DOI: 10.1111/tog.

12685 2020;22:242–4
The Obstetrician & Gynaecologist
CPD
http://onlinetog.org

CPD questions for volume 22 issue 3

CPD credits can be claimed for the following questions 8. anosmia/hyposmia is a feature of
online via the TOG CPD submission system in the RCOG Kallmann syndrome. ThFh
CPD ePortfolio. You must be a registered CPD participant of 9. serum anti-m€ ullerian hormone level is a
the RCOG CPD programme (available in the UK and reliable predictor of ovarian reserve. ThFh
worldwide) in order to submit your answers. 10. the main drawback of gonadotrophin-
Participants can claim 2 credits per set of questions if at releasing hormone (GnRH) replacement
least 70% of questions have been answered correctly. CPD treatment by comparison with
participants are advised to consider whether the articles are gonadotrophins for ovulation induction is
still relevant for their CPD, in particular if there are more multiple pregnancies. ThFh
recent articles on the same topic available and if clinical
guidelines have been updated since publication. With regard to hypopituitarism,
Please direct all questions or problems to the CPD Office. 11. most cases are transient and self-limiting. ThFh
Tel: +44(0) 20 7772 6307 or email: [email protected]. 12. it is probably associated with increased risk of
The blue symbol denotes which source the questions refer early pregnancy loss following conception
to including the RCOG journals, TOG and BJOG, and RCOG with ovulation induction. ThFh
guidance, such as Green-top Guidelines (GTGs) and 13. pelvic ultrasound shows multicystic ovaries
Scientific Impact Papers (SIPs). All of the above sources are with a large number of antral follicles and
available to RCOG Members and Fellows via the RCOG minimal intervening stroma in most cases. ThFh
website. RCOG Members, Fellows and Associates have full 14. fertility treatment usually involves
access to TOG content via the TOG app (available for iOS administration of gonadotrophins for
and Android). ovulation induction. ThFh

TOG WHO type 1 anovulation: an update on In relation to the management of WHO type 1 anovulation,
diagnosis, management and implications 15. hormone replacement therapy is associated
for long-term health with maintenance of bone mineral density
levels in the spine in women with
With regard to the World Health Organization (WHO) prolonged amenorrhoea. ThFh
classification of ovulatory disorders, 16. multidisciplinary management involving
1. type 1 is characterised by hypogonadotrophic counselling/behavioural therapies should be
hypo-estrogenic states. ThFh considered in women with HA. ThFh
2. type 2 includes polycystic ovary syndrome and 17. gonadotrophin treatment is significantly
premature ovarian failure. ThFh more successful and has lower chances of
With regard to hypothalamic amenorrhoea (HA), multiple pregnancies by comparison with
3. it is reversible in many cases with lifestyle GnRH therapy. ThFh
modification alone. ThFh 18. cognitive behavioural therapy does not have
4. it is characterised by a high serum level any proven value in the management of
of leptin. ThFh women with HA presenting with subfertility. T h F h
5. clomiphene citrate has been shown to
With regard to the physiological role of the hypothalamo–
successfully induce ovulation in women with
pituitary–ovarian axis in female individuals,
normal gonadotrophins. ThFh
19. pulsatile secretion of GnRH from the
6. leptin therapy is not associated with any
hypothalamus varies in frequency throughout
significant adverse effects. ThFh
the menstrual cycle. ThFh
With regard to hypogonadotrophic hypogonadism, 20. theca cells of the ovary lack the aromatase
7. most cases of Kallmann syndrome are enzyme required to convert androgens
associated with midline craniofacial defects. ThFh to estrogens. ThFh

242 ª 2020 Royal College of Obstetricians and Gynaecologists

 CPD

TOG 19. vascular surgeons should be called to assist

Vascular injury during laparoscopic unless the primary surgeon has adequate
gynaecological surgery: a methodological expertise to repair the injury independently. ThFh
approach for prevention and management 20. early declaration is not associated with better
Vascular injury at the time of laparoscopic surgery, team efficiency. ThFh
1. occurs in up to 1 in 100 cases. ThFh
2. is the most common cause of death following TOG Review of gynaecological
laparoscopic surgery. ThFh malignant melanomas
3. carries a mortality of less than 10%. ThFh
4. is most common during laparoscopic entry. ThFh Mucosal melanomas,
5. requires conversion to open surgery in more 1. have an incidence of about 1 per 100 000. ThFh
than 1 in 200 cases. ThFh 2. are known to also occur in the upper
digestive tract. ThFh
Adhesions from previous surgery are present in approximately,
3. are thought to be caused by exposure
6. 20% of patients who had a previous
to sunlight. ThFh
laparoscopic surgery. ThFh
4. generally have a good prognosis. ThFh
7. 50% of patients who have had a
5. that are vaginal in origin have an average age
midline laparotomy. ThFh
at diagnosis of 70 years. ThFh
The inferior epigastric artery, 6. of the vulva are associated with HIV as a
8. is easier to identify in patients with a raised risk factor. ThFh
body mass index. ThFh
9. is best avoided by inserting secondary ports at With regard to the staging and investigations for mucosal
least 6 cm from the midline. ThFh vulval melanomas,
10. is the most common vessel injured during 7. cystoscopy is essential for staging. ThFh
placement of the primary trocar. ThFh 8. American Joint Committee on Cancer staging
gives more prognostic information than the
During laparoscopy entry, International Federation of Gynecology and
11. deviation from the midline during umbilical Obstetrics staging. ThFh
entry may result in injury of the common iliac 9. the ulcerated types have a better prognosis. ThFh
veins or arteries. ThFh 10. positron-emission tomography–computed
12. as small an initial incision as possible should tomography scan is recommended for patients
be used to avoid vascular injury. ThFh who are being considered for exenteration. ThFh
13. increasing the intra-abdominal pressure
increases the distance of the umbilicus from With regard to the management of mucosal vulval
retroperitoneal vessels. ThFh melanomas,
14. the Royal College of Obstetricians and 11. molecular testing for C-KIT and BRAF should
Gynaecologists recommends the use of be done at the time of diagnosis. ThFh
Palmer’s point or Hasson open approach after 12. the mainstay of treatment is surgical excision. T h F h
two unsuccessful attempts at inserting the 13. a tumour free margin of 1.5 cm is
Veress needle via the umbilicus. ThFh recommended for satisfactory excision. ThFh
15. placing the patient in the Trendelenburg 14. patients should be followed up every 3 months
position is associated with a decreased risk of for the first 3 years following treatment. ThFh
vascular injury. ThFh 15. there is good evidence for adjuvant treatment
after surgical excision. ThFh
With regard to the management of vascular injury
at laparoscopy, With regard to the systemic therapy for mucosal melanoma,
16. the instrument that has caused the injury 16. dacarbazine is given to most patients as
should be removed immediately. ThFh adjuvant therapy. ThFh
17. fewer than 50% of laparoscopic vascular 17. ipilimumab is a monoclonal antibody that
injuries occur at entry. ThFh inhibits the programmed cell death protein
18. the use of clear situation, background, (PD-1). ThFh
assessment, recommendation (SBAR) 18. most patients with mucosal melanoma carry a
handovers aids management. ThFh C-KIT mutation. ThFh

ª 2020 Royal College of Obstetricians and Gynaecologists 243

 CPD

19. only 3–15% of mucosal melanomas carry a Features in ‘Hutchinson’s Triad’ include,
V600E mutation in the BRAF gene. ThFh 16. saber shins. ThFh
20. the toxicities associated with the BRAF 17. notched incisors. ThFh
inhibitor vemurafenib include 18. interstitial keratitis. ThFh
photosensitivity, nausea and diarrhoea. ThFh 19. eighth cranial nerve deafness. ThFh
20. saddle nose. ThFh
TOGSyphilis in pregnancy: identifying and
managing a historic problem on the rise TOG Ocular manifestations of pregnancy
and labour: from the innocuous to the
Syphilis is,
sight threatening
1. seen equally in male and female individuals. ThFh
2. the most common congenital Physiological changes in the eye in pregnancy include,
infection worldwide. ThFh 1. mild ptosis. ThFh
3. not part of the antenatal 2. increased intraocular pressure. ThFh
screening programme. ThFh 3. increased corneal thickness. ThFh
Risk factors for acquiring syphilis in pregnancy include, Referral to ophthalmology is indicated for,
4. three or more sexual partners in the last 4. subconjunctival haemorrhage. ThFh
12 months. ThFh 5. dry eyes. ThFh
5. a history of chlamydia. ThFh 6. central serous chorioretinopathy. ThFh
With regard to syphilis infection and pregnancy, 7. unilateral visual loss. ThFh
6. there is a 50% risk of transmission to the fetus 8. painful red eye with photophobia. ThFh
in primary disease. ThFh 9. bilateral blurred vision with headache. ThFh
7. transmission to the fetus is more likely if the
disease is in the latent stage. ThFh Pregnancy is a risk factor for,
8. 30–40% of infected fetuses will die in utero. ThFh 10. retinal detachment. ThFh
9. signs of congenital disease are seen at birth in 11. pituitary apoplexy. ThFh
approximately one-third of babies who
Eye drops deemed safe for dilatation of the pupils in
survive the pregnancy. ThFh
pregnancy include,
With regard to serological tests for syphilis, 12. tropicamide 1%. ThFh
10. the venereal disease research laboratory 13. phenylephrine 2.5%. ThFh
carbon antigen (VDRL) test does not illustrate 14. cyclopentolate 1%. ThFh
disease activity, only its presence. ThFh
11. inflammatory conditions such as systemic Regarding diabetic retinopathy in pregnancy,
lupus erythematosus are known to cause 15. if digital screening is normal after the first
false positives. ThFh antenatal appointment, repeat screening
12. when there are significant risk factors for the should be performed at 28 weeks. ThFh
infection, repeat tests should be sent at 6 and 16. if absent at the onset of pregnancy, the risk
12 weeks after the last sexual contact if the of severe retinopathy is high. ThFh
initial screening is negative. ThFh
Regarding central serous chorioretinopathy in pregnancy,
When using benzathine pencillin to treat syphilis in pregnancy, 17. binocular diplopia is a commonly
13. two doses are required to treat primary reported symptom. ThFh
disease after the first trimester. ThFh
14. the Jarisch–Herxheimer reaction is said to Causes of optic nerve head swelling in pregnancy include,
occur in up to 45% of cases. ThFh 18. idiopathic intracranial hypertension. ThFh
15. three doses are required when the patient has 19. migraine. ThFh
late-stage disease, regardless of trimester. ThFh 20. severe pre-eclampsia. ThFh

244 ª 2020 Royal College of Obstetricians and Gynaecologists