Answers t o Questions for Volume 4,

Number 3
Numbered references correspond with t h e citations in t h e original articles and so are not listed here.
References in roman numerals are not listed in t h e original article; instead they can be found a t t h e end of
each set of answers.
Complications of assisted reproduction
Ovarian hyperstimulation syndrome (OHSS)
1
is commonly associated with the use of oral ovulation
induction agents. .................................................
FALSE
2
increases in incidence with age. ......................... FALSE
3
in i t s mild form, occurs in more than 50% of in vitro
fertilisation (IVF) treatment cycles...................... FALSE
4
is more likely t o increase in severity if pregnancy
ensues. ................................................................... TRUE
5
in association with IVF can be reduced by using
progesterone for luteal support. .........................
TRUE
Discussion
OHSS is a potentially life-threatening complication
classically associated with ovarian stimulation using
gonadotrophins. It rarely occurs with the administration of
oral ovulation induction agents such as clomiphene citrate.
Risk factors for the development of OHSS include: young
age, low body weight, polycystic ovaries, high dose of
gonadotrophins, large number of oocytes retrieved, high
oestradiol level on the day of human chorionic
gonadotrophin (hCG) administration, use of hCG for luteal
support, and ensuing pregnancy.2OHSS may be classified as
mild, moderate or severe according t o the Golan
classification.6Mild OHSS occurs in 23-33% of treatment
cycles, moderate in 3 6 % of cycles and severe in 0.3-0.5%.'
Using progesterone for luteal-phase support rather than
hCG reduces the incidence of OHSS without having a
negative effect on pregnancy rates.'*
Regarding the management of OHSS,
6
biochemical consequences include hypokalaemic
acidosis..................................................................
FALSE
7
paracentesis is contraindicated for symptomatic relief
of ascites. .............................................................. FALSE
8
intravenous diuretics are indicated if the urinary
output is less than 30 ml/hr. ................................
FALSE
9
thromboprophylactic measures should be employed
TRUE
for patients admitted to hospital. .......................
10 physical exercise may increase the risk of ovarian
TRUE
torsion ....................................................................
Discussion
OHSS is associated with increased capillary permeability
and leakage of protein-rich fluid from the intravascular
space, which results in haemoconcentration and ascites.
Haematological and biochemical consequences include an
increase in haematocrit, leukocytosis, hyponatraemia and
hyperkalaemic acidosis. Correction of the hypovolaemia by
intravenous infusion will restore renal perfusion and,
hence, urine production. Diuretics are contraindicated.
They induce a diuresis by removing fluids from the
intravascular compartment and have no effect on the
ascites or the course of the disease.
Heparin (either conventional or low molecular weight)
and antiembolic stockings should be prescribed as
prophylaxis against deep venous thrombosis. Paracentesis,
carried out either transabdominally or transvaginally, is
indicated for symptomatic relief of large volumes of ascites.
50

In addition t o symptomatic relief, this also results in

improved renal function, improved blood osmolarity,
reduced haemoconcentration and reduced pulmonary
compromise. Patients should be advised t o avoid strenuous
activity, which increases the risk of ovarian torsion.
However, complete bed-rest should be avoided as it
increases the risk of thromboembolism.

c9

With re ard to early pregnancy loss associated with

assiste reproduction,
11 there is an increased rate compared t o natural
conception. ............................................................ TRUE
12 embryo transfer techniques may contribute to an
increased risk of ectopic pregnancies. .................TRUE
13 heterotopic pregnancy rates are in the region of 5%.
.............................................................................. FALSE
14 bilateral salpingectomy is recommended t o reduce
the risk of ectopic pregnancy in patients undergoing
IVFACSI. .................................................................
FALSE
Discussion
The apparent increase in miscarriage associated with IVF
appears t o be multifactorial, with infertility itself,
regardless of cause, being of major significance.
Miscarriage rates as high as 28% have been reported in
infertile women who conceive spontaneously.
The ectopic pregnancy rate varies between 2-11% in
reported series of IVF pregnancies." The aetiology of
ectopic pregnancy after IVF-embryo transfer i s
multifactorial, with tubal disease being the main factor. The
technique of embryo transfer may also contribute to the
increased risk of ectopic pregnancy, for example through
forcing the embryos into the tubal ostia by hydrostatic
pressure. Laparoscopic clipping of the proximal end of a
hydrosalpinx or salpingectomy would prevent the
occurrence of tubal pregnancies in patients with
hydrosalpinges and has, at the same time, been shown t o
increase their chance of a successful outcome with IVF.*
Heterotopic pregnancy is estimated to occur in 1% of IVF
pregnancie~.'~
It is likely, however, that a significant number
are undetected in the presence of an ongoing intrauterine
gestation.
Concerning the obstetric outcome of assisted
reproduction,
15 the perinatal mortality rate associated with singleton
pregnancies is similar t o that of an age-matched
spontaneous conception control group. ............FALSE
16 the Human Fertilisation and Embryology Authority
(HFEA) prohibits the transfer of more than two
embryos. ...............................................................
FALSE
17 blastocyst transfer does not increase the rate of
multiple pregnancy as long as only three blastocysts
are transferred. .................................................... FALSE
Discussion
The perinatal mortality rate in assisted reproduction
singleton pregnancies, even when matched for age, parity
and fetal sex, is greater than in spontaneously conceived
pregnancies." Perinatal mortality is increased seven-fold
0 2003 Royal College of Obstetricians and Gynaecologists

Answers to Questions for Volume 4, Number 3

among triplets and five-fold among twitxu Therefore,
reducing the proportion of multiple pregnancies among
IVF conceptions should contribute to a significant overall
reduction in perinatal mortality and morbidity. Currently, in
the UK, HFEA guidelines allow for the transfer of no more
than three embryos. The RCOG guidelines recommend that
no more than two embryos be transferred. In the future a
move towards transfer of single blastocysts in women with
high reproductive potential and two blastocysts in others
should help t o reduce the increase in perinatal mortality
due to multiple pregnancy."
According t o the 'Golan' classification for OHSS
18 maximum ovarian diameters of >10cm may be
associated with mild OHSS. .................................. TRUE
19 clinical ascites indicates grade 3 OHSS. ..............FALSE
20 an isolated hydrothorax does not indicate severe
FALSE
disease. .................................................................
Discussion

Table 1. Golan Classification of ovarian hyperstimulation

syndrome
Mild

Grade 1: abdominal distension and

discomfort.
Grade 2: grade 1 plus nausea, vomiting,
and/or diarrhoea; ovaries en la rged
5-12 crn.

Moderate

Grade 3: features of mild OHSS plus

ultrasonic evidence of ascites.

Severe

Grade 4: features of moderate OHSS

plus clinical ascites and/or hydrothorax
with dyspnoea.
Grade 5: grade 4 plus decreased blood
volume, increased blood viscosity,
hypercoagulability, diminished renal
perfusion and function.

Additional reference
i. Schenker JG, Weinstein D. Ovarian hyperstimulation
syndrome: a current survey. Fertil Steril 1978;30:255-68.

Unsafe abortion: a preventable problem

The following statements are true:
21 The induced abortion rate per 1000 women i s
significantly higher in developed than developing
countries. ..............................................................
FALSE
22 A rise in contraceptive practice is initially associated
with a rise in abortion rate. ................................. TRUE
23 On average, one woman in ten will have one induced
abortion before reaching the menopause.........FALSE
Discussion
The abortion rate, per 1000 women of fertile age, is similar
in developed and developing countries (39 and 34
respectively). Contraceptive prevalence and induced
abortion rates sometimes rise in parallel in communities
where couples are beginning t o try t o have fewer children.
Later, as fertility falls, high contraceptive use is associated
with lower abortion rates. On average, every woman now
entering her fertile years will have one abortion before
reaching the menopause.
Concerning mo rta I ity and morbidity,
24 the mortality associated with some traditional
abortion techniques is up t o 500-times higher than
vacuum aspiration abortion performed by a trained
TRUE
individual. ..............................................................

25
26
27

in Africa the risk of death from induced abortion is a t

least 500 times greater than in a developed country.
................................................................................ TRUE
about 13% of maternal deaths worldwide are
associated with abortion. ..................................... TRUE
despite restrictive laws regarding abortion in India,
malaria still remains a greater cause of death than
unsafe abortion.................................................... FALSE

Discussion
The risk of death from first-trimester unsafe abortion using
traditional techniques is up t o 500 times higher than
abortion using vacuum aspiration.' The World Health
Organization estimates that, of the 515 000-585000
maternal deaths that occur across the world each year, 13%
are abortion related.gData have shown that in Africa there
are 680 deaths for every 100000 abortions whereas in
developed countries, where most abortions performed are
safe, the death rate is between 0.2-1.2 (per 100000
abortions).' In India between 15 000-25 000 women die
each year as a result of unsafe abortion; it is, therefore,
responsible for more deaths than malaria.
Regarding solutions for unsafe abortion,
28 in India safe abortion is limited by the availability of
university-trained doctors.....................................
TRUE
29 vacuum aspiration enables most incomplete abortions
t o be treated as day cases. ...................................
TRUE
30 when post-abortion contraceptive advice was given,
the number of women using contraception in Bolivia
rose eight-fold ....................................................... TRUE
Discussion
Although India liberalised i t s abortion law in 1970, access
t o safe abortion is still limited as only university-trained
doctors can legally carry out abortions. Following manual
vacuum aspiration for incomplete abortion, most women
can be discharged from the hospital or clinic within a few
hours.
As part of post-abortion care, women should be
counselled and given contraceptive advice. A study on
contraceptive use before and after counselling revealedthat
in Bolivia contraceptive use before such intervention was
only 10%. Following intervention this figure rose t o 88%."
Regarding manual vacuum aspiration (MVA),
31 in Bangladesh approximately half of the trained MVA
practitioners are not doctors................................ TRUE
32 the equipment can be reused many times..........TRUE
33 this method can only be used up t o a menstrual age
FALSE
of 10 weeks. .........................................................
34 the weighted cost is more than 50% cheaper than
D&C. ....................................................................... TRUE
Discussion
In Bangladesh abortion, or menstrual regulation, i s
considered a legal family planning method. There is an
estimated 10000 individuals trained t o perform MVA,
approximately half of which are doctors and the others are
health workers. MVA equipment can cost as little as
USS5.00, a weighted cost of 87% less than D&C. The
equipment can be reused many times, but it is important
that the syringe is kept clean and the cannulae are
sterilised. This method can be used t o perform abortions up
t o a menstrual age of 12 weeks.
Concerning the use of rnisoprostol,
35 it is effective as an abortifacient only when used
orally. .................................................................... FALSE
36 when used as an abortifacient in countries where the
procedure remains illegal there has been no change
in the incidence of septic abortions...................FALSE

51

Answers to Questions for Volume 4, Number 3

37

38

there have been reports of an increased risk of

ectopia vesicae (exstrophy of the bladder) following
the unsuccessful use of misoprostol. ...................TRUE
the American manufacturers of misoprostol do not
recommend it for use as an abortifacient ...........TRUE

Discussion
Misoprostol can be used t o terminate pregnancy when
used either orally or vaginally. Where women have access
to misoprostol, even in areas where abortion is illegal, the
number of hospital admissions for septic abortions is
falling. Misoprostol is manufactured by Searle and
marketed under the tradename Cytotec", for the
treatment of gastric and duodenal ulcers. Misoprostol is
not licensed for use as an abortifacient and the
manufactures do not support i t s use for this purpose.
There have been reports of abnormalities in children
born following the unsuccessful use of misoprostol as an
abortifacient, including ectopia vesicae (exstrophy of the
bladder), Moebius syndrome (paralysis of the facial
muscles), Iimb defects, hydrocephaIus and a rthrogryposis.
Regarding the politics of abortion,
39 fifty percent of the world's women of reproductive
age live in countries with restrictive laws..........FALSE
40 overseas aid provided by Britain forbids the use of
taxpayers' money t o support safe abortion....... FALSE
Discussion
There are 1.4 billion women of reproductive age in the
world, 26% of these women live in countries with highly
restrictiveabortion laws. Only the United States permits safe
abortion inside the country while forbidding the use of
overseas aid t o help women obtain safe abortions
elsewhere.

Management of urge urinary incontinence

Urge urinary incontinence is
41 most .commonly
due t o idiopathic detrusor
.
overactivity............................................................. TRUE
42 often associated with frequency and nocturia. ..TRUE
43 rarely caused by factors extrinsic t o the bladder.
.............................................................................. FALSE
Discussion
Urge incontinence is most frequently caused by idiopathic
detrusor overactivity but has many other potential causes.
Causes that are extrinsic to the bladder include external
pressure (e.g. pregnancy), psychosocial factors (e.g.
dementia) and iatrogenic causes (e.g. diuretics and other
drugs); it can also arise due t o other medical conditions
(e.g. diabetes). The most common symptoms are frequency,
urgency and nocturia.
Idiopathic detrusor overactivity
is cured by pharmacotherapeutic treatments in over
50% of cases......................................................... FALSE
45 can reliably be diagnosed on a history of frequency,
urgency and nocturia. ......................................... FALSE
46 is often caused by excessive fluid intake. ..........FALSE
47 is usually due t o intrinsic disease of the detrusor
FALSE
muscle...................................................................
44

Discussion
While symptoms of idiopathic detrusor overactivity can
usually be ameliorated with behavioural and pharmacotherapeutic treatments it is rarely cured. Urodynamic
assessment is the only way of obtaining a clear diagnosis of
the cause of urinary incontinence as symptomatology is
often misleading.
Frequency of voiding is often caused by excessive fluid

52

intake but concentrated urine is known t o worsen the

symptoms of detrusor instability, as is excessive caffeine
intake. It is as yet unclear whether the cause of detrusor
overactivity is myogenic or neurogenic.
Urodynamic assessment (UDA)
48 may be more accurate if ambulatory techniques are
employed. .............................................................. TRUE
49 findings usually correlate well with the severity and
FALSE
types of symptoms experienced..........................
50 is being superseded by ultrasound of the bladder in
the diagnosis of detrusor instability...................FALSE
Discussion
UDA is mandatory if surgery, particularly repeat surgery, for
incontinence is t o be undertaken. UDA is required t o make
the diagnosis of idiopathic detrusor overactivity, however,
empirical treatment of urge incontinence also has a
recognised role. Often there is no significant relationship
between the reported severity and type of symptoms and
the actual urodynamic variables. Ambulatory urodynamics
are currently only being used in the research setting but are
thought t o be more physiological and perhaps more
accurate. Ultrasound evaluation of bladder wall thickness is
useful if outflow obstruction is suspected.
In the treatment of idiopathic detrusor overactivity,
51 bladder drill is unlikely t o be successful in the younger
FALSE
patient. .................................................................
52 routine cystodistension does not provide good longterm benefit. ......................................................... TRUE
53 slow release preparations have fewer side effects than
immediate release equivalents. ........................... TRUE
54 anticholinergic drugs are generally well tolerated.
.............................................................................. FALSE
55 surgery is reserved for intractable symptoms. ....TRUE
56 imipramine should be used as a first-line treatment.
.............................................................................. FALSE
Discussion
Bladder drill, although requiring good motivation, is much
more successful in the younger patient. Alternative
therapies such as acupuncture, hypnotherapy, and
transcutaneous electrical nerve stimulation have shown
promise in the treatment of idiopathic detrusor overactivity
but have not yet been rigorously evaluated. Controlledrelease preparations of oxybutynin are just as effective as
immediate-release preparations but are associated with a
lower incidence of dry mouth (68% versus 87%).
Anticholinergic drugs lack specificity for the muscarinic
receptor subtypes and as a result have an extensive adverse
effect profiles. Evidence for the value of imipramine as a
treatment is conflicting and, therefore, this should not be
used as a first-line treatment. Cystodistension was formerly
routinely used t o treat idiopathic detrusor overactivity but
has been shown to be of little long-term benefit. More
radical surgical procedures are reserved for the most
refractory cases.
Regarding muscarinic receptors,
57 M3 receptors are found in the bladder. ..............TRUE
58 M2 receptors are found in the salivary glands. .FALSE
59 oxybutynin is a nonselective muscarinic receptor
antagonist. ........................................................... FALSE
60 darifenacin is an M3 receptor antagonist. ..........TRUE
Discussion
There are five types of muscarinic receptor within the body
(Ml-M5). The M2 and M3 receptors are found within the
bladder; M2 receptors predominate but the M3 receptor
seems t o mediate the main part of bladder contraction. M3
receptors are also found in the salivary glands, the

Answers to Questions for Volume 4, Number 3

lachrymal glands and the bowel, which explains the adverse
effect profiles of many drug treatments for idiopathic
detrusor overactivity. Oxybutynin, a tertiary amine, is a
highly selective M1 and M3 muscarinic receptor antagonist.
Darifenacin is a highly selective M3 receptor antagonist.

and, at the time of writing, there have been no

documented failures. It is the only form of contraception t o
have a Pearl Index of zero. lmplanon is associated with an
immediate return of fertility on removal.

Impact of contraception on subsequent fertility

73

Following cessation of the combined oral contraceptive

pill (COC)
61 less than 30% of women will ovulate in the first cycle.

74

they increase the likelihood of ectopic pregnancy.

..............................................................................

75

women should be advised t o use a barrier method of

contraception for three months before they attempt
t o conceive. ..........................................................
FALSE

76

there is a peak incidence of pelvic infection in the first

few weeks after insertion..................................... TRUE
Levonorgestrel-releasing
intrauterine
system
(Mirenaq is associated with a higher risk of pelvic
infection than a copper IUD. ..............................
FALSE

62
63

FALSE
there is an increased risk of miscarriage............FALSE

Discussion
The return of ovulation following cessation of the
combined oral contraceptive pill is rapid and around 70%
of women will ovulate in the first cycle. Women who
conceive immediately following cessation of the combined
pill can be reassured that there is no evidence of increased
risk of miscarriage or fetal abnormality. There is no
scientific evidence that women need t o use an alternative
method of contraception on cessation of the combined pill
prior t o attempting to conceive.
With regard t o 'post-pill amenorrhoea',
64 more than 5% of women remain amenorrhoeic after
six months.............................................................
FALSE
65 it is more common in women who lose weight when
using COC. ............................................................. TRUE
66 if it lasts longer than six months, then investigation is
warranted. ............................................................. TRUE
Discussion
'Post-pill amenorrhoea' affects around 1% of women six
months after stopping the combined pill. It may signify the
unmasking of an underlying gynaecological abnormality
such as polycystic ovary syndrome, hyperprolactinaemia or
a premature ovarian failure so these conditions should be
excluded. Loss of weight while taking the combined pill is
associated with 'post-pill amenorrhoea' although the exact
mechanism of this is not understood.
After discontinuing depot medroxyprogesteroneacetate
67 ovulation does not return on average until after 12
months..................................................................
FALSE
68 around 90% of women will have conceived by 24
months. ..................................................................
TRUE
69 the delay in return to fertility is thought t o be due t o
delayed metabolism of crystalline deposits. .......TRUE
Discussion
Ovulation returns on average four t o five months following
the last injection of depot medroxyprogesterone acetate.
Although there is a small delay in the return of fertility, over
90% of women will have conceived by 24 months, which is
equivalent t o women discontinuing other methods of
contraception. The delay in return of fertility is thought t o
be due to slow metabolism of microcrystalline deposits in
muscle tissue.
Et ono rgest reI reIeasi ng subde rma I implant (ImpIanon@)
70 reliably inhibits ovulation ..................................... TRUE
71 has a Pearl Index of zero. ..................................... TRUE
72 is associated with an immediate return of fertility on
removal. ................................................................. TRUE

Discussion
lmplanon is a highly effective method of contraception

Concerning intrauterine devices (IUDs),

a young nulliparous woman should be screened for
sexually transmitted infections prior t o IUD insertion.

................................................................................

TRUE

..............................................................................

FALSE

Discussion
An IUD is not associated with a significantly increased risk of
pelvic infection when used by women in monogamous
relationships with no risk factors for sexually transmitted
diseases. IUDs protect against all types of pregnancy,
including ectopic pregnancy. Although in the event of
failure of an IUD, the risk of ectopic pregnancy is higher
than in the normal population. Higher risk women such as
young nulliparous women and those requesting a postcoital IUD should be screened bacteriologically prior t o
insertion. There is a peak incidence of pelvic infection in the
first few weeks following insertion due t o introduction of
organisms into the uterine cavity. Mirena may offer
additional protective benefit against the risk of pelvic
infection compared with copper IUDs, as a result of its
hormonal action.
A woman using a diaphragm and spermicide for
contraception
77 has a reduced risk of pelvic infection..................
TRUE
78 has an increased risk of having an infant with cleft
palate if the method fails. .................................. FALSE
Discussion
Women using barrier methods of contraception have a
lower risk of pelvic infection. Although there was some
concern in the past about possible teratogenesis in women
using spermicide at the time of conception, recent scientific
data have been reassuring. There is no evidence of
increased risk of congenital abnormality and use of
spermicide in the periconceptional period would not
represent grounds for therapeutic abortion.
The following statements are correct:
Inadvertent use of COC during early pregnancy
increases the risk of masculinsation of the female
fetus. .....................................................................
FALSE
80 There is no evidence t o support the use of routine
antibiotic prophylaxis on insertion of IUDs.........TRUE
79

Discussion
Inadvertent use of COC during early pregnancy does not
increase the risk of masculinsation of female fetuses,
especially with modern low-dose preparations. There is no
evidence t o support the use of routine antibiotic
prophylaxis on insertion of IUDs, although preinsertion
bacteriological screening may be appropriate in some
cases.

Fetal resuscitation in labour

With regard to caesarean section,
when performed for a cord prolapse it would be
classified as a grade three procedure.................FALSE
82 regional anaesthesia compared with a general
81

53

Answers t o Questions for Volume 4, Number 3

83

anaesthetic is associated with improved one-minute

Apgar scores. .........................................................
TRUE
there is strong evidence that a decision t o delivery
interval of 30 minutes i s a critical threshold in
intrapartum fetal hypoxia................................... FALSE

Discussion
A caesarean performed for a cord prolapse is a grade 1
caesarean as there is an immediate threat to the life of the
fetus." A regional anaesthetic is associated with a reduced
incidence of postoperative morbidity in the mother and is
also beneficial t o the fetus, as it improves one-minute
Apgar scores.MHowever, in certain circumstances, such as
during a persistent fetal bradycardia, there may not be
sufficient time t o site a regional block. Evidence concerning
the 30-minute decision t o delivery interval for emergency
caesarean sections is lacking.
Concerning maternal oxygen therapy,
84 a reservoir bag attached t o a Hudson mask reduces
the fraction of effective inspired oxygen (FiO,).
.............................................................................. FALSE
85 the use of prolonged prophylactic oxygen in the
second stage of labour increases arterial cord blood
pH. ........................................................................ FALSE
86 fetal brain tissue oxygenation is increased during
fifteen minutes of maternal oxygen therapy......TRUE
Discussion
A reservoir bag increases the oxygen concentration the
mother inspires, as a t the middle of normal inspiration the
flow of air can be as high as 30 Vminute, which will not be
met by the flow of oxygen alone. Therefore, the patient
will breathe in the surrounding air. When prophylactic
oxygen was used in the second stage of labour, prolonged
use was associated with a significantly lower cord blood
P H . ~However, when oxygen therapy is used for short
phases fetal brain tissue oxygenation is seen t o increase
when measured by near-infrared spectroscopy.6
Concerning cord prolapse,
87 distending the bladder with saline has been
successfully used as part of the management of cord
prolapse. ................................................................ TRUE
88 in complete cord prolapse, funic replacement and
delayed delivery has been described with good fetal
outcomes. .............................................................. TRUE
89 management regimes are guided by randomised
controlled clinical trials. ...................................... FALSE
Discussion
Although the traditional management for cord prolapse is
knee-chest position and immediate caesarean, both funic
replacementz8and distending the bladder have been
described.'6 There have been no randomised controlled
trials comparing different management regimens.
Concerning maternal position in labour,
90 measurement of maternal systemic blood pressure is
useful when assessing aortocaval compression. FALSE
91 a left-lateral position compared with a supine
position can improve fetal oxygen saturation by over
5%. ........................................................................ TRUE
Discussion
Kinsella et a/. demonstrated that aortic compression was
relieved by increasing the amount of tilt.12 This was
measured with toe pulse pressure. However, during the
compression there was no systemic hypotension. Fetal
oxygen saturation measured by oximetry shows a significant
decrease in mean fetal oxygen saturation from 53.2% in the
left-lateral position t o 46.7% the supine p0siti0n.l~

54

With regard t o cardiotocographic (CTG) abnormalities and

the use of tocolytics in labour,
92 amniotic infusion may be used in selected cases in
labour t o treat some CTG abnormalities.............TRUE
93 magnesium sulphate is a less effective tocolytic in
labour than terbutaline. ....................................... TRUE
94 intravenous glyceryl trinitrate is a long-acting
FALSE
tocolytic. ...............................................................
95 intravenous terbutaline reduces uterine activity by
over 75% in 15 minutes........................................ TRUE
96 adverse effects of terbutaline include vomiting.TRUE
Discussion
Amniotic infusion has been shown t o improve CTG
abnormalities and reduce the incidence of caesarean
sections, however, in these studies, fetal distress was not
confirmed by fetal blood ~arnpling.~
Magnesium sulphate is
significantly less effective than terbutaline a t reducing
uterine activity. Glyceryl trinitrate has a short half life;
whereas terbutaline, as well as effectively reducing uterine
contractions, has a more prolonged action.lgTerbutaline is
fast acting and can reduce uterine activity by up t o 87.3% in
15 minutes. However, it can have significant adverse effects
including maternal tachycardia, palpitations, vomiting and
tremors.
With regard t o uterine activity in labour,
97 a uterine contraction of 1 kPa causes cessation of
FALSE
placental bloodflow.............................................
98 a contraction interval of less than two minutes results
in a fall of cerebral oxygenation. ........................
TRUE
99 the effects of a rapid infusion of normal saline on
uterine activity will last for a t least one hour. ..FALSE
100 fifteen minutes after ceasing an oxytocin infusion
there
. . is approximately a 20% reduction in uterine
activity. ................................................................... TRUE
Discussion
Uterine contraction above 4-6 kPa causes a cessation of
maternal intervillous placental bloodflow.16This produces a
relative fetal hypoxia; recovery takes 60-90 seconds. A
short contraction interval of less than two minutes results
in a fall of cerebral oxygenation. The effects of a rapid
infusion last only last 20 minutes. Stopping an oxytocin
infusion will not cause an immediate cessation of uterine
activity. After 15 minutes there is only a 22% reduction in
activity, by 30 minutes a 39% reduction and by 45 minutes
a 48% reducti~n.'~

A clinical approach to heart disease in pregnancy

Part 1: general considerations in management

Pregnancy is contraindicated in the following cardiac
conditions:
101 Eisenmenger's syndrome. .....................................
TRUE
102 severe asymptomatic aortic stenosis. ...................TRUE
103 previous peripartum cardiomyopathy with residual
TRUE
mild left ventricular dysfunction..........................
104 mitral valve prolapse with severe mitral valve
regurgitation. ....................................................... FALSE
Discussion
There are some common contraindications t o pregnancy,
which have been well documented. These include severe
pulmonary hypertension, either primary or secondary, of
which Eisenmenger's syndrome is associated with up to
50% maternal mortality.' Any severe obstructive lesions,
whether they are symptomatic or not, are contraindicated
t o pregnancy. Severe aortic stenosis is associated with 17%
maternal mortality." Any minor decrease in preload or
increase in vascular volume is detrimental. Surgical

Answers to Questions for Volume 4, Number 3

management is, therefore, advisable before pregnancy."'
Previous peripartum cardiomyopathy is another
contraindication because of the high risk of recurrence and
overall poor prognosis.iv Regurgitant valve disease is well
tolerated in pregnancy because the systemic vasodilatation
favours a forward flow with an unimpeded left ventricular
filling."
Regarding heart disease in pregnancy,
105 evidence confirms that antibiotic regimens during
labour reduce the frequency of endocarditis....FALSE
106 valvular regurgitation carries a greater risk for the
mother than valvular stenosis............................. FALSE
107 urinary tract infection is a significant risk factor for
the development of heart failure. ....................... TRUE
Discussion
There is no evidence to suggest that prophylactic antibiotic
regimens have an effect on the frequency of endocarditis.
Valvular stenosis carries a moderate t o high risk of
mortality (1-1 5%) whereas mild to moderate valvular
regurgitation carries a low risk (el%). Risk factors for heart
failure include anaemia, hypertension, multiple pregnancy
and infections, especially urinary tract infections.
The following statements are correct:
108 The use of angiotensin-converting enzyme (ACE)
inhibitors is safe during pregnancy. ................... FALSE
109 Paroxysmal nocturnal dyspnoea may be a normal
FALSE
symptom of pregnancy........................................
110 Cardiac output a t 24 weeks gestation is 45% greater
than in the non-pregnant state. .......................... TRUE
Discussion
ACE inhibitors should be avoided during pregnancy, as
they are associated with fetal and neonatal renal failure
and death. While some symptoms such as palpitations can
be normal during pregnancy paroxysmal nocturnal
dyspnoea, synscope, haemoptysis and chest pain are not
and should be evaluated. Cardiac output increases in
pregnancy and by 24 weeks of gestation it rises to 45%
above the baseline.
Additional references
i. Gleicher N, Midwall J, Hochberger D, Jaffin H.
Eisenmenger's syndrome and pregnancy. Obstet
Gynecol Sun/ 1979;34:721-41.
ii. Arias F, Pineda J. Aortic stenosis and pregnancy. I
Reprod Med 1978;4:229-32.
iii. Oakley CM. Valvular disease in pregnancy. Curr Opin
Cardiol 1996;11:155-9.
iv. DeMarkis JG, Rahimtoola SH. Peripartum cardiomyopathy. Circulation 1971;44:964-8.
v. Tang LCH, Chan SYW, Wong VCW, Ma HK. Pregnancy in
patients with mitral valve prolapse. lnt I Gynaecol
Obstet 1985;23:217-21.

Interpreting statistics with confidence

A 95% confidence interval for the mean estimated from a
large random sample of observations
1 1 1 is a set of values within which, in the long run, 95%
of observations fall. ............................................. FALSE
112 is a way of measuring the precision of the estimate of
the mean................................................................ TRUE
113 is an interval within which the sample mean falls with
FALSE
probability 0.95....................................................
114 is chosen so that 95% of such intervals will include the
TRUE
population mean...................................................
115 can be calculated from mean minus 1.96 standard
errors to mean plus 1.96 standard errors............TRUE

Discussion
The confidence interval for the mean does not tell us
anything about the distribution or variability of the
observations. The sample mean is always in the middle of
the limits. In large samples, sample estimate k1.96standard
errors is the usual way of calculating confidence intervals.

A study of maternal depression was carried out in

Victoria, Australia, in September 1993.The point
prevalence of depression a t six t o seven months
postpartum was 16.9% (22511331;95% CI 14.9to 18.9%).'
116 Another sample of the same size from this population
would have shown a rate of depression between
14.9% and 18.9% ................................................. FALSE
117 95% of such women have a probability of between
14.9% and 18.9% of reporting depression........FALSE
118 It is likely that between 14.9% and 18.9% of women
in the area would report depression a t six to seven
TRUE
months postpartum. .............................................
119 If the sample were increased to 2662 mothers, the
95% confidence interval would be narrower. ....TRUE
120 It would be impossiblet o get these data if the rate for
all mothers in South Australia was 14%. ...........FALSE
Discussion
The confidence interval is an estimate of the overall
proportion, which applies to all women. It is the probability
that a woman chosen a t random will have depression. We are
not estimating the distribution of risk. Ninety-five percent of
possible samples will have confidence intervals that contain
the population proportion, but this particular confidence
interval will not include 95% of possible sample proportions.
A larger sample would result in a reduced standard error and
a narrower interval. A population proportion outside the
confidence interval is not impossible, as 5% of confidence
intervals do not include the population value.
In a randomised trial of vaginal clindamycin versus
placebo for early pregnancy bacterial vaginosis, the odds
ratio of preterm birth was 2.5 (95yo CI 0.6 t o 10.O).z
121 The odds ratio would be zero if the two treatments
FALSE
had the same effect.............................................
122 The treatments are not significantly different a t the
5% level. ................................................................ TRUE
Discussion
The odds ratio would be 1 .O if the treatment had no effect.
An odds ratio of zero would indicate a very large effect. As
the 95% confidence interval includes 1.0, the data are
consistent with the null hypothesis and the difference is not
significant.
In a trial of prednisolone versus placebo in children with
acute asthma, 2 of the 73 patients in the placebo group
were discharged a t first examination (3%; 95% CI -1 t o
6%).) Reported by Altn~an.~
123 This confidence interval is plausible. ..................FALSE
124 The exact binomial method should have been used
here. ....................................................................... TRUE
Discussion
The confidence interval should not include a negative
number, because the number of children discharged cannot
be negative. The large sample normal approximation to the
binomial distribution has been used, but the sample is too
small. The exact binomial method would be much better,
giving 0.3% t o 9.5%.
Children born during two randomised controlled trials of
routine ultrasound screening during pregnancy were
followed up a t ages eight to nine ears. A sample of
children underwent specific tests or dyslexia. The test

55

Answers t o Questions for Volume 4, Number 3

results classified 21 of the 309 screened children (7%;
95% CI 3 t o 10%) and 26 of the 294 controls (9%; 95% CI
4 to 12%) as dyslexic.'
125 A confidence interval for the difference between the

percentages would be more useful than those given.

126

................................................................................ TRUE
A confidence interval for the ratio of the percentages
would be more useful than those given. ............TRUE

Discussion
Confidence intervals are always calculated regarding the
data as a sample. A sample of a sample is still a sample.
Much more useful would be a confidence interval which
compares the two groups directly. For the difference
between prevalences it would be 6 . 3 t o +2.2 percentage
points, for the ratio it would be 0.44 t o 1.34.
In a study of mitomycin in the treatment of non-small-cell
lung cancer, subjective response was reported complete in
two of 20 patients, reported as 10%; 95% CI 0 t o 21.6
127 The confidence interval should not include zero.

................................................................................

TRUE

Discussion
As we have observed a complete response in two patients,
it is impossible for the proportion in the population of
patients that includes them t o be zero.

Danish women having undergone h sterectomy with

conservation of a t least one ovary or a benign indication
from 1977 to 1981 (n = 22 135)were compared with all
Danish women who had not undergone hysterectomy.The
extrapolated lifetime risk of developing ovarian cancer
was 2.1% after hysterectomy and 2.7% in the general
population (RR 0.78;95% C I 0.60to 0.96).'
128 If there were no difference, the expected relative risk
would be 1.0.......................................................... TRUE
129 The difference is statistically significant.............. TRUE
Discussion
The null hypothesis value for a ratio is usually 1.0.As the
confidence interval does not include this, the difference is
significant a t the 0.05 level.
Salpingectomy and conservative tuba1 surgery as
treatments for ectopic pregnancy were compared
economically In the short term, costs per patient were
f1,554 (95% CI f1,501 to f1.656)for salpingectomy and
f1,787 (95% CI f1,683t o f1,930)for conservative
surgery.8
130 The different in cost between the two regimens is
statistically significant. .......................................... TRUE
Discussion
The 95% confidence intervals do not overlap, so the
difference i s statistically significant. The authors also
correctly presented an estimate and confidence interval for
the difference in mean cost, f233 (95% CI f80 t o 371).

The Obstetrician & Gynaecologist

CPD QUESTIONS
A reminder to UK C P D Participants and Overseas C P D Participants.
Are you taking part in the C P D exercise provided in each issue of the
journal? If not, please note that a maximum of 20 personal C P D credits
per year may be available to you for undertaking this activity.

Full instructions are provided in each issue of

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56

For reference citations t o these answers, please refer to

those in the original questions, not those in the article (The
Obstetrician &
Gynaecologist
i
2002;4:1 50)

Greentop Guideline 30: Management of genital

herpes in pregnancy
The following statements are correct:
131 Most maternal herpes simplex virus (HSV) infections
are asymptomatic. ................................................. TRUE
132 Lower segment caesarean section (LSCS) is
recommended for all women presenting with firstepisode genital herpes lesions during the second
trimester................................................................ FALSE
133 Antenatal swabbing accurately predicts the shedding
FALSE
of virus a t the onset of labour............................
134 Almost all cases of neonatal herpes occur as a result of
postnatal transmission......................................... FALSE
135 The incidence of neonatal herpes is less than two per
100 000 live births annually in the UK.................TRUE
136 Serological testing for HSV in late pregnancy is cost
effective in preventing herpes related morbidity.

..............................................................................

FALSE

137 There is no clinical evidence of fetal toxicity when

aciclovir i s administered t o the mother in late

pregnancy. ............................................................. TRUE
138 Obtaining a history of genital herpes in the partner of
a woman is not an accurate way of determining the
risk of acquiring primary HSV infection during
pregnancy. ............................................................. TRUE
139 Where genital herpes is present for the first time a t
the time of delivery, the risk of transmission to the
fetus i s dependant upon the time that the
TRUE
membranes have been ruptured. ........................
140 Routine performance of LSCS in cases of maternal
recurrent genital herpes lesions has led t o a
significant decline in the incidence of neonatal
herpes. .................................................................. FALSE

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