CPD questions for volume 17 number 1

Transcription

1 DOI: /tog The Obstetrician & Gynaecologist ;17:62 7 questions for volume 17 number 1 credits can be claimed for the following questions online via the TOG submission system in the RCOG eportfolio. You must be a registered participant of the RCOG programme (available in the UK and worldwide) in order to submit your answers. Please log in to the RCOG website ( to access your eportfolio. Participants can claim 2 credits per set of questions if at least 70% of questions have been answered correctly. At least 50 credits must be obtained in this way over the 5-year cycle. Please direct all questions or problems to the Office. Tel: +44(0) or cpd@rcog.org.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 ST analysis for intrapartum fetal monitoring With regard to use of cardiotocography (CTG) and ST analysis (STAN), 1. the principle of STAN relies on the release of potassium ions during glycogen breakdown in anaerobic metabolism within fetal myocardium following oxygen deficiency, resulting in electrocardiogram (ECG) changes, which are picked up as STAN events. 2. STAN monitoring looks for changes in fetal ECG and compares them with the baseline ECG at the start of the monitoring. 3. the use of STAN monitoring does not significantly reduce the rate of emergency caesarean section. 4. operative vaginal delivery rate is reduced by approximately 11% with the use of STAN monitoring in comparison to CTG. With regard to starting STAN, 5. it cannot be started in labour where the woman has already been on CTG monitoring. 6. where atypical decelerations are present on prior CTG for minutes, commencing STAN is not advised. 7. where normal baseline fetal heart rate and variability are maintained on a prior CTG, commencing STAN is appropriate. 8. where a normal baseline fetal heart rate is maintained but variability is reduced on a prior CTG for more than 40 minutes, performing fetal blood sampling before commencing STAN is a reasonable option. 9. STAN in combination with CTG has been shown to significantly reduce the incidence of hypoxic ischaemic encephalopathy. With regard to interpreting STAN, 10. if the ST analysis as displayed by the crosses on the bottom of the screen is not picked up for more than 4 minutes the interpretation on STAN monitoring becomes invalid. With regard to ST events in STAN, 11. an episodic T/QRS rise in fetal ECG is an increase in T:QRS ratio that lasts less than 10 minutes and represents a period during which the fetus has utilised anaerobic metabolism but recovered back to aerobic metabolism. 12. a baseline T/QRS rise in fetal ECG is an increase in T:QRS ratio that lasts more than 10 minutes and represents a fetus utilising anaerobic metabolism for an extended period of time. 13. the greater magnitude of T/QRS rise with an intermediary CTG is as significant as lesser magnitude T/QRS rise with abnormal CTG. 14. a biphasic ST event is the ST depression of fetal ECG and usually indicates a situation where the fetus is suffering from hypoxia and either has not had time to respond by switching to anaerobic metabolism or lacks the capacity to respond. 15. an ST event during the second stage of labour should prompt delivery unless the delivery is quite imminent. 16. a new ST event will be recorded if STAN is commenced on a fetus suspected of possible hypoxia. 62 ª 2015 Royal College of Obstetricians and Gynaecologists

2 17. if the CTG becomes abnormal while on STAN without any ST events, delivery is indicated. With regard to the limitations of STAN, 18. when the STAN electrode is connected to the breech a false biphasic event is likely to be recorded. 19. STAN is recommended in fetal conditions such as cardiac malformations or dysrhythmias. 20. the absence of a P wave on the ECG and a normal fetal heart rate on CTG is highly suggestive of a misplaced STAN electrode. TOG The clinical application of Doppler ultrasound in obstetrics In the surveillance and management of the small-for-gestational-age fetus, 1. use of the umbilical artery Doppler has been shown to improve perinatal outcome. 2. the ductus venosus Doppler has a low predictive accuracy for perinatal outcome. 3. there is robust evidence from randomised controlled trials to support use of the ductus venosus. In relation to venous Dopplers, 4. a reversed A-wave develops in the ductus venosus waveform in severe fetal growth restriction. 5. they serve as an indirect marker of fetal cardiac function. 6. they are mild predictors of fetal acidaemia and outcome. 7. they are used commonly in general obstetric practice. In terms of the role of Doppler sonography in screening, 8. second trimester uterine artery Dopplers are useful in screening for pre-eclampsia in a low risk population. 9. second trimester uterine artery Dopplers should be performed at 30 weeks. 10.the presence of an abnormal waveform in the ductus venosus from the first trimester of pregnancy is a marker of fetal aneuploidy. 11. the umbilical artery Doppler should be used to assess for fetal compromise in small for gestational age pregnancies. The middle cerebral artery Doppler, 12. should be used to assist clinicians in the timing of delivery in the preterm growth restricted fetus. 13. typically has a reduced impedance in advanced fetal growth restriction. 14. does not require angle correction for interpretation of the peak systolic velocity fetus. In relation to the application of Doppler in twin pregnancy, 15. abnormalities in Doppler waveform correspond to Quintero II staging in twin-to-twin transfusion syndrome. 16. tricuspid regurgitation is a recognised marker of cardiac failure in the recipient fetus in pregnancies affected by twin-to-twin transfusion syndrome. 17. ductus venosus Doppler has no role in the assessment of fetal growth discordance in twins. 18. the middle cerebral artery Doppler is useful in the assessment of complications of twin-twin transfusion therapy. Which of the following factors is known to affect the umbilical artery Doppler measurement or waveform? 19. Fetal breathing. 20. The site where the umbilical cord is insonnated. TOG Latest evidence on using hormone replacement therapy in the menopause Women with premature ovarian insufficiency or failure (POI/POF), 1. have been shown to have an earlier onset of cardiovascular disease episodes. 2. have no greater risk of breast cancer (if treated with HRT) than the population risk for their age. 3. are advised to consider taking hormone replacement therapy (HRT) at least until the natural age of menopause. Common side effects of HRT include, 4. breast tenderness. 5. muscle cramps. ª 2015 Royal College of Obstetricians and Gynaecologists 63

3 With regard to morbidity with HRT, 6. transdermal HRT is associated with a lower risk of venous thromboembolism (VTE) compared to oral. 7. previous VTE is a contraindication to HRT. 8. HRT (estrogen plus progesterone) increases the risk of VTE four-fold over 5 years. 9. HRT is absolutely contraindicated in women with a family history of early onset breast cancer. 10. oral estrogen can be used in women on tamoxifen. The re-analysis of the WHI study in 2007 showed that giving HRT to women within 10 years of menopause was associated with, 11. fewer risks. 12. an increase in cardiovascular events. In women with (POI/POF), 13. bisphosphonates are an acceptable first line for the prevention of osteoporosis. Concerning HRT in low risk women, 14. the risk from taking HRT is greater than that from obesity. 15. the increased risk of breast cancer reverts to population risk 5 years after stopping. 16. mortality from breast cancer developed while on the HRT is much greater than that in those with cancer not on HRT. 17. prior to initiating HRT it is recommended that a breast examination is performed. 18. the risk of VTE is increased significantly after 12 months of use compared to soon after initiation. 19. the risk of VTE is greater with the oral compared to the transdermal route of administration. With regard to pathology in women on HRT, 20. the risk of endometrial hyperplasia in those on sequential HRT is similar to that in those on continuous combined HRT. TOG Endometrial pathology in the postmenopausal woman an evidence based approach to management With regard to endometrial polyps, 1. they account for approximately 10% of all causes of postmenopausal vaginal bleeding. 2. the risk of uterine perforation at hysteroscopic removal outweighs the risk of malignancy in those with asymptomatic polyps. In the postmenopausal endometrium, 3. the histological appearance of a biopsy specimen is dependent on the last hormonal pattern before the menopause. With regard to endometrial hyperplasia, 4. those without atypia have a 2% risk of progression to endometrial carcinoma. 5. where there is atypia, endometrial cancer coexists in less than 10% of cases. In women on selective estrogen receptor modulators (SERMs), 6. there is no increased risk of endometrial hyperplasia in those taking raloxifene. 7. routine screening for endometrial hyperplasia with transvaginal ultrasound in asymptomatic women on tamoxifen is recommended. 8. women on tamoxifen with symptoms and a thickened endometrium should be investigated with a hysteroscopy and targeted biopsy. 9. the levonorgestrel-releasing intrauterine system has been shown to reduce the risk of endometrial hyperplasia in those on tamoxifen. With regard to screening for endometrial pathology, 10. routine transvaginal ultrasonography is of proven benefit in asymptomatic postmenopausal women. 11. a threshold endometrial thickness of 5 mm has higher positive predictive value (PPV) than 4 mm. With regard to the aetiology and epidemiology of endometrial polyps, 12. the use of tamoxifen increases the prevalence by up to 60%. 13. in obese women, increasing circulating estradiol levels are thought to be the likely cause of their development and growth. 14. the increase in prevalence in women on anti-hypertensives is independent of their drugs. In a woman presenting with PMB, 15. the most common cause is atrophic cervicitis. 16. if she has a polyp, the risk of it being malignant is twice that of a woman who has an asymptomatic polyp. 64 ª 2015 Royal College of Obstetricians and Gynaecologists

4 Hysteroscopy, 17. has a specificity of 100% in diagnosing uterine polyps. 18. carries a higher risk of uterine perforation in women with symptomatic polyps. 19. has an accuracy of 100% in diagnosing polyps. 20. is the gold standard for diagnosing fibroids. TOG Thyroid dysfunction and reproductive health In women with thyroid disorders, 1. anovulation is common in those with hyperthyroidism. 2. pregnancy should be postponed for at least 3 months after radioactive iodine therapy. 3. overt hypothyroidism affects 0.5% of those of reproductive age. 4. treatment of those with subclinical hypothyroidism with levothyroxine is associated with higher rates of implantation. 5. the presence of thyroid stimulating hormone receptor antibodies can be used to distinguish Grave s disease from gestational hyperthyroidism. With regard to the physiology of the thyroid system and reproduction, 6. ovarian granulosa cells express thyroid hormone receptors. 7. the American Thyroid Association now recommends that TSH should remain at or below 2.5 mu/l pre-conceptually. 8. subclinical hypothyroidism has a prevalence of 5 10% in women of reproductive age. Concerning the physiological changes and functions of the thyroid system in early pregnancy, 9. fetal production of thyroxine begins at approximately 10 weeks of gestation. 10. thyroid hormones have been shown to play a role in placental development. 11. there is a rise in TSH levels in the early pregnancy accompanying a rise in b-hcg. With regard to thyroid autoimmunity, 12. thyroid autoantibodies are present in a third of those with Hashimoto s thyroiditis. 13. PCOS is a risk factor. 14. the mechanism of association between autoimmune thyroid disease and adverse reproductive outcomes is well established. 15. autoimmune thyroid disease is associated with poorer outcomes in fertility treatment. With regard to the treatment of thyroid disorders in pregnancy, 16. there is strong evidence to suggest that treating those who are euthyroid with thyroxine improves outcomes. 17. there is evidence to suggest that treatment of autoantibody negative women with subclinical hypothyroidism with thyroxine reduces miscarriage rates. 18. euthyroid women with thyroid autoimmunity have higher rates of miscarriage. 19. there is strong evidence to suggest that levothyroxine therapy in women with thyroid autoimmunity reduces miscarriage rates. 20. there is insufficient evidence to recommend the treatment of thyroid-autoantibody positive euthyroid women with levothyroxine in pregnancy. TOG Management of common disorders in psychosexual medicine Concerning chronic pelvic pain (CPP), 1. a diagnostic laparoscopy is the first-line treatment. 2. it is defined as intermittent or constant pain in the lower abdomen or pelvis of at least 12 months duration. 3. women with CPP are significantly more likely to have a history of somatisation. 4. one third to one half of diagnostic laparoscopies will be negative. 5. the intensity of CPP inversely correlates with the extent and duration of past physical or sexual abuse. With regard to vulvodynia, 6. it is vulval discomfort occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. 7. the diagnosis is clinical. 8. amitriptyline is contraindicated. ª 2015 Royal College of Obstetricians and Gynaecologists 65

5 Concerning hypoactive sexual desire disorder (HSDD), 9. the prognosis is worse in cases where the woman presents with the initial issue. 10. a reduction in libido of 70% has been found to occur following bilateral salpingo oophorectomy. 11. transdermal testosterone therapy has been found to increase sexual activity and satisfaction in at least 51% of women. 12. the majority of the women with this condition will respond to psychotherapy. Concerning patients with tokophobia, 13. the primary type has been shown to originate from childhood or adolescence. 14. it has a cultural association in some cases. 15. the secondary type is known to be associated with termination of pregnancy. 16. a plan of birthing care is detrimental to such patients. 17. some women avoid pregnancy. With regard to psychosexual consultations, 18. open questions are not recommended. 19. transference is the conscious redirection of feelings from the patient to the doctor. 20. basic seminar training with the Institute of Psychosexual Medicine (IPM) for a Pyschosexual Medicine Diploma takes 2 years. TOG Participation in research as a means of improving care quality The main challenges faced by clinicians undertaking clinical trials include, 1. difficulty in obtaining ethics approval. 2. recruitment to target in the planned time. 3. limited collaboration between the centres. Concerning research participation, 4. it improves patient outcomes irrespective of the study findings. 5. participants have improved outcomes if the treatment that is evaluated is found to be effective. Failure to recruit to target in a clinical trial has been shown to lead to, 6. an increased risk of reporting falsely that the observed clinically relevant differences are not significant due to lack of adequate power. 7. delay in the deployment of potentially useful interventions that have the ability to improve the health of women. The National Institute of Health Research (NIHR) definition of authorised healthcare professional responsible for conducting a trial at the trial site refers to the 8. principal investigator. 9. trial coordinator. The ultimate responsibility of ensuring that all members of the team are adequately trained in carrying out clinical research, including consent and data collection, lies with the 10. research midwife/nurse. 11. trial coordinator. 12. principal investigator. Studies are able to seek support from Clinical Research Network (CRN) if, 13. funded by the NIHR. 14. the clinical question evaluated by the study is relevant to practice. Costs incurred to support research activity or driven by NHS duty of care are categorised as, 15. research costs. 16. service support costs. 17. excess treatment costs. The contribution of the principal investigator to research is: 18. a recognised professional development activity. The role of a principal investigator is linked to the following domains of Good Clinical Practice (GCP): 19. providing a good standard of care for patients. 20. adequate communication. GTG Long-term consequences of polycystic ovary syndrome With regard to the risk of cancer in women with PCOS, 1. those with oligoamenorrhoea are less likely to develop cancer than those having regular periods. 2. there is an increased risk of estrogen dependent breast cancer. 3. an endometrial thickness of 6 mm in a 36 year old woman with oligoamenorrhoea is an indication for hysteroscopy. With regard to strategies for reducing the long-term health risk of PCOS, 4. the use of insulin-sensitising agents has been associated with significant side effects. 66 ª 2015 Royal College of Obstetricians and Gynaecologists

6 5. where there is associated obesity and hyperandrogenism, weight reduction drugs have been shown to be useful. 6. electrocautery of the ovaries is associated with weight loss. 7. bariatric surgery is recommended for those with a BMI of more than 30 kg/m 2 with a high-risk of obesity related conditions. With regard to the metabolic consequences of PCOS, 8. the prevalence of gestational diabetes mellitus is 3 4 times as high as in women with PCOS compared to women without. 9. insulin resistance is present in approximately 60 89% of women with PCOS independent of obesity. 10. continuous positive airway pressure (CPAP) therapy has been shown to improve insulin sensitivity in women with PCOS and obstructive sleep apnoea. GTG Umbilical cord prolapse Which of the following statement(s) about cord prolapse is (are) correct? 1. Routine ultrasound examination is sensitive enough to diagnose cord presentation. 2. When cord prolapse is suspected a digital examination should be performed. Following the diagnosis of a cord prolapse, 3. attempts should be made to manually replace it and allow labour to progress. 4. filling the bladder with normal saline has been shown to be associated with a better outcome than manually elevating the presenting part. 5. the use of tocolytics has not been shown to improve outcome. 6. the patient should be managed in the knee-chest position during transfer from the community to the hospital. Concerning the management of cord prolapse, 7. immediate delivery by CS is the recommended option in those diagnosed in late first stage. 8. the use of regional anaesthesia for delivery is associated with a poor outcome. 9. the diagnosis is commonly made when there is a fetal heart rate abnormality following amniorrhexis. 10. when it occurs at the threshold of viability, it should be replaced and the pregnancy allowed to continue. BJOGAcute kidney injury in major gynaecological surgery: an observational study With regard to acute kidney injury in major gynaecological surgery, 1. changes in serum creatinine concentration during hospitalisation as small as 0.3 mg/dl are associated with longterm mortality. 2. the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) defines acute kidney injury as a rise in serum creatinine of greater than 2 mg/dl from the preoperative value, or an acute need for renal replacement therapy. 3. most patients with acute kidney injury in this study had mild to moderate severity AKI. 4. most episodes of acute kidney injury occurred after 72 hours of admission. 5. AKI was more likely to occur among patients undergoing surgery for malignant disease. 6. most cases with increase in serum creatinine were found to be secondary to mechanical urologic injury in this study. 7. among gynaecology patients, AKI is more common than post-operative ileus. 8. fewer than 5% of the participants in this cohort had only partial or no renal recovery. 9. a major strength of this study is that AKI was used measuring longitudinal changes in serum creatinine. 10. a practitioner can prevent AKI by implementing kidney-sparing interventions postoperatively. Reference 1 Vaught AJ, Ozrazgat-Baslanti T, Javed A, Morgan L, Hobson CE, Bihorac A. Acute kidney injury in major gynaecological surgery: an observational study. BJOG August. DOI: / [Epub ahead of print] ª 2015 Royal College of Obstetricians and Gynaecologists 67