DOI: 10.1111/tog.

12540 2019;21:59–63
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 21 number 1

CPD credits can be claimed for the following questions online In relation to screening tests for the detection of a fetus with
via the TOG CPD submission system in the RCOG CPD Down syndrome,
ePortfolio. You must be a registered CPD participant of the
9. using a maternal age of >35 years has a
RCOG CPD programme (available in the UK and worldwide)
detection rate of 70% for a false positive rate
in order to submit your answers. Please log in to the RCOG
of 5%. ThFh
website (www.rcog.org.uk) to access your CPD ePortfolio.
10. using second trimester biochemistry (quadruple
Participants can claim 2 credits per set of questions if at
test) has a detection rate of 75% for a false
least 70% of questions have been answered correctly. At least
positive rate of 5%. ThFh
50 credits must be obtained in this way over the 5-year cycle.
11. using the combination of nuchal translucency
CPD participants are advised to consider whether the articles
and serum biochemistry in the first trimester
are still relevant for their CPD, in particular if there are more
has a detection rate of 90% for a false positive
recent articles on the same topic available and if clinical
rate of 5%. ThFh
guidelines have been updated since publication.
12. the cell-free DNA test detects >99% of fetuses
Please direct all questions or problems to the CPD Office.
with Down syndrome for a false positive rate
Tel: +44(0) 20 7772 6307 or email: cpd@rcog.org.uk
of <0.1%. ThFh
The blue symbol denotes which source the questions refer
to including the RCOG journals, TOG and BJOG, and RCOG Regarding Down syndrome screening in twin pregnancies,
guidance, such as Green-top Guidelines (GTGs) and Scientific
13. the detection rate of Down syndrome in twins
Impact Papers (SIPs). All of the above sources are available to
using the first trimester combined test is the
RCOG members and fellows via the RCOG website.
same as it is in singletons. ThFh
RCOG Members, Fellows, Registered Trainees and
14. the first trimester combined test has a higher
Associates have full access to TOG content via the TOG
false positive rate in the monochorionic than
app (available for iOS and Android).
in dichorionic type. ThFh
15. the risk of Down syndrome in monochorionic
TOG Evolution in screening twins is the average of the individual risks of
for Down syndrome each twin obtained from a first trimester
combined test. ThFh
The serum levels of the following fetoplacental products
16. the rate of failure to obtain a result in the cell-
are raised in pregnancies with fetal trisomy 21,
free DNA test is higher in monochorionic than
1. alphafetoprotein. ThFh in dichorionic types. ThFh
2. unconjugated estriol. ThFh
With regard to cell-free DNA testing on maternal blood,
3. free ß-human chorionic gonadotrophin. ThFh
4. inhibin A. ThFh 17. its performance in screening for trisomies is
5. pregnancy-associated plasma protein A. ThFh dependent on the fetal DNA fraction. ThFh
18. its use to screen for sex chromosome
With regard to Down syndrome screening tests,
aneuploidies is advisable. ThFh
6. the detection rate is the ability of a test to give a 19. the recommendation of the National
positive result in individuals who have the Screening Committee for implementation of
condition being screened for. ThFh the cell-free DNA test in the NHS is dependent
7. the screen-positive rate is the proportion of on available funding. ThFh
affected and unaffected individuals yielding a 20. offering this, rather than invasive testing, to
positive result. ThFh women identified by the first-trimester
8. the false positive rate is the proportion of combined test as being at high risk for trisomy
unaffected individuals yielding a positive result. T h F h increases the detection rate. ThFh

ª 2019 Royal College of Obstetricians and Gynaecologists 59

 CPD

15. ovarian tissue cryopreservation is a technique

TOG The transgender population: that is widely used in fertility preservation
improving awareness for gynaecologists for transmen. ThFh
and their role within the provision of care 16. transgender individuals are allowed to store
Regarding gender variance, their gametes for up to 55 years. ThFh
17. a hysterectomy is advised in transmen after
1. a 2012 survey of 10 000 people by the Equality 4–5 years of testosterone treatment. ThFh
and Human Rights Commission found an 18. the preferred surgical approach for
incidence of 1% in the survey population. ThFh hysterectomy is the abdominal route. ThFh
2. the Tavistock and Portman NHS Foundation
Trust, which provides a Gender Identity Regarding equality in health care,
Development Service for children and 19. in 2015, the World Health Organization
adolescents, had 2018 new referrals in reported that one in five transmen refused
2016–2017. ThFh health care because doctors call them by the
Regarding access to services for transgender patients, wrong gender. ThFh
20. the General Medical Council has published
3. the current waiting time from GP referral to advice for doctors who treat trans patients. ThFh
being seen in a Gender Identity Clinic in the
Tavistock and Portman Trust is 14 months. ThFh
Regarding Gender Identity Clinics, TOG Continence surgery at the time of
pelvic organ prolapse repair: a review
4. they provide a service led by specialists in of the literature
adult gender dysphoria medicine. ThFh
Pelvic floor muscle training,
Regarding hormone treatment,
1. increases the chance of improving prolapse
5. gonadotrophin-releasing hormone analogues stage by more than 30% compared with
are an option for use as ‘hormone blockers’ in no treatment. ThFh
adolescents to delay puberty. ThFh 2. is associated with less improvement in
6. weekly monitoring of bloods is required when symptoms compared with synthetic
a patient has commenced hormone therapy. ThFh midurethral sling (SMUS) in women with
7. estrogen therapy leads to a reduction in libido. ThFh stress urinary incontinence (SUI). ThFh
8. if polycythaemia occurs with testosterone
treatment, it should be stopped Pelvic organ prolapse,
immediately. ThFh 3. at or beyond stage 2 has been observed in up
9. transwomen who are at high risk of venous to one in four women 12 years after
thromboembolism should be prescribed their first delivery. ThFh
transdermal estrogen as opposed to oral 4. affects an estimated one in five women. ThFh
estrogen because it passes through the liver 5. and SUI coexist in up to 80% of women. ThFh
and confers a lower thromboembolic risk. ThFh
Urinary incontinence,
With regard to gender reconstructive surgery,
6. has been shown to be cured in 20–30% of
10. patients should have lived in the gender role women who have had transvaginal prolapse
that is congruent to their gender identity repair alone. ThFh
before the surgery. ThFh 7. occurs in more than 50% of women over the
11. five units in the UK offer this type of surgery. ThFh age of 40 years. ThFh
12. body contouring surgery is available on 8. in women is most commonly the mixed type. ThFh
the NHS. ThFh 9. has been demonstrated preoperatively in
13. transition at an early age is associated with a more than 50% of women after reduction
low regret rate following this type of surgery. ThFh of prolapse. ThFh
With regard to the gynaecologist’s role in treating Surgical treatment,
transgender patients,
10. for SUI is required for approximately 10% of
14. testosterone is recognised to be teratogenic. ThFh parous women over a lifetime. ThFh

60 ª 2019 Royal College of Obstetricians and Gynaecologists

 CPD

11. for SUI is required for less than 50% of In the treatment of symptoms of vaginal estrogen deficiency,
women with symptomatic incontinence before
6. caution should be exercised when prescribing
and after vaginal prolapse repair. ThFh
phytoestrogens to those with a history of
Abdominal sacrocolpopexy, breast cancer. ThFh
7. systemic hormone replacement therapy (HRT)
12. was shown to result in significantly greater SUI should be used when symptoms are
in the CARE trial when combined with predominantly vaginal. ThFh
concomitant Burch colposuspension. ThFh 8. vaginal estrogen therapy is known to improve
13. when combined with Burch colposuspension, sexual function. ThFh
has been shown to have no significant increase 9. lasofoxifene is effective. ThFh
in serious adverse events compared 10. oral preparations of dehydroepiandrosterone
with sacrocolpopexy alone. ThFh are ineffective. ThFh
11. tissue-selective estrogen complexes have been
Regarding SMUS at the time of vaginal prolapse repair, shown to prevent bone loss. ThFh
14. in continent women with stage 3 or With regard to the treatment of vulvovaginal atrophy,
4 prolapse, retropubic tension-free vaginal
tape has been shown to reduce the rate 12. raloxifene is effective. ThFh
of postoperative SUI. ThFh 13. androgens are not implicated in female
15. a rate of bladder injury of up to 8.7% has sexual function. ThFh
been reported. ThFh 14. the various intravaginal estrogenic
preparations show different efficacy when
Occult SUI, compared with each other. ThFh
15. monitoring endometrial thickness in
16. has no standardised diagnostic test. ThFh
asymptomatic, low-risk women receiving low-
17. has a ten-fold higher detection rate with
dose vaginal estrogen is not indicated. ThFh
speculum testing compared with
16. the effect of moisturisers is longer lasting
ring pessary use. ThFh
compared with lubricants. ThFh
18. was detected in approximately one-third of
17. erbium laser is not an effective treatment in
women in the CARE and OPUS trials. ThFh
breast cancer survivors. ThFh
18. vaginal testosterone is an effective option. ThFh
Asymptomatic prolapse,
19. vaginal moisturisers imitate natural
19. of stage 2 has been reported in more than one- vaginal secretions. ThFh
third of women presenting 20. systematic HRT is best used in the presence of
with SUI symptoms. ThFh osteoporosis and/or vasomotor symptoms. ThFh
20. is unlikely to progress at up to 3 years of
follow-up. ThFh
TOG Routes to parenthood for women with
Turner syndrome
TOG Vaginal estrogen deficiency
With regard to the epidemiology of Turner syndrome (TS),
Concerning the vagina,
1. it is the second most common chromosomal
1. superficial to parabasal cell proportion aneuploidy in humans. ThFh
increases with age. ThFh 2. its incidence increases with
2. the bacterial population remains unchanged increasing maternal age. ThFh
after menopause. ThFh 3. approximately 1 in 100 affected fetuses
3. atrophy is underdiagnosed worldwide. ThFh are born alive. ThFh
With regard to vaginal estrogen deficiency, With regard to the clinical features of TS,
4. dyspareunia is the second most 4. most affected women have
common symptom. ThFh spontaneous menarche. ThFh
5. recurrent urinary tract infections occur in up to 5. those presenting with primary amenorrhea are
20% of postmenopausal women. ThFh likely to have suboptimal uterine development. T h F h

ª 2019 Royal College of Obstetricians and Gynaecologists 61

 CPD

Concerning the pathogenesis of TS, Regarding acute appendicitis in pregnancy,

6. there is accelerated atresia of primordial 4. the gravid uterus displaces the appendix,
follicles in the ovary. ThFh causing right upper-quadrant pain. ThFh
7. those who have spontaneous menarche are 5. erythrocyte sedimentation rate is a useful
likely to be mosaic. ThFh marker of underlying infection and
8. serum anti-m€ ullerian hormone does not inflammation in pregnancy. ThFh
correlate with karyotype. ThFh 6. it occurs most commonly in the third trimester. ThFh
7. diagnosis by ultrasound has a high specificity. ThFh
With regard to treatment of women with TS,
When investigating the causes of abdominal
9. estrogen replacement should be started at
pain in pregnancy,
15 years of age. ThFh
10. estrogen needs to be started at half the 8. if the patient is unstable, treatment should be
normal adult dose. ThFh delayed until appropriate imaging
11. when childbearing is complete, it is advisable has been organised. ThFh
to stop HRT. ThFh 9. magnetic resonance imaging is the most
sensitive imaging modality. ThFh
Regarding pregnancy in women with TS,
Regarding assessment of abdominal pain in pregnancy,
12. the most dramatic risk during pregnancy
is aortic dissection. ThFh 10. focal right upper-quadrant pain is more
13. the risk of maternal mortality is around 2%. ThFh common as biliary colic progresses
14. a history of aortic dissection is a definite to cholecystitis. ThFh
contraindication to pregnancy. ThFh 11. absolute constipation is a common feature of
small-bowel obstruction. ThFh
Concerning fertility in women with TS,
12. displacing the uterus during examination may
15. approximately 8% conceive naturally. ThFh help to differentiate uterine from extrauterine
16. there is an increased risk of miscarriage. ThFh causes of pain. ThFh
With regard to assisted reproductive technology in Regarding investigating abdominal pain in pregnancy,
women with TS,
13. cardiotocographic abnormalities are helpful to
17. in gestational surrogacy, the surrogate is differentiate obstetric from non-obstetric
genetically unrelated to the baby. ThFh causes of pain. ThFh
18. there are reliable data on outcomes after 14. teratogenesis is the most common fetal risk of
oocyte freezing and embryo freezing. ThFh exposure to ionising radiation. ThFh
19. ovarian tissue freezing is an option for fertility 15. lactate values are typically higher in pregnant
preservation, even before the onset of women compared to nonpregnant women. ThFh
puberty. ThFh 16. tests for serum lipase levels are more sensitive
20. preserved embryos are allowed to be used for and specific than those for serum amylase
treatment even if there is a relationship levels for the diagnosis of pancreatitis. ThFh
breakdown and the male partner withdraws
Regarding the treatment of non-obstetric abdominal
consent for the use of embryos created using
pathology,
his sperm. ThFh
17. the risks of surgery during pregnancy mean it
is usually best to defer surgery
TOG Surgical causes of acute abdominal until after delivery. ThFh
pain in pregnancy 18. anti-D prophylaxis is not required as long as
the uterus is not entered. ThFh
Concerning physiological changes during pregnancy,
With regard to visceral artery aneurysms,
1. total blood volume increases
by approximately 30%. ThFh 19. dissecting aortic aneurysms are the most
2. respiratory rate remains unchanged. ThFh common type in pregnancy. ThFh
3. oxygen consumption increases 20. less than 20% of splenic aneurysm ruptures
by approximately 20%. ThFh occur during pregnancy. ThFh

62 ª 2019 Royal College of Obstetricians and Gynaecologists

 CPD

2. the risk of urinary stress incontinence among

BJOG Neurological outcomes by mode of women with twin pregnancy and a prior history
delivery for fetuses with open neural tube of urinary stress incontinence is modified by
defects: a systematic review mode of birth. ThFh
and meta-analysis 3. planned caesarean section compared with
With regard to neural tube defects (NTDs), planned vaginal birth reduces the risk of
problematic urinary stress incontinence
1. they are most commonly associated with at 2 years among women with twin pregnancy. T h F h
structural anomalies of the musculoskeletal 4. planned caesarean section compared with
system/extremities. ThFh planned vaginal birth reduces the risk of
2. the absence of the sac differentiates myeloschisis flatal incontinence in women with
from meningocele and myelomeningocele. ThFh twin pregnancy. ThFh
3. the most common location is sacral. ThFh
4. the incidence varies by region. ThFh In this randomised controlled trial,
5. multifetal gestation is a risk factor. ThFh 5. a power calculation was performed assuming a
6. the recommended dose of folic acid for 10% rate of loss to follow-up. ThFh
pregnancies at low risk for their occurrence is 4 mg. ThFh 6. data were analysed according to the group to
Regarding open NTDs, which the participants were assigned (i.e.
planned caesarean section or planned vaginal
7. the most commonly associated brain birth), regardless of the ultimate mode of birth. T h F h
abnormality is Chiari malformation type II. ThFh
8. there have been prospective randomised trials Regarding randomised controlled trials,
evaluating mode of delivery. ThFh 7. Allocation concealment is a technique used to
Regarding the MOMS trial, prevent selection bias. ThFh
8. Blinding ensures that the person randomising
9. the primary outcome was ambulation at 2 years. T h F h the patient does not know what the next
10. shunt requirement was found to be significantly treatment allocation will be. ThFh
reduced in the prenatal repair group. ThFh 9. The CONSORT statement sets out
recommendations for reporting randomised
controlled trials. ThFh
Reference 10. A core outcome set is an agreed minimum set
1 Tolcher MC, Shazly SA, Shamshirsaz AA, Whitehead WE, Espinoza J, Vidaeff AC, of standardised outcomes that should be
Belfort MA, Nassr AA. Neurological outcomes by mode of delivery for fetuses measured and reported in all clinical trials of a
with open neural tube defects: a systematic review and meta-analysis. BJOG
2018; https://doi.org/10.1111/1471-0528.15342. [Epub ahead of print].
specific condition. ThFh

BJOGUrinary stress incontinence and other Reference

maternal outcomes 2 years after caesarean 1 Hutton EK, Hannah ME, Willan AR, Ross S, Allen AC, Armson BA, Gafni
or vaginal birth for twin pregnancy: a A, Joseph KS, Mangoff K, Ohlsson A, Sanchez JJ, Asztalos EV, Barrett
JFR, for the Twin Birth Study Collaborative Group. Urinary stress
multicentre randomised trial incontinence and other maternal outcomes 2 years after caesarean or
vaginal birth for twin pregnancy: a multicentre randomised trial. BJOG
This study demonstrates that, 2018; 125:1682–90.

1. planned caesarean section compared with

planned vaginal birth reduces the prevalence
and severity of urinary stress incontinence at 2
years in women with twin pregnancy. ThFh

ª 2019 Royal College of Obstetricians and Gynaecologists 63