DOI: 10.1111/tog.

12720 2021;23:67–71
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 23 issue 1

CPD credits can be claimed for the following questions recognised ways of screening cancers for
online via the TOG CPD submission system in the RCOG characteristics suggestive of the syndrome. ThFh
CPD ePortfolio. You must be a registered CPD participant of 7. the National Institute for Health and Care
the RCOG CPD programme (available in the UK and Excellence endorses universal screening of
worldwide) in order to submit your answers. colorectal cancer patients for
Participants can claim 2 credits per set of questions if at Lynch syndrome. ThFh
least 70% of questions have been answered correctly. CPD 8. most gynaecological cancers found to have
participants are advised to consider whether the articles are aberrant mismatch repair
still relevant for their CPD, in particular if there are more immunohistochemical staining will be in
recent articles on the same topic available and if clinical those with the syndrome. ThFh
guidelines have been updated since publication. 9. the addition of MLH1 promotor
Please direct all questions or problems to the CPD Office. hypermethylation testing in a Lynch
Tel: +44 (0)20 7772 6307 or email: cpd@rcog.org.uk. syndrome diagnostic pathway
The blue symbol denotes which source the questions refer improves specificity. ThFh
to including the RCOG journals, TOG and BJOG, and RCOG
Regarding gynaecological surveillance in women with
guidance, such as Green-top Guidelines (GTGs) and
Lynch syndrome,
Scientific Impact Papers (SIPs). All of the above sources are
available to RCOG Members and Fellows via the RCOG 10. there is strong evidence to recommend its use. T h F h
website. RCOG Members, Fellows and Associates have full 11. this should be offered to women around 25
access to TOG content via the TOG app (available for iOS years of age. ThFh
and Android). 12. counselling should include education on red
flag symptoms of cancer and risk-
TOG Lynch syndrome for the gynaecologist reducing surgery. ThFh

With regard to Lynch syndrome, With regard to risk-reducing strategies for women with
Lynch syndrome,
1. loss of mismatch repair protein expression on
13. hysterectomy is strongly recommended for all
immunohistochemistry of cancer
those with the syndrome. ThFh
is diagnostic. ThFh
14. the timing of risk-reducing surgery depends
2. most carriers of the mutation associated with
on the syndrome gene. ThFh
the syndrome know they have the condition. ThFh
15. where possible, a laparoscopic approach
3. the first cancers associated with the syndrome
is recommended. ThFh
are predominantly endometrial or
16. aspirin is not recommended as a means of
ovarian cancers. ThFh
reducing their overall cancer risk. ThFh
4. when cancers occur, they have in them an
unusually high immune infiltrate. ThFh Regarding Lynch syndrome-associated gynaecological cancers,
With regard to testing for Lynch syndrome, 17. endometrial types that arise as a result of the
syndrome have a poorer prognosis than
5. consent must be sought before definitive sporadic types. ThFh
germline testing for Lynch syndrome by a 18. checkpoint inhibition of the PD-1/PD-L1
trained professional. ThFh pathway has been shown to be very effective
6. immunohistochemical staining of tumours in mismatch repair-deficient cancers. ThFh
for the mismatch repair proteins or 19. vaccination against these cancers is currently
microsatellite instability analysis are the focus of research. ThFh

ª 2021 Royal College of Obstetricians and Gynaecologists 67

 CPD

20. the Manchester International Consensus 18. levels correlate positively with ascitic volume. ThFh
guideline is a useful reference for gynaecologists
With regard to the use of CA125 in the screening of
managing women with these cancers. ThFh
ovarian cancer,
19. guidelines recommend it as part of
TOG Raised CA125 – what we actually know. . . initial investigation. ThFh
20. a one-off serum blood test has been shown to
Carbohydrate antigen 125 (CA125) is, reduce patient mortality. ThFh
1. elevated when the serum level is above 40 U/ml. ThFh
2. expressed in tissues derived from embryonic
coelomic tissue. ThFh TOG Does ovarian cystectomy pose a risk to
3. a mandatory test in follow-up of patients with ovarian reserve and fertility?
ovarian cancer. ThFh
With regard to functional ovarian cysts,
4. a reliable screening biomarker. ThFh
5. normal in 50% of women with stage I 1. they are the most frequently occurring cysts in
ovarian cancer. ThFh adults and children. ThFh
6. elevated in over 70% of women with advanced 2. luteal cysts are observed in 25% of natural
ovarian cancer. ThFh menstrual cycles in fertile women. ThFh
7. only elevated in ovarian epithelial cancers. ThFh 3. women with low ovarian reserve are at
increased risk of developing them. ThFh
With regard to ovarian cancer, 4. luteal cysts result from unruptured follicles. ThFh
8. it is the leading cause of death from any 5. they almost always regress spontaneously
gynaecological malignancy. ThFh within one to three menstrual cycles. ThFh
9. approximately 70% of women present in stage
With regard to dermoid cysts,
I–II. ThFh
10. a risk of malignancy index of over 300 only is 6. they are bilateral in 30–40% of cases. ThFh
a trigger for patient referral to a cancer centre. T h F h 7. they are associated with a reduction in
ovarian reserve. ThFh
In patients with an elevated CA125 and no evidence of
ovarian cancer on imaging, With regard to endometriomas,

11. additional tumour marking testing, such as
for CA19-9 and carcinoembryonic antigen,
is recommended.
With regard to current guidance on the diagnosis of
ovarian cancer,
12. pelvic ultrasound scan is considered the first-
line investigation for women presenting with
symptoms of ovarian cancer.
13. CA125 testing should be done in all
postmenopausal women with a cystic lesion of
1 cm or more on the ovary.
Recent studies relating to ovarian cancer tumour markers
have suggested that,
14. age-specific CA125 cut-offs are less accurate
and increase false-positive results.
With regard to CA125 in ascitic fluid,
15. levels correlate with those in the serum.
16. it is produced by tumour cells.
17. levels are higher than those in blood.
8. women with endometriomas have lower
ovarian reserve (as measured by anti-
ThFh m€ullerian hormone and antral follicle counts)
compared with age matched controls. ThFh
9. cystectomy prior to in vitro fertilisation
treatment has been shown to
improve outcomes. ThFh
10. recurrence rates are similar following either
ThFh cystectomy or drainage and diathermy. ThFh
With regard to benign ovarian cysts in children
and adolescents,
ThFh
11. malignant teratomas account for about 1% of
all teratomas in children. ThFh
12. functional ovarian cysts account for about
one-third of all paediatric adnexal masses. ThFh
ThFh
With regard to ovarian torsion,
13. it accounts for approximately 3% of all
ThFh emergency gynaecological surgery. ThFh
ThFh 14. laparoscopic detorsion appears to preserve
ThFh ovarian function. ThFh

68 ª 2021 Royal College of Obstetricians and Gynaecologists

15. premenarchal girls have elongated
infundibulopelvic ligaments, which increases
their risk.
16. untwisting at the time of surgery should be
followed by cystectomy if circulation returns.
With regard to ovarian reserve assessments,
17. ovarian cystectomy has been associated with a
reduction in the ovarian reserve. ThFh
18. they are recommended before ovarian
cystectomy in women who have severe
endometriosis and bilateral endometrioma. ThFh
With regard to recommendations for ovarian cystectomy,
19. the initial incision on the cyst should be made
close to the mesovarium. ThFh
20. gonadotrophin-releasing hormone agonist
therapy is used for large endometriomas to
reduce the thickness of the cyst wall. ThFh
TOG Very advanced maternal age
Pregnancy following conception via assisted reproductive
technologies in women of advanced maternal age,
1. is significantly more likely to result in a live
birth if a donor embryo rather than an
autologous embryo is used.
2. is associated with a two-fold increase in the
risk of developing pre-eclampsia in
comparison to a pregnancy following
spontaneous conception.
3. is an indication for aspirin (150 mg) from 12
weeks of gestation until delivery to decrease
the risk of pre-eclampsia and small-for-
gestational age.
With regard to early pregnancy in women of very advanced
maternal age,
4. there is an overall 53% risk of miscarriage. ThFh
5. the overall risk of ectopic pregnancy in those
aged 44 years or more is twice that in
younger women. ThFh
6. there is evidence that women aged 40 years
and above are twice as likely to need a blood
transfusion during an admission for an
ectopic pregnancy in comparison to
younger women. ThFh
Women of very advanced maternal age are more likely than
younger women to be,
7. multiparous.
8. overweight or obese.
ª 2021 Royal College of Obstetricians and Gynaecologists
Multiple pregnancy rates in women of very advanced
maternal age,
ThFh
9. have been consistently higher than in any
other age group due to multiple embryos
ThFh
being transferred during assisted
reproductive technology. ThFh
With regard to medical complications in women of very
advanced maternal age,
10. studies have shown that they are three to six
times more likely to develop gestational
hypertension than younger women. ThFh
11. the most significant risk factor for developing
pre-eclampsia is obesity. ThFh
Venous thromboembolism risk in women of very advanced
maternal age,
12. is increased in the first trimester following
assisted reproductive technology. ThFh
13. should be first assessed at 28 weeks’ gestation. T h F h
Regarding placental complications, women of very
advanced maternal age,
14. are three times more likely to have placenta
praevia than younger women. ThFh
15. have a similar risk of placental abruption as
younger women. ThFh
ThFh
Regarding postpartum haemorrhage,
16. it complicates one in four pregnancies in
women of very advanced maternal age. ThFh
ThFh 17. women of very advanced maternal age are
almost twice as likely to need blood products
than younger women. ThFh
Women of very advanced maternal age,
ThFh
18. are 33.5 times more likely to be admitted to
intensive care than younger women. ThFh
Regarding trisomy,
19. the risk of having a child with trisomy 21 is
1:35 at the age of 45. ThFh
20. if a cut off of 1 in 150 is used as a screen-
positive result, one in four women of very
advanced maternal age will screen positive. ThFh
TOG Care in pregnancies subsequent to
stillbirth or perinatal death
In relation to investigation of a stillbirth,
1. histopathological examination of the placenta
ThFh by a pathologist provides useful information
ThFh in less than 10% of cases. ThFh
69
 CPD
2. cytogenetic analysis is the most useful
investigation to identify a cause of stillbirth. ThFh
3. postmortem (autopsy) uptake in the UK has
increased over recent years. ThFh
4. histopathological examination of the placenta
by a perinatal pathologist reduces the
reporting of ‘unexplained’ stillbirth. ThFh
With respect to stillbirths,
5. approximately 80% of those in high-income
countries occur in women who have no
recognised risk factors at booking. ThFh
6. previous occurrence is associated with an
approximately 20-fold recurrence in a
subsequent pregnancy. ThFh
7. detection of fetal growth restriction
antenatally reduces the risk. ThFh
8. stopping smoking before 16 weeks’ gestation
reduces the risk to that of the
background population. ThFh
When a mother has a history of stillbirth in the
previous pregnancy,
9. the likelihood of preterm birth is reduced in a
subsequent pregnancy. ThFh
10. the likelihood of placental abruption is
increased in a subsequent pregnancy. ThFh
11. the recurrence risk is highest when cause of
the index stillbirth was of placental origin. ThFh
12. the likelihood of complications is significantly
influenced by the time interval between the
two pregnancies. ThFh
When caring for patients in a subsequent pregnancy
after stillbirth,
13. the cost to the NHS is comparable to that of a
pregnancy complicated by
gestational diabetes. ThFh
14. women and their families are at increased risk
of intense anxiety, depression, and complex
emotional responses that persist into the
subsequent pregnancy. ThFh
15. most families embark on a subsequent
pregnancy within 12 months of the stillbirth. ThFh
16. women who have a history of stillbirth are less
likely to stop smoking than women who have
had a live birth. ThFh
17. aspirin commenced before 16 weeks’ gestation
has been shown to significantly reduce the risk
of stillbirth in high-risk women. ThFh
18. guidelines exist to standardise the care
provided across the UK to women who have
experienced a stillbirth. ThFh
70
The risk of stillbirth recurrence in a subsequent pregnancy
can be reduced,
19. with the use of serial ultrasound scan
measurements of fetal biometry and uterine
and umbilical artery doppler waveforms. ThFh
With regard to establishing the cause of stillbirth,
20. using the relevant condition at death
(ReCoDe) system is associated with the lowest
unexplained rate. ThFh
TOG Obstetric outcomes of twin pregnancies
presenting with a complete hydatidiform
mole and coexistent normal fetus: A
systematic review and meta-analysis
A single complete hydatidiform mole (CHM),
1. is almost always diploid, with its
chromosomes derived entirely from the
paternal genome. ThFh
A twin pregnancy with a CHM and coexisting normal fetus
is a condition that,
2. contains a CHM and a normal fetus whose
placenta is often partially molar. ThFh
3. has become more common due to the
increasing use of assisted
reproductive techniques. ThFh
4. presents clinically with vaginal bleeding in at
least 70% of cases. ThFh
5. presents unique clinical challenges that should
be managed antenatally by a multidisciplinary
team with expertise in managing high-
risk pregnancies. ThFh
Women presenting with a CHM and coexisting
normal fetus,
6. experience obstetric and/or perinatal
complications in approximately 80% of cases. ThFh
7. have a 10-fold higher risk of clinical
hyperthyroidism than a single CHM. ThFh
8. should be advised that their chance of a live
birth if the pregnancy continues beyond the
first trimester is approximately 50%. ThFh
Following delivery of a twin pregnancy with confirmed
histopathologic diagnosis of CHM and coexisting normal
fetus, women should be advised that,
9. they have a lower risk of gestational
trophoblastic neoplasia compared to those
with a single CHM. ThFh
ª 2021 Royal College of Obstetricians and Gynaecologists
10. they have a one in three chance of developing
gestational trophoblastic disease.
Reference
1 Zilberman Sharon N, Maymon R, Melcer Y, Jauniaux E. Obstetric outcomes of
twin pregnancies presenting with a complete hydatidiform mole and
coexistent normal fetus: a systematic review and meta-analysis. BJOG
2020;127:1450–7.
TOG Controversies in prevention of
spontaneous preterm birth in
asymptomatic women: an evidence
summary and expert opinion
With regard to preterm birth,
1. approximately two-thirds occur in the low-
risk population. ThFh
2. an inter-pregnancy interval of <6 months is a
potentially modifiable risk factor. ThFh
3. universal cervical length screening by
transvaginal ultrasound, if introduced in the
UK, would be estimated to reduce the overall
rate by less than 0.5%. ThFh
With regard to the vaginal microbiome and its influence on
preterm birth,
4. assessment of the vaginal microbiota by 16S
rRNA sequencing in high-risk pregnancies is
likely to become common practice in the next
5 years.
ª 2021 Royal College of Obstetricians and Gynaecologists
5. current National Institute for Health and Care
ThFh Excellence guidelines suggest that women in the
general obstetric population should be screened
and treated for asymptomatic bacterial vaginosis
to reduce the chance of preterm birth. ThFh
6. women with vaginal group B streptococcus
(GBS) colonisation in the antenatal period
should be informed that they have a
significantly increased risk of preterm birth
and offered treatment for GBS. ThFh
With regard to methods for the prevention of preterm birth,
7. a second reinforcing cerclage in women with
progressive cervical shortening following
cerclage has proven effectiveness. ThFh
8. women with a cerclage placed within 10 mm
of a closed external cervical os are likely to be
at a higher risk of preterm birth compared
with those with a more proximally
placed cerclage. ThFh
9. the American College of Obstetrics and
Gynecology currently recommends cervical
length follow-up after cerclage placement. ThFh
10. vaginal progesterone therapy significantly
reduces the risk of preterm birth <33 weeks
when used to treat a short cervix ≤25 mm. ThFh
Reference
1 Goodfellow L, Care A, Alfirevic Z. Controversies in the prevention of sponta-
neous preterm birth in asymptomatic women: an evidence summary and
expert opinion. BJOG 2021;128:177–94.
ThFh
71