CPD questions for volume 16 number 2

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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 Medical management of miscarriage

With regard to miscarriage,

  • 1.the incidence of clinically recognised miscarriage ranges from 5–10%. T □ F □
  • 2.most occur before 12 weeks of pregnancy. T □ F □
  • 3.the risk in second trimester is approximately 15%. T □ F □

Regarding medical management of miscarriage,

  • 4.it is currently the gold standard and has therefore replaced surgical management. T □ F □
  • 5.the chief pharmacological agents include prostaglandins. T □ F □
  • 6.the success rate is higher for missed than for incomplete miscarriage. T □ F □

With regard to mifepristone,

  • 7.it is an antiprogestogenic agent. T □ F □
  • 8.it increases the sensitivity of the myometrium to prostaglandins that have uterotonic action. T □ F □
  • 9.the optimal timing of prostaglandin administration following mifepristone is 48–72 hours. T □ F □

Misoprostol is,

  • 10.a prostaglandin F2α analogue. T □ F □
  • 11.licensed for the treatment of miscarriage. T □ F □
  • 12.is cheap, stable at room temperature and does not require stringent storage conditions. T □ F □

Regarding the route of misoprostol administration,

  • 13.the vaginal route is more effective when it is moistened with water or saline. T □ F □
  • 14.the sublingual route has fewer gastrointestinal side effects. T □ F □

With regard to various medical regimens for the management of miscarriage,

  • 15.the risk of uterine rupture in women with a previous caesarean scar receiving these regimens in the second trimester is low. T □ F □

With regard to pain management,

  • 16.analgesia requirement is higher in older parous women. T □ F □
  • 17.non-steroidal anti-inflammatory drugs decrease the efficacy of misoprostol. T □ F □

Regarding psychological sequelae after miscarriage,

  • 18.counselling should be offered as per the woman's preferences. T □ F □

With regard to the prescription of medications in the management of miscarriage;

  • 19.it is illegal for a doctor to prescribe a licensed drug for unlicensed indication. T □ F □

With regard to the medical management of miscarriage at home,

  • 20.it carries a risk of heavy bleeding in a small number of cases. T □ F □

image Antibiotics for early-onset neonatal infection: a summary of the NICE guideline 2012

With regard to early-onset neonatal infection,

  • 1.the consensus definition is infection occurring within 48 hours of birth. T □ F □
  • 2.most cases are caused by Gram-positive micro-organisms. T □ F □
  • 3.Escherichia coli is the most frequently reported Gram-negative micro-organism. T □ F □

Risk factors for early-onset neonatal infection include:

  • 4.maternal group B streptococcus (GBS) colonisation in the current pregnancy. T □ F □
  • 5.invasive GBS infection in a previous baby. T □ F □
  • 6.multiple pregnancy. T □ F □
  • 7.preterm birth following spontaneous labour (before 37 weeks of gestation). T □ F □
  • 8.suspected or confirmed rupture of membranes for more than 12 hours in a preterm birth. T □ F □

In the management of early-onset neonatal infection,

  • 9.universal screening to detect GBS colonisation in pregnant women is recommended. T □ F □
  • 10.risk scoring systems are effective for identifying babies who will develop an infection. T □ F □

Intrapartum antibiotic prophylaxis to prevent early-onset neonatal infection should be offered to,

  • 11.women in preterm labour if there is prelabour rupture of membranes (PROM) of any duration. T □ F □
  • 12.women in term labour with PROM if the membranes have been ruptured for more than 24 hours. T □ F □
  • 13.women who have had GBS colonisation, bacteriuria or infection in the current pregnancy. T □ F □
  • 14.women with suspected or confirmed chorioamnionitis. T □ F □
  • 15.women who have had a previous baby with an invasive GBS infection. T □ F □

With regard to the choice of antibiotic used for intrapartum antibiotic prophylaxis to prevent early-onset neonatal infection,

  • 16.benzylpenicillin is the first choice. T □ F □
  • 17.clindamycin should be used in women who are allergic to penicillin unless individual GBS sensitivity results or local microbiological surveillance data indicate a different antibiotic. T □ F □
  • 18.in women with preterm labour erythromycin should be used. T □ F □

The following statements are correct:

  • 19.Pregnant women who have had GBS colonisation in a previous pregnancy but without infection in the baby should be reassured that this will not affect management of the birth in the current pregnancy. T □ F □
  • 20.At discharge, women who have had GBS colonisation in the pregnancy but without infection in the baby should be informed that if they become pregnant again, they will be offered intrapartum antibiotic prophylaxis to prevent an early-onset neonatal infection in the baby. T □ F □

image Idiopathic intracranial hypertension in pregnancy

Idiopathic intracranial hypertension (IIH),

  • 1.is a disease of unknown aetiology associated with increased intracranial pressure. T □ F □
  • 2.is commonly seen in obese young women. T □ F □

In making the diagnosis of IIH,

  • 3.the lumbar CSF opening pressure should be greater than 250 mm of water. T □ F □
  • 4.the modified Dandy criteria includes tinnitus and vertigo. T □ F □
  • 5.CT or MRI demonstrates normal to small symmetrical ventricles. T □ F □

In IIH and pregnancy,

  • 6.termination of pregnancy is recommended in symptomatic women. T □ F □
  • 7.there is an increased risk of recurrence in subsequent pregnancies. T □ F □
  • 8.visual outcome is the same as that for women with IIH who are not pregnant. T □ F □

With regard to the treatment of IIH in pregnancy,

  • 9.diet and weight control play a role in symptom improvement. T □ F □
  • 10.acetazolamide is contra indicated in pregnancy. T □ F □
  • 11.steroids are reserved for the acute phase only. T □ F □

Regarding the symptoms of IIH in pregnancy,

  • 12.there is a direct correlation between severe visual symptoms and the degree of papilloedema. T □ F □
  • 13.severe visual loss is a recognised complication of up to 50% of cases. T □ F □
  • 14.visual obscuration characteristically lasts for a few minutes to hours. T □ F □

With regard to IIH,

  • 15.when it occurs in pregnancy, there is an increased risk of obstetric complications. T □ F □
  • 16.the increased in intracranial pressure during labour means caesarean section is the preferred method of delivery. T □ F □
  • 17.when it predates pregnancy, it tends to worsen in pregnancy. T □ F □
  • 18.most cases in pregnancy present in the second half of gestation. T □ F □
  • 19.epidural anaesthesia carries a potential risk of increasing intracranial pressure. T □ F □
  • 20.the progestogen only contraceptive is recommended only in those in whom a thrombotic event has been excluded. T □ F □

image Pregnancy and spinal cord injury

Following a complete spinal cord injury (SCI) at the level of T5,

  • 1.pregnancy is contraindicated as it may be life-threatening. T □ F □
  • 2.autonomic dysreflexia and spasms are complications associated with pregnancy, labour and delivery. T □ F □

The quality of life in women with SCI

  • 3.is improved by having families and children of their own. T □ F □

With regard to autonomic dysreflexia,

  • 4.treatment is by removing the source of noxious stimulus. T □ F □
  • 5.if it persists or the cause cannot be identified, one treatment is with 10 mg of sustained release nifedipine. T □ F □

With regard to epidural analgesia in women with SCI,

  • 6.it is routinely recommended in those with a history of autonomic dysreflexia, prior to performing an external cephalic version. T □ F □
  • 7.it is advised in early labour in those who are tetraplegic. T □ F □
  • 8.it is contraindicated before artificial rupture of membranes in a tetraplegic woman. T □ F □

The following are true statements about caesarean sections in women with SCI:

  • 9.A midline skin incision is advised to allow for better access. T □ F □
  • 10.A classical caesarean section is recommended if bladder care is by a suprapubic catheter. T □ F □
  • 11.A suprapubic catheter should be changed 12–24 hours before surgery for infection control measures. T □ F □

In women who sustained a SCI during pregnancy,

  • 12.there is a high risk of DVT and PE in the months following acute spinal cord injury. T □ F □
  • 13.the risk of congenital abnormality is not increased. T □ F □

The following statement is true regarding support required for women with SCI:

  • 14.mood disorders require assessment by a psychiatrist with experience in caring for women with disability. T □ F □

With regard to pregnancy in women with SCI,

  • 15.the incidence of abnormal presentation is not increased compared to that in those without. T □ F □
  • 16.there are no known measures for the prediction of the need for ventilation. T □ F □
  • 17.a rise in systolic blood pressure of 20–40 mmHg above baseline is considered a sign of autonomic dysreflexia. T □ F □
  • 18.the incidence of urinary tract infections is not dissimilar to that in non SCI women. T □ F □
  • 19.there is robust evidence to support treatment of those with aysmptomactic bacteriuria. T □ F □
  • 20.the effectiveness of epidural analgesia is determined by testing the level of block. T □ F □

image Providing an obstetric teaching programme in a resource poor country

With regard to team planning prior to a teaching visit,

  • 1.the Belbin model of team structure states that including people of similar personality types would result in a successful team. T □ F □
  • 2.a ‘plant’ is a highly creative personality type who may find unconventional solutions to problems. T □ F □
  • 3.a ‘shaper’ is a motivational personality type that keeps the team focussed and moving forward. T □ F □

With regard to budgeting during planning to deliver an obstetric teaching programme in a low resource country,

  • 4.the RCOG is not a source of travel bursaries or scholarships. T □ F □

Regarding personal safety,

  • 5.routine travel vaccinations are provided free of charge by most occupational health departments. T □ F □
  • 6.post-exposure prophylaxis (PEP) should be taken in the event of contamination with blood suspected to be infected with HIV. T □ F □
  • 7.visiting obstetricians need not take their own supplies of PEP as it is freely available in most host hospitals in resource poor countries. T □ F □

When planning delivery of your teaching programme,

  • 8.the best approach is to decide your topics independently and stick rigidly to your syllabus, as too much flexibility may mean you don't get to deliver all the topics. T □ F □

During delivery of a teaching programme,

  • 9.a didactic, paternalistic approach is likely to generate the best results. T □ F □
  • 10.As the visiting obstetrician, it is unlikely that you will learn anything new (as you are ‘the teacher’). T □ F □
  • 11.contemporaneous post course feedback is easy to collect and useful when planning subsequent visits. T □ F □

Regarding follow-up after implementing a teaching programme,

  • 12.organisation of a reciprocal placement for some of your host doctors to visit your UK department would facilitate bi-directional learning and strengthen the link. T □ F □
  • 13.the use of Skype sessions and video links where available will facilitate an ongoing educational link. T □ F □

With regard to teaching theories,

  • 14.Maslow's theory states that humans are effective learners in the absence of the meeting of ‘safety needs’. T □ F □
  • 15.David Kolb's experimental learning model refers to the fact that people learn in one of four different ways. T □ F □

With regard to maternal mortality,

  • 16.there are over 500 000 global maternal deaths every year. T □ F □
  • 17.maternal mortality has fallen by about 50% since 1990. T □ F □
  • 18.the decline in maternal mortality is on track to meet millennium development goal number 5 by 2015. T □ F □
  • 19.in Sub-Saharan Africa there is only 1 health worker per 100 population. T □ F □
  • 20.training of health workers in the developing world improves clinical practice but not clinical outcomes. T □ F □

image Green-top Guideline No. 31. Small-for-Gestational Age Fetus, Investigation Management

With regard to the identification of women at risk of having small for gestational age (SGA) fetuses and their management,

  • 1.second trimester Down syndrome markers have been shown to improve accuracy for the delivery of SGA neonates. T □ F □
  • 2.those with an abnormal uterine artery Doppler at 20–24 weeks which subsequently normalises are not at increased risk of having an SGA neonate. T □ F □
  • 3.echogenic fetal bowel is an indication for serial ultrasound measurement of fetal size and assessment of wellbeing with umbilical artery Doppler. T □ F □
  • 4.serial measurement of symphysio-fundal height (SFH) from 24 weeks of gestation has not been shown to improve the prediction of delivering an SGA neonate. T □ F □

Following the diagnosis of SGA,

  • 5.it is recommended that karyotyping is discussed and offered to those where the uterine artery Doppler is normal. T □ F □
  • 6.serological screening for congenital cytomegalovirus (CMV) is indicated if the SGA is severe. T □ F □

With regard to interventions in the prevention of SGA,

  • 7.antiplatelet agents such as aspirin have been shown to be ineffective. T □ F □

In cases of diagnosed SGA,

  • 8.it is recommended that when the umbilical artery Doppler is normal, it should be repeated at least weekly. T □ F □
  • 9.in the preterm SGA, Doppler of the middle cerebral artery is more useful in timing delivery. T □ F □
  • 10.the use of biophysical profilometry in the preterm SGA is not recommended. T □ F □

image Maternal and perinatal consequences of antepartum haemorrhage of unknown origin

Antepartum bleeding of unknown origin,

  • 1.includes mild cases of placental separation. T □ F □
  • 2.includes bleeding from vasa praevia. T □ F □
  • 3.is an uncommon cause of bleeding in pregnancy. T □ F □

Risk factors for antepartum bleeding of unknown origin include,

  • 4.previous history of bleeding in pregnancy. T □ F □
  • 5.lower socio-economic status. T □ F □

Compared to those without antepartum bleeding of unknown origin, pregnancies complicated by this condition are at a higher risk of:

  • 6.spontaneous preterm delivery. T □ F □
  • 7.congenital malformations in the neonate. T □ F □
  • 8.delivery by caesarean section. T □ F □
  • 9.preterm prelabour rupture of fetal membranes. T □ F □
  • 10.postpartum haemorrhage. T □ F □