DOI: 10.1111/tog.

12357 2017;19:77–82
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 19 number 1

CPD credits can be claimed for the following questions 5. magnetic resonance imaging is rarely
online via the TOG CPD submission system in the RCOG required. ThFh
CPD ePortfolio. You must be a registered CPD participant of 6. combined transvaginal and transabdominal
the RCOG CPD programme (available in the UK and ultrasound scan reduces the risk
worldwide) in order to submit your answers. Please log in to of misdiagnosis. ThFh
the RCOG website (www.rcog.org.uk) to access your 7. the endogenic type grows towards the bladder. ThFh
CPD ePortfolio. 8. measuring the myometrial thickness over the
Participants can claim 2 credits per set of questions if at pregnancy mass has no clinical value. ThFh
least 70% of questions have been answered correctly. At least
Concerning the medical management of caesarean scar
50 credits must be obtained in this way over the 5-year cycle.
ectopic pregnancy,
CPD participants are advised to consider whether the articles
are still relevant for their CPD, in particular if there are more 9. the combined local and systemic
recent articles on the same topic available and if clinical administration of methotrexate gives better
guidelines have been updated since publication. results than systemic administration alone. ThFh
Please direct all questions or problems to the CPD Office. 10. an increase in the size of the pregnancy mass
Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk following methotrexate injection is expected. ThFh
The blue symbol denotes which source the questions refer 11. the time required for caesarean scar ectopic
to including the RCOG journals, TOG and BJOG, and RCOG mass to resolve after medical management
guidance, such as Green-top Guidelines (GTG) and Scientific does not depend on initial size. ThFh
Impact Papers (SIPs). All of the above sources are available to 12. chemoembolisation gives better results
RCOG members and fellows via the RCOG website. compared to systemic methotrexate ThFh
RCOG Members, Fellows and Registered Trainees have full
Surgical evacuation for caesarean scar ectopic
access to TOG content via the TOG app (available for iOS
pregnancy,
and Android).
13. is the most common method of
surgical management. ThFh
TOG Caesarean scar ectopic pregnancy:
14. should not be performed for a persistent
diagnostic challenges and management
caesarean scar ectopic pregnancy mass. ThFh
options
15. needs to be combined with uterine artery
With regard to the aetiopathology of caesarean scar embolisation in most cases. ThFh
ectopic pregnancy,
Surgical resection of caesarean scar ectopic pregnancy,
1. the risk of recurrence is more than 5%
16. allows removal of products of conception and
following treatment by dilatation
repair of the caesarean scar defect. ThFh
and evacuation. ThFh
17. is associated with a reduction in the risk of
2. second stage caesarean section is known to be a
adhesion formation when done vaginally. ThFh
risk factor. ThFh
18. is recommended to be performed after the
3. the exogenic type is known to lead to earlier
human chorionic gonadotropin levels are back
uterine rupture compared to the
to normal. ThFh
endogenous type. ThFh
Regarding the management of caesarean scar
With regard to the diagnosis of caesarean scar
ectopic pregnancy,
ectopic pregnancy,
19. the type of caesarean scar ectopic pregnancy is
4. an inevitable miscarriage is a differential
not relevant in choosing the treatment option. T h F h
diagnosis on ultrasound scan. ThFh

ª 2017 Royal College of Obstetricians and Gynaecologists 77

 CPD

20. initial expectant management should be 20. have followed-up children up to the age of
offered on confirmation of pregnancy. ThFh 18 years. ThFh

TOG Magnesium sulfate for neuroprotection TOG Update on radiotherapy in

in preterm deliveries gynaecological cancers

Preterm labour, With regard to treatment of endometrial cancer,
1. incidence is increasing worldwide. ThFh 1. adjuvant external beam radiotherapy improves
overall survival. ThFh
Cerebral palsy,
2. vaginal vault brachytherapy reduces the risk of
2. is thought to be largely cytokine mediated. ThFh local recurrence. ThFh
3. due to prematurity typically 3. vaginal vault brachytherapy has been shown
causes quadriplegia. ThFh convincingly to improve overall survival. ThFh
4. is diagnosed within the first 6 weeks of life. ThFh 4. neoadjuvant (preoperative) pelvic
5. is caused by a transient lesion affecting the radiotherapy is commonly used. ThFh
cerebral cortex. ThFh 5. lymphovascular space invasion is a proven
poor prognostic risk factor. ThFh
Periventricular leukomalacia,
6. women aged less than 60 years are considered
6. is a form of ‘white matter injury’. ThFh high risk for recurrence. ThFh
7. can be diagnosed on antenatal MRI. ThFh
With regard to primary treatment of cervical cancer,
Intraventricular haemorrhage,
7. one of the main uses of radiotherapy is for
8. is best diagnosed on postnatal ultrasound. ThFh definitive treatment for locally
9. is not related to cerebral palsy. ThFh advanced disease. ThFh
8. adjuvant radiotherapy should be
Magnesium sulfate,
considered for those with tumour size
10. has been shown to be an effective tocolytic. ThFh greater than 2 cm. ThFh
11. functions as a calcium channel blocker. ThFh 9. adenocarcinomas respond better to
radiotherapy than squamous cancers. ThFh
With regard to the use of magnesium sulfate
10. taxanes are the recommended first-line
for neuroprotection,
chemotherapy agents used in combination
12. the recommended antenatal dosage with radiotherapy. ThFh
regimen is similar to that used for
With regard to brachytherapy for cervical cancer,
pre-eclampsia. ThFh
13. it is recommended for preterm delivery up to 11. high dose rate brachytherapy is delivered over
36 weeks. ThFh 5–10 hours in 5 doses. ThFh
14. it may be administered as a bolus dose. ThFh 12. the risk of significant toxicity to the bladder or
15. it should routinely be continued for 24 hours bowel with conventional brachytherapy is
post delivery. ThFh 5–10%. ThFh
16. the mechanism of action is unclear. ThFh 13. magnetic resonance imaging is commonly
used to define tumour localisation. ThFh
Regarding research studies on magnesium sulfate,
Concerning relapsed cervical cancer,
17. there have been concerns about fetal mortality
with MgSO4. ThFh 14. stereotactic ablative radiation techniques
18. there are no randomised controlled trials pioneered for neurological tumours have been
assessing MgSO4 benefit in the context shown to be effective with large recurrences
of neuroprotection. ThFh over 5 cm. ThFh
15. radiotherapy is an option for isolated para-
School age studies on magnesium sulfate for
aortic nodal relapses. ThFh
neuroprotection,
16. positron emission tomography scan is just as
19. have shown a clear benefit in reduction of sensitive as magnetic resonance imaging in
cerebral palsy rates. ThFh identifying recurrence. ThFh

78 ª 2017 Royal College of Obstetricians and Gynaecologists

 CPD

With regard to vulval cancers, 12. uterine perforation is the most

common complication. ThFh
17. adjuvant radiation therapy is offered to
patients with more than one positive groin With regard to second generation ablation techniques,
node identified at staging surgery. ThFh
13. they are suitable for uterine cavity length of up
18. adjuvant radiation therapy is offered to
to 14 cm. ThFh
patients with a single groin node with
14. thermal balloon ablation has the shortest
extracapsular invasion. ThFh
treatment time. ThFh
19. adjuvant radiotherapy, even in selected cases,
15. the hydrothermablator is associated with
does not reduce the risk of local recurrence. ThFh
highest amenorrhoea rates. ThFh
20. combination radical radiotherapy with
16. endometrial preparation is required prior to
cisplatin chemotherapy is an option for
their application. ThFh
patients with unresectable vulval tumours. ThFh
Following endometrial ablation,
17. pain is more common if there has been a
TOGSurgical management of heavy
tubal sterilisation. ThFh
menstrual bleeding: part 1
18. pregnancy occurs in <1% of cases. ThFh
In women seeking treatment for heavy menstrual bleeding, 19. reoperation rates are up to 40%. ThFh
20. repeat surgery rates are higher after second
1. endometrial biopsy is an essential investigation
generation techniques. ThFh
in those over 40 years of age before
commencing treatment. ThFh
2. associated symptoms such as pain or TOG Effect of obesity on assisted
premenstrual symptoms play a role in
reproductive treatment outcomes and
determining the most appropriate
management: a literature review
management option. ThFh
With regard to assisted reproduction treatment
With regard to the surgical management of heavy
(ART) outcome,
menstrual bleeding,
1. maternal obesity is associated with an
3. hysterectomy rates are steadily rising. ThFh
increased risk of neural tube defects. ThFh
4. second generation techniques are safer,
2. maternal obesity is associated with an
quicker and simpler to learn when compared
increased risk of stillbirth. ThFh
to first generation ablation techniques. ThFh
3. the effect of obesity is more pronounced in
With regard to endometrial ablation, women >38 years. ThFh
4. the degree of obesity is positively correlated
5. it is recommended only to women whose
with worse outcomes. ThFh
family is complete. ThFh
5. metformin is more effective in obese women
6. can be combined with hysteroscopic
with polycystic ovary syndrome (PCOS) than
sterilisation for concomitant contraception. ThFh
non-obese women with PCOS. ThFh
7. it aims to destroy the endometrium down to
6. bariatric surgery improves pregnancy
the endomyometrial junction. ThFh
outcomes after ART. ThFh
Regarding first generation ablation techniques,
With regard to reproduction in obese women,
8. transcervical resection of the endometrium has
7. pregnancies have similar degrees of risk of
less complication rates when compared to
obstetric complications as in non-
roller ball ablation. ThFh
obese women. ThFh
9. the presence of other endometrial pathology
8. infertility is mainly explained by its relation
such as fibroids or structural anomalies is
with PCOS. ThFh
a contraindication. ThFh
9. they have a higher risk of aneuploid
10. transurethral resection syndrome is a
miscarriages than those of normal weight. ThFh
recognised complication. ThFh
10. the effect of obesity on ART outcomes could
11. a glycine deficit of 500 ml should be used as a
only be explained by abnormal oocyte quality. ThFh
reference mark to abandon the procedure. ThFh

ª 2017 Royal College of Obstetricians and Gynaecologists 79

 CPD

11. fertilisation rates of oocytes from ART are In the management of patients with diabetic ketoacidosis
similar to those of non-obese women. ThFh in pregnancy,
12. its management requires shared care pathways
8. phosphate therapy should be administered if
and multiple professional input. ThFh
their serum phosphate level is 1 mmol/l. ThFh
13. metformin or orlistat should be offered
9. intravenous bicarbonate is recommended to
routinely to those preparing for ART
correct acidosis. ThFh
treatment alongside diet and exercise. ThFh
10. using venous pH in place of arterial pH in
14. after bariatric surgery, ART is best offered
monitoring has been shown to be
once BMI has dropped to <35 kg/m2. ThFh
acceptable practice. ThFh
15. the use of orlistat is not recommended for
11. after the first 6 hours, serum bicarbonate level
more than 12 weeks. ThFh
cannot be used reliably to monitor
16. cognitive behavioural treatment should be
patient response. ThFh
part of the management of those requiring
12. hyperchloraemic acidosis does not need
fertility treatment. ThFh
specific treatment as the kidneys self-correct it. ThFh
Concerning the management of infertility,
With regard to the management of diabetic ketoacidosis
17. an obese woman with a BMI of 38 kg/m2 and in pregnancy,
a waist circumference of 90 cm will benefit
13. fluid resuscitation should be started with
from orlistat as first-line treatment
dextrose 10% at a rate of 1 litre/hour. ThFh
for obesity. ThFh
14. urine output should be kept to
18. a woman with a BMI of 38 kg/m2 and type II
≥0.5 ml/kg/hour. ThFh
diabetes will benefit from early referral to
15. dextrose of 10% should be added to the
bariatric surgery as first-line treatment. ThFh
ongoing intravenous saline infusion, when
19. the management of women who are infertile
blood sugar decreases to less than 15 mmol/l
due to obesity accounts for most of
(360 mg/dl). ThFh
this service. ThFh
16. the initial intravenous insulin infusion rate
20. a very low-calorie diet is advisable for those
should not exceed 15 units/hour. ThFh
with a BMI of >35 kg/m2 requesting ART. ThFh
17. the target drop rate in blood ketones aimed for
is 0.2 mmol/l/h. ThFh
18. intravenous rapid-acting insulin analogues are
TOG Management of diabetic ketoacidosis
preferred to regular insulin infusion. ThFh
in pregnancy
19. it is recommended that fixed rate intravenous
With regard to diabetic ketoacidosis in pregnancy, insulin infusion be stopped after
normalisation of blood ketones and after
1. it should be managed in at least level two
1 hour from a subcutaneous rapid-acting
critical care units. ThFh
insulin injection given with a meal. ThFh
2. the diagnosis is based on a combination of
20. potassium chloride should only be added to
features including a blood glucose level of
the saline infusion in patients with a serum
>11 mmol/l. ThFh
potassium level less 5.5 mmol/l. ThFh
3. hyperemesis is a precipitating factor. ThFh
4. the decision to deliver the baby should be based
only on cardiotocography changes. ThFh TOG Surgical management of bowel
5. those affected have an average fluid deficit of
obstruction in gynaecological cancer
about 100 ml/kg. ThFh
Symptoms or signs for bowel obstruction include:
With regard to diabetes in pregnancy,
1. nausea and vomiting. ThFh
6. women with type I diabetes should be provided
2. constant abdominal pain. ThFh
with a self-monitoring ketone meter to exclude
3. abdominal distension that is not always
diabetic ketoacidosis. ThFh
clinically evident. ThFh
7. patient education plays an important role
in management. ThFh

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 CPD

Bowel obstruction in gynaecological cancer, 2. hormone therapy is an appropriate treatment. T h F h

3. the US Food and Drug Administration has
4. is often associated with non-epithelial
approved paroxetine as the first non-
ovarian cancer. ThFh
hormonal treatment. ThFh
5. is a clinical manifestation of recurrent disease. ThFh
6. affects the large bowel more frequently than the The study shows that
small bowel. ThFh
4. compared with placebo, paroxetine
7. is commonly confined to a single site. ThFh
significantly reduced the VMS frequency at
With regard to the initial management of bowel week 4. ThFh
obstruction in women with ovarian cancer, 5. compared with placebo, paroxetine
significantly reduced the VMS frequency at
8. hydration should be with 10% intravenous
week 6. ThFh
dextrose as fluid replacement. ThFh
6. compared with placebo, paroxetine
9. hyoscine butylbromide helps relieve the crampy
significantly reduced the VMS frequency at
abdominal pain. ThFh
week 12. ThFh
10. a trial of chemotherapy is advised
before surgery. ThFh With regard to the conclusions from the analysis,
Bowel obstruction in gynaecological cancers is 7. the reduction in daily composite severity score
associated with, of VMS is greater in the paroxetine arm at
week 4. ThFh
11. a morbidity rate of 50% but no increase
8. the reduction in daily composite severity score
in mortality. ThFh
of VMS is greater in the paroxetine arm at
12. a median survival of about 3 months in
week 12. ThFh
recurrent disease. ThFh
9. the risk of dizziness with paroxetine for the
With regard to non-surgical management of patients with patients with VMS is similar to that
bowel obstruction, with placebo. ThFh
10. the risk of headache with paroxetine for the
13. the palliative care team should not be involved
patients with VMS is higher than placebo. ThFh
until surgery has been recommended. ThFh
14. those with prior radiotherapy are less likely to
have successful surgical palliation. ThFh
Reference
15. oral steroids are recommended to reduce
bowel oedema. ThFh 1 Wei D, Chen Y, Wu C et al. Effect and safety of paroxetine for vasomotor
16. if there is persistent vomiting, placement of a symptoms: systematic review and meta-analysis. BJOG 2016;123:1735–43.

gastrostomy tube has been shown to help

alleviate symptoms. ThFh
In a woman with prior radiotherapy for a gynaecological
BJOGDouble-balloon catheter versus
malignancy, bowel obstruction, prostaglandin E2 for cervical ripening and
labour induction: a systematic review and
17. is most likely due to tumour recurrence. ThFh meta-analysis of randomised controlled trials
18. is usually sited in the sigmoid colon/rectum. ThFh
19. should have an early recourse to surgery. ThFh In this systematic review,
20. is best treated in most cases with a colostomy. ThFh 1. PRISMA was used to aid
transparent reporting. ThFh
2. inductions of labour in women with a previous
BJOG Effect and safety of paroxetine for
caesarean section were included. ThFh
vasomotor symptoms: systematic review
and meta-analysis Secondary outcome measures in this systematic review
included:
With regard to vasomotor symptoms (VMS),
3. uterine hyperstimulation. ThFh
1. more than 80% of women in the UK 4. ripening-to-delivery interval. ThFh
experience VMS during the menopause. ThFh 5. need for oxytocin administration. ThFh

ª 2017 Royal College of Obstetricians and Gynaecologists 81

 CPD

Features included in the risk of bias in this review References

included:
1 Du YM, Zhu LY, Cui LN, Jin BH, Ou JL. Double-balloon catheter versus
6. random sequence generation. ThFh prostaglandin E2 for cervical ripening and labour induction: a systematic
review and meta-analysis of randomised controlled trials. BJOG. 2016 Aug
7. allocation concealment. ThFh 17. doi: 10.1111/1471-0528.14256. [Epub ahead of print]
8. blinding of participants. ThFh
This systematic review showed that locally applied PGE2
agents and double-balloon catheter are comparable with
regard to,
9. the need for oxytocin administration. ThFh
10. the risk of tachysystole. ThFh

82 ª 2017 Royal College of Obstetricians and Gynaecologists