CPD questions for volume 15 number 4


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image In vitro maturation

Regarding in vitro maturation (IVM),

  • 1.it minimises the risk of ovarian hyperstimulation syndrome (OHSS). T □ F □
  • 2.women over the age of 38 are ideal candidates. T □ F □
  • 3.more than 1 million children have been born from IVM. T □ F □
  • 4.women who desire fertility preservation and are facing gonadotoxic cancer therapy have been shown to benefit from the accelerated time course of IVM in order to cyro-bank oocytes or embryos. T □ F □

Regarding IVM protocols,

  • 5.current IVM techniques involve the retrieval of immature oocytes that have been exposed to minimal or no gonadotropin stimulation, followed by maturation in the laboratory. T □ F □
  • 6.despite variations, the average number of oocytes retrieved is similar regardless of protocol. T □ F □
  • 7.hCG priming has been shown to play an important role in endometrial receptivity. T □ F □
  • 8.follicular priming with low dose gonadotropin stimulation is necessary for IVM. T □ F □
  • 9.IVM media is typically supplemented with gonadotropins. T □ F □
  • 10.the prolonged cultured conditions necessary for IVM have raised concerns regarding the risk of imprinting disorders. T □ F □

Comparing IVM with IVF,

  • 11.an IVM retrieval utilises the same needle gauge and aspiration pressure as a conventional IVF retrieval. T □ F □
  • 12.fertilisation rates with IVM/ICSI are lower than those observed with conventional IVF/ICSI. T □ F □
  • 13.an increased rate of congenital anomalies is observed in children born from IVM compared with children born from IVF and IVF/ICSI. T □ F □
  • 14.IVM protocols typically require less cycle monitoring than in vitro fertilisation (IVF) protocols. T □ F □

With regard to oocytes,

  • 15.curetting a small follicle increases the yield. T □ F □
  • 16.immature oocytes enclosed in cumulus cells are cultured in IVM media for 24–48 hours to achieve maturation. T □ F □
  • 17.approximately 50–85% of immature oocytes retrieved will mature in vitro. T □ F □
  • 18.oocytes that are mature after 24 hours in culture are less developmentally competent than oocytes that mature after 48 hours in culture. T □ F □
  • 19.oocytes that do not mature in-vivo despite exposure to supraphysiological levels of gonadotropins produce a high rate of aneuploid embryos. T □ F □

Regarding women with polycystic ovary syndrome (PCOS),

  • 20.young women with polycystic appearing ovaries or PCOS are ideal candidates for IVM because their higher risk of OHSS is minimised. T □ F □

image Non-cervical human papillomavirus-related disease

With regard to human papillomavirus (HPV),

  • 1.it is a common double-stranded RNA virus. T □ F □
  • 2.most infections with this virus are symptom free. T □ F □

With regard to vulval disease,

  • 3.the incidence of vulval intraepithelial neoplasia (VIN) is increasing overall. T □ F □
  • 4.vulval squamous cell carcinoma (VSCC) accounts for over 90% of vulval cancers. T □ F □
  • 5.HPV prevalence in vulval cancer is around 80%. T □ F □

With regard to HPV related vaginal disease,

  • 6.HPV 18 is responsible for the majority of vaginal carcinomas. T □ F □

With regard to HPV related anal disease,

  • 7.transplant recipients are more likely to develop anal cancer. T □ F □

With regard to penile cancer,

  • 8.basaloid and warty subtypes are less associated with HPV infection than verrucous penile cancers. T □ F □

With regard to oropharyngeal cancer (OPC),

  • 9.HPV is associated with cancer in the tonsils and base of the tongue but not the soft palate. T □ F □
  • 10.HPV-positive cancers have a worse prognosis. T □ F □

With regard to HPV related skin disease,

  • 11.genus alpha papillomaviruses are most commonly involved. T □ F □

With regard to HPV related ocular disease,

  • 12.there are limited data for the role of HPV in squamous cell carcinoma of the conjunctiva. T □ F □

In pregnant women,

  • 13.if genital warts are present at delivery then a caesarean section will reduce the risk of recurrent respiratory papillomatosis in the infant. T □ F □
  • 14.laser therapy is an accepted treatment for genital warts in pregnancy. T □ F □
  • 15.topical treatments can be safely used for treatment of genital warts in pregnancy. T □ F □
  • 16.anogenital intraepithelial neoplasia should always be treated. T □ F □
  • 17.excision biopsies are appropriate if there is a suspicion of invasive disease. T □ F □

With regard to the sexual partners of women with HPV related disease,

  • 18.if female, they should have yearly cervical smear tests. T □ F □

With regard to the HPV vaccine,

  • 19.it is predicted to prevent almost 50% of all HPV associated cancers. T □ F □
  • 20.after receiving the HPV vaccine, cervical screening is no longer required. T □ F □

image Squamous vulval cancer–an update

Cancer of the vulva,

  • 1.accounts for 10% of gynaecological cancers. T □ F □
  • 2.is mainly squamous cell in origin. T □ F □
  • 3.is more commonly associated with human papillomavirus (HPV) in older women than in younger women. T □ F □
  • 4.is usually multifocal at presentation. T □ F □

A biopsy should be performed,

  • 5.in any postmenopausal woman presenting with genital warts. T □ F □
  • 6.under general anaesthesia in most instances. T □ F □
  • 7.in preference to wide local excision for initial diagnostic purposes. T □ F □
  • 8.that includes normal adjacent epithelium. T □ F □

Verrucous carcinomas typically,

  • 9.have nodal involvement at presentation. T □ F □
  • 10.present as large condylomatous lesions. T □ F □

In the treatment of early vulval cancer,

  • 11.ipsilateral lymph node resection is appropriate for lateral tumours. T □ F □
  • 12.en bloc surgery is associated with a higher postoperative complication rate than dissection through separate incisions. T □ F □
  • 13.radical vulvectomy is the gold standard treatment. T □ F □

Sentinel lymph node biopsy,

  • 14.reduces the postoperative complication rate. T □ F □
  • 15.incorporates frozen section histological examination. T □ F □

Sexual problems after surgery

  • 16.appear to correlate with the extent of operation. T □ F □
  • 17.should be discussed with the patient preoperatively. T □ F □
  • 18.respond well to clinical nurse specialist input. T □ F □

Recurrent vulval cancer,

  • 19.mainly occurs on the labia majora. T □ F □
  • 20.is associated with positive lymph nodes at presentation of disease. T □ F □

image Skin eruptions specific to pregnancy: an overview

With regard to dermatoses in normal pregnancy,

  • 1.increased skin pigmentation is more noticeable in women with light skin. T □ F □
  • 2.there is good evidence to support the use of emollients and oils in the prevention and treatment of striae. T □ F □
  • 3.spider naevi are more common in Caucasian than in Afro-Caribbean women. T □ F □
  • 4.prickly heat (miliaria) is caused by increased apocrine gland activity. T □ F □
  • 5.history taking is almost entirely irrelevant when trying to make a dermatological diagnosis. T □ F □
  • 6.it is important to ask about the family history of atopy when taking a dermatological history. T □ F □

With regard to pruritus in pregnancy,

  • 7.without an identifiable cause, it has been reported to affect up to 18% of pregnancies. T □ F □
  • 8.common sites include the face, hands and soles of the feet. T □ F □
  • 9.liver function tests and bile acids are important investigations if obstetric cholestasis is being considered as the diagnosis. T □ F □
  • 10.there is good evidence that ursodeoxycholic acid improves fetal outcome in obstetric cholestasis. T □ F □

With regard to polymorphic eruption of pregnancy,

  • 11.toxic erythema of pregnancy is another name for it. T □ F □
  • 12.it usually presents in the first trimester. T □ F □
  • 13.periumbilical sparing is typical. T □ F □

Regarding pemphigoid gestationis,

  • 14.it is the most common dermatosis of pregnancy. T □ F □
  • 15.it usually presents within the abdominal striae. T □ F □
  • 16.skin biopsy is necessary to make a diagnosis. T □ F □
  • 17.immunofluorescence studies are important in the differential diagnosis of pemphigoid gestationis. T □ F □
  • 18.It has no impact on the morbidity of the mother and fetus. T □ F □

In atopic eruption of pregnancy,

  • 19.patients with atopic eruption of pregnancy or a localised area of itching or skin eruption where initial management fails should be referred to the dermatologist. T □ F □
  • 20.postnatal exacerbation is not a feature. T □ F □

image Asthma in pregnancy

The following therapies are recommended in the standard management of pregnant women with asthma,

  • 1.leucotriene modifiers. T □ F □
  • 2.short-acting β-agonists. T □ F □
  • 3.anti-IgE. T □ F □
  • 4.inhaled corticosteroids. T □ F □

Poor asthma control in pregnancy is associated with the following adverse pregnancy outcomes:

  • 5.pre-eclampsia. T □ F □
  • 6.low birthweight. T □ F □
  • 7.preterm birth. T □ F □

Asthma in pregnancy,

  • 8.is reported to improve in approximately 25–30% of cases. T □ F □
  • 9.women with well controlled asthma are still at an increased risk of adverse pregnancy outcome. T □ F □
  • 10.women with daily symptoms of moderate asthma or a low respiratory flow are less likely to have low birthweight babies compared to those with severe symptoms. T □ F □

Intrapartum,

  • 11.syntometrine administration is a recognised cause of bronchoconstriction. T □ F □
  • 12.oral corticosteroids should not be used for exacerbations of asthma. T □ F □
  • 13.drugs used to control asthma should be discontinued. T □ F □
  • 14.the use of prostaglandin E2 is associated with bronchospasm. T □ F □

With regard to the management of the postpartum period in women with asthma,

  • 15.breastfeeding is recommended. T □ F □
  • 16.breastfeeding reduces the future risk of asthma in the neonate. T □ F □
  • 17.inhaled corticosteroids should be avoided in those breastfeeding. T □ F □
  • 18.asthma control usually worsens. T □ F □
  • 19.asthma control usually returns to prepregnancy severity. T □ F □
  • 20.exacerbations are more likely to occur after 36 weeks of gestation. T □ F □

image Myocardial infarction and pregnancy

The following are risk factors for myocardial infarction during pregnancy,

  • 1.higher parity (>3). T □ F □
  • 2.increasing maternal age (>35 years). T □ F □
  • 3.pre-existing hypertension. T □ F □
  • 4.pre-existing diabetes. T □ F □
  • 5.obesity. T □ F □

The following statements are true or false

  • 6.troponin levels are increased in prolonged labour and after a caesarean section. T □ F □
  • 7.troponin levels are raised in pre-eclampsia but never cross the set threshold for acute myocardial infarction (AMI). T □ F □
  • 8.echocardiogram findings are diagnostic of AMI. T □ F □

ECG changes seen in ST segment elevation myocardial infarction include,

  • 9.ST segment elevation. T □ F □
  • 10.newly developed Q waves. T □ F □
  • 11.left axis deviation. T □ F □

The following are safe in the management of AMI in pregnancy

  • 12.low dose aspirin. T □ F □
  • 13.angiotensin converting enzyme inhibitors. T □ F □
  • 14.coronary angiogram. T □ F □
  • 15.percutaneous coronary intervention. T □ F □
  • 16.thrombolysis. T □ F □

The following statements are either true or false

  • 17.low molecular weight heparin (LMWH) should be stopped 24 hours prior to induction of labour. T □ F □
  • 18.the use of intravenous tissue plasminogen activator during pregnancy is a recognised cause of maternal haemorrhage. T □ F □
  • 19.statins can be safely used during pregnancy. T □ F □
  • 20.angiotensin receptor blockers cannot be safely used during pregnancy. T □ F □

imageThe perforated uterus

Regarding the incidence of uterine perforation,

  • 1.the average is between 2 and 17%. T □ F □
  • 2.it has been reported at approximately 1.6% with hysteroscopic surgery. T □ F □

Regarding uterine perforation,

  • 3.most perforations are in the body of the uterus. T □ F □
  • 4.up to 55% of perforations caused by inserting an intrauterine device involve abdominal or pelvic viscera. T □ F □
  • 5.perforations caused by inserting an intrauterine device result in bowel injury in more than 3% of cases. T □ F □
  • 6.in 1984 in the USA 9% of women who had a recognised uterine perforation required a hysterectomy. T □ F □

With regard to the mechanism and identification of injury for uterine perforation,

  • 7.a Hegar dilator is the most common instrument causing perforation. T □ F □
  • 8.4% of perforations occur in the anterior wall. T □ F □
  • 9.the cervical canal is the least likely site for perforation. T □ F □
  • 10.a retroverted, acutely anteverted or retroflexed uterus increases the risk of uterine perforation. T □ F □
  • 11.loss of resistance with further instrumentation is highly indicative of a uterine perforation. T □ F □
  • 12.sudden loss of vision during hysteroscopic procedures due to collapse of the uterine cavity is not indicative of a perforation. T □ F □

With regard to uterine perforation, which of the following are true?

  • 13.Perforation during TOP is twice as common in the first trimester compared with the second. T □ F □
  • 14.A more experienced operator has a reduced chance of causing a uterine perforation during a TOP. T □ F □
  • 15.Hawkins-Ambler dilators require less force to achieve cervical dilatation than the parallel-sided Hegar dilators. T □ F □
  • 16.Small perforations with little associated bleeding do not require repair. T □ F □

Regarding risk management and ethical issues,

  • 17.women whose injury occurred in a day unit should be dealt with immediately and not transferred to a specialist centre. T □ F □
  • 18.following a perforation, alerting all members of the team is not necessary. T □ F □
  • 19.the patient must be seen for follow-up after discharge and a critical analysis of the situation made. T □ F □
  • 20.it is vital to counsel women thoroughly for a procedure and to explain potential complications and consequences in depth. T □ F □

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