CPD questions for volume 15 number 4

CPD credits can be claimed for the following questions online via the TOG CPD submission system. You must be a registered CPD participant of the RCOG CPD programme (available in the UK and worldwide) in order to submit your answers. Participants will need to log in to the RCOG website (www.rcog.org.uk) and go to the ‘Our Profession’ tab.

Participants can claim 2 credits per set of questions if at least 70% of questions have been answered correctly. At least 50 credits must be obtained in this way over the 5-year cycle.

Please direct all questions or problems to the CPD Office. Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk

The blue symbol denotes which source the questions refer to including the RCOG journals, TOG and BJOG, and RCOG guidance, such as Green-top Guidelines (GTG) and Scientific Impact Papers (SIPs). All of the above sources are available to RCOG members and fellows via the RCOG website.

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 □


  • 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 □