CPD questions for volume 16 number 1


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image Millennium Development Goal 4 – reducing perinatal and neonatal mortality in low resource settings

With regard to Millennium Development Goals (MDGs),

  • 1.they are important for highlighting health issues. T □ F □
  • 2.the target is to reduce mortality of those aged ≤5 years by 50%. T □ F □
  • 3.stillbirth is not addressed by the MDGs. T □ F □

With regard to neonatal death, stillbirth and perinatal mortality,

  • 4.the definition of neonatal death is babies who die within 7 days of being born. T □ F □
  • 5.the key factor in improving neonatal mortality is political commitment. T □ F □
  • 6.neonatal training packages for traditional birth attendants have been shown to reduce perinatal and neonatal death by more than 20%. T □ F □
  • 7.antenatal corticosteroids for those women in preterm labour could save over 300 000 babies annually. T □ F □
  • 8.kangaroo mother care is less effective than nursing in an incubator for stable babies. T □ F □
  • 9.birth spacing has no effect on pregnancy outcomes. T □ F □
  • 10.malaria contributes to 100 000 neonatal deaths annually. T □ F □

Concerning factors that affect the achievement of MDG4,

  • 11.a mother being alive reduces by one half the chances of her child dying by 5 years. T □ F □
  • 12.training is not a barrier to implementation of evidence to reduce under-5 mortality into practice. T □ F □
  • 13.approximately half of health workers in low resource settings cannot perform basic neonatal resuscitation. T □ F □
  • 14.women are usually in charge of their own access to care in low resource settings. T □ F □

With regard to the provision/delivery of services that may affect the attainment of MDG4 goals,

  • 15.user fees are the main cost consideration of accessing care. T □ F □
  • 16.poor quality services are poorly attended. T □ F □
  • 17.inequality and inequity essentially mean the same thing. T □ F □
  • 18.outcomes have improved most for those easy to reach. T □ F □
  • 19.caesarean section rate is approximately 1% for the poorest fifth of the population in some countries. T □ F □
  • 20.many of the possible solutions to reach MDG4 targets are known. T □ F □

image Retinoids and pregnancy: an update

With regard to isotretinoin,

  • 1.its mode of action is to reduce sebum secretion. T □ F □
  • 2.it is used as a first-line treatment for acne. T □ F □
  • 3.it has an elimination half-life of less than 10 hours. T □ F □
  • 4.the dose prescribed is adjusted according to the patient's weight. T □ F □
  • 5.the estimated pregnancy rate while on treatment is around 1%. T □ F □

Regarding side effects of retinoids (such as isotretinoin) including their teratogenicity,

  • 6.mood disturbance is well documented. T □ F □
  • 7.derivatives of the mesonephric duct are recognised malformations. T □ F □
  • 8.limb deformities are common. T □ F □
  • 9.their use in pregnancy is associated with ear abnormalities. T □ F □

With regard to the incidence of teratogenic effects of isotretinoin,

  • 10.30% of affected fetuses have been reported to perform poorly in neuropsychological tests. T □ F □
  • 11.approximately half of fetuses exposed to them suffer from mental retardation. T □ F □
  • 12.about a third of fetuses exposed to them have retinoid specific fetal malformations. T □ F □

Concerning the pregnancy prevention programme in those being placed on isotretinoin;

  • 13.the programme was launched in 2005 in the UK. T □ F □
  • 14.contraception should be used for 1 month prior to and 2 months following treatment. T □ F □
  • 15.pregnancy tests should be taken monthly throughout treatment. T □ F □

Isotretinoin,

  • 16.exerts its teratogenic effect through a mechanism that does not significantly affect vitamin A levels. T □ F □
  • 17.affects the development of the branchial arches by effecting haemopexin signalling. T □ F □
  • 18.is associated with a miscarriage of over 20% when used in the first trimester. T □ F □

Concerning retinoid embryopathy,

  • 19.topical application is not associated with an increased risk. T □ F □
  • 20.the most common malformations are those of the musculoskeletal system. T □ F □

image Abdominal incisions and sutures in obstetrics and gynaecology

With respect to the risk of surgical site infection following abdominal incisions,

  • 1.it is reduced with preoperative antiseptic showering. T □ F □
  • 2.it is reduced if the site is depilated preoperatively. T □ F □
  • 3.it is increased approximately seven-fold by morbid obesity. T □ F □

Which of the following is/are true about abdominal incisions?

  • 4.In a Pfannenstiel incision, the layers of the abdominal wall are cut transversely, including the rectus muscle. T □ F □
  • 5.A Joel-Cohen incision is located slightly lower than a Pfannenstiel incision. T □ F □
  • 6.The incidence of wound dehiscence is lower with paramedian compared with median incisions. T □ F □
  • 7.A caesarean section through the Joel-Cohen incision carries less postoperative febrile morbidity when compared to that through a Pfannenstiel incision. T □ F □
  • 8.A transverse incision is associated with reduced incidence of wound dehiscence compared with a vertical incision. T □ F □

With regard to skin incisions for laparoscopic surgery,

  • 9.those that are more than 7 mm will need formal deep sheath closure. T □ F □

Which of the following statements is/are true?

  • 10.The primary function of a suture is to maintain tissue approximation during healing. T □ F □
  • 11.Wound infection rate is higher with braided compared with monofilament sutures. T □ F □
  • 12.Non-absorbable sutures are associated with reduced incidence of wound dehiscence. T □ F □
  • 13.PDS (polydiaxanone) is a braided suture with high tissue reaction. T □ F □
  • 14.Polypropylene is a monofilament suture with least tissue reaction. T □ F □
  • 15.Vicryl rapide is absorbed in 60–90 days. T □ F □

With regard to use of staples for closure,

  • 16.the non-absorbable variety has the highest tensile strength of any wound closure device. T □ F □
  • 17.contaminated wounds closed with staples have a lower incidence of infection compared with those closed with sutures. T □ F □
  • 18.the absorbable varieties have a tissue half-life of 10 weeks. T □ F □

With regard to electrosurgery,

  • 19.it is associated with poor wound healing when used to incise the skin. T □ F □
  • 20.the use of a separate scalpel for superficial and deep incisions is recommended. T □ F □

image Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management

With regard to bladder injuries at laparoscopic gynaecological surgery,

  • 1.they are the second most common visceral injury. T □ F □
  • 2.the commonest site is the bladder's dome. T □ F □
  • 3.cancer is a known risk factor. T □ F □
  • 4.the incidence of fistula formation following a bladder injury is approximately 0.5%. T □ F □

With regard to injuries from electrosurgery in gynaecological laparoscopy,

  • 5.thermal bladder or ureteric injuries are known to present late due to delayed tissue breakdown. T □ F □
  • 6.brief intermittent activation prevents unnecessary thermal spread. T □ F □
  • 7.both the tip and the heel of the active electrode are recognised to be potential causes of thermal damage. T □ F □

With regard to the identification and management of bladder injuries,

  • 8.uroperitoneum is painless. T □ F □
  • 9.serum creatinine is likely to be elevated in a woman sustaining a bladder injury. T □ F □
  • 10.repair by laparotomy should be the first option when a bladder injury occurs during a laparoscopic operation. T □ F □
  • 11.post operative bladder drainage reduces the risk of fistula formation. T □ F □
  • 12.conservative management of a small retropubic bladder injury has been shown to be effective in some cases. T □ F □

With regard to ureteric injuries at laparoscopic gynaecological surgery,

  • 13.the commonest site is at the level of the ovarian fossa. T □ F □
  • 14.the commonest type of injury is ligation. T □ F □
  • 15.preoperative stenting has been proven to be of benefit in cases of severe endometriosis with ureteric involvement. T □ F □
  • 16.computed tomography intravenous urogram is an appropriate investigation when suspecting such an injury. T □ F □

With regard to the repair of ureteric injuries in laparoscopic gynaecological surgery,

  • 17.the type of repair is mainly dependent on the preference of the individual surgeon. T □ F □
  • 18.where crush injuries are minor, conservative management has been shown to be an effective option. T □ F □
  • 19.uretero-neocystostomy (with or without psoas hitch or Boari flap) is the most appropriate repair technique for major injuries at the lower third of the ureter. T □ F □
  • 20.trans-uretero-ureterostomy is a repair technique appropriate for major injuries at the upper third of the ureter. T □ F □

image Nerve injuries associated with gynaecological surgery

Regarding the pathophysiology of nerve injury,

  • 1.neuropraxia involves disruption of the axon and Schwann cells. T □ F □
  • 2.neurotmesis has a good prognosis without restorative surgery. T □ F □
  • 3.axonotmesis usually resolves with conservative management within months. T □ F □

The femoral nerve,

  • 4.is the nerve most commonly damaged during gynaecology surgery. T □ F □
  • 5.is compressed against the pelvic side wall from deeply seated self-retaining retractors. T □ F □

Regarding pelvic nerve neuropathies,

  • 6.foot drop is a feature of obturator nerve injury. T □ F □
  • 7.pain relief following the administration of a local anaesthetic is diagnostic of ilioinguinal/iliohypogastric neuropathy. T □ F □
  • 8.gluteal, perineal and vulval pain following a sacrospinous ligament fixation are features of pudendal nerve neuropathy. T □ F □
  • 9.following a Pfannenstiel incision, about 20% of patients report ilioinguinal or iliohypogastric related nerve injury. T □ F □
  • 10.the genitofemoral nerve is susceptible to injury during removal of the external iliac nodes. T □ F □
  • 11.an obturator nerve neuropathy is the likely culprit of a patient who reports a burning sensation radiating to the mons pubis and thigh following a retropubic mid urethral tape procedure. T □ F □
  • 12.meralgia paraesthesia is a feature of genitofemoral nerve neuropathy. T □ F □

The brachial plexus,

  • 13.originates from C7–T1 nerve roots. T □ F □

Ulnar nerve neuropathy,

  • 14.causes wrist drop. T □ F □
  • 15.presents with sensory loss over the lateral 3½ fingers of the hand. T □ F □

With regard to brachial plexus neuropathy,

  • 16.hyper-abduction of the arm greater than 90 degrees is associated with an Erb's palsy. T □ F □

Regarding the prevention and treatment of neuropathy associated with surgery,

  • 17.patient mal-positioning is the most likely cause of intraoperative nerve-related injury. T □ F □
  • 18.gamma-aminobutyric acid (GABA) antagonists are not effective in treating surgical nerve related neuropathies. T □ F □
  • 19.detailed neurological examination and electromyographic (EMG) studies are key in diagnosing neurologic deficit. T □ F □
  • 20.the majority of neuropathies following surgery resolve spontaneously without intervention. T □ F □

image The role of tubal patency tests and tubal surgery in the era of assisted reproductive techniques

Regarding in vitro fertilisation (IVF),

  • 1.it was developed primarily as an alternative to tubal surgery for the treatment of tubal factor infertility. T □ F □

Concerning tubal patency tests,

  • 2.laparoscopy is widely considered to be the gold standard test. T □ F □
  • 3.hysterosalpingogram (HSG) has a low sensitivity and high specificity. T □ F □
  • 4.radiation exposure during an HSG is significantly lower than from standard chest X-ray. T □ F □
  • 5.approximately 2% of patients develop pelvic infection following HSG. T □ F □
  • 6.with hysterosalpingo contrast sonography (HyCoSy) there is a higher likelihood of uncertainty when reporting (neither patent nor occluded) compared with HSG. T □ F □
  • 7.with tubal catheterisation, the risk of (tubal) perforation is approximately 4%. T □ F □
  • 8.fertiloscopy is an outpatient technique which combines hysteroscopy, transvaginal hydro laparoscopy and salpingoscopy. T □ F □

With regard to surgery and treatment for infertility,

  • 9.opportunistic treatment of mild or minimal endometriosis and peri-adnexal adhesions does not confer any significant therapeutic benefit. T □ F □
  • 10.previous pelvic surgery is not a risk factor for tubo-peritoneal pathology associated with tubal factor infertility. T □ F □
  • 11.there is strong evidence to suggest that women who are otherwise ovulating and exposed to sperm on a regular basis (unexplained or mild male factor infertility) do not benefit from clomiphene citrate. T □ F □
  • 12.surgical reversal of tubal sterilisation is less successful than IVF. T □ F □
  • 13.hydrosalpinx is an end stage of distal tubal disease. T □ F □
  • 14.intrauterine insemination has been shown to benefit couples with unexplained infertility. T □ F □
  • 15.salpingectomy followed by IVF is the recommended treatment for hydrosalpinx associated infertility. T □ F □

Regarding factors associated with infertility,

  • 16.Chlamydia is the single largest cause of acquired tubal pathology. T □ F □
  • 17.proximal tubal disease accounts for approximately 25% of causes of tubal factor infertility. T □ F □

Concerning transvaginal 2-D ultrasound,

  • 18.it has a sensitivity of approximately 85% for the diagnosis of hydrosalpinx. T □ F □

With regard to selective salpingography,

  • 19.it is associated with lower false positive rates from tubal spasm. T □ F □
  • 20.it is used primarily to assess tubal patency where other tests are not recommended. T □ F □

image Selective progesterone receptor modulators (SPRMs) and their use within gynaecology

With regard to mifepristone,

  • 1.it is a progesterone antagonist. T □ F □
  • 2.it has no effect on glucocorticoids. T □ F □

With regard to ulipristal acetate,

  • 3.it is licensed for use as an emergency contraceptive. T □ F □
  • 4.in the UK it is licensed for the preoperative treatment of uterine fibroids. T □ F □
  • 5.it is not available as an oral preparation. T □ F □

With regard to the actions of progesterone,

  • 6.selective progesterone receptor modulators (SPRMs) effectively reduce circulating levels of estrogen. T □ F □
  • 7.selective progesterone receptor modulators produce a pure antagonist effect on the progesterone receptor. T □ F □
  • 8.activation of human progesterone receptor B (hPR-B) counteracts estrogen-induced endometrial proliferation. T □ F □
  • 9.hPR-Bs are involved in proliferation of breast tissue. T □ F □

With regard to the management of fibroids with SPRMS.

  • 10.they have been shown to reduce fibroid volume by over 10%. T □ F □
  • 11.they have been shown to significantly increase breast tenderness. T □ F □

With regard to the mode of action of and uses of SPRMS,

  • 12.they inhibit ovulation by blocking the luteinising hormone surge. T □ F □
  • 13.they have no effect on implantation. T □ F □
  • 14.ulipristal acetate is effective emergency contraception when used for up to 120 hours after unprotected intercourse. T □ F □
  • 15.ulipristal acetate can be used more than once in any menstrual cycle. T □ F □
  • 16.amenorrhea rates of over 80% have been observed with asoprisnil. T □ F □
  • 17.they are licensed for use as long-term contraceptives in the UK. T □ F □
  • 18.the exact mechanisms by which they induce amenorrhoea are unknown. T □ F □

Concerning the side-effects of SPRMS,

  • 19.their use has been linked with pre-malignant and/or malignant endometrial histological changes. T □ F □
  • 20.they should be used with caution in those with hypertension. T □ F □

image Litigation in gynaecology

Within the remit of obstetrics and gynaecology,

  • 1.claims should be made within 5 years of the injury. T □ F □
  • 2.children who have suffered an injury are allowed to make a claim any time up to their 21st birthday. T □ F □
  • 3.it is recommended that claims by those who lack capacity are made within 10 years of the injury. T □ F □

Of the total claims made,

  • 4.5–10% reach court. T □ F □
  • 5.there is about a 40% chance that a case will be defended successfully. T □ F □

Regarding key cases that influence medico-legal rulings,

  • 6.the Roe ruling states that a defendant can be subsequently liable if more recent medical knowledge shows that they should have acted otherwise. T □ F □
  • 7.the Ashcroft ruling states that the burden of proof lies with the claimant to prove that on the balance of probabilities the defendant was negligent. T □ F □
  • 8.according to Hunter, departure from routine practice automatically constitutes negligence. T □ F □
  • 9.according to Crawford the standard of medical knowledge and its application will be judged on the basis of publication in medical journals. T □ F □
  • 10.according to Bolam the law imposes the duty of care; but the standard of care is a matter of medical judgement. T □ F □
  • 11.Chester states that a patient does not need to be informed of a risk if it would not have changed the claimant's decision to proceed with the treatment. T □ F □

Regarding overall claims for clinical negligence,

  • 12.the maximum number of claims are made in gynaecology. T □ F □
  • 13.the value of claims are highest for obstetrics. T □ F □

Regarding insurance cover,

  • 14.doctors need either Medical Defence Union (MDU) or Medical Protection Society (MPS) cover for NHS work. T □ F □
  • 15.the NHS Litigation Authority advises the NHS on human rights case law. T □ F □

Regarding valid consent,

  • 16.a patient's signature on a consent form implies valid consent. T □ F □
  • 17.research has identified that the best way to communicate uncertainty about harms and benefits of treatment to patients is through videos. T □ F □

Regarding sterilisation,

  • 18.medicolegal law states that parents are entitled to the cost of bringing up a child if it is born as a result of failed sterilisation. T □ F □

With regard to taking responsibility,

  • 19.saying sorry equates to admitting liability. T □ F □

In gynaecology malpractice suits,

  • 20.if an adult dies as a result of their medical treatment, their personal representatives or dependants are allowed to bring a claim within 3 years of the date of their death. T □ F □

image Menstrual and fertility outcomes following surgical management of postpartum haemorrhage: A systematic review

With regard to postpartum haemorrhage (PPH),

  • 1.it is a major cause of maternal morbidity and mortality, which is responsible for up to 25% of all maternal deaths worldwide. T □ F □
  • 2.approximately 15% of all births are complicated by loss of greater than 1000 ml. T □ F □

In the management of PPH,

  • 3.if bimanual uterine compression and pharmacological measures fail to control the haemorrhage, hysterectomy should be performed immediately. T □ F □
  • 4.intrauterine balloon tamponade is an appropriate first line surgical intervention for most women where uterine atony is the only or main cause of haemorrhage. T □ F □
  • 5.it has been proposed that a second (or even a third) uterine sparing procedure be performed in case of a failed first procedure before considering hysterectomy in a haemodynamically stable patient. T □ F □

Following uterine compression sutures in the treatment of PPH,

  • 6.more than 90% women will have a normal onset of menstruation. T □ F □
  • 7.more than 85% of women who had the desire of pregnancy, achieved conception following these procedures. T □ F □

With regard to uterine artery embolisation (UAE),

  • 8.the success rates for severe PPH have been reported to be between 30 to 50%. T □ F □
  • 9.only 50% of the women resumed menstruation within the normal time-frame after delivery following the procedure. T □ F □
  • 10.only 45% of women who desired another pregnancy achieved conception following UAE for PPH. T □ F □

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