CPD questions for volume 15, number 1

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image Outflow disorders of the female genital tract

With regard to embryology of the genital tract,

  • 1.primordial germ cells form by month 4. T □ F □
  • 2.all fetuses have a mesonephric and a paramesonephric duct. T □ F □
  • 3.normal female development depends on the absence of müllerian inhibitory factor. T □ F □
  • 4.the fallopian tubes are derived from the Wolffian ducts. T □ F □
  • 5.maldevelopment of one of the müllerian ducts results in a single horned uterus. T □ F □
  • 6.the commonest uterine abnormality is a bicornuate uterus. T □ F □

Regarding Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome,

  • 7.inheritance of the condition is sex-linked recessive. T □ F □
  • 8.laparoscopy is essential for diagnosis. T □ F □
  • 9.a psychologist is necessary for appropriate management of these patients. T □ F □

Considering outflow tract disorders,

  • 10.the hymen should normally be perforated in utero. T □ F □
  • 11.pink colouration of a bulging vaginal membrane should lead the clinician to suspect the diagnosis of an imperforate hymen. T □ F □
  • 12.a transverse vaginal septum is most common in the lower vagina. T □ F □
  • 13.stenosis is a recognised risk of incomplete lateral excision of a transverse septum. T □ F □
  • 14.vaginal dilators are not required for patients undergoing resection of lower third transverse septae. T □ F □
  • 15.endometriosis contributes to subfertility in women with an upper third vaginal septum. T □ F □
  • 16.difficulty inserting a tampon is recognised to occur in women with transverse and longitudinal vaginal septum. T □ F □

Regarding pregnancy in women with congenital abnormalities of the genital tract,

  • 17.pregnancy in a communicating uterine horn is a risk factor for maternal mortality. T □ F □

In patients with MRKH syndrome,

  • 18.there is an approximately 2:5 chance of having an associated renal abnormality. T □ F □
  • 19.the kidney is absent in approximately 1:5 cases. T □ F □
  • 20.spinal abnormalities are not a recognised associated feature. T □ F □

image Methods for specimen removal from the peritoneal cavity after laparoscopic excision

With regard to hernias following laparoscopic surgery,

  • 1.most trocar site hernias present between 2 weeks and 1 year of surgery. T □ F □
  • 2.early onset hernias typically present with features of small bowel obstruction. T □ F □
  • 3.Richter's hernias are commonly lined by peritoneum. T □ F □
  • 4.approximately 1:5 patients with Richter's hernia will require intestinal resection. T □ F □
  • 5.Richter's hernias are frequently seen at umbilical port sites. T □ F □

With regard to transvaginal natural orifice transluminal endoscopic surgery (NOTES),

  • 6.it is acceptable for it to be performed in cases of adhesions in the pouch of Douglas. T □ F □
  • 7.there is a low risk of fistula formation. T □ F □
  • 8.there is no need for bladder catheterisation prior to the procedure. T □ F □

Which of the following statements about posterior colpotomy is/are correct?

  • 9.The use of prophylactic antibiotics does not affect associated morbidity. T □ F □
  • 10.It allows for the successful removal of dermoid cysts without spillage when used in conjunction with laparoscopy. T □ F □

According to randomised controlled trials (RCTs), mini-laparoscopy is associated with,

  • 11.a significant increase in postoperative discomfort. T □ F □
  • 12.longer operative times. T □ F □

Which of the following statements is/are correct?

  • 13.RCTs have shown that mini-laparotomy is the best approach for the management of adnexal cysts. T □ F □
  • 14.There is strong evidence to suggest that ovarian masses >10 cm are best managed with laparotomy. T □ F □
  • 15.The most common site for a mini-laparotomy is the suprapubic level. T □ F □
  • 16.Tissue fragments left behind after using a morcellator are recognised to cause complications. T □ F □
  • 17.The bigger the diameter of the morcellator, the higher the risk of hernia formation. T □ F □

Morcellators are associated with,

  • 18.increased risk of port site herniation. T □ F □
  • 19.decreased operative time. T □ F □
  • 20.decreased risk of inadvertent visceral injury. T □ F □

image Nonpharmacological treatment of postmenopausal symptoms

Regarding vasomotor symptoms,

  • 1.hormone replacement therapy (HRT) is superior to all other options in the treatment of vasomotor symptoms. T □ F □
  • 2.there is a significant placebo effect in therapy trials for vasomotor symptoms. T □ F □
  • 3.paced respiration improves their severity. T □ F □
  • 4.there is strong evidence that exercise decreases their severity. T □ F □
  • 5.soy, red clover, and black cohosh are the most-studied complementary medicine agents in the treatment of hot flushes. T □ F □
  • 6.soy, red clover, and black cohosh should be avoided in women with a personal history of breast cancer or who are at high risk for breast cancer. T □ F □

Regarding sleep and mood disturbance associated with menopause,

  • 7.vasomotor symptoms are reognised to contribute to sleep disturbance. T □ F □
  • 8.mood disturbance is common in perimenopausal women. T □ F □
  • 9.antidepressants have been shown to be effective in treating mild depression. T □ F □
  • 10.psychotherapy is an underutilised treatment modality for depression. T □ F □
  • 11.estrogen deficiency has been clearly linked to cognitive dysfunction. T □ F □

Regarding genitourinary symptoms related to menopause,

  • 12.over-the-counter vaginal moisturisers improve the symptoms of atrophic vaginitis when used on a regular basis. T □ F □
  • 13.over-the-counter vaginal lubricants improve the symptoms of atrophic vaginitis if they are used on a regular basis. T □ F □
  • 14.regular sexual activity has been shown to decrease the symptoms of dyspareunia. T □ F □

Regarding musculoskeletal symptoms,

  • 15.up to 75% of postmenopausal women report musculoskeletal pain at the time of menopause. T □ F □

Regarding cardiovascular risk,

  • 16.the postmenopausal state is a risk factor. T □ F □
  • 17.the mortality rate from coronary artery disease in women in their sixth decade is greater than that in men. T □ F □

Regarding bone health,

  • 18.the recommended intake of calcium and vitamin D is 1200 mg and 1200 IU daily, respectively. T □ F □
  • 19.weight-bearing and strength-training exercises increase bone mass, thereby decreasing the risk of osteoporosis. T □ F □
  • 20.health interventions that decrease falls have been shown to decrease the risk of osteoporotic fractures. T □ F □

image Management of postpartum hypertension

Following delivery in a midwifery led unit,

  • 1.women should be transferred for medical review if they have two diastolic blood pressure measurements >90 mmHg, 4 hours apart. T □ F □
  • 2.a systolic blood pressure >160 mmHg on at least two occasions 4 hours apart is an indication for transfer for medical review. T □ F □

When prescribing antihypertensive medication in the postnatal period,

  • 3.β-blockers should be used as first-line medication because there is good evidence that they are the most effective agent. T □ F □
  • 4.calcium channel blockers are available in once-daily dosing preparations. T □ F □
  • 5.angiotension converting enzyme (ACE) inhibitors are contraindicated in women who have renal complications of pre-eclampsia. T □ F □

In women who have been hypertensive in the antenatal period,

  • 6.normotension in the first 24 hours following delivery is a reliable indicator that pregnancy induced hypertension has resolved. T □ F □
  • 7.methyldopa should be continued in the postnatal period if it has been used with good effect antenatally. T □ F □

Following an episode of pre-eclampsia requiring level 2 care,

  • 8.daily monitoring of biochemical indices are advised until discharge. T □ F □
  • 9.elevated serum levels of liver transaminases persisting more than 48 hours following delivery is an indication for prompt liver imaging and hepatology referral. T □ F □
  • 10.the possibility of underlying renal or hypertensive disease should be considered in the multiparous patient. T □ F □
  • 11.where delivery has been indicated before 30 weeks of gestation there is an approximate risk of recurrence of 40% in a future pregnancy. T □ F □

After discharge following a diagnosis of pre-eclampsia,

  • 12.arrangements should be made for blood pressure to be checked on alternate days until stable. T □ F □
  • 13.antihypertensive agents should be increased if blood pressure is >140/90 mmHg. T □ F □
  • 14.further investigation should be considered if proteinuria or hypertension persists for more than 6 weeks after delivery. T □ F □

With regard to postpartum hypertension;

  • 15.up to two thirds of eclamptic fits occur postpartum. T □ F □
  • 16.women with mild pre-eclampsia should be encouraged to remain on the ward for up to 5 days after delivery. T □ F □
  • 17.it is recommended that the blood pressure on discharge should be <160/100 mmHg. T □ F □

In the management of postpartum hypertension,

  • 18.monitoring of blood pressure should be every other day for the first 2 weeks. T □ F □
  • 19.a blood pressure of >150/100 mmHg 20 minutes apart is an indication for referral for medical review. T □ F □
  • 20.it is recommended that medication is stopped when BP is 130–140/80–90 mmHg. T □ F □

image Assessment of the infertile male

With regard to the revised WHO criteria for semen characteristics,

  • 1.the 10th percentile of various parameters is used to characterise semen in men initiating natural conception within 12 months of unprotected intercourse. T □ F □
  • 2.a period of abstinence from ejaculation of 72 hours is recommended prior to semen analysis. T □ F □
  • 3.semen volume >1.5 mL/ejaculate is normal. T □ F □
  • 4.sperm concentration of >15x106/mL is considered normal. T □ F □

Regarding male fertility,

  • 5.Klinefelter syndrome is associated with azoospermia. T □ F □
  • 6.congenital causes of azoospermia include cryptorchidism. T □ F □
  • 7.azoospermia with normal follicular stimulating hormone (FSH) indicates failure of spermatogenesis. T □ F □
  • 8.more than 50% of causes of azoospermia are obstructive. T □ F □
  • 9.the majority of men with bilateral absence of the vas deferens have renal tract abnormalities on ultrasound. T □ F □

In the evaluation of the subfertile male,

  • 10.FSH and testosterone should be measured in men with severe oligospermia. T □ F □
  • 11.a marked elevation of serum FSH is indicative of abnormal spermatogenesis. T □ F □
  • 12.high FSH and luteinising hormone (LH) and low testosterone suggest hypergonadotropic hypogonadism. T □ F □
  • 13.facilities for cryopreservation should always be available if testicular biopsy is considered. T □ F □

Regarding treatment of the subfertile male,

  • 14.varicocele repair has been proven to improve pregnancy rates. T □ F □
  • 15.intracytoplasmic sperm injection (ICSI) is recognised to result in the transmission of genetic causes of male infertility to female offspring. T □ F □

With regard to male infertility,

  • 16.causes at the pretesticular level are treatable with hormonal manipulation. T □ F □
  • 17.men older than 35 years of age have been shown to have a lower fertility rate compared with those aged under 35 years. T □ F □
  • 18.in the treatment of these men, changes in lifestyle factors known to affect spermatozoa normally take approximately 2 months to make a difference in sperm quality. T □ F □
  • 19.observational studies have shown that increasing exposure to electromagnetic waves emitted by mobile phones does not affect the semen quality. T □ F □
  • 20.in those taking anabolic steroids, discontinuation results in complete recovery of semen parameters to normal within 4–12 months in most cases. T □ F □

image Ovarian hyperstimulation syndrome

The following statements are true in relation to ovarian hyperstimulation syndrome (OHSS),

  • 1.the risk is increased in women with polycystic ovaries. T □ F □
  • 2.in vitro fertilisation (IVF) cycles where conception occurs are less likely to be complicated by OHSS compared with cycles without conception. T □ F □
  • 3.severe cases present with fluid shift into the third space and intravascular dehydration. T □ F □
  • 4.thrombosis in OHSS patients typically affects the veins of the thigh and lower leg.T □ F □
  • 5.serum vascular endothelial growth factor (VEGF) measurements are useful in predicting the risk of OHSS. T □ F □

In patients undergoing ovarian stimulation for IVF,

  • 6.the use of gonadotrophin-releasing hormone (GnRH) antagonist increases the risk of OHSS compared with regimens using GnRH agonist. T □ F □
  • 7.ovarian response as judged by egg numbers and serum estradiol provides reliable prediction of OHSS risk. T □ F □
  • 8.metformin use in women with PCOS reduces the risk of developing OHSS. T □ F □
  • 9.human chorionic gonadotrophin (hCG) is preferable to progesterone for luteal support. T □ F □

With regard to the ocurrence of OHSS in assisted conception cycles where the ovarian response is excessive,

  • 10.randomised controlled trials support the use of ‘coasting’.T □ F □
  • 11.dopamine agonists have been shown to reduce the risk of OHSS. T □ F □
  • 12.cancellation of the treatment cycle is the most effective preventative measure. T □ F □
  • 13.freezing of all embryos with delayed transfer eliminates the risk of early OHSS. T □ F □

In women with suspected OHSS,

  • 14.pelvic examination is necessary to confirm the diagnosis. T □ F □
  • 15.recovery is most likely within 7 to 10 days if pregnancy does not occur. T □ F □
  • 16.the finding of clinically-detectable ascites is a sign of severe OHSS. T □ F □

Regarding the management of patients with severe OHSS,

  • 17.vigorous intravenous crystalloid therapy should be started on admission. T □ F □
  • 18.ascitic tap is indicated if urine output does not improve despite rehydration. T □ F □
  • 19.thromboprophylaxis should be continued at least until the end of the first trimester of pregnancy. T □ F □
  • 20.ascitic tap should be considered if the course of OHSS is prolonged. T □ F □

image Pregnancy outcome following bariatric surgery

With regard to perinatal outcome following bariatric surgery,

  • 1.the prematurity rate differs significantly in pre- and post-surgery pregnancies. T □ F □
  • 2.adverse outcomes are higher in women who have had previous laparoscopic adjustable gastric banding (LAGB) and gastric bypass procedures as compared with obese groups. T □ F □
  • 3.there is a positive association between premature rupture of membranes and bariatric surgery. T □ F □
  • 4.congenital malformations are not much higher following a biliopancreatic diversion compared to obese controls. T □ F □

According to the 2003–2005 Confidential Enquiry into Maternal and Child Health report,

  • 5.approximately 35% of maternal deaths were linked with obesity. T □ F □

With regard to nutritional deficiencies in pregnancy postbariatric surgery,

  • 6.gastric bypass and laparoscopic adjustable gastric banding present minimal risk for nutrient problems. T □ F □
  • 7.mild nutritional deficiencies are infrequent after bariatric surgery. T □ F □
  • 8.additional multivitamin supplementation is often not required. T □ F □
  • 9.the standard 75 g glucose tolerance test has not been shown to have any untoward effects in pregnant women who have undergone Roux-en-Y gastric bypass (RYGB).T □ F □

With regard to maternal outcome in pregnancies following bariatric surgery,

  • 10.there is no statistically significant difference between obstetrical complications following different types of bariatric surgery. T □ F □
  • 11.there is a lower incidence of pregnancy induced hypertension compared with those who have not had any surgery. T □ F □

With regard to cosmetic surgery for contouring following bariatric surgery,

  • 12.approximately 50% of patients state a desire to undergo plastic surgery. T □ F □
  • 13.it is important to properly assess and address medical problems and psychosexual issues in those undergoing this type of surgery. T □ F □

With regard to the management of obese pregnant women following bariatric surgery,

  • 14.clear guidance exists in the UK.T □ F □
  • 15.optimal education is vital to enable the women to make well informed decisions. T □ F □

Current recommendations for the timing of pregnancy in women after bariatric surgery procedures include,

  • 16.delaying pregnancy for 24 months. T □ F □

With regard to surgical complications during pregnancy,

  • 17.band leakage is reported in 50% of post-LAGB pregnancies. T □ F □
  • 18.the most commonly reported complication is intestinal obstruction. T □ F □
  • 19.it is easy to diagnose intestinal obstruction. T □ F □
  • 20.computed tomography scan with contrast is suggested to be reliable in the diagnosis of intestinal obstruction. T □ F □

image Implementation strategies – moving guidance into practice

Preformatted consent forms for specific operations,

  • 1.help by reducing mundane tasks. T □ F □
  • 2.contain a free-text area for additional information. T □ F □
  • 3.aim to make the document more legible for patients. T □ F □
  • 4.ensure consistency of information provided to the patient about surgical procedures. T □ F □

Integrated care pathways are,

  • 5.documents that combine clinical guidance and documentation together. T □ F □
  • 6.consistently successful in improving outcomes. T □ F □
  • 7.unhelpful for audit. T □ F □

The eclampsia box contains,

  • 8.guidance on how to care for women with eclampsia. T □ F □
  • 9.equipment and drugs. T □ F □

PDSA stands for,

  • 10.plan, discuss, select, arrange. T □ F □

With regard to implementation strategies,

  • 11.they avoid the need for education of staff about a new policy. T □ F □
  • 12.run charts are useful in monitoring them. T □ F □
  • 13.they are known to be generally cost-effective. T □ F □
  • 14.they aim to overcome any human failings in clinical practice. T □ F □

The maternity handheld record is,

  • 15.a form of integrated care pathway. T □ F □

Surgical safety briefings are a means of,

  • 16.checking that important perioperative tasks are undertaken. T □ F □
  • 17.inculcating helpful team behaviours. T □ F □

There is evidence that a modified early warning score (MEWS) chart is a proven system for the effective identification of,

  • 18.maternal sepsis. T □ F □

Electronic fetal heart rate (eFHR) analysis stickers,

  • 19.contain the criteria used to categorise eFHR patterns as normal, suspicious or pathological. T □ F □
  • 20.remove the need for clinical judgement. T □ F □

image Mode of delivery in extreme obesity

Homer C, Kurinczuk J, Spark P, Brocklehurst P, Knight M. Planned vaginal delivery or planned caesarean delivery in women with extreme obesity. BJOG 2011;118:480–7. doi: 10.1111/j.1471-0528.2010.02832.x

Extremely obese women (≥BMI 50 kg/m2) should be counselled that,

  • 1.if they have diabetes, either gestational or pre-existing, they are twice as likely to deliver by caesarean section than women who do not have diabetes. T □ F □
  • 2.approximately 10% will give birth to a baby weighing 4.5 kg or greater. T □ F □
  • 3.there is an approximately 50% chance of problems with regional (epidural or spinal) anaesthesia. T □ F □
  • 4.if they have no medical or pregnancy complications, elective caesarean section is associated with significantly fewer maternal complications than planned vaginal birth. T □ F □
  • 5.about one in every twenty women will have a general anaesthetic for birth. T □ F □
  • 6.about one in fifty infants will have long-term disability following shoulder dystocia. T □ F □

In extremely obese women planning vaginal birth,

  • 7.about one third will give birth by caesarean section. T □ F □
  • 8.there is an increased risk of failure or problems with regional anaesthesia compared with women who plan a caesarean section. T □ F □
  • 9.about a quarter of women will have a wound infection or other wound complication. T □ F □
  • 10.approximately one in thirty deliveries are reported to be complicated by shoulder dystocia. T □ F □
  • 11.neonatal complications occur about twice as frequently compared with women who plan caesarean delivery. T □ F □

This study,

  • 12.provides evidence to say that extreme obesity is an indication for caesarean section. T □ F □
  • 13.is a national study and thus the sample size is adequate to reliably investigate outcomes such as neonatal death which occur in <1% of pregnancies. T □ F □
  • 14.provides a higher quality of evidence than a randomised controlled trial. T □ F □

With regard to shoulder dystocia,

  • 15.it occurs more frequently as fetal weight increases. T □ F □
  • 16.it is possible to accurately predict it antenatally in obese pregnant women using estimates of fetal weight. T □ F □

Based on the evidence in this paper,

  • 17.routine caesarean delivery for extremely obese women should not be recommended without considering individual and other risk factors. T □ F □
  • 18.systems need to be in place in health services to ensure appropriate consultation referral of women with extreme obesity. T □ F □
  • 19.women with extreme obesity must only give birth in consultant-led maternity units. T □ F □
  • 20.hospitals need to purchase a range of new bariatric equipment to care for these women. T □ F □