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The Obstetrician & Gynaecologist

CPD Answers to questions

for volume 11, number 4
Numbered references correspond with the citations in the original
article and so are not listed here.

The surgical approach to postpartum

haemorrhage
With regard to the use of inflatable balloons for the control of
postpartum haemorrhage,
1
inflation to up to 50 ml is advised.
False
2
if a Bakri balloon is not available, a Foley catheter
is a suitable alternative.
False
3
ideally, they should include a separate channel to drain the
lochia from above the balloon.
True
Discussion
Commonly, ~300 ml of sterile saline is needed to inflate a balloon. In the
absence of a balloon specifically designed for the purpose, similar tamponade
can be obtained using the stomach balloon of the Sengstaken catheter; the
capacity of the balloon needs to be up to 500 ml, so small balloons such as
those found on Foley catheters are insufficient.

With regard to the use of uterine compression sutures,

4
it is not necessary to open the uterus before insertion.
5
a nonabsorbable suture such as nylon is advisable
because of its strength and ease of insertion.
6
long-term follow-up shows a high rate of intrauterine
adhesions following their use.

With regard to placenta praevia,

10 the incidence after two previous caesarean sections
is one in 300.
11 if a woman has had two previous caesarean sections
and the placenta is praevia, there is approximately
a 1 in 6 chance that it will be placenta accreta.
12 the demonstration, using power Doppler, of pulsatile
blood flow in the bladder wall increases the likelihood
of placenta accreta being found.
13 placenta accreta is rare in the absence of placenta
praevia.

False

True

True
True

Discussion
The incidence is 1 in 60 after two caesarean sections.

In cases of suspected placenta accreta,

14 a wide, muscle-splitting Pfannenstiel incision should
be used.
15 intraoperative scanning can be very helpful.
16 methotrexate can be used as an alternative to removal
of the placenta.

False
True
True

Discussion
True

The most appropriate abdominal incision is a midline, which gives the best
access in case of heavy bleeding. Some authorities have suggested using

False

methotrexate to speed placental involution.

False

With regard to the use of inflatable balloons for the control of

postpartum haemorrhage,
17 insertion of a Mersilene suture around the cervix
is sometimes necessary in addition to the balloon
to aid uterine compression.

True

With regard to the use of uterine compression sutures,

18 square suturing can lead to pus collecting inside
the uterus.

True

Discussion
All compression sutures should be absorbable;21 as the uterus involutes, the
sutures will become loose and, if they are nonabsorbable and do not produce
an inflammatory reaction making them adhere to the uterine surface, there is
always the risk that loops of free suture will result. This can allow bowel to
become entangled in the loops, resulting in obstruction.

With regard to vessel occlusion,

7
uterine artery ligation should be avoided because it may
compromise future pregnancies.
False
8
completely occluding the aorta below the renal artery
for up to 4 hours does not significantly increase the risk
of damaging ischaemia to the lower limbs.
True
9
local occlusion of multiple bleeding vessels in the pelvis is
impossible because of an inability to maintain pressure on
them.
False
Discussion

Discussion
There is concern that a square suture may completely occlude the blood supply
to the uterine muscle within the square, leading to ischaemic necrosis and
subsequent complications.

With regard to caesarean hysterectomy,

19 it is very important to avoid obstructing the ureters
when oversewing bleeding sites, to avoid permanent
renal damage.

False

There appear to be no consequences for future pregnancies of uterine artery

Discussion

ligation, presumably because a collateral circulation develops from other

Any specific bleeding sites should be oversewn, even if it seems possible

vessels (particularly the ovarian arteries) to compensate. Blood flow to the

that the ureter may be obstructed. This can always be rectified at a later

legs can be completely stopped for 4 hours or more without irreversible

date, once the woman is no longer at risk of death from haemorrhage. Even

damage. Arrest of widespread oozing in the pelvis by tamponade can be

complete occlusion of the ureter for several days will not result in permanent

achieved using the Logethotopulos pack and maintained until more

damage to renal function, which will resume once the obstruction is

permanent techniques such as embolisation become available.

relieved.

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Answers to questions for volume 11, number 4

With regard to the use of packs for the control of postpartum

haemorrhage,
20 if bimanual compression appears effective, but bleeding
recommences when compression is stopped, a traditional
approach is to use a Logethotopulos pack in the uterus. False
Discussion
The Logethotopulos pack can be used to stabilise the situation if bleeding
continues after the uterus has been removed.

Fertility-saving treatment in
gynaecological oncology
With regard to cervical cancer,
21 approximately 45% of women diagnosed with cervical
cancer are under 45 years of age.
22 spread to pelvic lymph nodes occurs in approximately
4% of women with stage IA2 cervical cancer.
23 radical trachelectomy has an inferior recurrence rate
to radical hysterectomy.

Discussion
Knife cone biopsy has been shown to increase the risk of premature delivery,
low birthweight and caesarean section.13

For stage IA1 carcinoma of the cervix,

31 lymphovascular space invasion is not a contraindication
to knife or laser cone biopsy alone.
False
32 the risk of lymph node involvement is up to 5% in those
with tumour invading to a depth of 3 mm.
False
33 where ovarian transposition is an option for fertilitysparing treatment, ovulation induction followed
by oocyte retrieval and then surgery has been shown
in clinical trials to influence outcome.
False
Discussion
Women with FIGO stage IA1 disease (squamous cell carcinoma of the cervix

True

invading to a depth of 3 mm and width of 7 mm) have a risk of 1% of

lymph node involvement compared with approximately 5% in women with

True

tumour invading to a depth 3 mm.4,5 Ovarian transposition has been used to

preserve ovarian function in women with stage IB2 cervical cancer and above

False

Discussion

who are to undergo pelvic radiation.21

Concerning stage IA adenocarcinoma of the cervix,

34 cone biopsy is regarded as inadequate because the disease
tends to be present higher in the endocervical canal.
False

Case series and case controlled studies1517 have shown that there is no
significant difference in recurrence rates after radical vaginal trachelectomy
compared with radical hysterectomy.

With regard to endometrial cancer,

24 women with early cancer have a response rate to high
dose progestogens of approximately 55%.
25 women who respond to progestogens have an
approximately 10% recurrence rate.
26 an important concern is that up to almost one-quarter
of young women with the disease will have a co-existing
ovarian cancer.

CPD

Discussion
Traditionally, treatment was by hysterectomy because of its multifocal nature
and the fact that it was usually present higher up in the endocervical canal.

True

However, knife cone biopsy has become a frequently used management

option.11,12

False

True

Discussion
38

With regard to radical vaginal trachelectomy,

35 tumour diameter of 2 cm with or without
lymphovascular space invasion defines those
who are offered this treatment option.

A recent study by Ushijima et al. reported a complete response in 55%

Discussion

of the women with endometrial carcinoma given medroxyprogesterone

Most authors would require that the tumour diameter should be 2 cm,

acetate. A recurrence rate of 47% was documented. Other studies have

False

with no lymphovascular space invasion, and that the tumour should be

also demonstrated high recurrence rates, of 25%.39,40 In young women with

grade 12.18

endometrial cancer 1029% will have a co-existing ovarian cancer.36,37

With regard to ovarian cancer,

27 germ cell tumours of the ovary are highly chemosensitive. True
28 conservative treatment of borderline tumours is not the
standard approach in young women.
False
29 in epithelial ovarian cancers, women with no visible
metastases at the time of laparotomy will have
microscopic metastases in approximately 5% of cases.
False

Following fertility-sparing surgery for stage I ovarian germ

cell tumours,
36 the survival rate where the tumour is confined to one
ovary is over 90%.
37 those with mixed type of tumour on histology have
the worst prognosis.
38 where there is metastasis, chemotherapy is effective
as these tumours are highly chemosensitive.

Discussion

Discussion

Numerous reports have demonstrated an excellent prognosis for borderline

In a study conducted by Zanetta et al.,47 the survival rate was 100% for mixed

4951

tumours.

Most are confined to the ovaries and can therefore be managed

True
False
True

types in women who underwent unilateral salpingo-oophorectomy.

conservatively with preservation of the uterus and contralateral ovary. If the

tumour is bilateral, bilateral ovarian cystectomy may be performed. Metastasis
occurs in 1520% of women with apparent stage I epithelial ovarian cancer.57,58

With regard to cervical cancer,

30 women having treatment with knife cone biopsy need
to be made aware of an increase in the risk of obstetric
complications.

2010 Royal College of Obstetricians and Gynaecologists

True

With regard to borderline epithelial ovarian tumours,

39 where they occur in the reproductive age group and are
bilateral, removal of both ovaries is an acceptable
treatment option.
40 survival rates are similar between fertility-sparing
surgery and hysterectomy and bilateral
salpingo-ophorectomy.

True

True

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Answers to questions for volume 11, number 4

Reduced fetal movements

54

Is the following statement about fetal movements in pregnancy

correct?
41 According to CESDI, a (significant) number of stillbirths
were associated with reduced fetal movements to which
professionals failed to act appropriately.
True
Discussion
In their eighth annual report6 45% of stillbirths were associated with suboptimal

55
56

The Obstetrician & Gynaecologist

there is evidence that umbilical artery Doppler ultrasound

scanning is better at predicting perinatal mortality
and handicap than cardiotocography.
False
the use of kick charts has been shown to increase obstetric
interventions by approximately 1.5 to 3-fold.
True
the use of biophysical profiling in high risk pregnancies
has been shown in randomised controlled trials to reduce
perinatal deaths.
False

Discussion
Cardiotocography is useful in the detection of acute hypoxia but is a poor test

care; 69 cases (16.4%) were related to fetal movements.

for chronic hypoxia.4 Large-scale studies show that cardiotocography does

With regard to fetal movements,

42 maternal perception increases with gestation, so that
more movements are felt by term.
False
43 improved co-ordination of movements occurs as
pregnancy advances, making movement more cyclical.
True
44 intrauterine death is preceded by cessation of
movements within 24 hours.
False
45 there is evidence that the count-to-ten definition of
reduced fetal movements is better at predicting outcome
than maternal perception of reduced fetal movements.
False
Discussion
There is a gradual decline during the third trimester; it has been suggested that
this is due to improved fetal co-ordination and reduced amniotic fluid volume,
coupled with increased fetal size.8 There is no evidence that any formal
definition of reduced fetal movements is of greater value than subjective
maternal perception in the detection of fetal compromise.

gestational-age fetuses below the 10th centile than large-for-gestational-age

fetuses.16 Dubiel et al.32 found that cardiotocography seemed to be a better
predictor of mortality and infant handicap than Doppler velocimetry. Lalor et al.35
report that the available evidence from randomised controlled trials does not
support the use of the biophysical profile as a test of fetal wellbeing in high risk
pregnancy.35

Cardiotocography
57 is useful in detecting chronic fetal hypoxia where there
are decelerations and a history of reduced fetal
movements.
58 should be part of the assessment of every women
who presents with reduced fetal movements at
24 weeks of gestation.

False

False

Cardiotocography is useful in the detection of acute hypoxia but is a poor test for
chronic hypoxia.4 It is widely accepted as the primary method of antenatal fetal
monitoring to assess the current status of the fetus,19 but its use is particularly

True

Discussion
A clinical opinion about the size of the baby, including abdominal palpation
and the measurement of symphysealfundal height, should be part of every
assessment and is helpful in the management of reduced fetal movements.

130

and estimated fetal weight measurements are better at predicting small-for-

Discussion

In the presence of reduced fetal movements,

46 the symphysealfundal height should be measured
and plotted on a chart before further investigations
are undertaken.

With regard to investigations used in assessing reduced fetal

movements,
47 symphysealfundal height (SFH) measurement has
a positive predictive value of 60% for
small-for-gestational-age fetuses.
48 an SFH measurement that is within normal limits
implies that fetal growth restriction is unlikely to
be present.
49 approximately two-thirds of babies with birthweights
below the 10th centile are constitutionally small.
50 cardiotocography has been shown to be useful in the
identification of chronic hypoxia.
51 the use of cardiotocography has been shown from
large-scale studies to reduce the stillbirth and
perinatal mortality rates.
52 an advantage of computerised cardiotocography
is that it improves discrimination between normal
and questionable records after 24 weeks of
gestation.
53 estimated fetal weight and abdominal circumference
measurements are just as good at predicting small
as well as large for gestational age.

not reduce rates of stillbirth or perinatal morbidity.19 Abdominal circumference

difficult and cannot be recommended before 28 weeks of gestation.15

Fetal biometry to assess estimated fetal weight

59 should be considered in women presenting with reduced
fetal movements for the second or subsequent time.

True

Discussion
There is little evidence about how to manage these pregnancies. A practical
approach would be to perform ultrasound assessment to rule out a small-forgestational-age fetus, structural anomalies and oligo-or polyhydramnios and
invite the woman for daily cardiotocography until mother and clinician are

True

True
True

reassured.

In women presenting with reduced fetal movements,

60 up to approximately one-third of them have been shown
to be carrying a small-for-gestational-age fetus.

True

The postmenopausal vulva

False

False

True

False

With regard to the menopausal vulva,

61 ointments are less likely to cause allergy than creams.
62 more than half of all postmenopausal women have
vulvovaginal symptoms.
63 most women will seek help for their vulvovaginal
symptoms.
64 loss of pubic hair and adipose tissue occurs in vulval
atrophy.
65 irritant dermatitis is more common than allergic
dermatitis in postmenopausal women.

True
False
False
True
True

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Answers to questions for volume 11, number 4

urinary incontinence is a common cause of irritant

dermatitis.

True

Discussion
The Womens Health Initiative data2 revealed that vulvovaginal symptoms,
including dryness, irritation and itching, affect up to 27% of postmenopausal
women and other studies have supported this observation. Only a third of
women seek help for vulvovaginal symptoms of any kind.2

contentious. Risk of malignant change is low but change likely to be

rapid, which would necessitate very regular examination. As a
minimum, women should be advised to report non-healing ulcers,
bleeding, any lumps and any uncontrolled symptoms. Although
specific evidence is lacking, systemic absorption leading to adrenal
suppression from vulval steroid treatment is virtually unheard of and
many clinics have safely used vulval steroids for decades.
Lichen simplex chronicus
78 is caused by the overuse of steroids.

Regarding HRT,
67 the use of progestogens is not indicated with low-dose
vaginal estrogen therapy.

True

CPD

False

Discussion
This is a secondary condition resulting from the itch-scratch-itch cycle.

Discussion
One of the North American Menopause Societys recommendations2 regarding
vulvovaginal symptoms is that when low-dose estrogen is administered locally

With regard to contact dermatitis,

79 the use of emollients will help to alleviate any stinging.

False

for vaginal atrophy, progestogen is generally not indicated.

Discussion
The postmenopausal vulva
68 is more susceptible to bacterial pathogens due to a
decrease in skin pH.
69 is less permeable to irritants than other aged skin.

The use of a soap substitute and emollients can cause burning or stinging
initially in severe cases.

False
True

Discussion

Lichen planus
80 leads to a characteristic cigarette paper texture to the
vulva.

False

Estrogen deficiency and ageing both cause a rise in skin pH from its usual

Discussion

acidity, resulting in a decrease in the antimicrobial defences of the skin.1,2

The texture of parchment or cigarette paper is characteristic of lichen

Lichen sclerosus
70 requires treatment even if asymptomatic.
71 involves the vagina in approximately 70% of cases.

sclerosus.

False
False

Discussion
Lichen sclerosus is managed systematically. The vaginal vault and cervix are
6

spared; in lichen planus there is vaginal involvement in up to 70% of cases.

Lichen planus
72 is thought to have an autoimmune aetiology.
Vulvodynia
73 often leads to skin changes on the vulva.

True

False

Discussion
The International Society for the Study of Vulvovaginal Disease has recently
defined vulvodynia as vulval discomfort, most often described as burning pain,

Fused labia: a paediatric approach

With regard to labial fusion,
81 it has been reported to present in as many as 39% of girls.
82 low estrogen levels are considered the most important
aetiological factor.
83 the peak incidence is between the ages of 24 years.
Labial fusion
84 rarely occurs in the neonatal period.
85 is self-limiting and naturally corrects itself when it
occurs in early puberty.

True
True
True

True
True

Discussion
Fused labia occur when estrogen levels are low and are therefore extremely

occurring in the absence of relevant visible findings or a specific, clinically

rare in the first 3 months of life when maternal estrogens are still abundant

identifiable, neurologic disorder.

in the infants circulation.

With regard to lichen sclerosus,

74 a biopsy is always needed for diagnosis.
75 textural changes are recognised to help differentiate
from other diagnoses.
76 the risk of malignant change is approximately 60%.
77 topical steroids should not be continued long term.

False
True
False
False

Discussion
Clinical diagnosis is accepted as standard practice, with histology
reserved for diagnostically difficult cases, those which fail to respond
to treatment and suspicious areas.5 The classic appearance of lichen
sclerosus is of porcelain-white plaques on the vulva, perineum and
perianal skin. The texture of parchment or cigarette paper is
characteristic and helps to distinguish lichen sclerosus from lichen
planus or vitiligo. Follow-up of women with lichen sclerosus remains

2010 Royal College of Obstetricians and Gynaecologists

Concerning the pathogenesis of labial adhesions,

86 those associated with nappy rash require treatment once
the rash has resolved.
False
87 where the adhesions are associated with lichen sclerosus,
they are characteristically dense and difficult to treat.
True
88 entrapment of the clitoris in labial adhesions occurs
when these are associated with lichen sclerosus.
True
89 there is evidence to link labial adhesions and child sexual
abuse.
False
Discussion
In some children labial fusion is associated with nappy rash and may resolve
once the child is toilet trained. Both adhesions and child sexual abuse are
common and may co-exist, but it is not now thought that the two are linked.

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In girls with labial adhesions,

90 altered urinary stream is a common presentation in
those with urinary symptoms.
91 asymptomatic bacteruria occurs in the vast majority
of cases.
92 altered stream has not been shown to interfere with
toilet training.

False
False
False

Discussion
Labial adhesions are, in the vast majority of cases, asymptomatic. Rarely,
however, they can be associated with urinary symptoms, vulvovaginitis and
pain. Occasionally, an altered urinary stream interferes with toilet training or

The Obstetrician & Gynaecologist

Pregnancy outcomes after uterine artery

embolisation for fibroids
The following statements regarding uterine artery embolisation
(UAE) are true:
101 Fibroid expulsion occurs in up to 1 in 10 cases.
True
102 It should not be undertaken as a day-case procedure.
False
103 It has not previously been associated with
post-procedural deaths.
False
Discussion
A day-case or overnight stay is usually sufficient. Deaths from overwhelming

leads to soiling during micturition.

sepsis have been reported.10

Concerning treatment of labial adhesions,

93 severe adhesions have been reported to be associated
with sequelae to the patients reproductive and
sexual life.
False
94 meticulous hygiene is essential mainly in those cases
secondary to vulvovaginitis.
False
95 where the adhesions are associated with a skin condition,
such as lichen sclerosus, the condition should be
treated.
True
Discussion
The labial adhesions will resolve naturally when endogenous estrogen production
starts, usually before the age of 9 years, and there are no associated sequelae to
the girls future reproductive and sexual life. Irrespective of whether labial fusion is
symptomatic or not, advice on meticulous hygiene of the vulva is recommended,
as for vulvovaginitis. If the adhesions are associated with a skin condition, such as
lichen sclerosus, this is usually symptomatic and will need treatment.

Discussion
On the whole, there are very few studies looking at pregnancies post-UAE
and even fewer that set out to examine pregnancy outcome in women
following UAE prospectively and specifically. Uterine artery embolisation can
adversely affect fertility by inducing transient or permanent amenorrhoea
accompanied by other symptoms of ovarian failure in up to 5% of women.

With regard to treatment,

96 topical application of estrogen cream is not recommended
for more than 6 months.
False
97 topical betamethasone is a recommended treatment in
cases of severe adhesions.
False
Discussion
Local application of estrogen cream on the labia is not recommended for
longer than 6 weeks. Betamethasone is a potent steroid that can be
associated with local skin weakening and irritation, as well as potential
concerns from systemic absorption. It is therefore not a recommended
management option.

Surgical management
98 is recommended for adhesions associated with urinary
symptoms of alterations in stream.
99 in the form of gentle labial traction or running a
sound along the line of fusion is the recommended
approach.
100 is associated with a higher rate of recurrence than
estrogen treatment.

Regarding the impact of UAE on fertility and ovarian function,

104 it is relatively contraindicated in women wishing to
preserve their fertility.
True
105 its impact on future fertility has been extensively
investigated.
False
106 it has been associated with amenorrhoea.
True
107 symptoms of ovarian failure may occur in up to
1 out of 20 women.
True
108 the incidence of ovarian failure after the procedure
is reportedly higher in younger women.
False

Most cases appear to occur in women over 45 years,28 but younger women
are not immune from this devastating sequela.29

Pregnancies following UAE

109 currently number in the thousands.
110 are associated with a live birth rate of 60%.
111 end in preterm delivery in the majority of instances.
112 are particularly at risk of fetal growth restriction.
113 are likely to be delivered via caesarean section in
over 60% of cases.
114 do not appear to be at increased risk of postpartum
haemorrhage.
115 are at risk of miscarriage in up to 3540% of cases.

False
True
False
False
True
False
True

Discussion
See Table 1 and Table 2 in the article.

False

True

When compared with pregnancies following myomectomy

for uterine fibroids, pregnancies following UAE
116 are generally considered to be safer.
117 have a lower risk of miscarriage.

False
False

False

Discussion
Discussion

The most recent (2004) study5 showed that there was a trend towards higher

A conservative approach is usually suggested in cases where labial

rates of miscarriage (P  0.175; OR 1.7; CI 0.83.9). The authors of the study

adhesions cause urinary symptoms. Surgical correction may be indicated

concluded that pregnancies post-UAE are at increased risk compared with

where medical treatment has failed. Recurrence is a common problem in

pregnancies post-laparoscopic myomectomy.

labial adhesions after both application of estrogen cream and surgical

separation. Recurrence rates range between 1016%, depending on the
treatment.4

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Regarding the effects of UAE on uterine and endometrial integrity,

118 the endometrial cavity remains normal.
False

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119 fibroids that are initially intramural can migrate to a

submucosal location.

True

Discussion
It does not eliminate fibroids completely but instead induces a reduction in
fibroid volume of about 5060%9 accompanied by fibroid migration towards
the endometrial cavity that could result in distortion of the endometrial contour.

The following statements regarding uterine artery embolisation

(UAE) are true:
120 It eliminates fibroids completely in up to 5060% of women. False
Discussion
See discussion section for questions 118 and 119.

Green-top Guideline No. 52 (May 2009).

Postpartum Haemorrhage, Prevention
and Management
The following statements regarding postpartum haemorrhage
(PPH) are correct:
121 The highest risk factor is prolonged labour.
False

122 Regarding fluid therapy, 2 units of fresh frozen

plasma should be given for every 6 units of blood
transfused.
123 The main therapeutic goal is to maintain a
haemoglobin level 8g/dl.
124 Misoprostol is the most pharmacologically effective
agent in reducing bleeding.
125 Internal iliac ligation is the most effective surgical
haemostat.
126 There are no trials comparing oxytocin with
ergometrine as first line treatments for
PPH.
127 For women without risk factors for PPH, oxytocin
is the prophylaxis of choice in the third stage
of labour.
128 Following a major PPH, the woman should be
nursed in the left lateral position with the head
down.
129 Following a major PPH, blood filters should not
be used as they slow infusions.
130 The maximum that should be infused prior to the
arrival of blood is 3.5 l.

CPD

False
True
False
False

True

True

False
True
True

Instructions for CPD Questions

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Please log in to the website to use the TOG CPD function, which can be found in the Our profession section.
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are published.
Please direct all questions or problems to the CPD Office, Clinical Governance and Standards Department,
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