DOI: 10.1111/tog.

12252 2015;17:288–93
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 17 number 4

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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.
TOGThe obstetric care of asylum seekers
and refugee women in the UK
Regarding the legal status of asylum seekers,
1. they are allowed to work in the UK. ThFh
2. they must present themselves to the
immigration services on arrival in the UK. ThFh
3. they are entitled to 70% of the funding that
British citizens receive in income support. ThFh
Regarding the dispersal of pregnant asylum seekers,
4. the UK Border Agency recommends that they
can be dispersed up to 38 weeks of gestation. T h F h
5. it has a small deleterious effect on the quality
of care provided to these women. ThFh
6. it is carried out in order to reduce
overcrowding in the initial
accommodation centres. ThFh
Regarding the health needs of pregnant asylum seekers,
7. their health usually deteriorates between 2 and
3 years following moving to the UK. ThFh
8. 40% have experienced violation of their
human rights. ThFh
9. most are late bookers in pregnancy. ThFh
Regarding maternal mortality and morbidity amongst
pregnant asylum seekers,
10. migrant sub-Saharan African women are at
the highest risk of stillbirth. ThFh
11. they have a 60% higher risk of
preterm delivery. ThFh
Concerning sexual health in asylum seekers,
12. data are available regarding the rates of sexually
transmitted infections in this social group. ThFh
13. limited access to services and stigmatisation
leads to poor attendance. ThFh
14. HIV rates amongst the migrant population in
the UK are highest in the black African
ethnic group. ThFh
With regard to female genital mutilation,
15. Egypt is an area of high prevalence. ThFh
16. it leads to an increased risk of emergency
caesarean section. ThFh
17. type I involves cutting of the labia. ThFh
Regarding ways in which health professionals and
maternity services can care for pregnant asylum seekers,
18. multi-agency liaison and communication
minimises logistical challenges of dispersal. ThFh
19. telephone interpreting service (with dual
handsets) is the ideal way to communicate
when the patient does not speak English. ThFh
With regards to labour and delivery in asylum seekers,
20. the surgical intervention rates in labour are
not different from that of the
general population. ThFh
TOG The molecular and genetic basis of
inherited cancer risk in gynaecology
With regard to inherited cancers,
1. germline mutations are the cause of inherited
cancer syndromes. ThFh
2. they make up 5–10% of all cancers. ThFh
3. the autosomal dominant mode of inheritance
is the most common. ThFh
4. multifactorial interaction between low
penetration and environmental factors occurs
in 20–25% of cases. ThFh
Concerning hereditary breast and/or ovarian cancer,
5. BRCA1 and BRCA2 germline mutations are
inherited in an autosomal recessive fashion. ThFh

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6. the reported prevalence of BRCA1 and BRCA2

TOG Uterine arteriovenous malformations:
germline mutations in the UK is
approximately 1%. ThFh clinical implications
7. a woman carrying a mutation in the BRCA2 With regard to uterine ateriovenous
gene has a lifetime risk of ovarian cancer in malformations (AVMs),
the region of 30%. ThFh
8. aberrant promoter hypermethylation of the 1. the incidence in women with abnormal
BRCA1 gene causes it to be functionally uterine bleeding has been reported as 10–15%. ThFh
deficient in up to 35% of sporadic ovarian 2. a history of recent gynaecological procedure
cancer cases. ThFh or pregnancy is reported a few weeks or years
9. women with ovarian carcinoma who harbour prior to the diagnosis in most cases. ThFh
a BRCA mutation generally have a worse 3. they are more common after
prognosis compared with sporadic disease. ThFh instrumentation of the uterus than in the
10. serous carcinoma of the endometrium is now postpartum period. ThFh
an accepted member of hereditary breast- 4. where the malformations extend beyond the
ovarian cancer syndrome. ThFh uterus into the surrounding pelvis and involve
11. the RAD51C mutation is associated with high a number of vessels other than uterine vessels
grade epithelial ovarian tumours of both the they are most likely to be congenital. ThFh
serous subtype. ThFh 5. acquired lesions are characterised by a
12. RAD51D mutation carriers have an fistulous connection between intramural
approximately 10% cumulative life time risk arteries and venous plexus. ThFh
of ovarian cancer. ThFh Regarding the pathophysiology of uterine AVMs,
13. a distinctive phenotype of cancers associated
with BRCA2 mutation is early stage 6. evidence from systematic reviews shows that
at presentation. ThFh those associated with gestational trophoblastic
disease respond poorly to uterine
Concerning hereditary non-polyposis colon cancer artery embolisation. ThFh
syndrome (Lynch Syndrome),
Regarding the clinical manifestations of AVMs,
14. endometrial carcinomas that present on a
background of Lynch Syndrome have a 7. they are a recognised cause of
predilection for arising from the lower postmenopausal bleeding. ThFh
uterine segment. ThFh 8. vaginal bleeding occurs when the endothelial
15. the prevalence of Lynch Syndrome in lining of the vessels in the malformation
endometrial cancer patients is less than 1%. ThFh is disrupted. ThFh
16. MLH1 and MSH2 account for the majority 9. a negative serum beta-hCG is essential to
(90%) of all identified hereditary non- make a diagnosis. ThFh
polyposis colon cancer syndrome alterations. ThFh
With regard to imaging as a diagnostic tool for AVM,
17. germline mutations in MSH6 have greater
penetrance for endometrial than for 10. diagnostic features on spectral Doppler
colorectal carcinomas. ThFh include unidirectional turbulent flow. ThFh
11. a typical feature on colour Doppler is low
Concerning Peutz-Jeghers syndrome,
velocity resistance high impedance flow. ThFh
18. the associated risk of malignancy is elevated 12. magnetic resonance angiography findings
10–18 fold over the general population. ThFh correlate well with those of
pelvic angiography. ThFh
With regard to Cowden syndrome,
13. grey-scale ultrasound has features which are
19. 80% of patients have an identifiable germline specific and diagnostic. ThFh
mutation in PTEN. ThFh 14. embolisation is not recommended at the time
of diagnostic angiography. ThFh
In the hypercalcaemic type of small cell
ovarian carcinoma, With regard to the treatment of uterine AVMs,
20. there is a high incidence of SMARCA4 15. a rectovaginal fistula is a recognised
germline mutations. ThFh complication of embolisation. ThFh

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16. uterine curette is a first line therapeutic option. ThFh When taking consent in English from a
17. ligation of the internal iliac arteries is non-English speaker,
recognised to be an effective long-
12. a family member is allowed to give consent on
term treatment. ThFh
behalf of a patient who cannot
18. women in whom angiography demonstrates
understand English. ThFh
venous contrast filling within the
13. use of a family friend who speaks the same
malformation are more likely to
language is a simple and acceptable alternative
require intervention. ThFh
if a professional interpreter is not available. ThFh
In relation to subsequent fertility and pregnancy after
AVM treatment, General principles of consent include,

19. the embolic agent as opposed to the size of the 14. the clinician who performs the procedure that
lesion is the most important factor in is the subject of the consent should usually
determining future fertility. ThFh obtain consent. ThFh
20. most resulting pregnancies are complicated by 15. a person who is deemed to have capacity is
placenta accreta. ThFh entitled to withdraw their consent to
treatment at any given time, even after the
procedure has started. ThFh
TOG Consent in clinical practice 16. consent does not expire but should be
reviewed if there is significant delay before
For consent to be valid, a procedure. ThFh
1. the three key components of capacity, 17. research projects that patients are included in
information and volition need to be fulfilled. ThFh have to be discussed as part of the consent
2. it should have been obtained before process even if they do not affect the outcome
the procedure. ThFh of a procedure. ThFh
18. it is advised that women who refuse a
Considering mental capacity for consent, caesarean section, putting an unborn child’s
3. a person must be assumed to have capacity life at risk, are referred for assessment under
unless it has been clearly demonstrated the Mental Health Act. ThFh
otherwise by a trained professional. ThFh
Information to be provided to patients when obtaining
4. in an obstetric emergency setting, patients lack
consent should include,
capacity to consent if they are in pain. ThFh
5. when possible, consent should be taken when a 19. treatment options including not treating (i.e.
patient is not in pain. ThFh conservative versus the treatment options). ThFh
20. the complications of the treatment but not
Regarding unconscious patients,
including the statistics, e.g. rates of
6. when consent cannot be obtained, doctors these complications. ThFh
should (with the exception of valid advanced
declaration of refusal of treatment, for
example, blood products) provide medical TOG Vaccination in pregnancy
treatment that is in the patient’s best interests. T h F h
Concerning immunity,
7. it is acceptable to take consent for treating
unconscious patients from their next of kin. ThFh 1. the only physiological example of passive
immunity is seen in the neonatal period. ThFh
With conscious patients in an emergency situation,
2. administration of Varicella zoster
8. written consent is required for all immunoglobulin is an example of
operative procedures. ThFh active immunity. ThFh
9. verbal or implied consent is valid and must be 3. the first line of the host defence mechanism
documented in the patient’s notes. ThFh is through innate immunity. ThFh
10. acquiescence of a patient who is not fully 4. the adaptive immune response is usually
informed does not constitute consent. ThFh slow, often taking days. ThFh
11. treatment using the defense of necessity 5. immune memory is characteristic of
is acceptable. ThFh adaptive immunity. ThFh

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6. epithelial barriers are generally an example of and non-compliant compared with when it is
adaptive immunity. ThFh soft and compliant. ThFh
7. live vaccinations are usually more potent than 8. it has no effect on placental perfusion and
killed vaccines. ThFh fetal oxygenation. ThFh
8. killed vaccines predominantly induce
The cervix in labour
humoral immunity. ThFh
9. killed vaccines are often given by the 9. has no influence on intrauterine
parenteral route. ThFh pressure development. ThFh
10. passive immunity induces a long lived 10. alters myometrial wall tension when soft
resistance to infection. ThFh and compliant. ThFh
Regarding vaccination, With regard to the active management of labour,
11. the measles, mumps and rubella (MMR) 11. it has been shown to shorten labour. ThFh
vaccine is contraindicated in pregnancy. ThFh 12. it has been shown to significantly reduce the
12. the purpose of the maternal Pertussis caesarean section rate. ThFh
vaccination programme is to reduce the risk of 13. it results in a high percentage of women
neonatal Pertussis. ThFh requiring oxytocin. ThFh
13. administration of the MMR vaccine in early
pregnancy is an indication for termination The NHS Litigation Authority reports indicate that
of pregnancy. ThFh
14. obstetrics has the highest number of
14. pregnant women who are at high risk of
litiginous claims. ThFh
Hepatitis B infection should be vaccinated. ThFh
15. obstetric claims have the highest cost in terms
15. the optimum time for Whooping cough
of settlements. ThFh
vaccination in pregnancy is between 28 and 32
16. cardiotocography interpretation is amongst
weeks of gestation. ThFh
the top four most common causes for
16. live viral vaccines given to lactating women
maternity litigation. ThFh
affect the safety of breastfeeding. ThFh
17. toxoids are an example of a purified Studies on the use of oxytocin have
macromolecule vaccine. ThFh
18. vaccination is a method of artificially inducing 17. shown that injudicious use is a factor in 50%
active immunisation. ThFh of medicolegal claims. ThFh
19. viral vaccines are contraindicated in pregnancy. ThFh 18. resulted in Sweden introducing a series
20. immunisation in a pregnant woman is less of checklists to make oxytocin use
efficacious than in a non-pregnant woman. ThFh safer. ThFh
19. shown that fetal heart rate abnormalities
are common with its use and can
TOG The use and abuse of oxytocin be ignored. ThFh
20. shown that it is dangerous and should
With regard to oxytocin augmentation of labour, be banned. ThFh
1. it was introduced in the 1960s as part of the
active management of labour. ThFh
TOG Management of delivery when
2. it is a common cause of litigation. ThFh
3. it has been shown to significantly reduce the malposition of the fetal head complicates
rate of caesarean section. ThFh the second stage of labour
4. it should not be used if the fetal heart rate With regard to caesarean section,
pattern is suspicious or abnormal. ThFh
1. when performed in the second stage of labour,
Regarding intrauterine pressure, it carries an increased risk of blood
5. it is directly related to the strength of transfusion compared with that in the first
myometrial contraction. ThFh stage of labour. ThFh
6. it is quantified using Montevideo units. ThFh 2. it is safer for mother and baby when
7. for the same amount of myometrial performed in the second stage of labour than
contraction, it is higher if the cervix is firm an instrumental delivery. ThFh

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3. it offers long-term pelvic floor protection over Compared with the Kielland forceps, ventouse delivery
operative vaginal delivery. ThFh
19. has a significantly higher failure rate. ThFh
4. fetal head impaction is a recognised
20. has a higher admission into the neonatal unit
complication when undertaken in the
for the baby. ThFh
second stage. ThFh
With regard to ventouse delivery,
TOG Exercise in pregnancy
5. the rate is increasing in the UK on the
background of declining caesarean Exercise in pregnancy has been shown to influence
section deliveries. ThFh 1. insulin resistance. ThFh
6. the flexion point vital for this procedure is 2. gestational weight gain. ThFh
situated 2 cm in front of the 3. caesarean section rates. ThFh
posterior fontanelle. ThFh 4. the incidence of spina bifida. ThFh
7. rotation of the fetal head when there is
malposition occurs when the fetal head The effects to the baby of maternal exercise have been
contacts the pelvic floor. ThFh demonstrated to include which of the following?
8. the rotational type is four times more likely
5. Spontaneous preterm birth. ThFh
to fail compared with the non-
6. Reduced birth weight associated with exercise
rotational type. ThFh
in the third trimester. ThFh
9. it is not recommended in preterm births
7. Fetal bradycardia. ThFh
before 34 weeks of gestation. ThFh
8. Reduced risk of diabetes mellitus in
Concerning manual rotation (MROT), the offspring. ThFh
10. it is widely used in UK practice. ThFh Guidelines referring to exercise in pregnancy recommend
11. it is recommended by the Royal Australian
9. moderate exercise of at least 30 minutes
and New Zealand College of Obstetricians and
per day. ThFh
Gynaecologists prior to applying
10. avoiding scuba diving. ThFh
Kielland’s forceps. ThFh
11. gradually recommencing it
12. fetal skull fractures are a
immediately postpartum. ThFh
recognised complication. ThFh
12. avoiding it when there is pregnancy-
13. the sequential use of instruments is less likely
induced hypertension. ThFh
when successful MROT is combined with
the forceps. ThFh With regard to the physiological maternal adaptation in
pregnancy, there is
Concerning Kielland forceps,
13. a first trimester increase in maternal blood
14. it allows for the correction of asynclitism prior volume of greater than a third. ThFh
to delivery. ThFh 14. an increase in cardiac output during the
15. rotation is recommended to be in a second trimester. ThFh
clockwise direction. ThFh 15. a reduction in maternal muscle mass. ThFh
16. the risk of obstetric anal sphincter injuries is 16. an increase in tidal volume. ThFh
similar to that with other methods of
operative vaginal deliveries. ThFh With regard to increased maternal physical activity
in pregnancy,
With regard to operative vaginal delivery,
17. it reduces the risk of maternal diabetes
17. this occurs when the fetal head is mellitus in later life. ThFh
rotated through at least 30 to an occipito- 18. it should be recommended in
anterior position before delivery. ThFh sedentary women. ThFh
18. it is associated with the same 19. it increases the risk of symphysis
procedure failure rate as that for pubis dysfunction. ThFh
non-rotational deliveries. ThFh 20. it reduces the rate of glycosuria. ThFh

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BJOGAntenatal magnetic resonance imaging
versus ultrasound for predicting neonatal
macrosomia: a systematic review and
meta-analysis
In this systematic review,
1. only electronic databases were searched. ThFh
2. multiple resources were searched without
language restrictions. ThFh
3. diagnostic accuracy, case–control studies and
cohort studies were included. ThFh
4. random or consecutive recruitment of the study
population was deemed to have a low risk of bias. ThFh
5. the index test was deemed to have a high risk
of bias if the threshold to predict macrosomia
was not pre-specified. ThFh
6. most studies scored high or unclear risk of bias
in all domains other than patient selection. ThFh
ª 2015 Royal College of Obstetricians and Gynaecologists
CPD
7. summary estimates were calculated using
fixed effects meta-analysis. ThFh
8. differences in types of population accounted
for the heterogeneity in the summary sensitivity
of two dimensional ultrasound estimated fetal
weight for predicting fetal macrosomia. ThFh
Regarding diagnostic accuracy of the tests in this
systematic review,
9. sensitivity refers to the true negative rate. ThFh
10. high specificity means that the number of false
positives is low. ThFh
Reference
1 Malin GL, Bugg GJ, Takwoingi Y, Thornton JG, Jones NW. Antenatal
magnetic resonance imaging versus ultrasound for predicting neonatal
macrosomia: a systematic review and meta-analysis. BJOG 2015 29 July; DOI:
10.1111/1471-0528.13517. [Epub ahead of print]
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