DOI: 10.1111/tog.
12567 2019;21:143–7
The Obstetrician & Gynaecologist
http://onlinetog.org
CPD questions for volume 21 issue 2
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TOG Sports gynaecology
Regarding Relative Energy Deficiency in Sport (RED-S),
1. energy availability is determined by dividing
energy expenditure by energy intake relative to
fat-free mass. ThFh
2. the ‘female athlete triad’ encompasses the inter-
relationship between energy availability,
menstrual function and bone health. ThFh
3. less than 10% of clinicians feel comfortable
treating amenorrhoeic athletes. ThFh
4. women who partake in sports that emphasise
strength and power are more likely to suffer
from RED-S. ThFh
With regard to the physiology of RED-S,
5. luteinising hormone (LH) is produced in the
anterior pituitary gland. ThFh
ª 2019 Royal College of Obstetricians and Gynaecologists
CPD
6. estrogen levels are low in women with
polycystic ovary syndrome. ThFh
7. levels of LH and follicule-stimulating
hormone will be low in affected women. ThFh
8. anti-m€ ullerian hormone is an accurate marker
of ovarian reserve in affected women. ThFh
With regard to the clinical presentations of patients with
RED-S,
9. menstrual disturbances (such as amenorrhoea,
oligomenorrhoea and dysmenorrhoea) are
common symptoms. ThFh
10. eating disorders should be actively
screened for. ThFh
11. amenorrhoeic sportswomen continue to
remain at a 2–4-fold increased risk of stress
fractures once menstrual function has
been restored. ThFh
12. delayed menarche is particularly common
among athletes participating in aesthetic
sports that emphasise leanness. ThFh
13. polycystic ovary syndrome is common in
affected sportswomen. ThFh
Regarding management of sportswomen with RED-S,
14. elite sportswomen with formal eating
disorders should not be allowed to train or
compete until treatment has been initiated and
healthy eating behaviour has resumed. ThFh
15. energy intake should be initially increased by
between 500 and 800 kcal/day, with a target
body mass index of >20.0 kg/m2. ThFh
16. serial LH measurements are useful in
monitoring management. ThFh
17. the use of LH and human chorionic
gonadotrophin therapy should be avoided in
fertility treatment for sportswomen as they
are prohibited by the World Anti-
Doping Agency. ThFh
Concerning urinary incontinence in sportswomen,
18. it is more common during competition
compared with during training. ThFh
19. pelvic floor exercises are the mainstay
of treatment. ThFh
143
 CPD
20. duloxetine should be offered for improved
symptom control where pelvic floor exercises
are ineffective. ThFh
TOG Unscheduled bleeding with hormone
replacement therapy
Regarding menopause,
1. it is defined by the World Health Organization
1996 declaration as the permanent cessation of
menstruation resulting from the loss of
ovarian follicular activity. ThFh
2. it is the last menstrual bleed diagnosed
retrospectively after 1 year of amenorrhoea in
the absence of any pathologic disorder that
could be responsible for the amenorrhoea. ThFh
3. in the UK, the median age is 50.8 years. ThFh
4. follicle-stimulating hormone (FSH) is the first
gonadotrophin to rise in the biological
ageing process. ThFh
5. the findings of plasma estradiol below
20 pg/ml (range 5–25 pg/ml) as well as an
elevated FSH >100mU/ml are consistent with
cessation of ovarian function. ThFh
Regarding vasomotor symptoms and menopause,
6. the ‘domino effect’ of hormone replacement
therapy (HRT) refers to the reduction in
anxiety, depression and cognitive disorders
by its positive impact on
vasomotor symptoms. ThFh
7. hot flushes occur in about 70–80% of women
who go through physiological menopause. ThFh
Regarding osteoporosis and menopause,
8. menopause predisposes to type 2 osteoporosis. ThFh
9. postmenopausal osteoporosis is responsible
for fractures in one of every two
postmenopausal women. ThFh
Regarding postmenopausal HRT,
10. it increases muscle mass and
maintains strength. ThFh
11. it is indicated as first-line in women with
premature menopause. ThFh
12. the National Institute for Health and Care
Excellence (NICE) says the lowest effective
dose should be used for the shortest
possible period. ThFh
13. combined continuous therapy is
recommended in perimenopausal women. ThFh
144
14. combined continuous therapy has a lower risk
of endometrial cancer. ThFh
Regarding bleeding and HRT,
15. up to 80% of women on combined
continuous HRT will experience unscheduled
bleeding or spotting in the first 6 months
of treatment. ThFh
16. NICE recommends reporting any unscheduled
bleeding if it occurs after the first 6 months
of therapy. ThFh
17. unscheduled or abnormal bleeding is responsible
for 25–50% of women stopping HRT. ThFh
Regarding investigations and treatment for unscheduled
bleeding during HRT,
18. hysteroscopy with endometrial sampling
remains the gold standard for uterine cavity
evaluation in the UK. ThFh
19. using a cut-off reference of 5 mm endometrial
thickness on transvaginal ultrasound, the risk
of endometrial cancer in postmenopausal
women decreases by 90% for those with
thickness < 5 mm, regardless of hormone use. T h F h
20. endometrial biopsy has been shown to miss up
to 20% of focal lesions like
endometrial polyps. ThFh
TOG Surgical smoke – what are the risks?
With regard to the components of surgical smoke,
1. most of it is water vapour. ThFh
2. about 25% of the constituents
are carcinogenic. ThFh
3. carbon monoxide is a component. ThFh
4. the plume generated from electrocautery of
1g tissue is comparable to that from
three cigarettes. ThFh
5. human papillomavirus (HPV) and HIV have
not been identified in it. ThFh
With regard to surgical smoke particle size and
concentration,
6. particles of mean diameter >100 lm have
been shown to remain airborne. ThFh
7. particles generated by electrosurgery have a
mean diameter ≥0.35 lm. ThFh
8. particles <10 lm in diameter are inhalable. ThFh
9. particles <2.5 lm in size can penetrate
the alveoli. ThFh
10. the highest emission of surgical smoke is
from muscle. ThFh
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Exposure to surgical smoke has been associated with, Regarding fertility in women with EOA,
11. throat irritation. ThFh 14. the trend towards older age at motherhood
12. seizures. ThFh is now reversing. ThFh
13. sneezing. ThFh 15. fertility is lost early in the process. ThFh
14. diarrhoea. ThFh 16. EOA is associated with increased miscarriagerisk. T h F h
15. eye pain. ThFh
Regarding IVF in women with EOA,
A standard surgical facemask,
17. the live-birth rate per frozen oocyte is
16. offers good protection against surgical smoke. ThFh currently around 5–6%. ThFh
17. will filter out particles <5 lm in diameter. ThFh 18. mild ovarian stimulation has been shown to be
18. is effective whether it is loose or tight fitting. ThFh superior to normal or high-dose stimulation
19. when worn for long durations is in terms of live-birth rates. ThFh
less effective. ThFh 19. dehydroepiandrosterone improves pregnancy
20. is less effective against surgical smoke than a rates during IVF in women in some cases. ThFh
high-filtration respirator. ThFh 20. few adjuvants have consistently been shown to
improve outcomes in women with low
ovarian reserve. ThFh
TOG Early ovarian ageing
Regarding normal ovarian ageing, TOG Maternal, fetal, and neonatal outcomes
associated with long term use of
1. oocytes reach a maximum number in utero at
corticosteroids during pregnancy
16–20 weeks of gestation. ThFh
2. follicle loss is primarily due to ovulation. ThFh Placental transfer of exogenous corticosteroids is,
3. environmental factors affect ovarian ageing 1. similar for different corticosteroids. ThFh
more than genetic factors. ThFh 2. affected by their pharmacokinetics
4. oocyte quality declines from 37.5 years of age. ThFh and pharmacodynamics. ThFh
5. menopause occurs once the ovarian follicle
numbers decline to around 1000. ThFh Placental 11b-hydroxysteroid dehydrogenase type 2
(11b-HSD2) enzyme,
Regarding early ovarian ageing (EOA),
3. is a complete barrier to the fetoplacental
6. women with the condition usually passage of exogenous corticosteroids. ThFh
present with oligomenorrhoea. ThFh 4. has a different metabolism profile for
7. anti-m€ ullerian hormone levels are a good endogenous corticosteroids compared with
predictor of time to pregnancy exogenous corticosteroids. ThFh
in natural conception. ThFh
8. women with poor response to ovarian Fetal plasma corticosteroid concentration is,
stimulation during in vitro fertilisation (IVF) 5. higher with maternal exposure to fluorinated
have a higher risk of early menopause. ThFh corticosteroids compared with
9. it is associated with increased risk of other corticosteroids. ThFh
cardiovascular disease. ThFh 6. comparable following maternal administration
With regard to the pathophysiology of EOA, of hydrocortisone and dexamethasone. ThFh

10. oocyte quality is relatively preserved compared
with oocyte quantity.
11. it is recognised to occur either as a result of a
smaller follicle pool at birth or
accelerated follicle loss.
12. polycystic ovary syndrome is a risk factor.
13. the in utero environment has been shown to
affect the rate of ovarian ageing in
later life.
Regarding antenatal corticosteroid therapy,
ThFh 7. routine repeat courses are recommended to
enhance fetal lung maturation. ThFh
8. there is a dose-dependent relationship
ThFh between cumulative antenatal corticosteroid
ThFh exposure and reduced fetal growth. ThFh
9. neonatal benefits include reductions in
respiratory distress syndrome, neonatal death,
ThFh cerebroventricular haemorrhage and
necrotising enterocolitis. ThFh

ª 2019 Royal College of Obstetricians and Gynaecologists 145

 CPD
10. hydrocortisone is a last-resort alternative when
betamethasone and dexamethasone are
not available. ThFh
Betamethasone and dexamethasone,
11. are both fluorinated corticosteroids. ThFh
12. have 30–40-fold increased glucocorticoid
potency than cortisol. ThFh
13. are poor substrates for placental metabolism
by the 11b-HSD2 enzyme. ThFh
14. have significant mineralocorticoid action. ThFh
15. are considered ‘long-acting’ corticosteroids. ThFh
Considering maternal chronic use of systemic
corticosteroids,
16. no adverse effects have been reported in
breastfed infants with use during lactation. ThFh
17. they are associated with an increased risk of
gestational diabetes. ThFh
18. they are associated with neonatal
adrenal suppression. ThFh
There is sufficient evidence to,
19. recommend withholding antenatal
corticosteroid therapy for neonatal benefit in
the presence of maternal use of corticosteroids
on a chronic basis. ThFh
20. confirm the long-term safety of fetuses
exposed to chronic maternal corticosteroids. ThFh
TOG Placental histopathological
abnormalities and poor perinatal
outcomes
With regard to sending placentas for examination,
1. they should be stored at 8°C to enable proper
histopathological evaluation. ThFh
2. they should be fixed in formalin if cytogenetic
analysis is indicated. ThFh
3. histology will yield vital information if there is
severe fetal distress and unexpected admission
of the baby to the neonatal unit. ThFh
4. relevant information and clinical details are
vital to interpret the placental
histology findings. ThFh
Placentas should be sent for histology,
5. when there is unexplained polyhydramnios. ThFh
6. as the information sought from examination
helps to improve the outcome in
subsequent pregnancy. ThFh
146
7. when the woman experiences a late
miscarriage. ThFh
With regard to massive perivillous fibrin deposition,
8. it is seen in third-trimester placentas only. ThFh
9. the placenta appears stiff with a
yellowish colouration. ThFh
10. it is associated with 13–50% of stillbirths. ThFh
11. there is a low rate of recurrence in
subsequent pregnancy. ThFh
Concerning fetal thrombotic vasculopathy,
12. variations in umbilical cord anatomy are a
recognised association. ThFh
13. its prevalence is between 10% and 15%. ThFh
14. thrombophilia screening is indicated in those
for whom placental histology confirms
the diagnosis. ThFh
With regard to villitis of unknown aetiology,
15. it is a common finding in up to 15% of
near-term placentas. ThFh
16. it is associated with an infectious organism in
most cases. ThFh
Villous dysmaturity,
17. is associated with maternal diabetes. ThFh
In chorioamnionitis,
18. microbial invasion of the amniotic cavity has
been shown to also occur through
intact membranes. ThFh
19. acute onset has been shown to lead to
neurological morbidity in the neonatal period
in some cases. ThFh
20. the grade 1 (mild-to-moderate) histological
type is characterised by the presence of three
or more chorionic micro-abscesses. ThFh
BJOGImproving the effectiveness of lifestyle
interventions for gestational diabetes
prevention: a meta-analysis and
meta-regression
With regard to gestational diabetes mellitus (GDM),
1. the global prevalence is higher than 10%. ThFh
2. regulating gestational weight gain, according
to Institute of Medicine guidelines, has been
shown to reduce risk of occurrence. ThFh
3. risk prediction models provide a more
comprehensive evaluation of risk than body
mass index ThFh
ª 2019 Royal College of Obstetricians and Gynaecologists
 CPD

Concerning lifestyle interventions, 2. is more prevalent in offspring born from

pregnancies in which the mother had
4. they do not reduce the risk of GDM in
pre-eclampsia. ThFh
pregnant women with normal body
3. progression is significantly accelerated in
mass index. ThFh
women with recurrent pre-eclampsia
5. exercise of moderate intensity for
compared with women with a single event of
50–60 minutes twice a week during pregnancy
pre-eclampsia and subsequent
is associated with a more than 20% reduction
uncomplicated pregnancy. ThFh
in GDM. ThFh
4. risk is high in women who have only one
With regard to systematic reviews and meta-analyses, pregnancy complicated by pre-eclampsia and
no subsequent pregnancies. ThFh
6. the same person should extract all data to
maintain consistency. ThFh Women with a history of pre-eclampsia,
7. I2 is used to measure the effect size of
5. have an up to five-fold increased risk of
an intervention. ThFh
cardiovascular disease. ThFh
8. forest plots are used to show the relative risk
6. have a higher risk of future cardiovascular
of individual studies and the overall results. ThFh
disease when pre-eclampsia is early in onset. ThFh
9. relative risk is used to describe the
7. can decrease the risk of cardiovascular disease
heterogeneity of studies. ThFh
by almost 14% through lifestyle interventions
10. funnel plots are used to measure
after pregnancy. ThFh
publication bias. ThFh
Risk factors for recurrence of pre-eclampsia include,
Reference 8. inter-pregnancy interval of less than 4 years. ThFh
9. increasing body mass index
Guo X-Y, Shu J, Fu X-H, Chen X-P, Zhang L, Ji M-X, Liu X-M, Yu T-T, Sheng J-Z,
Huang H-F. Improving the effectiveness of lifestyle interventions for between pregnancies. ThFh
gestational diabetes prevention: a meta-analysis and meta-regression. BJOG 10. fetal growth restriction in the
2019;126:311–20. index pregnancy. ThFh

BJOG Recurrence of pre-eclampsia and the

Reference
risk of future hypertension and
cardiovascular disease: a systematic review Brouwers L, van der Meiden-van Roest AJ, Savelkoul C, Vogelvang TE, Lely AT,
Franx A, van Rijn BB. Recurrence of pre-eclampsia and the risk of future
and meta-analysis hypertension and cardiovascular disease: a systematic review and meta-
analysis. BJOG 2018;125:1642–54.
Cardiovascular disease,
1. is currently the leading cause of death in
women worldwide. ThFh

ª 2019 Royal College of Obstetricians and Gynaecologists 147