
performed in the second trimester. ThFh
15. should be delayed until antenatal corticosteroids
are given (in the absence of severe maternal
sepsis) if the gestation is critical. ThFh
Concerning acute appendicitis in pregnancy,
16. it is the most common cause of acute
surgical abdomen. ThFh
17. it most commonly occurs in the first trimester. ThFh
18. it has a fetal loss rate exceeding 50% if the
appendix perforates. ThFh

132 ª 2015 Royal College of Obstetricians and Gynaecologists

 CPD

With regard to imaging as an investigation for appendicitis Regarding new agents used in the management of
in pregnancy, constipation,
19. the primary goal is to rule out 19. prucalopride alters colonic motility patterns
differential diagnoses. ThFh via serotonin 5-HT4 receptor stimulation. ThFh
20. the secondary goal is to reduce the negative 20. linaclotide works by increasing the
appendicectomy rate. ThFh concentration of extracellular cyclic guanosine
monophosphate (c-GMP). ThFh

TOG Constipation in pregnancy

TOG Female fertility preservation: a fertile
Regarding constipation,
future?
1. the functional variety is attributable to an
When planning treatment, in which of the following
underlying psychological dysfunction. ThFh
circumstances would fertility preservation be considered?
2. the secondary variety results from either
pharmacotherapy or a medical condition. ThFh 1. Borderline ovarian tumour. ThFh
3. the prevalence is greatest in the 2. Cervical cancer stage 1B1. ThFh
third trimester. ThFh 3. Complex repeated ovarian surgery
4. large and small bowel hypomotility in for endometriosis. ThFh
pregnancy is attributed to estrogen. ThFh
Regarding oocyte cryopreservation,
With regard to treatment of constipation in pregnancy,
4. ideally these should be vitrified in metaphase I. T h F h
5. laxatives are the first-line therapy. ThFh 5. pregnancy success rates are similar with
6. sodium docusate is a good laxative option. ThFh vitrified and ‘fresh’ oocytes. ThFh
6. the major problem with this in pre-pubertal
Regarding the use of osmotic laxatives in pregnancy,
girls is the inability to do transvaginal scans
7. polyethylene glycol is the preferred option for and transvaginal oocycte retrieval. ThFh
chronic constipation. ThFh
Regarding ovarian stimulation in women with malignancy,
8. lactulose is best avoided in patients
with diabetes. ThFh 7. it is possible to commence stimulation at any
9. if used alone in opioid-induced constipation, point in the menstrual cycle. ThFh
they often need to be given in large doses. ThFh 8. conventional stimulation protocols are not
10. prolonged use is associated with recommended in these patients. ThFh
electrolyte imbalance. ThFh 9. aromatase inhibitors help to lower circulating
estrogen levels in ovarian hyperstimulation. ThFh
With regard to the use of stimulant laxatives in pregnancy,
10. the use of anti-estrogens in women with
11. they are a recognised cause of abdominal estrogen sensitive cancers (such as breast) is
cramps and diarrhoea. ThFh associated with an increased recurrence risk of
12. they are as effective as osmotic laxatives. ThFh the cancer. ThFh
13. they act by directly stimulating
Regarding in vitro maturation of oocytes (IVM),
bowel motility. ThFh
14. senna is not teratogenic. ThFh 11. fertilisation rates are of the order of 50–60%. ThFh
15. senokot is not excreted in the 12. it offers an alternative option for
breast milk. ThFh women who are at risk of ovarian
hyperstimulation cycles. ThFh
With regard to stopping laxatives in pregnancy,
Regarding ovarian tissue cryopreservation and
16. it is advised that this is effected by a
transplantation,
sudden discontinuation. ThFh
17. gradual withdrawal will reduce the risk of 13. it is a well-established option of
requiring re-initiation of therapy fertility preservation. ThFh
for recurrence. ThFh 14. small portions of ovarian tissue need only
18. when recurrence occurs, it is best managed by be preserved. ThFh
increasing the dose of laxatives. ThFh 15. it should not be used in malignancy. ThFh

ª 2015 Royal College of Obstetricians and Gynaecologists 133

 CPD

16. whole ovary preservation and transplant 13. MRI with T2 weighted images
appears technically more straightforward is the recommended imaging
compared to the use of ovarian cortex strips. T h F h for diagnosis. ThFh
17. orthotopic transplantation appears to be more
Regarding complications of UD,
successful than heterotopic transplantation. ThFh
14. an abscess is best managed with a formal
Regarding ovarian suppression during chemotherapy,
incision and drainage. ThFh
18. the use of GnRH analogues is of 15. a calculus is rare, occurring in less than 1%
definite benefit. ThFh of women. ThFh
16. when malignancies arise, the most common
Regarding ovarian transposition, variety are adenocarcinomas. ThFh
19. it should be performed weeks before 17. a urethrovaginal fistula following surgery is a
radiotherapy to allow time for healing. ThFh complication that occurs in up to 6%
20. radiotherapy may affect uterine function and of patients. ThFh
thus affect fertility. ThFh 18. the recurrence rate due to incomplete surgical
resection is up to 36%. ThFh

With regards to investigating women with UD

TOG Urethral diverticulum
19. a urethroscopy is best performed with a with a
With regard to urethral diverticulum (UD),
30 degrees scope. ThFh
1. it varies in size from 1–10 cm. ThFh 20. urodynamics is not indicated. ThFh
2. the median time from presentation to
diagnosis is 9.5 months. ThFh
3. most cases are thought to be acquired as a GTG Chickenpox in Pregnancy (Green-top

result of repeated infections. ThFh Guideline No. 13)

4. it has a characteristic shape.
Regarding the clinical features of UD,
5. the triad of dysuria, postvoid
dribbling and dyspareunia is a
common presentation.
6. dysuria occurs in 30–70% of cases.
7. purulent discharge on palpation
of the mass occurs in
25% of cases.
8. urinary incontinence is an associated
symptom in 20% of cases.
When investigating UD,
9. a micturating cystogram or
voiding cystourethrogram (VCUG)
will identify about 50–75%
of cases.
10. a micturating cystogram or VCUG
is useful in differentiating UD
from defects due to malignancy
or calculi.
11. transabdominal ultrasound is a
sensitive test for UD less than 5 mm
in diameter.
12. double balloon urethrogram
is considered the gold
standard investigation.
ThFh With regard to varicella virus infection,
1. the disease is infectious 24 hours before the
rash appears and remains infective until the
vesicles have crusted over. ThFh
ThFh 2. women who are varicella zoster virus
ThFh (VZV) IgG negative prepregnancy or
postpartum should be offered immunisation
as an option. ThFh
ThFh Concerning VZV immunisation,
ThFh 3. accidental immunisation in
pregnancy has been shown to be associated
with the occurrence of congenital
malformations of the fetal varicella
syndrome variety. ThFh
With regard to herpes zoster (shingles),
ThFh
4. ophthalmic infection does not pose a risk to
susceptible individuals. ThFh
5. thoracolumbar infection poses a remote risk
ThFh to susceptible individuals. ThFh
The administration of varicella zoster IgG is indicated in
following situations:
ThFh
6. Hypogammaglobuninaemia with
immunoglobulin A antibodies receiving
ThFh replacement therapy with immunoglobulin. ThFh

134 ª 2015 Royal College of Obstetricians and Gynaecologists


In a 25-year-old woman who develops a chicken pox rash,
7. acyclovir is most effective if given within the
first 2 days of the rash. ThFh
With regard to pain relief in labour in a woman who has
chickenpox infection,
8. epidural analgesia is preferred to spinal for
elective delivery. ThFh
Amniocentesis for the diagnosis of fetal varicella
syndrome (FVS),
9. has a high specificity for the development
of FVS. ThFh
10. should be performed only after the skin rash
has healed completely. ThFh
BJOG A re-evaluation of the role of rotational
forceps: retrospective comparison of
maternal and perinatal outcomes following
different methods of birth for malposition
in the second stage of labour
With regard to caesarean section (CS),
1. rates approximately doubled in the UK from
1990 to 2008. ThFh
2. when performed as an emergency is associated
with a risk of death of 0.6 per 1000 births. ThFh
With regard to rotational vaginal deliveries,
3. ventouse birth is associated with
a five times higher risk of
ª 2015 Royal College of Obstetricians and Gynaecologists
CPD
sub-aponeurotic haemorrhage than other
modes of childbirth. ThFh
4. in this study, the odds of women needing
caesarean section were about double with
rotational ventouse compared to
Kielland forceps. ThFh
In this study, Kielland forceps deliveries were associated
with,
5. the shortest stay in hospital compared to other
types of rotational vaginal delivery. ThFh
6. an approximately 7.1% chance of anal
sphincter injury. ThFh
7. a higher chance of achieving vaginal birth than
rotational ventouse. ThFh
8. a similar rate of neonatal admission for special
care as for rotational ventouse delivery. ThFh
Results from this retrospective comparison study,
9. show that the use of Kielland forceps is
associated with a higher incidence of maternal
and neonatal complications. ThFh
10. should encourage clinicians to re-evaluate
their choice of instrument for rotational birth. T h F h
Reference
Tempest N, Hart A, Walkinshaw S, Hapangama D. A re-evaluation of the role of
rotational forceps: retrospective comparison of maternal and perinatal
outcomes following different methods of birth for malposition in the second
stage of labour. BJOG 2013;120:1277–84.
135