CERTIFICATION IN OBSTETRICAL AND … · - Previous intrauterine fetal demise ... fetal and...

THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS

CERTIFICATION IN OBSTETRICAL AND

GYNAECOLOGICAL ULTRASOUND

TRAINING PROGRAM HANDBOOK

CURRICULUM ONLY 2017

Published by RANZCOG Publications The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 254-260 Albert Street, East Melbourne, Victoria 3002, Australia

© RANZCOG 2014

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Requests and enquiries concerning reproduction should be directed to the Chief Executive Officer, RANZCOG, 254-260 Albert Street, East Melbourne, Victoria 3002, Australia.

IMPORTANT NOTICE

ON INFORMATION AND REGULATIONS IN THIS HANDBOOK

Every effort has been made to ensure that the information and

College regulations in this handbook were correct at the time it was produced.

A regularly updated version of the handbook is available

on the College website (www.ranzcog.edu.au) Readers are strongly advised to consult the website version when checking information or regulations.

Updated March 2018

http://www.ranzcog.edu.au/

PART A: CURRICULUM

PART A: CURRICULUM

1.0 AIMS

1.0 AIMS

1.1 Subspecialist practice

Obstetrical and Gynaecological Ultrasound is a subspecialty of obstetrics and gynaecology. Obstetrical and Gynaecological Ultrasound subspecialists are specialists in Obstetrics and Gynaecology, awarded the FRANZCOG, who are trained and assessed as being competent in all aspects of ultrasound diagnosis relating to obstetrics and gynaecology, including ultrasound guided interventional diagnostic and therapeutic techniques. An obstetrical and gynaecological ultrasound subspecialist must spend at least 66% of his/her clinical time working in obstetrical and gynaecological diagnostic ultrasound practice. It is desirable but not mandatory that he/she works part of this time in a “tertiary care” institution where the ultrasound department provides a comprehensive diagnostic service to general obstetrics and gynaecology and to the subspecialties.

The Certificate of Obstetrical and Gynaecological Ultrasound (COGU) is a qualification only for individuals who hold the qualification of Fellow of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG).

1.2 Context

High quality Obstetrical and Gynaecological ultrasound services form an essential component in the provision of quality Obstetrical and Gynaecological care by complementing the clinical work of specialists and subspecialists.

Obstetrical and Gynaecological ultrasound practice at subspecialist level requires high-level scanning and procedural skills, an excellent knowledge base in obstetrical, gynaecological and fetal pathophysiology, and sound counselling skills.

The rapidly advancing technical aspects of ultrasound scanning and the changing medico-legal climate in Australia make excellent training and ongoing education essential.

A subspecialist in Obstetrical and Gynaecological Ultrasound would also be expected to promote clinical and basic research in this field and provide education and clinical support to Obstetrician Gynaecologists and other imaging specialists.

1.3 Aims of the Subspecialties

The College introduced certification in the five subspecialties in order to:

• improve knowledge, practice, teaching and research

• promote the concentration of specialised expertise, special facilities and clinical material that will be of considerable benefit to some patients

• improve the recruitment of talented graduates into areas of recognised subspecialisation

• establish a close understanding and working relationship with other disciplines

• encourage co-ordinated management of relevant clinical services throughout a region

• accept a major regional responsibility for higher training, research and audit in areas of recognised subspecialisation

• establish, as far as possible, consistency in recruitment, training and assessment across areas of recognised subspecialisation

1.4 Aims of the Subspecialty in Obstetrical and Gynaecological Ultrasound

The College introduced certification in the subspecialty of Obstetrical and Gynaecological Ultrasound in order to:

• improve knowledge, practice, teaching and research in the area of obstetric and gynaecologic ultrasound and pre-natal diagnosis, for specialists, subspecialists and others

PART A: CURRICULUM

2.0 OBJECTIVES

• ensure that women have access to subspecialist opinion in relation to fetal or gynaecologic abnormalities

• ensure that women receive the highest possible standard of care

• establish and maintain a close understanding and working relationship with related disciplines

2.0 OBJECTIVES OF THE COGU TRAINING PROGRAM

It is expected that the subspecialist in Obstetrical and Gynaecological Ultrasound will be able to demonstrate:

1. Knowledge of the basic sciences relevant to Obstetrical and Gynaecological Ultrasound, in particular Physics.

2. Knowledge of the pathophysiology, methods of evaluation and treatment of the maternal disorders and pregnancy complications contributing to high fetal risk and gynaecological disorders.

3. Both academic knowledge and practical competence in the fields of gynaecological imaging, prenatal screening and fetal diagnosis, including the relevant invasive procedures and fetal therapies.

4. State of the art skills and competence in the management of all acute and chronic problems within the discipline of Obstetrical and Gynaecological Ultrasound. (see Major subgroups of patients below)

5. An understanding of the concepts of investigative science, critical appraisal of published literature and the development of skills in research methods.

6. An understanding of the organisation of health services in the areas of Obstetrical and Gynaecological Ultrasound.

7. Understanding of the methods of quality assurance and audit.

Major subgroups of patients

The practice of an Obstetrical and Gynaecological Ultrasound subspecialist involves the

following major subgroups of patients:

A General population screening

B Patients requiring prenatal diagnosis

C Patients requiring gynaecological diagnosis

D Patients with maternal disease, including, but not limited to, the following examples:

- Class 3 or 4 cardiac disease

- SLE requiring corticosteroids

- Diabetes mellitus, class B or greater

- Chorionic hypertension (multiple medications at beginning of pregnancy)

- Thrombo-embolic disease

- Anti-phospholipid antibody syndrome

- Seizure disorder

- Thrombotic thrombocytopenia

- Hyperthyroidism

- Phaeochromocytoma

- Chronic renal disease

- Haemolytic uraemic syndrome

PART A: CURRICULUM

2.0 OBJECTIVES

- Kidney transplant

- Patients receiving anticoagulation during pregnancy

- Pulmonary hypertension

- Haemoglobinopathy such as sickle cell disease

- Maternal malignant disease

- Acute fatty liver of pregnancy

- Steroid dependent asthma

- Portal hypertension

- Immune thrombocytopenia

- Heart transplant

- Liver transplant

- Viral infection, ie; varicella, toxoplasmosis, parvovirus, cytomegalovirus

- Substance abuse (complicated)

- HIV

E Health of pregnant women with fetuses at high risk of adverse outcomes, including, but not limited to, the following examples:

- Preterm labour

- Prelabour rupture of membranes

- Multiple pregnancies

- IUGR

- Incompetent cervix

- Mullerian tract abnormalities

- Multiple prior preterm deliveries

- Oligohydramnios

- Polyhydramnios

- Fetus with major structural defect or cytogenic abnormality

- Fetal hydrops

- Twin-to-twin infusion

- Fetal supraventricular tachycardia

- Prior feto-maternal alloimmune thrombocytopenia

- Prior second trimester loss

- Previous intrauterine fetal demise

F Tertiary level opinion and counselling

The Obstetrical and Gynaecological Ultrasound subspecialist should be able to provide a tertiary level opinion and counselling for any of the above conditions or any other condition in obstetrics and gynaecology as it pertains to the use of diagnostic imaging.

G Diagnostic procedures in obstetrics and gynaecology – ultrasound guided.

3.0 KNOWLEDGE AND UNDERSTANDING

Knowledge and Understanding: The Building Blocks Required for the Development of Expertise in Obstetrical and Gynaecological Ultrasound

This section details areas of knowledge that underpin the practice of obstetric and gynaecological ultrasound. The purpose is to grasp the underlying principles on which modern obstetric and gynaecological ultrasound practice is based, not merely to memorise facts. Understanding of these principles will develop with regular clinical experience, for it is the interaction between knowledge and practice that provides the basis for growth in clinical expertise.

The areas of knowledge presented in this section are categorized as follows:

• scientific knowledge that forms the building blocks underpinning clinical practice (Sections 3.1 to 3.12)

• clinical or applied knowledge that links the science and the practice of gynaecological oncology (Sections 3.13 to 3.14)

• contextual knowledge (for example, consultation processes, business and management principles, professional expectations) that acknowledges the service obligations implicit in the practice of obstetrics and gynaecology (Sections 3.15 to 3.19)

Relevant knowledge may be accessed in a variety of ways, through text books, refereed articles in journals and book series, evidence-based electronic databases and publications, academic discourse, conference papers and many informal means of communication. It is through these publications and interactions that a consensus on standards is established for the discipline. Through these means, specialists certified in obstetric and gynaecological ultrasound learn accepted terminologies, appropriate vocabulary, levels of understanding expected of them and key applications for their clinical work. As clinical professionals, they are expected to select, organize and test this knowledge through their own experience and in academic conversation with colleagues.

3.1 Anatomy

General Aim Understand and describe: • Normal and abnormal anatomy and ultrasound appearance of the female pelvis and abdomen, including that of the pregnant woman • Anatomy, ultrasound appearance and development of the placenta, cord and membranes in single and multiple pregnancy • Normal human development and the ultrasound appearance of the growing fetus

Specific objectives 3.1.1 Female

Describe the normal and abnormal anatomy and ultrasound appearance in the pregnant and non-pregnant woman of:

Pelvis, including:

• Vagina

• Uterus

• Fallopian tubes

• Ovaries

• Pelvic floor

• Vasculature and innervation

• Pelvic wall

PART A: CURRICULUM


Abdomen, including:

• Liver

• Kidneys/urinary tract

• Gall bladder and biliary system

• Renal system

3.1.2 Fetus, including:

Understand and describe;

• Normal development of main organ systems

• Normal and abnormal cross-sectional anatomy and ultrasound appearance of the fetus

• Changing fetal appearances with increasing gestation

3.1.3 Placenta, including:


• Development of placenta, cord and membranes, including multiple pregnancy

• Anatomy and ultrasound appearance of placenta, umbilical cord, and membranes, including chorionicity in multiple pregnancy

3.2 Reproductive Physiology and Endocrinology

General Aim

Understand and describe normal and abnormal maternal, fetal and placental physiology and endocrinology, including changes occurring at birth.

Specific Objectives 3.2.1 Female/Maternal


• Hypothalamic pituitary ovarian axis

• Endocrine factors affecting the menstrual cycle, including menarche and post- menopause

• Changes that occur during pregnancy, labour and puerperium

• Immune mechanisms in pregnancy

• Coagulation system

3.2.2 Fetal


• Normal fetal growth patterns and the factors regulating fetal growth

• Physiological processes of maturation of fetal organs

• Fetal cardio-pulmonary physiology, including regulation of the fetal heart rate, oxygen and carbon dioxide transport and the fetal response to hypoxia

• Patterns of fetal activity, including fetal breathing and other movements

• Mechanisms of regulation of the volume and composition of amniotic fluid

• Factors involved in the initiation of parturition

• Fetal cardio-respiratory and endocrine responses to birth

3.2.3 Placenta


• Growth, development and function of the placenta

• Regulation of placental blood flow

• Mechanisms of action of placental hormones

3.3 Pathophysiology

General Aim

Understand and describe the aetiology, pathogenesis, pathology, epidemiology, clinical presentation, investigation, management, prognosis and prevention of maternal, fetal, and placental disorders. Candidates should also understand the value and limitations of investigations used to determine the cause of fetal/neonatal death.

Specific Objectives 3.3.1 Maternal pathophysiology

Understand the aetiology, pathogenesis, pathology, epidemiology, clinical presentation, investigation, management and fetal effects of the following:

• Recurrent miscarriage

• Pregnancy induced hypertension, diabetes, preterm labour, intrauterine infection, thromboembolism, haemorrhage and shock, autoimmune disease, renal disease, cardiac disease, amniotic fluid embolism, anaesthesia, bowel surgery

• Common malignancies

3.3.2 Fetal pathophysiology

Understand the aetiology, pathogenesis, pathology, epidemiology, clinical presentation, investigation, management and prevention of the following;

• Intrauterine growth restriction

• Hypoxia and acidosis

• Hydrops: immune and non-immune

• Complications in dichorionic and monochorionic multiple pregnancy

• Congenital infection, including toxoplasmosis, CMV, parvovirus, varicella, rubella, HIV, congenital herpes, syphilis, listeria

3.3.3 Placental pathophysiology

Understand the aetiology of the following:

• Intrauterine growth restriction

• Monochorionic multiple pregnancy

• Placental masses

3.3.4 Post mortem pathophysiology

Understand the value and limitations of post mortem examination of the fetus/ neonate

PART A: CURRICULUM


3.4 Genetics

General Aim

Understand and describe basic human genetics, common genetic and chromosomal disorders, current techniques in prenatal diagnosis, and principles of teratogenesis.

Specific Objectives 3.4.1 Modes of inheritance

Understand and explain modes of inheritance, including;

• Mendelian

• Polygenetic

• Epigenetic

3.4.2 Common genetic disorders

Understand and describe the more common genetic disorders, as pertains to prenatal diagnosis, including:

• Cystic fibrosis

• Alpha and Beta thalassaemia

• Spinal muscular atrophy

• Huntingtons chorea

• Achondroplasia

• Congenital adrenal hyperplasia

• Glycogen storage disorders

• Meckel gruber

• Fragile X

• Polycystic kidney disease (particularly ARPKD)

• Tay sachs

• Haemophilia

3.4.3 Chromosomal disorders

Understand and describe:

• Common aneuploidies, e.g. T21, T13, T18, 45X, 47XXX, 47XXY, 47XYY

• Structural chromosome disorders, e.g. Robertsonian translocation, insertion, deletion

• Mosaicism

• UPD and genomic imprinting

3.4.4 Fetal and paediatric syndromes

Understand and describe the genetics and other clinical features of the more common fetal (and paediatric) syndromes, including: di George (22q11 microdeletion), Beckwith Weidemann syndrome, wolf hirschorn (4p-), osteogenesis impertecta, achondrogenesis, Pierre Robin, Hot Oram, Fraser syndrome, multiple pterygia, Fryns syndrome, thanatophoric dysplasia, tuberose sclerosis, X linked hydrocephalus

3.4.5 Laboratory genetics

Understand the principles of:

• Basic techniques of karyotyping, FISH and DNA analysis

• Recombinant technology

• Emerging technologies, e.g. comparative genomic hybridization, DNA micro arrays, nanotechnology

3.4.6 Biochemical screening

Understand and describe the significance of common analytes at different stages of pregnancy, e.g. PAPP-A, BhCG, total hCG, AFP, E3, inhibin

3.4.7 Teratology


• Background rates of fetal malformation

• Mechanisms of teratogenesis

• Effects of possible teratogens, e.g. drugs (prescribed and illicit), infections (such as rubella, toxoplasmosis, CMV), radiation, environmental agents (including alcohol), vaccinations.

3.4.8 Advancements in gene technology

Have a basic understanding of recent advances in gene technology and their potential, e.g. gene manipulation

3.5 Principles of Screening

General Aim Understand and describe principles of screening and implications for patients.

Specific Objectives 3.5.1 Understanding of screening

Have a basic understanding of recent advances in gene technology and their potential, e.g. gene manipulation

3.5.2 Test performance

Understand the principles underpinning the performance of specific tests, e.g. screening, combined first trimester screen, Double/Triple/Quadruple test, sequential screening, integrated screening, contingent screening, morphology scan, CF screening

3.5.3 Harms and benefits

Understand the principles underpinning false positives and negatives

Understand psychological implications for patients of the harms and benefits of ultrasound

3.5.4 Economics

Understand principles of cost versus benefits with screening, patient preferences and factors affecting their choices

3.5.5 Common screening tests used in Obstetrical and Gynaecological ultrasound

Extensive knowledge required, including historical, text book, latest research and clinical application

PART A: CURRICULUM


3.6 Physics

General Aim Understand and describe the physics of ultrasound and relevant instrumentation.

Specific Objectives 3.6.1 Pulse echo imaging and signal processing


• Imaging, e.g. reflection and transmission of sound waves, B-mode and M-mode scanning, axial and lateral resolution, grey-scale, dynamic range, frame rates, persistence, harmonics

• Instrumentation

• Overall gain, Time Gain Compensation, digital processing, pre- and post- processing, compound imaging, display systems

• Real time systems

• 2-D, linear, matrix and phased arrays, 3-D, 4-D

3.6.2 Transducers

Understand and describe the principles of:

• Piezoelectric effect

• Design and construction of transducers

• Pulse operation

• Pulse shape and length

• Frequency spectrum

• Beam pattern

• Transducer planes

• Near and far field

• Beam width

• Focusing

3.6.3 Scanning techniques

Understand the principles of transabdominal, transvaginal, and transrectal scanning techniques

Understand the significance and use of protective barriers for endoscanning

Understand the principles of disinfection and sterilisation

3.6.4 Measurement


• Linear, area and volume measurements

• Limitations, equipment and performance testing

• Interobserver and intraobserver error

• The use of tissue phantoms

3.6.5 Image recording and storing

Understand the modalities for archiving

3.6.6 Doppler imaging


• Doppler Effect, including the derivation of basic Doppler formula

• Pulsed Doppler instrumentation

• Continuous wave Doppler

• Basic principles

• Range ambiguity

• Spectral analysis

• Display and recording of Doppler signals

• Colour flow mapping of Doppler signals

• Power Doppler

• Understand the limitations of velocity measurement

3.6.7 Artefacts

• Axial resolution

• Lateral resolution

• Reverberation

• Refraction

• Attenuation, shadowing, enhancement

• Beam width

• Multipath

• Non uniform velocity

• Side lobes

• Electronic noise

• Instrumentation

• Scanning techniques

• Equipment settings

3.7 Obstetric Ultrasound

General Aim Understand and describe the principles underpinning ultrasound assessment of:

• fetal growth and wellbeing in single and multiple pregnancy

• abnormalities in the fetus, placenta, and amniotic fluid in single and multiple pregnancy

• concurrent gynaecological pathology

Specific Objectives 3.7.1 Fetal biometry

Assessment of gestation

• Understand the principles of techniques used in 1st, 2nd, and 3rd trimester measurements

• Understand accuracy of assessment at different gestational ages Assessment of size

• Understand use and limitations of measurement charts • Understand the derivation of estimated fetal weight

3.7.2 Early pregnancy

Understand and describe the normal intrauterine temporal changes during the 1st trimester

PART A: CURRICULUM


3.7.3 Growth and wellbeing assessment

Growth • Understand and describe the limitations of growth charts

Doppler Understand and describe:

• The benefits and limitations of umbilical artery Doppler, with reference to Cochrane review

• Fetal Doppler in IUGR fetuses and their clinical role

Liquor volume and biophysical profile

• Understand the methods used in the measurement of liquor volume and biophysical profile

• Understand the role of liquor volume and biophysical profile in the assessment of fetal wellbeing

3.7.4 Screening Understand the screening techniques associated with assessing:

Aneuploidy

• In the 1st trimester, including nuchal translucency and other ultrasound markers, biochemistry and different combinations used, limitations, application in multiple pregnancy

• In the 2nd trimester, including markers used and their limitations, biochemical screening and different combinations

• Using combination screening, including understanding different approaches – sequential, integrated and contingency

Fetal abnormalities

• In the 1st trimester, including understanding possibilities and limitations, e.g. anencephaly

• In the 2nd trimester, including systematic approach, benefits and limitations, Cochrane evidence on routine screening

The cervix

• Measurement approach

• Current literature

• Current and potential roles in management of preterm birth

Other

• Placental location

• Doppler assessment of uterine artery

• C-section scar monitoring

3.7.5 Fetal abnormalities

Understand and describe the incidence, aetiology, pathology, associated anomalies, diagnosis, prognosis, counselling and management of:

• Normal anatomy and variation with gestation

• Abnormalities of fetal structure

• Thorax

• Fetal hydrops

• Fetal masses

• Amniotic band syndrome

• Genetic syndromes

• Aneuploidy

3.7.6 Placenta, umbilical cord

Understand screening techniques associated with assessing:

Location, including:

• Normal placentation

• Placenta and vasa praevia

• Percreta spectrum

• Role of ultrasound and MRI

Appearance, including:

• Molar

• Tumours

• Haemorrhage

• Cord cysts and masses

3.7.7 Amniotic fluid

Understand the different techniques used in the measurement of amniotic fluid and their limitations

Understand the aetiology and the principles of diagnosis of polyhydramnios and oligohydramnios

3.7.8 Multiple pregnancy

Understand screening techniques associated with assessing:

Chorionicity, including:

• Development and appearances of amnion and chorion with gestational age

• Understanding the relationship between zygosity and chorionicity

Monochorionic complications, including:

• TTTS

• Acardiac twin

• Demise of a twin

• Discordant abnormality

• Discordant growth

Dichorionic complications, including:

• Discordant abnormality

• Discordant growth

• Demise of a twin

3.7.9 Concurrent gynaecological pathology

Understand the principles of diagnosis and management of gynaecological pathology during pregnancy

PART A: CURRICULUM


3.8 Ultrasound and Gynaecology

General Aim Understand and describe the principles underpinning ultrasound assessment of: • Normal ultrasound appearance of the pelvis in both pregnant and non-pregnant women • Gynaecological benign and malignant conditions in both pregnant and non-pregnant women

Understand and describe the role of ultrasound in gynaecological oncology, urogynaecology and reproductive endocrinology and infertility.

Specific Objectives

3.8.1 Non-pregnant Anatomy and normal ultrasound size and appearance Describe the anatomy and normal ultrasound size and appearance of the pelvic organs, including;

• Correlation with menstrual cycle

• Changes in pre-puberty, reproductive, menopause

3.8.2 Benign conditions and ultrasound appearances

Understand and describe the following benign conditions, including ultrasound appearance;

• Congenital anomalies

• Uterine pathology

• Ovarian pathology

• Endometriosis

• PID

• Foreign body localization, including IUCD

• Pelvic cysts, masses and collections

• Adhesions

3.8.3 Malignant conditions and ultrasound appearances

Understand and describe the following malignant conditions, including ultrasound appearance:

• Uterine pathology involving cervix, myometrium and endometrium

• Ovarian pathology, including scoring systems

• Fallopian tubes

• Primary and secondary pelvic malignancies

3.8.4 Role of Doppler

Understand and describe the use and limitations of Doppler ultrasound in gynaecological scanning

3.8.5 Role of ultrasound in reproductive endocrinology and infertility


• Liaison with professionals

• Investigation including procedures used

• Monitoring and management of ART

• Diagnosis and management of complications of ART

• Awareness of emerging practices

3.8.6 Role of ultrasound in Gynaecological Oncology Understand and describe:



3.8.7 Role of ultrasound in Urogynaecology




• 3D pelvic floor studies

3.8.8 Pregnant Intrauterine pathology

Understand and describe the principles underpinning:

• Pregnancy failure

• Trophoblastic disease

3.8.9 Ectopic pregnancies


• Locations, diagnosis and treatment options

3.8.10 Pregnancy of unknown location

Understand and describe the principles underpinning the clinical management and biochemical investigation of pregnancy of unknown location, e.g., correlation of quantitative beta HCG

3.9 Neonatal Ultrasound

General Aim

Understand and describe the principles underpinning ultrasound assessment of intracranial pathophysiology in the neonate.

Specific Objectives

Understand and describe the pathophysiology underlying ischaemia and haemorrhage

Describe:

• Normal brain anatomy

• Appearances of ischaemic change

• Appearances and stages of intracranial haemorrhage

3.10 Abdominal Ultrasound

General Aim

Understand and describe the principles underpinning ultrasound assessment of normal and abnormal abdominal anatomy.

Specific Objectives 3.10.1 Normal anatomy

• Liver

• Kidneys

• Gall bladder

• Bowel

PART A: CURRICULUM


3.10.2 Abnormal

• Hydronephrosis

• Bowel masses

• Gallstones

• Ascites

• Fluid collections

• Liver metastases

3.11 Other Imaging Modalities

General Aim Understand and describe the principles underpinning other imaging modalities.

Specific Objectives

Understand and describe the indications, contraindications and limitations of fetal MRI Understand and describe the application of;

• CT for pelvic masses

• HSG

• Obstetric and post mortem MRI

• Uterine MRI

• X-ray

• Vascular ultrasound

3.12 Analysis of Clinical Information and Research

General Aim

Understand the principles and methods underpinning productive and ethical research, the analysis of clinical information, and the sharing of knowledge in the medical community.

Specific Objectives 3.12.1 Descriptive statistics

Understand the significance and limitations of measures of central tendency;

• Mean

• Standard deviation

• Median

• Mode

3.12.2 Statistical testing

Understand and describe how to;

• Formulate testable hypotheses for a clinical investigation

• Conduct power analyses

• Choose and apply appropriate statistical tests (parametric and non- parametric) to clinical data in order to test hypotheses

• Demonstrate application in research project

3.12.3 Diagnosis Understand and describe how to;

• Calculate the sensitivity and specificity of a clinical investigation and explain its clinical significance

• Calculate predictive value of a positive result of an investigation and explain its clinical significance

• Interpret and discuss the accuracy of screening tests

3.12.4 Health Outcomes

Understand the principles underpinning;

• Audit

• Clinical trials

3.12.5 Clinical Trials

Understand the principles of;

• Cross-sectional analysis

• Cohort

• Case controls

• RCTs

3.12.6 Critical appraisal of the literature

Understand how to critically appraise literature relating to diagnostic imaging in obstetrics, gynaecology and perinatology

3.12.7 Research Projects

• Understand the principles underpinning the development of a research project and writing of reports and papers at a standard for publication

• Understand how to use electronic databases, such as Medline and the Internet, to conduct literature searches

• Understand research methodology related to the design of studies in clinical, epidemiological or laboratory settings

• Understand statistical methods used in publication • Understand the principles underpinning the development and use of data

collection systems • Understand the framework of a published paper

3.12.8 Publications

• Know the current RANZCOG and RCOG guidelines in obstetric and gynaecological ultrasound and perinatology

• Know the relevant Cochrane reviews • Know significant published studies and trials in obstetric and gynaecological

ultrasound and perinatology

3.13 Obstetric Diagnostic and Therapeutic Interventions

General Aim

Understand and describe the principles underpinning obstetric diagnostic and therapeutic interventions.

Specific Objectives 3.13.1 Diagnostic

Understand the indications, contraindications, techniques, complications, advantages and disadvantages of;

• CVS

• Amniocentesis

• FBS

• Fetal biopsy

• Amnio-infusion

• Fetal aspiration

3.13.2 Fetal therapeutic interventions - surgical

• Understand the role of fetal surgery in the clinical and experimental contexts

• Understand the indications, techniques, complications, advantages and disadvantages, ethical and medico-legal considerations of;

• IUT

• Embryo/foetal reduction and fetocide

• Fetoscopy

• Intrauterine laser

• Cord ligation

• Fetal shunting

• Fetal Surgery eg diaphragmatic hernia repair

3.13.3 Fetal therapeutic interventions - medical

Understand the indications, techniques, complications, advantages and disadvantages, ethical and medico-legal considerations of;

• Steroids

• Fetal arrhythmia therapy

• Antibiotics for fetal disease

3.13.4 Fetal anaemia and thrombocytopenia

• Understand the ultrasound measurement and appearances of fetal conditions listed above, including liver length, pericardial effusion, intracranial haemorrhage

• Understand approaches, benefits and complications of fetal transfusion • Understand the incidence, pathophysiology, aetiology, diagnosis and

management of conditions;

• Parental investigations

• Role of MCA Doppler and its limitations

• Amniocentesis for genotyping and bilirubin levels

• FBS

PART A: CURRICULUM


PART A: CURRICULUM


3.14 Gynaecological Diagnostic and Therapeutic Interventions

General Aim

Understand and describe the principles underpinning gynaecological diagnostic and therapeutic interventions.

Specific Objectives 3.14.1 Diagnostic

Understand the indications, contraindications, techniques, complications, and limitations of;

• Saline infusion sonohysterography

• Tubal patency and ultrasound contrast studies

• Aspiration of fluid collections

• Biopsy of masses

3.14.2 Therapeutic

Understand the indications, contraindications, techniques, complications, and limitations of;

• Cyst aspiration

• Fluid collections

• Ectopic pregnancies and methotrexate injection

• Egg collections and other ART procedures

3.15 Consultation

General Aim Understand and describe the principles underpinning professional consultation.

Specific Objectives 3.15.1 Counselling

Understand the principles underpinning preconception, genetic, grief and non- directive counselling

3.15.2 Report Writing

Understand the appropriate wording used and construction of reports

3.15.3 Management and follow-up Understand the principles and importance of;

• Liaising appropriately with referring doctors

• Developing relationships with and fulfilling the duty of care to patients

• Working effectively with multi-disciplinary team

3.16 Professionalism and Management

General Aim

Understand the principles and methods underpinning the teaching and assessment of practical and theoretical concepts.

Specific Objectives • Understand the role and responsibilities of indemnity providers • Understand the importance of continuing professional development • Understand the principles of;

• Business management

• Effective systems for follow-up of results and record storage

• Risk management and practice audit

• Optimizing service delivery

• Protocol development

3.17 Teaching

General Aim

Understand and describe the organisational responsibilities inherent in the practice of obstetric and gynaecological ultrasound.

Specific Objectives • Understand the use of vocabulary that encourages and acknowledges learning • Understand the learning needs of oneself and others

• Understand the principles and methods underpinning teaching, assessment and feedback of practical and theoretical concepts to;

• Midwives

• Sonographers

• Undergraduate students

• OandG trainees

• Subspecialty trainees

• Specialists and subspecialists

3.18 Ethics and the Law

General Aim

Understand and discuss the ethical and legal aspects of obstetric and gynaecological ultrasound

Specific Objectives

• Know the current RANZCOG guidelines on termination of pregnancy

• Understand and discuss the ethical and legal aspects of obstetric and gynaecological ultrasound practice, including:

• Pre-implantation diagnosis

• Gene therapy

• Screening for genetic/fetal abnormality

• Rights of the foetus and neonate

• Termination of pregnancy

• Fetal reduction

• Research on embryo, fetus and neonate

PART A: CURRICULUM


PParartt B:B: CurriCurriCCulumulum

3.0 knowledge and underst1.0andingaims

3.19 Culture

General Aim

Understand and discuss the effect of the woman’s culture on reproduction, gynaecology and ultrasound assessment.

Specific Objectives

• Understand special implications for women’s health services with respect to women of diverse cultural backgrounds, including indigenous women and those with various spiritual beliefs, sexual orientations, lifestyles, beliefs, ages, social status and perceived economic worth.

• Understand and respect the ways in which culture impacts on women’s reaction to pregnancy, obstetric and gynaecological disorders and recommended treatments.

• Have an awareness of the general beliefs, values, behaviours and health practices of particular cultural groups and how these are applied in a clinical situation.

4.0 CLINICAL AND MANAGEMENT SKILLS

CLINICAL AND MANAGEMENT SKILLS FUNDAMENTAL TO THE PRACTICE OF OBSTETRIC and GYNAECOLOGICAL ULTRASOUND

Obstetric and gynaecological ultrasound subspecialists are expected to possess:

• An advanced knowledge of all aspects of ultrasound diagnosis relating to Obstetrics and Gynaecology

• Expertise in the most current approaches to ultrasound guided interventional diagnostic and therapeutic techniques

This requires a detailed factual knowledge of ultrasound physics and how this is exploited to achieve modern ultrasound imaging of pregnancy and the female reproductive system, as well as a comprehensive understanding of the physiological, endocrine and anatomical changes pertinent to menstrual cycling, pregnancy and fetal development and pathologies of the reproductive tract.

Practice at a subspecialist level presupposes a willingness to regularly review and update practices in line with current advances in knowledge and practice. Factual knowledge and clinical skills should be underpinned by effective and sensitive communication skills.

4.1 Obstetrics

General Aim

Be able to investigate, diagnose, counsel, and assist in the treatment and monitoring of complicated pregnancy and counsel and perform image-based screening in the well pregnant woman.

Specific Objectives

• Provide preconception, genetic and grief counselling

• Perform imaging based procedures used in IVF

• Diagnose, counsel and manage miscarriage and pregnancy of unknown location, including familiarity with running of early pregnancy clinic “EPAS”

• Counsel, perform and interpret image-based screening tests for aneuploidy and other fetal abnormality in pregnancy

• Diagnose, manage and counsel a woman with fetal abnormalities, including appropriate ultrasound examination of first, second and third trimester fetal anatomy

PART A: CURRICULUM


PART A: CURRICULUM


• Diagnose and manage fetal conditions, including IUGR, non-immune hydrops, anaemia, thrombocytopenia and cardiac arrhythmias

• Diagnose, manage and counsel the woman exposed to a risk of congenital infection

• Investigate and advise women at risk of preterm labour

• Diagnose, manage and counsel a woman with placental and amniotic fluid abnormalities

• Diagnose and manage a pregnant woman with concurrent gynaecological pathology

• Diagnose and counsel the pregnant woman with ovarian tumours

• Diagnose, counsel and assist in the management of complications of monochorionic and dichorionic multiple pregnancies

• Recognise and counsel a woman with an abnormal postnatal uterus

4.2 Gynaecology

General Aim Be able to investigate, diagnose, and manage gynaecological conditions.

Specific Objectives

• Locate, diagnose and treat ectopic pregnancies

• Investigate and counsel a woman with infertility and recurrent miscarriage

• Perform IVF monitoring

• Diagnose and counsel a woman with ovarian hyperstimulation

• Diagnose and counsel a woman with benign gynaecological disease, including vaginal cysts, myometrial disease, endometrial pathology, adnexal masses and ovarian cysts/tumours

• Diagnose and counsel a woman with polycystic ovarian disease

• Perform and interpret imaging of the woman with various grades of endometriosis

• Perform appropriate ultrasound screening of women on Tamoxifen

• Perform and interpret imaging of the pelvic floor

• Diagnose and counsel women with malignancies affecting the female reproductive tract

4.3 Diagnostic and Procedural Skills

General Aim

Be able to perform ultrasound and procedures relevant to obstetrical, medical and surgical complications of pregnancy and gynaecological conditions.

Specific Objectives

• Perform and interpret the following scans:

• Early pregnancy (<11 weeks)

• Nuchal translucency

• Routine morphology

• Third trimester

• Major fetal abnormality

• Monochorionic pregnancies

• Neonatal head

• Upper abdominal

• Gynaecological

46

• Perform and achieve competency in the following procedures:

• Amniocentesis

• CVS

• Saline Sonography

• HyCoSy, tests of tubal patency

• Ultrasound guidance of curettage/hysteroscopy

• Follicle tracking

• Be familiar with some of the following more specialised procedures during training

• IUT

• Fetocide

• Laser treatment of twin complications

• Fetal surgery eg shunts

• Ultrasound guided injection of ectopic pregnancies

• Gynaecological needling of cysts

• TV and TA OPU

4.4 Management and Professional Skills

General Aim

Trainees should have an awareness of sound management and administrative skills required to run a professional service but these will not be examined. The following areas of management and clinical service delivery should be considered.

Specific Objectives 4.4.1 Management

• Apply basic principles of Human Resources Management, including the steps associated with recruiting staff and the principles of good staff supervision

• Advocate on behalf of junior staff • Counsel staff and mange conflict resolution in the workplace

4.4.2 Administration • Create protocols for management

• Establish and maintaining regional transport systems with appropriate patterns of referral

• Be involved in research advisory and ethics committees • Participate in perinatal data collections systems • Organize and co-ordinate clinical meetings

4.4.3 Clinical Service Delivery

• Take steps to minimise areas of potential complaint in the delivery of clinical services

• Ensure that staff communicate clearly, verbally and in writing, with the women in their care

• Discuss costs, where appropriate, before treatment • Provide consistent information

• Apologise where you have inconvenienced a women in your care or made an error

• Personally discuss complaints with women in one’s care • Be able to convey bad news and sub-optimal outcomes compassionately,

appropriately and in person

PART A: CURRICULUM


4.4.4 Business/Financial Management • Apply the principles of effective bookkeeping

• Understand issues related to insurance, including professional indemnity and public liability

• Understand how income is affected by patient satisfaction and the ability to pay • Be able to convey bad news and sub-optimal outcomes compassionately,

appropriately and in person

4.4.5 Risk Management • Understand the principles and importance of risk management

• Understand the importance and functional basis of continuing professional

development in both the risk management and service improvement context

4.4.6 Relationships with Professional Bodies • Understand the need for accountability and its relationship to registration

• Understand the role of the relevant medical board and healthcare complaints body

• Understand the roles of the RANZCOG

4.4.7 Relationships with Professional Bodies • Understand the principles and importance of:

• good communication

• defining areas of individual responsibility

• collective goal setting

• providing opportunities for all team members to contribute

4.4.8 Time Management

• Understand the principles and importance of time management

4.4.9 Project Management

• Understand the importance of defining the scope of a project, the clustering of tasks and the principles of delegation

4.4.10 Economics

• Understand the basic principles of supply and demand, cost (total/marginal/ average), profit, cost effective analysis and cost utility analysis

• Explain to patients the realities of health resource allocation

4.5 Research Skills

General Aim

Be able to undertake productive and ethical research, and share knowledge in the medical

community.

Specific Objectives

• Use electronic databases such as Medline and the Internet to conduct literature searches and to locate information

• Critically appraise/evaluate relevant literature, reviews and new techniques/technologies • Use word processors, databases, spreadsheets and statistical packages to produce

statistical analyses and research papers • Conduct a literature review • Develop an hypothesis to be tested • Choose an appropriate research methodology and design a research study • Write a grant application to fund a research project • Apply for ethics committee approval for a clinical or laboratory based study • Collect, collate and interpret data

PART B: CURRICULUM

5.0 RECOMMENDED RESOURCES

Part B: CurriCulum

5.0 rECOmmENDED rEsOurCEs

• Apply basic statistical analysis to clinical data • Develop an outline structure for a research paper • Write a literature review for a research paper • Apply the developed outl

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