DOI: 10.1111/tog.

12703 2020;22:318–21
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 22 issue 4

CPD credits can be claimed for the following questions Regarding congenital adrenal hyperplasia,
online via the TOG CPD submission system in the RCOG 9. 21-hydroxylase deficiency accounts for about
CPD ePortfolio. You must be a registered CPD participant of 30% of cases. ThFh
the RCOG CPD programme (available in the UK and 10. it results in virilisation of the external
worldwide) in order to submit your answers. genitalia in a female infant. ThFh
Participants can claim 2 credits per set of questions if at 11. 3b-hydroxysteroid dehydrogenase deficiency
least 70% of questions have been answered correctly. CPD causes atypia of genitalia in XY individuals. ThFh
participants are advised to consider whether the articles are 12. feminising genitoplasty is best reserved for
still relevant for their CPD, in particular if there are more moderate and severe virilisation. ThFh
recent articles on the same topic available and if clinical
guidelines have been updated since publication. In cases of 5a-reductase deficiency,
Please direct all questions or problems to the CPD Office. 13. breasts develop at puberty. ThFh
Tel: +44 (0)20 7772 6307 or email: cpd@rcog.org.uk. 14. the karyotype is XX. ThFh
The blue symbol denotes which source the questions refer to 15. AMH causes the regression of
including the RCOG journals, TOG and BJOG, and RCOG m€ullerian structures. ThFh
guidance, such as Green-top Guidelines (GTGs) and Scientific 16. virilisation at puberty is caused by isoenzymes
Impact Papers (SIPs). All of the above sources are available to of 5a-reductase. ThFh
RCOG Members and Fellows via the RCOG website. RCOG Regarding surgery for disorders of sexual development,
Members, Fellows and Associates have full access to TOG 17. it is recommended that those with gonadal
content via the TOG app (available for iOS and Android). dysgenesis undergo early gonadectomy. ThFh
18. vaginal dilation is the second-line treatment
TOG Differences of sexual development and for a hypoplastic vagina. ThFh
their clinical implications 19. vaginoplasty aims to facilitate future
penetrative intercourse. ThFh
Regarding normal sexual development, 20. the main risk of cliteroplasty is disrupted
1. male and female embryos are indistinguishable blood supply. ThFh
at 8 weeks. ThFh
2. Sertoli cells secrete anti-m€
ullerian hormone
TOG An update on the management
(AMH) under the influence of the sex-
determining region Y gene. ThFh
of male infertility
3. testosterone promotes maturation of the With regard to male infertility,
Wolffian ducts in males. ThFh 1. it is the cause or contributory cause of
4. the m€ullerian ducts develops into the uterus, infertility in up to half of couples experiencing
cervix, fallopian tubes and lower one-third of difficulty conceiving. ThFh
the vagina. ThFh 2. it is thought to affect 15% of all men. ThFh
5. transformation of the genital tubercle in the 3. data from the Human Fertilisation and
male is under the influence of testosterone. ThFh Embryology Authority indicate that it
accounts for 60% of in vitro fertilisation (IVF)
Investigations for disorders of sexual development include, treatment cycles in the UK. ThFh
6. karyotyping as a priority. ThFh 4. obese men have worse semen analysis
7. a magnetic resonance imaging scan as the parameters than men with normal weight. ThFh
first-line imaging modality in adults. ThFh 5. testosterone secretion follows a diurnal pattern,
8. measurement of AMH levels to distinguish with a rise coinciding with non-REM sleep. ThFh
between functioning testicular tissue and 6. normal sperm production is the result of the
androgen insensitivity. ThFh aggregated action of 230 genes. ThFh

318 ª 2020 Royal College of Obstetricians and Gynaecologists

 CPD

Concerning measures to improve male infertility, TOG Pelvic floor functional bowel disorders
7. weight loss has a demonstrable positive in gynaecology
impact on improving semen
analysis parameters. ThFh With regard to faecal incontinence,
8. a systematic review and meta-analysis found 1. approximately 10% of women attending
favourable effects of folic acid, vitamin D urogynaecology clinics report symptoms. ThFh
and full-fat dairy products on 2. the annual NHS bill for treating incontinent
semen characteristics. ThFh patients is 1% of the budget. ThFh
3. up to 25% of women who delivered vaginally
With regard to causes of male infertility, are affected. ThFh
9. oxidative stress leads to sperm dysfunction by 4. anal sphincter repair should be considered in
causing DNA damage. ThFh patients with full-length external anal
10. cigarette smoking is associated with reduced sphincter defect. ThFh
sperm count, motility and morphology. ThFh 5. patients undergoing anal sphincter repair
11. antidepressant drugs have no effect on usually require temporary stoma. ThFh
semen quality. ThFh 6. complete continence is achieved in 90% of
patients treated with permanent sacral
With regard to the treatment of male infertility, nerve stimulation. ThFh
12. current data support the association between
high sperm DNA fragmentation and poor With regard to chronic constipation,
reproductive outcome in terms of natural 7. it affects 40% of pregnant women. ThFh
conception, intrauterine insemination 8. botulinum toxin is a recognised treatment
and IVF. ThFh for anismus. ThFh
13. standard methods of sperm selection in 9. there is good evidence to support long-term
assisted reproduction technology include use of laxatives in pregnancy. ThFh
density gradient centrifugation or swim-up. ThFh
14. sperm recovery using the zeta potential is high With regard to obstructed defaecation,
(typically 90%), making this method 10. it is associated with constipation in
potentially clinically useful for most cases. ThFh
sperm selection. ThFh 11. it typically presents with several days
of constipation alternating with loose
With regard to testing in male infertility, stools. ThFh
15. genetic tests routinely recommended in the 12. irrigation systems are used as part of
evaluation of men with azoospermia and conservative management to evacuate
bilaterally palpable vas deferens include cystic the bowels. ThFh
fibrosis transmembrane conductance
regulator mutation analysis. ThFh Concerning anal fissures,
16. a karyotype is able to detect DNA 13. those that are acute involve tears of the skin
abnormalities 4 million base pairs or larger and submucosa, with exposure of the internal
in size. ThFh and external sphincter. ThFh
17. the most common aneuploidy detected on 14. lateral types are a recognised sign of
karyotype of azoospermic men is testicular Crohn’s disease. ThFh
disorder of sex development (46,XX). ThFh 15. dietary changes have on impact on
18. azoospermia factor microdeletions are this condition. ThFh
detected in about 7% of azoospermic men. ThFh 16. treatment with glyceryl trinitrate has been
19. current data have shown that approximately shown to have better healing rates. ThFh
50% of the spermatozoa in the ejaculate of a
fertile male are aneuploid when evaluated for Concerning haemorrhoids,
five chromosomes (chromosomes 13, 18, 21, 17. third degree types protrude beyond the anal
X and Y). ThFh canal on straining but spontaneously reduce
20. media that contains theophylline have been when straining is stopped. ThFh
shown to be clinically useful for 18. internal types are visible on examination
sperm selection. ThFh when prolapsed. ThFh

ª 2020 Royal College of Obstetricians and Gynaecologists 319

 CPD
With regard to solitary rectal ulcers,
19. the prevalence is approximately 1–3 cases
per 1000. ThFh
20. up to 30% are multiple ulcerated lesions. ThFh
TOG Multifetal pregnancy reduction and
selective termination
With regard to multifetal pregnancies,
1. 1 in 5 births following in vitro fertilisation
conception are multiple pregnancies. ThFh
2. cerebral palsy affects approximately 1 in 400
singleton births and 1 in 100 twin births. ThFh
3. when a fetal abnormality is identified in one
fetus of a multifetal pregnancy, women should
be referred to a tertiary fetal medicine service
for counselling and detailed diagnosis within
5 weeks. ThFh
4. the incidence of monochorionic diamniotic
(MCDA) gestations is increased by blastocyst
transfer during in vitro fertilisation. ThFh
With regard to multifetal pregnancy reduction (MFPR),
5. when more than one embryos are reduced, the
risk of miscarriage exceeds 1 in 10. ThFh
6. in monochorionic pregnancies a 20 G or 22 G
amniocentesis needle is advanced into the
fetal heart and 0.5–2 ml of KCl 15% are
administered until fetal asystole is confirmed. T h F h
7. when reduced to dichorionic (DCDA) twins,
the risk of preterm birth is largely similar to
that in originally conceived
DCDA pregnancies. ThFh
8. less than 20% of women undergoing this
procedure experience acute feelings of anxiety,
stress and emotional trauma. ThFh
9. the long-term emotional response and the risk
of postnatal depression following a successful
procedure are comparable to those following
standard live birth. ThFh
10. following a mid-trimester cord occlusion the
overall risk of losing the co-twin is about
1 in 5. ThFh
Selective termination (ST),
11. is the termination of an abnormal fetus in a
multifetal pregnancy. ThFh
12. in the third trimester is preferable to ST in the
first trimester in DCDA twins. ThFh
13. in triplets with monochorionic twin pair to
achieve a reduction to MCDA twins carries a
smaller risk of severe preterm birth than
reduction to singleton. ThFh
320
14. in DCDA twins in the second trimester is
advisable at 16–24 weeks because of a reduced
rate of pregnancy loss and preterm birth
compared with third trimester ST. ThFh
15. for fetal abnormality in England, Wales and
Scotland is only legal up until week 24 under
clause E of the 1967 Abortion Act. ThFh
With regard to the procedure of MFPR,
16. bipolar diathermy cord coagulation (BDCC)
is an acceptable approach for
monochorionic pregnancies. ThFh
17. there is a higher risk of co-twin death if BDCC
is carried out at gestations earlier than
18 weeks. ThFh
18. radiofrequency ablation (RFA) carries a
higher risk of preterm rupture of membranes
than BDCC. ThFh
19. RFA is the treatment of choice in cases of twin
reversed arterial perfusion (TRAP) sequence
where the acardiac fetus compromises the
pump twin. ThFh
20. the treatment of choice for TRAP sequence is
intravascular KCl in the cord of the
acardiac fetus. ThFh
TOG Preimplantation genetic testing for
aneuploidy: the past, present and future
Regarding techniques used for preimplantation genetic
testing for aneuploidy (PGT-A),
1. the earliest methods used array comparative
genomic hybridisation (aCGH) for
detecting aneuploidy. ThFh
2. real-time polymerase chain reaction is the
fastest method used. ThFh
3. next generation sequencing (NGS) is
now considered to be the most
appropriate method. ThFh
4. fluorescent in situ hybridisation (FISH) can
only screen up to 12 chromosomes. ThFh
5. aCGH is better at detecting mosaicism
than NGS. ThFh
6. comprehensive chromosome screening is
better at detecting balanced chromosome
rearrangements than FISH. ThFh
Embryo biopsies,
7. of the polar body allow for the detection of
both maternal and paternal aneuploidy. ThFh
8. in the cleavage-stage have been shown to be
harmful to the embryo, with reduced
implantation rates. ThFh
ª 2020 Royal College of Obstetricians and Gynaecologists
 CPD

9. in the cleavage-stage have lower rates of 4. damage to the common peroneal nerve causes
mosaicism than biopsies of a high stepping gait. ThFh
the trophectoderm. ThFh
10. of the trophectoderm are now considered to Regarding the pathophysiology of nerve injuries,
be the most suitable for PGT-A. ThFh 5. the outermost layer of connective tissue of a
peripheral nerve is called the perineurium. ThFh
Regarding indications for PGT-A, 6. Sunderland classified nerve injuries into
11. recurrent miscarriage is the most common. ThFh five subtypes. ThFh
7. most obstetric neurological injuries are severe
Regarding aneuploidy, (grade 5). ThFh
12. levels in young patients have been found to be
as high as 45%. ThFh Regarding postpartum neurological symptoms,
13. rates are higher in the in vitro 8. most are anaesthetic-related. ThFh
fertilisation population. ThFh 9. postpartum back pain is often caused by an
epidural/spinal anaesthetic. ThFh
PGT-A using comprehensive chromosome screening has 10. bilateral signs/symptoms are a ‘red flag’. ThFh
been shown to, 11. nerve conduction studies are often necessary
14. increase implantation rates in good when investigating these symptoms. ThFh
prognosis patients. ThFh 12. computed tomography of the spine is the
15. reduce miscarriage rates in women of investigation of choice if an epidural
advanced maternal age. ThFh haematoma/abscess is suspected. ThFh
16. result in fewer twin pregnancies when used to 13. slowly deteriorating symptoms postnatally
select an embryo for single embryo transfer. T h F h indicate a likely obstetric cause. ThFh
17. decrease miscarriage rates in women with
recurrent miscarriages. ThFh To reduce the risk of obstetric neurological injuries,
14. intervene in obstructed labour in a
Concerning the cost-effectiveness of PGT-A, timely fashion. ThFh
18. NGS is thought to reduce future costs. ThFh 15. place the patient’s legs in lithotomy before
‘time out’. ThFh
Regarding mosaicism in PGT-A embryos, 16. avoid excessive traction on tissues to avoid
19. rates of mosaicism have been shown to be as compromising the femoral nerve. ThFh
high as 50%. ThFh
20. detection rates with aCGH are similar to those Regarding obstetric neurological injuries,
with NGS. ThFh 17. some prospective series found neurological
symptoms in approximately 5% of
postpartum patients. ThFh
TOG Obstetric neurological injuries
18. there has been a decline in the incidence in the
Regarding nerves in the pelvis, UK in recent years. ThFh
1. damage to the lumbo-sacral trunk causes 19. they are part of the obstructed labour
foot drop. ThFh injury complex. ThFh
2. damage to the lateral cutaneous nerve of the 20. reassurance is adequate in most cases when
thigh causes meralgia paraesthetica. ThFh complications of regional anaesthesisa have
3. damage to the obturator nerve is bilateral in been excluded. ThFh
less than 5% of cases. ThFh

ª 2020 Royal College of Obstetricians and Gynaecologists 321