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Questions for volume 9, number 2

Please note that the maximum number of CPD credits you can claim for each issue of The Obstetrician & Gynaecologist is five. Please be selective when undertaking the questions and ensure that you submit answers to no more than five topics.

The deadline for submitting your answers to the questions in Volume 9 number 2 is 17 October 2007.

The current management of vaginal birth after previous caesarean delivery

In the UK

1 the relative risk of uterine rupture during vaginal birth after caesarean section is under 3%. T   F   2 a countrywide audit has reported a caesarean section rate of 26%. T   F   3 over 50% of women attempt vaginal birth after one caesarean section. T   F   4 over 30% of women with a previous caesarean section achieve a vaginal delivery. T   F

With regard to caesarean section,

5 there are no overall cost savings from VBAC compared with elective repeat caesarean. T   F   6 there is a higher risk of caesarean hysterectomy associated with VBAC compared with caesarean section. T   F   7 endometritis is more common after failed than successful VBAC. T   F

With regard to the risks of VBAC,

8 epidural anaesthesia masks the pain associated with scar dehiscence. T   F   9 a baby of more than 4000 g predisposes to failed VBAC, but not to uterine rupture. T   F   10 the rate of uterine rupture where there is a classical caesarean scar is over 20%. T   F   11 the maternal mortality rate is 0.02 per 1000. T   F

With regard to research into VBAC,

12 most of the evidence available today is based on large randomised controlled trials. T   F   13 a recent statistical model includes antenatal findings to predict the likelihood of success. T   F   14 one aim of the Caesarean Section Surgical Techniques (CAESAR) trial is to evaluate the effect of uterine closure on future pregnancies. T   F

Regarding the diagnosis of uterine rupture,

15 cardiotocography (CTG) changes are present in more than 90% of cases. T   F   16 CTG changes include tachycardia, late decelerations and the disappearance of contractions. T   F   17 uterine rupture usually leads to fetal death. T   F

With regard to induction in cases of VBAC,

18 the use of oxytocin is associated with rupture precisely at the site of the previous scar. T   F   19 recent evidence suggests that sequential use of prostaglandin and oxytocin is more hazardous than oxytocin after amniotomy. T   F   20 one study has reported a >15% increase in risk of uterine rupture with prostaglandin induction. T   F

Cardiac disease in pregnancy. Part 2: acquired heart disease

Regarding the management of acute myocardial infarction during pregnancy and the puerperium,

21 coronary angiography is safe. T   F   22 most deaths occur within 2 weeks of treatment. T   F   23 thrombolysis is contraindicated. T   F

In a woman with mitral stenosis,

24 pregnancy increases the risk of atrial fibrillation. T   F   25 pregnancy is associated with an approximately 10% maternal mortality rate. T   F   26 pregnancy should be delayed until surgical correction where the symptoms or the stenosis are severe. T   F   27 treatment with balloon mitral valvuloplasty is required in those with refractory symptoms. T   F

During pregnancy, open heart surgery with cardiac bypass is

28 best avoided. T   F   29 associated with a 25% maternal mortality rate. T   F   30 associated with a 16–33% risk of fetal mortality. T   F

With regards to peripartum cardiomyopathy,

31 the diagnosis is usually one of exclusion. T   F   32 the mortality is approximately 20%. T   F   33 subsequent pregnancies do not carry a risk of relapse if left ventricular systolic function has recovered completely. T   F

Cardiac arrhythmias

34 should be treated with amiodarone during pregnancy. T   F   35 should not be treated with cardioversion during pregnancy. T   F

In pregnant women with mechanical heart valves

36 oral anticoagulation during pregnancy is associated with a rate of maternal thromboembolism of less than 5%. T   F   37 the use of low molecular weight heparin during the first trimester carries a high risk of fetal embryopathy compared with use in the second trimester. T   F   38 the fetal mortality rate is approximately 1 in 3. T   F

With regard to maternal mortality rates in the United Kingdom,

39 valvular disease following rheumatic fever has recently become one of the major causes. T   F

During pregnancy

40 all women with heart valve lesions should be given antibiotics to prevent endocarditis. T   F

Uterine leiomyosarcomas: a review of the diagnostic and therapeutic pitfalls

Uterine leiomyosarcomas

41 are associated with exposure to tamoxifen. T   F   42 are the commonest uterine sarcomas. T   F   43 belong to the subgroup of mixed mesodermal tumours. T   F   44 originate from leiomyomas. T   F   45 most commonly metastasise to the bones. T   F

Regarding the diagnosis of uterine leiomyosarcoma,

46 a frozen section is not beneficial if a leiomyosarcoma is suspected intraoperatively. T   F   47 the presence of coagulative necrosis is indicative of leiomyosarcoma. T   F   48 the presence of coagulative tumour cell necrosis is a more accurate diagnostic criterion than mitotic count. T   F

Concerning adjuvant therapy for uterine leiomyosarcomas,

49 adjuvant pelvic radiotherapy has a significant impact on survival. T   F   50 anthracycline-based chemotherapy has a role in treatment. T   F

With regard to surgical treatment of uterine leiomyosarcomas,

51 bilateral salpingo-oophorectomy is mandatory. T   F   52 myomectomy is contraindicated. T   F   53 the role of pelvic lymphadenectomy is unclear. T   F   54 if the pelvic disease is controlled, resection of a single metastasis may be indicated. T   F

With regard to treatment for uterine leiomyosarcomas,

55 palliative radiotherapy is preferred for advanced unresectable disease. T   F   56 aggressive surgical cytoreduction at initial operation offers the best long-term prognosis. T   F

In women with recurrent uterine leiomyosarcomas,

57 more than half have been shown to respond to gemcitabine combined with docetaxel. T   F

Concerning the prognosis of uterine leiomyosarcomas,

58 the most important factor is tumour size. T   F   59 staging is similar to that of endometrial carcinoma. T   F   60 there is a direct relationship between high levels of Ki67 and rapid tumour growth. T   F

Obstetric management of women with female genital mutilation

The following statements about female genital mutilation are true:

61 The World Health Organization is working towards its recognition as a violation of human rights. T   F   62 Under the Female Genital Mutation Act 2003, it is illegal to perform the procedure in the UK, but a health worker can perform it abroad. T   F

In the UK,

63 the incidence of female genital mutilation has fallen since the introduction of the Female Circumcision Act 1985. T   F   64 around 7 000 women are still at risk of having genital mutilation. T   F

Regarding female genital mutilation,

65 girls are being mutilated at increasingly younger ages. T   F

With regards to the practice of female genital mutilation in African countries,

66 it is performed in 28 to 30 countries in Sub-Saharan Africa. T   F   67 approximately 500 procedures are carried out per day. T   F

The following are acute complications of female genital mutilation

68 Retention of urine resulting from pelvic haematoma. T   F   69 Haematocolpos from retention of menstrual blood. T   F   70 Faecal incontinence. T   F

Regarding obstetric complications from the procedure,

71 there is a significant increase in the rate of infant morbidity from fetal hypoxia. T   F   72 there is an increased incidence of postpartum haemorrhage. T   F

In women with type III female genital mutilation, the defibulation procedure

73 should be left until the second stage of labour if it is not performed at 20 weeks of gestation. T   F   74 should preferably be performed under general anaesthesia to avoid evoking painful memories of the past. T   F

In women with type III mutilation,

75 the labia minora are absent. T   F   76 difficulty in bladder catheterisation during labour can lead to a prolonged second stage. T   F

Recent research shows that, where indicated, many pregnant women with genital mutilation

77 prefer to undergo defibulation between 34 and 38 weeks of gestation. T   F

Healthcare professionals caring for women with genital mutilation during pregnancy,

78 should ensure that women have a pelvic examination at the first antenatal visit. T   F

Regarding female genital mutilation,

79 defibulation may be necessary if urinary tract infections keep recurring. T   F

One way in which obstetric services could be improved,

80 would be to ensure that midwives are trained in performing an anterior episiotomy. T   F

Modern management of miscarriage

In women with threatened miscarriage,

81 the therapeutic role of progesterone in prevention and treatment has not been established. T   F   82 the use of uterine muscle relaxant drugs improves outcome. T   F

Regarding non-viable pregnancy,

83 approximately 30% of women will choose expectant management if given the choice. T   F   84 use of biochemical markers is not a practical consideration when considering the best treatment option. T   F   85 the incidence of diarrhoea is significantly higher with the use of vaginal misoprostol when compared with oral misoprostol. T   F   86 nulliparity is a factor that predicts success with misoprostol. T   F

Regarding treatment of miscarriage,

87 the risk of infection is higher with medical treatment than with surgical treatment. T   F   88 about 50% of women would opt for the same management in the future. T   F   89 expectant management appears to be the least costly alternative. T   F   90 filmy intrauterine adhesions may develop following surgical evacuation but not after conservative or medical management. T   F   91 anti-D should be given to all women with a confirmed miscarriage <12 weeks of gestation. T   F   92 women who choose their own treatment have been shown to have the best health-related quality of life over time. T   F

Regarding early pregnancy assessment units,

93 one of the benefits is a reduction in inpatient admission by an average of 1 day for women requiring no treatment. T   F

Regarding viable intrauterine pregnancy,

94 miscarriage is likely to occur in about 1 in 10 pregnancies where a fetal heartbeat is present. T   F

Regarding treatment of miscarriage,

95 the duration of expectant management can be up to approximately 2 months. T   F   96 the low levels of progesterone present in non-viable pregnancy means that prostaglandins can be administered on their own. T   F   97 research has shown that treatment with vaginal misoprostol can lead to heavy bleeding for about 2 weeks afterwards. T   F   98 a benefit of using vacuum aspiration is that there is no need for analgesia. T   F   99 metronidazole may be given as part of a prophylactic antibiotic regime in women with Chlamydia trachomatis before undergoing surgical evacuation. T   F   100 there are no differences between treatments with regard to long-term conception rates and pregnancy outcomes. T   F

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