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Answers to the Multiple Choice Questions

from Volume 1, Number 2
ANSWERS TO PACE TEST 3 MCQs
Chronic renal disease in pregnancy 6 In a pregnant nniiian with chronic renal disease
increasing proteinuria is ;in indication for delivery .....FALSE

In pregnant woiiien with chronic renal di:ctse, 7 A woman with a satisfactor). renal transplant can be
hypei-tension is a iiiajoi- factor in fetal prognosis .........TRUE advised t o become pregnant within ;I year of
1ran:iplantalion ........................................................... ..,.FALSE
The presence o f a renal transplant in a pregnant
n m n a n is an indication for c x s a r e a n section FALSE 8 Peril oneal dialysis is more adbantageous than
haelnodialysis during pregnancy................................... FALSE
1,ithotripsy is usef~ilin the manageitient o f renal
c~ilculiin pregnancy ....................................................... FALSE 9 With inoderate chronic renal disease pregnancy
complications before 28 weeks can influence
Syntlictic ei-ythropoietin (rHuEpo) should not he long-term tnaternal prognosis ........................................ TRUE
used in pregnant dial) sis patients ................................. FALSE
10 Adult respiratory distress syndrome can he :I
l reterm delivery is c o ~ n m o nin pregnant rend cornplicati8:m in pregnant woineii bvith
transplant patients ........................................................ ..TRUE pyclunepl-1ritis ............................ , , , , . . , .TRUE

ANSWERS TO PACE TEST 4 MCQs

The treatment of ovulatory disorders

,\lild obesity Iias z i significant association \vith
:inoc.ul;t~ion................................. ............... .TRUE
I ulsatik gonCidotrophinreleasing hormone (GnRH)
:tdministration in the tiratinent of primary
hypotlialainic 1iypogon;idisiii is ;I
Kites of multiple pi-egnancy.......... ...............FALSE
Patients undergoing o w r i m drilling should he
counselled almut a high risk of multiple pregnancy ...... FALSE
RCOG guidelines state that all uonien t a b k g
cloniipliene should ha\;e ;iccess t o monitoring with
ovarian ultrasound ......................................................... ,.TRUE
The Conirnitter o n Safety of Medicines ;rclvi.ses that
clomiphene should not normally he ~iseclfor longer
than six cycles ................................................................. TRUE
6 l aticnts with polycystic 01 ar). syndrome (I CoS ) are
ant t o cilation iiiduction with
gonadoti-ophins............... ........................... .FALSE
7 Rec(irnhn:int human FSH is prod~icetlfrom
genetically modified E. coli bacteria ...............
8 Gonadotrophin preparations which contain n o
Iutrinising hormone (LH) are inore c ffic;icjoLis than
LH-mntaining preparations in ovnlation induction
in women with polycystic o\,ar). syndrome (PCOS) ......FALSE
9 Clomipheiie is responsible for more triplets in the
LJK than is the use of gonadotrophins for ovulation
induction ......................................................................... . T R W
10 Ovulation induction is rcsponsihle for more rnultiple
pregnancies t l i m irz zlitro fertilisation (TVF) ................ ..TRCE

ANSWERS TO GREEN-TOP GUIDELINE 21 MCQS

The management of tubal pregnancies
6 There is n o evidence t o support the use of anti-l)
iinniunr)glolxdin (Ig) in a non-sensitisecl H i
Suturing the t u l x ;ifrixr s;ilpingotoiny provicles no negative vminan following surgery.............................. .FALSE
Ixnefit .................................................................... ,,,,,,,.,.TRuE
7 In rion-randomised trials. sulxequent intrauterine
I ersistent trop1iol)last following treatment requircs pregnancy rates were similar ~~1ietlie.r
laparoscopy
further surgery ............................................................... FALSE o r 1ap:irotc)my was used as the method of treatment ...TRI_IE
Tlir laparoscopic approach is no cheaper than 8 Siic cessful treatment with niethotrexate is directly
lqxirotoiny .................................................................. ,,,.FALSE proportional to the serum level of PliCCr ..................... FALSE
The incidencc o f cic:lth Iias irisen t o 4.9/1000 9 Salpingectomy is t o be preferred t o salpingotomy
ectopic pregnancies .......... .................................. ..FALSE in t h e presence o f a healthy contralateral tube ............TRUE
I ersistent tropholilast is more common following
.,
10 I h eincidence of side effects in patients treated
laparoscopic surgery compared to laparolomy .............TRUE with systemic inethotrexate exceeds one in five ..........TRUE

i%e Obstetrician C Gyaaecologist Jariutay 2000 Vol. 2 No. 1 23

 mcqS
ANSWERS TO MCQs SET 6
The management of vulval cancer and related
conditions
A The following are recognised risk factors f o r vulval
cancer:
1 Smoking .................................................... ........... .TRUE
2 Lichen sclcrosiis ................ .......... ,.TRUE
3 Herpes genitalis ............... .........,.FALSE
4 Cer\ i u l c;aiicer .................
5 h~lolluscunicontagiosunn . .
DISCUSSION: ,4Itliough the ;issociation hetween smoking and
vulv;il cancer is n c i k , it is more pronounced for vulva1 intra-
epithelial neopl:isins (\’I[c). The putative inechanisni is that
cigarette smoking. either inclependently Lia DNA atlducts or as
I: cofactor thro~igliimmune suppression. may enhance onc’o-
genesis in the pi-esence o f oncogenic viruses. The association is
mwker than ~ l i a tnoted for cervicil c3nc’er.
The iricre:ised prewlence o f cervical intraepithelial neoplasia
and cen,iGil c;incei- ,scym in p;itients \\.it11 \ulval cancer (and I?CC>
WKW) is again suggesth e of ;I coinmon aetiological agent, in this
instmce oncogenic hiiman papillomavinises, u hich may account
for approxim:ately one-third o f v i i l \ d cancers. Other sexually
transmitted agents ha\ e I)een e\duated as potentid ;retiological
agents. I x i t there are no rotxist data iiiiplicating herpes si~nplex
\ii-cis or molluscuiii cotit;igios~ini.There is continiiing detxite over
the possilile milignant potential o f lichen sclerosus. The current
coiisensus is t1i:it rlierc possildy is a link, h i t the lifetime risk
rcmains re1;ttibely siixill.
Stage Pa vulval carcinoma:
Is ;ilso known as supcrfici;iIly inrasive \uIval can
Is carcinoma 0 1 less tlixi 3 i i i i i i depth. measured from
the adiacent papilla .............................
Involves the groin lynipli noclrs in only 5%) of cases ......FALSE
Is besr man;ige!t"I17y cirlion dioxide laser vai""isation ....FALSE
(kin be distinguished from \?h l i y viilvosc~opy................FALSE
DISCUSSION Stage 1:i \ uI\~alcincer is ;ilso k n o w n ;IS superficially
in\xiie carcinoiii:i and is defined as a tunioiir measuring 1nim in
depth \\here the Ixse of tlie adjacent skin papilla is used ;as ;I
rcfcwnce point. Tlie tunioiir sliould l i e no grcater tlian 2 ciii iti
l a ~ e ~extension
il t o tie inclcidcd in this substage. Tnvolvcnient of tlie
lytnph nocks is \.eiy rare indeed bvitli less than fi\,e rases repcirted
in the world 1iter;it~ire:tliiis. it represents ;I situation nhere groin-
node dissection is nor required. As the major difficcilty in this
condition is ensuring adeqiiate excision margins (and providing
good. iioii-distorted matenal fot- tlie pathologist), destructive
methods 01’ treatiiicnt slioiiltl he avoided. ’1’11er.e are no cl;issi~al
\-ulvoscopic features tllat dlo\v \,’IN t o he reliably diagnosed aiid
ceit:iinI~.none that :iIlo\\~superfici;illy invasive disease t o tie
recognised \vitliin ;I field o f k l h .
C Regarding pre-invasive vulval disease:
1 ’l’he risk o f inalignant progression o f Vln’ varies
fr0111 LO'!.i, t o HO’X/;,......................................................... .FfLSE resonanace iiinging M U ) and ultrasvuiid might detect enlxged
2 (:hanging syniptom and o r appe;irances of the
lesion slioulcl proiiipt Icirtlier biopsies ...................... ,,,.TRUE and sh~iildtherefort. not tie relied o n to do so. As there is :I recog-
3 The I-isk of progression iiiay he higher in
niiiltifoctil \’In ancl niulticentric disease ........................ TRUE
4 Simple \ul\,ecromy is the treatinent of choice for
VIK 3 .............................................................................. .FALSE so recently. From the histopatliologiail perspective. interpretation
5 I’aget’s disease is associated with other
malign:incies in 50(%1o f c;ises ........................................ FALSE
DISCUSSION: The risk of inalignant progression or \'IN is difficult
t o cletermine. Few. if :my: series r e p )i-i on sufficient nutnt)ers o f
women nianaged without any treatment. This is Linderst:mldde
given that the majority present \vith sy-iiiptoms ;and therefore
require some form o f intervention, which is also likely t o influence
the natural history of tlie disease. One snlall and \velI-piiblicised
series has documented progression in seven of eight c i s c s of \TIN
3. This report. hom.ever, is ~iniisiial,with tlie majority rcxcording
rates o f progression from 3% t o 1O(x1,One niiglit expect. with
longer follow-up and more carefully documented and categorised
lesions. that this figure .might well incrrase. Suffice it to say at
present that our belief is that a lo\v rate o f progression iiistifies a
conseiwtive appro:ich to iilanageinent given the moi-hiclity such
manageirient a n inflict. A consenuti ipprc-iach requires cnrefiil
surveillance,as any change in symptoms o r appearance may be the
earliest sign o f invasion and should prompt hiither hiopsy. Biopsy
is the only safe inetliod o f excluding inusion ;it present. Multifocal
and niulticcntric \'IK map tie associated with ;I higher progression
cite. pirticularly in itninunosuppresssed women. There is. of course.
grearer scope for sampling eri-or at the time of the original chgnosis
in these cases. Loc:il excision ~ o i i l dappear t o lie the current
trettrnent of choice for most cases o f VIK. This conhines the
:icculacy of good liistopathology ivhile minimising d;image t o the
\-~ilviilanatomy. Simple milvectomy remove; f:ir more tissue in
tei-ins of depth than is requirecl and is disfiguring. \ ; u l ~ i l Paget’s
disease is associated with other malignancies in approxinxitely 20%
of cases and should prompt 21 thorough srarch.
D With regard t o t h e diagnosis of carcinoma of t h e vulva:
1 1,esions should ala~aysbe t>iopsied prior t o
instituting definitive nianageirient ................................. FALSE
2 Excision biopsies slioulcl include I: riiargin o f 1 cin
of normal tissue ............................................................... TRUE
3 Computed tomography scanning SlKJLdd I x
performed to exclude pelvic lymphaclenop~thy..........FALSE
4 A ccivical snicir should he perfoi-niecl if the cervix
is i i i sitri ...................................................................... .....TRUE
5 Dizignostic biopsies shodd include the zirea
Iietnwn the lesion and normal skin ............................. TRUE
DISCUSSION: In gener:il. all lesions sliould be Iiiopsied prior t o
instit~itingprimary management. There are, however, exceptions.
The first and most ohious is that of the small suspicious lesion
where 21 wide local excision may be tlie only loc:il treatiiient
required and will also provide tlie diagnosis. It is only \Then an
extensive resection is contemplated that it m-oiild Ix considerc~tl
’ e t o I>iopsy first. A second exception is that of the elclerly mcl
’oman. Here. :I radical wide excision will pro-
md symptom relief. F~irthertreatincmt may lie
contemplated and L I S U ; I ~ is ~ ~ required. h i t it scenia illogic’;il t o clela),
syniptc~iii-controllinp treatment when there is a high suspicion o f
cancer iincl where only excision can provide that reliel. Wide local
excision is associated with control cites siiriilar t o tliose for i-xlical
y long 21s clearance margins :ii-e at Icmt H 111111. Aiiiiing
v ~ i l v ~ . c t o i n;is
to excise :I margin o f normal tissue 10 niin in a.idth allocvs for ;I
sninll inargin o f error. While computed toinogcipliy (C’l’), magnetic
pelvic lymph nodes, they cannot e x c l ~ i d rmalignancy ;it this s i t r
niscd increased risk (of pre-invasive and invasive cen.ic:il clise:ise. it
is good practice to a:,sess the cervix along \vitli the rest o f the lonw
genital tract. ;ind cervical cytology shoulcl he performed if not done
and reporting are more accurate if the sul~mitteclIiopsy contains
the xea o f transition from normal t o turnour.

E With regard to the treatment of vulva1 cancer:
1 All cancers. other t h n stage Ia squamous, have a
high risk of involved nodes ...............................
2 lxeralised T1 and ’1’2 tumours invohre contralateral
groin nodes rarely ......................................................... .TRUE
3 Eiz-bloc groin node dissection should always be
performed for malignant melanoma ............................. FALSE
4 Vulval cancer is relatively resistant to radiotlierapy ....FALSE
5 Lymphoedema is a frequent problem associated
with groin node dissection ............................................ TRUE
DISCUSSION: Basal cell carcinomas and veniicous cancer rarely, if
ever, metastasise to tlie groins. It is for this reason that the hist-
ological nature o f the primary should be defined prior to addres-
sing the potential f o r disease in the groin. Sixill latenilised tumours
generallj, only spread to the contralateral groins if the ipsilateral
nodes are found to be positive. The data in suppolt of this only
ANSWERS TO MCQs SET 7
The lessons of CESDI
A Regarding the CESDI process:
1 CESDI IS the College’s method o f addressing tlie
effects of surgical complications and deaths in
pregnant women ............................................................ FALSE
2 CESDI conies under the umlirella of NICE . . . . . . . . . . . . . . . . . . . T R U E a I3ove ...............
3 Cases reviel.\red are graded 0-3, where a rating of
I implies that suboptimal care occurred but different
management would not have affected the outconie ....TRUE
4 CESDI aims to assess all deaths in infancy and
stillbirths........................................................................ ..FALSE
j The assessments are anonymous and there is no
feedback to individuals or their units ............................ TRUE
B Uterine rupture associated w i t h the death of a baby:
1 Occurs hetween one in 140 and one in 100
women who labour with a uterine scar ....................... FALSE
2 1s associated with induction of labour in wornen
with a uterine scar.. .................................................. .TRUE
3 Occurs most freque at near (9 cm or more) full
dilation ........................................ .....TRUE
4 Is generally thought to tie an u
and not associated with problems in the provision
........................................ .FALSE
likely to lie necessary .......... ...........TRUE
DISCUSSION: The event o f scar rupture occurs in between one
in 140 and one in 300 women who labour with a pre-existing
sc;ir. It is not known accurately lvhat the risk of tlie death of the
l x h y occurring in such an event is, hut it has been estimated at
around one in ten. In the review o f 42 cases (5th Annual Report),
18 women with prc-existing scars had been induced. At least
lialf (20) occurred at near full dilatation. This event W;IS judged
t o he particularly associated with suboptim;il care (95% were
grade 2 or grade 3 ) . It is recommended that any scar rupture is
tlie subject of a departmental review. Nine out o f 42 women who
had :I death of a liaby associated with uterine scar rupture in
19()4/95 unclerwent hysterectomy at the time.
i%e Obstetrician C Gyaaecologist Jariutay 2000 Vol. 2 No. 1
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relate to Tl and T2 turnours. It is recognised that malignant nielan-
omas have a high risk of metastases that include the groin.
However, as the depth o f penetration of Inelanomas is the strongest
prognostic indicator. prophylactic groin node dissection is unlikel!.
to influence outcome. There may be a case for considering e?z-hlo(:
dissection if thy nodes are enlarged, but this is Pal-gely palliative.
Squatnous cancers of the vulva are no more or less radioresistant
tlian squtimous cancers elsewhere. ?lie problem lies in the morl,id-
ity of trying to achieve high doses in this sire. With careful planning
and management of problems such as moist desquanution, good
responses can be seen n-ith radiotherapy w-hich is incorporated into
multirnodality approaches, paiticularly with large turnours where
surgery may adversely affect function. Despite quite radical improve-
ments in approaches to morbidity avoidance and inanqqment,
lymphoedema rcniains a problem following inguinofemoral node
dissection. A lyniphoedema nurse specialist should lie ;I part of the
multidisciplinary team managing these a-omen.
C Fatal shoulder dystocia
1 lhis event is considered to be predictable and
therefore a\vidable ...................................................... ..FALSE
2 Most cases occur during an operative vaginal delivery ..FALSE
3 The head-to-body delivery intend u a s less than
five minutes in nearly half o f the c;iscs ......................... TRUE
4 Three-quarttrs of the babies weighed 4 kg and
............ ......................... .TRUE
j It would h a i ~ been less likely to have occurred
had fundal pressure and the Zavanelli technique
been iused ....................................................................... FALSE
DISCUSSION: This event is generally unpredictable, and factors
such as estimated weight of the baby are ineffective screening
tests. Most cases occur during a spontaneous vaginal delivery and
the rniclwife is the prtifessional most likely to tie present. Surpris-
ingly, 47% of the cases had a head-to-body delivery interval of
less than five minutes recorded. This iniplied that there was
unrecognised feral distress prior lo the event. Funddl pressure is
t o tie avoided. Suprapubic pressure is recommended. ln none of
the cases was the Zavenelli technique used. This is not a standard
procedure for nianagement o f shoulder dystocia.
Intraparturn-related deaths:
Account for nearly jc% o f the 10 000 losses reported
to CESDl every year.. ............................................. .TRUE
Always die in kabour ...................................................... FALSE
The most common category o f StlbOptimdl care is
failure t o recognise delay in labour .............................. FALSE
Resusciration of tlie baby was a problem in 10% of
the liveborn babies ........................................................ FALSE
In a significant proportion (20?410 tlie cause was
attril2uted to an indiviclual’s action (failure to
recognise o r act appropriately (ir communicate
effectively) ...................................................................... FALSE
DISCUSSION: Inlrapartum-relatei1ipartum-rekateddeaths are rare events. occurring
in approxiniately one per 1569 deliveries. They account for nearly
5% of the losses reported to CESDI. The term refers t o babies that
die as a result of an event in L h u r and not necessarily t o the
timing of {.hede;ith. The most coininon cornmenrs rnade by the
25
 mcqS
panels in the cause of death of these babies concerned problems
in the use and interpretation of the cardiotocographs. Twenty-two
percent of the neonates were noted to have suboptimal resusc-
itation. It is very rare that an individual s action is responsible for
the death, which is usually a combination of factors.
Postmortem
The national postmortem rate has been increasing
recently and was 60% in 1997....................................... FALSE
Neonatal deaths are less likely to undergo a
postmortem than stillbirths .......................................... ...TRUE
In the case of a stillbirth the cause of death is
altered by a postmortem in 25% of cases .................... FALSE
ANSWERS TO MCQs SET 8
Intrapartum fetal monitoring - basic knowledge
A In the presence of an abnormal CTG, fetal hypoxia
and acidosis may develop faster or may affect the
neonatal outcome in the following situations
compared with an averagely grown fetus at term
1 In the presence of thick meconium with scanty fluid..TRUE
2 When there is intrauterine infection ...........
3 When the fetus has intrauterine growth re
4 When the fetus is preterm <32 weeks ........................... TRUE
5 In a labour with rapid progress ..............FALSE
DISCUSSION Reduction of the amniotic fluid volume in the
absence of ruptured membranes and fetal urinary tract obstruction
may indicate the possibility of reduced renal perfusion and less
urinary output. This may be as part of a compensatory mechanism
whereby the essential organs of brain, heart and adrenals are per-
fused in preference to skm, muscle, liver, gut and, finally, the
kidneys. Passage of meconium may be as a function of maturity.
It is also postulated that this may be due to hypoxia and relaxation
of the anal sphincter. In such cases reduction of perfusion to the
placenta via the fetal or maternal circulation reflected by abnormal
fetal heart rate (FHR) patterns may lead to rapid development of
hypoxia and acidosis. When the FHR is abnormal in the first stage
of labour there is significant excess of low pH at delivery. The
metabolic rate is increased with infection, resulting in increased
use of oxygen and substrates. Lack of oxygen due to compromise
of placental perfusion is likely to cause rapid development of
hypoxia and acidosis.* Intrauterine growth restriction is associated
with a small placenta. Some cotyledons may be infarcted and
appear pale compared with healthy buff-coloured cotyledons. In
such situations when there is reduction to placental circulation the
much needed extra placental surface is not available for gas
exchange, leading to hypoxia and acidosis.3 Preterm fetuses are
known to develop rapid hypoxia, and acidosis can predispose
preterm babies to develop hyaline membrane disease and respira-
tory distress ~ y n d r o m e .A~ fetus need not necessarily become
hypoxic or acidotic because the labour was rapid. With normal
uterine activity the cervix may dilate rapidly and the baby may be
born in good condition.
B Concerning Intrapartum CTG:
1 The CTG trace produced by pulsation of maternal
vessels picked up by an ultrasound transducer is
distinctly different from that from the fetal heart ........FALSE
2 Maternal ECG may be transmitted to the fetal
monitor via fetal scalp electrode to produce a CTG
which resembles that of FHR ................................ .........TRUE will correct and there is no need to i n t e ~ e n e . ~
7be Obstetrician G Gynaecologist
4 The liver is the most common organ to be retained
following a postmortem. ................................................ FALSE
5 Consent is unnecessary for a coroner s postmortem ....TRUE
DISCUSSION: The postmortem rate has been falling since 1993
from around 58% to j4%. Neonatal deaths are the least likely to
undergo postmortem (44% rate) and the cause of death is altered
in stillbirth in approximately 12% of cases. The organs most likely
to be retained are the heart and the brain and, legally, consent
for a postmortem is necessary for all deaths from 24 weeks
gestation onwards. Good practice is to ask for permission in all
circumstances. However, it is technically unnecessary for a
coroner s postmortem.
3 In the presence of meconium-stained amniotic fluid
it is better to expedite delivery by augmenting
labour with a syntocinon infusion ................................ FALSE
4 A scalp electrode is necessary to monitor the fetus
when there is an abnormal fetal heart-rate pattern
observed with the use of ultrasound transducer .........FALSE
5 A fetal scalp blood sample is essential prior to
delivery in cases with prolonged bradycardia ............. FALSE
DISCUSSION The ultrasound transducer picks up the maternal
vessel wall movement or the fetal heart wall movement. The rate
will depend on the rate of the vessel or heart wall movement. When
the fetus is dead, the ultrasound may pass through the soft tissue of
the fetus and may pick up the maternal vessel wall movement and
give a trace that is identical to the fetal heart rate. In some cases of
intrauterine fetal death, there may be marked oligohydramnios. The
maternal heart ECG signals traverse the pericardium, maternal
diaphragm, uterine wall, the dead fetus and, via the scalp electrode
applied on the fetal scalp, produce a trace on the fetal monitor
similar to the FHR trace For these reasons it is important to make
sure that the FHR is different from that of the mother. The presence
of meconium may indicate an element of hypoxia in the fetus. The
use of oxytocin will increase the frequency and duration of uterine
contractions. This is likely to reduce the perfusion to the fetus.
Hence, oxytocin should be used judiciously only when indicated,
such as the slow progress of labour. The latest fetal monitors have
facilities for autocorrelation. The time intervals of fetal heart beats
are correlated in an overlapping manner. If the reflected ultrasound
beam is entirely at a different frequency to that reflected off maternal
bowel or muscle movement, the machine does not print a heart rate.
As a result, the baseline variability produced with the use of the
ultrasound transducer with fetal monitors present is good and
reliable. Hence, there is little need to use a scalp electrode when the
trace is abnormal. If there is difficulty in obtaining a cardiotoce
graphic (CTG) trace with an ultrasound transducer then the use of
a scalp electrode may be advisable. Fetal bradycardia, especially
with a rate 4 0 beats per minute (bpm), is associated with less
circulation through the placenta. This interferes with gas exchange
and initially results in respiratory acidosis due to slower elimination
of CO,. With the progress of time, less oxygen delivery to the fetus
results in anaerobic metabolism and metabolic acidosis. If the
bradycardia continues for more than nine to ten minutes there is a
greater chance of acidosis. If the bradycardia recovers to normal
FHR, CO, is eliminated and more oxygen transfer takes place, result-
ing in normalisation of blood gases. Hence, there is little to be
gained by fetal blood sampling (FBS). If bradycardia continues for
>10 minutes with no signs of recovery, there is a need to deliver the
fetus immediately. However, if the FHR recovers, the blood gases
Janua y 2000 Vol. 2 No. 1

Concerning the interpretation of features of a CTG
A normal baseline FHR of 110-160 bpm is an
adequate indication that the fetus is not hypoxic .......FALSE
A fetus exhibits a baseline FHR of 170 bpm and
has two accelerations in 15 minutes. The presence
of tachycardia suggests the presence of hypoxia ........FALSE
A fetus with a baseline variability of 10-25 bpm for
20 minutes prior to delivery is usually not associated
with fetal acidosis ................ :........................................... TRUE
Late decelerations suggest that the fetus is acidotic ....FALSE
A fetus with a baseline variability of <5 bpm is
usually associated with fetal acidosis ........................... FALSE
DISCUSSION The reassuring signs of a non-hypoxic fetus are the
features of accelerations (two accelerations >15 beats lasting for
>15 seconds in a 15-minute window - reactive trace) and normal
baseline variability (10-25 bpm). These features indicate adequate
oxygenation to the autonomic nervous system and brain stem
centres. A normal baseline rate alone does not indicate fetal health
in the absence of accelerations and reduced baseline variability of
<5 bpm. Non-hypoxic fetuses can have moderate baseline tachy-
cardia (170 bpm) but should have accelerations and normal base-
line variability.’ Good baseline variability indicates good oxygenation
to the autonomic nervous system and it is unusual to find fetal
acidaemia when the fetus has normdl baseline variability in the last
20 minutes of trace prior to delivery." Late decelerations indicate
that the retroplacental pool of blood during contractions is not
adequate for the oxygen needs of the fetus and there is transient
hypoxaemia. There may be other changes such as a rise in base-
line rate and reduction in baseline variability prior to the fetus
becoming acidaemic. This is an important reason to perform FBS
when indicated.’ The baseline variability changes and it can be <5
bpm for many reasons, the most common of which is fetal sleep?
The other causes of reduced baseline variability of 1 5 bpm are
drugs, infection, congenital malformations and, rarely, cerebral
haemorrhage.
Concerning decelerations in a CTG:
variable decelerations are due to cord compression. ...TRUE
Variable decelerations may be due to head
compression.. ................................................................ ...TRUE
A CTG with variable decelerations is categorised as
. .
........................
DISCUSSION: Variable decelerations are due to cord compression.
Head compression also can give rise to variable decelerations.
Variable decelerations are more common in breech presentations
and in cases of occipito-posterior positions of the vertex compared
with occipito-anterior positions." Variable decelerations are sub-
classified into simple and complicated variable decelerations.
Some of the features of complicated variable decelerations are:
0 duration >6O seconds and depth >60 beats
0 combined decelerations - variable followed by late component
slow recovery to baseline.
In the presence of these features variable decelerations are
categorised as abnormal.9 Early decelerations are due to head
compression. It is unlikely for the head to be compressed until
the late first stage and second stage of labour. The decelerations
observed at 3 cm are more likely to be variable than early
decelerations.’
The Obstetrician G Gynaecologist Janua y 2000 Vol. 2 No. 1
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Concerning fetal scalp blood sampling in labour:
It is compulsory to take an FBS prior to caesarean
section for an abnormal trace ....................................... FALSE
On the basis of scalp blood pH if an operative
delivery is to be performed the cut-off value is 7.10..FALSE
A baby with scalp blood pH value of 7.10 is likely
to be born with low Apgar scores ................................ FALSE
The greater the delay between decision to delivery
the more chance there is that a baby delivered
operatively based on abnormal FHR pattern may be
born in poor condition .....................................
Scalp blood pH can be normal but the fetus may be
born in poor condition when there is intrauterine
infection .................................................................. .........TRUE
DISCUSSION It is not compulsory to take an FBS prior to
caesarean section for an abnormal trace. A typical example is
one of prolonged bradycardia > l o minutes with no signs of
recovery. The scalp blood pH cut-off or threshold is defined as
7.20 and has worked well to date.1 The baby delivered with a
scalp blood pH of 7.10may have respiratory acidosis and may
have a good Apgar score at birth.ll It is well known that, once
the decision is made to deliver the fetus for an abnormal FHR,
the greater the delay there is the greater are the chances of the
baby being born in a poor condition.12 The fetus with intra-
uterine infection may have a normal scalp blood pH. At delivery
the baby may cry but soon afterwards may develop tachypnoea
and respiratory problems. In the presence of intrauterine infect-
ion and an abnormal trace, labour should not be prolonged by
performing repeated FBS.Z
References
1 Steer PJ, Eigbe F, Lissauer V, fkdrd RW (1989) Interrelationships
among ahnormdl cdrdiOtOcOgrdmSin labor, meconium staining of the
amniotic fluid, arterial cord blood pH and Apgar scores. Obstet
Gynecol74,715-21
2 Gibb DMF, Arulkumardn S (1977) Fetal Monitoring in Practice, 2nd
edn. Oxford: Hutterworth Heinemann
3 Low JA, Karchmar J, Hroekhoven L, Leonard T et al. (1981) The
probability of fetal metabolic acidosis during labor in a population at
risk as determined by clinical factors. Am J Obstet Gynecol 141,
941-51
4 Hobel W, Hyvarinen MA, Oh W (1972) Abnormal fetal heart rate
patterns and fetal acid base balance in low birth weight infants in
relation t o the respiratory distress syndrome. Obstet Gynecol39, 83-8
5 Ingemarsson I, Arulkumaran S, Ratnam SS (1985) Single injection of
terbutaline in term labor. Effect of fetal pH in cases with prolonged
bradycardia. Am J Ohstet Gynecol153, 859-65
6 Ingemarsson I, Ingemarsson E, Spencer JAD (1993) Practical Guide
to Fetal Heart Rate Monitoring. Oxford: Oxford University Press
7 Arulkumaran S, Chud S (1996) Cardiotocograph in kdbour. Current
Obstetrics and Gynaecology 6,182-8
8 Spencer JAD, Johnson P (1986) Fetal heart rate variability and fetal
behdViOUrdl cycles during labour. BrJ Obstet Gynaecol93, 314-21
9 FIG0 (1987) Guidelines for the use of fetal monitoring. IntJGynaecol
Obstet 25, 159-67
10 Beard RW, Morris ED, Clayton SG (1967) pH of fecal capillary blood
as an indicator of the condition of the foetus. J Obstet Gynaecol Br
Cwlth 74,812-22
11 Sykes GS, Molloy PM, Johnson P et al. (1982) Do Apgdr scores
indicate asphyxia? Lancet i, 494-5
12 Dunphy HC, Robinson JN, Sheil OM et al. (1991) Caesarean section
for fetal distress, the interval from decision t o delivery, and the
relative risk of poor neonatal condition. journal of Obstetrics and
Gynaecology 11, 241-4
27
 mcqS
ANSWERS TO MCQs - SET 9
Intrapartum fetal monitoring - medico-legal
implications
A Medico-legal claims related to birth asphyxia are
mainly due to:
1 Inability to understand the significance of abnormal
FHR traces ................ ................................... .TRm
2 The actual loss experienced by the wonian and the
need for costs o f future care of the baby .....................TRUE
3 Poor conimunic:ition by medical personnel leading
parents to believe that the truth is not being told.,......TRUE DISCUSSION: Jt is important to rccorcl uterine contr;ictions in
4 Driven by advertisements from law firms to claim
large sums of money .............................
5 The feeling by parents that no one else should
suffer t h e same way and that such legal action
would reduce recurrence o f such events ......................TRUE uterine contractions. When oxytocics are used t o induce or ;tug-
DISCUSSION: In the majority of cases the inability to interpret
traces o r delay in taking action has been linked t o medico-legal
c1aims.l The niain driving force for parents to file action is the
actual loss experienced b y the woman and the need for the pro-
vision for the costs of the future care of the baby, which can be
quite expensive. Many parents feel that the tnith has not been
told to them and that taking legal action will bring out the truth.
There are legal firms which advertise to consult them and under-
take to split the compensation if they win, but cases based on
this reason are few-. In most cases the parents are emotionally
devastated by the incident and some file a case with the convict-
ion that such incidents should not recur.?
B Intermittent auscultation is adequate or preferable:
1 If the CTG is of poor technical quality despite
attempts at using different transducers or electrodes...TRUE
2 In a low-risk labour after an admission CTG ................TRUE
3 In a low-risk labour without an admission CTG ..........TRUE
4 When there are two different rates of 70 bpm and
140 bpm seen on the trace ............................................. TRUE
5 When a high-risk mother is not willing to have
continuous monitoring ................................................... FALSE
DISCUSSION: It is important to have good-quality reading while
performing a CTG. A poor-quality reading may have missing
sections and artifacts and inay be difficult to interpret. In these
situations it may be wise to perform intermittent auscultation.
In low-risk labour intermittent auscultation is the accepted
form of care with or without admission CTG. There is inadequate
evidence to suggest that admission CTG followed by intermittent
auscultation is a better form of care compared with intermittent
auscultation only in low-risk When there are two FHRs
displayed on the trace, one at 70 bpm and the other at 140 bpm,
this may be due to:
’double counting’ of a slow FHR by the monitor (counts the
atrial and ventricular beats separately instead of 21s one)
c detection of separate atrial and ventricular rates of the fetus,
as in cases of systemic lupus erythematosus in the mother
with the fetus having a conduction branch block
fetal death in utew and detection of miternal vessel-wall
movement of two vessels together at times and at other times
of only one vessel wa1l.j
One cannot compel a mother with high-risk factors to have
continuous electronic monitoring. She should be made aware
that it is preferable to have continuous monitoring of the fetus
and should have the risks explained.
C Recording of uterine contractions:
1 Is not important in spontaneous laliour ....................... FALSE
2 Is of value but not essential when oxytocic agents
are used to induce or augment labour
3 Is niancbatoiy in a woman with augme
and a previous caesarean scar ..............
4 Should be nith intrauterine catheters in a woman in
augmented labour u,ith a previous caesarean scar.,, , , .FALSE
5 It is adequate to store the trace of the FHR and
uterine contractions with the case notes ...................... FALSE
labour. These could be quantified by palpating the frequency and
.FALSE duration. Alternatively. they could be recorded by using an external
tocotransducer o r an intrauterine catheter. Should there be ;I s l o n r
progress of labour the action taken n4l be hased on the recorded
inent labour the close is increased until adequate uterine contract-
ions are achieved; hence the recording of uterine contractions i s
important." It is important to record uterine contractions in aug-
mented labour with a previous caesarean scar. Hypt:rstimulation of
the uteius if not detected and the oxytocin infiision stopped or
reduced may lead to uterine rupture. There is no strong evidence
to suggest that the use of an intrauterine catheter is preferalde in
cases of previous caesarean where labour is augmented. Features
of sudden decline of pressure with scar rupture liave been reported
and may help to detect a rupture earlier. If the external transducer
is not recording the contractions adequately it is important t o use
an intrauterine czitherer in these situations.’ Currently. FHR record-
ings are stored in the case notes. After a few years thc recordings
may be missing from the case notes :IS they niay have dropped
from the envelope or the trace may have faded, as niost recordings
are on thermally sensitive papers. Should there lie litigation a dec-
ade later it would be useful to have the recordings. A computerisecl
archiving and retrieval system would he useful.
D Birth asphyxia leading to long-term neurological
sequelae is likely to have:
1 Profound umbilical arterial acidaemia of pH <7.O ........TRUE
2 Persistence of low Apgar score ~3 for >5 minutes .......TRUE
3 Abnormal neurologicd signs during the neonatal
period ............................................ ...................TRUE
4 Evidence of hypoxic damage to kidneys and
gastrointestinal system ................
5 Early imaging evidence of acute c
DISCUSSION. These statements :ire’ taken from the consensus
statement of the Perinatal Society of Australia and New Zealand
and international contributing experts \vho have provided ;I
template for defining a causal relationship between acute intra-
partum events and cerebral
E The following steps are useful to reduce litigation for
reasons of birth asphyxia
1 Regular education o n interpreting CTG and
appropriate action ............................................... ............TRUE
2 Attempts t o shorten the intewal between decision
........................................................ .TRUE
isk m:in:igemcn t tea n1 . . ................ .FALSE
4 Fetal scalp blood sampling when encountering an
abnormal CTG ...................................... .............FALSE
5 Umbilical cord arterial Iiloocl samplirlg for pft anct
blood gas analysis ........................................................... TRUE
DISCUSSION The 4th CESDI report rcconimeiicls rrgLilar ecluc,-
ation sessions in CI’C m d reduction in the decision to deliveiT

interval to reduce the cases of intraparturn-related deaths. This also
applies to intrapartum-related morbidity? Although the establish-
ment of a risk management team should logically reduce the
number of cases of litigation there is no evidence to support this
view. Fetal scalp blood sampling helps to establish the diagnosis
of fetal acidosis and in decision making. This step mainly helps in
avoiding unnecessary operative delivery. There is no evidence to
suggest that performing fetal scalp blood sampling helps to reduce
cases of medical litigation. An abnormal CTG and the action taken
may be interpreted differently by the experts. If the baby was
found to have neurological deficits in later life, it may be attributed
to the abnormal CTG. Performance and documentation of a good
umbilical arterial pH should help to defend the case. Performing
umbilical arterial pH on every case may i n m s e the workload and
expenses and may not be necessary. Certain guidelines should be
drawn up to i d e n e those cases that will benefit from umbilical
artery sampling.
References
1 Ennis M, Vincent CA (1390) Obstetric accidents: a review of 64 cases.
WW, 1365-7
ANSWER!3 TO FREE-STANDING MCQs SET 10
Reproductive medicine
A In the UK, the success rate for in vitm fedisation
OVF) treatment is:
1 Of the order of 25% live births per cycle started ........FALSE
2 Higher in women with tubal disease compared with
those with endometriosis............................................... FAISE
3 Dependent on the age of the woman ........................... TRUE
4 Dependent on the past obstetric histoly of the woman ..TRUE
5 Less than 1% live birth per cycle in women aged
40 years ........................................................................... FALSE
DISCUSSION The world s first IVF baby was born on 25 July 1978
in Oldham, near Manchester in England. Although IVF was first
introduced as a treatment for tubal infertility, the indications have
widened and it now has a place in the treatment of almost all
causes of infertility. The current widespread use of IVF is
illustrated by the fact that, in 1935 alone, 141 130 IVF cycles were
performed in 775 centres world-wide.* It was originally thought
that IVF was more successful in women with tubal disease than in
those with other causes. However, it has been shown that the
female cause of infertility has no effect on the success rate3 The
presence of male factor, on the other hand, reduces the chances
of success because the lower rate of fertilisation reduces the
numbers of embryos available for transfer. The most sisruficant
factor affecting IVF success rate is the woman s age. According to
the UK Human Fertilisation and Embryology Authority (HFFA), the
live-birth rate per IVF cycle (often referred to as the take-home-
baby rate) was 15.3% in 1%/97, based on data from 25 281 IVF
cycles where the woman s own eggs were used.*The live-birth
rate decreases with advancing age, being 20.1% at the age of 30
years, 14.4% at the age of 35 years, 9.7% at the age of 40 years and
1% at 45 years and over. Other factors which affect IVF success are
the duration of infertility, previous pregnancy, previous live birth
and the number of praious unsuccessful IVF cycles3Women with
primary infertility of long duration with previous unsuccessful rvF
attempts have the lowest chance of success. Women with
secondary infertility of short duration, particularly if they have had
a live birth in the past, have the best chance. This is even more
evident if the previous live birth was from IVF.
me dbstetrician G Gynaecologist Januuy 2000
mcqS
2 Vincent C, Young M, Philips A (1994) Why d o people sue doctors? A
study of patients and relatives taking legal action. Lancet 343,
1609-13
3 Ingemarsson I, Arulkumaran S , Ingemarsson E, Tambyraja RL,
Ratnam SS (1986) Admission test - a screening test for fetal distress
in labor. Obstet G ~ o l 6 8800-6
,
4 Nelson JP (1994) The usefulness of antepartum and intraparmm fetal
monitoring. Contemp Rev Obstet Gynaecol6, 72-8
5 Gibb DMF, Arulkumaran S (1977) Fetalhfonitorfngin practice, 2nd
edn. Oxford: Hutterworth HeinemaM
6 Amlkumaran S (1994) Uterine activity in labour in: T Chard, JG
Grudzinskas (Eds) The Uterus, pp. 356-77. Cambridge: Cambridge
University Press
7 Chua S, Arulkumaran S (1997) Trial of scar. Aust N Z J Obs?t?t
Gynaecol37, 6-11
8 Perinatal Society of Australia and New Zealand (1999) A Consensus
Statement from the Perinatal Society of Australia and New Zealand
and contributing expem. A Template for Defining a Causal
Relationship between Acute Intraparturn Events and Cerebral Palsy.
9 Confidential Enquiry into Stillbirths and Deaths in Infancy (1997)
Fourth Annual Report: Concentrating on Intraparturn Deaths
1994-95.London: Maternal and Child Health Research Consortium
B Systemic methotrexate in the mmqement of
-P- ectopic Presnancyr
1 Is the treatment of choice in cases of hetemtopic
pregnancy ....................................................................... FALSE
2 Compared with conservative surgery, leads to a
significantly higher subsequent patency rate of the
affected tube ................................................................... FALSE
3 Is contraindicated in cases associated with ovarian
hyperstimulation syndrome .......................................... .FAISE
4 Is associated with a success rate similar to that of
laparoscopic surgery........................................................ TRUE
5 Is contraindicated in cases of cervical pregnancy........FAISE
DISCUSSION In haemodynarmcally stable patients with unrup
tured tubal pregnancy, systemic methotrexate and lapamscopic
salpingotomy are equally successful. In a controlled trial, 100
haemodynamicdy stable women with laparoscopically contirmed
unruptured tubal pregnancy were randondsed to receive a fourday
course of intramuscular methotrexate (1 mg/kg/day) on alternate
days, alternating with folinic add m e to minimise side effects, or
to have Iaparoscopic salping~tomy.~ The treament was s u c c e d
in 82% of patients treated with methotreme compared with 72?!
of those treated with salpingotomy (a statistically non-slgruficant
difference). Those in whom treatment failed received htha
methotrexate or surgical intervention. Overall, the tube was pre-
served in 90% of patients in the methmxate group vmus 92%in
the salpingotomy group. After m, the affected tube was
patent in 55% of patients in the mehotmate group and in 5946 of
patients in the salpingotomy group. On follow-up 18 m o n h later,
there was no dihence between the two treatments in terms of
intrauterine pregnancy and recummt ectopic pregnancy6 There are
certain circumstances where mthotrexate may be preferable to
surgery. These include cervical pregnancy, where surgical jnter-
vention may be associated with a high risk of bleeding (because of
the proximity of the implantation site to the uterine arteries) which
may necessitate hysterectomy. In cases where ectopic pregnancy
coexists with ovarian hypmtimdation syndrome, the pelvic
organs are vascular and surgical intervention may be better
avoided On the other hand, in hetemtopic pgnancy whae a
viable intrauterine pregnancy coexists with an ectopic pregnancy,
mthmmte is conrfaindicated.
Vol. 2 No. 1 29
 mcqS
C Fertility rate is improved in infertile women with
minimaVmild endometriosis:
1 After surgical ablation of endometriotic lesions
2 After medical treatment using danazol .........................
3 With the use of ovarian stimulation and intrauterine
insemination ...... .................................. .TRUE
4 After medical tre
releasing hormone agonists .........
5 After a period of ovarian suppression using the
DISCUSSION: There is a considerable spontaneous pregnancy rate in
cases of infertility associated with minimavmild endometriosis?
Therefore, any claim of successful treatment should be tested in a
randomised conrrolled trial ( R O , with a no-treatment (or placebo)
arm. Many of the treatments that were thought to be effective on the
basis of uncontrolled studies were later found to be no better (some-
times worse) than no treatment when tested in RCTs. Additionally,
medical treatment will cause delay in ovulatory cycles. A systematic
review and meta-analysis to determine the effectiveness of ovulation
suppression (with danazol, medroxyprogesterone acetate, gestrinone,
the combined oral contraceptive pill or gonadotrophin releasing hor-
mone agonists) for the treatment of infertility associated with e n d e
metriosis showed no benefit? The common odds ratio for pregnancy
following ovulation suppression versus placebo or no treatment was
0.83 (95% CI 0.5-1.39). On the other hand, a multicentre RCT involv-
ing 341 infertile women with minimal or mild endomemosis showed
that surgical ablation (performed laparoscopically) increased the cum-
ulative probability of pregnancy by 73% in the fvst 36 weeks follow-
ing the procedure; cumulative incidence ratio was 1.7(95% CI 1.2-2.61.’
Similarly, a number of RCTs showed that ovarian stimulation and
intrauterine insemination (IUI) are more effective than no treatment
or IUI alone in infertile women with minimal or mild endometriosis.1
D Sperm suitable for intracytoplasmic sperm injection
(ICSI) treatment may be obtained in the following
conditions:
1 Sertoli cell only syndrome .............................................. TRUE
2 Congenital absence of the vas .....
3 Azoospermia with
hormone (FSH) of
4 Following vasectomy ................
5 Following chemotherapy with a1
prepubertal males .......................
DISCUSSION In conventional IVF, where the sperm is incubated
with the oocytes, about 5000&100000 sperm are needed per
oocyte to achieve fertilisation. ICSI involves the microinjection of a
single live sperm into the oocyte to achieve fertilisation." It is used
to overcome severe male factor infertility where there are very few
sperm available in the ejaculate. In azoospermia, sperm suitable for
ICSI can be obtained through testicular biopsy or fine-needle aspir-
ation. The sperm characteristics do not seem to be important to
success following ICSI.12 In all conditions listed in the question,
pregnancies have been reported following treatment with ICSI.13
Sperm can be retrieved relatively easily in obstructive cases such as
absence of the vas and following vasectomy. However, it is import-
ant to recognise that there is an association between congenital
bilateral absence of the vas and cystic fibrosis carrier status. Before
embarking on ICSI for congenital bilateral absence of the vas the
patient should be screened for cystic fibrosis and counselled accord-
ingly.14 In cases of Sertoli cell only syndrome it was originally
thought that the disorder was present throughout the testicular
tissue. However, the concept of ’focality’ is now well recognised,
where there are foci of normal spermatogenesis in the testis from
which sperm for ICSI may be obtained. In about 50% of cases of
testicular failure, even when the FSH is over 25 iuA, sperm have
been retrieved and pregnancies using ICSI reported.
The Obstetrician & Gynaecologist Januay 2000
E Premature menopause is associated with:
1 Hot flushes in approximately 90% of patients .............FALSE
2 Galactosaemia .................................................................. TRUE
3 Mumps .............................................................................. "’RUE
4 Autoimmune diseas ...........
5 Chromosomal abno .......................................... .TRUE
DISCUSSION: Premature menopause is commonly defmed as ovar-
ian failure before the age of 40 years. It affects approximately 1%0 of
women in that age group, t o t a h g over 100OOO affected women in
the UK.15 It is associated with primary amenorrhoea in 25% of cases
and with secondary amenorrhw in 75%. In most cases the condition
is idiopathic with no identifiable cause.Recognised causes include
chromosomal disorders (such as Turner syndrome and pure gonadal
dysgenesis), metabolic defects (17a-hydroxylase deficiency and gal-
actosaemia), immunological disorders (Di George syndrome and
ataxia telangiectasia), autoimmune diseases, infections (mumps ooph
oritis and pelvic tuberculosis) and iatrogenic causes such as pelvic
irradiation, ovarian surgery and chemotherapy. In general the diag-
nosis is based on a triaa of amenorrhoea, elevated gonadotrophin
levels (particularly FSH) and symptoms of oesmgen deficiency. How-
ever, only about 50% of patients with primary ovarian failure will have
hot flushes and genital atrophy. Some might not be amenonhoeic and
may ovulate and menstruate sporadically,with reported pregnancies
in rare cases.16Long-term care should include hormone replacement
therapy, as these patients are prone to osteoporosis as well as the
other ill effects of long-term oestrogen deficiency. The only effective
treatment for infertility associated with primaty ovarian failure is it?
uitro fertilisation of donated eggs.
References
1 Steptoe PC, Edwards KG (1978) Birth after the reimplantation of a
human embryo (letter). Lancet G, 366
2 de Mouzon J, Lancaster P (1997) World collaktrative report on in tWo
fertilization: preliminary data for 1995.JAssM Reprod Cenef 14,251-65s
3 Templeton A, Moms J, Parslow W (1996) Factors that affect outcome of
in-vitro fertilisation treatment. Lancet 348,14024
tion and Embryology Authority (1998) Sewnth Annual
Report. London: HFEA
5 Hajenius PJ, Engelsbel S, Mol RW et al. (1997) Randornised uidl of
systemic methotrexate versus laparoscopic salpingostoiny in tubal
pregnancy. Lancet 350,774-9
6 Dias Pereira G, Hajenius PJ, Mol RW et al. (1999) Fertility outcome after
systemic methouexate and laparoscopic salpingostomy for tubal
pregnancy (letter). Lancet 353,7 2 4 5
7 Hull MGK (1992) Review. Infertility treatment relative effectiveness of
conventional and assisted conception methods. Hum Reprod 7,785-96
8 Hughes E, Fedmkow DM, Collins J, Vandekerckhove I’ (1998)
’Ovulation suppression versus placebo in the treatment of
endometriosis’ in: iThe CccbraneLibmy, Lrue 2. Oxford: Update st)ftwarr
9 Marcoux S, Maheux R, Berube S (1997) Iaparoscopic surgery in infertile
women with minimal or mild endometriosis. Canadian Collahrative
Group on Endometriosis. NEngl JMed 337,217-2
10 Tummon IS, Asher LJ, Martin JS, Tulandi T (1997) Randomid controlled
uial of superowlation and insemination for infertility asstxriated with
minimal or mild endometriosis. F a i l Stetil68, S.12
11 Palermo G, Joris H, Devroey P, Van Steiteghem AC (1992) Pregnancies
after intracytoplasmic injedon of single spemtozoon into an t ~ ~ y e .
Lancet 340,17-18
12Mansour K (1998) Intracytoplasmic sperm injection: a state of the arf
technique. Hum Reprod Update4,4 5 5 6
13 Mansour KT, Kamal A, Fahmy I, Tawab N, Serour GI, Aboulghar U4
(1997) Intracytoplasmic sperm injection in obstructive and non-
obstructive aZ<KX3peMlid.Hum R e d 12, 19749
14 Dohle GK, Veeze HJ, Overbeek SE et al. (1999) The complex
relationships between cystic fibrosis and congenital bilateral absence of
the vas deferens: clinical, elecvophysiological and genetic data.. Hum
Reprod 14,3 7 1 4
15 Barlow DH (1996) Premature ovarian failure. Z?uillk?res Cfin Ohstet
Gynaecol 10,36144
16 Cohen I, Speroff L (191) Premature ovarian failure: update. Ohsfef
Gynaecol Suw 46, 1 5 6 6 2
Vol. 2 No. I