Curriculum for Subspecialty Training in Maternal and Fetal Medicine

Module 1 Medical complications of pregnancy

Module 2 Genetics

Module 3 Structural fetal abnormalities

Module 4 Antenatal complications

Module 5 Intrapartum complications

Module 6 Infectious diseases

Module 7 Generic (common to all subspecialties)

How to use Subspecialty Training Logbook

1 MODULE 1 MEDICAL COMPLICATIONS OF PREGNANCY 1.1 Hypertension Objectives: 1. To be able to carry out appropriate assessment and management of women with chronic hypertension 2. To be able to carry out appropriate assessment and management of women with pregnancy induced hypertension, pre- eclampsia and associated complications Knowledge criteria Clinical competency Professional skills and Training support Evidence/ Attitudes Assessment Chronic hypertension (HT) Take an appropriate medical history Ability to take an appropriate history Observation of and Log of Definition / diagnosis from a woman with pre-existing HT & conduct an examination to screen discussion with senior experience and - measurement of BP in pregnancy (incl. • family history for secondary causes and medical staff Competence validated devices) • secondary causes of chronic HT complications of chronic HT - impact of pregnancy on BP • complications of chronic HT Appropriate Mini-CEX - superimposed pre-eclampsia (PE) • outcomes of previous pregnancies Ability to postgraduate courses - prevalence (primary & secondary causes) • drug therapy • perform and interpret e.g. Maternal Medicine

Patholophysiology appropriate investigations - acute HT Perform an examination to screen for; • formulate, implement and where Attendance at: - chronic HT (including end organ damage) • secondary causes of HT appropriate modify a multi- • maternal medicine • complications of HT disciplinary management plan clinic Management • manage antihypertensive drug • HT clinic - screening for common causes secondary HT Manage a case of chronic HT including; therapy in antenatal & postnatal - pregnancy management (incl. fetal monitoring) • counsel regarding fetal and periods Attachments in: - maternal and fetal risks maternal risks (including long term • liaise with primary care & • obstetric - contraception health implications physicians in management of HT anaesthesia Pharmacology (incl. adverse effects) • arrange appropriate investigations • counsel women accordingly • ITU / HDU - anti-adrenergics (e.g. propanolol, labetolol, • institute / modify drug therapy - maternal and fetal risks oxprenolol) • plan delivery / postnatal care - safety of antihypertensive Personal study - calcium channel blockers (e.g. nifedipine) • refer, where appropriate, for therapy

- vasodilators e.g. hydralazine further assessment / treatment - contraception - ACE inhibitors (e.g. lisonopril)

Outcome - long term cardiovascular risks

2 Knowledge criteria Clinical competency Professional skills and Training support Evidence/ Attitudes Assessment Preeclampsia (PE) Take an appropriate medical history Ability to take an appropriate history Observation of and Log of Definition / diagnosis from a woman with PE and conduct an examination to assess discussion with senior experience and - pregnancy-induced HT (PIH) • family history a woman with PE medical staff Competence - proteinuria • symptoms of severe disease - prevalence Ability to: Appropriate Mini-CEX

Perform an examination to screen for • perform and interpret postgraduate courses Pathophysiology complications in a woman with PE appropriate investigations - placental pathology • formulate list of differential Attachments in: - endothelial dysfunction / systemic manifestations Manage a case of complex PE (or PIH) diagnoses • obstetric - oxidative stress with (a) HELLP, (b) severe hypertension, • formulate, implement and where anaesthesia (c) eclampsia and (d) pulmonary oedema appropriate modify a multi- • ITU / HDU Prediction of PE (see 4.2) • counsel regarding fetal and disciplinary management plan maternal risks • manage antihypertensive drug Personal study Management severe PE • arrange and interpret appropriate therapy in antenatal & postnatal - maternal and fetal risks investigations periods RCOG guideline - maternal monitoring (incl. indications for • liaise with primary care & ‘Management of severe invasive monitoring) • institute / modify drug therapy - fetal monitoring • plan delivery and postnatal care physicians in management of HT pre-eclampsia and - management of complications • refer, where appropriate, for • counsel women accordingly eclampsia’ • HELLP syndrome further assessment / treatment - maternal and fetal risks • eclampsia (incl. differential diagnosis - safety of anti-hypertensive convulsions, altered consciousness [see Manage a case of PE with acute renal therapy 1.18] failure; - recurrence risks and future • cerebrovascular accident [see 1.9] • counsel re fetal and maternal risks management (see 4.2) • pulmonary oedema, ARDS [see 1.5] - contraception - contraception • arrange and interpret appropriate

investigations Pharmacology (incl. adverse effects) • refer to for further assessment / - magnesium sulphate treatment - frusemide

Outcome of PE - Long term cardiovascular risks

3 1.2 Renal Disease Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing renal disease & renal transplants 2.. To be able to carry out appropriate assessment and management of women with pregnancy induced renal disease Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Kidney in normal pregnancy Take an appropriate history from a woman Ability to take an appropriate Observation of and Log of - anatomical changes (incl. hydronephrosis) with CRD history and conduct an discussion with senior experience & - functional changes • family history examination to assess a woman medical staff competence - interpretation renal function tests • complications of CRD with CRD - fluid and electrolyte balance • outcome of previous pregnancies Appropriate Mini-CEX

Pre-existing renal disease [CRD] (reflux • drug therapy Ability to postgraduate courses nephropathy, glomerulonephritis, PKD) • perform and interpret e.g. Maternal Medicine - pathology Perform an examination to screen for appropriate investigations - prevalence complications of CRD • formulate list of differential Attendance at - pre-pregnancy assessment diagnoses • renal medicine clinic - pregnancy management Manage a case of CRD • formulate, implement and - outcome (including genetic implications) • counsel re fetal and maternal risks where appropriate modify a Attachment in ITU/HDU Renal transplant recipients • arrange and interpret appropriate multi-disciplinary - pre-pregnancy assessment - diagnosis rejection investigations management plan Personal study - pregnancy management • institute/modify drug treatment • manage antihypertensive - long term considerations • plan delivery and postnatal care therapy in antenatal and - pharmacology (including adverse effects) • refer where appropriate, for further postnatal periods • cyclosporine, tacrolimus assessment / treatment • liaise with nephrologists and • azothiaprine (see 1.10) intensivists in management of • corticosteroids (see 1.5,1.6,1.10) Manage a case of renal transplant or ARF; acute and CRD

• counsel re fetal and maternal risks • counsel women accordingly Acute renal failure (ARF) in pregnancy & puerperium • arrange and interpret appropriate - maternal and fetal risks - aetiology and diagnosis (incl. differential investigations - inheritance diagnosis abnormal renal function – see 1.18) • refer for further assessment / - recurrence risks - management and outcome treatment - contraception - indications for and principles of renal support

Urinary Tract infection (see 6.15) - differential diagnosis proteinuria (see 1.18)

4 1.3 Cardiac Disease Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing cardiac disease 2. To be able to carry out, under supervision, appropriate assessment and management of women with pregnancy induced cardiac disease

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Heart in normal pregnancy Take an appropriate history from a Ability to take an Observation of and Log of - anatomical and functional changes (incl. differential diagnosis woman with cardiac disease appropriate history and discussion with experience & heart murmur [see 1.18]) • family history conduct an examination to senior medical staff competence - ECG, echocardiography and assessment of cardiac function • previous operations/procedures assess a woman with HD Congenital heart disease (HD) • complications of cardiac Appropriate Mini-CEX - classification (cyanotic and acyanotic) & risks - prevalence disease Ability to postgraduate - functional impact of pregnancy • drug therapy • perform and interpret courses e.g. - pre-pregnancy assessment, indications for TOP appropriate Maternal Medicine - pregnancy management (incl. prevention / management of Perform an examination to assess investigations endocarditis, thromboembolism, arrhythmias, cardiac failure cardiac disease • formulate list of Attendance at - maternal / fetal outcome (incl. genetic implications) differential diagnoses • adult cardiac - contraception Manage a case of congenital and • formulate, implement clinic Acquired heart disease (rheumatic HD, ischaemic HD, valve acquired HD in pregnancy and where appropriate • ‘Grown Up replacement, Marfan syndrome, arrythmias) - functional impact of pregnancy • counsel re fetal and maternal modify a multi- Congenital - pre-pregnancy assessment risks disciplinary management Heart Disease’ - diagnosis (incl. differential diagnosis chest pain, palpitations [see • arrange and interpret plan in liaison with clinic 1.18]) appropriate investigations cardiologists, • Echocardiograph - pregnancy management (incl. management of CF) • refer to cardiologists, haematologists, y session(s) Pharmacology (including adverse effects) haematologists, anaesthetists intensivists and - diuretics / antihypertensives (see 1.2/1.3) for further assessment / anaesthetists Attachments in - inotropes e.g. digoxin, ACEI treatment • counsel women • Obstetric - anti-arrhythmics (e.g. adenosine, mexiletine, lidocaine, procainamide) • plan delivery and postnatal care accordingly anaesthesia - anticoagulants (LMW heparin, warfarin – see 1.12, 4.2) in liaison with cardiologists, - maternal and fetal • ITU/HDU Peripartum cardiomyopathy intensivists and anaesthetists risks - diagnosis (incl. differential diagnosis breathlessness [see 1,18]) • counsel re contraception - recurrence risks Personal study - management and outcome - contraception - recurrence risks

5 1.4 Liver Disease Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing liver disease 2. To be able to carry out appropriate assessment and management of women with pregnancy induced liver disease Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Liver in normal pregnancy Take an appropriate history from a woman Ability to take an appropriate Observation of and Log of - anatomical and functional changes with liver disease; history and conduct an discussion with senior experience & - interpretation of liver function tests in pregnancy • complications of liver disease examination to assess a woman medical staff competence • drug therapy with liver disease Pre-existing liver disease (primary Appropriate Mini-CEX biliary cirrhosis, chronic active hepatitis, liver Perform an examination to assess liver transplant recipient [see also 1.2]) disease Ability to postgraduate courses - pathology • perform and interpret e.g. Maternal Medicine - functional impact of pregnancy Manage a case of chronic liver disease in appropriate investigations - pregnancy management pregnancy • formulate list of differential Attendance at - maternal and fetal outcome • counsel re fetal and maternal risks diagnoses hepatology clinic - contraception • arrange and interpret appropriate • formulate, implement and investigations where appropriate modify a RCOG Clinical Obstetric cholestasis (OC) • refer to hepatologists for further multi-disciplinary Guideline (43) - pathogenesis assessment / treatment - prevalence • plan delivery and postnatal care in management plan - diagnosis (incl. differential diagnosis of itching & liaison with hepatologists • liaise with hepatologists altered liver function [see 1.18]) • counsel re contraception where appropriate (e.g Personal study - pregnancy management (including fetal monitoring) chronic liver diesase, AFLP) - pharmacology (including adverse effects) Manage a case of OC & AFLP • counsel women accordingly • UDCA • counsel re fetal and maternal risks - maternal and fetal risks • Corticosteroids (see 1.2,1.5,1.6,1. • arrange and interpret appropriate - inheritance investigations & fetal monitoring - recurrence risks Acute fatty liver of pregnancy (AFLP) • institute/modify drug treatment - diagnosis (incl. differential diagnosis of overlap • refer where appropriate for further - contraception syndromes e.g. PE ) assessment / treatment - management and outcome (incl. management of liver • plan delivery and postnatal care failure) • counsel re contraception - recurrence risks

Viral hepatitis (see 6.2)

6 1.5 Respiratory Disease Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing lung disease 2. To be able to carry out, under supervision, appropriate assessment and management of women with acute lung disease Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Lungs in normal pregnancy Take an appropriate history from a Ability to take an appropriate Observation of and Log of - anatomical and functional changes woman with lung disease; history and conduct an discussion with senior experience & - interpretation of chest X-ray and pulmonary function • lung function results examination to assess a woman medical staff competence tests (incl. blood gases) in pregnancy • drug therapy with respiratory disease

Perform an examination to assess lung Appropriate Mini-CEX Pre-existing lung disease (asthma, sarcoidosis, cystic fibrosis [CF], restrictive lung disease) disease Ability to postgraduate courses - pathogenesis Manage a case of chronic lung disease in • perform and interpret e.g. Maternal Medicine - prevalence pregnancy appropriate investigations - functional impact of pregnancy • counsel re fetal and maternal risks • formulate list of Attendance at - pregnancy management • arrange and interpret appropriate differential diagnoses • chest clinic - maternal and fetal outcome investigations • formulate, implement and • CF clinic - pharmacology (incl adverse effects) • institute/modify drug therapy where appropriate modify • Pulmonary • β-sympathomimetcs (e.g. salbutamol, terbutaline) • plan delivery and postnatal care a multi-disciplinary function lab • theophyllines • disodium cromoglycate • refer, where appropriate, for management plan • corticosteroids (see 1,2,1.6, 1.9) further assessment, treatment • liaise with respiratory Attachment in - tuberculosis (see 6.10) Manage a case of acute lung disease in physicians / intensivists ITU/HDU pregnancy where appropriate (e.g CF, Acute lung disease in pregnancy (ARDS, pneumothorax, • counsel re fetal and maternal risks ARDS) Personal study pneumonia) • arrange and interpret appropriate • counsel women accordingly - pathogenesis investigations & fetal monitoring - maternal and fetal BTS/SIGN guidelines: - diagnosis (incl. differential diagnosis of chest pain,, • refer to respiratory physicians / risks Management of asthma breathlessness [see 1.18], tachypnoea, acute hypoxamia) - oxygen therapy intensivists for further assessment - safety of asthma - management of respiratory failure (incl. indications for / treatment therapy in pregnancy BTS guideline: and principles of ventilatory support) • plan delivery and postnatal care in - contraception Management of - pharmacology (incl. adverse effects) liaison with respiratory physicians pneumonia • amoxicillin & other antibiotics (see 6)

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1.6 Gastrointestinal (GI) Disease Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing GI disease 2. To be able to carry out appropriate assessment and management of women with pregnancy induced GI disease Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment GI Tract in normal pregnancy Take an appropriate history from a Ability to take an appropriate Observation of and Log of - anatomical and functional changes woman with GI disease; history and conduct an discussion with experience & Pre-existing GI disease (ulcerative colitis, Crohn’s disease, • previous surgery / procedure examination to assess a woman senior medical staff competence coellac disease irritable bowel syndrome) with GI disease • drug therapy - pathogenesis Appropriate Mini-CEX - Ability to - functional impact of pregnancy Perform an examination to assess lung • perform and interpret postgraduate - pregnancy management disease appropriate investigations courses e.g. - maternal and fetal outcome • formulate list of Maternal Medicine - pharmacology (incl. adverse effects) Manage a case of chronic GI disease differential diagnoses • sulphasalazine, 5-ASA in pregnancy and pregnancy-induced • formulate, implement and Attendance at • corticosteroids (see 1.2,1.5, 1.9) GI disease where appropriate modify a • GI clinic • bulking agents, lactulose multi-disciplinary • counsel re fetal & maternal risks • anti-spasmodics management plan • arrange and interpret Personal study Pregnancy-related GI disease (hyperemesis gravidarum [HG], • liaise with reflux oesophagitis, constipation) appropriate investigations gastroenterologists, - pathogenesis • institute/modify drug therapy surgeons where appropriate - prevalence • plan delivery and postnatal care • counsel women accordingly - diagnosis (incl. differential diagnosis of vomiting [see 1.18] • refer, where appropriate, for - maternal and fetal and role of endoscopy further assessment / treatment risks - pregnancy management (incl. parenteral nutrition & steroids - safety of anti-emetic, - pharmacology (incl. adverse effects) anti-inflammatory Manage a case of appendicitis in • anti-emetics e.g. cyclizine, metoclopramide, therapy in pregnancy pregnancy • antacids (e.g. magnesium trisilicate) - contraception • H2-receptor antagonists (e.g. ranitidine) • counsel re fetal & maternal risks Appendicitis • arrange and interpret - diagnosis (incl differential diagnosis abdominal pain [see 1.18, appropriate investigations 6.15/6.16], & role of ultrasound • refer, for further assessment / - management (incl. antibiotics) surgery - maternal and fetal outcome

8 1.7 Diabetes Objectives: 1. To be able to carry out appropriate assessment and management of women with pre-gestational diabetes 2. To be able to carry out appropriate assessment and management of women with gestational diabetes Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Glucose homeostasis in pregnancy Take an appropriate history from a woman Ability to take an appropriate Observation of Log of with pre-existing diabetes; history and conduct an and discussion experience & Pre-existing diabetes • diabetic control examination to assess a woman with senior competence - pathogenesis & classification • presence / severity of complications with pre-existing diabetes medical staff - prevalence • drug therapy Mini-CEX - complications (metabolic, retinopathy, nephropathy, neuropathy, vascular disease) Perform an examination to screen for Ability to Appropriate - pre-pregnancy assessment diabetic complications • perform and interpret postgraduate - functional impact of pregnancy in uncomplicated and appropriate investigations courses e.g. complicated diabetes Manage a case of pre-gestational diabetes • formulate, implement and Maternal Medicine - pregnancy management • counsel re fetal and maternal risks where appropriate modify • pre-pregnancy care • arrange and interpret appropriate a multi-disciplinary Attendance at • maternal monitoring (glycaemic control) investigations and monitoring management plan • obstetric • fetal monitoring • institute/modify drug therapy (incl • liaise with diabetologists, medicine clinic • intrapartum care - maternal and fetal outcome (incl. fetal abnormality, management of hypoglycemia) diabetic nurse specialists, • diabetic clinic macrosomia, FGR • plan delivery and postnatal care dieticians, and other - pharmacology (incl adverse effects) • refer, where appropriate, for further specialists where Attachment in; • insulin assessment, treatment (e.g. in women appropriate (e.g complex • Neonates • oral hypoglycaemics (e.g. metformin) with complications) diabetes) • ITU/HDU - contraception • counsel women accordingly Gestational diabetes (GDM) Manage a case of GDM - maternal and fetal Personal study - pathophysiology and diagnosis • counsel re fetal and maternal risks risks - prevalence - pregnancy management (incl. diet, insulin & oral • arrange and interpret appropriate - importance of good hypoglcaemic agents) investigations & fetal monitoring glycaemic control (incl. - maternal and fetal outcome • refer to dietician for further use of insulin in GDM) - long term risks & management assessment - contraception - contraception • institute/modify drug therapy, where - long term risks & Outcome appropriate management

- neonatal complications and management • plan delivery and postnatal care

9 1.8 Other endocrine disease Objectives: 1. To be able to carry out appropriate assessment and management of women with pre-existing thyroid disease 2. To be able to carry out, under supervision, appropriate assessment and management of women with other endocrine diseases Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Endocrine function in pregnancy Take an appropriate history from a woman Ability to take an Observation of Log of - Thyroid physiology in pregnancy with thyroid/pituitary/adrenal disease appropriate history and and discussion experience & - Pituitary and adrenal physiology in pregnancy • previous / current therapy conduct an examination to with senior competence - Fetal thyroid and adrenal function Perform an examination to screen for assess a woman with medical staff

endocrine dysfunction in pregnancy endocrine disease Mini-CEX Thyroid disease (hyperthyroidism, hypothyroidism) - Prevalence Appropriate - pathogenesis (incl. Graves disease) Manage a case of hyper/hypo thyroidism Ability to postgraduate - diagnosis during / after pregnancy • perform and interpret courses e.g. - maternal and fetal outcome (incl. fetal • counsel re fetal and maternal risks appropriate Maternal Medicine hypo/hyperthyroidism, developmental delay) • arrange and interpret appropriate investigations - pregnancy management investigations and monitoring • formulate list of Attendance at • maternal monitoring (FT4, TSH, TSH-receptor Igs) • institute/modify drug therapy differential diagnoses • obstetric • fetal monitoring (ultrasound, blood sampling) • plan delivery and postnatal care • formulate, implement medicine clinic - pharmacology (incl adverse effects) • thyroxine • refer, where appropriate, for further and where appropriate • endocrine • thionamides (e.g. carbimazole, PTU) assessment, treatment modify a multi- clinic - outcome – management and outcome of neonatal hypo- & disciplinary management hyper-thyroidism Manage a case pituitary / adrenal disease plan Attachment in; Pituitary and adrenal diseases disease during / after pregnancy • liaise with • Neonates - pathophysiology (hyperprolactinomaemia, Cushing’syndrome, • counsel re fetal and maternal risks endocrinologist, and • ITU/HDU hypopituitarism, Addison’s disease, diabetes insipidus) • arrange and interpret appropriate other specialists where - maternal and fetal outcome investigations & fetal monitoring appropriate Personal study - pregnancy management • • - pharmacolopgy (incl. adverse effects) institute/modify drug therapy, where counsel women • bromocriptine appropriate accordingly • • DDAVP refer, where appropriate, to - maternal and fetal regnancy induced endocrine disease endocrinologist for further risks - pathophysiology (postpartum thyroiditis, lymphocytic assessment / therapy - contraception hypophysitis, diabetes insipidus) • plan delivery and postnatal care - long term risks & - pregnancy / postnatal management management

10 1.9 Neurological Disease

Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing neurological disease 2. To be able to carry out appropriate assessment and management of women with pregnancy-induced neurological disease

Knowledge criteria Clinical competency Professional skills and Training Evidence / attitudes support Assessment Neurological function in pregnancy Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of neurological disease history and conduct an and discussion experience & Pre-existing neurological disease (epilepsy, migraine, • previous / current therapy examination to assess a woman with senior competence multiple sclerosis, myasethenia gravis, myotonic dystrophy, • previous procedures / operations with neurological disease medical staff idiopathic intracranial hypertension, spina bifida) • drug therapy Mini-CEX - pathogenesis Perform an examination in a woman with - prevalence neurological disease. Ability to Appropriate - functional impact of pregnancy • perform and interpret postgraduate - pregnancy management incl; Manage a case of chronic neurological disease in appropriate investigations courses e.g. • pre-pregnancy care pregnancy (including previous stroke) • formulate list of differential Maternal • prenatal diagnosis (see 3.1) • counsel re fetal and maternal risks (incl. diagnoses Medicine • peripartum care risks therapy) • formulate, implement and - maternal and fetal outcome • arrange and interpret appropriate where appropriate modify a Attendance at - pharmacology (incl adverse effects) investigations multi-disciplinary • obstetric • phenytoin, valproic acid, carbamezepine, • institute/modify drug therapy lamotrigine • plan delivery and postnatal care management plan medicine • propanolol, tricyclic antidepressants (see 1.13) • refer, where appropriate, for further • liaise with neurologists, clinic • acetazolamide assessment, treatment physiotherapists, intensivists • neurology • pyridostigmine where appropriate (e.g CF, clinic - contraception Manage a case of neuropathy in pregnancy; ARDS) Acute / pregnancy-induced neurological disease (stroke, • counsel re maternal risks / prognosis • counsel women accordingly Attachment in neuropathies –Bell’s palsy, carpal tunnel syndrome, meralgia • institute/modify therapy (incl., where - maternal and fetal risks ITU/HDU parasthetica) appropriate drug therapy) - risks of anti-epileptic - pathogenesis stroke (incl. cerebrovascular disease, • refer, where appropriate, for further cerebral venous thrombosis, SAH), neuropathies assessment / treatment therapies Personal study - diagnosis (incl. differential diagnosis headache, - postnatal care convulsions and altered consciousness [see 1,18] & - contraception cerebral imaging, electrophysiology) - long term outcome - management (incl. corticosteroids [see 1.5, 1.6] - maternal and fetal outcome

11 1.10 Connective Tissue Disease

Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing connective tissue disease (CTD)

Knowledge criteria Clinical competency Professional skills and Training Evidence / attitudes support Assessment Systemic lupus erythematosis (SLE) & antiphospholipid Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of syndrome (APS) CTD history and conduct an and discussion experience & - pathogenesis • previous obstetric history examination to assess a woman with senior competence - prevalence • drug therapy with neurological disease medical staff - diagnosis (incl. classification criteria [Sapporo, American Mini-CEX Rheumatoid Association] , laboratory investigations) Manage a case of SLE and APS in pregnancy; - functional impact of pregnancy • counsel re fetal and maternal risks (incl. Ability to Appropriate - management incl; risks therapy) • perform and interpret postgraduate • pre-pregnancy care • arrange and interpret appropriate appropriate investigations courses e.g. • maternal and fetal monitoring investigations (incl. fetal monitoring) • formulate list of differential Maternal - maternal and fetal outcome • institute/modify drug therapy diagnoses Medicine - pharmacology (incl adverse effects) • plan delivery and postnatal care • formulate, implement and • corticosteroids, azothiaprine (see 1.2,1.5,1.6) • refer, where appropriate, for further where appropriate modify a Attendance at • aspirin, LMW heparin (see 1.12, 4.2) assessment, treatment multi-disciplinary • obstetric - contraception - outcome (incl. management of neonatal lupus) Manage a case of other CTD in pregnancy management plan medicine Other CTDs (incl. scleroderma, rheumatoid arthritis, mixed • counsel re fetal and maternal risks (incl. • liaise with immunologists, clinic CTD) risks therapy) physicians, physiotherapists, • SLE / CTD - pathogenesis • arrange and interpret appropriate s where appropriate clinic - diagnosis investigations (incl. fetal monitoring) • counsel women accordingly - functional impact of pregnancy • plan delivery and postnatal care - maternal and fetal risks Attachment in - Management incl; • refer, where appropriate, for further - contraception ITU/HDU • pre-pregnancy care assessment, treatment - long term outcome • maternal and fetal monitoring - maternal and fetal outcome Personal study - pharmacology (incl adverse effects) • aspirin (see 4.2), NSAIDs • corticosteroids (see 1.2,1.5,1.6) • chloroquine (see 6.9), sulphasalazine (see 1.6), azothiaprine (see 1.2), penicillamine - contraception

12 1.11 Haematological Disease

Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing haematological disease 2. To be able to carry out appropriate assessment and management of women with pregnancy-induced haematological disease

Knowledge criteria Clinical competency Professional skills and Training Evidence / attitudes support Assessment Haematological function in pregnancy Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of - red cell / plasma volume changes during pregnancy haematological disease. history and conduct an and discussion experience & - changes in coagulation system during pregnancy • diagnosis examination to assess a woman with senior competence - interpretation of haematological / clotting tests • drug therapy with haematological disease medical staff

Mini-CEX Anaemia Perform an examination to assess anaemia / - pathogenesis (iron, folate & vitamin B12 deficiency thrombocytopenia Ability to Appropriate - prevalence • perform and interpret postgraduate - diagnosis Manage a case of anaemia during pregnancy; appropriate investigations courses e.g. - maternal and fetal outcome • counsel re fetal and maternal risks • formulate list of differential Maternal - pharmacology (incl adverse effects) • arrange and interpret appropriate diagnoses Medicine • iron (oral & parenteral), folic acid, vitamin B12 investigations • formulate, implement and • institute/modify drug therapy (incl. where where appropriate modify a Attendance at Haemoglobinopathies (Sickle cell & Thalassemia syndromes) appropriate parenteral iron, blood multi-disciplinary • obstetric - genetic basis and pathogenesis transfusion) - prevalence • plan delivery and postnatal care management plan medicine - prenatal diagnosis (see 2.1), fetal monitoring • refer, where appropriate, for further • liaise with haematologists, clinic - functional impact of pregnancy assessment / treatment geneticists where • haematology - maternal and fetal outcome appropriate clinic - management (incl. vaso-occlusive crisis in SCD, Manage a case of sickle cell and thalassemia • counsel women accordingly haematinic & transfusion therapy) syndromes; - maternal and fetal risks Personal study • counsel re fetal and maternal risks / - prenatal diagnosis (see prenatal diagnosis 2.1) • arrange and interpret appropriate investigations (incl fetal monitoring in SCD) - contraception • institute/modify therapy (incl. vaso-occlusive - long term outcome crisis in SCD, blood transfusion) • plan delivery and postnatal care • refer, where appropriate, for further assessment / treatment

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Thrombocytopenia Manage a case of immune thrombocytopenic - prevalence purpura in pregnancy - diagnosis (incl. differential diagnosis thrombocytopenia) • counsel re fetal and maternal risks - pathogenesis (incl. gestational thrombocytopenia, ITP, • arrange and interpret appropriate HUS and TTP) investigations - maternal and fetal outcome • institute/modify therapy - management (incl. role of splenectomy) • plan delivery and postnatal care - pharmacology (incl adverse effects) • refer, where appropriate, for further • corticosteroids, azathiaprine (see 1.2,1.10) assessment / treatment • iv immunoglobulin G Manage a case of congenital coagulation disorder Congenital coagulation disorders in pregnancy - genetic basis / pathogenesis vWD, haemophilia • counsel re fetal and maternal risks / - prevalence prenatal diagnosis - prenatal diagnosis (see 2.1) • arrange and interpret appropriate - diagnosis / maternal monitoring (clotting factor levels / investigations vWF antigen activity, vWF:RCo) • institute/modify therapy - maternal and fetal outcome • plan delivery and postnatal care - management (incl pre-pregnancy counseling and • refer, where appropriate, for further intrapartum care) assessment / treatment - pharmacology (incl adverse effects) ƒ DDAVP Manage a case of DIC in pregnancy ƒ recombinant and plasma derived factor • identify and treat underlying cause concentrates • arrange and interpret appropriate investigations Disseminated intravascular coagulation [DIC] (see 5.7,5.10) • institute/modify resuscitative and - aetiology and pathogenesis replacement therapy - diagnosis - management • resuscitation [see 5.10] with volume replacement • platelet, fresh frozen plasma replacement • recombinant fVIIa (see 5.7)

14 1.12 Thromboembolic disease

Objectives: 1. To be able to carry out appropriate assessment and management of women at risk or with a history of thromboembolic disease (TED) 2. To be able to carry out appropriate assessment and management of a women with pregnancy-induced TED

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Venous thromboembolism (VTE) in pregnancy Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of - pathogenesis of deep venous thrombosis (DVT), pulmonary suspected VTE in pregnancy. history and conduct an and discussion experience & embolism (PE) • previous VTE examination to assess a woman with senior competence - prevalence • family history with suspected VTE in pregnancy medical staff - risk factors (incl. thrombophilias) Mini-CEX - diagnosis (clinical, D-dimer, ultrasound , Doppler, CXR, ECG, Perform an examination to assess suspected Ability to blood gases, isotope scanning, spiral CT) VTE in pregnancy • perform and interpret Appropriate - acute management appropriate investigations postgraduate • antithrombotic agents Manage a case of VTE in pregnancy; • formulate list of courses e.g. • laboratory monitoring • arrange and interpret appropriate differential diagnoses Maternal Medicine • thrombolytic therapy / surgery investigations • formulate, implement and - subsequent prophylaxis (incl. non-pharmacological methods) • counsel re maternal and fetal risks where appropriate modify a Attendance at - pharmacology (incl adverse effects) • plan subsequent care (incl. delivery and multi-disciplinary • obstetric • unfractioned heparin, LMWH postnatal care) management plan medicine clinic • warfarin • refer, where appropriate, for further • liaise with physicians, • thrombophilia • streptokinase assessment, treatment radiologists, haematologists / haematology - outcome (jncl. postphlebitic syndrome) where appropriate - contraception Manage a case of thrombophilia and / or • counsel women accordingly clinic Thrombophilia / previous VTE previous VTE in pregnancy - maternal and fetal - genetic basis and pathogenesis of congenital and acquired • arrange and interpret appropriate risks RCOG Clinical thrombophilias (see 1,10) investigations - risks / benefits of Guideline (37) - diagnosis of thrombophilia (lab investigations and • counsel re risks of VTE in prophylactic interpretation in pregnancy) pregnancy/puerperium antithrombotic therapy Personal study - risk of VTE (based on thrombophilia, past history) • institute/modify VTE prophylaxis where during pregnancy,

- maternal and fetal risks (incl.fetal loss, PE, FGR) appropriate labour and puerperium - Management incl; • plan delivery and postnatal care - long term outcome • non-pharmacological approaches • refer, where appropriate, for further - contraception • LMWH, aspirin assessment, treatment • fetal monitoring - contraception

15 1.13 Psychiatric disease

Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing psychiatric disease 2. To be able to carry out, under supervision, appropriate assessment and management of a women with pregnancy-induced/related psychiatric disease

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Pre-existing psychiatric disease (incl. depression / bipolar Take an appropriate history from a woman Ability to take an appropriate Observation of Log of disorders, anxiety disorders, schizophrenia) with psychiatric illness history to assess a woman with and discussion experience & - prevalence • previous history / drug history psychiatric disease with senior competence - functional impact of pregnancy • risk factors medical staff - pregnancy / postnatal management Ability to Mini-CEX ƒ role of specialist team / community liaison / mother Manage a case of chronic psychiatric and baby units disease in pregnancy; • formulate, implement and Appropriate ƒ psychotherapy • refer for further assessment / where appropriate modify a postgraduate ƒ pharmacological therapy / risks of withdrawal treatment to psychiatric services multi-disciplinary management courses e.g. ƒ mother and baby units • counsel re maternal, fetal and plan Maternal Medicine - maternal and fetal risks neonatal risks • formulate list of differential - pharmacology (incl. adverse effects) • institute/modify drug therapy, diagnoses Attendance at • tricyclics, SSRIs where appropriate • liaise with psychiatrists, • obstetric • phenothiazines (e.g. trifluoperazine, chlorpromazine) • plan pregnancy, delivery and community psychiatric nurses psychiatry • butyrophenones (e.g. haloperidol) postnatal care • counsel women accordingly clinic • benzodiazepines - maternal risks • psychiatry • lithium, carbamezepine Manage a case of postnatal depression / - neonatal management (incl. withdrawal and long term risks) puerperal psychosis; - risks / benefits of therapy clinic - Legal issues (incl. Mental Health Act and consent, child • identify high risk women and refer - long term outcome / protection) for further assessment / treatment recurrence risks Attachment in Pregnancy-induced / related psychiatric disease to psychiatric services - breast feeding / perinatal - risk factors • institute/modify therapy where contraception psychiatry - diagnosis (incl. differential diagnosis postnatal depression) appropriate - management • counsel re maternal and neonatal Personal study • role of specialist team / community liaison / mother risks, long term outcome (incl risk of

and baby units recurrence) • support / psychotherapy • pharmacological therapy / ECT - maternal and neonatal outcome (incl. recurrence risks)

16 1.14 Substance abuse

Objectives: 1. To be able to carry out appropriate assessment and management of women with previous / current history of alcohol abuse 2. To be able to carry out appropriate assessment and management of a women with previous / current history of substance abuse / dependency

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Maternal and fetal effects (incl. maternal psychosocial Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of effects) alcohol / substance abuse / dependence history and perform an and discussion experience & - alcohol (incl. acute intoxication) • social problems / support examination to assess a woman with senior competence - cannabis • previous detoxification, methadone with alcohol / substance abuse medical staff - opiates maintenance / dependency Mini-CEX - cocaine and crack • complications - benzodiazepines Perform an examination to assess suspected alcohol Ability to Appropriate - amphetamines / substance abuse • provide sympathetic postgraduate lysergic acid diethylamide (LSD), phencyclidine (angel dust) - support (suppress any courses e.g. - toluene (glue sniffing) Manage a case of alcohol abuse in pregnancy; display of personal Maternal Medicine - smoking • arrange and interpret appropriate maternal & judgement) Management fetal investigations • formulate, implement and - screening methods / diagnosis Attendance at • liaise with primary care, social services, alcohol where appropriate modify - structure / organization of antenatal care • drug / alcohol dependency team and refer, where a multi-disciplinary - organization of drug/alcohol dependency services and links abuse clinic appropriate, for further assessment / management plan with psychiatric and social services treatment • liaise with drug • psychiatry - prenatal diagnosis and fetal monitoring • counsel re maternal, fetal and neonatal risks dependency team, clinic - overdose • institute/modify supportive / drug therapy psychiatrists, social - detoxification • plan pregnancy, delivery and postnatal care services, pharmacists Personal study - maintenance therapy and neonatologists - analgesia in labour Manage a case of substance abuse in pregnancy; • counsel women - smoking cessation strategies (and their effectiveness) RCOG Clinical • arrange and interpret appropriate maternal & accordingly Pharmacology (incl. adverse effects) Guideline (9) fetal investigations - drinking / drug - methadone • liaise with primary care, social services, alcohol cessation - benzodiazepines (see 1.13) dependency team and refer, where - maternal, fetal and - nicotine replacement appropriate, for further assessment / neonatal risks Outcome treatment - long term health - Neonatal management and outcome (incl. management of • counsel re maternal, fetal and neonatal risks implications withdrawal) • institute/modify supportive / drug therapy - breast feeding / - Legal issues (child protection) • plan pregnancy, delivery and postnatal care contraception

17 1.15 Skin Disease

Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing skin disease 2. To be able to carry out appropriate assessment and management of women with pregnancy-induced skin disease

Knowledge criteria Clinical competency Professional skills and Training Evidence / attitudes support Assessment Physiological skin changes of pregnancy Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of - Skin changes skin disease history and conduct an and discussion experience & - Nail / hair changes • diagnosis examination to assess a woman with senior competence • drug therapy with skin disease medical staff Pre-existing skin disease (eczema, psoriasis, acne) Perform an examination in a woman with skin Mini-CEX - pathogenesis disease. - prevalence Ability to Appropriate - functional impact of pregnancy Manage a case of chronic skin disease in • perform and interpret postgraduate - pregnancy / postnatal management pregnancy appropriate investigations courses e.g. - pharmacology (incl adverse effects) • arrange and interpret appropriate • formulate list of Maternal • emollients investigations differential diagnoses Medicine • topical corticosteroids • institute/modify drug therapy • formulate, implement and • topical benzoyl peroxide • refer, where appropriate, for further where appropriate modify Attendance at assessment, treatment a management plan • obstetric Pregnancy-induced skin disease (pemphigoid gestatuinis, polymorphic eruption of pregnancy [PEP], prurigo of pregnancy, Manage a case of pregnancy-induced skin disease • liaise with dermatologists medicine pruritic folliculitis of pregnancy) • arrange and interpret appropriate maternal appropriate clinic - pathogenesis & fetal investigations • counsel women accordingly • dermatology - prevalence • counsel re maternal and fetal risks - maternal and fetal clinic - diagnosis (incl. skin histological and immunofluoresecnt • institute/modify drug therapy risks findings) • plan pregnancy, delivery and postnatal care - safety of topical Personal study - maternal and fetal outcome • refer for further assessment / treatment therapies in pregnancy - management (incl. plasmapheresis, immunosuppressants) - recurrence risks - pharmacology (incl adverse effects) • topical / systemic corticosteroids [see 1.5, 1.6] • antihistamines (e.g. diphenhydramnine) - recurrence risks

18 1.16 Malignant Disease

Objectives: 1. To be able to carry out, under supervision, appropriate assessment and management of women with previous/current malignant disease

Knowledge criteria Clinical competency Professional skills and Training Evidence / attitudes support Assessment Maternal & fetal effects of cancer therapies Take an appropriate history from a woman with Ability to take an appropriate Observation of Log of - Radiotherapy suspected / prior malignancy history and conduct an and discussion experience & • fetal dose • diagnosis examination to assess a woman with senior competence • teratogenic / fetal risks • previous procedures / operations with malignant disease medical staff - Chemotherapy • drug therapy Mini-CEX • pharmacokinetics in pregnancy

• teratogenic / fetal risks Ability to Appropriate Perform a breast examination in pregnancy • perform appropriate postgraduate

Breast cancer investigations courses e.g. Manage a case of breast cancer in pregnancy - pathology • arrange appropriate investigations • formulate list of differential Maternal - prevalence • counsel re maternal and fetal risks (incl. diagnoses Medicine - diagnosis in pregnancy (incl. examination, FNA, ultrasound) management options e.g. termination of • formulate, implement and - maternal and fetal risks pregnancy, preterm delivery ) where appropriate modify a Attendance at - pregnancy / postnatal management • plan pregnancy, delivery and postnatal management plan • obstetric • surgery care • adjuvant chemo/radio-therapy • liaise with primary care, medicine • refer for further assessment / treatment • indications for termination / preterm delivery palliative care, surgeons and clinic

- prognosis and recurrence risks oncologists • breast clinic

- contraception Manage a case of gynaecological or other • counsel women accordingly • oncology

malignancy in pregnancy - maternal and fetal risks clinic Gynaecological and other cancer (cervical cancer, ovarian • arrange appropriate investigations - management options cancer, melanoma) • counsel re maternal and fetal risks (incl. - prognosis & recurrence RCOG Clinical - pathology management options e.g. termination of risks Guideline (12) - prevalence pregnancy / preterm delivery) - diagnosis in pregnancy (incl. colposcopy, biopsy) - breastfeeding • plan pregnancy, delivery and postnatal - maternal and fetal risks - contraception Personal study care - pregnancy/postnatal management • refer for further assessment / treatment • surgery (incl. hysterectomy, salpingo-oophorectomy) Ability to act with empathy, • adjuvant chemo/radiotherapy honesty and sensitivity when • palliative care breaking bad news - prognosis and recurrence risks

19 1.17 Clinical Scenarios

Objectives: 1. To be able to reach a diagnosis in women presenting with various clinical problems in pregnancy

Knowledge criteria Clinical competency Professional skills and Training Evidence / attitudes support Assessment Presenting problems in pregnancy Take an appropriate history and conduct an examination in Ability to take an appropriate Observation of Log of o proteinuria (see 1.2) a woman presenting with the symptom / sign / abnormality history and conduct an and discussion experience & o abnormal renal function (see 1.2) examination to assess a pregnant with senior competence o chest pain (see 1.3, 1.4) Manage a case of gynaecological or other malignancy in woman presenting with symptom / medical staff o palpitations (see 1.3) pregnancy sign / abnormality Mini-CEX o heart murmur (see 1.3) • arrange appropriate investigations o breathlessness (see 1.3, 1.5) • counsel re maternal and fetal risks (incl. management Appropriate o abdominal pain (see 1.6) options e.g. termination of pregnancy / preterm Ability to postgraduate o vomiting (see 1.6) delivery) • formulate list of differential courses e.g. o itching (see 1.6, 1.15) • plan pregnancy, delivery and postnatal care diagnoses Maternal o abnormal liver function (see 1.6) • refer for further assessment / treatment • arrange and interpret Medicine o convulsions (see 1.9) appropriate investigations o headache (see 1.9) • formulate a management plan Attendance at o altered consciousness (see 1.9) • reassure women about the • general o anaemia (1.11) o thrombocytopenia (1.11) safety of radiological medicine investigations in pregnancy clinics - causes (physiological and pathological) - investigations Personal study • ECG • chest X-Ray • echocardiogram • arterial blood gases • lung function tests .

20 MODULE 2 GENETICS 2.1 Genetic disorders Objectives To be able to carry out appropriate counselling and management in families with a previous genetic disorder Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Genetics Take an appropriate history and construct, where Ability to identify patients with, or Observation of and Log of - gene structure & function appropriate, a family tree in patients with or at at risk of a genetic condition discussion with senior experience and • DNA as genetic material risk of genetic disease. medical staff competence • replication, transcription & translation Ability to • mechanisms & effects of mutation Manage a case with a personal / family history of: Appropriate • formulate, implement and where Mini-CEX - inheritance & susceptibility • genetic disease (incl. cystic fibrosis, appropriate modify management postgraduate courses

• patterns of inheritance of single genes myotonic dystrophy, muscular dystrophy, plan e.g. Fetal Medicine Case-based • genetic heterogeneity (locus & allele) Fragile X, haemoglobinopathy, haemophilia, • liaise with clinical geneticist and • new mutations causing single gene disorder IEM) associated laboratory disciplines Attendance at: discussions • expression & penetrance • syndromic anomaly (see 3.3) (incl. cyto- and molecular • specialist • multifactorial inheritance (incl. summation / including: genetics) and refer where paediatric clinics interaction gene effects, polymorphisms) • counsel about: appropriate. • mitochondrial inheritance - risk and impact of disease • counsel women and their partners Attachments in; - information sources & support groups about; • genetics • Service & Laboratory aspects - prenatal diagnostic options (incl. risks - genetics in an laboratory - organisation & role of Clinical Genetics Services timing of tests / results, accuracy) specialties (incl. understandable & non- - DNA testing in clinical practice - management options after testing (incl. cyto- / molecular directive way • ethical & societal issues termination of pregnancy) genetics • diagnostic, predictive & carrier testing • arrange appropriate fetal & maternal - fetal risks • neonatology • uses and limitations of laboratory tests investigations - prenatal screening / • paediatric - indications, methods and limitations (incl. failure / • refer where appropriate for further diagnostic options (incl. surgery error rates) of: specialist and/or genetic counselling limitations of tests) • perinatal • cytogenetics • plan care of ongoing pregnancy / delivery - treatment, management pathology • FISH - reproductive options • PCR • formulate management plan for Personal study • Southern / Northern blotting ongoing and future pregnancies • Gene tracking using RFLPs • support parent(s) • Enzyme/ biochemical analysis • respect confidentiality

Ability to use genetic testing appropriately

21 Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Methods of prenatal diagnosis (incl. indications, Perform: techniques, complications) • detailed ultrasound: • ultrasound - at appropriate gestation

• amniocentesis - using appropriate technique (incl. • chorion villus sampling (CVS) transvaginal, Doppler, 3D/4D) • fetal blood sampling • amniocentesis • fetal tissue biopsy • chorion villus sampling • CVS Single gene defects • fetal blood sampling or refer, where - epidemiology & inheritance appropriate, for same

- effects of mutation & associated pathology • skin/muscle biopsy or refer, where - clinical / pathological features appropriate, for same - prognosis - recurrence risks - prenatal diagnosis of the following defects: • cystic fibrosis • muscular dystrophy • myotonic dystrophy • fragile X • haemoglobinopathies (see also • haemophilias (see also • common inborn errors of metabolism

22 2.2 Chromosomal disorders Objectives To be able to carry out appropriate counselling and management in families with a previous chromosomal disorder To be able to understand and supervise a programme of screening for chromosomal anomaly during pregnancy To be able to carry out appropriate counselling and management of fetal chromosome anomaly To be able to carry to appropriate counselling and management of rarer cytogenetic anomalies including translocations, markers and mosacism. Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Chromosomes Take an appropriate history Ability to take an Observation of and Log of - structure & function (see 3.2/3.3) appropriate history discussion with senior experience and - cell division Manage a case with a personal / family history of a medical staff competence - types of abnormality (incl. structural chromosomal anomaly (incl. structural alterations) Ability to; rearrangements, trisomies, sex chromosome including: Appropriate • counsel women and partners Mini-CEX anomalies, extra markers, mosaicism) • counsel about: - before screening test postgraduate courses

Screening / diagnosis - risk and impact of anomaly - after positive result e.g. Fetal Medicine Case-based - biochemical markers (incl. AFP, uE3, hCG, - prenatal diagnostic options • formulate, implement and PAPP-A, inhibin-A) - management options after testing where appropriate modify Attendance at: discussions - ultrasound markers • arrange appropriate fetal & parental investigations management plan in a woman • specialist • 11-14 weeks (incl. nuchal translucency, • refer where appropriate for further specialist and/or at ‘higher’ risk of paediatric clinics nasal bone, ductus venosus Doppler, genetic counselling chromosomal anomaly tricuspid regurgitation) • plan subsequent care of ongoing pregnancy Attachments in; • 18-21 weeks (incl. nuchal oedema, Ability to • genetics clinodactyly, echogenic bowel, Counsel women about screening for / diagnosis of • formulate, implement and • laboratory pyelectasis, choroid plexus cysts, nasal chromosomal anomalies in pregnancy including: where appropriate modify specialties (incl. bone, short femur/humerus) • screening options (biochemistry & ultrasound) management plan in a case cyto- / molecular - Likelihood ratios & risk calculation • diagnostic tests (incl. laboratory methods, risks, with a chromosomal anomaly genetics, serum - screening strategies accuracy and timing of results) • liaise with clinical geneticist screening) • accuracy (incl. detection rate, false and cytogenetics and refer • neonatology positive rate) Manage a case of chromosomal anomaly diagnosed in where appropriate. • paediatric • service / cost implications pregnancy including; • counsel women and their surgery - laboratory diagnosis (incl. methods, failure / • counsel about fetal / infant risks and long term partners about; • perinatal error rates) outcome of the following anomalies: - fetal risks pathology • cytogenetic analysis - trisomy 21 (Down syndrome) - prenatal screening / • FISH - trisomy 18 (Edward syndrome) diagnostic options (incl. Personal study • PCR - trisomy 13 (Patau syndrome) limitations of tests) - 45X (Turner syndrome)

23 Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment - mosaicism (incl. classification and - triploidy - reproductive options National Screening management) - common sex chromosome anomalies (incl. 47XXY • formulate management plan Committee Guidance - principles & organisation of screening / (Kleinfelter syndrome), 47XXX) for ongoing and future on Down syndrome diagnostic programme for chromosomal - structural rearrangements pregnancies screening anomalies - markers • support parent(s) • National Screening Committee - mosaicism • respect confidentiality • role of regional screening coordinators • counsel about management options (incl. TOP) • quality control & audit • refer where appropriate for further counselling / Ability to use chromosomal support testing appropriately Chromosomal anomalies • plan care of ongoing pregnancy / delivery - epidemiology Perform: - pathology • Ultrasound screening for chromosomal anomaly at: - clinical / pathological features - 10-14 wk including: - prognosis • nuchal translucency - recurrence risks • nasal bone - prenatal diagnosis • ductus venosus Doppler of the following chromosomal anomalies • tricuspid valve regurgitation • trisomy 21 - 18-21 wk including: • trisomy 18 • nuchal oedema • trisomy 13 • nasal bone • pyelectasis • Turner syndrome • short femur/humerus • Kleinfelter syndrome • echogenic bowel • XXX • echogenic intracardiac focus • triploidy • ventriculomegaly • structural rearrangement (incl. • major structural defect balanced & unbalanced • risk calculation for trisomy 21 based on ultrasound translocation) (+/- biochemical) markers • marker chromosome • amniocentesis • chorion villus sampling • uniparental disomy • fetal blood sampling or refer, where • mosaicism appropriate, for same

• skin biopsy or refer, where appropriate, for same

24 2.3 Multiple anomalies and syndromic disorders Objectives To be able to carry out appropriate counselling and management in families with a previous child with multiple anomalies / syndromic disorder To be able to carry out appropriate counselling and prenatal diagnosis in a fetus with multiple anomalies

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Screening / diagnosis Take an appropriate history Ability to take a history and Observation of and Log of - Ultrasound features of common identify patients with, or at risk of discussion with senior experience and syndromes and associations Manage a case with a personal / family history of syndromic anomaly a genetic condition medical staff competence - Use of databases to aid diagnosis including:

• counsel about: Appropriate Ability to Mini-CEX Syndromic anomalies and associations - risk and impact of disease • diagnose fetal anomalies using postgraduate courses

- epidemiology - information sources & support groups ultrasound and formulate e.g. Fetal Medicine Case-based - pathology - prenatal diagnostic options (incl. risks timing of tests / differential diagnosis - clinical features results, accuracy) • liaise with clinical geneticist and Attendance at: discussions - prognosis - management options after testing (incl. termination of associated laboratory disciplines • specialist - inheritance / recurrence risks pregnancy) (incl. cyto- and molecular paediatric clinics - prenatal diagnosis (incl. ultrasound • arrange appropriate fetal investigations genetics) and refer where features, lab diagnosis [where • refer where appropriate for further specialist and/or appropriate. Attachments in; applicable – see 3.1]] genetic counselling • counsel women and their • genetics of the following syndromic anomalies • plan care of ongoing pregnancy / delivery partners about; • laboratory • DiGeorge - possible diagnoses (incl. specialties (incl. • Fryn’s Manage a case of with multiple fetal anomalies: cyto- / molecular outcomes) • Beckwith-Wiedemann • use computer database (e.g. London Dysmorphology Database, genetics - further investigations (incl. • Meckel-Gruber OMIM) to reach differential diagnosis • neonatology limitations of tests) • Smith-Lemli-Opitz • counsel about • paediatric - treatment, management • VATER / VACTERL - possible diagnoses & implications surgery - reproductive options - information sources and support groups • perinatal • formulate management plan for - further prenatal diagnostic options where appropriate pathology ongoing and future (incl. risks / accuracy) pregnancies - management options (incl. termination of pregnancy) Dysmorphology • arrange further fetal investigations where appropriate • support parent(s) databases • refer where appropriate for further specialist and/or • respect confidentiality genetic counselling Personal study • plan care of ongoing pregnancy / delivery

25 MODULE 3 STUCTURAL FETAL ANOMALIES 2.4 CNS anomalies Objectives To be able to carry out appropriate assessment and management of a fetus with a CNS anomaly To understand the management, complications and outcomes of neonates with CNS anomalies Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of - brain & spinal cord (incl. postnatal development) discussion with senior experience and Pathology / Epidemiology Perform an ultrasound scan to assess: Ability to medical staff competence - pathology of major CNS anomalies • head shape, biometry • perform detailed ultrasound

- incidence of CNS anomalies • cavum, corpus callosum assessment of fetal CNS Appropriate Mini-CEX - risk factors • thalami, cortex • reach a differential diagnosis postgraduate courses - associated chromosomal / genetic / syndromic • ventricles, choroid plexus • perform and interpret appropriate e.g. Fetal Medicine anomalies • cerebellum, cisterna magna investigations Case-based Screening / diagnosis • cerebral Doppler (see 4.8) Attendance at: discussions - ultrasound appearance of normal Ability to • paediatric embryonic/fetal/neonatal CNS Be able to diagnose and counsel about the • formulate, implement and where neurology clinics - biometric measurements (incl. transcerebellar following: appropriate modify management plan

diameter, ventricular size, cisternal magna) • anencephaly / exencephaly • liaise with neonatologists, paediatric Attachments in; - ultrasound appearances of CNS anomalies (incl. • spina bifida, encephalocele neurologists and paediatric surgeons • neonatology differential diagnosis) • iniencephaly, microcephaly where appropriate (including • paediatric - role of antenatal and postnatal MRI • ventriculomegaly (all degrees) appropriate referral for second surgery Management / outcome • holoprosencephaly opinion) • perinatal - acrania / exencephaly / anencephaly • Dandy Walker spectrum • counsel women and their partners pathology - spinal bifida • tumours, cysts accordingly - encephalocele • intracranial haemorrhage (see also 4.9) - fetal (and maternal) risks Personal study - holoprosencepahly - neonatal management - ventriculomegaly Manage a case of CNS anomaly including: - long term outcome - Dandy Walker spectrum • counsel regarding fetal / infant risks - postnatal or post mortem - microcephaly (including long term health implications) findings - intracranial mass • arrange / perform appropriate fetal & - recurrence risks Recurrence risks / prevention maternal investigations (+ MRI if • formulate management plan for - CNS anomalies appropriate) future pregnancy - Prevention of neural tube defects • refer where appropriate for further • support parent(s) Pharmacology counselling

- Folic acid • plan delivery / appropriate neonatal support

26 3.2 Cardiac anomalies Objectives To be able to carry out appropriate assessment and management of a fetus with a cardiac anomaly To understand the management, complications and outcome of neonates with cardiac anomalies Knowledge criteria Clinical competency Professional skills Training Evidence/ and Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate Observation of and Log of - heart and cardiovascular system history discussion with senior experience and - circulatory adaptations at birth Perform echocardiography to assess: medical staff competence Pathology / Epidemiology • cardiac size, position Ability to

- pathology of major cardiac anomalies • venous system (incl. ductus venosus) • perform echocardiography Appropriate Mini-CEX - incidence of cardiac anomalies • atria & ventricless (including Doppler and M- postgraduate courses - risk factors (incl. family history) • outflow tracts mode) e.g. Fetal Medicine - associated chromosomal / genetic (incl. 22q • arterial system (incl. ductus arteriosus) • reach a differential Case-based deletions) / syndromic anomalies • heart rate and rhythm diagnosis Attendance at: discussions - mechanisms of tachy- & brady-arrhymthmias • paediatric Screening / diagnosis Be able to diagnose and counsel about the following: Ability to cardiology clinics - ultrasound appearance of normal fetal heart • septal defects • formulate, implement and

- biometric measurements (incl. chamber sizes) • valvular abnormalities & hypoplastic heart: where appropriate modify Attachments in; - ultrasound appearances of cardiac anomalies (incl. - mitral stenosis / atresia management plan • neonatology differential diagnosis) - aortic stenosis / atresia • liaise with paediatric • perinatal - role of 3D / 4D ultrasound (STIC) - tricuspid stenosis / atresia cardiologists and pathology - role of M-mode & Doppler echocardiography (incl. - pulmonary stenosis / atresia neonatologists (including normal transvalvular velocities) • outflow tract anomalies (coarctation , appropriate referral for Personal study Management / outcome transposition, double outlet ventricle) second opinion) - septal defects • cardiac tumour • counsel women and their - hypoplastic heart syndromes • arrhythmia partners accordingly - outflow tract anomalies - fetal risks - cardiac tumours Manage a case of cardiac anomaly including: - neonatal - arrhythmias • counsel regarding fetal / infant risks (including management Recurrence risks long term health implications) - long term outcome - cardiac anomalies • arrange / perform appropriate fetal & maternal - postnatal or post Pharmacology Incl. adverse effects of drugs used to investigations (incl. M-mode, Doppler mortem findings treat fetal arrhythmias: echocardiography) - digoxin • refer where appropriate for further - recurrence risks - flecainide • assessment / counselling • formulate management plan - amiodarone • institute / modify anti-arrhythmic therapy for future pregnancy - adenosine • plan delivery / appropriate neonatal support • support parent(s)

27 3.3 Genitourinary (GU) anomalies Learning outcomes To be able to carry out appropriate assessment, counselling and management of a fetus with a genitourinary anomaly To understand the management, complications and outcomes of neonates with genitourinary anomalies Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of - genitor-urinary system (incl. physiology of fetal discussion with senior experience and urinary system) Perform ultrasound scan to assess: Ability to medical staff competence - functional adaptations after birth • renal size • perform detailed ultrasound

Pathology / Epidemiology • renal parenchyma & collecting system assessment of fetal GU system Appropriate Mini-CEX - pathology of major GU anomalies • ureters & bladder • reach a differential diagnosis postgraduate courses - incidence of GU anomalies • genitalia • perform and interpret appropriate e.g. Fetal Medicine - risk factors • renal artery Doppler investigations (incl. vesicocentesis) Case-based - associated chromosomal / genetic / syndromiv Attendance at: discussions anomalies Be able to diagnose and counsel about the Ability to • paediatric Screening / diagnosis following: • formulate, implement and where nephrology - ultrasound appearance of normal embryonic/fetal appropriate modify management plan clinics • renal agenesis / neonatal urinary tract • renal cystic disease (ADPKD, IPKD) • liaise with neonatologists, paediatric - ultrasound appearances of GU anomalies (incl. • multicystic / dyspalstic kidney nephrologists, paediatric surgeons Attachments in; differential diagnosis) where appropriate (including • neonatology • renal cyst - biochemical measurement of fetal urine function appropriate referral for second • perinatal • pylectasis / hydronephrosis - neonatal / paediatric investigations (incl. opinion incl. vesicoamniotic shunting) pathology cystourethrography, MAG3 / DMSA scanning) • megacystis ± megaureter • counsel women and their partners Management / outcome • ambiguous genetalia accordingly Personal study - renal agenesis - fetal risks (incl. risks of - renal cystic disease Manage a case of GU anomaly including: diagnostic and therapeutic • counsel regarding fetal / infant risks - hydronephrosis procedures) - duplex kidney (including long term health implications) - neonatal management - lower urinary tract obstruction • arrange / perform appropriate fetal and - long term outcome - bladder/claocal exstrophy maternal investigations (including - postnatal or post mortem - indications for / risks of: amnioinfusion [see 3.11] and vesicocentesis) • perform vesicoamniotic shunting or refer, findings • amnioinfusion (see 3.11) where appropriate, for same - recurrence risks • vesicocentesis • refer where appropriate for further • formulate management plan for • vesicoamniotic shunting counselling future pregnancy Recurrence risks • plan delivery / appropriate neonatal support • support parent(s) - GU anomalies

28 3.4 Pulmonary abnormalities Objectives To be able to carry out appropriate assessment, counselling and management of a fetus with a pulmonary anomaly To understand the management, complications and outcomes of neonates with pulmonary anomalies

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of - Trachea, lungs & diaphragm discussion with senior experience and - functional adaptations after birth Perform ultrasound scan to assess: Ability to medical staff competence • chest size and shape • perform detailed ultrasound assessment

Pathology / Epidemiology • mediastinal shift of fetal thorax Appropriate Mini-CEX - pathology of pulmonary anomalies • ribs • reach a differential diagnosis postgraduate courses - incidence of pulmonary anomalies • lung parenchyma • perform and interpret appropriate e.g. Fetal Medicine - risk factors • diaphragm investigations (incl. thoracocentesis) Case-based - associated chromosomal / genetic / syndromic Attendance at: discussions anomalies Be able to diagnose and counsel about the Ability to • paediatric chest following: • formulate, implement and where clinics Screening / diagnosis • Laryngeal atresia/ stenosis appropriate modify management plan

- ultrasound appearance of normal embryonic/fetal (CHAOS) • liaise with neonatologists, paediatric Attachments in; thorax • CAML chest physicians, paediatric surgeons • neonatology - ultrasound appearances of pulmonary anomalies • pulmonary sequestration where appropriate (including appropriate • paediatric (incl. differential diagnosis) • diaphragmatic hernia referral for second opinion incl. surgery - role of antenatal and postnatal MRI / CT imaging • pleural effusion pleuroamniotic shunting) • perinatal • counsel women and their partners pathology Management / outcome Manage a case of thoracic anomaly including: accordingly - laryngeal/tracheal atresia (incl. principles of • counsel regarding fetal / infant risks - fetal risks (incl. risks of Personal study EXIT procedure) (including long term health implications) diagnostic and therapeutic - cystic adenomatoid malformation of lung (CAML) • arrange / perform appropriate fetal procedures) - pulmonary sequestration investigations (including - neonatal management - diaphragmatic hernia thoracocentesis) - long term outcome - pleural effusion • perform pleuroamniotic shunting or - indications for / risks of: refer, where appropriate, for same - postnatal or post mortem findings • thoracocentesis • refer where appropriate for further - recurrence risks • pleuroamniotic shunting counselling • formulate management plan for future • plan delivery / appropriate neonatal pregnancy Recurrence risks support support parent(s) - pulmonary anomalies

29 3.5 Abdominal wall (AW) and gastrointestinal (GI) anomalies Objectives To be able to carry out appropriate assessment, counselling and management of a fetus with an AW or GI anomaly To understand the management, complications and outcomes of neonates with AW or GI anomalies

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - Abdominal wall discussion with senior and competence - Gastrointestinal tract Perform ultrasound scan to assess: Ability to medical staff • abdominal shape & biometry • perform detailed ultrasound Mini-CEX Pathology / Epidemiology • abdominal wall / cord insertion assessment of fetal AW and GI Appropriate

- pathology of AW and GI anomalies • stomach, small & large bowel tract postgraduate courses - incidence of AW and GI anomalies • liver, gallbladder • reach a differential diagnosis e.g. Fetal Medicine Case-based - risk factors • intrahepatic vein & ductus venosus • perform and interpret appropriate discussions - associated chromosomal / genetic anomalies investigations Attachments in; Be able to diagnose and counsel about the • neonatology Screening / diagnosis following: Ability to • paediatric - ultrasound appearance of normal embryonic/fetal • gastroschisis / body wall defect • formulate, implement and where surgery AW and GI tract • umbilical hernia / exomphalos appropriate modify management plan • perinatal - ultrasound appearances of AW and GI anomalies • absent / enlarged stomach • liaise with neonatologists, paediatric pathology (incl. differential diagnosis) • duodenal, small & large bowel atresia surgeons where appropriate (including • meconium ileus appropriate referral for second Personal study Management / outcome • hepatic calcification / mass opinion) - gastroschisis • echogenic bowel • counsel women and their partners - umbilical hernia / exomphalos • abdominal cyst accordingly - oesophageal atresia / TOF • ascites - fetal risks - bowel atresia (small and large) - neonatal management - meconium ileus Manage a case of AW /GI anomaly including: - long term outcome - hepatic calcification / mass • counsel regarding fetal / infant risks - postnatal or post mortem - echogenic bowel (including long term health implications) findings - abdominal cyst • arrange / perform appropriate fetal - recurrence risks - isolated ascites investigations • formulate management plan for • refer where appropriate for further future pregnancy Recurrence risks counselling • support parent(s) - AW and GI anomalies • plan delivery / appropriate neonatal support

30 3.6 Neck and face anomalies Objectives To be able to carry out appropriate assessment, counselling and management of a fetus with a neck or facial anomaly To understand the management, complications and outcomes of neonates with neck or facial anomalies

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - fetal face discussion with senior and competence - fetal neck Perform ultrasound scan to assess: Ability to medical staff - fetal thyroid • head shape & biometry (incl. orbital • perform detailed ultrasound Mini-CEX diameters) assessment of fetal neck & face Appropriate

Pathology / Epidemiology • face and palate • reach a differential diagnosis postgraduate courses - pathology of neck and facial anomalies • neck • perform and interpret appropriate e.g. Fetal Medicine Case-based - incidence of neck and facial anomalies • thyroid investigations discussions - risk factors Attendance at: - associated chromosomal / genetic / syndromic Be able to diagnose and counsel about the Ability to • facial cleft anomalies following: • formulate, implement and where clinics • cystic hygroma appropriate modify management plan Screening / diagnosis • facial cleft • liaise with neonatologists, paediatric Attachments in; - ultrasound appearance of normal fetal neck and • micrognathia surgeons, facial cleft team where • neonatology face • anopthalmia appropriate (including appropriate • paediatric - ultrasound appearances of neck and facial • macroglossia referral for second opinion) surgery anomalies (incl. differential diagnosis) • fetal goitre • counsel women and their partners • perinatal - role of antenatal 3D ultrasound / MRI • absent / hypoplastic nasal bone accordingly pathology - fetal risks Management / outcome Manage a case of neck / facial anomaly - neonatal management Personal study - cystic hygroma including: - long term outcome - facial cleft • counsel regarding fetal / infant risks - postnatal or post mortem - micrognathia (including long term health implications) findings - macroglossia • arrange / perform appropriate fetal - recurrence risks - anopthalmia investigations • formulate management plan for - fetal goitre • refer where appropriate for further future pregnancy counselling • support parent(s) Recurrence risks • plan delivery / appropriate neonatal support - Neck and facial anomalies

31 3.7 Skeletal anomalies Objectives To be able to carry out appropriate assessment, counselling and management of a fetus with a skeletal anomaly To understand the management, complications and outcomes of neonates with skeletal anomalies Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - Fetal skeleton and spine discussion with senior and competence Perform ultrasound scan to assess: Ability to medical staff Pathology / Epidemiology • long bone shape & biometry • perform detailed ultrasound Mini-CEX - pathology of skeletal anomalies • ribs & spine assessment of fetal skeleton Appropriate

- incidence of skeletal anomalies • minerlisation of skeleton • reach a differential diagnosis postgraduate courses - risk factors • feet and hands • perform and interpret appropriate e.g. Fetal Medicine Case-based - associated chromosomal / genetic / syndromic • joints investigations discussions anomalies • fetal tone and movements Attendance at: Ability to • paediatric Screening / diagnosis Be able to diagnose and counsel about the • formulate, implement and where orthopaedic - ultrasound appearance of normal fetal skeleton following: appropriate modify management plan lclinics - ultrasound appearances of skeletal anomalies • micromelia (due to lethal and non- • liaise with geneticists, neonatologists, (incl. differential diagnosis) lethal dysplasias) orthopaedic surgeons where Attachments in; - role of antenatal 3D ultrasound / MRI • talipes appropriate (including appropriate • genetics • polydactyly referral for second opinion) • neonatology Management / outcome • limb reduction defect • counsel women and their partners • perinatal - thanatophoric dysplasia • scoliosis accordingly pathology - acondroplasia • sirenomelia - fetal risks - acondrogenesis • sacral agenesis - neonatal management Personal study - ostogenesis imperfeca • scoliosis (due to hemivertebra) - long term outcome - camptomelic dysplasia • fetal akinesia / hypokinesia sequence - postnatal or post mortem - talipes findings - polydactyly Manage a case of skeletal anomaly including: - limb reduction defect • counsel regarding fetal / infant risks - recurrence risks sirenomelia - (including long term health implications) • formulate management plan for - sacral agenesis • arrange / perform appropriate fetal future pregnancy - hemivertebra investigations • support parent(s) - fetal akinesia / hypokinesia sequence • refer where appropriate for further

counselling Recurrence risks • plan delivery / appropriate neonatal support - Skeletal anomalies

32 3.8 Fetal tumours Objectives To be able to carry out appropriate assessment, counselling and management of a fetus with a teratoma To understand the management, complications and outcomes of neonates with teratoma

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - fetal lymphangiomas & teratomas discussion with senior and competence Perform ultrasound scan of a teratoma to Ability to medical staff assess: • perform detailed ultrasound Mini-CEX Pathology / Epidemiology • size, position and relationship to assessment of a fetal tumour Appropriate

- pathology of fetal lymphangiomas & adjacent structures • reach a differential diagnosis postgraduate courses • Case-based teratomas structure (incl. blood flow) e.g. Fetal Medicine Ability to discussions - incidence of fetal tumours Be able to diagnose and counsel about the • formulate, implement and where Attachments in; following: appropriate modify management plan • neonatology Screening / diagnosis • cervical teratoma • liaise with neonatologists, paediatric and • paediatric • Sacrococcygeal teratoma - ultrasound appearances of fetal ENT surgeons and ENT where surgery appropriate (including appropriate • perinatal lymphangiomas / teratomas (incl. Manage a case of fetal teratoma including: referral for second opinion) pathology differential diagnosis of complex • counsel regarding fetal / infant risks • counsel women and their partners masses) (including long term health implications) accordingly Personal study • arrange / perform appropriate fetal - role of antenatal 3D ultrasound / MRI - fetal risks investigations - neonatal management • refer where appropriate for further - long term outcome Management / outcome counselling - postnatal or post mortem findings - cervical lymphangioma / teratoma • plan delivery / appropriate neonatal support (incl. where appropriate EXIT - delivery (incl. EXIT - sacrococcygeal teratoma procedure) procedure) • formulate management plan for future Recurrence risks pregnancy - fetal teratomas • support parent(s)

33 3.9 Fetal hydrops Objectives To be able to carry out appropriate assessment, counselling and management of a fetus with hydrops fetalis To understand the management, complications and outcomes of neonates with congenital hydrops

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Pathology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - pathology of fetal hydrops (incl. immune and discussion with senior and competence non-immune causes – see also 4.8) Perform ultrasound scan to assess: Ability to medical staff - incidence of fetal hydrops cause of hydrops including: • perform detailed ultrasound Mini-CEX - risk factors • cause of hydrops (incl. echocardiography [see assessment of fetal hydrops Appropriate

- associated chromosomal / genetic / 3.2] and middle cerebral artery Doppler [see • reach a differential diagnosis postgraduate courses syndromic anomalies 4.8]) • perform and interpret appropriate e.g. Fetal Medicine Case-based • severity of hydrops (incl. amniotic fluid investigations discussions Diagnosis volume [see 3.10]) Attachments in; - ultrasound appearance of fetal hydrops • fetal condition (see 4.3) Ability to • genetics (incl. differential diagnosis) • formulate, implement and where • neonatology - role of, echocardiography (see 3.2), Be able to diagnose and counsel about the following: appropriate modify management plan • haematology antenatal 3D ultrasound / MRI and fetal • immune hydrops (see also 4.8) • liaise with neonatologists, • perinatal blood sampling • non-immune hydrops haematologists and geneticists where pathology appropriate (including referral for Management / outcome Manage a case of fetal hydrops including: second opinion) Personal study - red cell alloimmunisation (see 4.8) • counsel regarding fetal / infant risks (including • counsel women and their partners - cardiac arrhymthmias (see 3.2) long term health implications) accordingly • - other non-immune causes of hydrops arrange / perform appropriate maternal - fetal risks investigations - maternal risks • ± Recurrence risks perform fetal blood sampling ( transfusion - neonatal management - immune and non-immune hydrops or refer, where appropriate, for same - long term outcome • refer where appropriate for further - postnatal or post mortem

counselling findings • plan delivery / appropriate neonatal support - recurrence risks • formulate management plan for future pregnancy • support parent(s)

34 3.10 Multiple pregnancies Objectives To be able to carry out appropriate assessment, counselling and management of abnormalities in multiple pregnancies To understand the management, complications and outcomes of abnormalities in twins

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - mono- & di-zygous twinning (see 4.6) discussion with senior and competence - placentation – chorionicity / amnionicity (see Perform ultrasound scan in multiple pregnancy Ability to medical staff 4.6) to assess: • perform detailed ultrasound Mini-CEX • chorionicity and amnionicity assessment of a multiple pregnancy Appropriate

Pathology / Epidemiology • fetal anatomy with a fetal anomaly postgraduate courses - pathology of abnormalities related to twinning • fetal growth (see 4.3) • reach a differential diagnosis e.g. Fetal Medicine Case-based and twin placentation (incl. twin-to-twin discussions transfusion syndrome [TTTS], twin reversed Be able to diagnose and counsel about the Ability to Attachments in; arterial perfusion [TRAP] and conjoining. following: • formulate, implement and where • neonatology - incidence of abnormalities related to twinning • Multiple pregnancy with discordant appropriate modify management plan • paediatric - risk factors for twinning and related anomalies fetal abnormality • liaise with fetal medicine subspecialists, surgery • TRAP sequence neonatologists and paediatric surgeons • perinatal Screening / diagnosis • Conjoined twin where appropriate (including pathology - ultrasound determination of zygosity / • TTTS appropriate referral for second opinion) chorionicity • counsel women and their partners Personal study - chorionicity and amnionicity Manage a case of multiple pregnancy with fetal accordingly - ultrasound appearances of abnormalities abnormality including: - fetal risks (incl. selective related to twinning (incl. differential diagnosis) • counsel regarding fetal / infant risks (incl. feticide and laser ablation) - invasive procedures in multiple pregnancies selective feticide & laser ablation) - neonatal management • arrange / perform appropriate fetal and - long term outcome Management / outcome maternal investigations (incl. where - postnatal or post mortem - Triplet & higher order multiple pregnancy appropriate fetal karyotyping) findings - Discordant anomalies in multiples • refer where appropriate for further - TRAP sequence counselling / management - delivery - Conjoined twins • perform selective feticide or refer, where • formulate management plan for - TTTS appropriate, for same future pregnancy - Discordant fetal growth (see 4.3) • plan delivery / appropriate neonatal support • support parent(s)

35 3.11 Disorders of amniotic fluid (AF) Objectives To be able to carry out appropriate assessment, counselling and management of a pregnancy with abnormal AF

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Embryology / Physiology Take an appropriate history Ability to take an appropriate history Observation of Log of experience - placenta and membranes and discussion and competence - formation / function of amniotic fluid Perform ultrasound scan to assess AF volume Ability to with senior • perform detailed ultrasound medical staff Mini-CEX Pathology / Epidemiology Be able to diagnose and identify cause of: assessment of AF

- pathology of disorders of AF (incl. • oligo/an-hydramnios (incl. ROM [see 4.5], renal • reach a differential diagnosis Appropriate secondary effects of early amnion anomaly [see 3.3], FGR [see 4.3], postmaturity. • perform and interpret appropriate postgraduate Case-based rupture & oligohydramnios) • Hydramnios (incl. GI anomaly [see 3.5], neuromuscular investigations courses discussions - incidence of AF disorders anomaly, maternal diabetes [see 1.7], placental e.g. Fetal - risk factors angioma) Ability to Medicine - associated chromosomal / genetic / • formulate, implement and where syndromic anomalies Manage a case of oligo/an-hydramnios including: appropriate modify management Attachments in; • counsel regarding fetal / infant risks plan • neonatology Diagnosis • arrange / perform appropriate fetal investigations (incl. • liaise with neonatologists where • genetics - ultrasound measurement of AF amnioinfusion) appropriate (including appropriate • paediatric - diagnosis of oligohydramnios and • institute appropriate maternal and fetal monitoring referral for second opinion) surgery hydramnios (incl. differential diagnosis) • refer where appropriate for further • counsel women and their partners • perinatal - invasive procedures in multiple counselling accordingly pathology pregnancies (incl. risks & indications of • plan delivery / appropriate neonatal support - fetal and neonatal risks amnioinfusion / amnioreduction) - maternal risks Personal study

Manage a case of hydramnios including - neonatal management Management / outcome • counsel regarding fetal/infant risks (incl. preterm - postnatal or post mortem - oligo/an-hydramnios delivery) findings - hydramnios • arrange / perform appropriate fetal & maternal - recurrence risks - indications for / risks of: investigations • support parent(s) • amnioinfusion (see 3.3) • refer where appropriate for further counselling

• amnioreduction • institute appropriate maternal and fetal monitoring • institute, where appropriate, maternal medical Pharmacology therapy - prostaglandin synthase inhibitors • perform, where appropriate, amnioreduction • plan delivery / appropriate neonatal support

36 3.12 Termination of pregnancy Objectives To be able to carry out counselling and management of families undergoing TOP for fetal anomaly

Knowledge criteria Clinical competency Professional skills and Attitudes Training Evidence/ support Assessment Law / Ethics Observation of and Log of experience - abortion law Manage a case of major fetal anomaly: Ability to: discussion with senior and competence - ethics issues relating to TOP for fetal • counsel regarding: • reach a definitive diagnosis of major medical staff anomaly - risk / impact of handicap associated fetal anomaly (where possible) Mini-CEX - guidance on use of feticide with anomaly • assess risks of death and/or handicap Appropriate

Epidemiology - feticide • counsel women and their partners postgraduate courses - incidence of & indications for TOP for fetal - methods of TOP (medical & surgical) regarding: e.g. Fetal Medicine Case-based anomaly - complications of TOP - risks of death / handicap discussions - rates of TOP for fetal anomalies and - post-mortem - option of TOP ± feticide Attendance at: factors influencing decision - aftercare • bereavement Pathology • plan TOP and post-TOP care Ability to support - consent for post-mortem (& tissue • arrange appropriate fetal (and maternal) • formulate, implement and where retention) investigations incl. post-mortem appropriate modify management plan for Attachments in; - conduct of post-mortem examination • refer, where appropriate, for further TOP (incl. post-TOP review) • perinatal Management (incl. methods, complications) counselling • liaise with midwives, neonatologists and pathology - medical TOP • conduct post-TOP counselling pathologists where appropriate • genetics - surgical TOP (incl. suction aspiration and • counsel women and their partners dilatation & evacuation) Perform: accordingly; RCOG Guidance of - feticide • medical TOP or refer, where appropriate, - procedure & risks of TOP Late TOP for Fetal - impact of gestational age on complications for same - post-mortem Anomaly • (physical and psychological) vacuum aspiration and dilatation / • support women and their partners Pharmacology evacuation or refer, where appropriate, for Personal study • refer, where appropriate, for further - mifepristone same counselling / support - prostaglandin analogues (incl. cervagem, • feticide or refer, where appropriate for

misoprostol [see 4.1] same - potassium chloride • supportive counselling Bereavement • post-TOP counselling incl: - Process and milestones - postmorterm findings (where - Management appropriate) - recurrence risks - management plan for future pregnancy

37 3.13 Preconception counselling Objectives: To be able to carry out preconception counselling in families at increased risk of fetal anomaly (including those with family history, prior anomaly, medical disorder or exposure to teratogenic drugs) Knowledge criteria Clinical competency Professional skills and Attitudes Training Evidence/ support Assessment Preconception counselling Take an appropriate history Ability to take an appropriate history Observation of and Log of experience - assessment of risk of fetal anomaly discussion with and competence • personal / family history of genetic disorder Counsel ‘at risk’ woman/family pre- Ability to senior medical • prior chromosomal disorder / advanced age conception • assess risks of fetal anomaly staff Mini-CEX • prior structural anomaly • risks of fetal anomaly • liaise with clinical geneticists, fetal • current medical disorder e.g. diabetes • screening / diagnostic options • teratogen exposure medicine specialists, physicians, Case-based - investigations (incl. genetic testing) refer, where appropriate, to clinical teratologists and refer where Sessions in discussions - methods of screening / diagnosis geneticist or fetal medicine specialist appropriate • clinical - alternative options (incl. assisted conception / • counsel women and their partners genetics preimplantation diagnosis) accordingly

- screening / diagnostic options Personal study Teratogenicity - management plan for future - mechanisms of teratogenicity pregnancy - information sources (including National Teratology Centre) - teratogenetic effects of commonly used drugs incl: • lithium • warfarin • anti-epileptic drugs • ACE inhibitors • anti-neoplastic drugs - teratogenic effects of radiological investigations

38 MODULE 4 ANTENATAL COMPLICATIONS 4.1 Miscarriage and fetal death Objectives: To be able to carry out appropriate assessment and management of women with fetal death before and after <24 weeks gestation To be able to carry out assessment and management of women with trophoblastic disease To be able to carry out assessment and management of women with suspected cervical weakness

Knowledge criteria Clinical competency Professional skills and Training Evidence/ Attitudes support Assessment Pathophysiology - fetal death – early & late Take an appropriate medical & obstetric Ability to take an appropriate history Observation of Log of experience - cervical weakness history and discussion and competence - trophoblastic disease Ability to with senior Manage a case of fetal death including; • perform and interpret ultrasound medical staff Mini-CEX Epidemiology • ultrasound diagnosis in women with suspected fetal - incidence of miscarriage / fetal deth • arrange appropriate investigations death and cervical weakness Appropriate OSAT (cervical - risk factors • plan delivery / postdelivery care [see • formulate, implement and where postgraduate cerclage) 3.12] appropriate modify a management courses Screening • indications for aspirin/LMWH plan for fetal death and - cervical length (see 4.5) suspected cervical weakness Personal study Manage a case of suspected cervical • perform elective and emergency Diagnosis, management and outcome weakness including; cervical cerclage - fetal death • perform and interpret ultrasound • liaise with other services e.g.

- cervical weakness (including cervical measurement of cervical length bereavement support cerclage) • appropriate selection of cases for • formulate, implement and where - trophoblastic disease (incl. surgical intervention appropriate modify a management registration and principles of follow • perform elective and emergency plan for women with up) cervical cerclage trophoblastic disease • counsel women and their partners Pharmacology Manage a case of trophoblastic disease including: accordingly: • Incl. adverse effects of drugs used in ultrasound diagnosis - empathy in bereavement support • arrange appropriate investigations, miscarriage / fetal death: - consent for post mortem registration and follow up

- mifepristrone • perform uterine evacuation - postmortem findings - prostaglandin analogues

39 4.2 Poor / Failed placentation

Objectives: To be able to carry out appropriate assessment and management of women with previous placental disease To be able to carry out appropriate assessment and management of women with biochemical / ultrasound markers of poor placentation

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Normal placental development Take an appropriate medical and obstetric Ability to take an appropriate Observation of and Log of - vascular development (incl. mechanisms of history history discussion with senior experience & spiral artery transformation) • family history medical staff competence - endocrine function • outcome of previous pregnancies Ability to

• perform and interpret Appropriate Mini-CEX Placental pathophysiology Perform and interpret an ultrasound appropriate investigations (incl. postgraduate courses - pre-eclampsia (see 1.1) - fetal growth retardation examination to screen for placental disease: uterine artery Doppler) e.g. Maternal Medicine, - placental abruption (see 4.4) • uterine artery Doppler • formulate, implement and Ultrasound - fetal death (see 4.1) • placental morphology where appropriate modify a multi-disciplinary management Attendance at Screening Manage a case at risk of poor placentation plan • thrombophilia clinics Incl. indications for & predictive abilities of: based on previous history or positive • liaise, where appropriate, with • serum screening lab - biochemical screening (AFP, hCG and screening: haematologists other Down syndrome markers) • arrange appropriate investigations • counsel women and their Personal study - uterine artery Doppler • institute, where appropriate, partners accordingly - placental morphology prophylactic therapy - maternal and fetal risks - thrombophilia screening

- risks / benefits of prophylactic therapies Pharmacology Incl. adverse effects of drugs used in - long term health prevention of poor placentation / fetal death implications - aspirin - low molecular weight eparin - vitamin C/E

40 4.3 Fetal growth disorders Objectives: To be able to carry out appropriate assessment and management of the SGA / growth restricted fetus To be able to understand the management, complications and outcomes of growth restricted neonates To be able to carry out appropriate assessment and management fetal macrosomia To understand the management, complications and outcome of neonates with growth disorders Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Fetal growth Take an appropriate history and p erform Ability to take an appropriate history Observation of and Log of - pattern (incl. organ-specific growth) an exam to screen for fetal growth and conduct an examination to assess discussion with senior experience & - regulation (incl. insulin, IGF system) disorders (incl. use of customized growth fetal size medical staff competence - causes (incl. fetal, placental & maternal factors) chart)

Definitions Ability to Mini-CEX - small for gestational age (SGA) / fetal growth Perform and interpret the following; • perform and interpret ultrasound Attachments in restriction (FGR) • ultrasound morphometry - large for gestational age (LGA) / macrosomia in fetus with suspected growth • Neonatology OSAT (Arterial • umbilical artery Doppler Screening / diagnosis disorder & venous • middle cerebral artery Doppler - previous history • formulate, implement and where Attendance at Dopplers in FGR) • ductus venosus Doppler - clinical exam (incl. symphysis fundal distance) appropriate modify a management • Paediatric follow • biophysical profile (incl. AFV, - ultrasound morphometry – basic and derived plan up clinics (incl. measurements (incl. estimated fetal weight) CTG) • liaise where appropriate with neurodevelopment) - customised growth charts neonatologists Tests of fetal wellbeing Manage a case of SGA /FGR • counsel women and their partners Technique, indications for & interpretation of; • arrange appropriate - Doppler (umbilical artery (UA), middle cerebral accordingly Personal study investigations to identify cause artery (MCA), ductus venosus (DV)) - fetal and neonatal risks (incl. • institute appropriate monitoring - amniotic fluid volume (AFV) consideration, where • plan time / mode of delivery (incl. - cardiotocography (incl. computerized analysis) appropriate, of TOP) TOP where appropriate) - biophysical profile - long term health implications Management for infant - strategy for monitoring Manage a case of LGA/macrosomia - recurrence risks and - timing / mode of delivery • arrange appropriate management plan for future - management of FGR in pre-viable/extremely investigations to identify cause preterm fetus & in multiple pregnancy pregnancy • plan time / mode of delivery Outcome

- neonatal complications of SGA/LGA infant - long term health implications of fetal growth disorders

41 4.4 Antepartum haemorrhage (APH) Objectives: To be able to carry out appropriate assessment and management of women at risk of and presenting with antepartum haemorrhage

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Pathophysiology Take an appropriate history form a Ability to take an appropriate history and Observation of Log of experience - placental abruption woman with APH conduct an examination to assess APH and discussion & competence - placenta praevia with senior - other causes (incl vasa praevia) Perform an examination to assess the Ability to medical staff Mini-CEX - morbidly adherent placenta cause and consequences of APH • perform and interpret appropriate investigations to assess cause and Appropriate OSAT (CS for Epidemiology Perform an ultrasound examination to consequences of APH postgraduate placenta praevia) - incidence assess; • formulate, implement and where courses - risk factors • placental site appropriate modify a management • morphology (incl. retroplacental plan Attachment in Screening / diagnosis haemorrhage & abnormal • liaise with anaesthetists, • Haematology - risk factors (incl. previous CS) implantation) haematologists and radiologists where • Anaesthesia / - ultrasound determination of placental appropriate ITU site (incl. transvaginal ultrasound) Manage a case of APH including; • counsel women and their partners • arrange and interpret appropriate accordingly Personal study Management laboratory investigations - maternal and fetal risks - clinical & laboratory assessment of; • plan mode and timing of delivery - recurrence risks • haemorrhage • appropriate use of blood and blood • coagulation products - assessment of fetal wellbeing (see 4.3) - strategy for monitoring Manage a case of suspected morbidly - timing / mode of delivery adherent placenta - appropriate use of blood and blood • arrange appropriate investigations products (see 5.7) • plan CS (see 5.7)

42 4.5 Preterm delivery Objectives: To be able to carry out appropriate assessment and management of women with previous preterm birth / PPROM To be able to carry out appropriate assessment and management of women with preterm labour / PPROM To understand the management, complications and outcome of the preterm neonate Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Pathophysiology / Epidemiology Take an appropriate history from a woman Ability to take an appropriate Observation of and Log of - preterm labour (PTL) at risk of, or presenting with, preterm history discussion with experience & - preterm premature rupture of membranes (PPROM) – labour / PPROM senior medical staff competence incl. acute chorioamnionitis (see 6.16) Ability to - maternal & fetal conditions leading to elective preterm Manage a case of prior preterm birth / • perform and interpret Appropriate Mini-CEX delivery PPROM - epidemiology of PTL/PPROM • arrange and interpret appropriate appropriate investigations postgraduate Screening / diagnosis investigations • formulate, implement and courses - risk factors where appropriate modify a - clinical exam Manage a case of PPROM management plan Attachment in - fetal fibronectin (fFN) • confirm diagnosis • manage corticosteroid, • Neonatology - cervical length (CL) (see 4.1) • arrange and interpret investigations tocolytic and other therapy - vaginal infection (incl. bacterial vaginosis – see 6.14) & fetal monitoring • arrange in-utero transfer Attendance at - C reactive protein • institute / modify antibiotic therapy • liaise with neonatologists • Paediatric follow Management - in-utero transfer (principles & process) Manage a case of PTL • counsel women and their up clinics (incl. - tocolysis, corticosteroid & antibiotic administration • assess likelihood of preterm birth partners accordingly neurodevelopme - mode of delivery (incl. where appropriate measurement - maternal risks (incl. nt) - strategy for monitoring in PPROM (incl. lab of CL & fFN) chorioamnionitis) investigations, ultrasound) • arrange and interpret appropriate - fetal and neonatal risks Personal study - acute chorioamnionitis (see 6.16) investigations & fetal monitoring (incl. risks pulmonary Pharmacology (Incl. adverse effects; • institute corticosteroid ± tocolysis hypoplasia & - corticosteroids (for lung maturity) • arrange in-utero transfer consideration, where - sympathomimetics, nifedipine, atosiban, indomethacin • plan delivery - progesterone appropriate, of TOP) - erythromycin (see also 6.16) - side effects of therapy Outcome - long term health - neonatal complications of preterm birth (incl.. jaundice, implications for infant RDS, ROP, IVH, PFC) - recurrence risks and - long term health implications of preterm birth (incl. management plan for CLD, neurodevelopmental delay, CP) future pregnancy

43 4.6 Multiple pregnancy Objectives: To be able to carry out appropriate assessment and management of women with a twin pregnancy To be able to carry out appropriate assessment and management of a woman with a higher order multiple pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Embryology / Epidemiology Perform and interpret ultrasound screening / Ability to; Observation of and Log of - mono- & di-zygous twinning diagnosis in multiple pregnancy; • perform and interpret appropriate discussion with experience & - placentation – chorionicity / amnionicity • chorionicity / amnionicity investigations senior medical staff competence - incidence of multiple pregnancy • aneuploidy (incl. nuchal translucency) • formulate, implement and where

appropriate modify a management plan Appropriate Mini-CEX Maternal adaptation / Antenatal care Manage a case of twin pregnancy complicated in MC and DC twin pregnancy - blood & cardiovascular system by; • liaise, where appropriate, with postgraduate - other organ systems • discordant fetal anomaly (see 3.7) colleagues in fetal medicine and courses - organization of antenatal care • fetal growth retardation / discordancy neonatology (see 4.3) • counsel women with multiple pregnancy Attachment in Screening /diagnosis • single fetal death and their partners accordingly • Neonatology - ultrasound determination of zygosity / • monoamniotic twinning - maternal & fetal risks in both MC & including; DC twins chorionicity (see 3.7) Attendance at - aneuploidy (see 3.X) • arrange appropriate investigations - prenatal diagnosis • Multiple - structural anomaly (see 3.7) • institute appropriate monitoring - selective feticide and fetal pregnancy clinic - morphometry (incl. criteria for discordancy) • plan time/mode of delivery reduction - maternal and fetal risks of • Fetal Medicine Management & outcome Manage a higher order multiple pregnancy interventions in MC twins Unit (to witness - preterm delivery (see 4.5) including; - fetal and neonatal risks of preterm interventions in - discordant fetal anomaly (see 3.7) • arrange appropriate investigations birth MC twins) - discordant growth / FGR (see 4.3) • perform fetal reduction or refer, where - fetal death (including empathy in appropriate, for same bereavement support, consent for - single fetal death Personal study - complications of monochorionic (MC) twinning post mortem)

(see 3.7)

- higher order multiple pregnancy (incl. fetal reduction)

44 4.7 Malpresentation Objectives: To be able to carry out appropriate assessment and management of women with a breech presentation To be able to carry out appropriate assessment and management of a woman with an unstable lie

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Epidemiology / aetiology Take an appropriate obstetric history Ability to take an appropriate history Observation of and Log of - incidence and conduct an examination to assess discussion with senior experience & - likelihood of spontaneous version Perform an exam to determine fetal lie fetal lie / presentation medical staff competence - risk factors Manage a case of breech presentation Ability to; Appropriate Mini-CEX Screening / diagnosis including; • perform and interpret ultrasound postgraduate courses - clinical exam • ultrasound diagnosis (incl. exclusion in fetus with suspected breech OSAT (ECV) - ultrasound (incl. diagnosis of associated of fetal, placental and extra-uterine presentation / unstable lie Personal study anomalies) anomalies) • formulate, implement and where • appropriate selection and counseling appropriate modify a management Management / outcome of cases for ECV plan (incl. timing and mode of - external cephalic version (incl. • perform ECV delivery) indications, technique, complications) • perform ECV [See 4.5 re: tocolysis] Manage a case of unstable lie including; • counsel women and their partners - management options in breech • ultrasound diagnosis (incl. exclusion accordingly presentation (incl. induction of labour / of fetal, placental and extra-uterine - risks and benefits of ECV CS / attempted vaginal breech delivery anomalies) - management options (see 5.4) - mode of delivery - management options in unstable lie (incl. induction of labour / CS - fetal / neonatal risks

45 4.8 Red cell alloimmunisation Objectives: To understand the principles and practical aspects of screening for and prevention of red cell alloimmunisation To be able to carry out appropriate assessment and management of a woman with an unstable lie To understand the management, complications and outcome of a neonate with haemolytic disease of the newborn (HDN) Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Blood group systems / pathophysiology Take an appropriate obstetric Ability to take an appropriate history Observation of and Log of - rhesus (incl. gene structure and prediction of history discussion with senior experience & genotype) • past obstetric history Ability to; medical staff competence - other red cell antigens causing HDN • timing / method of • perform and interpret appropriate - fetal pathology in HDN (see also 3.8) sensitisation investigations in fetus at risk of Appropriate Mini-CEX Epidemiology - incidence (alloimmunisation & complications) haemolytic anaemia (incl. MCA postgraduate courses - risk factors (sensitizing events) Manage a case of red cell Doppler) Laboratory methods alloimmunisation • formulate, implement and where Attachments: - Antibody detection (antiglobulin tests) • institute appropriate appropriate modify a management • Neonatology - Kleihauer testing / flow cytometry for FMH maternal and fetal plan for a woman with red cell • Haematology fetomaternal haemorrhage (FMH) monitoring antibodies • Blood transfusion - DNA analysis (incl. use of free fetal DNA in • assess risk of fetal anaemia • liaise with neonatologists and maternal plasma) (incl. perform & interpret laboratory (haematology/blood Attendance at: Prevention - FMH MCA Doppler) transfusion) • Fetal Medicine - organisation & effectiveness of screening and • perform fetal blood sampling • counsel women and their partners Unit (to witness prevention programmes and transfusion or refer, accordingly fetal blood Management where appropriate, for same - prevention of alloimmunisation sampling / - screening and diagnosis fetal anaemia (incl. MCA • plan mode / place / timing of - fetal / neonatal risks of red cell transfusion) Doppler) delivery antibodies - fetal transfusion therapy - fetal transfusion therapy Personal study - hydrops (see 3.8) - recurrence risks and management Outcome - Neonatal complications of HDN (incl. hyper- plan for future pregnancy bilirubinaemia, anaemia) - Management of complications (incl. exchange transfusion) - Long term implications of HDN Pharmacology - Anti-D immunoglobulin

46 4.9 Platelet alloimmunisation Objectives: To be able to carry out appropriate assessment and management of a woman with an unstable lie To understand the management, complications and outcome of a neonate with alloimmune thrombocytopenia (AIT)

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Platelet groups / pathophysiology Take an appropriate obstetric history Ability to take an appropriate history Observation of and Log of - HPA system • Past obstetric history discussion with senior experience & - fetal / neonatal pathology in AIT Ability to; medical staff competence

Manage a case of platelet alloimmunisation • perform and interpret appropriate Epidemiology • institute appropriate maternal and fetal investigations in fetus at risk of Appropriate Mini-CEX - Incidence (alloimmunisation & complications) monitoring thrombocytopenia postgraduate courses • assess risk of fetal thrombocytopenia • formulate, implement and where Laboratory methods • institute, where appropriate, maternal appropriate modify a management Attachments: - Antibody detection iv Ig therapy plan for a woman with anti-platelet • Neonatology - DNA analysis • perform fetal blood sampling and cell antibodies • Haematology platelet transfusion or refer, where • liaise with neonatologists and • Blood transfusion Management appropriate, for same laboratory (haematology/blood - assessment of risk of fetal haemorrhage • plan mode / place / timing of delivery transfusion) Attendance at: - diagnosis of fetal thrombocytopenia - therapy options (maternal immunoglobulin • counsel women and their partners • Fetal Medicine therapy / fetal transfusion therapy) accordingly Unit (to witness - fetal / neonatal risks fetal blood Outcome - maternal & fetal therapy sampling / - Neonatal complications of AIT - recurrence risks and transfusion) - Management of AIT (incl. platelet management plan for future transfusion) pregnancy Personal study - Long term implications of AIT

Pharmacology - Intravenous immunoglobulin (iv Ig) incl. effectiveness and adverse effects)

47 4.10 Gynaecological problems in pregnancy Objectives: To be able to carry out appropriate assessment and management of a woman with a pelvic tumour complicating pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Pathology Take an appropriate obstetric and Ability to take an appropriate history Observation of and Log of - uterine fibroids gynaecological history and perform an examination in a women discussion with senior experience & - ovarian tumours (benign & malignant) with a pelvic mass or abdominal pain in medical staff competence - complications encountered during Manage a case of pelvic tumour in pregnancy pregnancy pregnancy (see 6.17) • perform ultrasound assessment of Appropriate Mini-CEX

Epidemiology uterus and ovaries / pelvic mass Ability to; postgraduate courses - incidence of pelvic tumours and • institute appropriate maternal and fetal • perform and interpret ultrasound in complications monitoring women with a pelvic tumour Personal study - acute abdomen in pregnancy • institute, where appropriate, maternal • formulate, implement and where supportive therapy appropriate modify a management Diagnosis • perform, under supervision, surgical plan for a woman with a pelvic - ultrasound diagnosis (incl. assessment of management of ovarian cyst tumour in pregnancy risk of malignancy) • plan mode / place / timing of delivery • liaise where appropriate with - complications (incl. differential diagnosis of acute abdomen in pregnancy [see 6.17]) gynaecologists, gynaecological Manage a case of acute abdomen in oncologists and general surgeons Management pregnancy • counsel women and their partners - indications for surgical intervention • arrange appropriate investigations to accordingly - analgesia (see 5.10) identify cause - maternal and fetal risks - anaesthesia (see 5.10) • refer, where appropriate, for further - management options - role of radiotherapy and chemotherapy in management - prognosis ovarian malignancies

48 MODULE 5 INTRAPARTUM COMPLICATIONS 5.1 Labour Ward Management

Objectives: To understand the organization and management of the delivery suite To understand and apply the principles of risk management in the delivery suite

Knowledge criteria Clinical competency Professional skills and Training support Evidence/ Attitudes Assessment

Organization / Management of Co-ordinate the clinical running of the LW Ability to Observation of and Log of experience Labour ward (LW) at a daily level including; • lead a multidisciplinary team discussion with senior and competence - staffing structure • staff allocation effectively medical staff - equipment • appropriate triaging of clinical cases • co-ordinate the DS [OSAT] - DS Forum appropriately Appropriate postgraduate - emergency skills / drills Write an evidence-based guideline relevant • write an evidence-based courses e.g. - guidelines to LW guidelines (relevant to DS) • Management of the - audit (incl. collection / analysis • set up, run and feedback on an Labour Ward of DS workload) Lead an emergency drill on LW emergency drill • ALSO / MOET • set up & running of drill • investigate a critical incident Risk management on LW • feed back to staff appropriately and make Attendance at: - principles of risk management recommendations • Risk management forum - critical incident reporting Investigate a critical incident • DS Forum • review the case Ability communicate effectively Personal study • take appropriate statements with:

• perform root cause analysis • junior medical staff

• write a report • senior medical staff • midwifery staff • patients & relatives • obstetric anaesthetists • neonatologists

49

5.2 Failure to progress in labour

Objectives: To understand the physiology of normal labour and the factors that can adversely affect progress To be able to carry out appropriate assessment and management of women with failure to progress in first stage and second stage of labour

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Anatomy / Physiology Take an appropriate history and perform an Ability to take an appropriate Observation of and Log of - Anatomy of pelvis / fetal skull examination to assess progress in labour history discussion with senior experience & - Regulation of myometrial medical staff competence contractility Manage a case of failure to progress in the first stage Ability to - Stages of labour of labour; • perform and interpret Appropriate postgraduate Mini-CEX • perform exam to identify cause e.g. inefficient Pathophysiology uterine activity / malposition / cephelopelvic abdominal/pelvic examination courses e.g. Incl. causes and consequences of poor disproportion (relative and absolute) • formulate, implement and • Management of the progress in labour: • counsel regarding management where appropriate modify a Labour Ward - inefficient uterine action • institute appropriate management (incl. delivery management plan • ALSO / MOET - malposition where appropriate) • liaise, where appropriate, - relative / absolute cephalopelvic with anaesthetists / Attachments in disproportion Manage a case of failure to progress in the second neonatologists • obstetric anaesthesia - fetal acid base status stage of labour; • counsel women and their • neonataology - postpartum uterine atony • perform exam to identify cause • counsel regarding management partners accordingly Management • institute appropriate management - management RCOG Clinical Guideline - maternal support - maternal and fetal risks (26) - amniotomy Perform: - mobilization / position • manual rotation NCCWCH Guideline - analgesia (see 5.10) • ventouse (rotational and non-rotational) (Caesarean Section) - oxytocin • forceps – outlet and mid-cavity

- manual rotation • Kielland’s forceps Personal study - instrumental vaginal delivery • caesarean secon - caesarean section

Pharmacology (incl. adverse effects) - oxytocin

50 5.3 Non-reassuring fetal status in labour

Objectives: To be able to carry out appropriate assessment and management of fetal acideamia in labour To understand the management, complications and outcomes of hypoxic ischaemic encephalopathy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Pathophysiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - regulation of fetal heart rate discussion with senior experience & - fetal acid base balance Manage a case of suspected and Ability to medical staff competence - hypoxic ischaemic encephalopathy (HIE) confirmed fetal acidaemia in labour: • perform and interpret

- arrange appropriate investigations to assess fetal Appropriate postgraduate OSAT Fetal monitoring in labour Incl. principles, interpretation and predictive investigations to confirm fetal status in labour courses e.g. value of fetal; acidaemia • formulate, implement and where • Management of the - meconium - counsel regarding fetal / neonatal appropriate modify a management Labour Ward - cardiotocography (CTG) risks and management options plan • ALSO / MOET - ECG - institute, where appropriate, in- • liaise, where appropriate, with - pulse oximetry utero resuscitation / emergency anaesthetists / neonatologists Attachments in - pH, blood gases and lactate delivery • counsel women and their partners • obstetric anaesthesia - oligohydramnios accordingly • neonataology

Management Perform: - maternal and fetal risks - position / oxygen therapy • CTG interpretation - management options Attendance at - acute tocolysis • fetal blood sampling - long term health implications • neonatal follow up clinics - amnioinfusion • ECG waveform analysis for infant - emergency operative delivery • ultrasound assessment of RCOG / CESY Guideline (The amniotic fluid volume (see 4.3) Use of Electronic Fetal Pharmacology (incl. adverse effects) • intrapartum amnioinfusion Monitoring) - terbutaline / ritodrine

Outcome NCCWCH Guideline - neonatal complications of HIE (Incl. (Caesarean Section) seizures, abnormal neurological function, organ failure) Personal study - Long term health implications of HIE (incl. cerebral palsy)

51 5.4 Multiple pregnancy and malpresentation

Objectives: To be able to carry out appropriate assessment and management of women with multiple pregnancy in labour To be able to carry appropriate assessment and management of women with breech and transverse lies diagnosed in labour

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Epidemiology / aetiology Take an appropriate history Ability to take an appropriate Observation of and Log of - incidence history discussion with senior experience & - predisposing factors Manage a case of twin pregnancy in labour; medical staff competence • arrange and interpret fetal monitoring Ability to Intrapartum care in twins • counsel regarding management • perform and interpret Appropriate postgraduate OSAT - physiology of labour • institute appropriate management - fetal monitoring investigations to confirm fetal courses e.g. - inter-twin interval Manage a case of breech presentation in lie in labour • Management of the - effects of chorionicity labour: • formulate, implement and Labour Ward • arrange and interpret fetal monitoring where appropriate, modify a • ALSO / MOET Diagnosis / management • counsel regarding management incl. management plan - clinical exam risks/benefits of CS • perform vaginal breech Attachments in - ultrasound • institute appropriate management delivery & twin delivery • obstetric anaesthesia - risks / benefits of caesarean section in: • liaise, where appropriate, with • neonataology • breech presentation Manage a case of transverse lie in labour: • transverse / oblique lie • counsel regarding management anaesthetists / neonatologists • twin and higher order multiple • institute appropriate management • counsel women and their RCOG Clinical Guideline pregnancy (see 4.6) partners accordingly (20) - breech delivery Perform: - maternal and fetal risks • manoeuvres (assisted breech • ECV in labour (incl. breech, transverse lie - management options incl. delivery and breech extraction) and second twin) mode of delivery Personal study • complications (incl. problems with • vaginal breech delivery

after coming head) • breech extraction - twin delivery • internal podalic version • ECV for second twin (see (4.7) • ARM / oxytocin in second stage • operative delivery second twin

52 5.5 Shoulder dystocia

Objectives: To be able to carry out appropriate assessment and management of women with shoulder dystocia To understand the management, complications and outcomes of neonates with birth trauma

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Epidemiology / aetiology Take an appropriate history Ability to take an appropriate Observation of and Log of - incidence history discussion with senior experience & - predisposing factors Manage a case of shoulder dystocia medical staff competence - risks of recurrence • institute and document appropriate Ability to management • formulate, implement and Appropriate postgraduate OSAT Management • perform: document a management plan courses e.g. - clinical - McRobert’s manoeuvres and • - fire drill procedures e.g. HELPERR suprapubic pressure for shoulder dystocia Management of the • - advanced manoeuvres - incl. indications, - internal rotation of shoulders perform manoeuvres to achieve Labour Ward procedure and risks of: • - removal of posterior arm delivery in shoulder dystocia ALSO / MOET • Zavanelli • liaise, where appropriate, with • Symphysiotomy anaesthetists / neonatologists Attachments in Manage a case of previous shoulder • counsel women and their • obstetric anaesthesia Outcome dystocia; partners accordingly • neonataology - neonatal complications of birth trauma • assess recurrence risk

(incl. IVH, bone fractures, brachial • arrange, where appropriate, - maternal and fetal risks

plexus injury, HIE) appropriate investigations - long term health Attendance at • - management of complications • counsel regarding maternal / fetal implications of birth neonatal follow up - long term outcome risks trauma clinics • • plan mode / timing of delivery - recurrence risks and paediatric orthopaedic management plan for clinics future pregnancy RCOG Clinical Guideline (42)

Personal study

53 5.6 Genital Tract Trauma

Objectives: To be able to carry out appropriate assessment and management of a women with a third or fourth degree perineal tear To be able to carry out appropriate assessment and management of a women with a uterine rupture

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Anatomy / Physiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - perineum / pelvic floor discussion with senior experience & - anal sphincter function Manage a case of third / fourth degree perineal Ability to medical staff competence tear (see also 5.7): • diagnose presence and extent of Epidemiology / aetiology • assess type of tear genital tract trauma Appropriate postgraduate OSAT - incidence • counsel regarding management - predisposing factors • institute appropriate management (incl. • formulate, implement and where courses e.g. surgical repair) appropriate, modify a management • Management of the Diagnosis / management • plan appropriate follow up plan Labour Ward - clinical examination • perform appropriate surgical repair • ALSO / MOET rd th - ultrasound (endoanal) Manage a case of prior 3 /4 degree perineal • liaise, where appropriate, with - surgical repair tear: gynaecologists, surgeons Attendance at • anal sphincter • arrange and interpret appropriate • arrange appropriate follow up • pelvic floor clinic • cervix / uterus investigations (incl. endoanal ultrasound) • counsel women and their partners - postpartum haemorrhage (see 5.7) • counsel regarding management options • plan mode of delivery accordingly RCOG Clinical Guideline Outcome - maternal and fetal risks (29) - long term health implications Manage a case of uterine rupture (see also 5.7): - long term health implications (incl. pain, incontinence) • assess maternal and fetal condition - recurrence risks and Personal study - implications for future pregnancy • counsel regarding management management plan for future • institute appropriate management (incl. pregnancy emergency CS, repair of uterus)

Perform: • repair of 3rd / 4th degree perineal tear • repair of uterine rupture • hysterectomy (see 5.7)

54 5.7 Postpartum haemorrhage and other third stage problems Objectives: To be able to carry out appropriate assessment and management of a women with a massive postpartum haemorrhage (PPH) To be able to recognise and manage complications of the third stage of labour

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Anatomy Observation of and Log of - pelvic anatomy and blood supply Manage a case of massive PPH Ability to; discussion with senior experience & • assess blood loss and consequences • rapidly assess extent of medical staff competence Epidemiology / aetiology (PPH) • undertake resuscitation (see 5.10) haemorrhage and institute - incidence • ascertain cause of haemorrhage appropriate resuscitative Appropriate postgraduate Fire drill - predisposing factors (incl. adherent • arrange and interpret appropriate placenta, uterine inversion) investigations measures courses e.g. • counsel regarding management options • formulate, implement and • Management of the Laboratory methods • institute /modify appropriate medical where appropriate, modify a Labour Ward - diagnosis / monitoring DIC (see 1.11) and/or surgical management for; management plan • ALSO / MOET - cross-matching - uterine atony • perform appropriate surgical - inverted uterus intervention Attachment in Management massive PPH - adherent placenta • liaise, where appropriate, with • Anaesthesia - maternal resuscitation (incl. use of: gynaecologists, haematologists • Intensive Care • crystalloid / colloid iv fluids • blood and blood products Perform: and radiologists. • Haematology - medical management (see below) • manual removal of placenta • counsel women and their • Blood transfusion - surgical management • correction of uterine inversion partners accordingly • intrauterine balloon (manual and hydrostatic replacement) - management options and Personal study • brace suture • insertion of uterine balloon catheter maternal risks • internal iliac ligation • insertion of brace suture - recurrence risks and • hysterectomy • internal iliac ligation / hysterectomy management plan for - interventional radiology (vascular balloons (under supervision) or refer, where future pregnancy and coils) appropriate, for same • debrief family and staff Pharmacology Incl. adverse effects of drugs used in PPH - oxytocin, ergometrine - 15 methyl prostaglandin F2α - misoprostol - recombinant fVIIa

55 5.8 Caesarean section Objectives: To be able to carry out appropriate assessment and management of a women with a previous caesarean section (CS) To plan and perform caesarean section in special circumstances Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - Risks of CS discussion with senior experience & • visceral damage Manage a case of previous CS; Ability to; medical staff competence • infection • arrange appropriate investigations • counsel women and their partners • venous thrombosis • counsel regarding management options and about the risks of emergency and Appropriate OSAT - Risks associated with previous CS fetal and maternal risks • uterine rupture • plan mode / timing of delivery elective CS postgraduate courses • abnormal placentation • perform and interpret e.g. - vaginal birth after CS (VBAC) Perform CS using the appropriate surgical appropriate investigations in • Management of the • success rates technique in the following circumstances; women undergoing CS Labour Ward • complication rates • major placental praevia • formulate, implement and where • ALSO / MOET • morbidly adherent placenta (see 4.4) appropriate modify a management Diagnosis • fetal anomaly likely to cause dystocia plan for a women undergoing CS Attachment in - ultrasound determination of placental • extreme prematurity • perform CS using the appropriate • Anaesthesia site (see 4.4) • extensive prior abdominal surgery

surgical technique Management Manage complications of CS (under supervision • liaise with anaesthetists, NCCWCH Guideline - CS where appropriate): haematologists, neonataologists (Caesarean Section) • surgical technique (incl. abdominal • extension of uterine incision and radiologists where wall & uterine entry/closure) • haemorrhage (see 5.7) appropriate Personal study • prevention of complications (incl. • visceral damage thrombosis, infection) • wound dehiscence Ability to ; • impact of following conditions; • infection • counsel women with a prior CS o placenta praevia • venous thrombosis o morbidly adherent placenta about options (CS vs VBAC) o fetal anomaly o extreme prematurity o prior abdominal surgery - VBAC - incl. • use of oxytocics • role of induction of labou • fetal monitoring (see 5.3)

56 5.9 Anaesthesia and analgesia Objectives: To understand the methods, indications for and complications of anaesthesia To understand the methods, indications for and complications of systemic analgesia and sedation Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Anantomy / Physiology - spinal cord Counsel women about the different Ability to; Observation of and Log of - innervation of pelvic organs forms of analegesia and anaesthesia • counsel women and their partners about discussion with senior experience & - pain (incl. efficacy and risks) efficacy and risks of different methods medical staff competence

of analgesia for labou Management Perform - pain management during labour • pudendal nerve block • counsel women and their partners about Appropriate • nonpharmacological techniques efficacy and risks of different methods postgraduate courses • inhalational analgesia of anaesthesia for assisted vaginal e.g. • systemic analgesia (opiods) delivery & CS • Management of the - regional analgesia and anaesthesia (incl. • formulate, implement and where Labour Ward techniques and complications) appropriate modify a analgesic / • ALSO / MOET • pudendal anaesthetic management plan • epidural • liaise with anaesthetists Attachment in • spinal - general anesthesia (incl. techniques and • Anaesthesia complications) - analgesia and anaesthesia in high risk women (incl. hypertensive disease, Personal study cardiac disease & FGR)

Pharmacology - opiod analgesics - local anaesthetics - general anaesthetics - phenylephrine / ephedrine

Outcome - effects of neuraxial anaesthesia on; • labour outcome • temperature • fetal wellbeing

57 5.10 Resuscitation Objectives: To be able carry out appropriate assessment and management of maternal collapse (including cardiac arrest) To be able to carry out appropriate assessment and management of the depressed neonate Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Pathophysiology - hypovolaemia Manage a case of maternal collapse Ability to; Observation of and Log of - pulmonary embolism (see 1.12) • ascertain cause of collapse • rapidly assess maternal discussion with senior experience & - amniotic fluid embolism • undertake resuscitation (as part of a collapse and institure medical staff competence - primary cardiac event (see 1.3) multidisciplinary team) resuscitative measures - trauma • institute/modify appropriate medical - cerebrovascular event management for; • work effectively as part of Appropriate Fire drill - electrocution - pulmonary embolism a multidisciplinary team postgraduate courses - neonatal depression - amniotic fluid embolism • formulate, implement and e.g. Epidemiology - cardiac arrhythmia where appropriate modify • Management of the - maternal collapse (causes / risk factors) • arrange appropriate investigations a management plan in Labour Ward - neonatal depression • perform (under supervision) perimortem maternal collapse / cardiac • ALSO / MOET Management CS or refer, whwre appropriate, for arrest - maternal resuscitation same • liaise with physicians, Attachment in • respiratory management (incl. basic airway management, indications for intubation, Perform anaesthetists, • Anaesthesia ventilation) • neonatal resuscitation neonatologists • Neonatology • circulatory management (incl. cardiac massage, - mask ventilation • debrief family and staff defibrillation) - endotracheal intubation • fluid management (see 5.7) - cardiac massage Ability to perform effective Personal study - indications for perimortem CS neonatal resuscitation - principles neonatal resuscitation

• respiratory depression / apnea

• bradycardia / cardiac arrest • meconiun aspiration Pharmacology - oxygen - epinephrine - sodium bicarbonate - atropine

58

5.11 Medical disorders on the labour ward

Objectives: To be able carry out appropriate intrapartum and immediate postpartum assessment and management of women with medical disorders

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Pathophysiology Take and appropriate history and perform an Ability to take an appropriate Observation of and Log of Incl. the effect of labour and delivery on the examination to assess medical disorder history and conduct an discussion with senior experience & following diseases; appropriate examination in a medical staff competence - diabetes Manage a woman with a medical disorder in labour woman with a medical disorder - cardiac/respiratory abnormalities incl.; Appropriate - haemoglobinopathies • monitor blood glucose and maintain euglycaemia - thrombotic / haemostatic abnormalities (see 1.7) using intravenous glucose and insulin Ability to; postgraduate courses - epilepsy • monitor cardiorespiratory function and • formulate, implement and e.g. - severe pre-eclampsia / eclampsia maintain oxygenation and cardiac output (see where appropriate modify • Management of the - renal disease 5.11) a medical management plan Labour Ward - hypertension • monitor abnormal blood clotting and respond ifor labour and delivery • ALSO / MOET - HIV / sepsis accordingly, including therapeutic intervention • liaise with physicians, Management • monitor blood pressure and, where appropriate, anaesthetists, Attachment in - maternal monitoring treat hypertension (see 1.1) neonatologists • Anaesthesia • blood glucose • monitor renal function and respond where • respiratory function (incl. respiratory appropriate by adjusting fluid balance or with • counsel women and their • Neonatology rate, Sa02, , blood gases) drugs partners accordingly • cardiovascular function (incl. blood • use anticonvulsants effectively - management options in Attendance at; pressure, heart rate, cardiac output) labour • Medical clinics • renal function (incl. urine output, Manage a case of sickle cell disease during labour - risks of medical creatinine) (see 1.11); therapies Personal study - analgesia and anesthesia (see 5.9) • counsel regarding management and risks

Pharmacology • optimize hydration, oxygenation, analgesia

- effects of drugs used to treat above • manage sickle crisis (incl. fluids, oxygen, conditions on course and outcome of labour antibiotics and analgesics) - effects of drugs used in management of labour (e.g. oxytocin, syntometrine) on Manage a case of HIV in labour (see 6.2); above conditions • plan mode of delivery - effects of analgesics and anaesthetics on • institute iv zidovudine therapy the above conditions

59 5.12 Intensive Care

Objectives: To understand the organization and role of high dependency and intensive care To understand the indications for and methods of invasive monitoring To understand the management of organ failure

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Organisation Take and appropriate history and perform Ability to take an appropriate history Observation of and Log of - structure and organization of an and conduct an appropriate examination discussion with senior experience & • high dependency care examination to assess critically ill woman in a critically ill woman medical staff competence • intensive care

- role of outreach teams Manage a woman with organ failure; Ability to; Appropriate - indications for high dependency and • undertake resuscitation (see 5.10) intensive care in obstetrics • arrange and interpret appropriate • perform and interpret postgraduate courses investigations to confirm diagnosis / investigations to diagnose / monitor e.g. Management cause and monitor organ function organ failure • Management of the - methods of invasive monitoring • arrange transfer to HDU / ITU • formulate, implement and where Labour Ward • oxygenation / acid base where appropriate arrange appropriate modify a management • ALSO / MOET • arterial pressure appropriate investigations plan including transfer to HDU/ITU • cardiac output, preload and • liaise with intensivists, physicians, Attachment in contractility Perform anaesthetists, neonatologists • Anaesthesia - organ failure (incl. principles/techniques of • insertion of CVP line • • supportive therapy) • endotracheal intubation counsel women and their partners Intensive Care • respiratory failure • insertion arterial line / PA catheter accordingly • cardiac failure (under supervision) or refer, where - management options, including Attendance at; • renal failure appropriate, for same therapeutic interventions • Medical clinics • hepatic coagulation - maternal and fetal risks • coagulation failure - debrief family and staff Personal study

60 MODULE 6 INFECTIOUS DISEASES 6.1 Human immunodeficiency virus (HIV)

Objectives: To be able to carry out appropriate assessment and management of women with HIV infection in pregnancy

Knowledge criteria Clinical competency Professional skills and Training support Evidence / attitudes Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate Observation of and Log of - HIV1 & 2 history discussion with senior experience & - natural history / viral dynamics Counsel women about screening for HIV medical staff competence - pathophysiology HIV infection/AIDS in pregnancy Ability to; - mode / risk of transmission • counsel women Appropriate postgraduate Mini-CEX - epidemiology of infection in pregnancy Manage a case of HIV infection in Screening / diagnosis pregnancy; - before screening test courses e.g. - rationale & organization of screening programme • arrange and interpret appropriate - after positive result • Maternal medicine - laboratory tests investigations (incl. viral load / o screening e.g. enzyme immunoassay CD4) Ability to; Attachments in o diagnostic e.g. Western blot • counsel regarding maternal and • formulate, implement and • HIV clinic / - referral pathways fetal risks, strategies to reduce where appropriate modify a multidisciplinary team Management mother-child transmission and management plan in HIV • Neonatology - screening for coincident infection (genital management options positive women infection / hepatitis) • institute, and where appropriate, - laboratory monitoring – viral load / CD4 T- modify anti-retroviral therapy (in • liaise with HIV expert, RCOG Clinical Guideline lymphocyte count collaboration with HIV expert) multidisciplinary team, (39) - strategies to reduce mother-child transmission • plan mode of delivery neonatologists & GP (incl. anti-retroviral therapy, mode of delivery, • manage labour and delivery / CS • counsel women and their NCCWCH Guideline feeding) partners accordingly (Antenatal Care) - conduct of labour / CS - management options - advanced HIV Perform: - risks / benefits of anti- Personal study - antenatal complications (incl. preterm birth) • CS in a woman with HIV infection retroviral therapy - neonatal management – testing, Pharmacology (incl. adverse effects) - long term outcome for - zidovudine mother and infant - HAART Outcome Ability to respect patient - neonatal infection (diagnosis / complications) confidentiality - long term outcome - chronic HIV infection

61 6.2 Hepatitis

Objectives: To be able to carry out appropriate assessment and management of women with hepatitis in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate history and Observation of and Log of - hepatitis A,B.C (HAV, HBV, HCV) conduct an examination to assess a woman with discussion with experience & - natural history / viral dynamics Perform an examination to assess jaundice jaundice senior medical staff competence - pathophysiology acute / chronic hepatitis

- mode / risk of transmission Counsel women about screening for HBV and Ability to counsel women Appropriate Mini-CEX - epidemiology of infection in pregnancy HCV in pregnancy • before HBV/HCV screening test Screening / diagnosis • after positive result postgraduate - differential diagnosis of jaundice / abnormal Manage a case of HAV infection in • about HAV/HBV vaccination courses LFTs pregnancy; - rationale & organization of Hepatitis B • arrange and interpret appropriate Ability to; Attachments in (HbsAg) screening programme investigations • formulate, implement and where • Virology - laboratory tests • institute appropriate supportive care appropriate modify a management plan in • Neonatology o serology e.g. enzyme immunoassay (EIA) acute HAV infection

o diagnostic e.g. Western blot, PCR Manage a case of HBV infection in pregnancy • formulate, implement and where Attendance at - risk groups for HCV • arrange and interpret appropriate appropriate modify a management plan in a - neonatal testing investigations women with HBV / HCV infection • Hepatology Management • counsel regarding maternal and fetal • liaise with hepatologists, virologists, clinic - supportive care risks, strategies to reduce mother-child neonatologists & GP - screening for coincident infection (HBC, HCV) transmission and management options • counsel HBV/HCV infected women and NCCWCH Guideline Prevention • manage labour and delivery / CS their partners accordingly (Antenatal Care) - HAV / HBV vaccination in pregnancy - management options - Prevention perinatal infection Manage a case of HCV infection in pregnancy - risks of perinatal transmission and Personal study • HA immunoglobulin (IG) • arrange and interpret appropriate methods of prevention • HBIG and vaccination investigations in high risk cases - long term outcome for mother and - Mode of delivery / breastfeeding • counsel regarding maternal and fetal infant Outcome risks, strategies to reduce mother-child - HBV/HCV -related disease (cirrhosis, transmission and management options Ability to respect patient confidentiality hepatocellular carcinoma) • manage labour and delivery / CS Pharmacology - HAV vaccine, HAIG Counsel regarding HAV and HBV vaccination - HBV vaccine, HBIG in pregnancy

62 6.3 Cytomegalovirus

Objectives: To be able to carry out appropriate assessment and management of women with cytomegalovirus (CMV) infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - cytomegalovirus discussion with senior experience & - pathophysiology primary infection (in adult Manage a case of CMV infection in medical staff competence and fetus) pregnancy Ability to; - mode / risk of transmission • arrange and interpret appropriate • perform and interpret appropriate Appropriate Mini-CEX - epidemiology of infection in pregnancy – high risk groups maternal and fetal investigations investigations (incl. ultrasound) postgraduate courses • perform an ultrasound scan to detect • formulate, implement and where Screening / diagnosis features of fetal CMV infection appropriate modify a management Attachments in - laboratory tests • institute appropriate supportive care plan in a women with CMV infection • Virology • maternal serology - immunofluoresent and monitoring in pregnancy • Neonatology tests, EIA • counsel regarding maternal and fetal • liaise with virologists & • fetal diagnosis e.g. AF PCR/culture, risks neonatologists Personal study viral DNA, serology • institute where appropriate fetal • counsel women and their partners - ultrasound features fetal infection - primary vs recurrent infection therapy accordingly • arrange, where appropriate, - maternal and fetal risks Management termination of pregnancy - management options incl. fetal - supportive care diagnostic testing - maternal and fetal risks - risks of perinatal transmission - CMV infection in immunocompromised and methods of prevention women - long term outcome for infants - fetal therapy (ganciclovior, CMV with congenital CMV infection hyperimmune globulin) - termination of pregnancy

Outcome - sequelae of congenital CMV infection

63 6.4 Herpes simplex virus (HSV)

Objectives: To be able to carry out appropriate assessment and management of women with herpes simplex virus infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - HSV 1 & 2 and conduct an examination to screen discussion with senior experience & - pathophysiology of primary and recurrent Perform an examination for active HSV for HSV infection in pregnancy medical staff competence infection & congenital herpes lesions - mode /risk of transmission Ability to; Appropriate Mini-CEX - epidemiology of infection in pregnancy Manage a case of HSV infection in • formulate, implement and where postgraduate courses Management pregnancy appropriate modify a management - differential diagnosis oral / genital ulcers • arrange and interpret appropriate plan in a women with HSV infection Attachments in - screening – HSV serology investigations in pregnancy • Virology - diagnosis – viral culture • institute symptomatic treatment and • liaise with virologists, • Neonatology - maternal and fetal risks acyclovir for active disease neonatologists and GP - acyclovir for active disease / prophylaxis • counsel regarding maternal and fetal • counsel women and their partners Personal study - prevention of perinatal infection risks accordingly ƒ role of CS ƒ avoidance scalp electrodes / • institute, where appropriate, - methods of reducing sexual RCOG Clinical prophylactic acyclovir transmission Guideline (30) Outcome • plan time / mode of delivery - risks of perinatal transmission - sequelae of congenital HSV infection and methods of prevention - maternal and fetal risks Pharmacology (incl. adverse effects) - safety of acyclovir in - acyclovir (oral & iv) pregnancy - management options

Ability to respect patient confidentiality

64 6.5 Parvovirus

Objectives: To be able to carry out appropriate assessment and management of women with parvovirus infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - parvovirus B19 and conduct an examination to diagnose discussion with senior experience & - pathophysiology of maternal and fetal Manage a case of parvovirus infection in parvovirus infection medical staff competence infection (incl. anaemia / hydrops) pregnancy - mode /risk of transmission • arrange and interpret appropriate Appropriate Mini-CEX - epidemiology of infection in pregnancy investigations Ability to; postgraduate courses Screening / diagnosis • counsel regarding maternal and fetal • perform and interpret appropriate - differential diagnosis fever, rash, risks investigations (incl. ultrasound) Attachments in arthropathy in pregnancy • institute appropriate fetal monitoring • formulate, implement and where • Virology - laboratory tests (incl. perform and interpret MCA appropriate modify a management • Neonatology • maternal serology – ELISA Doppler) plan in a women with parvovirus • fetal diagnosis e.g. AF PCR/culture, • perform fetal blood sampling and infection Personal study viral DNA, serology transfusion or refer, where • liaise with virologists, - ultrasound features of fetal infection appropriate, for same (see 4.8) neonatologists, haematology/blood Management • plan mode / place / timing of delivery transfusion - maternal and fetal risks • counsel women and their partners - ultrasound monitoring in maternal infection accordingly - screening & diagnosis fetal anaemia (incl. - risks of perinatal transmission MCA Doppler (see 4.8) - maternal and fetal risks - differential diagnosis fetal hydrops (see - management options (incl. fetal 3.7) transfusion) - fetal transfusion therapy (see 4.8)

Outcome - sequelae of congenital parvovirus HSV

65 6.6 Rubella

Objectives: To be able to carry out appropriate assessment and management of women with rubella infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - Rubella virus and conduct an examination to diagnose discussion with senior experience & - pathophysiology of maternal and fetal infection Perform an examination to assess rubella infection medical staff competence (incl. congenital rubella syndrome [CRS]) fever, lymphadenopathy, arthralgia - mode /risk of transmission Ability to; Appropriate Mini-CEX - epidemiology of infection in pregnancy Manage a pregnant woman found to be • formulate and implement a postgraduate courses Screening / diagnosis susceptible to rubella management plan in a susceptible - rationale & organization of screening programme • arrange and interpret women exposed to rubella Attachments in - laboratory tests appropriate investigations if • counsel women accordingly • Virology • maternal serology (ELISA) suspected exposure - vaccination • Neonatology • fetal diagnosis – AF PCR, serology • arrange postnatal vaccination - ultrasound features CRS Ability to; NCCWCH Guideline

Manage a case of rubella in pregnancy • perform and interpret appropriate (Antenatal Care) Management - differential diagnosis rash / fever / arthralgia / • arrange and interpret investigations (incl. ultrasound) lymphadenopathy in pregnancy appropriate investigations • formulate, implement and where Personal study - maternal and fetal risks • counsel regarding maternal and appropriate modify a management - termination of pregnancy fetal risks plan in women with rubella infection • arrange, where appropriate, • liaise with virologists, Prevention termination of pregnancy neonatologists - rubella vaccination programme • counsel women and their partners - postnatal vaccination accordingly

Outcome - maternal and fetal risks - sequelae of congenital rubella syndrome (incl. - management options (incl eye disorders, heart defects, neurological termination of pregnancy) defects)

Pharmacology (incl. adverse effects) - rubella vaccine

66 6.7 Varicella

Objectives: To be able to carry out appropriate assessment and management of women with varicella-zoster infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Virology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - Varicella-zoster virus and conduct an examination to diagnose discussion with experience & - pathophysiology of varicella, zoster & Perform an examination to assess vesicular varicella / zoster in fection senior medical staff competence congenital varicella syndrome (CVS) rash - mode /risk of transmission Ability to; Appropriate Min-CEX - epidemiology of infection in pregnancy Manage a pregnant woman found to be • formulate and implement a postgraduate susceptible to varicella management plan in a susceptible courses Management • arrange and interpret appropriate women exposed to varicella/zoster - differential diagnosis vesicular rash investigations if suspected exposure • counsel women accordingly Attachments in - screening – HSV serology • institute VZIG - vaccination • Virology - fetal diagnosis – ultrasound, serology, • arrange postnatal vaccination • Neonatology viral DNA Ability to; - maternal risks (lung / CNS Manage a case of varicella / zoster in • perform and interpret appropriate Personal study involvement) pregnancy investigations (incl. ultrasound) - acyclovir • arrange and interpret appropriate • formulate, implement and where RCOG Clinical - fetal risks (CVS) investigations appropriate modify a management Guideline (13) • counsel regarding maternal and fetal plan in women with varicella / Outcome risks zoster - sequelae of congenital CVS • institute acyclovir where appropriate • liaise with virologists, • institute appropriate maternal and fetal neonatologists Prevention monitoring • counsel women and their partners - varicella vaccination programme • perform ultrasound to screen for CVS accordingly - maternal and fetal risks Pharmacology (incl. adverse effects) - benefits of acyclovir

- varicella zoster immunoglobulin (VZIG) - management options (incl termination of pregnancy)

67 6.8 Toxoplasmosis

Objectives: To be able to carry out appropriate assessment and management of women with toxoplasmosis infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Parasitology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - Toxoplasma gondii discussion with senior experience & - pathophysiology maternal and fetal infection Manage a pregnant woman found to be Ability to; medical staff competence - mode / risk of transmission susceptible to toxoplasmosis • formulate and implement a - epidemiology of infection in pregnancy – high • arrange and interpret appropriate management plan in a susceptible Appropriate Mini-CEX risk groups / geographical variation investigations if suspected exposure Screening / diagnosis • counsel regarding preventative women postgraduate courses - laboratory tests strategies • counsel regarding prevention • maternal serology – dye test, ELISA, Attachments in agglutination assays Manage a case of toxoplasmosis infection in Ability to; • Virology • IgG avidity tests pregnancy • perform and interpret appropriate • Neonatology • fetal diagnosis - ultrasound, AF PCR, • arrange and interpret appropriate investigations (incl. ultrasound) viral DNA maternal and fetal investigations • formulate, implement and where Personal study - ultrasound features fetal infection • perform an ultrasound scan to detect appropriate modify a management - distant vs recent infection features of fetal toxoplasmosis Management • institute appropriate supportive care plan in women with toxoplasmosis - supportive care and monitoring • liaise with micobiologists, - maternal and fetal risks • counsel regarding maternal and fetal neonatologists - toxoplasmosis infection in immunocpmpromised risks • counsel women and their partners women • institute spiramycin and pyrimethamine accordingly - maternal therapy (spiromycin) / sulphadiazine where appropriate - maternal and fetal risks - fetal therapy (pyrimethamine / sulphadiazine) • arrange, where appropriate, termination - management options (incl - termination of pregnancy of pregnancy termination of pregnancy) Outcome - sequelae of congenital toxoplasmosis - benefits / risks of spiromycin Pharmacology (incl. adverse effects) and pyrimethamine / - spiromycin sulphadiazine - pyrimethamine / sulphadiazine

68 6.9 Malaria

Objectives: To be able to carry out appropriate assessment and management of women with malaria infection in pregnancy To be able to advise women travelling abroad about prevention of malaria

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Parasitology/ Epidemiology Take an appropriate history Ability to take an appropriate history Observation of Log of - plasmodium genus and discussion experience & - pathophysiology of malaria (incl. severe Perform an examination to assess fever Ability to; with senior competence disease and placental/fetal infection) • counsel women traveling to endemic medical staff - mode / risk of transmission Manage women traveling to endemic areas; areas; Mini-CEX - epidemiology of malarial infection (incl. chloroquine resistance) • counsel women about preventative - risks of infection Appropriate measures - prevention (incl. postgraduate Management • institute appropriate chemoprophylaxis chemoprophylaxis) courses - diagnosis – blood smears - supportive care (incl. management of anaemia) Manage a case of malarial infection in Ability to; Attachments in - anti-malarial treatment (incl. chloroquine, pregnancy; • formulate, implement and where • Microbiology quinine, mefloquine, clindamycin) • arrange and interpret appropriate appropriate modify a management - severe disease (incl. renal failure, pulmonary investigations plan in a women with malaria Personal study oedema, severe anaemia, hypoglycaemia) - fetal complications (FGR/preterm birth) • counsel regarding maternal and fetal infection in pregnancy (with risks reference to risk of Prevention • institute anti-malarial treatment • liaise with microbiologists, - avoidance of travel to endemic areas • refer, where appropriate, for further consultants in infectious disease - spray / nets assessment / treatment • counsel women and their partners - chemoprophylaxis accordingly

- maternal and fetal risks Pharmacology (incl. adverse effects) - management options incl. anti- - chloroquine - mefloquine malarial treatment - risks of early onset GBS infection in the newborn - breastfeeding

69 6.10 Tuberculosis

Objectives: To be able to carry out appropriate assessment and management of women with or at risk of tuberculosis (TB) infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of Log of - mycobaterium tuberculosis and discussion experience & - pathophysiology of TB (incl. infection vs. Manage women with previous history of Ability to; with senior competence pulmonary / extrapulmonary disease) positive tuberculin test / TB; • formulate, implement and where medical staff - mode / risk of transmission • arrange and interpret appropriate appropriate modify a management plan Min-CEX - epidemiology of TB infection in pregnancy (incl. high risk groups) investigations and follow up in a women with previous positive Appropriate • counsel regarding maternal / neonatal tuberculin test / TB postgraduate Management risks • formulate, implement and where courses - differential diagnosis fever / cough appropriate modify a management plan - diagnosis – tuberculin testing, direct Manage a case of tuberculosis in in a women with TB during pregnancy Attachments in identification bacilli, culture pregnancy; • liaise with microbiologists, consultants • Microbiolog - anti-tuberculous treatment (incl. isoniazid • arrange and interpret appropriate in infectious disease, neonatologists • Neonatology [+ pyridoxine], rifampicin, ethambutol investigations • counsel women and their partners - extrapulmonary disease • counsel regarding maternal and accordingly Personal study Prevention neonatal risks - maternal and neonatal risks - procedures for prevention & control (incl. • institute anti-TB treatment - management options incl. anti-TB contact tracing) • refer, where appropriate, for further treatment - BCG vaccination assessment / treatment - prevention of neonatal infection - isoniazid prophylaxis (in high risk neonates) - breastfeeding

Pharmacology (incl. adverse effects) - isoniazid - rifampicin - ethambutol

70 6.11 Streptococcal disease Objectives: To be able to carry out appropriate assessment and management of women with group A streptococcal (GAS) infection in pregnancy To be able to carry out appropriate assessment and management of women with group B haemolytic streptococcus (GBS) infection in pregnancy Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology/ Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - streptococcal species discussion with experience & - pathophysiology of GAS disease (incl. toxic shock Perform an examination to assess Ability to; senior medical staff competence syndrome and other invasive infections) puerperal fever / sepsis • counsel women - pathophysiology of GBS disease (adult and neonate) - before screening for GBS Appropriate Mini-CEX - mode / risk of transmission - epidemiology of streptococcal infection in Counsel women about screening for - after positive result postgraduate pregnancy/puerperium (incl. risk factors and GBS in pregnancy courses colonization rates) • routine screening Ability to; Screening / diagnosis • screening in high risk cases (e.g. • formulate, implement and where Attachments in - differential diagnosis PPROM, previous neonatal GBS) appropriate modify a management • Microbiology • septic shock / fever plan in a women with GBS infection • Neonatology • vaginitis / vaginal discharge (see 6.10) Manage a case of GBS infection in in pregnancy • chorioamnionitis / postpartum endometritis pregnancy; • liaise with microbiologists & Personal study - laboratory diagnosis (swabs / culture) - risks / benefits of GBS screening strategies • arrange and interpret neonatologists • routine bacteriological screening appropriate investigations • counsel women and their partners RCOG Clinical • risk based screening • counsel regarding maternal and accordingly Guideline (36) Management fetal risks - maternal and fetal risks - GAS infection (supportive care / antibiotics) • institute IAP - management options incl. IAP - GBS infection – intrapartum antibiotic prophylaxis - risks of early onset GBS (IAP) infection in the newborn • GBS carrier • other groups (e.g. suspected chorioamnionitis) - ‘at risk’ newborn infants Outcome - early and late onset GBS infection in newborn Pharmacology (incl. adverse effects) - Penicillin G - Clindamycin

71 6.12 Syphilis

Objectives: To be able to carry out appropriate assessment and management of women with syphilis infection in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology/ Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - treponema pallidum discussion with experience & - pathophysiology of syphilis (incl. stages of adult Perform an examination to assess Ability to; senior medical staff competence disease and congenital infection) genital ulcer • counsel women - mode / risk transmission - before screening for syphilis Appropriate Mini-CEX - epidemiology of syphilis infection in pregnancy Counsel women about screening for - after positive result postgraduate Screening / diagnosis syphilis in pregnancy courses - rationale & organization of screening programme • routine screening Ability to; - serological tests (incl. non-specific and specific • screening in high risk cases • formulate, implement and where Attachments in antibody tests) appropriate modify a management • Microbiology - darkfield visualization Manage a case of syphilis infection in plan in a women with syphilis • Neonatology - differential diagnosis genital ulcer pregnancy; infection in pregnancy - ultrasound features of fetal infection • arrange and interpret appropriate • liaise with microbiologists, GUM NCCWCH Guideline

Management investigations consultants, neonatologists (Antenatal Care) - penicillin G (see 6.11) incl. management Jarisch- • counsel regarding maternal and • counsel women and their partners Herxheimer reaction fetal risks accordingly Personal study - contact tracing • institute treatment with penicillin - maternal and fetal risks • refer for further assessment / - penicillin treatment Outcome treatment / contact tracing - congenital syphilis (early & late)

72 6.13 Other sexually transmitted diseases in pregnancy

Objectives: To be able to carry out appropriate assessment and management of women with a sexually transmitted disease in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - neisseria gonorrhoea, chlamydia trachomatis, discussion with experience & genital mycoplasma Manage a case of gonorrhea in pregnancy; Ability to; senior medical staff competence - pathophysiology of gonococcal, chlamydial and • arrange and interpret appropriate • formulate, implement and where mycoplasma disease (incl. chorioamnionitis and investigations (including screening for appropriate modify a management Appropriate Mini-CEX postpartum endometritis) - epidemiology of STDs in pregnancy other STDs) plan in a women with gonorrhea in postgraduate • counsel regarding maternal, fetal and pregnancy courses Screening / diagnosis neonatal risks • formulate, implement and where - rationale and organization of screening for • institute antibiotic therapy appropriate modify a management Attachments in chlamydia in pregnancy • refer for further assessment / plan in a women with Chlamydia • Microbiology - differential diagnosis of vaginal discharge, treatment / contact tracing pregnancy • Neonatology cervicitis in pregnancy • liaise with microbiologists, GUM - laboratory diagnosis (swabs / culture, nucleic Manage a case of chlamydia in pregnancy; consultants, neonatologists Personal study acid amplification techniques) • arrange and interpret appropriate • counsel women and their Management investigations (incl. screening for partners accordingly - Antibiotics other STDs) - maternal and fetal risks • chlamydia – azithromycin • counsel regarding maternal, fetal and - antibiotic therapy • gonorrhea – ceftriaxone, cefixime, neonatal risks - risks of neonatal infection spectinomycin • institute antibiotic therapy and outcome • mycoplasmas – erythromycin, clindamycin • refer for further assessment / - contact tracing (where appropriate) treatment / contact tracing - fetal risks - incl. PPROM, preterm birth (see 4.5) - maternal risks (chorioamnionitis, endometritis)

Outcome - neonatal infection (conjunctivitis, pneumonia) Pharmacology (incl. adverse effects) - azithromycin - ceftriaxone

73 6.14 Bacterial vaginosis

Objectives: To be able to carry out appropriate assessment and management of women with bacterial vaginosis (BV) in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - garnerella vaginalis, selected anaerobes, and conduct an examination to discussion with experience & mycoplasma hominis Perform an examination to diagnose BV in diagnose BV in pregnancy senior medical staff competence - pathophysiology of BV pregnancy - epidemiology of BV in pregnancy Ability to; Appropriate Mini-CEX

Screening / Diagnosis Manage a case of BV in pregnancy; • formulate, implement and where postgraduate - rationale for screening in high risk groups (incl. • arrange and interpret appropriate appropriate modify a management courses previous preterm birth) investigations plan in a women with BV in - differential diagnosis vaginal discharge (see 6.11, • counsel regarding maternal and fetal pregnancy Attachments in 6.13) risks • liaise with microbiologists • Microbiology - clinical diagnosis (Amsel criteria), Gram stain • institute antibiotic therapy • counsel women and their vaginal discharge partners accordingly Personal study

- maternal and fetal risks Management - treatment – metronidazole, clindamycin - antibiotic therapy - fetal risks - incl. miscarriage, preterm birth (see 4.5)

Pharmacology (incl. adverse effects) - metronidazole - clindamycin

74 6.15 Asymptomatic bacteruria and acute symptomatic urinary tract infection

Objectives: To be able to carry out appropriate assessment and management of women with asymptomatic bacteruria (AB) in pregnancy To be able to carry out appropriate assessment and management of women with urinary tract infection (UTI) in pregnancy

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology / Epidemiology Take an appropriate history Ability to take an appropriate history Observation of and Log of - E coli, Klebsiella / Proteus / Pseudomonas discussion with experience & sp, cagulase-negative staphylococci, Counsel women about screening for AB in Ability to; senior medical staff competence - pathophysiology of UTI / acute pregnancy • counsel women pyelnephritis - before screening for AB Appropriate Mini-CEX - epidemiology of asymptomatic bacteruira and UTI in pregnancy Manage a case of AB in pregnancy; - after positive result postgraduate Screening / Diagnosis • arrange and interpret appropriate • formulate, implement and where courses - rationale / organization of screening for AB investigations appropriate modify a management during pregnancy • counsel regarding maternal risks plan in a women with AB detected Attachments in - MSU culture (colony counts) • institute and where appropriate, modify during pregnancy • Maternal - Differential diagnosis acute abdominal pain antibiotic therapy medicine in pregnancy, antenatal pyrexia (see 6.16) • arrange, where appropriate, postnatal Ability to; • Microbiology - diagnosis of relapse / reinfection IVU • formulate, implement and where Management - antibiotic therapy appropriate modify a management NCCWCH Guideline • AB – nitrofurantoin Manage a case of symptomatic UTI in plan in a women with symptomatic (Antenatal Care) • UTI – ampicillin, cephalosporins / pregnancy; UTI in pregnancy second line therapies • arrange and interpret appropriate • liaise with microbiologists and Personal study • duration of therapy investigations nephrologists (where appropriate) - maternal risks (incl. acute pyelonephritis, • counsel regarding maternal and fetal • counsel women and their partners gram negative sepsis, acure renal failure) risks accordingly - fetal risks - incl. preterm birth (see 4.5) • institute and where appropriate, modify - maternal and fetal risks - postnatal investigation (IVU) antibiotic therapy - antibiotic therapy Pharmacology (incl. adverse effects) • refer, where appropriate, for further - postnatal investigation - nitrofurnatoin assessment / treatment - broad spectrum penicillins (e.g. ampicillin) • arrange, where appropriate, postnatal - cephalosporins (e.g. cephalxin) IVU

75 6.16 Other infective conditions

Objectives: To be able to carry out appropriate assessment and management of women with acute chorioamnionitis To be able to carry out appropriate assessment and management of women with puerperal sepsis Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Microbiology / Epidemiology Take an appropriate history Ability to take an appropriate history and Observation of and Log of - common organisms implicated in chorioamnionitis / conduct an examination to assess a woman with discussion with senior experience & puerperal sepsis (incl. GAS/GBS [see 6.11], gram Perform an examination to assess acute acute abdominal pain in pregnancy medical staff competence negative bacilli, anaerobes, genital mycoplasmas abdominal pain in pregnancy [see 6.13]) Ability to; Attachments in Mini-CEX - pathophysiology of acute chorioamnionitis [see Manage a case of acute chorioamnionitis; • formulate, implement and where • Microbiology 4.5] and puerperal sepsis (incl. endometritis, • arrange and interpret appropriate appropriate modify a management plan in a pelvic vein thrombophlebitis, UTI [see 6.15]) investigations women with acute chorioamnionitis - epidemiology of chorioamnionitis and puerperal • counsel regarding maternal and fetal • liaise with microbiologists / pathologists pyrexia / infection risks • counsel women and their partners

Diagnosis / Management – chorioamnionitis • institute and where appropriate, accordingly - differential diagnosis acute abdominal pain in modify antibiotic therapy - maternal and fetal risks pregnancy, antenatal pyrexia (see , vaginal • refer, where appropriate, for further - antibiotic therapy discharge (see 6.11), assessment / treatment - delivery (incl. termination of - investigations (blood, cultures, US) • mode / timing of delivery (incl., where pregnancy) - antibiotic therapy appropriate, termination of - fetal risks (incl. fetal death, preterm labour) pregnancy) Ability to take an appropriate history and - maternal risks (incl. gram negative sepsis, acure conduct an examination to assess a woman with renal failure) Perform an examination to assess puerperal pyrexia Diagnosis / Management – postnatal sepsis postnatal pyrexia - differential diagnosis puerperal pyrexia Ability to; - investigations (culture, US, CT/MRI) Manage a case of puerperal pyrexia; • formulate, implement and where - antibiotic therapy (incl. clindamycin / gentamicin) • arrange and interpret appropriate appropriate modify a management plan in a - maternal risks (incl. gram negative sepsis, acure investigations women with puerperal sepsis renal failure) • counsel regarding maternal risks • liaise with microbiologists / pathologists Pharmacology (incl adverse effects) • institute and where appropriate, • counsel women and their partners - clindamycin modify antibiotic therapy accordingly - gentamicin • refer, where appropriate, for further - maternal and fetal risks assessment / treatment - antibiotic therapy - breastfeeding

76 MODULE 7 GENERIC

7.1 Communication, team working and leadership skills Objectives: Demonstrate effective communication with patients and colleagues Demonstrate good working relationships with colleagues Demonstrate the ability to work in clinical teams and have the necessary leadership skills

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Communication Be able to communicate both verbally Ability to communicate Observation of TPD report - how to structure a patient interview to and in writing with patients & effectively with: and discussion identify: relatives including; • colleagues with senior Team ƒ concerns & priorities • breaking bad news • patients and relatives medical staff observations ƒ expectations • appropriate use of interpreters ƒ understanding & acceptance - breaking bad news Ability to break bad news - bereavement process and behavior Be able to communicate both verbally appropriately and support and in writing with colleagues distress Team working - roles and responsibilities of team Ability to: members • work effectively within a - factors that influence & inhibit team subspecialty team development • lead a clinical team - ways of improving team working incl. • objective setting & planning • respect other’s opinions • motivation and demotivation • deal with difficult • organization colleagues • respect - contribution of mentoring and supervision

Leadership - qualities and behaviors - styles - implementing change / change management (see 7.5)

77

7.2 Good Medical Practice and maintaining trust Objectives: To inculcate the habit of life long learning and continued professional development To ensure trainee has the knowledge, skills and attitudes to act in a professional manner at all times

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Continuing professional development Be able to recognize and Ability to recognize and use Observation of and TPD report use learning opportunities learning opportunities discussion with Doctor-patient relationship senior medical staff Team observations Be able to gain informed Ability to: Personal health consent for: • learn from: • patient care & - colleagues Understand relevance of: procedures - experience • RCOG • research • work independently but seek • GMC, Defence Unions, BMA advice appropriately • specialist societies • deal appropriately with • STC & postgraduate dean challenging behavior • Defence unions Understand: Ethical principles • ethical issues relevant to • respect for autonomy subspecialty • beneficence & non maleficence • legal responsibilities • justice Recognize; Informed consent ƒ own limitations ƒ when personal health takes Confidentiality priority over work pressure

Legal issues Ability to gain informed consent • death certification • mental illness • advance directives, living wills

78

7.2 Teaching

Objectives: Understand and demonstrate appropriate skills and attitudes in relation to teaching

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Teaching strategies appropriate to Prepare and deliver a Ability to communicate Observation of and Log of experience adult learning teaching session effectively discussion with and competence • small group (<10) senior medical staff RCOG core and advanced training • large group (>20) Ability to teach postgraduates relevant to subspecialty • at the bedside on topic(s) relevant to Appropriate subspecialty using appropriate postgraduate Identification of learning principles, Teach practical procedures teaching resources courses needs and styles (incl. ultrasound) Ability to organize a programme Principles of evaluation of postgraduate education e.g. short course or multidisciplinary meeting

79 7.3 Research Objectives Understand and demonstrate appropriate skills and attitudes in relation to research relevant to the subspecialty

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Epidemiological techniques, Perform a scientific Ability to design and conduct a Discussion with senior Peer-reviewed population parameters, sampling experiment: scientific experiment staff (clinicians, publications and or techniques and bias • review evidence scientists, higher degree • develop a hypothesis and Ability to write up research (as statisticians) Randomised trials and meta-analysis design experiment to evidenced by award of MD or test hypothesis PhD thesis or 2 first author Attendance at Statistical tests • define sample papers in citable journals) scientific meetings • parametric tests • conduct experiment • non-parametric tests • perform statistical Ability to present a piece of Personal study • correlation & regression analysis of data scientific research • multi-variate analysis • draw appropriate Appropriate • chi-squared analysis conclusions from results postgraduate courses (e.g. research methods, statistics)

80 7.4 Clinical governance (CG) and risk management

Objectives: Understand and demonstrate appropriate knowledge and skills in relation to CG and risk management

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Clinical Governance Perform clinical audit Ability to practice Observation of and Log of experience - organizational framework at local, • define standard based on evidence based medicine discussion with and competence SHA and national levels evidence senior medical staff - standards e.g. NSF, NICE, RCOG • prepare project & collate data Ability to perform a and clinical TPD report guidelines • re-audit and close audit loop clinical audit relevant to governance team. - clinical effectiveness • formulate policy subspecialty • principles of evidence based Attendance at risk practice Develop and implement a clinical Ability to develop and management • types of clinical trial/evidence guideline implement a clinical meetings classification • purpose and scope guideline relevant to • grades of recommendation • identify and classify evidence subspecialty DH, RCOG and Trust - guidelines and integrated care • formulate recommendations publications pathways • identify auditable standards Ability to report and • formulation investigate a critical • advantages and disadvantages Participate in risk management incident - clinical audit • investigate a critical incident - patient / user involvement • assess risk Ability to respond to a • formulate recommendations complaint in a focused and Risk management • debrief staff constructive manner. - incidents/near miss reporting - complaints management Perform appraisal Ability to perform - litigation and claims management appraisal

Appraisal and revalidation - principles - process

81 7.5 Administration and service management

Objectives: Display knowledge of the structure and organization of the NHS nationally and locally Understand and demonstrate appropriate skills and attitudes in relation to administration and management

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Organization of NHS services Develop and implement Ability to develop and implement Observation of and Log of experience • Directorate, Trust organizational change organizational change discussion with senior and competence • PCT, SHA • development of strategy medical and • formulate a business plan Ability to collaborate with: management staff TPD report Managed clinical network for • manage project • other professions subspecialty service • other agencies Attendance at Be able to participate in Directorate Health and safety recruitment Develop interviewing techniques management meetings • job specification and those required for / interviews Management • interview and selection performance review • strategy development Management course • business planning • project management

Financial resource management

Human resources • team building • appointments procedures • disciplinary procedures

Scrutiny of organization • Healthcare Commission • PMETB / educational inspection visits

82 7.6 Information use and management

Objective Demonstrate competence in the use and management of health information

Knowledge Criteria Clinical Competency Professional skills and Training support Evidence / attitudes Assessment Input, retrieval and utilization of Be able to use relevant Ability to apply principles of Observation and TPD report data recorded on clinical systems • software confidentiality in context of discussion with senior relevant to subspecialty • databases IT medical staff • web sites Main local and national projects and World wide web initiatives in IT and its applications • NPfIT and Connecting for Health

Confidentiality of data • principles and implementation • role of Caldicott guardian

83 How to use the Subspecialty Training Logbook

The first section of the logbook provides a summary of your training. This includes a weekly timetable and a description of any modules you have completed and also information about your on-call commitments.

The next section records the experience, skills and competencies acquired during subspecialty training. • The left hand columns (Experience) record your experience of a range of relevant clinical cases. You should complete the number of relevant cases you have: (a) Observed someone else manage (b) Managed under supervision (c) Managed independently Where a column is blanked out, you do not need to record your experience

• The right hand columns (Competence) record the level of competence you have achieved. This part of the logbook will be completed by your trainers who should sign and date the level of competence when this has been achieved. There are 3 levels: (1) Observe or assist a colleague perform a procedure or manage a case (2) Perform a procedure or manage a case under direct supervision (4) Perform a procedure or manage a case without the need for supervision Most skill / competence targets will either be at: - Level 1 - where the trainee needs to have observed a case managed by, or procedure undertaken by, a colleague (usually from another specialty) in order that they can counsel future patients more appropriately or - Level 3 - where the trainee needs to be able to manage a case or perform a procedure independently. Where a column is blanked out either you are expected to have achieved this level of competence during core training (usually Levels 1) or you are not expected to have achieved this level of competence during subspecialty training (usually Levels 3).

The final section records aspects of general training including evidence of communication, team working, teaching, research and clinical governance. Your trainers should sign relevant sections when these have been completed successfully.

84 Timetable – From ……………………………………….. to ………………………………………….

Monday Tuesday Wednesday Thursday Friday

AM

AM

PM

PM

Modules completed: Module Duration Signature

85

86 Number Competence Observed Managed Managed Module 1 - Maternal Medicine under supervision independently 1 2 3

Hypertension Chronic hypertension Pre-eclampsia with - HELLP - severe hypertension - eclampsia - pulmonary oedema - renal failure Renal disease

Hydronephrosis Reflux nephropathy Glomerulonephritis Polycystic kidney disease Renal transplant recipient Acute renal failure (not related to PET)

Cardiac disease Congenital heart disease - corrected - uncorrected Rheumatic heart disease Ischaemic heart disease Artificial heart valve Arrhythmia Marfan's syndrome Peripartum cardiomyopathy

Liver disease Primary biliary cirrhosis Chronic active hepatitis Obstetric cholestasis Acute fatty liver of pregnancy

Number Competence Observed Managed Managed under supervision independently 1 2 3

Respiratory disease Asthma Sarcoidosis Cystic fibrosis Restrictive lung disease e.g. kyphoscoliosis ARDS / Respiratoty failure Pneumothorax

Gastrointestinal disease Crohn's disease Ulcerative colitis Irritbale bowel disease Reflux oesophagitis Hyperemesis gravidarum

Diabetes Pre-existing diabetes without complications Pre-existing diabetes with - retinopathy - nepthropathy - autonomic neuropathy - vascular disease Gestational DM Number Competence Observed Managed Managed under supervision independently 1 2 3

Other endocrine disease Hypothyroidism Hyperthyroidism Microprolactinoma Macroprolactinoma Adrenal disease Diabetets insipidus Postpartum thyroiditis

Neurological disease Epilepsy Migraine Multiple sclerosis Previous CVA Myaesthenia gravis Idiopathic intracranial hypertension Spina bifida Bell's palsy Carpal tunnel syndrome Number Competence Observed Managed Managed under supervision independently 1 2 3

Connective tissue disease Systemic lupus erythematosis APS without complications APS with - thrombosis - fetal complications (FGR/SB/PET) Rheumatoid arthritis Mixed CT disease Scleroderma

Haematological disease Sickle cell disease Other haemoglobinopathies Haemophilia von Willebrands disease Immune thrombocytopenic purpura

Thromboembolic disease Previous VTE Thrombophilia - without previous VTE - with previous VTE Acute DVT Non-massive pulmonary embolism

Number Competence

Observed Managed Managed

under supervision independently 1 2 3

Psychiatric disease Anxiety Depression Bipolar affective disorder Schizophrenia Postnatal depression Puerperal psychosis

Skin disease Eczema Psoriasis Prurigo/pruritic folliculitis Polymorphic eruption of pregnancy Pemphigoid gestationis

Neoplastic disease Breast

Substance abuse Alcohol Drug abuse - narcotics - cocaine & crack

Performed under Performed

Procedures Observed supervisionindependently 132 ECG interpretation Chest X-ray interpretation Arterial blood gas interpretation Insertion CVP catheter Insertion PA catheter Section under Mental Health Act Number Competence

Observed Managed Managed Module 2 - Genetics under supervision independently 1 2 3

Chromosomal anomalies Previous history - trisomy 21 - trisomy 13/18 - translocation, deletion - sex chromosome aneuploidy Affected fetus - trisomy 21 - trisomy 18 - trisomy 13 - 45 X - 47XXX, 47XXY - translocation / deletion - confined placental mosaicism

Genetic anomalies (Previous/family history/current)

Cystic fibrosis Muscular dystrophy Myotonic dystrophy Huntington's disease Fragile X Haemoglobinopathy Haemophilia / other bleeding disorder Inborn error of metabolism

Number Competence Observed Managed Managed under supervision independently 1 2 3

Syndromic anomalies (Previous/family history /current) DiGeorge Beckwith-Wiedemann Meckel-Gruber Smith-Lemli-Opitz VATER/VACTERL Performed under Performed Observed supervision independently 1 23

Procedures

Ultrasound screen for trisomy 21 - 1st trimester - 2nd trimester Construction of family tree Use of dysmorphology database Cytogenetics FISH Direct mutation detection Enzyme / biochemical analysis (IEM) Analyte analysis / interpretation (trisomy 21) Number Competence Observed Managed Managed Module 3 - Fetal Anomalies under supervision independently 1 2 3

CNS anomalies Anencephaly Spina bifida Ventriculomegaly Dandy Walker malformation / variant Holoprosecencephaly Choroid Plexus cyst

Cardiac anomalies Septal defects Hypoplastic heart Outflow tract anomalies Arrhythmia

Renal anomalies Renal agenesis Hydronephrosis - renal pelvis ≤ 15 mm - renal pelvis > 15 mm Multicystic kidney Polycystic kidney disease (AR/AD) Megacystis / LUTO

Number Competence Observed Managed Managed under supervision independently 1 2 3

Pulmonary anomalies Cystic adenomatoid malformation Sequestration Diaphragmatic hernia Pleural effusion Laryngeal atresia

Abdominal wall and gastrointestinal anomalies Gastroschisis Exomphalos Echogenic bowel Oesophageal atresia Bowel atresia Abdominal cyst Ascites

Face and neck anomalies Nuchal oedema / increased nuchal translucency Cystic hygroma Facial cleft

Skeletal anomalies Lethal skeletal dysplasia Non-lethal skeletal dysplasia Talipes Limb reduction defect Fetal akinesia/hypokinesia sequence Sacral agenesis / syrenomelia Number Competence Observed Managed Managed under supervision independently 1 2 3

Hydrops Immune hydrops Non-immune hydrops

Muiltiple pregnancy Twin-twin transfusion syndrome Twins with discordant anamaly Twin reverse arterial perfusion sequence Performed under Performed Procedures Observed supervision independently 12 3 Preconception counselling

Fetal echocardiography Amniocentesis Twin amniocentesis Chorion villus sampling Amnioinfusion Amnioreduction Vesicocentesis Shunt (Pleuro- & vesico-amniotic) Placental laser Counselling for termination of pregnancy Feticide Selective pregnancy reduction Fetal post-mortem examination Fetal MRI Paediatric surgery - abdominal wall defect - diaphragmatic hernia - bowel atresia - spina bifida Number Competence Observed Managed Managed Module 4 - Antenatal Complications under supervision independently 1 23

Miscarriage/fetal death Recurrent first trimester miscarriage Intrauterine fetal death Trophoblastic disease Cervical weakness

Poor / failed placentation Biochemical markers of poor placentation Previous history poor / failed placentation

Fetal growth disorders Fetal growth restriction - singleton > 26 weeks - singleton ≤ 26 weeks Macrosomia

Antepartum haemorrhage Placental abruption Placenta praevia

Preterm birth Prior history of preterm birth / PROM Preterm PROM - < 24 weeks - > 24 weeks Elective preterm delivery In-utero transfer

Number Competence Observed Managed Managed under supervision independently 1 2 3

Multiple pregnancy

Screening for trisomy (using NT) Monochorionic twin Monoamniotic twin Co-twin demise after 12 weeks' Twin with growth discordance

Malpresentation Breech at term

Alloimmunisation Red cell alloimmunisation - anti-D,c - anti-Kell - other Platelet alloimmunisation

Abdominal / Gynaecological problems

Acute abdomen

Ovarian mass Fibroid uterus Performed under Performed Procedures Observed supervision independently 12 3 Ultrasound screen for preterm birth (CL) Cervical cerclage - elective - rescue Uterine artery Doppler Umbilical artery Doppler Middle cerebral artery Doppler Ductus venosus Doppler Biophysical profile Ultrasound assessment placental site (TVS) Ultrasound assessment of chorionicity External cephalic version Ultrasound screen for fetal anaemia Fetal red cell intravascular transfusion Fetal platelet intravascular transfusion Ultrasound assessment of pelvic mass Number Competence Observed Managed Managed Module 5 - Intrapartum Care under supervision independently 1 2 3

Failure to progress in labour First satge of labour Second stage of labour

Non-reassuring fetal status Suspected fetal acidaemia Confirmed fetal acidaemia Multiple pregnancy and malpresentation Labour and delivery in multiple pregnancy Breech labour and delivery

Shoulder dystocia Prior history of shoulder dystocia Shoulder dystocia

Genital tract trauma Prior history of 3rd/4th degree perineal tear 3rd/4th degree perineal tear Uterine scar rupture

Third stage problems

Massive PPH - without laparotomy - with laparotomy DIC

Caesearean section Prior history of CS Complex CS (assessment/counselling/performance)

Number Competence Observed Managed Managed under supervision independently 1 2 3 Anaesthesia / analgesia Assessment / counselling high risk case

Maternal collapse Massive haemorrhage - medical management - surgical management Amniotic fluid embolism Massive pulmonary embolism Cerebrovascular event Asseement and transfer critically ill woman to ITU Performed under Performed

Procedures Observed supervision independently 132 Assisted vaginal delivery - manual rotation - rotational ventouse - Keilland's forceps CTG Interpretation Fetal blood sampling Improving fetal acidaemia - physiological methods - pharmacological methods Intrapartum amnioinfusion Vaginal breech delivery Breech extraction Shoulder dystocia - McRobert's/suprapubic pressure - internal rotation of shoulders - removal posterior arm Repair of perineal tear - third degree - fourth degree Repair of uterine rupture Peripartum hysterectomy Correction of uterine inversion Insertion uterine balloon Insertion Brace suture Internal iliac artery ligation Caesarean section - major placental praevia - placenta accreta/percreta - fetal anomaly (likely dystocia) - classical incision - extensive abdominal surgery - large fibroids Maternal resuscitation Neonatal resuscitation Medical disorders - IDDM - seizures - clotting disorder - sickle cell disease - HIV infection Set up & running of an emergency drill Number Competence Observed Managed Managed Module 6 - Infection under supervision independently 1 2 3

Human Immunodeficiency virus (HIV) Positive HIV result after screening HIV infection

Hepatitis Positive hepatitis result after screening Hepatitis C infection Acute hepatitis B infection Chronic hepatitis B carrier

Other viral infections in pregnancy

Acute genital herpes simplex infection Acute CMV infection Acute parvovirus B19 infection Acute varicella infection

Toxoplasmosis Acute toxoplasmosis infection

Urinary tract infection Asymptomatic bacteruria Lower urinary tract infection Acute pyelonephritis

Pulmonary infection Pneumonia Tuberculosis

Number Competence Observed Managed Managed under supervision independently 1 2 3

Genital tract infection Chlamydia Bacterial vaginosis Group B haemolytic streptococcus Acute chorioamnionitis Puerperal sepsis

Other infectious conditions in pregnancy Malaria Acute appendicitis Acute cholecystitis

Module 7 - Generic

Communication, team working and leadership Year 1 Year 2 Unable to Un- Improvement Satisfactory Good Unable to Un- Improvement Satisfactory Good Summary of team observations comment satisfactory needed comment satisfactory needed Treats patients politley and considerately Involves patient in decisions about their care Respects patients' privacy and dignity Respects confidentiality Responds when asked to review a patient Liaises with colleagues about continuing care of patient Works as a member of a team Accepts criticism and responds constructively Keeps records of acceptable quality Keeps up to date with administrative tasks Acts within own capability, seeks advice appropriately Delegates work/supervises junior staff approrpriately Manages time efficiently

Comments

Teaching Signature of assessor Date Comments Prepare and deliver a teaching session - small group - large group Organise short course or multidisciplinary meeting Research Full reference Papers published in citable journals during training Other publications during training

Scientific presentations during training Clinical governance and risk management Audit(s) Title(s) Signature of assessor Date

Guideline(s) developed Title(s) Signature of assessor Date

Details Signature of assessor Date Report and investigation of a critical incident Respond to a complaint in focused and constructive manner Performance of appraisal