CPD questions for volume 16 number 1

DOI: 10.1111/tog.12076 The Obstetrician & Gynaecologist

2014;16:58?63

CPD questions for volume 16 number 1

CPD

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 (.uk) and go to the `Our Profession' tab.

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

TOG 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. 2. the target is to reduce mortality of those aged

5 years by 50%. 3. stillbirth is not addressed by the MDGs.

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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.

5. the key factor in improving neonatal mortality is political commitment.

6. neonatal training packages for traditional birth attendants have been shown to reduce perinatal and neonatal death by more than 20%.

7. antenatal corticosteroids for those women in preterm labour could save over 300 000 babies annually.

8. kangaroo mother care is less effective than nursing in an incubator for stable babies.

9. birth spacing has no effect on pregnancy outcomes.

10. malaria contributes to 100 000 neonatal deaths annually.

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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.

12. training is not a barrier to implementation of evidence to reduce under-5 mortality into practice.

13. approximately half of health workers in low resource settings cannot perform basic neonatal resuscitation.

14. women are usually in charge of their own access to care in low resource settings.

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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.

16. poor quality services are poorly attended. 17. inequality and inequity essentially mean the

same thing. 18. outcomes have improved most for those easy

to reach. 19. caesarean section rate is approximately 1%

for the poorest fifth of the population in some countries. 20. many of the possible solutions to reach MDG4 targets are known.

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TOG Retinoids and pregnancy: an update

With regard to isotretinoin,

1. its mode of action is to reduce sebum secretion. 2. it is used as a first-line treatment for acne. 3. it has an elimination half-life of less than

10 hours. 4. the dose prescribed is adjusted according to

the patient's weight. 5. the estimated pregnancy rate while on

treatment is around 1%.

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

6. mood disturbance is well documented. 7. derivatives of the mesonephric duct are

recognised malformations.

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8. limb deformities are common. 9. their use in pregnancy is associated with

ear abnormalities.

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With regard to the incidence of teratogenic effects of isotretinoin,

10. 30% of affected fetuses have been reported to perform poorly in neuropsychological tests.

11. approximately half of fetuses exposed to them suffer from mental retardation.

12. about a third of fetuses exposed to them have retinoid specific fetal malformations.

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

13. the programme was launched in 2005 in the UK. 14. contraception should be used for 1 month

prior to and 2 months following treatment. 15. pregnancy tests should be taken monthly

throughout treatment.

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Isotretinoin,

16. exerts its teratogenic effect through a mechanism that does not significantly affect vitamin A levels.

17. affects the development of the branchial arches by effecting haemopexin signalling.

18. is associated with a miscarriage of over 20% when used in the first trimester.

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Concerning retinoid embryopathy,

19. topical application is not associated with an increased risk.

20. the most common malformations are those of the musculoskeletal system.

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TOG 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.

2. it is reduced if the site is depilated preoperatively. 3. it is increased approximately seven-fold by

morbid obesity.

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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.

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5. A Joel-Cohen incision is located slightly lower than a Pfannenstiel incision.

6. The incidence of wound dehiscence is lower with paramedian compared with median incisions.

7. A caesarean section through the Joel-Cohen incision carries less postoperative febrile morbidity when compared to that through a Pfannenstiel incision.

8. A transverse incision is associated with reduced incidence of wound dehiscence compared with a vertical incision.

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With regard to skin incisions for laparoscopic surgery,

9. those that are more than 7 mm will need formal deep sheath closure.

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Which of the following statements is/are true?

10. The primary function of a suture is to maintain tissue approximation during healing.

11. Wound infection rate is higher with braided compared with monofilament sutures.

12. Non-absorbable sutures are associated with reduced incidence of wound dehiscence.

13. PDS (polydiaxanone) is a braided suture with high tissue reaction.

14. Polypropylene is a monofilament suture with least tissue reaction.

15. Vicryl rapide is absorbed in 60?90 days.

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With regard to use of staples for closure,

16. the non-absorbable variety has the highest tensile strength of any wound closure device.

17. contaminated wounds closed with staples have a lower incidence of infection compared with those closed with sutures.

18. the absorbable varieties have a tissue half-life of 10 weeks.

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With regard to electrosurgery,

19. it is associated with poor wound healing when used to incise the skin.

20. the use of a separate scalpel for superficial and deep incisions is recommended.

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TOG 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.

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2. the commonest site is the bladder's dome. 3. cancer is a known risk factor. 4. the incidence of fistula formation following a

bladder injury is approximately 0.5%.

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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.

6. brief intermittent activation prevents unnecessary thermal spread.

7. both the tip and the heel of the active electrode are recognised to be potential causes of thermal damage.

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With regard to the identification and management of bladder injuries,

8. uroperitoneum is painless. 9. serum creatinine is likely to be elevated in a

woman sustaining a bladder injury. 10. repair by laparotomy should be the first

option when a bladder injury occurs during a laparoscopic operation. 11. post operative bladder drainage reduces the risk of fistula formation. 12. conservative management of a small retropubic bladder injury has been shown to be effective in some cases.

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With regard to ureteric injuries at laparoscopic gynaecological surgery,

13. the commonest site is at the level of the ovarian fossa.

14. the commonest type of injury is ligation. 15. preoperative stenting has been proven to be of

benefit in cases of severe endometriosis with ureteric involvement. 16. computed tomography intravenous urogram is an appropriate investigation when suspecting such an injury.

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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.

18. where crush injuries are minor, conservative management has been shown to be an effective option.

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.

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20. trans-uretero-ureterostomy is a repair

technique appropriate for major injuries at the

upper third of the ureter.

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TOG Nerve injuries associated with gynaecological surgery

Regarding the pathophysiology of nerve injury,

1. neuropraxia involves disruption of the axon and Schwann cells.

2. neurotmesis has a good prognosis without restorative surgery.

3. axonotmesis usually resolves with conservative management within months.

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The femoral nerve,

4. is the nerve most commonly damaged during gynaecology surgery.

5. is compressed against the pelvic side wall from deeply seated self-retaining retractors.

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Regarding pelvic nerve neuropathies,

6. foot drop is a feature of obturator nerve injury. 7. pain relief following the administration of a

local anaesthetic is diagnostic of ilioinguinal/ iliohypogastric neuropathy. 8. gluteal, perineal and vulval pain following a sacrospinous ligament fixation are features of pudendal nerve neuropathy. 9. following a Pfannenstiel incision, about 20% of patients report ilioinguinal or iliohypogastric related nerve injury. 10. the genitofemoral nerve is susceptible to injury during removal of the external iliac nodes. 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. 12. meralgia paraesthesia is a feature of genitofemoral nerve neuropathy.

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The brachial plexus,

13. originates from C7?T1 nerve roots.

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Ulnar nerve neuropathy,

14. causes wrist drop.

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15. presents with sensory loss over the lateral 3?

fingers of the hand.

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With regard to brachial plexus neuropathy,

16. hyper-abduction of the arm greater than 90

degrees is associated with an Erb's palsy.

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Regarding the prevention and treatment of neuropathy associated with surgery,

17. patient mal-positioning is the most likely cause of intraoperative nerve-related injury.

18. gamma-aminobutyric acid (GABA) antagonists are not effective in treating surgical nerve related neuropathies.

19. detailed neurological examination and electromyographic (EMG) studies are key in diagnosing neurologic deficit.

20. the majority of neuropathies following surgery resolve spontaneously without intervention.

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TOG 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.

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Concerning tubal patency tests,

2. laparoscopy is widely considered to be the gold standard test.

3. hysterosalpingogram (HSG) has a low sensitivity and high specificity.

4. radiation exposure during an HSG is significantly lower than from standard chest X-ray.

5. approximately 2% of patients develop pelvic infection following HSG.

6. with hysterosalpingo contrast sonography (HyCoSy) there is a higher likelihood of uncertainty when reporting (neither patent nor occluded) compared with HSG.

7. with tubal catheterisation, the risk of (tubal) perforation is approximately 4%.

8. fertiloscopy is an outpatient technique which combines hysteroscopy, transvaginal hydro laparoscopy and salpingoscopy.

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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.

10. previous pelvic surgery is not a risk factor for tubo-peritoneal pathology associated with tubal factor infertility.

11. there is strong evidence to suggest that women who are otherwise ovulating and exposed to

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sperm on a regular basis (unexplained or mild male factor infertility) do not benefit from clomiphene citrate. 12. surgical reversal of tubal sterilisation is less successful than IVF. 13. hydrosalpinx is an end stage of distal tubal disease. 14. intrauterine insemination has been shown to benefit couples with unexplained infertility. 15. salpingectomy followed by IVF is the recommended treatment for hydrosalpinx associated infertility.

Regarding factors associated with infertility,

16. Chlamydia is the single largest cause of acquired tubal pathology.

17. proximal tubal disease accounts for approximately 25% of causes of tubal factor infertility.

Concerning transvaginal 2-D ultrasound,

18. it has a sensitivity of approximately 85% for the diagnosis of hydrosalpinx.

With regard to selective salpingography,

19. it is associated with lower false positive rates from tubal spasm.

20. it is used primarily to assess tubal patency where other tests are not recommended.

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

With regard to mifepristone,

1. it is a progesterone antagonist. 2. it has no effect on glucocorticoids.

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With regard to ulipristal acetate,

3. it is licensed for use as an emergency contraceptive.

4. in the UK it is licensed for the preoperative treatment of uterine fibroids.

5. it is not available as an oral preparation.

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With regard to the actions of progesterone,

6. selective progesterone receptor modulators (SPRMs) effectively reduce circulating levels of estrogen.

7. selective progesterone receptor modulators produce a pure antagonist effect on the progesterone receptor.

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8. activation of human progesterone receptor B (hPR-B) counteracts estrogen-induced endometrial proliferation.

9. hPR-Bs are involved in proliferation of breast tissue.

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With regard to the management of fibroids with SPRMS.

10. they have been shown to reduce fibroid volume by over 10%.

11. they have been shown to significantly increase breast tenderness.

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

12. they inhibit ovulation by blocking the luteinising hormone surge.

13. they have no effect on implantation. 14. ulipristal acetate is effective emergency

contraception when used for up to 120 hours after unprotected intercourse. 15. ulipristal acetate can be used more than once in any menstrual cycle. 16. amenorrhea rates of over 80% have been observed with asoprisnil. 17. they are licensed for use as long-term contraceptives in the UK. 18. the exact mechanisms by which they induce amenorrhoea are unknown.

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Concerning the side-effects of SPRMS,

19. their use has been linked with pre-malignant and/ or malignant endometrial histological changes.

20. they should be used with caution in those with hypertension.

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TOG Litigation in gynaecology

Within the remit of obstetrics and gynaecology,

1. claims should be made within 5 years of the injury.

2. children who have suffered an injury are allowed to make a claim any time up to their 21st birthday.

3. it is recommended that claims by those who lack capacity are made within 10 years of the injury.

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Of the total claims made,

4. 5?10% reach court.

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5. there is about a 40% chance that a case will be

defended successfully.

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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.

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.

8. according to Hunter, departure from routine practice automatically constitutes negligence.

9. according to Crawford the standard of medical knowledge and its application will be judged on the basis of publication in medical journals.

10. according to Bolam the law imposes the duty of care; but the standard of care is a matter of medical judgement.

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.

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Regarding overall claims for clinical negligence,

12. the maximum number of claims are made in gynaecology.

13. the value of claims are highest for obstetrics.

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Regarding insurance cover,

14. doctors need either Medical Defence Union (MDU) or Medical Protection Society (MPS) cover for NHS work.

15. the NHS Litigation Authority advises the NHS on human rights case law.

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Regarding valid consent,

16. a patient's signature on a consent form implies valid consent.

17. research has identified that the best way to communicate uncertainty about harms and benefits of treatment to patients is through videos.

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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.

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With regard to taking responsibility,

19. saying sorry equates to admitting liability. T h F h

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