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Questions for volume 9, number 4

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 4 is 16 April 2008.

Current thoughts on psychosexual disorders in women

Sexual desire in women

1 is reported more frequently by the younger age group. T   F   2 commonly derives from a desire for intimacy. T   F   3 is reported more frequently by women in long-term relationships. T   F   4 commonly derives from an innate desire. T   F

Sexual dysfunction

5 occurs in about one in 10 women. T   F

The sexual problems most commonly reported by women include

6 sexual pain syndromes. T   F   7 desire disorders. T   F

Desire disorders

8 commonly present around the time of the menopause. T   F

Difficulty in achieving orgasm

9 is more common in older women taking hormone replacement therapy. T   F   10 is treatable with cognitive behavioural treatment programmes. T   F   11 may respond to pelvic floor exercises. T   F   12 can be treated with sildenafil. T   F

Vulval vestibulitis is

13 caused by thrush. T   F   14 more common in women who have been sexually abused. T   F

Women with pelvic pain

15 are more likely to have a history of emotional abuse. T   F   16 may have a theory about the origin of the pain. T   F

In women with vaginismus

17 there is repeated difficulty in allowing the entry of an object into the vagina, despite an expressed wish to do so. T   F   18 long-term psychotherapy is required to help overcome the problem. T   F   19 the diagnosis is made after exclusion of structural abnormalities. T   F   20 systematic desensitisation has been demonstrated from systematic reviews to be the most effective and, therefore, the best recommended treatment. T   F

Current minimal access techniques in the treatment of heavy menstrual bleeding

First-generation endometrial ablation techniques

21 are associated with fluid overload. T   F   22 include endometrial laser intrauterine thermal therapy. T   F

The following statements regarding second-generation devices for endometrial ablation are correct:

23 A silicone balloon catheter is used in hydrothermablation. T   F   24 Microwave endometrial ablation has been approved by the National Institute for Health and Clinical Excellence (NICE). T   F   25 Thermachoice® is not a recommended device in a woman with a septate uterus. T   F   26 The Cavaterm® system uses free fluid to ablate the endometrium. T   F

The NovaSure® system

27 uses carbon monoxide to check for uterine cavity integrity. T   F   28 does not require endometrial pretreatment. T   F   29 delivers unipolar radiofrequency energy, which is impedance controlled. T   F

Cryotherapy

30 is done under hysteroscopic guidance. T   F   31 is carried out using an 8 mm diameter probe. T   F

Compared with second-generation endometrial ablation techniques, the following is more common with the use of first-generation techniques:

32 Postoperative uterine cramping. T   F

The following statements are true:

33 Trichloracetic acid is used as a photosensitiser in photodynamic therapy. T   F   34 Photodynamic therapy has been approved by NICE. T   F

Uterine artery embolisation

35 has been shown to be associated with a lower incidence of postoperative readmission when compared with hysterectomy. T   F

With regards to mortality following the use of first-generation endometrial ablation techniques,

36 a rate of approximately 1 in 5000 in the UK has been reported in one study. T   F

The following statements regarding second-generation devices for endometrial ablation are correct:

37 The Thermachoice system should be considered for women who are planning to have future pregnancies. T   F

With regards to anaesthesia for microwave endometrial ablation,

38 approximately 1 in 10 women who are offered local anaesthesia require additional general anaesthesia. T   F

The following statements are true:

39 The presence of a large submucous myoma is a relative contraindication to treatment with second-generation ablation techniques. T   F   40 Hysterectomy has been shown in one study to result in more cost per quality adjusted life years than thermal balloon ablation. T   F

Mesh-free anterior vaginal wall repair: history or best practice?

With regard to anterior vaginal wall prolapse,

41 anterior colporrhaphy is considered the ‘gold standard’ surgical correction. T   F   42 it is defined as the pathological descent of the anterior vaginal wall and overlying bladder base. T   F

Regarding pelvic organ prolapse,

43 approximately 25% of women will require surgery for this condition at some point in their lifetime. T   F   44 rates of recurrence following surgical correction are reported to be as high as 60%. T   F   45 paravaginal defects result in loss of the vaginal rugae. T   F

With regard to classification of anterior vaginal wall prolapse,

46 the pelvic organ prolapse quantification (POPQ) classification is recommended for all women complaining of vaginal prolapse. T   F   47 the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ) is a validated tool for assessing subjective symptoms of vaginal prolapse. T   F   48 stage II in the POPQ classification occurs when the most distal portion of the prolapse is <1 cm proximal to or distal to the plane of the hymen. T   F

When assessing the anterior vaginal wall using the POPQ system,

49 the woman should be in the left lateral position. T   F   50 point Aa, located in the midline 3 cm from the urethral meatus, is noted. T   F

With regard to the use of synthetic meshes,

51 success rates of approximately 95% have been reported for sacrocolpopexy. T   F   52 evidence-based medicine has shown that permanent mesh is superior to absorbable mesh. T   F   53 pores in the mesh should be >75 µ to facilitate passage of bacteria, macrophages and fibroblasts. T   F   54 vaginal erosion rates of approximately 20% following vaginal insertion have been reported. T   F

With regard to the anatomy of the pelvic floor,

55 the arcus tendineus fasciae pelvis is a strong ligament that attaches the obturator internus muscle to the symphysis pubis and ischial spine. T   F   56 Delancy's level I support is provided by the uterosacral and cardinal ligaments. T   F   57 the terms endopelvic fascia and Halban's fascia are interchangeable. T   F   58 the muscularis layer of the vagina is a continuation of the levator ani muscles. T   F   59 the arcus tendineus fasciae pelvis is also known as the ‘white line’. T   F

When performing vaginal surgery for pelvic organ prolapse,

60 each compartment should be considered separately and repaired independently from the others. T   F

Management of early-stage epithelial ovarian cancer

Concerning epithelial ovarian cancer,

61 the disease will recur in approximately half of women with stage I disease. T   F   62 risk-of-malignancy indices (RMIs) are less likely to predict ovarian cancer in women with stage I disease than more advanced cancer. T   F   63 unilateral oophorectomy combined with surgical staging is an accepted approach to treatment in women wishing to retain their fertility. T   F   64 about 50% of cases will be associated with a normal CA125. T   F   65 the prognosis with a clear cell tumour is less favourable than with other epithelial ovarian cancers. T   F   66 germ cell tumours occur more frequently in women under 40 years of age. T   F   67 it accounts for 30% of ovarian malignancies. T   F   68 it is confined to the ovary in all cases of stage I disease. T   F

With regard to the staging of epithelial ovarian cancer,

69 the 5-year survival rate for stage IA grade 1 disease is 90%. T   F   70 at least 40% of women with apparent early-stage disease will have more advanced disease if fully staged. T   F   71 the risk of recurrence in those with early clear cell tumour is independent of positive pelvic washings. T   F

In women under the age of 40 years,

72 the chance that an epithelial ovarian tumour is borderline or malignant is approximately 10%. T   F   73 where fertility-sparing surgery is considered for early-stage ovarian cancer, a frozen section would identify over 95% of those who would benefit. T   F   74 chemotherapy is recommended after unilateral oophorectomy for those with stage IA and IB cancer with low-risk features. T   F

Concerning adjuvant chemotherapy for early-stage ovarian cancer (ESOC),

75 the combined results of the ACTION and ICON1 studies demonstrated a significant increase in overall survival in the chemotherapy arm. T   F

Concerning the laparoscopic management of early-stage ovarian cancer,

76 laparoscopy is contraindicated in women with suspected ovarian cancer. T   F   77 full FIGO staging is not possible using minimal access techniques. T   F   78 the published incidence of port site metastases is approximately 20–25%. T   F   79 aspiration of ovarian lesions within an endoscopic bag is useful in suspicious ovarian lesions. T   F   80 exposure to carbon dioxide causes accelerated growth of ovarian cancer in vitro. T   F

Management of cornual (interstitial) pregnancy

Regarding cornual pregnancy,

81 assisted conception is an important predisposing factor. T   F

Regarding the diagnosis of cornual pregnancy,

82 the presence of a separate gestational sac >2 cm from the most lateral edge of the uterine cavity and surrounded by a thick myometrial mantle are the two diagnostic ultrasound features. T   F   83 it was made before rupture in half of the cases reported in the last Confidential Enquiry into Maternal and Child Health. T   F   84 the interstitial line sign is most commonly seen in early cornual gestation. T   F   85 early diagnosis with the aid of transvaginal sonography is critical in enabling a more conservative approach. T   F   86 this should be considered when attempts at inducing an abortion do not succeed. T   F   87 transvaginal sonography has a sensitivity of approximately 98%. T   F

With regard to surgical treatment of cornual pregnancy,

88 most case reports do not show increased rates of uterine rupture in subsequent pregnancies following cornual resection. T   F   89 cornual excision is useful for treatment of both the ruptured and the unruptured variety. T   F   90 most authors agree that the size of the cornual gestation determines the best laparoscopic approach. T   F

Regarding hysteroscopic treatment of cornual pregnancy,

91 there is robust evidence to support the superiority of hysteroscopic management over medical treatment with methotrexate. T   F   92 there is evidence that ultrasound guidance is better than laparoscopic guidance. T   F

Concerning medical treatment of cornual pregnancy,

93 the essential prerequisites for methotrexate use are haemodynamic stability with absence of signs of rupture. T   F   94 local injection of potassium chloride is a recognised treatment for heterotopic pregnancy. T   F   95 the follow-up period is shorter than that for tubal ectopic pregnancy. T   F   96 local administration of methotrexate has a significantly favourable side-effect profile compared with single-dose systemic regimens. T   F   97 folinic acid rescue is not needed when using low-dose systemic methotrexate. T   F   98 following ultrasound-guided medical treatment, the resolution time for women injected with potassium chloride is much shorter than for those injected with methotrexate. T   F

With regard to future pregnancy following cornual pregnancy,

99 the two major concerns are uterine rupture and recurrence. T   F   100 the risk of ipsilateral recurrence of ectopic pregnancy after conservative laparoscopic management is not increased if a good anatomical result is demonstrated (whether by hysterosalpingography or direct laparoscopic visualisation). T   F

Confidentiality, disclosure and access to medical records

With regard to disclosure of patient information,

101 information that is trivial can be privileged information. T   F   102 disclosure of HIV status to an employer is allowed. T   F   103 a doctor receiving information from a third party about a patient may have a duty of confidence against disclosure. T   F   104 disclosure of a patient's HIV status to the newspapers may be acceptable if in the public interest. T   F   105 consent is justification. T   F

With regard to confidentiality and disclosure,

106 information in the public domain is not subject to an obligation of confidence. T   F   107 patients with mental incapacity cannot expect the duty of confidentiality to be the same as that for a patient with capacity. T   F   108 the duty of confidentiality can be overridden by the private interest of disclosure. T   F   109 the legal and ethical duties of confidentiality cease after a patient has died. T   F

With regard to access to information from medical records:

110 information held about a patient in their medical notes belongs to the patient. T   F   111 any breach of the Data Protection Act 1998 will result in a fine. T   F   112 the ‘data controller’ within the context of the Data Protection Act 1998 controls the purpose and manner in which data is processed. T   F   113 the data controller need not comply with a request for data if it would result in serious harm to a third party, regardless of whether or not consent has been given by them. T   F   114 patients can obtain information held by public authorities about them under the Freedom of Information (FOI) Act 2000. T   F   115 information given in confidence is an exception to disclosure under the FOI Act 2000. T   F   116 disclosure under the Access to Health Records Act (AHR) 1990 is not allowed where there is a note to state that a deceased patient has previously objected. T   F   117 Caldicott guardians are responsible only for patient confidentiality. T   F

With regard to disclosure of patient information,

118 a doctor has a duty of care to protect a potential victim from a violent patient. T   F   119 a doctor must have written consent to disclose information to a third party. T   F

Regarding the Health and Social Care Act 2001,

120 one area of concern is that the NHS could potentially hold genetic information that people do not themselves know. T   F

Guideline No. 29 (March 2007). The Management of Third and Fourth-Degree Perineal Tears

121 About 30% of women will have sonographic abnormalities of the anal sphincter after vaginal delivery. T   F   122 The further the episiotomy is made from the midline, the lower the risk of a third-degree tear. T   F   123 A second-degree tear includes the external anal sphincter. T   F   124 A tear involving anal mucosa with intact internal and external anal sphincters is classified as a fourth-degree tear. T   F   125 Post-delivery endoanal scanning significantly increases the rate of detection of sphincter injuries. T   F   126 Repair of the external anal sphincter using the overlap technique significantly reduces the risk of anal incontinence. T   F   127 Prophylactic episiotomy should be performed where there is a history of previous anal sphincter injury. T   F   128 Around 70% of women undergoing external anal sphincter repair are asymptomatic at 12 months. T   F   129 The use of prophylactic antibiotics following anal sphincter repair is recommended best practice. T   F   130 The use of polydiaxonone (PDS) sutures has been shown to be superior in terms of outcome to polyglactin (Vicryl®). T   F

Guideline No. 5 (September 2006). The Management of Ovarian Hyperstimulation Syndrome

Regarding ovarian hyperstimulation syndrome,

131 clinical ascites is a symptom of moderate ovarian hyperstimulation syndrome. T   F   132 women over the age of 30 are at greater risk. T   F   133 even where the condition is suspected, progesterone luteal support should be continued. T   F   134 a fluid output of <1 litre per day is a cause for concern. T   F

The following statements are correct:

135 Because of the increased risk of thrombosis associated with ovarian hyperstimulation syndrome all women should undergo a thrombophilia screen prior to assisted conception. T   F   136 There is frequent thrombotic involvement of the arterial system in those with ovarian hyperstimulation syndrome. T   F   137 Hydroxyethylstarch has a lower molecular weight than human albumin. T   F   138 An increase of the white cell count to >25 000/ml is indicative of critical ovarian hyperstimulation syndrome. T   F   139 Late onset ovarian hyperstimulation syndrome is likely to be more severe than that occurring within 9 days of the ovulatory dose of hCG. 140 Where a pregnancy continues successfully following ovarian hyperstimulation syndrome, there is a higher rate of pregnancy-induced hypertension. T   F

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