DOI: 10.1111/tog.

12633 2020;22:83–6
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 22 issue 1

CPD credits can be claimed for the following questions 6. occurs more in robotic compared with
online via the TOG CPD submission system in the RCOG laparoscopic instruments. ThFh
CPD ePortfolio. You must be a registered CPD participant of
Concerning antenna coupling,
the RCOG CPD programme (available in the UK and
7. it is initiated in the surgical field. ThFh
worldwide) in order to submit your answers.
8. it is reduced by separating the laparoscopy
Participants can claim 2 credits per set of questions if at
tower from the electrosurgical unit and
least 70% of questions have been answered correctly. CPD
avoiding close parallel arrangement of
participants are advised to consider whether the articles are
the cords. ThFh
still relevant for their CPD, in particular if there are more
recent articles on the same topic available and if clinical Active electrode monitoring technology,
guidelines have been updated since publication. 9. is used with monopolar and
Please direct all questions or problems to the CPD Office. bipolar instruments. ThFh
Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk. 10. eliminates burns caused by insulation failure
The blue symbol denotes which source the questions refer and capacitive coupling. ThFh
to including the RCOG journals, TOG and BJOG, and RCOG 11. does not protect against direct coupling. ThFh
guidance, such as Green-top Guidelines (GTGs) and
Scientific Impact Papers (SIPs). All of the above sources are With regard to the use of electrosurgery in patients with
available to RCOG members and fellows via the cardiac implantable electronic devices,
RCOG website. 12. bipolar or ultrasonic devices are
RCOG Members, Fellows and Associates have full access to recommended in patients highly dependent
TOG content via the TOG app (available for iOS on the devices. ThFh
and Android). 13. patients with an implantable cardioverter
defibrillator should deactivate it
before surgery. ThFh
TOG Safe use of electrosurgery in
gynaecological laparoscopic surgery Electrosurgical smoke,
14. contains carcinogenic chemicals with few
With regard to the variables that influence electrosurgical
documented cases of cancer. ThFh
tissue effects,
15. contains particles mostly bigger than 5 µm. ThFh
1. reducing the active electrode surface area would
significantly increase the thermal effect without With regard to electrosurgery,
increasing the power output. ThFh 16. it is the application of high-frequency
2. increasing tension on the tissue enhances direct current. ThFh
coagulation but compromises cutting. ThFh 17. cutting occurs when the intracellular
temperature rises to between 60°C and 95°C. ThFh
With regard to electrosurgical complications during
laparoscopy, With regard to power outputs,
3. direct coupling is the most common type 18. the power setting should be between 50 W
of complication. ThFh and 80 W for effective cutting. ThFh
4. about half of unintended burns are recognised 19. the setting should be between 20 W and 30 W
during surgery. ThFh for effective coagulation. ThFh
Insulation failure in laparoscopic surgery, In conventional bipolar devices,
5. is associated with severe burns when the 20. the two electrodes are situated at the tip of
insulation defect is microscopic. ThFh the instrument. ThFh

ª 2020 Royal College of Obstetricians and Gynaecologists 83

 CPD

In secondary prevention of stroke,

TOG A review of stroke in pregnancy: 17. administration of aspirin is recommended
incidence, investigations and management within 24–48 hours after onset of symptoms. ThFh
In the general population and during pregnancy, 18. clopidogrel is classified as Category B in the
1. acute ischaemic stroke is the most common US Food and Drug Administration
type of stroke in pregnancy. ThFh Pregnancy Classification. ThFh
2. the symptoms of stroke are typically sudden, 19. warfarin is the anticoagulation agent of choice
with focal symptoms and clinical deficit in the first trimester. ThFh
conforming to a vascular territory. ThFh 20. statins should be started/continued
3. stroke is more common in the antenatal period in pregnancy. ThFh
than in the peripartum and postnatal periods. ThFh
4. patients with a small penumbra and a large
infarct core are most likely to benefit from TOG Antenatal management of singleton
reperfusion therapies. ThFh pregnancies conceived using assisted
In the investigation of stroke in pregnancy, reproductive technology
5. non-contrast computed tomography (CT) of With regard to pregnancies after assisted reproductive
the brain poses significant radiation risk to the technology (ART),
fetus and should be avoided. ThFh 1. they contribute up to 5–10% of babies born in
6. magnetic resonance imaging (MRI) is not developed countries. ThFh
associated with any radiation exposure. ThFh 2. the miscarriage rate is estimated to be
7. cardiac monitoring with a 24-hour cardiac/ approximately 10%. ThFh
Holter monitor or event loop recorder should 3. women who miscarry are more likely to have a
be delayed until after delivery. ThFh live birth in a subsequent cycle than if they had
8. transthoracic echo with a ‘bubble test’ is safe to never conceived. ThFh
perform in pregnancy to demonstrate an intra- 4. women with overt hypothyroidism are at
atrial shunt. ThFh increased risk of miscarriage. ThFh
9. inherited thrombophilia screening should be 5. the risk of ectopic pregnancy is lower than that
performed routinely. ThFh with spontaneous conceptions. ThFh
For the management of stroke, 6. progesterone supplementation during the luteal
10. time-sensitive and reperfusion therapies are phase has been proven to increase the live-
associated with improved birth rate. ThFh
functional outcomes. ThFh With regard to complications during pregnancies
11. mechanical thrombectomy is an invasive conceived using ART,
procedure suitable for patients presenting 7. the risk is increased with in vitro fertilisation
with symptoms of large vessel occlusion using donor eggs. ThFh
stroke within 24 hours of onset. ThFh 8. the absolute increase in risk of hypertensive
12. all patients should have a non-contrast CT or complications is about 5%. ThFh
MRI of the brain prior to 9. ART is considered to be a moderate risk factor
intravenous thrombolysis. ThFh for pre-eclampsia. ThFh
13. systolic hypertension of over 185 mmHg is an 10. the absolute increase in risk of gestational
absolute contraindication to thrombolysis, diabetes is about 1%. ThFh
but once treated, the patient can be 11. in the UK, it is recommended that women with
still thrombolysed. ThFh polycystic ovary syndrome who have conceived
In the management of stroke in pregnancy, using assisted conception have a glucose
14. recombinant tissue plasminogen activator tolerance test at 24–28 weeks’ gestation. ThFh
crosses the placenta. ThFh 12. the risk of venous thromboembolism is
15. thrombolytic therapy should never greatest in the first trimester of pregnancy. ThFh
be considered. ThFh In women who have conceived following ART,
16. the treatment of cerebral venous thrombosis 13. there is a significantly increased risk of fetal
is predominantly anticoagulation structural abnormalities. ThFh
with heparin. ThFh

84 ª 2020 Royal College of Obstetricians and Gynaecologists

 CPD

14. the absolute risk of fetal structural
abnormalities is approximately 12%.
15. increased fetal growth monitoring
is recommended.
16. there is a 2–3-fold increase in
perinatal mortality.
17. the risk of preterm labour is the same as that
for women who have previously given
birth prematurely.
18. there is an increased risk of placenta praevia,
morbidly adherent placenta and
placental abruption.
19. placental anomalies are thought to be related
to maternal structural abnormalities (e.g.
Asherman’s syndrome), rather than a direct
effect of the ART process itself.
20. there is an increased a risk of venous
thromboembolism compared with
spontaneous pregnancies.
TOG Maternal sepsis update: current
management and controversies
With regard to maternal sepsis,
1. it is defined as life-threatening organ
dysfunction caused by a dysregulated host
response to infection.
2. it is the leading cause of maternal death in
the UK.
3. globally, it carries an 8% mortality risk in low-
income countries.
4. evidence suggests there is a greater risk of
infection in pregnant women than in non-
pregnant women.
5. infection has been associated with 50% of cases
of stillbirth in high-income countries.
6. pregnancy-related sepsis has been shown to
contribute up to 40% of maternal
deaths worldwide.
With regard to immunological and physiological changes
in pregnancy,
7. a healthy pregnancy has been associated with
an altered innate immune phenotype
consistent with a relative state
of immunosuppression. ThFh
8. upregulated nitric oxide in sepsis plays a key
role in regulating vascular tone, smooth muscle
relaxation and the vasodilatation that leads
to shock. ThFh
With regard to the prevention of sepsis,
ThFh 9. antibiotic prophylaxis during caesarean section
is associated with a reduction in the incidence
ThFh of wound infection but not endometritis. ThFh
10. the incidence of infection following an
ThFh unassisted vaginal delivery may be as high
as 16%. ThFh
Concerning sepsis biomarkers,
ThFh
11. procalcitonin is a more specific biomarker
than white cell count and C-reactive protein
in identifying the sick patient with
ThFh
bacterial infection. ThFh
12. elevated serum lactate levels appear to be
associated with severity of clinical outcome in
maternal sepsis. ThFh
ThFh
With regard to the management of sepsis in
pregnancy,
ThFh 13. the administration of synthetic colloids as
intravenous fluids for the treatment of sepsis
and septic shock has been associated with
acute kidney injury. ThFh
14. levosimendan is the first-line vasopressor of
choice for the management of septic shock
in pregnancy. ThFh
15. intravenous immunoglobulins are
ThFh contraindicated in pregnancy. ThFh
In the management of women with severe sepsis,
ThFh
16. it should be recognised that positive cultures
are obtained in approximately 30–40%
ThFh
of cases. ThFh
17. a serum lactate of >2 mmol/l should prompt
critical care input. ThFh
ThFh
18. when administering oxygen, the aim should
be to achieve an oxygen saturation of at
ThFh
least 94%. ThFh
19. there is evidence against the use of synthetic
colloids for fluid resuscitation. ThFh
ThFh
20. the Royal College of Obstetricians and
Gynaecologists recommends an intravenous
fluid resuscitation rate of 30 ml/kg. ThFh
TOG The role of frozen–thawed embryo
replacement cycles in assisted conception
With regard to embryo cryopreservation,
1. embryo vitrification requires a cryo-machine. ThFh
2. embryo vitrification is associated with higher
embryo survival than slow freezing. ThFh
3. approximately 50% of vitrified embryos survive
after thawing. ThFh

ª 2020 Royal College of Obstetricians and Gynaecologists 85

 CPD

With regard to frozen–thawed embryo replacement (FER) 12. involves embryo transfer 10 days after the
in the UK, luteinising hormone surge. ThFh
4. approximately 30% of in vitro fertilisation
(IVF) cycles involve the transfer of frozen– In medicated FER,
thawed embryos. ThFh 13. the window of implantation is determined by
5. recent years have seen a fall in the number of the number of days of endometrial exposure
FER cycles. ThFh to estrogen. ThFh
14. prolonged duration of estrogen is believed to
With regard to the freeze-all strategy, result in a lower pregnancy rate. ThFh
6. freezing all embryos reduces the chance of 15. the day of embryo transfer is flexible. ThFh
ovarian hyperstimulation syndrome. ThFh
Ovarian stimulation,
When compared with fresh IVF, frozen embryo replacement, 16. is used in the majority of cases to prepare the
7. may be associated with a lower chance of endometrium for FER. ThFh
gestational hypertensive disorders. ThFh 17. involving clomiphene is associated with
8. has approximately the same chance of clinical improved subendometrial blood flow. ThFh
pregnancy per embryo transferred. ThFh 18. with letrozole involves taking fewer days of
Natural cycle FER, medication than standard medicated FER. ThFh
9. is associated with a lower chance of cycle
With regard to embryo storage,
cancellation compared with
19. embryos can be destroyed only with the
medicated FER. ThFh
consent of both genetic parents. ThFh
10. necessitates the use of a human chorionic
20. the maximum period for which embryos can
gonadotrophin trigger. ThFh
be stored in cases of fertility preservation
11. is believed to result in a higher pregnancy rate
prior to gonadotoxic therapy in the UK is
than medicated FER. ThFh
55 years. ThFh

86 ª 2020 Royal College of Obstetricians and Gynaecologists