DOI: 10.1111/tog.
12124 2014;16:214–9
The Obstetrician & Gynaecologist
http://onlinetog.org
CPD questions for volume 16 number 3
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Please direct all questions or problems to the CPD Office.
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The blue symbol denotes which source the questions refer
to including the RCOG journals, TOG and BJOG, and RCOG
guidance, such as Green-top Guidelines (GTG) and Scientific
Impact Papers (SIPs). All of the above sources are available to
RCOG members and fellows via the RCOG website.
TOG Reproductive health during conflict
Reproductive health as a human right is not applicable to,
1. family planning services. ThFh
With regard to the minimum initial services package
(MISP), it
2. has specifically designed kits for
rapid deployment. ThFh
3. provides legal services for survivors of rape. ThFh
4. should be implemented once the situation
is stable. ThFh
5. should be enacted one component at a time. ThFh
With regard to maternal and newborn care, the MISP
should include,
6. emergency obstetric care 24 hours a day, 7
days a week. ThFh
7. facilities capable of performing emergency
caesarean section. ThFh
8. distribution of clean delivery packs to
obviously pregnant women. ThFh
The ‘three delays’ model,
9. is a theory explaining increased levels of
maternal morbidity and mortality. ThFh
10. does not apply to deliveries inside of
healthcare facilities. ThFh
11. is applicable to resource poor settings without
violent conflict. ThFh
214
CPD
With regard to sexually transmitted infections during
conflict and displacement,
12. they should be treated on symptoms alone. ThFh
During conflict and displacement,
13. free supply of condoms should be a priority. ThFh
14. adolescents are particularly vulnerable to
sexual exploitation. ThFh
15. approximately10% of women of reproductive
age will be pregnant. ThFh
During a humanitarian response,
16. the maternal mortality rate remains worse for
refugees than that of their country-of-origin. T h F h
17. services should be expanded to include
programmes targeting early/forced marriage
and female genital mutilation. ThFh
18. programmes raising awareness of gender based
violence should include men and boys. ThFh
Developing countries affected by conflict,
19. receive less official development aid than those
at peace. ThFh
20. account for 8 out of 10 countries with the
highest maternal mortality rates globally. ThFh
TOG Catheter use in gynaecological practice
With regard to indwelling urethral catherisation,
1. urethritis is a common complication of short
term usage. ThFh
2. where the duration of usage is more than 28
days the polytetrafluroethylene (PTFE) type of
catheter is recommended. ThFh
3. the use of catheters coated with hydrophilic
polymers has not been shown to reduce
bacterial colonisation and encrustation. ThFh
4. the length of catheters used in obese women is
considerably longer than that for non-obese. ThFh
5. the use of normal saline to inflate the balloon
is associated with a higher deflation rate
compared with sterile water. ThFh
6. removing the catheter 2 days after anterior
colporrhapy compared with 5 days after
surgery is associated with more temporary
catheter replacements. ThFh
ª 2014 Royal College of Obstetricians and Gynaecologists
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With regard to the use of suprapubic catheters,
7. they are not associated with a lower incidence
of bacteriuria compared to the use of
urethral catheters.
8. if a silicon catheter is used, it should be
replaced every 4 months.
9. they are associated with a lower incidence of
urinary leakage around the catheter.
10. they allow the patient to take control of
voiding trials which are difficult with
urethral catheters.
With regard to complications of catheters,
11. catheter associated symptomatic urinary
tract infections (CASUTI) are the
leading cause of hospital acquired
infections.
12. coating catheters with antibiotics is thought
to be an ineffective means of
preventing CASUTI.
13. there is evidence to show that the use of silver
alloy coated catheters is associated with
a significant reduction in the incidence
of CASUTI.
14. in those on long-term catherisation, where
spontaneous balloon rupture occurs,
cystoscopy should be performed.
15. patients who have been on long-term
catheterisation for more than 10 years should
be screened for bladder cancer.
With regard to long-term intraurethral catheters
16. asymptomatic bacteriuria does not
require treatment.
17. prophylactic antibiotics should be given prior
to routine catheter change.
18. 80% of the patients suffer from recurrent
encrustations of their catheters frequently due
to a urinary tract infection.
19. catheter balloon diffusion can be a
problem with the use of 100% silicone
catheters.
20. catheter balloon cuff formation is less likely
with 100% silicone catheters.
TOG The conservative (non-pharmacological)
management of female urinary
incontinence
With regard to female urinary incontinence (UI),
1. the estimated prevalence is up to
approximately one third of the
adult population.
2. lack of knowledge regarding possible
treatment options is recognised as a barrier to
reporting UI symptoms. ThFh
ThFh 3. it is the most common trigger for admission to
residential care. ThFh
ThFh
With regard to the assessment of UI symptoms,
4. bladder diaries are helpful in the initial
ThFh
assessment of symptoms. ThFh
5. urodynamic investigations are advised prior to
commencing any treatment of UI. ThFh
ThFh
6. patient reported outcome measures primarily
help to assess objective outcomes
after interventions. ThFh
7. prescribing antibiotics for women with lower
urinary tract infections regardless of the result
ThFh of urine dipstick is not recommended. ThFh
In terms of lifestyle interventions for UI,
8. there is robust evidence from several
ThFh
randomised trials indicating that weight loss
in obese women results in significant
improvement in symptoms. ThFh
9. cessation of smoking is associated with a
ThFh
reduction in reports of UI. ThFh
10. addressing chronic constipation has not been
shown to reduce reports of UI. ThFh
ThFh
11. high caffeine intake has been associated with
increases in detrusor overactivity. ThFh
ThFh With regard to pelvic floor muscle training (PFMT),
12. it is recommended as first-line management
(IUCs),
for urge incontinence. ThFh
13. vaginal examination is not recommended
ThFh
prior to commencement of PFMT. ThFh
14. continued PFMT has been shown to be
ThFh
significantly associated with better
long-term outcomes. ThFh
15. biofeedback has been shown to significantly
ThFh
improve outcomes in UI compared to
PFMT alone. ThFh
16. five-year follow-up studies have shown a
ThFh
significant direct correlation between relapse of
UI and baseline symptom severity. ThFh
ThFh
The use of weighted vaginal cones,
17. has been shown to be difficult in patients
who have previously undergone vaginal
surgery. ThFh
18. requires supervision by a trained professional. T h F h
The use of electrostimulation of the pelvic floor for the
treatment of UI,
19. is supported by consistent evidence of efficacy
ThFh compared with sham stimulation. ThFh

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 CPD
Regarding the role of bladder training in UI,
20. it is recommended as first-line management of
urge incontinence. ThFh
TOG Headaches in pregnancy
Red flag features for headaches include:
1. headache that changes with posture
2. associated vomiting
3. occipital location
4. associated visual disturbance.
Migraine is classically,
5. bilateral.
6. pulsating.
7. aggravated by physical exercise.
With regard to migraine headaches in pregnancy,
8. there is an increase in the frequency of attacks
without aura.
9. women who suffer from this have not been
shown to have an increase in the risk
of pre-eclampsia.
10. the 5HT1-receptor sumatriptan has been
shown to be teratogenic.
11. women presenting with an aura for the first
time are not at an increased risk of
intracranial disease.
Posterior reversible encephalopathy syndrome,
12. is associated with an impairment of the
autoregulatory mechanism which maintains
constant cerebral blood flow where there are
blood pressure fluctuations.
13. when it is associated with pre-eclampsia,
management should follow the pathway for
managing severe pre-eclampsia.
With regard to cerebral venous thrombosis,
14. the incidence in western countries in
pregnancy ranges from 1 in 2500 deliveries to
1 in 10 000 deliveries.
15. the greatest risk in pregnancy is mainly in the
last four weeks.
16. the most common site is the sagittal sinus.
17. a plain computed tomography is a highly
sensitive investigation.
18. T2-weighted magnetic resonance imaging has
been shown to have limited value in diagnosis.
19. the outcome is better when it is associated
with pregnancy and the puerperium compared
to that occurring outside pregnancy.
20. when it occurs in pregnancy, it is a
contraindication for future pregnancies.
216
TOG Risk-reducing surgery for women at risk
of epithelial ovarian cancer
With regard to ovarian cancer,
1. the incidence of ovarian cancer in the general
population is <2%. ThFh
2. women with a hereditary ovarian cancer
syndrome have a life-time risk as high
ThFh
as 13–46%. ThFh
ThFh
3. most women present with early stage disease. ThFh
ThFh
4. overall 5-year survival is 70%. ThFh
ThFh
With regard to family history of ovarian cancer,
5. women with a single family member with
ThFh
epithelial ovarian cancer have a 4–5% risk. ThFh
ThFh
6. women with Lynch syndrome have a 20%
ThFh
lifetime risk of ovarian cancer. ThFh
With regard to reduction in risk with use of the oral
contraceptive pill (OCP),
ThFh
7. the relative risk of ovarian cancer appears to
be decreased by approximately 20% for each 5
years of use of the oral contraceptive pill. ThFh
ThFh
8. the protective effect of the OCP continues for
less than 20 years after cessation of use. ThFh
ThFh
With regard to infertility,
9. ovulation induction has been proven to
ThFh increase the risk of ovarian cancer. ThFh
With regard to screening,
10. the Prostate, Lung, Colorectal and Ovarian
(PLCO) trial demonstrated that a
combination of annual CA125 testing with
ThFh ultrasound decreased ovarian cancer mortality
in the general population. ThFh
11. CA125 levels are only elevated in 50–60% of
ThFh stage one ovarian cancers. ThFh
Regarding risk-reducing surgery,
12. bilateral salpingo-oophorectomy (BSO) in
premenopausal BRCA mutation carriers
ThFh reduces the risk of breast cancer by up to
75%. ThFh
ThFh 13. BRCA carriers who have had risk reducing
ThFh BSO still have a small risk of developing
primary peritoneal cancer PPC. ThFh
ThFh 14. serum CA125 level and ultrasound should be
performed prior to risk-reducing surgery. ThFh
ThFh 15. the risk of incidental ovarian tubal cancer in
BRCA carriers who are over 45 years and
are undergoing risk-reducing surgery is
ThFh around 10%. ThFh
16. BRCA 2 carriers develop ovarian cancer at a
ThFh younger age compared with BRCA 1 carriers. ThFh
ª 2014 Royal College of Obstetricians and Gynaecologists
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17. radical fimbriectomy has been proposed
as a risk reducing option for BRCA carriers
who wish to retain ovarian function
and fertility.
With regard to consideration of
hysterectomy,
18. women with Lynch syndrome have a 10%
lifetime risk of endometrial cancer.
19. clear evidence shows that estrogen therapy (as
hormone replacement therapy) is unsafe in
women following BSO and hysterectomy.
20. it is an appropriate procedure in BRCA
carriers wishing to take tamoxifen for
chemoprophylaxis for breast cancer.
With regard to treatment of EAP,
16. medical management is commonly used first
line when potential torrential bleeding during
ThFh surgery is anticipated. ThFh
17. there are well defined clinical indicators for
concurrent
successful medical management. ThFh
18. when diagnosed in the second trimester,
conservative management is recommended. ThFh
ThFh
19. the use of laparoscopic angiographic
embolisation has not been shown to reduce
the need for surgery. ThFh
ThFh
20. the use of vasoppressin analogues for
haemorrhage control at the time of surgery
does not increase the risk of
ThFh
cardiac complications. ThFh

TOG Early abdominal ectopic pregnancy: TOG Caesarean section at full dilatation:
challenges, update and review of current incidence, impact and current management
management
Possible reasons for the escalating full dilatation caesarean
With regard to early abdominal ectopic pregnancy (EAP), section (CS) rate include:
1. it occurs in approximately 1% of all 1. reduced one to one midwifery care ThFh
ectopic pregnancies. ThFh 2. de-skilling in operative vaginal delivery ThFh
2. it is primary EAP if implantation is directly 3. increasing maternal request ThFh
into the abdominal cavity. ThFh 4. increased vaginal birth after CS rates. ThFh
3. it is usually diagnosed prior to surgery. ThFh
With regard to the changing incidence of CS at
4. the pathophysiology is uncertain. ThFh
full dilatation,
5. it shares similar risk factors with tubal
5. consultant input in decision making has been
ectopic pregnancies. ThFh
shown to reduce it by as much as 75%. ThFh
6. mortality from it has remained unchanged
6. increasing maternal body mass index has been
over the past decade. ThFh
shown to be associated with an increase. ThFh
With regard to the incidence of EAP,
Possible sequelae to mother of full dilatation CS compared
7. it occurs in approximately 1 in 1000 births. ThFh
to first stage CS include:
8. assisted reproductive technologies have caused
7. extension of uterine incisions ThFh
an increase. ThFh
8. haemorrhage ThFh
With regard to the diagnosis of EAP, 9. urinary incontinence. ThFh
9. the Studdiford criteria for the primary type
The following maternal morbidity is more likely during
include evidence of a utero-peritoneal fistula. ThFh
full dilatation CS than for operative vaginal delivery:
10. pregnancy in a congenital uterine anomaly
10. Subsequent conception. ThFh
such as bicornuate uterus is a recognised
differential diagnosis. ThFh With respect to neonatal morbidity, the following have
11. the use of intraoperative ultrasound has been been reported with full dilatation CS:
shown to be of added value. ThFh 11. reduced APGAR scores ThFh
12. MRI has been shown to be valuable in the 12. reduced IQ at 5 years ThFh
assessment of organ involvement. ThFh 13. increased periosteal haematomas ThFh
14. Erb’s palsy. ThFh
With regard to the location of EAP,
13. it is more common in the posterior compared The following techniques have been reported to aid
to the anterior pelvic pouch. ThFh delivery of an impacted head at full dilation CS:
14. when it occurs on the liver it is more 15. placing the woman in the
frequently on the right lobe. ThFh lithotomy position ThFh
15. this has no bearing on treatment options. ThFh 16. digital disempaction via the vagina ThFh

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 CPD
17. breech delivery through the incision
18. symphisiotomy.
With regard to maternal morbidity following CS at
full dilatation,
19. the risk of intraoperative trauma is
approximately 1.5 times that for CS in the
first stage. ThFh
20. the incidence of haemorrhage has been
reported to be between 10 and 15%. ThFh
TOGPolyhydramnios in singleton
pregnancies: perinatal outcomes and
management
With regard to polyhydramnios,
1. it is defined as liquor volume above the 97th
centile for that gestation.
2. a cause is identified in approximately 60%
of cases.
3. the risk of aneuploidy in unexplained cases is
approximately 3–5%.
With regard to the production of amniotic fluid,
4. its volume progressively increases until 40
weeks of gestation.
5. abnormalities in the fetal swallowing
mechanism leads to polyhydramnios.
6. lithium exposure reduces the amount
of secretion.
7. neuromuscular and skeletal abnormalities
such as fetal akinesia-dyskinesia syndrome are
associated with polyhydramnios.
Regarding unexplained polyhydramnios,
8. there is an association with the VACTERL
group of abnormalities.
9. it is associated with increased
perinatal mortality.
10. parents should be counselled about the
importance of a thorough neonatal survey and
follow-up in such cases.
11. there is evidence in published literature
regarding the most appropriate time to
induce labour.
While investigating polyhydramnios,
12. ultrasound assessment of the amniotic fluid
index is better than assessment of the deepest
vertical pool of liquor.
13. a detailed anatomical survey of the fetus
is recommended.
218
ThFh With regard to the management of polyhydramnios,
ThFh 14. referral to maternal-fetal medicine specialists
is advisable in cases of persistent or
worsening polyhydramnios. ThFh
15. therapeutic amniocentesis is associated with a
small chance of complications such
as chorioamnionitis. ThFh
With regard to medical management of polyhydramnios,
16. indomethacin has no effect on fetal kidneys. ThFh
17. sulindac has been proven to be particularly
effective against unexplained polyhdramnios. T h F h
18. sulindac safety in pregnancy has not
been established. ThFh
While counselling patients with polyhydramnios,
19. they should be warned regarding the increased
risks of operative interventions. ThFh
ThFh 20. parents should be advised that mild
polyhydramnios is usually not associated
ThFh with an increased risk of adverse perinatal
outcomes. ThFh
ThFh
GTG Green-top Guideline No. 66.
Management of Beta Thalassaemia in
ThFh
Pregnancy
ThFh With regard to beta thalassaemia,
1. it is major if the woman sufferer
ThFh requires at least eight transfusion episodes
per year. ThFh
2. in the major variety, the inheritance of the
ThFh defective gene is from both parents. ThFh
3. splenectomy is the mainstay of treatment for
the major and intermedia types. ThFh
ThFh Recognised complications of multiple blood transfusions
in women with beta thalassaemia include,
ThFh 4. hypogonadotrophic hypogonadism. ThFh
Beta thalassaemia in pregnancy is associated with,
ThFh 5. an increased risk of cardiomyopathy. ThFh
Pre-conception care of women with thalassaemia
should include,
ThFh
6. recommendation against pregnancy when
there is severe iron overload. ThFh
7. continuation of chelating agents in the
first trimester. ThFh
ThFh 8. reliable monitoring of those with
diabetes by measuring serum
ThFh fructosamine concentrations. ThFh
ª 2014 Royal College of Obstetricians and Gynaecologists
 CPD

During pregnancy in women with beta thalassaemia, 4. she should be referred to the hospital for further
9. repeated transfusion should aim to maintain a assessment and antihypertensive therapy. ThFh
steady state of haemoglobin of approximately
While a woman with pre-eclampsia is receiving
80 g/L. ThFh
magnesium sulphate,
With regard to thromboprophylaxis in pregnant women 5. no additional agent for blood pressure
with beta thalassaemia, lowering is required. ThFh
10. antenatal low molecular weight heparin and 6. parenteral hydralazine is an appropriate agent
low-dose aspirin is recommended for those to use for severe hypertension. ThFh
who have had a splenectomy and have a
For the treatment of severe hypertension in pregnancy,
platelet count of at least 600x109/L. ThFh
7. nifedipine is effective in lowering severely
elevated blood pressure in more than 80% of
pregnant women. ThFh
BJOGOral antihypertensive therapy for
8. oral prazosin is associated with an increased
severe hypertension in pregnancy and
risk of stillbirth. ThFh
postpartum: a systematic review
9. nifedipine is the oral antihypertensive drug of
If a pregnant woman has a blood pressure of 165/ first choice based on the evidence in this
112 mmHg (confirmed by repeat measurement after at systematic review. ThFh
least 15 minutes) at a routine office visit, 10. use of beta-blockers is contraindicated in
1. she should receive antihypertensive therapy to women with severe asthma. ThFh
decrease stroke risk. ThFh
2. she should be considered for hypertensive
‘emergency’ treatment that requires Reference
blood pressure lowering over a few
minutes. ThFh Firoz T, Magee L, MacDonell K, Payne B, Gordon R, Vidler M et al. Oral
antihypertensive therapy for severe hypertension in pregnancy and postpartum:
3. administer an oral antihypertensive agent in a systematic review. BJOG 2014 May 16. DOI: 10.1111/1471-0528.12737.
the office as a first step. ThFh [Epub ahead of print]

ª 2014 Royal College of Obstetricians and Gynaecologists 219