Maternal and Fetal Medicine Curriculum Curriculum for Subspecialty Training in Maternal and Fetal Medicine

Module 1 Medical Complications of

Module 2 Genetics

Module 3 Structural Fetal Abnormalities

Module 4 Antenatal Complications

Module 5 Intrapartum Complications

Module 6 Infectious Diseases

1 Last updated February 2013 Maternal and Fetal Medicine Curriculum Module 1 Medical complications of pregnancy 1.1 Hypertension Objectives Manage a case of chronic hypertension, including: Counsel regarding fetal and maternal risks 1. To be able to carry out appropriate assessment (including long-term health implications. and management of women with chronic hypertension. Arrange appropriate investigations. 2. To be able to carry out appropriate assessment institute and modify drug therapy. and management of women with pregnancy- Plan delivery and postnatal care. induced hypertension, pre-eclampsia and Refer, where appropriate, for further assessment associated complications. and treatment.

Chronic hypertension Professional skills and attitudes Knowledge criteria Ability to take an appropriate history and conduct an examination to screen for secondary causes and Definition and diagnosis: complications of chronic hypertension. Measurement of blood pressure in pregnancy, including validated devices. Ability to perform and interpret appropriate Impact of pregnancy on blood pressure. investigations. Superimposed pre-eclampsia. Prevalence (primary and secondary causes). Ability to formulate, implement and, where appropriate, modify a multidisciplinary management Pathophysiology: plan. Acute hypertension. Chronic hypertension (including end-organ Ability to manage antihypertensive drug therapy in damage). antenatal and postnatal periods.

Management: Ability to liaise with primary care and physicians in Screening for common causes of secondary management of hypertension. hypertension. Ability to counsel women about: Pregnancy management, including fetal monitoring. maternal and fetal risks Maternal and fetal risks. safety of antihypertensive therapy Contraception. contraception

Pharmacology, including adverse effects: Training support Anti-adrenergics (e.g. propranolol, labetalol, Observation of and discussion with senior oxprenolol). medical staff. Calcium channel blockers (e.g. nifedipine). Appropriate postgraduate courses Vasodilators (e.g. hydralazine). (e.g. ICL/RCP/BMFMS Maternal Complications ACE inhibitors (e.g. lisinopril). in Pregnancy). Attendance at maternal medicine and Outcome: long-term and cardiovascular risks. hypertension clinics. Attachments in: Clinical competency o obstetric anaesthesia Take an appropriate medical history from a woman o intensive care unit/high-dependency unit with pre-existing hypertension: Personal study. family history secondary causes of chronic hypertension Evidence complications of chronic hypertension Log of experience and competence. outcomes of previous Mini-CEX. drug therapy. Case-based discussions. Perform an examination to screen for: secondary causes of hypertension complications of hypertension.

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Pre-eclampsia

Knowledge criteria Professional skills and attitudes Definition and diagnosis: Ability to take an appropriate history and conduct an pregnancy-induced hypertension (PIH) examination to assess a woman with pre-eclampsia. proteinuria prevalence. Ability to perform and interpret appropriate investigations. Pathophysiology: placental pathology Ability to formulate list of differential diagnoses. endothelial dysfunction and systemic manifestations Ability to formulate, implement and, where oxidative stress. appropriate, modify a multidisciplinary management plan. Prediction (see 4.2). Ability to manage antihypertensive drug therapy in Management of severe pre-eclampsia: antenatal and postnatal periods. maternal and fetal risks maternal monitoring, including indications for Ability to liaise with primary care and physicians in invasive monitoring) management of hypertension. fetal monitoring management of complications Ability to counsel women about: HELLP syndrome maternal and fetal risks Eclampsia, including differential diagnosis safety of anti-hypertensive therapy convulsions, altered consciousness (see 1.18) recurrence risks and future management (see cerebrovascular accident (see 1.9) 4.2) pulmonary oedema, acute respiratory distress contraception. syndrome (see 1.5) contraception. Training support Observation of and discussion with senior Pharmacology, including adverse effects: medical staff. magnesium sulphate Appropriate postgraduate courses (e.g. frusemide. ICL/RCP/BMFMS Maternal Complications in Pregnancy). Outcome, including long-term cardiovascular risks. Attachments in: o obstetric anaesthesia Clinical competency o intensive care unit/high-dependency unit. Take an appropriate medical history from a woman Personal study. with pre-eclampsia: RCOG Green-top Guideline Management of family history Severe Pre-eclampsia/Eclampsia (No. 10A). symptoms of severe disease. Evidence Perform an examination to screen for complications in a woman with pre-eclampsia. Log of experience and competence. Mini-CEX. Manage a case of complex pre-eclampsia (or PIH) Case-based discussions. with: (a) HELLP, (b) severe hypertension, (c) eclampsia and (d) pulmonary oedema: counsel regarding fetal and maternal risks arrange and interpret appropriate investigations institute and modify drug therapy plan delivery and postnatal care refer, where appropriate, for further assessment and treatment.

Manage a case of pre-eclampsia with acute renal failure: counsel regarding fetal and maternal risks arrange and interpret appropriate investigations refer to for further assessment and treatment.

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1.2 Renal disease Objectives Manage a case of CRD: counsel regarding fetal and maternal risks 1. To be able to carry out, under supervision, appropriate assessment and management of arrange and interpret appropriate investigations women with pre-existing renal disease and renal institute and modify drug treatment transplants. plan delivery and postnatal care 2. To be able to carry out appropriate assessment refer where appropriate, for further assessment and management of women with pregnancy- and treatment. induced renal disease. Manage a case of renal transplant or ARF: Knowledge criteria counsel regarding fetal and maternal risks arrange and interpret appropriate investigations The kidney in normal pregnancy: refer for further assessment and treatment. anatomical changes, including hydronephrosis) functional changes Professional skills and attitudes interpretation renal function tests fluid and electrolyte balance. Ability to take an appropriate history and conduct an examination to assess a woman with CRD. Pre-existing renal disease (CRD): reflux nephropathy, glomerulonephritis, polycystic kidney Ability to perform and interpret appropriate disease (PKD): investigations. pathology Ability to formulate list of differential diagnoses. prevalence prepregnancy assessment Ability to formulate, implement and, where pregnancy management appropriate, modify a multidisciplinary management outcome (including genetic implications). plan.

Renal transplant recipients: Ability to manage antihypertensive drug therapy in prepregnancy assessment antenatal and postnatal periods. diagnosis rejection pregnancy management Ability to liaise with nephrologists and intensivists in long term considerations the management of acute and CRD. pharmacology (including adverse effects) cyclosporine, tacrolimus Ability to counsel women about maternal and fetal azathioprine (see 1.10) risks, inheritance, recurrence risks, contraception. corticosteroids (see 1.5, 1.6, 1.10). Training support Acute renal failure (ARF) in pregnancy and the puerperium: Observation of and discussion with senior aetiology and diagnosis, including differential medical staff. diagnosis of abnormal renal function (see 1.18) Appropriate postgraduate courses (e.g. management and outcome ICL/RCP/BMFMS Maternal Complications in Pregnancy). indications for and principles of renal support. Attendance at renal medicine clinic. Urinary tract infection (see 6.15): differential Attachment in intensive care unit/high- diagnosis proteinuria (see 1.18). dependency unit. Personal study. Clinical competency Evidence Take an appropriate history from a woman with CRD: family history Log of experience and competence. complications Mini-CEX. outcome of previous pregnancies Case-based discussions. drug therapy.

Perform an examination to screen for complications of CRD.

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1.3 Cardiac disease Objectives Clinical competency 1. To be able to carry out, under supervision, Take an appropriate history from a woman with appropriate assessment and management of cardiac disease: women with pre-existing cardiac disease. family history previous operations/procedures 2. To be able to carry out, under supervision, complications of cardiac disease appropriate assessment and management of drug therapy. women with pregnancy-induced cardiac disease. Perform an examination to assess cardiac disease. Knowledge criteria The heart in normal pregnancy: Manage a case of congenital and acquired heart anatomical and functional changes, including disease in pregnancy: differential diagnosis heart murmur (see 1.18) counsel regarding fetal and maternal risks ECG, echocardiography and assessment of arrange and interpret appropriate investigations cardiac function. refer to cardiologists, haematologists, anaesthetists for further assessment and Congenital heart disease: treatment classification (cyanotic and acyanotic) and risks plan delivery and postnatal care in liaison with prevalence cardiologists, intensivists and anaesthetists functional impact of pregnancy counsel regarding contraception. prepregnancy assessment, indications for termination of pregnancy Professional skills and attitudes pregnancy management including prevention Ability to take an appropriate history and conduct an and management of endocarditis, examination to assess a woman with heart disease. thromboembolism, arrhythmias, cardiac failure maternal and fetal outcome, including genetic Ability to perform and interpret appropriate implications) investigations. contraception. Ability to formulate list of differential diagnoses. Acquired heart disease (rheumatic, ischaemic, valve replacement, Marfan syndrome, arrythmias): Ability to formulate, implement and, where functional impact of pregnancy appropriate, modify a multidisciplinary management prepregnancy assessment plan in liaison with cardiologists, haematologists, diagnosis, including differential diagnosis chest intensivists and anaesthetists. pain, palpitations (see 1.18) pregnancy management, including management Ability to counsel women about: of cardiac failure. maternal and fetal risks recurrence risks Pharmacology, including adverse effects: contraception. diuretics and antihypertensives (see 1.2, 1.3) inotropes (e.g. digoxin, ACE inhibitor) Training support anti-arrhythmics (e.g. adenosine, mexiletine, lidocaine, procainamide) Appropriate postgraduate courses (e.g. ICL/RCP/BMFMS Maternal Complications in anticoagulants (low-molecular-weight heparin, Pregnancy). warfarin; see 1.12, 4.2).

Peripartum cardiomyopathy: Evidence diagnosis, including differential diagnosis Log of experience and competence. breathlessness (see 1,18) Mini-CEX. management and outcome Case-based discussions. recurrence risks.

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1.4 Liver disease Manage a case of obstetric cholestasis and AFLP: Objectives counsel regarding fetal and maternal risks 1. To be able to carry out, under supervision, arrange and interpret appropriate investigations appropriate assessment and management of and fetal monitoring women with pre-existing liver disease. institute and modify drug treatment 2. To be able to carry out appropriate assessment refer, where appropriate, for further assessment and management of women with pregnancy- and treatment induced liver disease. plan delivery and postnatal care counsel regarding contraception. Knowledge criteria Professional skills and attitudes Liver in normal pregnancy: anatomical and functional changes Ability to take an appropriate history and conduct an interpretation of liver function tests in pregnancy. examination to assess a woman with liver disease.

Pre-existing liver disease (primary Ability to perform and interpret appropriate biliary cirrhosis, chronic active hepatitis, liver investigations. transplant recipient (see also 1.2): pathology Ability to formulate list of differential diagnoses. functional impact of pregnancy Ability to formulate, implement and, where pregnancy management appropriate, modify a multidisciplinary management maternal and fetal outcome plan contraception. liaise with hepatologists where appropriate (e.g. chronic liver disease, AFLP). Obstetric cholestasis: pathogenesis Ability to counsel women about: prevalence maternal and fetal risks diagnosis, including differential diagnosis of inheritance itching and altered liver function (see 1.18) recurrence risks pregnancy management, including fetal contraception. monitoring pharmacology, including adverse effects: Training support o ursodeoxycholic acid o corticosteroids (see 1.2, 1.5, 1.6,1.9). Observation of and discussion with senior medical staff. Acute fatty liver of pregnancy (AFLP): Appropriate postgraduate courses (e.g. diagnosis, including differential diagnosis of ICL/RCP/BMFMS Maternal Complications in overlap syndromes (e.g. pulmonary embolism) Pregnancy). management and outcome, including Attendance at hepatology clinic. management of liver failure RCOG Green-top Guideline Obstetric recurrence risks. Cholestasis (No. 43) Personal study. Viral hepatitis (see 6.2). Evidence Clinical competency Log of experience and competence. Take an appropriate history from a woman with liver Mini-CEX. disease: Case-based discussions. complications of liver disease drug therapy.

Perform an examination to assess liver disease.

Manage a case of chronic liver disease in pregnancy: counsel regarding fetal and maternal risks arrange and interpret appropriate investigations refer to hepatologists for further assessment and treatment plan delivery and postnatal care in liaison with hepatologists counsel regarding contraception.

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1.5 Respiratory disease refer, where appropriate, for further assessment, treatment. Objectives Manage a case of acute lung disease in pregnancy: 1. To be able to carry out, under supervision, appropriate assessment and management of counsel regarding fetal and maternal risks women with pre-existing lung disease. arrange and interpret appropriate investigations and fetal monitoring 2. To be able to carry out, under supervision, refer to respiratory physicians and intensivists appropriate assessment and management of for further assessment and treatment women with acute lung disease. plan delivery and postnatal care in liaison with respiratory physicians. Knowledge criteria The lungs in normal pregnancy: Professional skills and attitudes anatomical and functional changes Ability to take an appropriate history and conduct an interpretation of chest X-ray and pulmonary examination to assess a woman with respiratory function tests, including blood gases in disease. pregnancy. Ability to perform and interpret appropriate Pre-existing lung disease (asthma, sarcoidosis, cystic investigations. fibrosis, restrictive lung disease): pathogenesis Ability to formulate list of differential diagnoses. prevalence functional impact of pregnancy Ability to formulate, implement and, where pregnancy management appropriate, modify a multidisciplinary management maternal and fetal outcome plan. pharmacology, including adverse effects: o betasympathomimetics (e.g. salbutamol, Ability to liaise with respiratory physicians and terbutaline) intensivists where appropriate (e.g. cystic fibrosis, o theophyllines ARDS). o sodium cromoglicate o corticosteroids (see 1,2, 1.6, 1.9) Ability to counsel women about maternal and fetal tuberculosis (see 6.10). risks, safety of asthma therapy in pregnancy, contraception. Acute lung disease in pregnancy: acute respiratory distress syndrome (ARDS), pneumothorax, Training support pneumonia: Observation of and discussion with senior pathogenesis medical staff. diagnosis, including differential diagnosis of Appropriate postgraduate courses (e.g. chest pain, breathlessness (see 1.18), ICL/RCP/BMFMS Maternal Complications in tachypnoea, acute hypoxaemia) Pregnancy). oxygen therapy Attendance at chest and cystic fibrosis clinics management of respiratory failure, including and pulmonary function laboratory. indications for and principles of ventilatory Attachment in intensive care unit/high- support dependency unit. pharmacology, including adverse effects Personal study. o amoxicillin and other antibiotics (see 6). British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Clinical competency Management of Asthma (SIGN Guideline No. Take an appropriate history from a woman with lung 63) (www.sign.ac.uk/guidelines). disease: British Thoracic Society guideline: Guidelines lung function results for the Management of Community Acquired drug therapy. Pneumonia in Adults (www.brit-thoracic.org.uk).

Perform an examination to assess lung disease. Evidence Log of experience and competence. Manage a case of chronic lung disease in pregnancy: Mini-CEX. counsel regarding fetal and maternal risks Case-based discussions. arrange and interpret appropriate investigations institute and modify drug therapy plan delivery and postnatal care

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1.6 Gastrointestinal disease institute and modify drug therapy plan delivery and postnatal care Objectives refer, where appropriate, for further assessment and treatment. 1. To be able to carry out, under supervision, appropriate assessment and management of Manage a case of appendicitis in pregnancy: women with pre-existing gastrointestinal (GI) counsel regarding fetal and maternal risks disease. arrange and interpret appropriate investigations 2. To be able to carry out appropriate assessment refer for further assessment and surgery. and management of women with pregnancy induced GI disease. Professional skills and attitudes Knowledge criteria Ability to take an appropriate history and conduct an examination to assess a woman with GI disease. The GI tract in normal pregnancy: anatomical and functional changes. Ability to perform and interpret appropriate investigations. Pre-existing GI disease (ulcerative colitis, Crohn’s disease, coeliac disease irritable bowel syndrome): Ability to formulate list of differential diagnoses. pathogenesis. functional impact of pregnancy Ability to formulate, implement and, where pregnancy management appropriate, modify a multidisciplinary management maternal and fetal outcome plan. pharmacology, including adverse effects): o sulfasalazine, 5-ASA Ability to liaise with gastroenterologists or surgeons, o corticosteroids (see 1.2,1.5, 1.9) where appropriate. o bulking agents, lactulose o antispasmodics. Ability to counsel women about: maternal and fetal risks Pregnancy-related GI disease (hyperemesis safety of anti-emetic, anti-inflammatory therapy gravidarum, reflux oesophagitis, constipation): in pregnancy pathogenesis contraception. prevalence diagnosis, including differential diagnosis of Training support vomiting (see 1.18) and role of endoscopy pregnancy management, including parenteral Observation of and discussion with senior nutrition and steroids medical staff. pharmacology, including adverse effects Appropriate postgraduate courses (e.g. anti-emetics (e.g. cyclizine, metoclopramide) ICL/RCP/BMFMS Maternal Complications in Pregnancy). antacids (e.g. magnesium trisilicate) Attendance at GI clinic. H2-receptor antagonists (e.g. ranitidine). Personal study. Appendicitis: diagnosis, including differential diagnosis Evidence abdominal pain (see 1.18, 6.15, 6.16) and role of Log of experience and competence. ultrasound Mini-CEX. Management, including antibiotics) Case-based discussions. maternal and fetal outcome.

Clinical competency Take an appropriate history from a woman with GI disease: previous surgery/procedure drug therapy.

Perform an examination to assess lung disease.

Manage a case of chronic GI disease in pregnancy and pregnancy-induced GI disease: counsel regarding fetal and maternal risks arrange and interpret appropriate investigations

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1.7 Diabetes institute and modify drug therapy, including management of hypoglycaemia Objectives plan delivery and postnatal care refer, where appropriate, for further assessment, 1. To be able to carry out appropriate assessment treatment (e.g. in women with complications). and management of women with pregestational diabetes. Manage a case of gestational diabetes: 2. To be able to carry out appropriate assessment counsel regarding fetal and maternal risks and management of women with gestational arrange and interpret appropriate investigations diabetes. and fetal monitoring refer to dietician for further assessment Knowledge criteria institute and modify drug therapy, where Glucose homeostasis in pregnancy. appropriate plan delivery and postnatal care. Pre-existing diabetes: pathogenesis and classification Professional skills and attitudes prevalence Ability to take an appropriate history and conduct an complications (metabolic, retinopathy, examination to assess a woman with pre-existing nephropathy, neuropathy, vascular disease) diabetes. prepregnancy assessment functional impact of pregnancy in uncomplicated Ability to perform and interpret appropriate and complicated diabetes investigations. pregnancy management o prepregnancy care Ability to formulate, implement and, where o maternal monitoring (glycaemic control) appropriate, modify a multidisciplinary management o fetal monitoring plan. o intrapartum care maternal and fetal outcome, including fetal Ability to liaise with diabetologists, diabetic nurse abnormality, macrosomia, fetal growth restriction specialists, dieticians and other specialists where pharmacology, including adverse effects appropriate (e.g. complex diabetes). insulin oral hypoglycaemics (e.g. metformin) Ability to counsel women about: contraception. maternal and fetal risks importance of good glycaemic control, including Gestational diabetes: use of insulin in gestational diabetes) pathophysiology and diagnosis contraception prevalence long-term risks and management. pregnancy management, including diet, insulin and oral hypoglycaemic agents) Training support maternal and fetal outcome long term risks and management Observation of and discussion with senior medical staff. contraception. Appropriate postgraduate courses (e.g. Outcome: neonatal complications, management. ICL/RCP/BMFMS Maternal Complications in Pregnancy). Clinical competency Attendance at obstetric medicine and diabetes clinics. Take an appropriate history from a woman with pre- Attachments in neonatal unit and intensive care existing diabetes: unit/high-dependency unit. diabetic control Personal study. presence and severity of complications drug therapy. Evidence

Perform an examination to screen for diabetic Log of experience and competence. complications. Mini-CEX. Case-based discussions. Manage a case of pregestational diabetes: counsel regarding fetal and maternal risks arrange and interpret appropriate investigations and monitoring

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1.8 Other Endocrine Disease Counsel regarding fetal and maternal risks Arrange and interpret appropriate investigations Objectives and monitoring Institute and modify drug therapy To be able to carry out appropriate assessment and Plan delivery and postnatal care management of women with pre-existing thyroid Refer, where appropriate, for further assessment disease. and treatment. To be able to carry out, under supervision, appropriate assessment and management of women Manage a case of pituitary/adrenal disease during with other endocrine diseases. and after pregnancy: Counsel regarding fetal and maternal risks Knowledge Criteria Arrange and interpret appropriate investigations Endocrine function in pregnancy: and fetal monitoring Thyroid physiology in pregnancy Institute and modify drug therapy, where Pituitary and adrenal physiology in pregnancy appropriate Fetal thyroid and adrenal function. Refer, where appropriate, to endocrinologist for further assessment and therapy Thyroid disease (hyperthyroidism, hypothyroidism): Plan delivery and postnatal care. Prevalence Pathogenesis (including Graves disease) Professional Skills and Attitudes Diagnosis Ability to take an appropriate history and conduct an Maternal and fetal outcome, including fetal examination to assess a woman with endocrine hypo/hyperthyroidism, developmental delay disease. Pregnancy management: o maternal monitoring (FT4, TSH, TSH- Ability to perform and interpret appropriate receptor immunoglobulins) investigations. o fetal monitoring (ultrasound, blood sampling) Ability to formulate list of differential diagnoses. Pharmacology, including adverse effects: o thyroxine Ability to formulate, implement and, where o thionamides (e.g. carbimazole, appropriate, modify a multidisciplinary management propylthiouracil) plan. Management and outcome of neonatal hypo- and hyperthyroidism. Ability to liaise with endocrinologist, and other specialists, where appropriate. Pituitary and adrenal diseases: Pathophysiology (hyperprolactinaemia, Cushing Ability to counsel women about maternal and fetal syndrome, hypopituitarism, Addison’s disease, risks, contraception, long-term risks and diabetes insipidus) management. Maternal and fetal outcome Pregnancy management Training support Pharmacology, including adverse effects: Observation and discussion with senior medical Bromocriptine staff. Desmopressin acetate. Appropriate postgraduate courses (e.g. Pregnancy-induced endocrine disease: ICL/RCP/BMFMS Maternal Complications in Pregnancy). Pathophysiology (postpartum thyroiditis, Attendance at obstetric medicine and endocrine lymphocytic hypophysitis, diabetes insipidus) clinics. Pregnancy and postnatal management. Attachment in neonatal unit and intensive care/high-dependency unit. Clinical Competency Personal study. Take an appropriate history from a woman with thyroid/pituitary/adrenal disease: Evidence Previous and current therapy. Log of experience and competence. Perform an examination to screen for endocrine Mini-CEX. dysfunction in pregnancy. Case-based discussions.

Manage a case of hyper-/hypothyroidism during and after pregnancy:

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1.9 Neurological Disease Counsel regarding fetal and maternal risks, including risks therapy Objectives Arrange and interpret appropriate investigations Institute and modify drug therapy To be able to carry out, under supervision, Plan delivery and postnatal care appropriate assessment and management of women Refer, where appropriate, for further assessment with pre-existing neurological disease. and treatment.

To be able to carry out appropriate assessment and Manage a case of neuropathy in pregnancy: management of women with pregnancy-induced Counsel regarding maternal risks and prognosis neurological disease. Institute and modify therapy, including, where appropriate, drug therapy Knowledge Criteria Refer, where appropriate, for further assessment Neurological function in pregnancy. and treatment.

Pre-existing neurological disease (epilepsy, migraine, Professional Skills and Attitudes multiple sclerosis, myasthenia gravis, myotonic dystrophy, idiopathic intracranial hypertension, spina Ability to take an appropriate history and conduct an bifida): examination to assess a woman with neurological disease. Pathogenesis Prevalence Ability to perform and interpret appropriate Functional impact of pregnancy investigations. Pregnancy management, including: Prepregnancy care Ability to formulate list of differential diagnoses. Prenatal diagnosis (see 3.1) Peripartum care Ability to formulate, implement and, where appropriate, Maternal and fetal outcome modify a multidisciplinary management plan. Pharmacology, including adverse effects: o phenytoin, valproic acid, carbamazepine, Ability to liaise with neurologists, physiotherapists lamotrigine and intensivists where appropriate (e.g. cystic o propranolol, tricyclic antidepressants (see fibrosis, acute respiratory distress syndrome). 1.13) o acetazolamide Ability to counsel women about: o pyridostigmine Maternal and fetal risks Contraception. Risks of anti-epileptic therapies Postnatal care Acute and pregnancy-induced neurological disease Contraception (stroke, neuropathies – Bell’s palsy, carpal tunnel Long-term outcome. syndrome, meralgia paresthetica): Pathogenesis, stroke (including cerebrovascular Training Support disease, cerebral venous thrombosis, subarachnoid haemorrhage), neuropathies Observation of and discussion with senior Diagnosis, including differential diagnosis, medical staff. headache, convulsions and altered Appropriate postgraduate courses (e.g. consciousness (see 1.18) and cerebral imaging, ICL/RCP/BMFMS Maternal Complications in electrophysiology Pregnancy). Management, including corticosteroids (see Attendance at obstetric medicine and neurology modules 1.5, 1.6) clinics. Maternal and fetal outcome. Attachment in intensive care unit/high- dependency unit. Clinical Competency Personal study.

Take an appropriate history from a woman with Evidence neurological disease: Previous and current therapy Log of experience and competence. Previous procedures and operations Mini-CEX. Drug therapy. Case-based discussions.

Perform an examination in a woman with neurological disease. Manage a case of chronic neurological disease in pregnancy (including previous stroke):

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1.10 Connective Tissue Disease Institute and modify drug therapy Plan delivery and postnatal care Objective Refer, where appropriate, for further assessment and treatment, To be able to carry out, under supervision, appropriate assessment and management of women Manage a case of other CTD in pregnancy: with pre-existing connective tissue disease (CTD). Counsel regarding fetal and maternal risks, including risks therapy Knowledge Criteria Arrange and interpret appropriate investigations, Systemic lupus erythematosus (SLE) and including fetal monitoring antiphospholipid syndrome (APS): Plan delivery and postnatal care Pathogenesis Refer, where appropriate, for further assessment Prevalence and treatment. Diagnosis, including classification criteria (Sapporo, American Rheumatoid Association), Professional Skills and Attitudes laboratory investigations) Ability to take an appropriate history and conduct an Functional impact of pregnancy examination to assess a woman with neurological Management, including: disease. Prepregnancy care Maternal and fetal monitoring Ability to perform and interpret appropriate Maternal and fetal outcome investigations. Pharmacology, including adverse effects: o corticosteroids, azathioprine (see modules Ability to formulate list of differential diagnoses. 1.2, 1.5, 1.6) o aspirin, low-molecular-weight heparin (see Ability to formulate, implement and, where modules 1.12, 4.2) appropriate, modify a multidisciplinary management Contraception plan. Outcome, including management of neonatal lupus. Ability to liaise with immunologists, physicians, physiotherapists, where appropriate. Other CTD, including scleroderma, rheumatoid arthritis, mixed CTD: Ability to counsel women about: Pathogenesis Maternal and fetal risks Diagnosis Contraception Functional impact of pregnancy. Long-term outcome.

Management, including: Training Support Prepregnancy care Observation of and discussion with senior Maternal and fetal monitoring medical staff. Maternal and fetal outcome Appropriate postgraduate courses (e.g. Pharmacology, including adverse effects: ICL/RCP/BMFMS Maternal Complications in o aspirin (see module 4.2), nonsteroidal anti- Pregnancy). inflammatory drugs, Attendance at obstetric medicine and SLE/CTD o corticosteroids (see modules 1.2, 1.5, 1.6) clinics. o chloroquine (see module 6.9) Attachment in intensive care unit/high- o sulfasalazine (see module 1.6) o azathioprine (see module 1.2) dependency unit. o penicillamine. Personal study. Contraception. Evidence Clinical Competency Log of experience and competence. Take an appropriate history from a woman with CTD: Mini-CEX. Previous obstetric history Case-based discussions. Drug therapy.

Manage a case of SLE and APS in pregnancy: Counsel regarding fetal and maternal risks, including risks of therapy Arrange and interpret appropriate investigations, including fetal monitoring

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1.11 Haematological Disease Prenatal diagnosis (see 2.1) Diagnosis and maternal monitoring (clotting Objectives factor levels/von Willebrand factor (vWf) antigen activity, vWf ristocetin cofactor activity (vWf:rco) To be able to carry out, under supervision, Maternal and fetal outcome appropriate assessment and management of women Management, including pre-pregnancy with pre-existing haematological disease. counselling and intrapartum care Pharmacology, including adverse effects: To be able to carry out appropriate assessment and o desmopressin acetate management of women with pregnancy-induced o recombinant and plasma-derived factor haematological disease. concentrates.

Knowledge Criteria Disseminated intravascular coagulation (DIC) (see Haematological function in pregnancy: modules 5.7,5.10): Red cell and plasma volume changes during Aetiology and pathogenesis pregnancy Diagnosis Changes in coagulation system during Management: pregnancy o resuscitation (see module 5.10) with volume Interpretation of haematological and clotting replacement tests. o platelet, fresh frozen plasma replacement o recombinant factor VIIa (see module 5.7). Anaemia: Pathogenesis (iron, folate and vitamin B12 Clinical Competency deficiency Take an appropriate history from a woman with Prevalence haematological disease: Diagnosis Diagnosis Maternal and fetal outcome Drug therapy. Pharmacology, including adverse effects: o iron (oral and parenteral) Perform an examination to assess o folic acid anaemia/thrombocytopenia. o vitamin B12. Manage a case of anaemia during pregnancy: Haemoglobinopathies (sickle cell and thalassaemia Counsel regarding fetal and maternal risks syndromes): Arrange and interpret appropriate investigations Genetic basis and pathogenesis Institute and modify drug therapy (including, Prevalence where appropriate, parenteral iron, blood Prenatal diagnosis (see 2.1) transfusion) Fetal monitoring Plan delivery and postnatal care Functional impact of pregnancy Refer, where appropriate, for further assessment Maternal and fetal outcome and treatment. Management, including vaso-occlusive crisis in sickle cell disease, haematinic and transfusion Manage a case of sickle cell and thalassaemia therapy. syndromes: Counsel regarding fetal and maternal risks and Thrombocytopenia: prenatal diagnosis Prevalence Arrange and interpret appropriate investigations Diagnosis, including differential diagnosis (including fetal monitoring in sickle cell disease) Pathogenesis, including gestational Institute and modify therapy (including vaso- thrombocytopenia, idiopathic thrombocytopenic occlusive crisis in sickle cell disease, blood purpura, haemolytic uraemic syndrome and transfusion) thrombotic thrombocytopenic purpura) Plan delivery and postnatal care Maternal and fetal outcome Refer, where appropriate, for further assessment Management, including role of splenectomy and treatment. Pharmacology, including adverse effects: o corticosteroids, azathioprine (see 1.2, 1.10) Manage a case of immune thrombocytopenic purpura o intravenous immunoglobulin G. in pregnancy: Counsel regarding fetal and maternal risks Congenital coagulation disorders: Arrange and interpret appropriate investigations Genetic basis and pathogenesis, von Institute and modify therapy Willebrand’s disease, haemophilia Plan delivery and postnatal care Prevalence

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Refer, where appropriate, for further assessment and treatment.

Manage a case of congenital coagulation disorder in pregnancy: Counsel regarding fetal and maternal risks and prenatal diagnosis Arrange and interpret appropriate investigations Institute and modify therapy Plan delivery and postnatal care Refer, where appropriate, for further assessment and treatment.

Manage a case of DIC in pregnancy: Identify and treat underlying cause Arrange and interpret appropriate investigations Institute and modify resuscitative and replacement therapy.

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to assess a woman with haematological disease.

Ability to perform and interpret appropriate investigations.

Ability to formulate list of differential diagnoses.

Ability to formulate, implement and, where appropriate, modify a multidisciplinary management plan.

Ability to liaise with haematologists and geneticists where appropriate.

Ability to counsel women about: Maternal and fetal risks Prenatal diagnosis (see 2.1) Contraception Long-term outcome.

Training Support Observation of and discussion with senior medical staff. Appropriate postgraduate courses (e.g. ICL/RCP/BMFMS Maternal Complications in Pregnancy).Attendance at obstetric medicine and haematology clinics. Personal study.

Evidence Log of experience and competence. Mini-CEX. Case-based discussions.

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1.12 Thromboembolic Disease Plan subsequent care, including delivery and postnatal care Objectives Refer, where appropriate, for further assessment and treatment. To be able to carry out appropriate assessment and management of women at risk or with a history of Manage a case of thrombophilia and/or previous VTE thromboembolic disease. in pregnancy: Arrange and interpret appropriate investigations To be able to carry out appropriate assessment and Counsel regarding risks of VTE in pregnancy management of a woman with pregnancy-induced and the puerperium thromboembolic disease. Institute and modify VTE prophylaxis, where appropriate Knowledge Criteria Plan delivery and postnatal care Venous thromboembolism (VTE) in pregnancy: Refer, where appropriate, for further assessment Pathogenesis of deep-venous thrombosis and treatment. (DVT), pulmonary embolism Prevalence Professional Skills and Attitudes Risk factors, including thrombophilias Ability to take an appropriate history and conduct an Diagnosis (clinical, D-dimer, ultrasound , examination to assess a woman with suspected VTE Doppler, chest X-ray, ECG, blood gases, isotope in pregnancy. scanning, spiral CT) Acute management Ability to perform and interpret appropriate Antithrombotic agents investigations. Laboratory monitoring Thrombolytic therapy and surgery Ability to formulate list of differential diagnoses. Subsequent prophylaxis, including non- pharmacological methods Ability to formulate, implement and, where Pharmacology, including adverse effects: appropriate, modify a multidisciplinary management o unfractionated heparin, low-molecular- plan. weight heparin o warfarin Ability to liaise with physicians, radiologists and o streptokinase haematologists, where appropriate. Outcome, including postphlebitic syndrome Contraception. Ability to counsel women about: Maternal and fetal risks Thrombophilia/previous VTE: Risks and benefits of prophylactic antithrombotic Genetic basis and pathogenesis of congenital therapy during pregnancy, labour and the and acquired thrombophilias (see 1.10) puerperium Diagnosis of thrombophilia (laboratory Long-term outcome investigations and interpretation in pregnancy) Contraception. Risk of VTE (based on thrombophilia, past history) Training Support Maternal and fetal risks (including fetal loss, Observation of and discussion with senior pulmonary embolism, fetal growth restriction) medical staff. Management, including; o non-pharmacological approaches Appropriate postgraduate courses (e.g. ICL/RCP/BMFMS Maternal Complications in o LMWH, aspirin Pregnancy). o fetal monitoring Contraception. Attendance at obstetric medicine and thrombophilia/haematology clinics. Clinical Competency RCOG Green-top Guideline Thromboembolic Disease in Pregnancy and the Puerperium (No. 28). Take an appropriate history from a woman with RCOG Green-top Guideline suspected VTE in pregnancy, including previous VTE Thromboprophylaxis during Pregnancy, Labour and family history. and after (No. 37). Personal study. Perform an examination to assess suspected VTE in pregnancy. Evidence Manage a case of VTE in pregnancy: Arrange and interpret appropriate investigations Log of experience and competence. Counsel regarding maternal and fetal risks Mini-CEX. Case-based discussions.

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1.13 Psychiatric Disease Manage a case of chronic psychiatric disease in pregnancy: Objectives Refer to psychiatric services for further assessment and treatment To be able to carry out, under supervision, Counsel regarding maternal, fetal and neonatal appropriate assessment and management of women risks with pre-existing psychiatric disease. Institute and modify drug therapy, where appropriate To be able to carry out, under supervision, Plan pregnancy, delivery and postnatal care. appropriate assessment and management of women with pregnancy-induced/related psychiatric disease. Manage a case of postnatal depression/puerperal psychosis: Knowledge Criteria Identify high-risk women and refer to psychiatric Pre-existing psychiatric disease, including depression services for further assessment and treatment and bipolar disorders, anxiety disorders, Institute and modify therapy where appropriate schizophrenia: Counsel regarding maternal and neonatal risks, Prevalence long-term outcome, including risk of recurrence. Functional impact of pregnancy Pregnancy and postnatal management Professional Skills and Attitudes Role of specialist team, community liaison, Ability to take an appropriate history to assess a mother and baby units woman with psychiatric disease. Psychotherapy Pharmacological therapy and risks of withdrawal Ability to formulate, implement and where appropriate Mother and baby units modify a multidisciplinary management plan. Maternal and fetal risks Pharmacology, including adverse effects: Ability to formulate list of differential diagnoses. o tricyclic, selective serotonin reuptake inhibitors Ability to liaise with psychiatrists and community o phenothiazines (e.g. trifluoperazine, psychiatric nurses. chlorpromazine) o butyrophenones (e.g. haloperidol) Ability to counsel women about: o benzodiazepines Maternal risks o lithium, carbamazepine Risks and benefits of therapy Neonatal management, including withdrawal and Long-term outcome and risk of recurrence long-term risks Breastfeeding Legal issues, including Mental Health Act and Contraception. consent, child protection. Training Support Pregnancy-induced and related psychiatric disease: Risk factors Observation of and discussion with senior Diagnosis, including differential diagnosis of medical staff. postnatal depression Appropriate postgraduate courses (e.g. Management ICL/RCP/BMFMS Maternal Complications in Role of specialist team, community liaison, Pregnancy). mother and baby units Attendance at obstetric psychiatry and Support and psychotherapy psychiatry clinics. Pharmacological therapy and electroconvulsive Attachment in perinatal psychiatry. therapy Personal study. Maternal and neonatal outcome, including recurrence risks. Evidence Log of experience and competence. Clinical Competency Mini-CEX. Take an appropriate history from a woman with Case-based discussions. psychiatric illness: Previous history Drug history Risk factors.

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1.14 Substance Abuse Manage a case of alcohol abuse in pregnancy: Arrange and interpret appropriate maternal and Objectives fetal investigations To be able to carry out appropriate assessment and Liaise with primary care, social services, alcohol management of women with previous or current dependency team and refer, where appropriate, history of alcohol abuse. for further assessment and treatment Counsel regarding maternal, fetal and neonatal To be able to carry out appropriate assessment and risks management of a woman with previous or current Institute and modify supportive and drug therapy history of substance abuse or dependency. Plan pregnancy, delivery and postnatal care.

Knowledge Criteria Manage a case of substance abuse in pregnancy: Arrange and interpret appropriate maternal and fetal Maternal and fetal effects, including maternal investigations psychosocial effects: Liaise with primary care, social services, alcohol Alcohol, including acute intoxication dependency team and refer, where appropriate, Cannabis for further assessment and treatment Opiates Counsel regarding maternal, fetal and neonatal Cocaine and crack risks Benzodiazepines Institute and modify supportive and drug therapy Amphetamines Plan pregnancy, delivery and postnatal care. Lysergic acid diethylamide (LSD), phencyclidine (angel dust) Professional skills and attitudes Toluene (glue sniffing) Smoking. Ability to take an appropriate history and perform an examination to assess a woman with alcohol or Management: substance abuse or dependency. Screening methods and diagnosis Structure and organisation of antenatal care Ability to provide sympathetic support (suppressing Organisation of drug and alcohol dependency any display of personal judgement). services and links with psychiatric and social services Ability to formulate, implement and where appropriate modify a multidisciplinary management plan. Prenatal diagnosis and fetal monitoring Overdose Ability to liaise with drug dependency team, Detoxification psychiatrists, social services, pharmacists and Maintenance therapy neonatologists. Analgesia in labour Smoking cessation strategies (and their Ability to counsel women about: effectiveness). Drinking and drug cessation Maternal, fetal and neonatal risks Pharmacology, including adverse effects: Long-term health implications Methadone Breastfeeding Benzodiazepines (see 1.13) Contraception. Nicotine replacement. Training support Outcome: Neonatal management and outcome, including Observation of and discussion with senior management of withdrawal medical staff. Legal issues (child protection). Appropriate postgraduate courses (e.g. ICL/RCP/BMFMS Maternal Complications in Clinical competency Pregnancy). Attendance at drug and alcohol abuse and Take an appropriate history from a woman with psychiatry clinics. alcohol or substance abuse or dependence: Personal study. Social problems and support RCOG Green-top Guideline Alcohol Previous detoxification, methadone maintenance Consumption in Pregnancy (No. 9) Complications. Evidence Perform an examination to assess suspected alcohol or substance abuse. Log of experience and competence. Mini-CEX. Case-based discussions.

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1.15 Skin Disease Arrange and interpret appropriate maternal and fetal investigations Objectives Counsel regarding maternal and fetal risks Institute and modify drug therapy To be able to carry out, under supervision, Plan pregnancy, delivery and postnatal care appropriate assessment and management of women Refer for further assessment and treatment. with pre-existing skin disease.

To be able to carry out appropriate assessment and Professional Skills and Attitudes management of women with pregnancy-induced skin Ability to take an appropriate history and conduct an disease. examination to assess a woman with skin disease.

Knowledge Criteria Ability to perform and interpret appropriate investigations. Physiological changes of pregnancy: Skin Ability to formulate list of differential diagnoses. Nails and hair. Ability to formulate, implement and where appropriate Pre-existing skin disease (eczema, psoriasis, acne): modify a management plan. Pathogenesis Prevalence Ability to liaise with dermatologists where Functional impact of pregnancy appropriate. Pregnancy and postnatal management Pharmacology, including adverse effects: Ability to counsel women about: o emollients Maternal and fetal risks o topical corticosteroids Safety of topical therapies in pregnancy o topical benzoyl peroxide. Recurrence risks.

Pregnancy-induced skin disease (pemphigoid Training Support gestationis, polymorphic eruption of pregnancy, prurigo of pregnancy, pruritic folliculitis of pregnancy): Observation of and discussion with senior Pathogenesis medical staff. Prevalence Appropriate postgraduate courses (e.g. Diagnosis, including skin histological and ICL/RCP/BMFMS Maternal Complications in immunofluorescent findings Pregnancy). Maternal and fetal outcome Attendance at obstetric medicine and Management, including plasmapheresis, dermatology clinics. immunosuppressants Personal study. Pharmacology, including adverse effects: o topical and systemic corticosteroids (see Evidence 1.5, 1.6) Log of experience and competence. o antihistamines (e.g. diphenhydramine) Mini-CEX. Recurrence risks. Case-based discussions. Clinical Competency Take an appropriate history from a woman with skin disease: Diagnosis Drug therapy.

Perform an examination in a woman with skin disease.

Manage a case of chronic skin disease in pregnancy: Arrange and interpret appropriate investigations Institute and modify drug therapy Refer, where appropriate, for further assessment and treatment.

Manage a case of pregnancy-induced skin disease:

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1.16 Malignant Disease Manage a case of gynaecological or other Objective malignancy in pregnancy: Arrange appropriate investigations To be able to carry out, under supervision, Counsel regarding maternal and fetal risks, appropriate assessment and management of women including management options (e.g. termination with previous or current malignant disease. of pregnancy, preterm delivery) Plan pregnancy, delivery and postnatal care Knowledge Criteria Refer for further assessment and treatment. Maternal and fetal effects of cancer therapies: Radiotherapy Professional Skills and Attitudes o Fetal dose Ability to take an appropriate history and conduct an o Teratogenic and fetal risks examination to assess a woman with malignant Chemotherapy disease. o Pharmacokinetics in pregnancy o Teratogenic and fetal risks. Ability to perform appropriate investigations.

Breast cancer: Ability to formulate list of differential diagnoses. Pathology Prevalence Ability to formulate, implement and, where Diagnosis in pregnancy, including examination, appropriate, modify a management plan. fine-needle aspiration, ultrasound Maternal and fetal risks Ability to liaise with primary care, palliative care, Pregnancy and postnatal management surgeons and oncologists. Surgery Adjuvant chemo- and radiotherapy Ability to counsel women about: Indications for termination or preterm delivery Maternal and fetal risks Prognosis and recurrence risks Management options Contraception. Prognosis and recurrence risks Breastfeeding Gynaecological and other cancer (cervical cancer, Contraception. ovarian cancer, melanoma): Pathology Ability to act with empathy, honesty and sensitivity Prevalence when breaking bad news. Diagnosis in pregnancy, including colposcopy and biopsy Training Support Maternal and fetal risks Observation of and discussion with senior Pregnancy and postnatal management medical staff. Surgery, including , salpingo- Appropriate postgraduate courses (e.g. oophorectomy ICL/RCP/BMFMS Maternal Complications in Adjuvant chemo- and radiotherapy Pregnancy). Palliative care Attendance at obstetric medicine, breast and Prognosis and recurrence risks. oncology clinics. RCOG Green-top Guideline Pregnancy and Clinical Competency Breast Cancer (No. 12). Take an appropriate history from a woman with Personal study. suspected or prior malignancy: Diagnosis Evidence Previous procedures and surgery Log of experience and competence. Drug therapy. Mini-CEX. Case-based discussions. Perform a breast examination in pregnancy.

Manage a case of breast cancer in pregnancy: Arrange appropriate investigations Counsel regarding maternal and fetal risks, including management options (e.g. termination of pregnancy, preterm delivery) Plan pregnancy, delivery and postnatal care Refer for further assessment and treatment.

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1.17 Clinical Scenarios Ability to reassure women about the safety of radiological investigations in pregnancy. Objective Training Support To be able to reach a diagnosis in women presenting with various clinical problems in pregnancy. Observation of and discussion with senior medical staff. Knowledge Criteria Appropriate postgraduate courses (e.g. Maternal Medicine). Presenting problems in pregnancy: Attendance at general medicine clinics. Proteinuria (see 1.2) Personal study. Abnormal renal function (see 1.2) Chest pain (see 1.3, 1.4) Evidence Palpitations (see 1.3) Heart murmur (see 1.3) Log of experience and competence. Breathlessness (see 1.3, 1.5) Mini-CEX. Abdominal pain (see 1.6) Case-based discussions. Vomiting (see 1.6) Itching (see 1.6, 1.15) Abnormal liver function (see 1.6) Convulsions (see 1.9) Headache (see 1.9) Altered consciousness (see 1.9) Anaemia (1.11) Thrombocytopenia (1.11).

Causes (physiological and pathological).

Investigations: ECG Chest X-ray Echocardiogram Arterial blood gases Lung function tests.

Clinical Competency Take an appropriate history and conduct an examination in a woman presenting with the symptom, sign or abnormality.

Manage a case of gynaecological or other malignancy in pregnancy: Arrange appropriate investigations Counsel regarding maternal and fetal risks, including management options (e.g. termination of pregnancy, preterm delivery) Plan pregnancy, delivery and postnatal care Refer for further assessment and treatment.

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to assess a pregnant woman presenting with symptom, sign or abnormality.

Ability to formulate a list of differential diagnoses.

Ability to arrange and interpret appropriate investigations.

Ability to formulate a management plan.

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Module 2 Genetics

2.1 Genetic Disorders o fragile X o haemoglobinopathies (see also module Objective 1.11) o haemophilias (see also module 1.11) To be able to carry out appropriate counselling and o common inborn errors of metabolism. management in families with a previous genetic disorder. Clinical Competency Knowledge Criteria Take an appropriate history and construct, where appropriate, a family tree in patients with or at risk of Genetics: genetic disease. Gene structure and function DNA as genetic material Manage a woman with a personal or family history of Replication, transcription and translation genetic disease, including cystic fibrosis, myotonic Mechanisms and effects of mutation dystrophy, muscular dystrophy, fragile X, Inheritance and susceptibility haemoglobinopathy, haemophilia, inborn error of Patterns of inheritance of single genes metabolism or syndromic anomaly (see 3.3). Genetic heterogeneity (locus and allele) New mutations causing single-gene disorder Counsel about: Expression and penetrance Risk and impact of disease Multifactorial inheritance (including summation Information sources and support groups and interaction gene effects, polymorphisms) Prenatal diagnostic options, including risks Mitochondrial inheritance. timing of tests and results, accuracy) Management options after testing, including Service and laboratory aspects: termination of pregnancy. Organisation and role of clinical genetics services Arrange appropriate fetal and maternal DNA testing in clinical practice investigations. Ethical and societal issues Refer, where appropriate, for further specialist and/or Diagnostic, predictive and carrier testing genetic counselling. Uses and limitations of laboratory tests Indications, methods and limitations, including Plan care of current pregnancy and delivery. failure and error rates, of: o cytogenetics Perform: o fluorescence in situ hybridisation (FISH) Detailed ultrasound: o polymerase chain reaction (PCR) At appropriate gestation o Southern and Northern blotting Using appropriate technique, including o gene tracking using restriction fragment transvaginal, Doppler, 3D/4D length polymorphisms o enzyme and biochemical analysis. Chorion villus sampling Methods of prenatal diagnosis, including indications, Fetal blood sampling or refer, where techniques, complications: appropriate, for same Ultrasound Skin/muscle biopsy or refer, where appropriate, Amniocentesis for same. Chorion villus sampling (CVS) Fetal blood sampling Professional Skills and Attitudes Fetal tissue biopsy. Ability to identify women with or at risk of a genetic condition. Single-gene defects: Epidemiology and inheritance Ability to formulate, implement and where appropriate Effects of mutation and associated pathology modify management plan. Clinical and pathological features Prognosis Ability to liaise with clinical geneticist and associated Recurrence risks laboratory disciplines, including cyto- and molecular Prenatal diagnosis of the following defects: genetics, and refer where appropriate. o cystic fibrosis o muscular dystrophy o myotonic dystrophy

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Ability to counsel women and their partners about: Genetics in an understandable and non-directive way Fetal risks Prenatal screening and diagnostic options, including limitations of tests Treatment, management Reproductive options.

Ability to formulate management plan for this and future pregnancies.

Ability to support parent(s) and to respect confidentiality.

Ability to use genetic testing appropriately.

Training Support Observation of and discussion with senior medical staff. Appropriate postgraduate courses (e.g. RCOG/BMFMS Fetal Medicine). Attendance at specialist paediatric clinics. Attachments in: o genetics o laboratory specialties (including cyto- and molecular genetics o neonatology o paediatric surgery o perinatal pathology. Personal study.

Evidence Log of experience and competence. Mini-CEX. Case-based discussions.

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2.2 Chromosomal Disorders Clinical and pathological features Prognosis Objectives Recurrence risks To be able to carry out appropriate counselling and Prenatal diagnosis of the following chromosomal management in families with a previous anomalies: chromosomal disorder. o trisomy 21 o trisomy 18 To be able to understand and supervise a o trisomy 13 programme of screening for chromosomal anomaly o Turner syndrome during pregnancy. o Klinefelter syndrome o XXX To be able to carry out appropriate counselling and o triploidy management of fetal chromosome anomaly. o structural rearrangement, including balanced and unbalanced translocation To be able to carry to appropriate counselling and o marker chromosome management of rarer cytogenetic anomalies, o uniparental disomy including translocations, markers and mosaicism. o mosaicism.

Knowledge Criteria Clinical Competency Chromosomes Take an appropriate history. Structure and function (see 3.2, 3.3) Cell division Manage a woman with a personal or family history of Types of abnormality, including structural a chromosomal anomaly, including structural rearrangements, trisomies, sex chromosome alterations: anomalies, extra markers, mosaicism. Risk and impact of anomaly Prenatal diagnostic options Screening and diagnosis: Management options after testing Biochemical markers, including alphafetoprotein, unconjugated estriol, human chorionic Arrange appropriate fetal and parental investigations. gonadotrophin, pregnancy-associated plasma protein A, inhibin A Refer where appropriate for further specialist and/or Ultrasound markers: genetic counselling. o 11–14 weeks (including nuchal translucency, nasal bone, ductus venosus Plan subsequent care of this pregnancy. Doppler, tricuspid regurgitation) o 18–21 weeks (including nuchal oedema, Counsel women about screening for and diagnosis of clinodactyly, echogenic bowel, pyelectasis, chromosomal anomalies in pregnancy including: choroid plexus cysts, nasal bone, short Screening options (biochemistry and ultrasound) femur/humerus) Diagnostic tests (including laboratory methods, Likelihood ratios and risk calculation risks, accuracy and timing of results). Screening strategies o Accuracy (including detection rate, false Manage a case of chromosomal anomaly diagnosed positive rate) in pregnancy, including counselling about fetal and o Service and cost implications infant risks and long-term outcome of the following Laboratory diagnosis (including methods, failure anomalies: and error rates): Trisomy 21 (Down syndrome) o cytogenetic analysis Trisomy 18 (Edwards syndrome) o FISH Trisomy 13 (Patau syndrome) o PCR. 45X (Turner syndrome) Triploidy Mosaicism, including classification and management. Common sex chromosome anomalies (including 47XXY (Klinefelter syndrome), 47XXX) Principles and organisation of screening and Structural rearrangements diagnostic programme for chromosomal anomalies: Markers National Screening Committee Mosaicism. Role of regional screening coordinators Quality control and audit. Counsel about management options, including termination of pregnancy. Chromosomal anomalies: Epidemiology Refer, where appropriate, for further counselling and Pathology support.

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Training Support Plan care of this pregnancy and delivery. Observation of and discussion with senior Perform: medical staff. Ultrasound screening for chromosomal anomaly Appropriate postgraduate courses (e.g. at 10–14 weeks, including: RCOG/BMFMS Fetal Medicine). o nuchal translucency Attendance at specialist paediatric clinics. o nasal bone Attachments in: o ductus venosus Doppler Genetics o tricuspid valve regurgitation Laboratory specialties, including cyto- Ultrasound screening for chromosomal anomaly and molecular genetics, serum screening at 18–21 weeks, including: Neonatology o nuchal oedema Paediatric surgery o nasal bone Perinatal pathology. o pyelectasis Personal study. o short femur/humerus National Screening Committee Guidance on o echogenic bowel Down syndrome screening. o echogenic intracardiac focus o ventriculomegaly Evidence o major structural defect o risk calculation for trisomy 21 based on Log of experience and competence. ultrasound (± biochemical) markers Mini-CEX. Amniocentesis Case-based discussions. Chorion villus sampling Fetal blood sampling or refer, where appropriate, for same Skin biopsy or refer, where appropriate, for same.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to counsel women and partners: Before a screening test After a positive result.

Ability to formulate, implement and, where appropriate, modify management plan in a woman at ‘higher’ risk of chromosomal anomaly.

Ability to formulate, implement and where appropriate modify management plan in a case with a chromosomal anomaly.

Ability to liaise with clinical geneticist and cytogenetics and refer where appropriate.

Ability to counsel women and their partners about: Fetal risks Prenatal screening and diagnostic options (including limitations of tests) Reproductive options.

Ability to formulate management plan for this and future pregnancies: Support parent(s) Respect confidentiality.

Ability to use chromosomal testing appropriately.

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2.3 Multiple Anomalies and Syndromic Use computer database (e.g. London Disorders Dysmorphology Database, Online Mendelian Inheritance in Animals database) to reach Objectives differential diagnosis Counsel about possible diagnoses and To be able to carry out appropriate counselling and implications management in families with a previous child with Information sources and support groups multiple anomalies or syndromic disorder. Further prenatal diagnostic options where appropriate, including risks and accuracy To be able to carry out appropriate counselling and Management options, including termination of prenatal diagnosis in a fetus with multiple anomalies. pregnancy Arrange further fetal investigations where Knowledge Criteria appropriate Screening and diagnosis: Refer where appropriate for further specialist Ultrasound features of common syndromes and and/or genetic counselling associations. Plan care of this pregnancy and delivery. Use of databases to aid diagnosis. Professional Skills and Attitudes Syndromic anomalies and associations: Ability to take a history and identify patients with, or Epidemiology at risk of a genetic condition. Pathology Clinical features Ability to diagnose fetal anomalies using ultrasound Prognosis and to formulate differential diagnosis. Inheritance and recurrence risks Prenatal diagnosis, including ultrasound Ability to liaise with clinical geneticist and associated features, laboratory diagnosis (where applicable, laboratory disciplines, including cyto- and molecular see module 3.1). genetics, and refer where appropriate.

Syndromic anomalies: Ability to counsel women and their partners about: DiGeorge Possible diagnoses (including outcomes) Fryn’s Further investigations, including limitations of Beckwith–Wiedemann tests Meckel–Gruber Treatment, management Smith-Lemli-Opitz Reproductive options. VATER (vertebral defects, imperforate anus, tracheo-oesophageal fistula, radial and renal Ability to formulate management plan for current and dysplasia)/VACTERL (vertebral anomalies, anal future pregnancies. atresia, cardiac abnormalities, tracheoesophageal fistula and/or oesophageal Ability to support parent(s). atresia, renal agenesis and dysplasia and limb defects). Ability to respect confidentiality.

Clinical Competency Training Support Take an appropriate history. Observation of and discussion with senior medical staff. Manage a woman with a personal or family history of Appropriate postgraduate courses (e.g. syndromic anomaly, including: RCOG/BMFMS Fetal Medicine) Counsel about risk and impact of disease Attendance at specialist paediatric clinics. Information sources and support groups Attachments in: Prenatal diagnostic options, including risks, Genetics timing of tests, results, accuracy Laboratory specialties, including cyto- and Management options after testing, including molecular genetics termination of pregnancy Neonatology Arrange appropriate fetal investigations Paediatric surgery Refer where appropriate for further specialist Perinatal pathology. and/or genetic counselling Dysmorphology databases. Plan care of this pregnancy and delivery. Personal study.

Manage a case of multiple fetal anomalies: Evidence Log of experience and competence.

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Mini-CEX. Case-based discussions.

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Module 3. Structural Fetal Anomalies

3.1 Central Nervous System (CNS) Cerebellum, cisterna magna Anomalies Cerebral Doppler (see module 4.8).

Objectives Be able to diagnose and counsel about the following: Anencephaly, exencephaly To be able to carry out appropriate assessment and Spina bifida, encephalocele management of a fetus with a CNS anomaly. Iniencephaly, microcephaly Ventriculomegaly (all degrees) To understand the management, complications and Holoprosencephaly outcomes of neonates with CNS anomalies. Dandy Walker spectrum Tumours, cysts Knowledge Criteria Intracranial haemorrhage (see also module 4.9). Embryology: Brain and spinal cord, including postnatal Manage a case of CNS anomaly including: development. Counsel regarding fetal and infant risks, including long-term health implications Pathology and epidemiology: Arrange and perform appropriate fetal and Pathology of major CNS anomalies maternal investigations (and MRI if appropriate) Incidence of CNS anomalies Refer where appropriate for further counselling Risk factors Associated chromosomal, genetic and Plan delivery and appropriate neonatal support. syndromic anomalies. Professional Skills and Attitudes Screening and diagnosis: Ability to take an appropriate history. Ultrasound appearance of normal embryonic/fetal/neonatal CNS Ability to perform detailed ultrasound assessment of Biometric measurements, including fetal CNS. transcerebellar diameter, ventricular size, cisterna magna Ability to reach a differential diagnosis. Ultrasound appearances of CNS anomalies, including differential diagnosis Ability to perform and interpret appropriate Role of antenatal and postnatal MRI. investigations.

Management and outcome: Ability to formulate, implement and, where Acrania, exencephaly and anencephaly appropriate, modify management plan. Spinal bifida Encephalocele Ability to liaise with neonatologists, paediatric Holoprosencephaly neurologists and paediatric surgeons, where Ventriculomegaly appropriate, including appropriate referral for second Dandy Walker spectrum opinion. Microcephaly Intracranial mass. Ability to counsel women and their partners about: Fetal (and maternal) risks Recurrence risks and prevention Neonatal management CNS anomalies: Long-term outcome Neural tube defects. Postnatal or postmortem findings Recurrence risks. Pharmacology: Ability to formulate management plan for future Folic acid. pregnancy. Ability to support parent(s). Clinical Competency Training Support Take an appropriate history. Observation of and discussion with senior Perform an ultrasound scan to assess: medical staff. Head shape, biometry Appropriate postgraduate courses (e.g. Cavum, corpus callosum RCOG/BMFMS Fetal Medicine). Thalami, cortex Attendance at paediatric neurology clinics. Ventricles, choroid plexus Attachments in:

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Neonatology Paediatric surgery Perinatal pathology. Personal study.

Evidence Log of experience and competence. Mini-CEX. Case-based discussions.

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3.2 Cardiac Anomalies Valvular abnormalities and hypoplastic heart: Mitral stenosis/atresia Objective Aortic stenosis/atresia Tricuspid stenosis/atresia To be able to carry out appropriate assessment and Pulmonary stenosis/atresia management of a fetus with a cardiac anomaly. Outflow tract anomalies (coarctation, transposition, double outlet ventricle) Knowledge Criteria Cardiac tumour Embryology: Arrhythmia. Heart and cardiovascular system Circulatory adaptations at birth. Manage a case of cardiac anomaly including: Counsel about fetal and infant risks, including Pathology and epidemiology: long-term health implications Pathology of major cardiac anomalies Arrange and perform appropriate fetal and Incidence of cardiac anomalies maternal investigations, including M-mode, Risk factors, including family history Doppler echocardiography Associated chromosomal and genetic (including Refer for further assessment and counselling 22q deletions) syndromic anomalies Institute and modify anti-arrhythmic therapy Mechanisms of tachy- and brady-arrhymthmias. Plan delivery and appropriate neonatal support.

Screening and diagnosis: Professional Skills and Attitudes Ultrasound appearance of normal fetal heart Ability to take an appropriate history. Biometric measurements, including Chamber sizes Ability to perform echocardiography, including Ultrasound appearances of cardiac anomalies, Doppler and M-mode. including differential diagnosis Role of 3- and 4D ultrasound (spatio-temporal Ability to reach a differential diagnosis. image correlation) Role of M-mode and Doppler echocardiography, Ability to formulate, implement and, where including normal transvalvular velocities. appropriate, modify management plan.

Management and outcome: Ability to liaise with paediatric cardiologists and Septal defects neonatologists, including appropriate referral for Hypoplastic heart syndromes second opinion. Outflow tract anomalies Cardiac tumours Ability to counsel women and their partners about: Arrhythmias. Fetal risks Neonatal management Recurrence risks of cardiac anomalies. Long-term outcome Postnatal or postmortem findings Pharmacology, including adverse effects of drugs Recurrence risks. used to treat fetal arrhythmias: digoxin Ability to formulate management plan for future pregnancy. flecainide amiodarone Ability to support parent(s). adenosine. Training support Clinical competency Observation of and discussion with senior Take an appropriate history. medical staff. Appropriate postgraduate courses (e.g. Perform echocardiography to assess: RCOG/BMFMS Fetal Medicine). Cardiac size, position Attendance at paediatric cardiology clinics. Venous system, including ductus venosus Attachments in neonatology and perinatal pathology. Atria and ventricles Personal study. Outflow tracts Arterial system, including ductus arteriosus Evidence Heart rate and rhythm. Log of experience and competence. Diagnose and counsel about the following: Mini-CEX. Septal defects Case-based discussions.

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3.3 Genitourinary Anomalies Renal cystic disease (autosomal dominant polycystic kidney disease, infantile polycystic Objective kidney disease) Multicystic/dysplastic kidney To be able to carry out appropriate assessment, Renal cyst counselling and management of a fetus with a Pyelectasis/hydronephrosis genitourinary anomaly and to understand the Megacystis megaureter management, complications and outcomes of Ambiguous genitalia. neonates with genitourinary anomalies. Manage a case of GU anomaly including: Knowledge Criteria Counsel regarding fetal/infant risks, including Embryology: long-term health implications Genitourinary (GU) system (including physiology Arrange/perform appropriate fetal and maternal of the fetal urinary system). investigations, including (see Functional adaptations after birth. 3.11) and vesicocentesis Perform vesicoamniotic shunting or refer, where Pathology and epidemiology: appropriate, for same Pathology of major GU anomalies Refer, where appropriate, for further counselling Incidence of GU anomalies Plan delivery and appropriate neonatal support. Risk factors Associated chromosomal/genetic/syndromic Professional Skills and Attitudes anomalies. Ability to take an appropriate history. Screening/diagnosis: Ability to perform detailed ultrasound assessment of Ultrasound appearance of normal fetal GU system. embryonic/fetal/neonatal urinary tract Ultrasound appearances of GU anomalies, Ability to reach a differential diagnosis. including differential diagnosis Biochemical measurement of fetal urine function Ability to perform and interpret appropriate Neonatal/paediatric investigations, including investigations, including vesicocentesis. cystourethrography, MAG3/DMSA scanning. Ability to formulate, implement and, where Management/outcome: appropriate, modify management plan. Renal agenesis Renal cystic disease Ability to liaise with neonatologists, paediatric Hydronephrosis nephrologists, paediatric surgeons, where Duplex kidney appropriate, including appropriate referral for second Lower urinary tract obstruction opinion including vesicoamniotic shunting. Bladder/cloacal exstrophy Indications for and risks of: Ability to counsel women and their partners about: o amnioinfusion (see 3.11) Fetal risks (including risks of diagnostic and o vesicocentesis therapeutic procedures) o vesicoamniotic shunting. Neonatal management Long-term outcome Recurrence risks: Postnatal or postmortem findings GU anomalies. Recurrence risks Formulate management plan for future Clinical Competency pregnancy.

Take an appropriate history. Ability to support parent(s). Perform ultrasound scan to assess: Training Support Renal size Renal parenchyma and collecting system Observation of and discussion with senior Ureters and bladder medical staff. Genitalia Appropriate postgraduate courses (e.g. Renal artery Doppler. RCOG/BMFMS Fetal Medicine). Attendance at paediatric nephrology clinics. Be able to diagnose and counsel about: Renal agenesis

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Attachments in: Neonatology Perinatal pathology Personal study

Evidence Log of experience and competence. Mini-CEX. Case-based discussions.

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3.4 Pulmonary Abnormalities Manage a case of thoracic anomaly including: Counsel regarding fetal and infant risks, Objective including long-term health implications Arrange and perform appropriate fetal To be able to carry out appropriate assessment, investigations, including thoracocentesis counselling and management of a fetus with a Perform pleuroamniotic shunting or refer, where pulmonary anomaly and to understand the appropriate, for same management, complications and outcomes of Refer where appropriate for further counselling neonates with pulmonary anomalies. Plan delivery and appropriate neonatal support.

Knowledge Criteria Professional Skills and Attitudes Embryology: Ability to take an appropriate history. Trachea, lungs and diaphragm Functional adaptations after birth. Ability to: Perform detailed ultrasound assessment of fetal Pathology and epidemiology: thorax Pathology of pulmonary anomalies Reach a differential diagnosis Incidence of pulmonary anomalies Perform and interpret appropriate investigations Risk factors (including thoracocentesis). Associated chromosomal and genetic/syndromic anomalies. Ability to formulate, implement and, where appropriate, modify management plan. Screening and diagnosis: Ultrasound appearance of normal Ability to liaise with neonatologists, paediatric chest embryonic/fetal thorax physicians, paediatric surgeons where appropriate, Ultrasound appearances of pulmonary including appropriate referral for second opinion anomalies (including differential diagnosis) including pleuroamniotic shunting). Role of antenatal and postnatal MRI/CT imaging. Ability to counsel women and their partners about: fetal risks (including risks of diagnostic and Management/outcome: therapeutic procedures) Laryngeal/tracheal atresia (including Principles neonatal management of EXIT procedure) long-term outcome Cystic adenomatoid malformation of lung postnatal or postmortem findings Pulmonary sequestration recurrence risks Diaphragmatic hernia Pleural effusion Ability to formulate management plan for future Indications for/risks of: pregnancy and to support parent(s). o thoracocentesis o pleuroamniotic shunting. Training Support Recurrence risks of pulmonary anomalies. Observation of and discussion with senior medical staff. Clinical Competency Appropriate postgraduate courses (e.g. RCOG/BMFMS Fetal Medicine). Take an appropriate history. Attendance at paediatric chest clinics. Attachments in: Perform ultrasound scan to assess: o Neonatology Chest size and shape o Paediatric surgery Mediastinal shift o Perinatal pathology. Ribs Personal study. Lung parenchyma Diaphragm Evidence Be able to diagnose and counsel about the following: Log of experience and competence. Laryngeal atresia/stenosis (CHAOS) Mini-CEX. CAML Case-based discussions. Pulmonary sequestration Diaphragmatic hernia Pleural effusion

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3.5 Abdominal wall and Gastrointestinal Hepatic calcification/mass Anomalies Echogenic bowel Abdominal cyst Objective Ascites. To be able to carry out appropriate assessment, Manage a case of abdominal wall /GI anomaly, counselling and management of a fetus with an including: abdominal wall or gastrointestinal (GI) anomaly and Counsel regarding fetal/infant risks (including to understand the management, complications and long term health implications) outcomes of neonates with abdominal-wall or Arrange/perform appropriate fetal investigations gastrointestinal anomalies. Refer where appropriate for further Counselling Knowledge Criteria Plan delivery and appropriate neonatal support. Embryology: Abdominal wall Professional Skills and Attitudes Gastrointestinal tract. Ability to take an appropriate history. Pathology and epidemiology: Ability to perform detailed ultrasound assessment of Pathology of abdominal wall and GI anomalies fetal abdominal wall and GI tract. Incidence of abdominal wall and GI anomalies Risk factors Ability to reach a differential diagnosis: Associated chromosomal/genetic anomalies. Perform and interpret appropriate investigations.

Screening and diagnosis: Ability to formulate, implement and, where Ultrasound appearance of normal embryonic appropriate, modify management plan. and fetal abdominal wall and GI tract Ultrasound appearances of abdominal wall and Ability to liaise with neonatologists and paediatric GI anomalies, including differential diagnosis. surgeons, where appropriate, including appropriate referral for second opinion. Management and outcome: Gastroschisis Ability to counsel women and their partners about: Umbilical hernia/exomphalos Fetal risks Oesophageal atresia/tracheo-oesophageal Neonatal management fistula Long term outcome Bowel atresia (small and large) Postnatal or postmortem findings Meconium ileus Recurrence risks Hepatic calcification/mass Formulate management plan for future Echogenic bowel pregnancy Abdominal cyst Support parent(s) Isolated ascites. Training Support Recurrence risks of abdominal wall and GI anomalies. Observation of and discussion with senior medical staff. Clinical Competency Appropriate postgraduate courses (e.g. RCOG/BMFMS Fetal Medicine). Take an appropriate history. Attachments in: o neonatology Perform ultrasound scan to assess: o paediatric surgery Abdominal shape and biometry o perinatal pathology. Abdominal wall/cord insertion Personal study. Stomach, small and large bowel Liver, gallbladder Evidence Intrahepatic vein and ductus venosus. Log of experience and competence. Diagnose and counsel about the following: Mini-CEX. Gastroschisis/body wall defect Case-based discussions. Umbilical hernia/exomphalos Absent/enlarged stomach Duodenal, small and large bowel atresia Meconium ileus

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3.6 Neck and Face Anomalies Manage a case of neck/facial anomaly including: Counsel regarding fetal/infant risks (including Objective long-term health implications) Arrange and perform appropriate fetal To be able to carry out appropriate assessment, investigations counselling and management of a fetus with a neck Refer, where appropriate, for further counselling or facial anomaly and to understand the Plan delivery and appropriate neonatal support. management, complications and outcomes of neonates with neck or facial anomalies. Professional Skills and Attitudes Knowledge Criteria Ability to take an appropriate history.

Embryology: Ability to perform detailed ultrasound assessment of Fetal face fetal neck and face. Fetal neck Fetal thyroid. Ability to reach a differential diagnosis.

Pathology and embryology: Ability to perform and interpret appropriate Pathology of neck and facial anomalies investigations. Incidence of neck and facial anomalies Risk factors Ability to formulate, implement and, where Associated chromosomal/genetic/syndromic appropriate, modify management plan. anomalies. Ability to liaise with neonatologists, paediatric Screening and diagnosis: surgeons and facial cleft team, where appropriate, Ultrasound appearance of normal fetal neck and including appropriate referral for second opinion. face Ultrasound appearances of neck and facial Ability to counsel women and their partners about: anomalies, including differential diagnosis Fetal risks Role of antenatal 3D ultrasound/MRI. Neonatal management Long-term outcome Management and outcome of: Postnatal or postmortem findings Cystic hygroma Recurrence risks. Facial cleft Micrognathia Ability to formulate management plan for future Macroglossia pregnancy and support parent(s). Anopthalmia Fetal goitre. Training Support Observation of and discussion with senior Recurrence risks of neck and facial anomalies. medical staff. Appropriate postgraduate courses (e.g. Clinical Competency RCOG/BMFMS Fetal Medicine). Take an appropriate history. Attachments in: o neonatology Perform ultrasound scan to assess: o paediatric surgery Head shape and biometry, including orbital o perinatal pathology. diameters Personal study. Face and palate Neck Evidence Thyroid. Log of experience and competence. Mini-CEX. Diagnose and counsel about the following: Case-based discussions. Cystic hygroma Facial cleft Micrognathia Anopthalmia Macroglossia Fetal goitre Absent/hypoplastic nasal bone.

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3.7 Skeletal Anomalies Scoliosis Sirenomelia Objective Sacral agenesis Scoliosis (due to hemivertebra) To be able to carry out appropriate assessment, Fetal akinesia/hypokinesia sequence. counselling and management of a fetus with a skeletal anomaly and to understand the Manage a case of skeletal anomaly, including: management, complications and outcomes of Counsel regarding fetal/infant risks, including neonates with skeletal anomalies. long-term health implications Arrange and perform appropriate fetal Knowledge Criteria investigations Embryology: Refer where appropriate for further counselling Fetal skeleton and spine. Plan delivery and appropriate neonatal support.

Pathology and embryology: Professional Skills and Attitudes Pathology of skeletal anomalies Ability to take an appropriate history. Incidence of skeletal anomalies Risk factors Ability to perform detailed ultrasound assessment of Associated chromosomal/genetic/syndromic fetal skeleton. anomalies. Ability to reach a differential diagnosis. Screening and diagnosis: Ultrasound appearance of normal fetal skeleton Ability to perform and interpret appropriate Ultrasound appearances of skeletal anomalies, investigations. including differential diagnosis Role of antenatal 3D ultrasound/MRI. Ability to formulate, implement and, where appropriate, modify management plan, liaise with Management and outcome of: geneticists, neonatologists and orthopaedic Thanatophoric dysplasia surgeons, where appropriate, including appropriate Achondroplasia referral for second opinion. Achondrogenesis Osteogenesis imperfecta Ability to counsel women and their partners about: Camptomelic dysplasia Fetal risks Talipes Neonatal management Polydactyly Long-term outcome Limb reduction defect Postnatal or postmortem findings Sirenomelia Recurrence risks. Sacral agenesis Hemivertebra Ability to formulate management plan for future Fetal akinesia/hypokinesia sequence pregnancy and support parent(s).

Recurrence risks of skeletal anomalies. Training Support Observation of and discussion with senior Clinical Competency medical staff. Take an appropriate history. Appropriate postgraduate courses (e.g. RCOG/BMFMS Fetal Medicine). Perform ultrasound scan to assess: Attachments in: Long-bone shape and biometry o neonatology Ribs and spine o paediatric surgery Mineralisation of skeleton o perinatal pathology. Feet and hands Personal study. Joints Fetal tone and movements. Evidence Log of experience and competence. Diagnose and counsel about the following: Mini-CEX. Micromelia (due to lethal and non-lethal Case-based discussions. dysplasias) Talipes Polydactyly Limb reduction defect

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3.8 Fetal Tumours Ability to formulate, implement and where appropriate modify management plan. Objective Ability to liaise with neonatologists, paediatric and To be able to carry out appropriate assessment, ENT surgeons, where appropriate, including counselling and management of a fetus with a appropriate referral for second opinion. and to understand the management, complications and outcomes of neonates with Ability to counsel women and their partners about: teratoma. Fetal risks Neonatal management Knowledge Criteria Long term outcome Embryology: Postnatal or postmortem findings Fetal lymphangiomas and . Delivery, including EXIT procedure.

Pathology and embryology: Ability to formulate management plan for future Pathology of fetal lymphangiomas and pregnancy and support parent(s). teratomas Incidence of fetal tumours. Training Support Observation of and discussion with senior Screening and diagnosis: medical staff. Ultrasound appearances of fetal Appropriate postgraduate courses (e.g. lymphangiomas/teratomas (including differential RCOG/BMFMS Fetal Medicine). diagnosis of complex masses) Attachments in: Role of antenatal 3D ultrasound/MRI. o neonatology o paediatric surgery Management and outcome of: o perinatal pathology. Cervical lymphangioma/teratoma Personal study. Sacrococcygeal teratoma. Evidence Recurrence risks of fetal teratomas. Log of experience and competence. Clinical Competency Mini-CEX. Case-based discussions. Take an appropriate history.

Perform ultrasound scan of a teratoma to assess: size, position and relationship to adjacent structures structure, including blood flow.

Be able to diagnose and counsel about the following: cervical teratoma sacrococcygeal teratoma.

Manage a case of fetal teratoma, including: Counsel regarding fetal/infant risks, including long-term health implications Arrange and perform appropriate fetal investigations Refer where appropriate for further counselling Plan delivery and appropriate neonatal support, including, where appropriate, EXIT procedure.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to perform detailed ultrasound assessment of a fetal tumour.

Ability to reach a differential diagnosis.

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3.9 Fetal Hydrops Professional Skills and Attitudes Objective Ability to take an appropriate history. To be able to carry out appropriate assessment, counselling and management of a fetus with hydrops Ability to perform detailed ultrasound assessment of fetalis and to understand the management, fetal hydrops. complications and outcomes of neonates with congenital hydrops. Ability to reach a differential diagnosis.

Knowledge Criteria Ability to perform and interpret appropriate investigations. Pathology and embryology: Pathology of fetal hydrops, including Immune Ability to formulate, implement and, where and non-immune causes (see also 4.8) appropriate, modify management plans, liaise with Incidence of fetal hydrops neonatologists, haematologists and geneticists where Risk factors appropriate, including referral for second opinion. Associated chromosomal, genetic and syndromic anomalies. Ability to counsel women and their partners about: Fetal risks Diagnosis: Maternal risks Ultrasound appearance of fetal hydrops, Neonatal management including differential diagnosis Long term outcome Role of echocardiography (see 3.2), antenatal Postnatal or postmortem findings 3D ultrasound/MRI and fetal blood sampling. Recurrence risks.

Management and outcome: Ability to formulate management plan for a future Red cell alloimmunisation (see 4.8) pregnancy. Cardiac arrhythmias (see 3.2) Other non-immune causes of hydrops Ability to support parent(s).

Recurrence risks of immune and non-immune Training Support hydrops. Observation of and discussion with senior Clinical Competency medical staff. Appropriate postgraduate courses (e.g. Take an appropriate history. RCOG/BMFMS Fetal Medicine). Attachments in: Perform ultrasound scan to assess: o neonatology Cause of hydrops, including echocardiography o paediatric surgery (see 3.2) and middle cerebral artery Doppler o perinatal pathology. (see 4.8) Personal study. Severity of hydrops (including amniotic fluid volume (see 3.10) Evidence Fetal condition (see 4.3). Log of experience and competence. Be able to diagnose and counsel about the following: Mini-CEX. Immune hydrops (see also 4.8) Case-based discussions. Non-immune hydrops.

Manage a case of fetal hydrops including: Counsel regarding fetal/infant risks, including long term health implications Arrange and perform appropriate maternal investigations Perform fetal blood sampling (with or without transfusion or refer, where appropriate, for same Refer, where appropriate, for further counselling Plan delivery and appropriate neonatal support.

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3.10 Multiple Pregnancies Refer where appropriate for further Counselling/management Objective Perform selective feticide or refer, where appropriate, for same To be able to carry out appropriate assessment, Plan delivery and appropriate neonatal support. counselling and management of abnormalities in multiple pregnancies to understand the management, Professional Skills and Attitudes complications and outcomes of abnormalities in twins Ability to take an appropriate history. Knowledge Criteria Ability to perform detailed ultrasound assessment of Embryology: a multiple pregnancy with a fetal anomaly. Mono- and dizygous twinning (see 4.6) Placentation: chorionicity/amnionicity (see 4.6). Ability to reach a differential diagnosis.

Pathology and embryology: Ability to formulate, implement and, where Pathology of abnormalities related to twinning appropriate, modify management plan. and twin placentation, including twin-to-twin transfusion syndrome (TTTS), twin reversed Ability to liaise with fetal medicine subspecialists, arterial perfusion (TRAP) and conjoining neonatologists and paediatric surgeons, where Incidence of abnormalities related to twinning appropriate, including appropriate referral for second Risk factors for twinning and related anomalies. opinion.

Screening and diagnosis: Ability to counsel women and their partners about: Ultrasound determination of zygosity/chorionicity Fetal risks, including selective feticide and laser Chorionicity and amnionicity ablation Ultrasound appearances of abnormalities related Neonatal management to twinning, including differential diagnosis Long-term outcome Invasive procedures in multiple pregnancies. Postnatal or postmortem findings Delivery. Management/outcome: Triplet and higher-order multiple pregnancy Ability to formulate management plan for a future Discordant anomalies in multiples pregnancy. TRAP sequence Conjoined twins Ability to support parent(s). TTTS Discordant fetal growth (see 4.3). Training Support Observation of and discussion with senior Clinical Competency medical staff. Take an appropriate history. Appropriate postgraduate courses (e.g. RCOG/BMFMS Fetal Medicine). Perform ultrasound scan in multiple pregnancy to Attachments in: assess: o neonatology Chorionicity and amnionicity o paediatric surgery Fetal anatomy o perinatal pathology. Fetal growth (see 4.3). Personal study.

Diagnose and counsel about the following: Evidence Multiple pregnancy with discordant fetal Log of experience and competence. abnormality Mini-CEX. TRAP sequence Case-based discussions. Conjoined twin TTTS.

Manage a case of multiple pregnancy with fetal abnormality including: Counsel regarding fetal/infant risks, including Selective feticide and laser ablation Arrange and perform appropriate fetal and maternal investigations (including, where appropriate, fetal karyotyping)

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3.11 Disorders of Amniotic Fluid Plan delivery and appropriate neonatal support.

Objective Manage a case of hydramnios, including: Counsel regarding fetal/infant risks, including To be able to carry out appropriate assessment, Preterm delivery counselling and management of a pregnancy with Arrange and perform appropriate fetal and abnormal amniotic fluid. maternal investigations Refer, where appropriate, for further counselling Knowledge Criteria Institute appropriate maternal and fetal Embryology and physiology: monitoring Placenta and membranes Institute, where appropriate, maternal medical Formation and function of amniotic fluid. therapy Perform, where appropriate, amnioreduction Pathology and embryology: Plan delivery and appropriate neonatal support. Pathology of disorders of amniotic fluid, including secondary effects of early amnion Professional Skills and Attitudes rupture and oligohydramnios Ability to take an appropriate history. Incidence of amniotic fluid disorders Risk factors Ability to perform detailed ultrasound assessment of Associated chromosomal, genetic and amniotic fluid. syndromic anomalies. Ability to reach a differential diagnosis. Diagnosis: Ultrasound measurement of amniotic fluid Ability to perform and interpret appropriate Diagnosis of oligohydramnios and hydramnios, investigations. including differential diagnosis Invasive procedures in multiple pregnancies, Ability to formulate, implement and, where including risks and indications of amnioinfusion appropriate, modify management plan and to liaise and amnioreduction. with neonatologists, where appropriate (including appropriate referral for second opinion). Management/outcome: Oligo- and anhydramnios Ability to: Hydramnios Counsel women and their partners about Indications and risks: Fetal and neonatal risks o Amnioinfusion (see 3.3) Maternal risks o Amnioreduction. Neonatal management Postnatal or postmortem findings Pharmacology: Recurrence risks Prostaglandin synthase inhibitors. Support parent(s).

Clinical Competency Training Support Take an appropriate history. Observation of and discussion with senior medical staff. Perform ultrasound scan to assess amniotic fluid Appropriate postgraduate courses (e.g. volume. RCOG/BMFMS Fetal Medicine). Attachments in: Diagnose and identify cause of: o neonatology Oligo- and an-hydramnios, including rupture of o paediatric surgery membranes (see 4.5), renal anomaly (see 3.3), o perinatal pathology. fetal growth restriction (see 4.3), postmaturity. Personal study. Hydramnios, including gastrointestinal anomaly (see 3.5), neuromuscular anomaly, maternal Evidence diabetes (see 1.7), placental angioma. Log of experience and competence. Manage a case of oligo/an-hydramnios, including: Mini-CEX. Counsel regarding fetal and infant risks Case-based discussions. Arrange and perform appropriate fetal investigations, including amnioinfusion Institute appropriate maternal and fetal monitoring Refer, where appropriate, for further counselling

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3.12 Termination of Pregnancy Refer, where appropriate, for further counselling.

Objective Conduct post-termination of pregnancy counselling. To be able to carry out counselling and management Perform: of families undergoing termination of pregnancy for Medical termination of pregnancy or refer, where fetal anomaly. appropriate, for same Vacuum aspiration and dilatation and evacuation Knowledge Criteria or refer, where appropriate, for same Law and ethics: Feticide or refer, where appropriate, for same Abortion law Supportive counselling Ethics issues relating to termination of Post-termination of pregnancy counselling, pregnancy for fetal anomaly including: o Guidance on use of feticide. postmortem findings, where appropriate o recurrence risks o Epidemiology: management plan for future pregnancy. Incidence of and indications for termination of pregnancy for fetal anomaly Professional Skills and Attitudes Rates of termination of pregnancy for fetal Ability to reach a definitive diagnosis of major fetal anomalies and factors influencing decision. anomaly, where possible.

Pathology: Ability to assess risks of death and/or handicap. Consent for postmortem (and tissue retention) Conduct of postmortem examination. Ability to counsel women and their partners about: Risks of death/handicap Management (including methods, complications): Option of termination of pregnancy with or Medical termination of pregnancy without feticide. Surgical termination of pregnancy, including suction aspiration and dilatation and evacuation Ability to formulate, implement and, where Feticide appropriate, modify management plan for termination Impact of gestational age on complications of pregnancy, including post-termination of (physical and psychological). pregnancy review, liaise with midwives, neonatologists and pathologists, where appropriate. Pharmacology: Mifepristone Ability to counsel women and their partners about: Prostaglandin analogues, including gemeprost, Procedure and risks of termination of pregnancy misoprostol (see 4.1) Postmortem. Potassium chloride. Ability to support women and their partners. Bereavement process and milestones; management. Ability to refer, where appropriate, for further Clinical Competency counselling and support. Manage a case of major fetal anomaly. Training Support Counsel regarding: Observation of and discussion with senior Risk/impact of handicap associated with medical staff. anomaly Appropriate postgraduate courses (e.g. Feticide RCOG/BMFMS Fetal Medicine). Methods of termination of pregnancy (medical Attachments in: and surgical) o neonatology Complications of termination of pregnancy o paediatric surgery Postmortem o perinatal pathology. Aftercare. Personal study.

Plan termination of pregnancy and post-termination Evidence of pregnancy care. Log of experience and competence. Mini-CEX. Arrange appropriate fetal and maternal investigations, including postmortem. Case-based discussions.

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3.13 Preconception Counselling Training Support Objective Observation of and discussion with senior To be able to carry out preconception counselling in medical staff. families at increased risk of fetal anomaly, including Sessions in clinical genetics. those with family history, prior anomaly, medical Personal study disorder or exposure to teratogenic drugs. Evidence Knowledge Criteria Log of experience and competence. Preconception counselling. Mini-CEX. Case-based discussions. Assessment of risk of fetal anomaly: Personal/family history of genetic disorder Prior chromosomal disorder/advanced age Prior structural anomaly Current medical disorder e.g. diabetes Teratogen exposure Investigations, including genetic testing Methods of screening and diagnosis Alternative options, including assisted conception and preimplantation diagnosis.

Teratogenicity: Mechanisms of teratogenicity Information sources, including National Teratology Centre Teratogenetic effects of commonly used drugs including: o lithium o warfarin o anti-epileptic drugs o ACE inhibitors o anti-neoplastic drugs Teratogenic effects of radiological investigations.

Clinical Competency Take an appropriate history.

Counsel an ‘at risk’ woman and her family preconceptually about: Risks of fetal anomaly Screening/diagnostic options.

Refer, where appropriate, to clinical geneticist or fetal medicine specialist.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to assess risks of fetal anomaly, to liaise with clinical geneticists, fetal medicine specialists, physicians, teratologists and refer where appropriate.

Ability to counsel women and their partners about: Screening/diagnostic options. Management plan for future pregnancy.

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Module 4 Antenatal Complications

4.1 Miscarriage and Fetal Death Manage a case of trophoblastic disease including: Ultrasound diagnosis Objective Arrange appropriate investigations, registration and follow-up To be able to carry out appropriate assessment and Perform uterine evacuation. management of women with fetal death before and after 24 weeks of gestation. Professional Skills and Attitudes To be able to carry out assessment and management Ability to take an appropriate history. of women with trophoblastic disease. Ability to perform and interpret ultrasound in women To be able to carry out assessment and management with suspected fetal death and cervical weakness. of women with suspected cervical weakness. Ability to formulate, implement and, where Knowledge Criteria appropriate, modify a management plan for fetal death and suspected cervical weakness. Pathophysiology: Fetal death (early and late) Ability to perform elective and emergency cervical Cervical weakness cerclage. Trophoblastic disease. Ability to liaise with other services, e.g. bereavement Epidemiology: support. Incidence of miscarriage/fetal death Risk factors . Ability to formulate, implement and, where appropriate, modify a management plan for women Screening: with trophoblastic disease. Cervical length (see 4.5). Ability to counsel women and their partners about: Diagnosis, management and outcome: Empathy in bereavement support Fetal death Consent for postmortem Cervical weakness, including cervical cerclage Postmortem findings. Trophoblastic disease, including registration and principles of follow-up. Training support

Pharmacology: Observation of and discussion with senior Including adverse effects of drugs used in medical staff. miscarriage/fetal death: Sessions in clinical genetics o mifepristone Personal study. o prostaglandin analogues. Evidence Clinical Competency Log of experience and competence. Take an appropriate medical and obstetric history. Mini-CEX. Case-based discussions. Manage a case of fetal death, including: Ultrasound diagnosis Arrange appropriate investigations Plan delivery and post-delivery care (see 3.12) Indications for aspirin/low-molecular-weight heparin.

Manage a case of suspected cervical weakness including: Perform and interpret ultrasound measurement of cervical length Appropriate selection of cases for surgical intervention Perform elective and emergency cervical cerclage.

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4.2 Poor and Failed Placentation Professional Skills and Attitudes Objective Ability to take an appropriate history. To be able to carry out appropriate assessment and management of women with previous placental Ability to perform and interpret appropriate disease. investigations (including uterine artery Doppler).

To be able to carry out appropriate assessment and Ability to formulate, implement and, where management of women with biochemical/ultrasound appropriate, modify a multidisciplinary management markers of poor placentation. plan.

Knowledge Criteria Ability to liaise, where appropriate, with haematologists. Normal placental development: Vascular development, including mechanisms of Ability to counsel women and their partners about: spiral artery transformation Maternal and fetal risks Endocrine function. Risks/benefits of prophylactic therapies Long-term health implications. Placental pathophysiology: Pre-eclampsia (see 1.1) Training Support Fetal growth restriction Placental abruption (see 4.4) Observation of and discussion with senior Fetal death (see 4.1). medical staff. Appropriate postgraduate courses, e.g. Maternal Screening, Including Indications for and predictive Medicine, Ultrasound. abilities of: Attendance at: Biochemical screening (alphafetoprotein, human o thrombophilia clinics chorionic gonadotrophin and other Down o serum screening laboratory. syndrome markers) Personal study. Uterine artery Doppler Placental morphology Evidence Thrombophilia screening. Log of experience and competence. Mini-CEX. Pharmacology, Including adverse effects of drugs Case-based discussions. used in prevention of poor placentation/fetal death: Aspirin Low-molecular-weight heparin Vitamins C and E.

Clinical Competency Take an appropriate medical and obstetric history: Family history Outcome of previous pregnancies.

Perform and interpret an ultrasound examination to screen for placental disease: Uterine artery Doppler Placental morphology.

Manage a case at risk of poor placentation based on previous history or positive screening: Arrange appropriate investigations Institute, where appropriate, prophylactic therapy.

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4.3 Fetal Growth Disorders Clinical Competency Objective Take an appropriate history and perform an To be able to carry out appropriate assessment and examination to screen for fetal growth disorders, management of the small-for-gestational including use of customised growth chart. age(SGA)/growth restricted fetus. Perform and interpret the following: To be able to understand the management, Ultrasound morphometry complications and outcomes of growth-restricted Umbilical artery Doppler neonates. Middle cerebral artery Doppler Ductus venosus Doppler To be able to carry out appropriate assessment and (including amniotic fluid management fetal macrosomia. volume, CTG).

To understand the management, complications and Manage a case of SGA /FGR: outcome of neonates with growth disorders. Arrange appropriate investigations to identify cause Knowledge Criteria Institute appropriate monitoring Fetal growth: Plan time and mode of delivery, including termination of pregnancy, where appropriate. Pattern, including organ-specific growth Regulation, including insulin, IGF system Manage a case of LGA/macrosomia: Causes, including fetal, placental and maternal Arrange appropriate investigations to identify factors. cause Plan time/mode of delivery. Definitions: SGA/fetal growth restriction (FGR) Professional Skills and Attitudes Large-for-gestational age (LGA)/macrosomia. Ability to take an appropriate history and conduct an Screening and diagnosis: examination to assess fetal size. Previous history Clinical examination, including symphysis fundal Ability to perform and interpret ultrasound in fetus distance with suspected growth disorder. Ultrasound morphometry: basic and derived measurements, including estimated fetal weight Ability to formulate, implement and, where Customised growth charts. appropriate, modify a management plan and to liaise, where appropriate, with neonatologists. Tests of fetal wellbeing: Technique, indications for and interpretation of: Ability to counsel women and their partners about: o Doppler (umbilical artery, middle cerebral Fetal and neonatal risks, including artery, ductus venosus consideration, where appropriate, of termination o Amniotic fluid volume of pregnancy o (including computerised Long-term health implications for infant analysis) Recurrence risks and management plan for o Biophysical profile. future pregnancy.

Management: Training support Strategy for monitoring Timing/mode of delivery Observation of and discussion with senior medical staff Management of FGR in previable/extremely preterm fetus and in multiple pregnancy. Attachments in neonatology. Attendance at paediatric follow-up clinics, Outcome: including neurodevelopment. Neonatal complications of SGA/LGA infant Personal study. Long-term health implications of fetal growth disorders. Evidence Log of experience and competence Mini-CEX OSATS (Arterial and Venous Dopplers in Fetal Growth Restriction)

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4.4 Antepartum Haemorrhage Professional Skills and Attitudes Objective Ability to take an appropriate history and conduct an To be able to carry out appropriate assessment and examination to assess APH. management of women at risk of and presenting with antepartum haemorrhage (APH). Ability to perform and interpret appropriate investigations to assess cause and consequences of Knowledge Criteria APH. Pathophysiology: Ability to formulate, implement and, where Placental abruption appropriate, modify a management plan and to liaise Placenta praevia with anaesthetists, haematologists and radiologists, Other causes, including vasa praevia where appropriate. Morbidly adherent placenta. Ability to counsel women and their partners about: Epidemiology: Maternal and fetal risks Incidence Recurrence risks. Risk factors. Training support Screening and diagnosis: Observation of and discussion with senior Risk factors, including previous caesarean medical staff. section Appropriate postgraduate courses. Ultrasound determination of placental site, including transvaginal ultrasound Attachment in: o haematology Management: o anaesthesia/ITU. Clinical and laboratory assessment of: Personal study. o haemorrhage o coagulation Evidence Assessment of fetal wellbeing (see 4.3) Log of experience and competence Strategy for monitoring Mini-CEX Timing and mode of delivery OSAT ( for placenta praevia) Appropriate use of blood and blood products (see 5.7).

Clinical Competency Take an appropriate history from a woman with APH.

Perform an examination to assess the cause and consequences of APH.

Perform an ultrasound examination to assess: Placental site Morphology, including retroplacental haemorrhage and abnormal implantation.

Manage a case of APH, including; Arrange and interpret appropriate laboratory investigations Plan mode and timing of delivery Appropriate use of blood and blood products

Manage a case of suspected morbidly adherent placenta: Arrange appropriate investigations Plan caesarean section (see 5.7).

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4.5 Preterm delivery Clinical Competency Objective Take an appropriate history from a woman at risk of, To be able to carry out appropriate assessment and or presenting with, preterm labour/PPROM. management of women with previous preterm birth and preterm prelabour rupture of membranes Manage a case of prior preterm birth/PPROM. (PPROM). Arrange and interpret appropriate investigations.

To be able to carry out appropriate assessment and Manage a case of PPROM: management of women with preterm labour/PPROM. Confirm diagnosis Arrange and interpret investigations and fetal To understand the management, complications and monitoring outcome of the preterm neonate. Institute and modify antibiotic therapy.

Knowledge Criteria Manage a case of preterm labour: Assess likelihood of preterm birth, including Pathophysiology and epidemiology: Where appropriate measurement of cervical Preterm labour length and PPROM, including acute chorioamnionitis (see Arrange and interpret appropriate investigations 6.16) and fetal monitoring Maternal and fetal conditions leading to elective Institute corticosteroid with or without tocolysis preterm delivery Arrange in-utero transfer Epidemiology of preterm labour/PPROM. Plan delivery. Screening and diagnosis: Professional Skills and Attitudes Risk factors Clinical examination Ability to take an appropriate history. Fetal fibronectin Cervical length (see 4.1) Ability to perform and interpret appropriate Vaginal infection, including bacterial vaginosis investigations, formulate, implement and, where (see 6.14) appropriate, modify a management plan. C-reactive protein. Ability to manage corticosteroid, tocolytic and other Management: therapy, to arrange in-utero transfer and to liaise with In-utero transfer (principles and process) neonatologists. Tocolysis, corticosteroid and antibiotic administration Ability to counsel women and their partners about: Mode of delivery Maternal risks, including chorioamnionitis Strategy for monitoring in PPROM, including Fetal and neonatal risks, including risks of laboratory investigations, ultrasound and consideration, where appropriate, of termination of pregnancy Acute chorioamnionitis (see 6.16). Adverse effects of therapy Pharmacology, including adverse effects: Long-term health implications for infant Corticosteroids (for lung maturity) Recurrence risks and management plan for Sympathomimetics, nifedipine, atosiban, future pregnancy. indomethacin Progesterone Training support Erythromycin (see also 6.16). Observation of and discussion with senior medical staff. Outcome: Appropriate postgraduate courses. Neonatal complications of preterm birth, Attachment in neonatology. including. jaundice, respiratory distress Attendance at paediatric follow-up clinics, syndrome, retinopathy of prematurity, including neurodevelopment. intraventricular haemorrhage, persistent fetal Personal study. circulation) Long-term health implications of preterm birth Personal Study Evidence (including chronic lung disease, neurodevelopmental delay, cerebral palsy) Log of experience and competence Mini-CEX Case-based discussions.

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4.6 Multiple pregnancy Professional Skills and Attitudes Ability to perform and interpret appropriate Objective investigations. To be able to carry out appropriate assessment and management of women with a twin pregnancy. Ability to formulate, implement and, where appropriate, modify a management plan in To be able to carry out appropriate assessment and monochorionic and dichorionic twin pregnancy. management of a woman with a higher-order multiple pregnancy. Ability to liaise, where appropriate, with colleagues in fetal medicine and neonatology. Knowledge Criteria Ability to counsel women with multiple pregnancy and Embryology and epidemiology: their partners about: Mono- and dizygous twinning Maternal and fetal risks in both monochorionic Placentation: chorionicity and amnionicity and dichorionic twins Incidence of multiple pregnancy. Prenatal diagnosis Selective feticide and fetal reduction Maternal adaptation and antenatal care: Maternal and fetal risks of interventions in Blood and cardiovascular system monochorionic twins Other organ systems Fetal and neonatal risks of preterm birth Organisation of antenatal care. Fetal death, including empathy in bereavement support, consent for postmortem. Screening and diagnosis: Ultrasound determination of zygosity/chorionicity Training support (see 3.7) Aneuploidy (see 2.2) Observation of and discussion with senior Structural anomaly (see 3.7) medical staff. Morphometry, including criteria for discordancy. Appropriate postgraduate courses. Attachment in neonatology. Management and outcome: Attendance at: Preterm delivery (see 4.5) o multiple pregnancy clinic Discordant fetal anomaly (see 3.7) o fetal medicine unit (to witness interventions Discordant growth/FGR (see 4.3) in monochorionic twins). Single fetal death Personal study. Complications of monochorionic twinning (see 3.7) Personal Study Evidence Higher-order multiple pregnancy (including fetal Log of experience and competence reduction). Mini-CEX Case-based discussions. Clinical Competency Perform and interpret ultrasound screening and diagnosis in multiple pregnancy; Chorionicity and amnionicity Aneuploidy, including nuchal translucency

Manage a case of twin pregnancy complicated by: Discordant fetal anomaly (see 3.7) Fetal growth restriction/discordancy (see 4.3) Single fetal death Monoamniotic twinning Including: o arrange appropriate investigations o institute appropriate monitoring o plan time and mode of delivery.

Manage a higher-order multiple pregnancy including: Arrange appropriate investigations Perform fetal reduction or refer, where appropriate, for same

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4.7 Malpresentation Ability to counsel women and their partners about: Risks and benefits of ECV Objective Management options Mode of delivery. To be able to carry out appropriate assessment and management of women with a breech presentation. Training Support To be able to carry out appropriate assessment and Observation of and discussion with senior management of a woman with an unstable lie. medical staff. Appropriate postgraduate courses. Knowledge Criteria Personal study. Epidemiology and aetiology: Evidence Incidence Likelihood of spontaneous version Log of experience and competence Risk factors. Mini-CEX OSATS (ECV) Screening and diagnosis: Clinical examination Ultrasound, including diagnosis of associated anomalies.

Management and outcome: External cephalic version, including Indications, technique, complications (see 4.5 re: tocolysis) Management options in breech presentation, including Induction of labour/caesarean section/attempted vaginal breech delivery (see 5.4) Management options in unstable lie (including Induction of labour/caesarean section Fetal/neonatal risks.

Clinical Competency Take an appropriate obstetric history.

Perform an examination to determine fetal lie.

Manage a case of breech presentation including: Ultrasound diagnosis, including exclusion of fetal, placental and extra-uterine anomalies Appropriate selection and counselling of cases for external cephalic version (ECV) Perform ECV.

Manage a case of unstable lie including; Ultrasound diagnosis, including exclusion of fetal, placental and extrauterine anomalies

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to assess fetal lie/presentation.

Ability to perform and interpret ultrasound in fetus with suspected breech presentation/unstable lie.

Ability to formulate, implement and where appropriate modify a management plan, including timing and mode of delivery and to perform ECV.

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4.8 Red Cell Alloimmunisation Manage a case of red cell alloimmunisation: Institute appropriate maternal and fetal Objective monitoring Assess risk of fetal anaemia, including perform To understand the principles and practical aspects of and interpret MCA Doppler screening for and prevention of red cell Perform fetal blood sampling and transfusion or alloimmunisation. refer, where appropriate, for same Plan mode and place and timing of delivery. To be able to carry out appropriate assessment and management of a woman with an unstable lie. Professional Skills and Attitudes To understand the management, complications and Ability to take an appropriate history. outcome of a neonate with haemolytic disease of the newborn (HDN). Ability to perform and interpret appropriate investigations in fetus at risk of haemolytic anaemia, Knowledge Criteria including MCA Doppler.

Blood group systems/pathophysiology: Ability to formulate, implement and, where Rhesus, including gene structure and prediction appropriate, modify a management plan for a woman of genotype with red cell antibodies. Other red cell antigens causing HDN Fetal pathology in HDN (see also 3.8). Ability to liaise with neonatologists and laboratory (haematology/blood transfusion). Epidemiology: Incidence (alloimmunisation and complications) Ability to counsel women and their partners about: Risk factors (sensitising events). Prevention of alloimmunisation Fetal and neonatal risks of red cell antibodies Laboratory methods: Fetal transfusion therapy Antibody detection (antiglobulin tests) Recurrence risks and management plan for Kleihauer testing/flow cytometry for fetomaternal future pregnancy. haemorrhage fetomaternal haemorrhage DNA analysis, including use of free fetal DNA in Training Support maternal plasma. Observation of and discussion with senior Prevention of fetomaternal haemorrhage. medical staff. Appropriate postgraduate courses. Organisation and effectiveness of screening and Attachments: prevention programmes. o Neonatology o Haematology Management: o Blood transfusion. Screening and diagnosis fetal anaemia Attendance at fetal medicine unit (to witness (including MCA Doppler) fetal blood sampling/transfusion). Fetal transfusion therapy Personal study. Hydrops (see 3.8). Evidence Outcome: Neonatal complications of HDN, including Log of experience and competence Hyperbilirubinaemia, anaemia Mini-CEX Management of complications, including OSATS (ECV) Exchange transfusion Long term implications of HDN.

Pharmacology: Anti-D immunoglobulin.

Clinical Competency Take an appropriate obstetric history: Past obstetric history Timing and method of sensitisation.

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4.9 Platelet Alloimmunisation Ability to formulate, implement and, where appropriate, modify a management plan for a woman Objective with anti-platelet cell antibodies and to liaise with neonatologists and laboratory (haematology/blood To be able to carry out appropriate assessment and transfusion), management of a woman with an unstable lie. Ability to counsel women and their partners about: To understand the management, complications and Fetal and neonatal risks outcome of a neonate with alloimmune Maternal and fetal therapy thrombocytopenia (AIT). Recurrence risks and management plan for future pregnancy. Knowledge Criteria Platelet groups/pathophysiology: Training Support human platelet antigen system Observation of and discussion with senior Fetal and neonatal pathology in AIT. medical staff. Appropriate postgraduate courses. Epidemiology: Attachments: Incidence (alloimmunisation and complications). Neonatology Haematology Laboratory methods: Blood transfusion. Antibody detection Attendance at fetal medicine unit (to witness DNA analysis. fetal blood sampling/transfusion). Personal study. Management: Assessment of risk of fetal haemorrhage Evidence Diagnosis of fetal thrombocytopenia Therapy options (maternal immunoglobulin Log of experience and competence therapy/fetal transfusion therapy). Mini-CEX OSATS (ECV) Outcome: Neonatal complications of AIT Management of AIT, including platelet transfusion Long-term implications of AIT.

Pharmacology: Intravenous immunoglobulin, including effectiveness and adverse effects.

Clinical Competency Take an appropriate obstetric history: Past obstetric history.

Manage a case of platelet alloimmunisation: Institute appropriate maternal and fetal monitoring Assess risk of fetal thrombocytopenia Institute, where appropriate, maternal intravenous immunoglobulin therapy Perform fetal blood sampling and platelet transfusion or refer, where appropriate, for same Plan mode, place and timing of delivery.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to perform and interpret appropriate investigations in fetus at risk of thrombocytopenia.

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4.10 Gynaecological Problems in Ability to perform and interpret ultrasound in women Pregnancy with a pelvic tumour. Ability to formulate, implement and, where Objective appropriate, modify a management plan for a woman To be able to carry out appropriate assessment and with a pelvic tumour in pregnancy. management of a woman with a pelvic tumour complicating pregnancy. Ability to liaise, where appropriate, with gynaecologists, gynaecological oncologists and Knowledge Criteria general surgeons.

Pathology: Ability to counsel women and their partners about: Uterine fibroids Maternal and fetal risks Ovarian tumours (benign and malignant) Management options Complications encountered during pregnancy Prognosis. (see 6.17). Training Support Epidemiology: Incidence of pelvic tumours and complications Observation of and discussion with senior Acute abdomen in pregnancy. medical staff. Appropriate postgraduate courses. Diagnosis: Personal study. Ultrasound diagnosis, including assessment of risk of malignancy Evidence Complications, including differential diagnosis of acute abdomen in pregnancy (see 6.17). Log of experience and competence Mini-CEX Management: Case-based discussions Indications for surgical intervention Analgesia (see 5.10) Anaesthesia (see 5.10) Role of radiotherapy and chemotherapy in ovarian malignancies.

Clinical Competency Take an appropriate obstetric and gynaecological history.

Manage a case of pelvic tumour in pregnancy: Perform ultrasound assessment of and ovaries/pelvic mass Institute appropriate maternal and fetal monitoring Institute, where appropriate, maternal supportive therapy Perform, under supervision, surgical management of ovarian cyst Plan mode, place and timing of delivery.

Manage a case of acute abdomen in pregnancy: Arrange appropriate investigations to identify cause Refer, where appropriate, for further management.

Professional skills and attitudes Ability to take an appropriate history and perform an examination in a woman with a pelvic mass or abdominal pain in pregnancy.

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Module 5 Intrapartum Complications

5.1 Labour Ward Management Ability communicate effectively with: Junior medical staff Objective Senior medical staff Midwifery staff To understand the organisation and management of Patients and relatives the delivery suite. Obstetric anaesthetists. Neonatologists. To understand and apply the principles of risk management in the delivery suite. Training Support Knowledge Criteria Observation of and discussion with senior medical staff. Organisation and management of labour ward: Appropriate postgraduate courses (e.g. Staffing structure Management of the Labour Ward, ALSO/MOET) Equipment Attendance at: Delivery suite forum o risk management forum Emergency skills and drills o delivery suite forum. Guidelines Personal study. Audit, including collection and analysis of delivery suite workload. Evidence Risk management on the labour ward: Log of experience and competence Principles of risk management OSATS Critical incident reporting. Case-based discussion.

Clinical Competency Coordinate the clinical running of the labour ward at a daily level including: Staff allocation Appropriate triaging of clinical cases.

Write an evidence-based guideline relevant to the labour ward.

Lead an emergency drill on the labour ward: Set up and running of drill Feedback to staff.

Investigate a critical incident: Review the case Take appropriate statements Perform root cause analysis Write a report.

Professional Skills and Attitudes Ability to lead a multidisciplinary team effectively.

Ability to coordinate the delivery suite appropriately.

Ability to write an evidence-based guideline relevant to the delivery suite.

Ability to set up, run and feedback on an emergency drill and investigate a critical incident appropriately and make recommendations.

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5.2 Failure to Progress in Labour Perform: Manual rotation Objective Ventouse (rotational and non-rotational) Forceps (outlet and mid-cavity) To understand the physiology of normal labour and Kielland forceps the factors that can adversely affect progress. Caesarean section training support. To be able to carry out appropriate assessment and management of women with failure to progress in Professional Skills and Attitudes first stage and second stage of labour. Ability to take an appropriate history.

Knowledge Criteria Ability to perform and interpret abdominal/pelvic examination. Anatomy and physiology: Anatomy of and fetal skull Ability to formulate, implement and, where Regulation of myometrial contractility appropriate, modify a management plan. Stages of labour. Ability to liaise, where appropriate, with anaesthetists and neonatologists. Pathophysiology, including causes and consequences of poor progress in labour: Ability to counsel women and their partners about: Inefficient uterine action Management Malposition Maternal and fetal risks. Relative and absolute cephalopelvic disproportion Training Support Fetal acid base status Postpartum uterine atony. Observation of and discussion with senior medical staff. Management: Appropriate postgraduate courses e.g. Maternal support Management of the Labour Ward, ALSO/MOET. Amniotomy Attachments in: Mobilisation/position o Obstetric anaesthesia Analgesia (see 5.10) o Neonatology. Oxytocin Royal College of Obstetricians and Manual rotation Gynaecologists. Operative Vaginal Delivery. Green-top Guideline No. 26. Instrumental vaginal delivery National Collaborating Centre for Women’s and Caesarean section. Children’s Health. Caesarean Section. (Clinical Guideline). Pharmacology, including adverse effects: Personal study. Oxytocin.

Clinical Competency Evidence Take an appropriate history and perform an Log of experience and competence examination to assess progress in labour. Mini-CEX Case-based discussion Manage a case of failure to progress in the first stage of labour: Perform examination to identify cause, e.g. Inefficient uterine activity, malposition, cephalopelvic disproportion (relative and absolute) Counsel regarding management Institute appropriate management, including delivery, where appropriate.

Manage a case of failure to progress in the second stage of labour: Perform examination to identify cause Counsel regarding management Institute appropriate management.

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5.3 Non-reassuring Fetal Status in Perform: Labour CTG interpretation Fetal blood sampling Objective ECG waveform analysis Ultrasound assessment of amniotic fluid volume To be able to carry out appropriate assessment and (see 4.3) management of fetal acidaemia in labour. Intrapartum amnioinfusion.

To understand the management, complications and Professional Skills and Attitudes outcomes of hypoxic ischaemic encephalopathy. Ability to take an appropriate history. Knowledge Criteria Ability to perform and interpret investigations to Pathophysiology: assess fetal status in labour. Regulation of fetal heart rate Fetal acid base balance Ability to formulate, implement and, where Hypoxic ischaemic encephalopathy (HIE). appropriate, modify a management plan.

Fetal monitoring in labour, including principles, Ability to liaise, where appropriate, with anaesthetists interpretation and predictive value of fetal: and neonatologists. Meconium Cardiotocography (CTG) Ability to counsel women and their partners about: ECG Maternal and fetal risks Pulse oximetry Management options Ph, blood gases and lactate Long-term health implications for infant. Oligohydramnios. Training Support Management: Observation of and discussion with senior Position/oxygen therapy medical staff. Acute tocolysis Appropriate postgraduate courses, e.g. Amnioinfusion Management of the Labour Ward, ALSO/MOET. Emergency operative delivery. Attachments in: Obstetric anaesthesia Pharmacology, including adverse effects: Neonatology Terbutaline/ritodrine. Attendance at neonatal follow-up clinics Outcome: RCOG. The Use of Electronic Fetal Monitoring. Neonatal complications of HIE, including National Evidence-based Guideline No. 8. seizures, abnormal neurological function, organ National Collaborating Centre for Women’s and failure Children’s Health. Caesarean Section. (Clinical Long-term health implications of HIE, including Guideline). Cerebral palsy. Personal study.

Clinical Competency Evidence Take an appropriate history. Log of experience and competence Mini-CEX Manage a case of suspected and confirmed fetal Case-based discussions. acidaemia in labour: OSATS Arrange appropriate investigations to confirm fetal acidaemia Counsel regarding fetal/neonatal risks and management options Institute, where appropriate, in utero resuscitation/emergency delivery.

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5.4 Non-Reassuring Fetal Status in Manage a case of transverse lie in labour: Labour Counsel regarding management Institute appropriate management. Objective Perform: To be able to carry out appropriate assessment and ECV in labour, including breech, transverse lie management of women with multiple pregnancy in and second twin labour. Vaginal breech delivery Breech extraction To be able to carry appropriate assessment and Internal . management of women with breech and transverse lies diagnosed in labour. Professional Skills and Attitudes Knowledge Criteria Ability to take an appropriate history.

Epidemiology and aetiology: Ability to perform and interpret investigations to Incidence confirm fetal lie in labour. Predisposing factors. Ability to formulate, implement and, where Intrapartum care in twins: appropriate, modify a management plan. Physiology of labour Fetal monitoring Inter-twin interval Ability to perform vaginal breech delivery and twin Effects of chorionicity. delivery.

Diagnosis and management: Ability to liaise, where appropriate, with anaesthetists Clinical exam and neonatologists. Ultrasound Risks and benefits of caesarean section in: Ability to counsel women and their partners about: o breech presentation Maternal and fetal risks o transverse/oblique lie Management options, including mode of o twin and higher order multiple pregnancy delivery. (see 4.6) Breech delivery: Training Support o manoeuvres (assisted breech delivery and Observation of and discussion with senior breech extraction) medical staff. o complications, including problems with after coming head Appropriate postgraduate courses e.g. Management of the Labour Ward; ALSO/MOET. Twin delivery: o external cephalic version (ECV) for second Attachments in: o twin (see (4.7) obstetric anaesthesia o o artificial rupture of membranes/oxytocin in neonatology. second stage RCOG. Management of Breech Presentation. o operative delivery second twin. Green-top Guideline No. 20 Personal study Clinical Competency Evidence Take an appropriate history. Log of experience and competence Manage a case of twin pregnancy in labour: Mini-CEX Arrange and interpret fetal monitoring Case-based discussions. Counsel regarding management OSATS Institute appropriate management.

Manage a case of breech presentation in labour: Arrange and interpret fetal monitoring Counsel regarding management, including risks and benefits of caesarean section Institute appropriate management.

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5.5 Ability to counsel women and their partners about: Objective Maternal and fetal risks Long-term health implications of birth trauma To be able to carry out appropriate assessment and Recurrence risks and management plan for management of women with shoulder dystocia. future pregnancy.

To understand the management, complications and Training Support outcomes of neonates with birth trauma. Observation of and discussion with senior Knowledge Criteria medical staff. Appropriate postgraduate courses e.g. Epidemiology and aetiology: Management of the Labour Ward; ALSO/MOET Incidence Attachments in: Predisposing factors o obstetric anaesthesia Risks of recurrence o neonataology. Attendance at: Management: o Neonatal follow-up clinics Clinical o Paediatric orthopaedic clinics. Fire drill procedures, e.g. HELPERR RCOG. Shoulder Dystocia. Green-top Guideline Advanced manoeuvres, including Indications, No. 42. procedure and risks of: Personal study. o Zavanelli manoeuvre o . Evidence Outcome: Log of experience and competence Neonatal complications of birth trauma, including Mini-CEX intraventricular haemorrhage, bone fractures, Case-based discussions. brachial plexus injury, hypoxic-ischaemic OSATS encephalopathy Management of complications Long-term outcome.

Clinical Competency Take an appropriate history.

Manage a case of shoulder dystocia: Institute and document appropriate management Perform: o McRoberts’ manoeuvres and suprapubic pressure o Internal rotation of shoulders Removal of posterior arm.

Manage a case of previous shoulder dystocia: Assess recurrence risk Arrange appropriate investigations Counsel regarding maternal and fetal risks Plan mode and timing of delivery.

Professional Skills and Attitudes Ability to take an appropriate history

Ability to formulate, implement and document a management plan for shoulder dystocia.

Ability to perform manoeuvres to achieve delivery in shoulder dystocia.

Ability to liaise, where appropriate, with anaesthetists/neonatologists.

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5.6 Genital Tract Trauma Perform: Repair of third- or fourth-degree perineal tear Objective Repair of uterine rupture Hysterectomy (see 5.7). To be able to carry out appropriate assessment and management of a woman with a third- or fourth- Professional Skills and Attitudes degree perineal tear. Ability to take an appropriate history. To be able to carry out appropriate assessment and management of a woman with a uterine rupture. Ability to: Diagnose presence and extent of genital tract Knowledge Criteria trauma Formulate, implement and where appropriate, Anatomy and physiology: modify a management plan Perineum and pelvic floor Perform appropriate surgical repair Anal sphincter function. Liaise, where appropriate, with gynaecologists and surgeons Epidemiology and aetiology: Arrange appropriate follow up Incidence Counsel women and their partners about: Predisposing factors. o Maternal and fetal risks o Long-term health implications Diagnosis and management: o Recurrence risks and management plan for Clinical examination future pregnancy. Ultrasound (endoanal) Surgical repair Training Support Anal sphincter Cervix/uterus Observation of and discussion with senior Postpartum haemorrhage (see 5.7) medical staff Appropriate postgraduate courses, e.g. Outcome: Management of the Labour Ward; ALSO/MOET Long-term health implications, including pain, Attendance at pelvic floor clinic incontinence RCOG. The Management of Third- and Fourth- Implications for future pregnancy. degree Perineal Tears. Green-top Guideline No. 29. Clinical Competency Personal study.

Take an appropriate history Evidence Manage a case of third- or fourth-degree perineal Log of experience and competence tear (see also 5.7): Mini-CEX Assess type of tear Case-based discussions. Counsel regarding management OSATS Institute appropriate management, including Surgical repair Plan appropriate follow-up.

Manage a case of prior third- or fourth-degree perineal tear: Arrange and interpret appropriate investigations, including endoanal ultrasound Counsel regarding management options Plan mode of delivery.

Manage a case of uterine rupture (see also 5.7): Assess maternal and fetal condition Counsel regarding management Institute appropriate management, including emergency caesarean section, repair of uterus.

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5.7 Postpartum Haemorrhage and Other Perform: Third-stage Problems Manual removal of placenta Correction of uterine inversion (manual and Objective hydrostatic replacement) Insertion of uterine balloon catheter To be able to carry out appropriate assessment and Insertion of brace suture management of a woman with a massive postpartum Internal iliac ligation/hysterectomy (under haemorrhage (PPH). supervision) or refer, where appropriate, for same. To be able to recognise and manage complications of the third stage of labour. Professional Skills and Attitudes Knowledge Criteria Ability to: Rapidly assess extent of haemorrhage and Anatomy: institute appropriate resuscitative measures Pelvic anatomy and blood supply. Formulate, implement and, where appropriate, modify a management plan Epidemiology and aetiology of PPH Perform appropriate surgical intervention Incidence Liaise, where appropriate, with gynaecologists, Predisposing factors, including adherent haematologists and radiologists. placenta, uterine inversion. Counsel women and their partners about: o Management options and maternal risks Laboratory methods: o Recurrence risks and management plan for Diagnosis and monitoring of disseminated future pregnancy debrief family and staff. intravascular coagulation (see 1.11) Crossmatching Training Support

Management of massive PPH: Observation of and discussion with senior Maternal resuscitation, including use of: medical staff o crystalloid/colloid iv fluids Appropriate postgraduate courses, e.g. o blood and blood products Management of the Labour Ward; ALSO/MOET Medical management (see below) Attachment in: Surgical management o Anaesthesia Intrauterine balloon o Intensive Care Brace suture o Haematology Internal iliac ligation o Blood transfusion. Hysterectomy Personal study. Interventional radiology (vascular balloons and coils). Evidence Log of experience and competence Pharmacology, including adverse effects of drugs Mini-CEX used in PPH: Case-based discussions. Oxytocin, ergometrine OSATS 15 methyl prostaglandin F2 Fire drill Misoprostol Recombinant factor VIIa.

Clinical Competency Manage a case of massive PPH: Assess blood loss and consequences Undertake resuscitation (see 5.10) Ascertain cause of haemorrhage Arrange and interpret appropriate investigations Counsel regarding management options Institute and modify appropriate medical and/or surgical management for: o uterine atony o inverted uterus o adherent placenta

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5.8 Caesarean Section Perform caesarean section using the appropriate surgical technique in the following circumstances: Objective Major placental praevia Morbidly adherent placenta (see 4.4) To be able to carry out appropriate assessment and Fetal anomaly likely to cause dystocia management of a woman with a previous caesarean Extreme prematurity section. Extensive prior abdominal surgery.

To plan and perform caesarean section in special Manage complications of caesarean section, under circumstances. supervision where appropriate: Extension of uterine incision Knowledge Criteria Haemorrhage (see 5.7) Epidemiology: Visceral damage Risks of caesarean section: Wound dehiscence o visceral damage Infection o infection Venous thrombosis. o venous thrombosis Risks associated with previous caesarean Professional Skills and Attitudes section: o uterine rupture Ability to take an appropriate history. o abnormal placentation Vaginal birth after caesarean section (VBAC): Ability to counsel women and their partners about the o success rates risks of emergency and elective caesarean section. o complication rates. Ability to perform and interpret appropriate Diagnosis: investigations in women undergoing caesarean section. Ultrasound determination of placental site (see 4.4). Ability to formulate, implement and, where appropriate, modify a management plan for a woman Management: undergoing caesarean section. CS Surgical technique, including abdominal wall and Ability to perform caesarean section using the uterine entry/closure appropriate surgical technique. Prevention of complications, including thrombosis, infection Ability to liaise with anaesthetists, haematologists, Impact of following conditions: neonatologists and radiologists, where appropriate. o placenta praevia o morbidly adherent placenta Ability to counsel women with a prior caesarean o fetal anomaly section about options (caesarean section vs. VBAC). o extreme prematurity o prior abdominal surgery. Training Support VBAC, including: o use of oxytocics Observation of and discussion with senior o role of induction of labour medical staff o fetal monitoring (see 5.3). Appropriate postgraduate courses, e.g. Management of the Labour Ward; ALSO/MOET Clinical Competency Attachment in anaesthesia NCCWCH. Caesarean Section. Clinical Take an appropriate history. Guideline. Personal study. Manage a case of previous caesarean section: Arrange appropriate investigations Evidence Counsel regarding management options and fetal and maternal risks Log of experience and competence Plan mode and timing of delivery. Mini-CEX Case-based discussions OSATS

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5.9 Anaesthesia and Analgesia Ability to formulate, implement and, where appropriate, modify a analgesia/anaesthesia Objective management plan. To understand the methods, indications for and Ability to liaise with anaesthetists. complications of anaesthesia. Training Support To understand the methods, indications for and complications of systemic analgesia and sedation. Observation of and discussion with senior medical staff. Knowledge Criteria Appropriate postgraduate courses, e.g. Management of the Labour Ward; ALSO/MOET. Anatomy and physiology: Attachment in anaesthesia. Spinal cord Personal study. Innervation of pelvic organs Pain. Evidence Management: Log of experience and competence Pain management during labour: Mini-CEX o nonpharmacological techniques Case-based discussions o inhalational analgesia OSATS o systemic analgesia (opioids) Regional analgesia and anaesthesia, including Techniques and complications: o pudendal o epidural o spinal General anaesthesia, including techniques and complications Analgesia and anaesthesia in women at high risk of complications, including hypertensive disease, cardiac disease and fetal growth restriction.

Pharmacology: Opioid analgesia Local anaesthesia General anaesthesia Phenylephrine/ephedrine.

Outcome: Effects of neuraxial anaesthesia on: o labour outcome o temperature o fetal wellbeing.

Clinical Competency Counsel women about the different forms of analgesia and anaesthesia, including efficacy and risks.

Perform pudendal nerve block.

Professional Skills and Attitudes Ability to counsel women and their partners about efficacy and risks of different methods of analgesia for labour.

Ability to counsel women and their partners about efficacy and risks of different methods of anaesthesia for assisted vaginal delivery and caesarean section.

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5.10 Resuscitation Perform neonatal resuscitation: Objective Mask ventilation Endotracheal intubation To be able carry out appropriate assessment and Cardiac massage. management of maternal collapse, including cardiac arrest. Professional Skills and Attitudes To be able to carry out appropriate assessment and Ability to rapidly assess maternal collapse and management of the depressed neonate. institute resuscitative measures.

Knowledge Criteria Ability to work effectively as part of a multidisciplinary team. Pathophysiology: Hypovolaemia Ability to formulate, implement and where appropriate Pulmonary embolism (see 1.12) modify a management plan in maternal Amniotic fluid embolism collapse/cardiac arrest. Primary cardiac event (see 1.3) Trauma Ability to liaise with physicians, anaesthetists and Cerebrovascular event neonatologists. Electrocution Neonatal depression. Ability to debrief family and staff.

Epidemiology: Ability to perform effective neonatal resuscitation. Maternal collapse (causes and risk factors) Neonatal depression. Training Support Observation of and discussion with senior Management: medical staff. Maternal resuscitation: Appropriate postgraduate courses, e.g. o respiratory management, including basic Management of the Labour Ward; ALSO/MOET. airway management, indications for Attachment in: intubation, ventilation o anaesthesia o circulatory management, including cardiac o neonatology. massage, defibrillation o fluid management (see 5.7) Personal study. Indications for perimortem caesarean section Principles neonatal resuscitation: Evidence o respiratory depression/apnoea Log of experience and competence o bradycardia/cardiac arrest Mini-CEX o meconium aspiration. Case-based discussions Fire drill Pharmacology: Oxygen Adrenaline (epinephrine) Sodium bicarbonate Atropine.

Clinical Competency Manage a case of maternal collapse: Ascertain cause of collapse Undertake resuscitation (as part of a multidisciplinary team) Institute and modify appropriate medical management for: o pulmonary embolism o amniotic fluid embolism o cardiac arrhythmia Arrange appropriate investigations Perform (under supervision) perimortem caesarean section or refer, where appropriate, for same

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5.11 Medical Disorders on the Labour Monitor renal function and respond where Ward appropriate by adjusting fluid balance or with drugs Objective Use anticonvulsants effectively. To be able carry out appropriate intrapartum and Manage a case of sickle cell disease during labour immediate postpartum assessment and management (see 1.11): of women with medical disorders. Counsel regarding management and risks Optimise hydration, oxygenation, analgesia Knowledge Criteria Manage sickle crisis, including fluids, oxygen, antibiotics and analgesics. Pathophysiology, including the effect of labour and delivery on the following diseases: Manage a case of HIV in labour (see 6.2): Diabetes Plan mode of deliver Cardiac and respiratory abnormalities Institute intravenous zidovudine therapy. Haemoglobinopathies Thrombotic and haemostatic abnormalities Professional Skills and Attitudes Epilepsy Severe pre-eclampsia/eclampsia Ability to take an appropriate history and conduct an Renal disease appropriate examination in a woman with a medical Hypertension disorder. HIV Sepsis. Ability to formulate, implement and, where appropriate, modify a medical management plan for Management: labour and delivery. Maternal monitoring: o blood glucose Ability to liaise with physicians, anaesthetists and o respiratory function, including respiratory neonatologists. rate, SaO2, blood gases o cardiovascular function, including blood Ability to counsel women and their partners about pressure, heart rate, cardiac output management options in labour risks of medical o renal function, including urine output, therapies. creatinine Analgesia and anaesthesia (see 5.9). Training Support Observation of and discussion with senior Pharmacology: medical staff. Effects of drugs used to treat above conditions Appropriate postgraduate courses, e.g. on course and outcome of labour Management of the Labour Ward; ALSO/MOET. Effects of drugs used in management of labour Attachment in: (e.g. oxytocin, Syntometrine) on above o Anaesthesia conditions o Neonatology. Effects of analgesics and anaesthetics on the Attendance at medical clinics. above conditions. Personal study.

Clinical Competency Evidence Take and appropriate history and perform an Log of experience and competence examination to assess medical disorder. Mini-CEX Manage a woman with a medical disorder in labour, Case-based discussions including: Monitor blood glucose and maintain euglycaemia (see 1.7) using intravenous glucose and insulin Monitor cardiorespiratory function and maintain oxygenation and cardiac output (see 5.11) Monitor abnormal blood clotting and respond, including therapeutic intervention Monitor blood pressure and, where appropriate, treat hypertension (see 1.1)

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5.12 Intensive Care Professional skills and attitudes Objective Ability to take an appropriate history and conduct an To understand the organisation and role of high appropriate examination in a critically ill woman. dependency and intensive care. Ability to perform and interpret investigations to To understand the indications for and methods of diagnose and monitor organ failure. invasive monitoring. Ability to formulate, implement and, where To understand the management of organ failure. appropriate, modify a management plan, including transfer to high-dependency/intensive care unit. Knowledge Criteria Ability to liaise with intensivists, physicians, Organisation: anaesthetists and neonatologists. Structure and organisation of: o High-dependency care Ability to counsel women and their partners about: o intensive care Management options, including therapeutic Role of outreach teams interventions Indications for high-dependency and intensive Maternal and fetal risks. care in obstetrics. Ability to debrief family and staff. Management: Methods of invasive monitoring: Training Support o oxygenation/acid base o arterial pressure Observation of and discussion with senior o cardiac output, preload and contractility medical staff. Organ failure, including principles and Appropriate postgraduate courses, e.g. techniques of supportive therapy: Management of the Labour Ward; ALSO/MOET. o respiratory failure Attachment in: o cardiac failure o anaesthesia o renal failure o intensive care. o hepatic coagulation Attendance at medical clinics. o coagulation failure. Personal study.

Clinical Competency Evidence Take and appropriate history and perform an Log of experience and competence examination to assess a critically ill woman. Mini-CEX Case-based discussions Manage a woman with organ failure: Undertake resuscitation (see 5.10) Arrange and interpret appropriate investigations to confirm diagnosis/cause and monitor organ function Arrange transfer to high-dependency/intensive care unit and, where appropriate, arrange appropriate investigations.

Perform: Insertion of central venous pressure line Endotracheal intubation Insertion arterial line/PA catheter (under supervision) or refer, where appropriate, for same.

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MODULE 6 INFECTIOUS DISEASES

6.1 Human Immunodeficiency Virus (HIV) Institute, and where appropriate, modify anti- retroviral therapy (in collaboration with HIV Objective expert) Plan mode of delivery To be able to carry out appropriate assessment and Manage labour and delivery/caesarean section. management of women with HIV infection in pregnancy. Perform caesarean section in a woman with HIV infection. Knowledge Criteria Virology and epidemiology: Professional Skills and Attitudes HIV1 and 2 Ability to take an appropriate history. Natural history and viral dynamics Pathophysiology of HIV infection/AIDS Ability to counsel women: Mode and risk of transmission Before screening test Epidemiology of infection in pregnancy. After positive result.

Screening and diagnosis: Ability to formulate, implement and, where Rationale and organisation of screening appropriate, modify a management plan in HIV- programme positive women. Laboratory tests Screening, e.g. enzyme immunoassay Ability to liaise with HIV expert, multidisciplinary Diagnostic, e.g. Western blot team, neonatologists and GP. Referral pathways. Ability to counsel women and their partners about: Management: Management options Screening for coincident infection (genital Risks and benefits of anti-retroviral therapy infection, hepatitis) Long-term outcome for mother and infant. Laboratory monitoring: viral load/CD4 T- lymphocyte count Ability to respect patient confidentiality. Strategies to reduce mother–child transmission, including anti-retroviral therapy, mode of Training Support delivery, feeding Observation of and discussion with senior Conduct of labour/caesarean section medical staff. Advanced HIV Appropriate postgraduate courses, e.g. Maternal Antenatal complications, including preterm birth medicine. Neonatal management and testing. Attachments in: o HIV clinic/multidisciplinary team Pharmacology, including adverse effects: o Neonatology. Zidovudine RCOG. Management of HIV in Pregnancy. HAART. Green-top Guideline No. 39. NCCWCH. Antenatal Care. Clinical Guideline. Outcome: Personal study Neonatal infection (diagnosis and complications) Long-term outcome: chronic HIV infection. Evidence Clinical Competency Log of experience and competence Mini-CEX Take an appropriate history. Case-based discussions Counsel women about screening for HIV in pregnancy.

Manage a case of HIV infection in pregnancy: Arrange and interpret appropriate investigations, including viral load/CD4 Counsel regarding maternal and fetal risks, strategies to reduce mother–child transmission and management options

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6.2 Hepatitis Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks, Objective strategies to reduce mother–child transmission and management options To be able to carry out appropriate assessment and Manage labour and delivery/caesarean section. management of women with hepatitis in pregnancy. Manage a case of HCV infection in pregnancy: Knowledge Criteria Arrange and interpret appropriate investigations Virology and epidemiology: in high-risk cases Hepatitis A,B,C (HAV, HBV, HCV) Counsel regarding maternal and fetal risks, Natural history and viral dynamics strategies to reduce mother–child transmission Pathophysiology of acute and chronic hepatitis and management options Mode and risk of transmission Manage labour and delivery/caesarean section. Epidemiology of infection in pregnancy Counsel regarding HAV and HBV vaccination in pregnancy. Screening and diagnosis: Differential diagnosis of jaundice/abnormal liver function tests Professional Skills and Attitudes Rationale and organisation of hepatitis B Ability to take an appropriate history and conduct an (HbsAG) screening programme examination to assess a woman with jaundice. Laboratory tests: o serology, e.g. enzyme immunoassay Ability to counsel women: o diagnostic, e.g. Western blot, polymerase Before HBV/HCV screening test chain reaction After positive result Risk groups for HCV About HAV/HBV vaccination. Neonatal testing. Ability to formulate, implement and, where Management: appropriate, modify a management plan in acute Supportive care HAV infection. Screening for coincident infection (HBC, HCV). Ability to formulate, implement and, where Prevention: appropriate, modify a management plan in a woman HAV/HBV vaccination in pregnancy with HBV/HCV infection. Prevention perinatal infection: o HA immunoglobulin Ability to liaise with hepatologists, virologists, o HBIG and vaccination neonatologists and GP. Mode of delivery Breastfeeding. Ability to counsel HBV/HCV-infected women and their partners about: Outcome: Management options HBV/HCV-related disease (cirrhosis, Risks of perinatal transmission and methods of hepatocellular carcinoma). prevention Long-term outcome for mother and infant. Pharmacology: HAV vaccine, HAIG Ability to respect patient confidentiality. HBV vaccine, HBIG. Training Support Clinical Competency Observation of and discussion with senior Take an appropriate history. medical staff. Appropriate postgraduate courses. Perform an examination to assess jaundice. Attachments in virology and neonatology. Attendance at hepatology clinic. Counsel women about screening for HBV and HCV NCCWCH. Antenatal Care. Clinical Guideline. in pregnancy. Personal study.

Manage a case of HAV infection in pregnancy: Evidence Arrange and interpret appropriate investigations Institute appropriate supportive care. Log of experience and competence Mini-CEX Manage a case of HBV infection in pregnancy: Case-based discussions

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6.3 Cytomegalovirus Ability to formulate, implement and, where appropriate, modify a management plan in a woman Objective with CMV infection in pregnancy. To be able to carry out appropriate assessment and Ability to liaise with virologists and neonatologists. management of women with cytomegalovirus (CMV) infection in pregnancy. Ability to counsel women and their partners about: Maternal and fetal risks Knowledge Criteria Management options, including fetal diagnostic Virology and epidemiology: testing Cytomegalovirus Risks of perinatal transmission and methods of prevention Pathophysiology of primary infection (in adult and fetus) Long-term outcome for infants with congenital CMV infection. Mode and risk of transmission Epidemiology of infection in pregnancy (high-risk groups). Training Support Observation of and discussion with senior Screening and diagnosis: medical staff. Laboratory tests: Appropriate postgraduate courses. o maternal serology, immunofluorescent Attachments in: tests, enzyme immunoassay o virology o fetal diagnosis, e.g. amniotic fluid o neonatology. polymerase chain reaction/culture, viral Personal study. DNA, serology Ultrasound features of fetal infection Evidence Primary vs. recurrent infection. Log of experience and competence Management: Mini-CEX Supportive care Case-based discussions. Maternal and fetal risks CMV infection in immunocompromised women Fetal therapy (ganciclovir, CMV hyperimmune globulin) Termination of pregnancy.

Outcome: Sequelae of congenital CMV infection.

Clinical Competency Take an appropriate history.

Manage a case of CMV infection in pregnancy: Arrange and interpret appropriate maternal and fetal investigations Perform an ultrasound scan to detect features of fetal CMV infection Institute appropriate supportive care and monitoring Counsel regarding maternal and fetal risks Institute, where appropriate, fetal therapy Arrange, where appropriate, termination of pregnancy.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to perform and interpret appropriate investigations, including ultrasound.

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6.4 Herpes Simplex Virus Ability to counsel women and their partners about: Methods of reducing sexual transmission Objective Risks of perinatal transmission and methods of prevention To be able to carry out appropriate assessment and Maternal and fetal risks management of women with herpes simplex virus Safety of acyclovir in pregnancy (HSV) infection in pregnancy. Management options.

Knowledge Criteria Ability to respect patient confidentiality. Virology and epidemiology: HSV 1 and 2 Training Support Pathophysiology of primary and recurrent Observation of and discussion with senior infection and congenital herpes medical staff. Mode and risk of transmission Appropriate postgraduate courses. Epidemiology of infection in pregnancy. Attachments in: o virology Management: o neonatology/ Differential diagnosis oral/genital ulcers Personal study. Screening: HSV serology RCOG. Management of Genital Herpes in Diagnosis: viral culture Pregnancy. Green-top Guideline No. 30. Maternal and fetal risks Acyclovir for active disease/prophylaxis Evidence Prevention of perinatal infection: o role of caesarean section Log of experience and competence o avoidance scalp electrodes. Mini-CEX Case-based discussions. Outcome: Sequelae of congenital HSV infection.

Pharmacology, including adverse effects: Acyclovir (oral and intravenous).

Clinical Competency Take an appropriate history.

Perform an examination for active HSV lesions.

Manage a case of HSV infection in pregnancy Arrange and interpret appropriate investigations Institute symptomatic treatment and acyclovir for active disease Counsel regarding maternal and fetal risks Institute, where appropriate, prophylactic acyclovir Plan time and mode of delivery.

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to screen for HSV infection in pregnancy.

Ability to formulate, implement and, where appropriate, modify a management plan in a woman with HSV infection in pregnancy.

Ability to liaise with virologists, neonatologists and GP.

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6.5 Parvovirus Ability to liaise with virologists, neonatologists and haematology/blood transfusion service. Objective Ability to counsel women and their partners about: To be able to carry out appropriate assessment and Risks of perinatal transmission management of women with parvovirus infection in Maternal and fetal risks pregnancy. Management options, including fetal transfusion.

Knowledge Criteria Training Support Virology and epidemiology: Observation of and discussion with senior Parvovirus B19 medical staff. Pathophysiology of maternal and fetal infection, Appropriate postgraduate courses. including anaemia/hydrops Attachments in: Mode and risk of transmission o virology Epidemiology of infection in pregnancy. o neonatology. Personal study. Screening and diagnosis: Differential diagnosis fever, rash, arthropathy in Evidence pregnancy Laboratory tests: Log of experience and competence o maternal serology – ELISA Mini-CEX o fetal diagnosis, e.g. amniotic fluid Case-based discussions. polymerase chain reaction/culture, viral DNA, serology Ultrasound features of fetal infection.

Management: Maternal and fetal risks Ultrasound monitoring in maternal infection Screening and diagnosis fetal anaemia, including MCA Doppler (see 4.8) Differential diagnosis of fetal hydrops (see 3.7) Fetal transfusion therapy (see 4.8).

Outcome: Sequelae of congenital parvovirus HSV.

Clinical Competency Take an appropriate history.

Manage a case of parvovirus infection in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Institute appropriate fetal monitoring, including Perform and interpret MCA Doppler Perform fetal blood sampling and transfusion or refer, where appropriate, for same (see 4.8) Plan mode, place and timing of delivery,

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to diagnose parvovirus infection.

Ability to perform and interpret appropriate investigations, including ultrasound.

Ability to formulate, implement and, where appropriate, modify a management plan in a woman with parvovirus infection.

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6.6 Rubella Professional Skills and Attitudes Ability to take an appropriate history and conduct an Objective examination to diagnose rubella infection. To be able to carry out appropriate assessment and management of women with rubella infection in Ability to formulate and implement a management pregnancy. plan in a susceptible women exposed to rubella.

Knowledge Criteria Ability to counsel women about vaccination. Virology and epidemiology: Ability to perform and interpret appropriate Rubella virus investigations, including ultrasound. Pathophysiology of maternal and fetal infection, including congenital rubella syndrome (CRS) Ability to formulate, implement and, where Mode and risk of transmission appropriate, modify a management plan in women Epidemiology of infection in pregnancy. with rubella infection.

Screening and diagnosis: Ability to liaise with virologists and neonatologists. Rationale for and organisation of screening programme Ability to counsel women and their partners about: Laboratory tests Maternal and fetal risks Maternal serology (ELISA) Management options, including termination of Fetal diagnosis – amniotic fluid PCR, serology pregnancy. Ultrasound features of CRS Training Support Management: Observation of and discussion with senior Differential diagnosis medical staff. rash/fever/arthralgia/lymphadenopathy in Appropriate postgraduate courses. pregnancy Attachments in: Maternal and fetal risks o virology Termination of pregnancy. o neonatology NCCWCH. Antenatal Care. Clinical Guideline. Prevention: Personal study. Rubella vaccination programme Postnatal vaccination. Evidence Outcome: Log of experience and competence Sequelae of congenital rubella syndrome, Mini-CEX including eye disorders, heart defects, Case-based discussions neurological defects.

Pharmacology, including adverse effects: Rubella vaccine.

Clinical Competency Take an appropriate history.

Perform an examination to assess fever, lymphadenopathy, arthralgia.

Manage a pregnant woman found to be susceptible to rubella: Arrange and interpret appropriate investigations if suspected exposure Arrange postnatal vaccination.

Manage a case of rubella in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Arrange, where appropriate, termination of pregnancy.

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6.7 Varicella Ability to formulate and implement a management plan in a susceptible women exposed to varicella Objective zoster Ability to counsel women about vaccination. To be able to carry out appropriate assessment and management of women with varicella zoster Ability to perform and interpret appropriate infection in pregnancy. investigations, including ultrasound.

Knowledge Criteria Ability to formulate, implement and, where appropriate, modify a management plan in women Virology and epidemiology: with varicella zoster. Varicella zoster virus Pathophysiology of varicella, zoster and Ability to liaise with virologists and neonatologists. congenital varicella syndrome (CVS) Mode and risk of transmission Ability to counsel women and their partners about: Epidemiology of infection in pregnancy. Maternal and fetal risks Benefits of aciclovir Management: Management options, including termination of Differential diagnosis vesicular rash pregnancy. Screening (HSV serology) Fetal diagnosis (ultrasound, serology, viral DNA) Training Support Maternal risks (lung/central nervous system involvement) Observation of and discussion with senior Acyclovir medical staff. Fetal risks (CVS). Appropriate postgraduate courses. Attachments in: Outcome: o virology Sequelae of congenital CVS. o neonatology. Personal study. Prevention: RCOG. Chickenpox in Pregnancy. Green-top Varicella vaccination programme. Guideline No. 13.

Pharmacology, including adverse effects: Evidence Varicella zoster immunoglobulin (VZIG). Log of experience and competence Clinical Competency Mini-CEX Case-based discussions. Take an appropriate history.

Perform an examination to assess vesicular rash.

Manage a pregnant woman found to be susceptible to varicella: Arrange and interpret appropriate investigations if suspected exposure Institute VZIG Arrange postnatal vaccination.

Manage a case of varicella/zoster in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Institute aciclovir where appropriate Institute appropriate maternal and fetal monitoring Perform ultrasound to screen for CVS.

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to diagnose varicella zoster infection

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6.8 Toxoplasmosis Institute spiramycin and pyrimethamine/sulfadiazine, where appropriate Objective Arrange, where appropriate, termination of pregnancy. To be able to carry out appropriate assessment and management of women with toxoplasmosis infection Professional Skills and Attitudes in pregnancy. Ability to take an appropriate history. Knowledge Criteria Ability to formulate and implement a management Parasitology and epidemiology: plan in a susceptible woman. Toxoplasma gondii Pathophysiology maternal and fetal infection Ability to counsel regarding prevention. Mode and risk of transmission Epidemiology of infection in pregnancy (high-risk Ability to perform and interpret appropriate groups, geographical variation). investigations, including ultrasound.

Screening and diagnosis: Ability to formulate, implement and, where Laboratory tests: appropriate, modify a management plan in women o maternal serology (dye test, ELISA, with toxoplasmosis. agglutination assays) o immunoglobulin G avidity tests Ability to liaise with microbiologists and o fetal diagnosis (ultrasound, amniotic fluid neonatologists. PCR, viral DNA) Ultrasound features of fetal infection Ability to counsel women and their partners about: Distant vs. recent infection. Maternal and fetal risks Management options, including termination of Management: pregnancy Supportive care Benefits and risks of spiramycin and Maternal and fetal risks pyrimethamine/sulfadiazine. Toxoplasmosis infection in immunocompromised women Training Support Maternal therapy (spiramycin) Observation of and discussion with senior Fetal therapy (pyrimethamine/sulfadiazine) medical staff. Termination of pregnancy. Appropriate postgraduate courses. Attachments in: Outcome: o virology Sequelae of congenital toxoplasmosis. o neonatology Personal study. Pharmacology, including adverse effects: Spiramycin Evidence Pyrimethamine/sulfadiazine. Log of experience and competence Clinical Competency Mini-CEX Take an appropriate history. Case-based discussions

Manage a pregnant woman found to be susceptible to toxoplasmosis: Arrange and interpret appropriate investigations if suspected exposure Counsel regarding preventative strategies.

Manage a case of toxoplasmosis infection in pregnancy: Arrange and interpret appropriate maternal and fetal investigations Perform an ultrasound scan to detect features of fetal toxoplasmosis Institute appropriate supportive care and monitoring Counsel regarding maternal and fetal risks

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6.9 Malaria Professional Skills and Attitudes Objective Ability to take an appropriate history. To be able to carry out appropriate assessment and management of women with malaria infection in Ability to counsel women travelling to endemic areas: pregnancy. Risks of infection Prevention, including chemoprophylaxis. To be able to advise women travelling abroad about prevention of malaria. Ability to formulate, implement and, where appropriate, modify a management plan in a woman Knowledge Criteria with malaria infection in pregnancy.

Parasitology and epidemiology: Ability to liaise with microbiologists and consultants in Plasmodium genus infectious disease. Pathophysiology of malaria, including severe disease and placental/fetal infection Ability to counsel women and their partners about: Mode and risk of transmission Maternal and fetal risks Epidemiology of malarial infection, including Management options, including anti-malarial chloroquine resistance. treatment Breastfeeding. Management: Diagnosis (blood smears) Training Support Supportive care, including management of anaemia Observation of and discussion with senior Anti-malarial treatment, including chloroquine, medical staff. quinine, mefloquine, clindamycin Appropriate postgraduate courses. Severe disease, including renal failure, Attachments in microbiology. pulmonary oedema, severe anaemia, Personal study. hypoglycaemia Fetal complications (fetal growth Evidence restriction/preterm birth). Log of experience and competence Prevention: Mini-CEX Avoidance of travel to endemic areas Case-based discussions Spray/nets Chemoprophylaxis

Pharmacology, including adverse effects: Chloroquine Mefloquine.

Clinical Competency Take an appropriate history.

Perform an examination to assess fever.

Manage women travelling to endemic areas: Counsel women about preventative measures Institute appropriate chemoprophylaxis.

Manage a case of malarial infection in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Institute anti-malarial treatment Refer, where appropriate, for further assessment and treatment.

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6.10 Tuberculosis Ability to formulate, implement and, where appropriate, modify a management plan in a woman Objective with TB during pregnancy. To be able to carry out appropriate assessment and Ability to liaise with microbiologists, consultants in management of women with or at risk of tuberculosis infectious disease and neonatologists. (TB) infection in pregnancy. Ability to counsel women and their partners about: Knowledge criteria Maternal and neonatal risks Microbiology and epidemiology: Management options including anti-TB treatment Mycobacterium tuberculosis Prevention of neonatal infection Pathophysiology of TB, including infection vs. Breastfeeding. pulmonary/extrapulmonary disease Mode and risk of transmission Training Support Epidemiology of TB infection in pregnancy, Observation of and discussion with senior including high-risk groups. medical staff. Appropriate postgraduate courses. Management: Attachments in: Differential diagnosis fever/cough o microbiology Diagnosis (tuberculin testing, direct identification o neonatology. bacilli, culture) Personal study. Anti-tuberculous treatment, including isoniazid (+ pyridoxine), rifampicin, ethambutol Evidence Extrapulmonary disease. Log of experience and competence Prevention: Mini-CEX Procedures for prevention and control, including Case-based discussions contact tracing BCG vaccination Isoniazid prophylaxis (in high-risk neonates)

Pharmacology, including adverse effects: Isoniazid Rifampicin Ethambutol.

Clinical Competency Take an appropriate history.

Manage women with previous history of positive tuberculin test/TB: Arrange and interpret appropriate investigations and follow-up Counsel regarding maternal/neonatal risks.

Manage a case of tuberculosis in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and neonatal risks Institute anti-TB treatment Refer, where appropriate, for further assessment and treatment.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to formulate, implement and, where appropriate, modify a management plan in a woman with previous positive tuberculin test/TB.

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6.11 Streptococcal Disease Screening in high risk cases (e.g. preterm prelabour rupture of membranes, previous Objective neonatal GBS). To be able to carry out appropriate assessment and Manage a case of GBS infection in pregnancy; management of women with group A streptococcal Arrange and interpret appropriate investigations (GAS) infection in pregnancy. Counsel regarding maternal and fetal risks Institute intrapartum antibiotic prophylaxis. To be able to carry out appropriate assessment and management of women with group B haemolytic Professional Skills and Attitudes streptococcus (GBS) infection in pregnancy. Ability to take an appropriate history. Knowledge Criteria Ability counsel women: Microbiology and epidemiology: Before screening for GBS Streptococcal species After positive result Pathophysiology of GAS disease, including toxic shock syndrome and other invasive infections Ability to formulate, implement and, where Pathophysiology of GBS disease (adult and appropriate, modify a management plan in a woman neonate) with GBS infection in pregnancy. Mode and risk of transmission Epidemiology of streptococcal infection in Ability to liaise with microbiologists and pregnancy and the puerperium, including risk neonatologists. factors and colonisation rates Ability to counsel women and their partners about: Screening and diagnosis: Maternal and fetal risks Differential diagnosis: Management options, including intrapartum o septic shock/fever antibiotic prophylaxis o vaginitis/vaginal discharge (see 6.10) Risks of early-onset GBS infection in the o chorioamnionitis/postpartum endometritis newborn. Laboratory diagnosis (swabs/culture) Risks and benefits of GBS screening strategies: Training Support o routine bacteriological screening o risk-based screening. Observation of and discussion with senior medical staff. Management: Appropriate postgraduate courses. GAS infection (supportive care/antibiotics) Attachments in: GBS infection (intrapartum antibiotic o microbiology prophylaxis) o neonatology. o GBS carrier Personal study o other groups (e.g. suspected RCOG. Prevention of Early Onset Neonatal chorioamnionitis) Group B Streptococcal Disease. Green-top ‘at risk’ newborn infants. Guideline No. 36

Outcome: Evidence Early- and late-onset GBS infection in newborn Log of experience and competence Mini-CEX Pharmacology, including adverse effects: Case-based discussions Penicillin G Clindamycin.

Clinical Competency Take an appropriate history.

Perform an examination to assess puerperal fever/sepsis.

Counsel women about screening for GBS in pregnancy: Routine screening

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6.12 Syphilis Ability to liaise with microbiologists, genitourinary consultants and neonatologists. Objective Ability to counsel women and their partners about: To be able to carry out appropriate assessment and Maternal and fetal risks management of women with syphilis infection in Penicillin treatment. pregnancy. Training Support Knowledge Criteria Observation of and discussion with senior Microbiology and epidemiology: medical staff. Treponema pallidum Appropriate postgraduate courses. Pathophysiology of syphilis, including stages of Attachments in: adult disease and congenital infection o microbiology Mode and risk transmission o neonatology. Epidemiology of syphilis infection in pregnancy. NCCWCH. Antenatal Care. Clinical Guideline. Personal study. Screening and diagnosis: Rationale and organisation of screening Evidence programme Serological tests, (including nonspecific and Log of experience and competence specific antibody tests Mini-CEX Dark field visualisation Case-based discussions Differential diagnosis of genital ulcer Ultrasound features of fetal infection.

Management: Penicillin G (see 6.11), including management of Jarisch–-Herxheimer reaction Contact tracing.

Outcome: Congenital syphilis (early and late).

Clinical Competency Take an appropriate history.

Perform an examination to assess genital ulcer.

Counsel women about screening for syphilis in pregnancy: Routine screening Screening in high risk cases.

Manage a case of syphilis infection in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Institute treatment with penicillin Refer for further assessment, treatment and contact tracing.

Professional Skills and Attitudes Ability to take an appropriate history.

Ability to counsel women: Before screening for syphilis After positive result.

Ability to formulate, implement and, where appropriate, modify a management plan in a woman with syphilis infection in pregnancy.

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6.13 Other Sexually Transmitted Manage a case of chlamydia in pregnancy; Diseases in Pregnancy Arrange and interpret appropriate investigations, including screening for other STDs Objective Counsel regarding maternal, fetal and neonatal risks Institute antibiotic therapy To be able to carry out appropriate assessment and Refer for further assessment, treatment and management of women with a sexually transmitted contact tracing. disease (STD) in pregnancy.

Knowledge Criteria Professional Skills and Attitudes Ability to take an appropriate history. Microbiology and epidemiology: Neisseria gonorrhoea, Chlamydia trachomatis, Ability to formulate, implement and, where genital mycoplasma appropriate, modify a management plan in a woman Pathophysiology of gonococcal, chlamydial and with gonorrhoea in pregnancy. mycoplasmal disease, including chorioamnionitis and postpartum endometritis Ability to formulate, implement and, where Epidemiology of STDs in pregnancy appropriate, modify a management plan in a woman with chlamydia in pregnancy. Screening and diagnosis: Rationale and organisation of screening for Ability to liaise with microbiologists, genitourinary chlamydia in pregnancy medicine consultants and neonatologists. Differential diagnosis of vaginal discharge, cervicitis in pregnancy Ability to counsel women and their partners about: Laboratory diagnosis (swabs/culture, nucleic Maternal and fetal risks acid amplification techniques) Antibiotic therapy Risks of neonatal infection and outcome. Management: Antibiotics: Training Support o Chlamydia – azithromycin o Gonorrhoea – ceftriaxone, cefixime Observation of and discussion with senior o Mycoplasmas – erythromycin, clindamycin medical staff. Contact tracing (where appropriate) Appropriate postgraduate courses. Fetal risks, including preterm prelabour Attachments in: rupture of membranes, preterm birth (see o microbiology 4.5) o neonatology. Maternal risks (chorioamnionitis, Personal study. endometritis). Evidence Outcome: Neonatal infection (conjunctivitis, pneumonia) Log of experience and competence Mini-CEX Pharmacology, including adverse effects: Case-based discussions Azithromycin Ceftriaxone.

Clinical Competency Take an appropriate history.

Manage a case of gonorrhoea in pregnancy: Arrange and interpret appropriate investigations, including screening for other STDs Counsel regarding maternal, fetal and neonatal risks Institute antibiotic therapy Refer for further assessment, treatment and contact tracing.

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6.14 Bacterial Vaginosis Training Support Observation of and discussion with senior Objective medical staff. Appropriate postgraduate courses. To be able to carry out appropriate assessment and Attachments in microbiology. management of women with bacterial vaginosis (BV) Personal study. in pregnancy. Evidence Knowledge Criteria Log of experience and competence Microbiology and epidemiology: Mini-CEX Garnerella vaginalis, selected anaerobes, Case-based discussions Mycoplasma hominis Pathophysiology of BV Epidemiology of BV in pregnancy.

Screening and diagnosis: Rationale for screening in high-risk groups, including previous preterm birth Differential diagnosis of vaginal discharge (see 6.11, 6.13) Clinical diagnosis (Amsel criteria), Gram stain, vaginal discharge.

Management: Treatment – metronidazole, clindamycin Fetal risks, including miscarriage, preterm birth (see 4.5).

Pharmacology, including adverse effects: Metronidazole Clindamycin.

Clinical Competency Take an appropriate history.

Perform an examination to diagnose BV in pregnancy.

Manage a case of BV in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Institute antibiotic therapy.

Professional Skills and Attitudes Ability to take an appropriate history and conduct an examination to diagnose BV in pregnancy.

Ability to formulate, implement and ,where appropriate, modify a management plan in a woman with BV in pregnancy.

Ability to liaise with microbiologists.

Ability to counsel women and their partners about: Maternal and fetal risks Antibiotic therapy.

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6.15 Asymptomatic Bacteriuria and Acute Symptomatic Urinary Tract Manage a case of symptomatic UTI in pregnancy; Infection Arrange and interpret appropriate investigations Counsel regarding maternal and fetal risks Institute and where appropriate, modify antibiotic Objective therapy Refer, where appropriate, for further To be able to carry out appropriate assessment and assessment/treatment management of women with asymptomatic Arrange, where appropriate, for postnatal bacteriuria (AB) in pregnancy. intravenous urogram. To be able to carry out appropriate assessment and Professional Skills and Attitudes management of women with urinary tract infection (UTI) in pregnancy. Ability to take an appropriate history.

Knowledge Criteria Ability to counsel women: o before screening for AB Microbiology and epidemiology: o after positive result. Escherichia coli, Klebsiella/Proteus/Pseudomonas sp, coagulase- Ability to formulate, implement and, where negative staphylococci appropriate, modify a management plan in a woman Pathophysiology of UTI/acute pyelonephritis with AB detected during pregnancy. Epidemiology of asymptomatic bacteriuria and UTI in pregnancy. Ability to formulate, implement and, where appropriate, modify a management plan in a woman Screening and diagnosis: with symptomatic UTI in pregnancy. Rationale for and organisation of screening for AB during pregnancy Ability to liaise with microbiologists and nephrologists Midstream urine culture (colony counts) (where appropriate). Differential diagnosis of acute abdominal pain in pregnancy, antenatal pyrexia (see 6.16) Ability to counsel women and their partners about: Diagnosis of relapse/reinfection. Maternal and fetal risks Antibiotic therapy Management: Postnatal investigation. Antibiotic therapy: o AB – nitrofurantoin Training Support o UTI – ampicillin, cephalosporins/second- line therapies Observation of and discussion with senior o Duration of therapy medical staff. Maternal risks, including acute pyelonephritis, Appropriate postgraduate courses. Gram-negative sepsis, acute renal failure Attachments in: Fetal risks, including preterm birth (see 4.5) o maternal medicine Postnatal investigation (intravenous urogram) o microbiology. NCCWCH. Antenatal Care. Clinical Guideline. Pharmacology, including adverse effects: Personal study Nitrofurantoin Broad-spectrum penicillins (e.g. ampicillin) Evidence Cephalosporins (e.g. cefalexin). Log of experience and competence Mini-CEX Clinical Competency Case-based discussions Take an appropriate history.

Counsel women about screening for AB in pregnancy.

Manage a case of AB in pregnancy: Arrange and interpret appropriate investigations Counsel regarding maternal risks Institute and where appropriate, modify antibiotic therapy Arrange, where appropriate, postnatal intravenous urogram.

78 Last updated February 2013 MFM Curriculum

6.16 Other Infective Conditions Manage a case of acute chorioamnionitis: Arrange and interpret appropriate investigations Objective Counsel regarding maternal and fetal risks Institute and, where appropriate, modify To be able to carry out appropriate assessment and antibiotic therapy management of women with acute chorioamnionitis. Refer, where appropriate, for further assessment and treatment. To be able to carry out appropriate assessment and Mode and timing of delivery, including, where management of women with puerperal sepsis. appropriate, termination of pregnancy.

Knowledge Criteria Perform an examination to assess postnatal pyrexia. Microbiology and epidemiology: Manage a case of puerperal pyrexia: Common organisms implicated in Arrange and interpret appropriate investigations chorioamnionitis and puerperal sepsis, including Counsel regarding maternal risks group A and group B streptococcus (see 6.11), Institute and, where appropriate, modify Gram-negative bacilli, anaerobes, genital antibiotic therapy mycoplasmas (see 6.13) Refer, where appropriate, for further Pathophysiology of acute chorioamnionitis (see assessment/treatment, 4.5) and puerperal sepsis, including endometritis, pelvic vein thrombophlebitis, Professional Skills and Attitudes urinary tract infection (see 6.15) Epidemiology of chorioamnionitis and puerperal Ability to take an appropriate history and conduct an pyrexia/infection. examination to assess a woman with acute abdominal pain in pregnancy. Diagnosis and management of chorioamnionitis: Differential diagnosis of acute abdominal pain in Ability to formulate, implement and, where pregnancy, antenatal pyrexia (see 6.11) appropriate, modify a management plan in a woman Investigations (blood, cultures, ultrasound) with acute chorioamnionitis. Antibiotic therapy Fetal risks, including fetal death, preterm labour Ability to take an appropriate history and conduct an Maternal risks, including Gram-negative sepsis, examination to assess a woman with puerperal acute renal failure. pyrexia.

Diagnosis and management of postnatal sepsis: Ability to formulate, implement and, where appropriate, modify a management plan in a woman Differential diagnosis of puerperal pyrexia with puerperal sepsis. Investigations (culture, ultrasound, CT/MRI) Antibiotic therapy, including Ability to liaise with microbiologists and pathologists: clindamycin/gentamicin Maternal risks, including Gram-negative sepsis, Ability to counsel women and their partners about: acute renal failure. Maternal and fetal risks Antibiotic therapy Pharmacology, including adverse effects: Delivery, including termination of pregnancy. Clindamycin Gentamicin. Training Support Clinical Competency Observation of and discussion with senior medical staff. Take an appropriate history. Attachments in microbiology. Perform an examination to assess acute abdominal pain in pregnancy. Evidence Log of experience and competence Mini-CEX Case-based discussions

79 Last updated February 2013