CPD questions for volume 15, number 3

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image Postpartum psychosis

Postpartum psychosis complicating childbirth occurs in approximately,

  • 1.1–2 in 1000 women in the general population. T □ F □
  • 2.1 in 4 women with bipolar disorder. T □ F □

The definition of postpartum psychosis includes,

  • 3.the continuation of a chronic schizophrenic illness into the postpartum period. T □ F □
  • 4.the onset of a severe obsessive–compulsive illness in the first 2 weeks following delivery. T □ F □
  • 5.an episode of major depression with onset in the first postpartum month. T □ F □
  • 6.acute onset in the first postpartum week of an episode with marked manic and psychotic features. T □ F □
  • 7.acute onset 2 years postpartum of an episode with manic and psychotic features, including delusional thoughts of harming the baby. T □ F □

The postpartum onset specifier in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) identifies postpartum episodes as those with an onset following delivery within:

  • 8.1 month. T □ F □
  • 9.6 months. T □ F □
  • 10.3 months. T □ F □

In the treatment of postpartum psychosis,

  • 11.the woman should not breastfeed. T □ F □
  • 12.lithium is the gold standard. T □ F □
  • 13.referral to safeguarding teams should be routine. T □ F □
  • 14.the whole range of psychotropic medication may need to be employed. T □ F □

In the prevention of puerperal psychosis,

  • 15.a woman who has experienced an episode should be advised about both the risk of postpartum and non-postpartum recurrence. T □ F □
  • 16.only women with psychiatric symptoms at their antenatal booking visit should be screened for risk factors. T □ F □
  • 17.women at high risk, even if they are well, should be referred in pregnancy for psychiatric assessment and management. T □ F □

With regard to postpartum mood disorders in the UK,

  • 18.suicide is a leading cause of maternal mortality. T □ F □
  • 19.a survival analysis comparing women with bipolar disorders who stopped taking lithium because of pregnancy compared with age-matched non-pregnant control, has shown similar recurrence rates during the first 40 weeks after lithium discontinuation. T □ F □
  • 20.women with schizophrenia have a similar risk of admission for this disorder in the postpartum period compared to those with bipolar disorders. T □ F □

image Pelvic congestion syndrome

The following aetiological factors have been associated with pelvic congestion syndrome:

  • 1.ovarian varicoceles. T □ F □
  • 2.pregnancy. T □ F □
  • 3.estrogen and progesterone. T □ F □
  • 4.nutcracker syndrome. T □ F □

Regarding pelvic congestion syndrome (PCS),

  • 5.it is a widely accepted clinical condition. T □ F □
  • 6.more than 75% of affected individuals are symptomatic. T □ F □

Regarding the clinical presentation of PCS,

  • 7.pain is the most common feature. T □ F □
  • 8.psychological symptoms such as anxiety and depression are common. T □ F □

Regarding investigations for PCS,

  • 9.selective venography is recommended first line. T □ F □
  • 10.tortuous pelvic veins greater than 4 mm in diameter are diagnostic of PCS on ultrasound. T □ F □

Regarding the medical management of PCS,

  • 11.ovarian suppression can cause venous vasoconstriction. T □ F □
  • 12.medroxyprogesterone acetate (MPA) has only been shown to subjectively reduce pelvic pain. T □ F □
  • 13.gonadotropin-releasing hormone (GnRH) agonists shave been shown to subjectively and objectively improve pelvic pain. T □ F □
  • 14.MPA has been proven to be more effective treatment than GnRH agonist at 12 months. T □ F □
  • 15.psychotherapy has been shown to have an additive benefit to the treatment of pelvic pain compared with MPA alone. T □ F □

Regarding the surgical management of PCS,

  • 16.there is good evidence to suggest the application of laparoscopic bilateral transperitoneal ligation of ovarian veins. T □ F □
  • 17.hysterectomy and bilateral oophorectomy has not been shown to achieve a statistically significant reduction in pelvic pain in women with PCS. T □ F □

Regarding the role of endovascular treatment in PCS,

  • 18.transcatheter embolotherapy has been shown to improve overall pain perception by more than 60%. T □ F □
  • 19.only the refluxing ovarian vein should be embolised. T □ F □
  • 20.there has been no significant hormonal disturbance after embolotherapy. T □ F □

image Ambulatory hysteroscopy

Pain can be minimised during diagnostic outpatient hysteroscopy by the routine use of,

  • 1.a vaginal speculum. T □ F □
  • 2.conscious sedation. T □ F □
  • 3.non-steroidal anti-inflammatory agents 1-hour pre-procedure. T □ F □


  • 4.refers to a ‘no touch’ technique for hysteroscopy that bypasses the routine requirement for a vaginal speculum or instrumentation of the cervix. T □ F □
  • 5.requires a hysteroscope with a 30° offset distal lens. T □ F □
  • 6.is useful in women with atrophic lower genital tracts or restricted vaginal access. T □ F □

Outpatient hysteroscopic removal of endometrial polyps,

  • 7.requires infiltration into or around the cervix with a local anaesthetic. T □ F □
  • 8.has evidence to support feasibility, but not effectiveness. T □ F □
  • 9.is limited to some degree by the size, location and number of lesions. T □ F □
  • 10.with Versapoint® bipolar diathermy requires continuous flow hysteroscopes >5 mm in outer diameter. T □ F □
  • 11.using bipolar electrosurgery needs a non-conducting distension media. T □ F □
  • 12.using the new morcellator systems is compatible with standard hysteroscopes. T □ F □

Regarding submucous fibroids,

  • 13.most can be removed in an outpatient setting. T □ F □
  • 14.formal resection of fibroids usually requires general anaesthesia. T □ F □
  • 15.the likelihood of complete excision of a grade 1 submucous fibroid (>50% visible within the uterine cavity) is increased with preliminary capsular incision in the outpatient setting following diagnosis. T □ F □

Hysteroscopic sterilisation with the Essure® system:

  • 16.is not feasible in approximately 20% of women. T □ F □
  • 17.is completed in less than 15 minutes. T □ F □
  • 18.requires routine dilatation of the cervix. T □ F □
  • 19.has a higher cumulative pregnancy rate compared with laparoscopic sterilisation. T □ F □
  • 20.needs a routine hysterosalpingogram to confirm tubal occlusion. T □ F □

image Management of vault prolapse

Regarding the role of conservative treatment in vaginal vault prolapse,

  • 1.physiotherapy has been shown in trials to be beneficial. T □ F □
  • 2.pessary use has a high patient satisfaction rate. T □ F □

Regarding the vaginal route for the surgical treatment of vaginal vault prolapse,

  • 3.objective outcomes for sacrospinous fixation are poor. T □ F □
  • 4.complications of sacrospinous fixation are comparable to those of sacrocolpopexy. T □ F □
  • 5.NICE recommends the use of routine iliococcygeal fixation. T □ F □
  • 6.colpocleisis is the procedure of choice in the frail and elderly. T □ F □
  • 7.erosion is a recognised complication in cases treated with a mesh. T □ F □

Regarding sacrocolpopexy,

  • 8.open abdominal sacrocolpopexy has a lower incidence of recurrent prolapse compared to vaginal sacrospinous fixation. T □ F □
  • 9.laparoscopic sacrocolpopexy has a shorter stay and quicker recovery in comparison to the open procedure. T □ F □
  • 10.robotic laparoscopic sacrocolpopexy involves more ports. T □ F □
  • 11.robotic procedures have poorer visualisation of the surgical field. T □ F □
  • 12.capital cost is high for laparoscopic sacrocolpopexy in comparison to the robotic surgery. T □ F □

Risk factors for vault prolapse include:

  • 13.body mass index. T □ F □

With regard to the use of pessaries in the treatment of vault prolapse,

  • 14.the outcome (in terms of success) is similar to that of surgery at 1 year. T □ F □
  • 15.difficulties in fitting them are encountered in less than 10% of patients at presentation. T □ F □
  • 16.spontaneous expulsion is one of the commonly reported side effects. T □ F □

With regard to colpocleisis,

  • 17.when undertaken, the reported success rate is approximately 75%. T □ F □

Regarding the vaginal routine for the surgical treatment of vaginal vault prolapse,

  • 18.when mesh is used, its contraction is not a recognised complication. T □ F □

With regard to the abdominal approach to surgery for vaginal vault prolapse,

  • 19.sacrocolpopexy has a lower recurrent prolapse rate compared to sacrospinous fixation. T □ F □
  • 20.laparoscopic sacrocolpopexy has been shown to have similar reoperation rates as those after treatment with a vaginal mesh. T □ F □

image Polycystic ovary syndrome and the differential diagnosis of hyperandrogenism

Androgen excess in women is associated with,

  • 1.menstrual irregularity. T □ F □

With regard to normal androgen physiology in women,

  • 2.the adrenal medulla makes dehydroepiandrosterone sulfate. T □ F □
  • 3.less than 10% of testosterone is bound to sex hormone binding globulin. T □ F □

With regard to androgen action and metabolism,

  • 4.androgens are excreted unchanged in the urine. T □ F □
  • 5.testosterone binds to a nuclear receptor. T □ F □

With regard to the clinical presentation of hyperandrogenism,

  • 6.the Ferriman-Gallwey score is useful in objectively assessing the severity of hirsutism. T □ F □
  • 7.deepening voice and breast atrophy are features suggestive of an adrenal tumour. T □ F □

Regarding the biochemical assessment of hyperandrogenic patients,

  • 8.serum testosterone >5 nmol/l should prompt further investigation. T □ F □

Regarding the pathophysiology of polycystic ovary syndrome,

  • 9.a combination of genetic and lifestyle factors are likely to be causative. T □ F □
  • 10.arrest of follicular development is characteristic. T □ F □

Regarding the differential diagnoses of hyperandrogenism,

  • 11.ovarian hyperthecosis is a disease of childhood. T □ F □
  • 12.congenital adrenal hyperplasia is often diagnosed in infancy. T □ F □
  • 13.the most common virilising adrenal tumours are the Sertoli-Leydig cell type. T □ F □

With regard to the pathophysiology of hyperandrogenism,

  • 14.approximately 50% of circulating androgens are conjugated with either glucuronic or sulfuric acid. T □ F □

In hyperandrogenaemic women with PCOS,

  • 15.it has been shown that there is an increased risk of breast cancer. T □ F □

With regard to the quantification of androgens in secondary care institutions in the UK,

  • 16.automated immunoassays on whole serum are known to consistently overestimate serum testosterone concentrations. T □ F □

In case of hyperandrogenism,

  • 17.ovarian hyperthecosis accounts for less than 50% of cases in postmenopausal women. T □ F □
  • 18.the non-classic 21-hydroxylase deficiency tends to typically present in childhood. T □ F □
  • 19.luteomas of the ovary are one of the most common causes of gestational hyperandrogenism. T □ F □
  • 20.unilateral solid ovarian lesions as a cause have an increased risk of malignancy when presenting in pregnancy. T □ F □

image The relationship between infertility treatment and cancer including gynaecological cancers

Infertile patients,

  • 1.are at increased risk of developing ovarian cancers. T □ F □


  • 2.is associated with a ten-fold increase in the risk of developing ovarian cancer. T □ F □

Regarding infertility treatment and ovarian cancer,

  • 3.when clomiphene citrate is given for more than 12 cycles, it is associated with an increased risk of borderline and invasive cancer. T □ F □
  • 4.nulligravidae who received fertility treatment have been shown to be at an increased risk of ovarian cancer regardless of whether they conceived or not. T □ F □
  • 5.there is strong evidence linking multiple in vitro fertilisation (IVF) cycles and an increased risk of developing the cancer. T □ F □
  • 6.treatment with fertility drugs does not increase risk compared with non treated infertile women. T □ F □
  • 7.compared with the general population, those who have IVF treatment are at an increased risk of ovarian cancer. T □ F □

Regarding infertility treatment and uterine cancer,

  • 8.there is a persistent trend linking usage of clomiphene citrate and increased risk. T □ F □
  • 9.there is some evidence pointing to a transient increase in risk in the first year following infertility treatment. T □ F □
  • 10.there is evidence showing that ever use of gonadotropins is associated with increased risk. T □ F □
  • 11.IVF, particularly after multiple IVF cycles, increases risk. T □ F □

Regarding infertility treatment and breast cancer,

  • 12.most studies observed an increased risk following the use of fertility drugs. T □ F □
  • 13.there is strong evidence showing an increased risk following fertility treatment in women with family history of the disease. T □ F □
  • 14.there is strong evidence linking the development of the cancer with increased maternal age at first IVF cycle. T □ F □
  • 15.there is robust evidence linking the development of the cancer with multiple IVF cycles. T □ F □
  • 16.there is good evidence that women exposed to fertility drugs have a transient increase in the risk of the cancer diagnosed in the first year after treatment. T □ F □

Regarding infertility treatment and non gynaecological cancers,

  • 17.there is evidence linking fertility treatment with increased risk of melanoma. T □ F □
  • 18.the evidence linking thyroid cancer with clomiphene citrate is weak. T □ F □

Regarding fertility treatment and childhood cancer,

  • 19.there is a consistently increased risk of retinoblastoma. T □ F □
  • 20.children born following IVF are at a significantly increased risk of developing cancer compared with the general population. T □ F □

image Delivery outcomes for nulliparous women at the extremes of maternal age – a cohort study

Vaughan DA, Cleary BJ, Murphy DJ. Delivery outcomes for nulliparous women at the extremes of maternal age – a cohort study. BJOG 2013; DOI: 10.1111/1471-0528.12311

With regard to the epidemiology of maternal age in pregnancy,

  • 1.the live birth rate in young women aged 20 years and under has halved in the UK between 1997 and 2007. T □ F □
  • 2.the number of live births in women aged between 40 and 44 years has almost doubled in the UK between 1997 and 2007. T □ F □

With regard to maternal risk factors, compared to women aged 20 to 34 years,

  • 3.young teenagers (under 18 years) are more likely to be underweight (BMI <18.5 kg/m2) when assessed at the first antenatal visit. T □ F □
  • 4.young teenagers are more likely to report smoking cigarettes when questioned at the first antenatal visit. T □ F □
  • 5.women aged 40 years and over are more likely to abstain from alcohol in pregnancy. T □ F □
  • 6.women aged 40 years and over are more likely to have hypertension in pregnancy. T □ F □
  • 7.women aged 40 years and over are more likely to be of higher socioeconomic status. T □ F □

When compared to women aged 20 to 34 years,

  • 8.young teenagers are more likely to deliver preterm (<37 weeks of gestation). T □ F □
  • 9.young teenagers are no more likely to have small for gestational age babies (<10th percentile) when potential confounding factors are taken into account. T □ F □
  • 10.young teenagers are more likely to have an instrumental delivery by vacuum or forceps. T □ F □