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Fetal Medicine - Advanced Training Skills Module - Fetal Medicine

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					          Advanced Training Skills Module




                                                                      Fetal Medicine

This module is designed to prepare the future consultant for dealing with congenital abnormalities detected during pregnancy. This includes the organisation and
supervision of screening programmes for structural and chromosomal anomalies. Many of these cases need to be managed within a multidisciplinary team which
includes clinical geneticists and fetal medicine subspecialists. Apart from a sound knowledge of embryology and fetal physiology, clinicians working in this field
must be competent in the prenatal diagnosis of common abnormalties. They also require a sound working knowledge of clinical and laboratory genetics in order
that they can investigate and, where appropriate, refer suitable families.

Competency in ultrasound is a prerequisite for advanced skills in prenatal diagnosis and fetal medicine. A pre-requisite for starting the ATSM is possession of of
all three of the obstetric RCOG/RCR ultrasound modules (Ultrasound & Screening in the First Trimester, Ultrasound of Fetal Anatomy and Ultrasound
assessment of FEtal Size, Fetal Wellbeing & Placenta).

Attendance at the annual “Fetal Medicine” Course run jointly by the RCOG & BMFMS is a compulsory requirement of the module. This must be attended before
completion of the ATSM and can have been done not more than three years previously.

Specifically, once trained, individuals should:
   • Work well as part of a multidiscipliny team
   • Understand the organization of prenatal screening and diagnostic services at a local and regional level
   • Be clinically competent in the prenatal diagnosis, counselling and management of common fetal abnormalities and markers of chromosomal anomality
   • Be clinically competent at amniocentesis
   • Be clinically competent in the counselling and management of families with common genetic diseases (e.g. muscular dystrophy, cystic fibrosis)
   • Understand the neonatal implications of common fetal abnormalties
   • Be aware of their own clinical and professional limitations and comfortable with seeking advice from other specialists or professional groups
   • Be able to undertake and use clinical audit
   • Be able to write evidence based guidelines

The ATSM should be undertaken under the supervision of an identified supervisor, who must be in a position to directly supervise and assess competence. The
supervisor must undertake at least two sessions of obstetric ultrasound per week, at least one of which must include referred cases and involve an appropriate
spectrum of fetal conditions. The trainee will undertake sessions under the supervision of professionals other than the named supervisor. In these




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circumstances, it is the supervisor’s duty to ensure that the professional to whom training is delegated is sufficiently competent, willing and able to teach the
trainee. Dual supervision is also acceptable e.g. with a consultant radiologist with an interest in the field.

A minimum of two sessions per week should be dedicated to this ATSM. In addition to attending fetal medicine / prenatal ultrasound sessions the trainee must
attend four fetal echocardiography sessions, four clinical genetics clinics (preferably combined fetal medicine / genetics), four neonatal ward rounds or clinics,
two perinatal post-mortem examinations and eight sessions in related disciplines (which must include cytogenetics and molecular genetics). In addition the trainee
will be expected to attend at least 2 sessions at a fetal medicine tertiary referral centre (to witness more complex cases and procedures and gain an insight into
referral patterns and organisation of services). Sessions should be documented in the appropriate section of the logbook. The trainee should also develop a
practice guideline and conduct or supervise a audit relevant to the ATSM.




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1. CNS anomalies
Learning Outcomes                To be able to carry out appropriate assessment and management of a fetus with a major CNS anomaly
                                 To understand the management, complications and outcomes of neonates with major CNS anomalies
Knowledge criteria                                     Clinical competency                                     Professional skills and                     Training                 Evidence/
                                                                                                               Attitudes                                   support                  Assessment
Embryology                                             Take an appropriate history                             Ability to take an appropriate history      Observation of and       Log of
-   brain & spinal        cord    (incl.   postnatal                                                                                                       discussion with senior   experience and
    development)                                       Perform an ultrasound scan to assess:                   Ability to                                  medical staff            competence
                                                           • head shape, biometry                              • perform detailed ultrasound
Pathology / Epidemiology                                   • cavum,                                                 assessment of fetal CNS                Appropriate
-   pathology of common major CNS anomalies                • thalami, cortex                                   • reach a differential diagnosis            postgraduate courses
                                                                                                                                                                                    Mini-CEX
-   incidence of CNS anomalies                             • ventricles, choroid plexus                        • perform and interpret appropriate         e.g. Fetal Medicine
-   risk factors                                           • cerebellum, cisterna magna                          investigations                                                     Case-based
-   associated chromosomal anomalies                                                                                                                       Sessions in;             discussions
                                                       Be able   to diagnose the following:                    Ability to                                  •   fetal medicine
Screening / diagnosis                                      •     anencephaly / exencephaly                     • liaise with fetal medicine specialists,   •   neonatology
-   ultrasound       appearance       of     normal        •     spina bifida                                    neonatologists, paediatric                •   perinatal
    embryonic/fetal CNS                                    •     encephalocele                                   neurologists and paediatric surgeons          pathology
-   biometric measurements (incl. transcerebellar          •     ventriculomegaly (all degrees)                  where appropriate (including
    diameter, ventricular size, cisterna magna)            •     holoprosencephaly                               appropriate referral for second           Personal study
-   ultrasound appearances of common CNS                   •     Dandy Walker spectrum                           opinion)
    anomalies (incl. differential diagnosis)                                                                   • formulate, implement and where
                                                       Manage a case of neural tube defect,                      appropriate modify management plan
Management / outcome                                   ventriculomegaly including:                             • counsel women and their partners
-   acrania / exencephaly / anencephaly                •   counsel regarding fetal / infant risks (including     accordingly
-   spinal bifida                                          long term health implications)                           -    fetal (and maternal) risks
-   encephalocele                                      •   arrange / perform appropriate fetal &                    -    long term outcome
-   ventriculomegaly                                       maternal investigations                                  -    postnatal or post mortem
-   holoprosencephaly                                  • refer to fetal medicine centre where                            findings
                                                           appropriate for further counselling /
                                                                                                                   -    recurrence risks
Recurrence risks / prevention                              management
                                                                                                               • formulate management plan for
-   CNS anomalies                                      •    discuss and offer termination if appropriate
                                                                                                                    future pregnancy in collaboration
-   Prevention of neural tube defect                   •    provide appropriate support / follow up of
                                                                                                                    with specialists
                                                            ongoing pregnancy
                                                                                                               • support parent(s)
Pharmacology                                           • plan delivery / appropriate neonatal support in
-   Folic acid                                             collaboration with fetal medicine specialist /
                                                           neonatologist



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2 Cardiac anomalies
Learning Outcomes                To be able to carry out appropriate assessment and management of a fetus with a major cardiac anomaly
                                 To understand the management, complications and outcome of neonates with cardiac anomalies
Knowledge criteria                            Clinical competency                                          Professional skills and                     Training                 Evidence/
                                                                                                           Attitudes                                   support                  Assessment
Embryology                                    Take an appropriate history                                  Ability to take an appropriate history      Observation of and       Log of
-   heart and cardiovascular system                                                                                                                    discussion with senior   experience and
-   circulatory adaptations at birth          Perform   echocardiography to assess:                        Ability to                                  medical staff            competence
                                                  •      cardiac size, position                            • perform echocardiography (including
Pathology / Epidemiology                          •      atria & ventricles                                     Doppler)                               Appropriate
-   pathology      of     major     cardiac       •      outflow tracts                                    • reach a differential diagnosis            postgraduate courses
                                                                                                                                                                                Mini-CEX
    anomalies                                     •      heart rate                                                                                    e.g. Fetal Medicine
-   incidence of major cardiac anomalies                                                                   Ability to                                                           Case-based
-   risk factors (incl. family history)       Be able to diagnose the following:                           • liaise with fetal medicine specialists,   Sessions in;             discussions
-   associated chromosomal / genetic              • atrioventricular and large ventricular septal            paediatric cardiologists and              •   fetal medicine
    (incl. 22q deletions) anomalies                     defects)                                             neonatologists (including appropriate     •   neonatology
                                                  • major valvular abnormalities & hypoplastic               referral for second opinion)              •   perinatal
Screening / diagnosis                                 heart (e.g. aortic / mitral atresia)                 • in collaboration with specialists,            pathology
-   ultrasound appearance of normal               • major outflow tract anomalies (e.g. transposition)       formulate, implement and where            •   paediatric
    fetal heart                                   • arrhythmia                                               appropriate modify management plan            cardiology
-   biometric    measurements       (incl.                                                                 • counsel women and their partners
    chamber sizes)                            Manage a case of septal defect, hypoplastic heart              accordingly                               Personal study
-   ultrasound appearances of major           including:                                                        -    fetal risks
    cardiac anomalies (incl. differential          • counsel regarding likely diagnosis and fetal /             -    long term outcome
    diagnosis)                                           infant risks                                           -    postnatal or post mortem
                                                   • arrange appropriate fetal & maternal investigations             findings
Management / outcome                                     (incl. M-mode, Doppler echocardiography)
                                                                                                               -    recurrence risks
-   septal defects                                 • refer to fetal medicine centre where appropriate
                                                                                                           • formulate management plan for future
-   hypoplastic heart syndromes                          for further counselling / management
                                                                                                                pregnancy in collaboration with
-   outflow tract anomalies                        • discuss and offer termination if appropriate
                                                                                                                specialists
-   arrhythmia                                     • provide appropriate support / follow up of ongoing
                                                                                                           • support parent(s)
                                                         pregnancy
Recurrence risks                                   • plan delivery / appropriate neonatal support in
-   cardiac anomalies                                    collaboration with fetal medicine
                                                         specialist/paediatric cardiologist




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3.          Genitourinary (GU) anomalies

Learning outcomes              To be able to carry out appropriate assessment, counselling and management of a fetus with a major genitourinary anomaly
                               To understand the management, complications and outcomes of neonates with genitourinary anomalies
Knowledge criteria                                Clinical competency                                     Professional skills and                       Training                 Evidence/
                                                                                                          Attitudes                                     support                  Assessment
Embryology                                        Take an appropriate history                             Ability to take an appropriate history        Observation of and       Log of
-   genitor-urinary system (incl. physiology of                                                                                                         discussion with senior   experience and
    fetal urinary system)                         Perform ultrasound scan to assess:                      Ability to                                    medical staff            competence
-   functional adaptations after birth                • renal size                                        • perform detailed ultrasound
                                                      • renal parenchyma & collecting system                   assessment of fetal GU system            Appropriate
Pathology / Epidemiology                              • ureters & bladder                                 • reach a differential diagnosis              postgraduate courses
                                                                                                                                                                                 Mini-CEX
-   pathology of major GU anomalies                   • genitalia                                                                                       e.g. Fetal Medicine
-   incidence of GU anomalies                         • liquor volume                                     Ability to                                                             Case-based
-   risk factors                                                                                          • liaise with fetal medicine specialists,     Sessions in;             discussions
-   associated chromosomal anomalies              Be able to diagnose the following:                        neonatologists, paediatric nephrologists,   •   fetal medicine
                                                      •    renal agenesis                                   paediatric surgeons where appropriate       •   neonatology
Screening / diagnosis                                 •    multicystic / dysplastic kidney                  (including appropriate referral for         •   perinatal
-   ultrasound      appearance     of  normal         •    pylectasis / hydronephrosis                      second opinion)                                 pathology
    embryonic/fetal / neonatal urinary tract                                                              • formulate, implement and where              •   paediatric
                                                      •   lower urinary tract obstruction
-   ultrasound appearances of GU anomalies                                                                  appropriate modify management plan              nephrology
    (incl. differential diagnosis)                                                                        • counsel women and their partners
                                                  Manage a case of renal agenesis, multicystic /
-   biochemical measurement of fetal urine                                                                  accordingly                                 Personal study
                                                  dysplastic kidney, hydronephrosis including:
    function
                                                  •   counsel regarding fetal / infant risks (including
                                                                                                              -    fetal risks
                                                      long term health implications)                          -    long term outcome
Management / outcome                                                                                          -    postnatal or post mortem
                                                  •   arrange / perform appropriate fetal and
-   renal agenesis                                                                                                 findings
                                                      maternal investigations
-   renal cystic disease
                                                  • refer to fetal medicine centre where appropriate          -    recurrence risks
-   hydronephrosis
                                                      for further counselling / management                • formulate management plan for future
-    lower urinary tract obstruction
                                                  •    discuss and offer termination if appropriate           pregnancy in collaboration with
                                                  •    provide appropriate support / follow up of             specialists
Recurrence risks
                                                       ongoing pregnancy                                  • support parent(s)
-   GU anomalies
                                                  • plan delivery / appropriate neonatal support in
                                                      collaboration with fetal medicine
                                                      specialist/neonatologist




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4. Thoracic abnormalities

Learning Outcomes               To be able to carry out appropriate assessment, counselling and management of a fetus with a thoracic anomaly
                                To understand the management, complications and outcomes of neonates with thoracic anomalies
Knowledge criteria                            Clinical competency                                   Professional skills and Attitudes                   Training                 Evidence/
                                                                                                                                                        support                  Assessment
Embryology                                    Take an appropriate history                           Ability to take an appropriate history              Observation of and       Log of
-   Trachea, lungs & diaphragm                                                                                                                          discussion with senior   experience and
-   functional adaptations after birth        Perform ultrasound scan to assess:                    Ability to                                          medical staff            competence
                                                  • chest size and shape                            • perform detailed ultrasound assessment of
Pathology / Epidemiology                          • mediastinal shift                                    fetal thorax                                   Appropriate
-   pathology of pulmonary anomalies              • ribs                                            • reach a differential diagnosis                    postgraduate courses
                                                                                                                                                                                 Mini-CEX
-   incidence of pulmonary anomalies              • lung parenchyma                                                                                     e.g. Fetal Medicine
-   associated chromosomal anomalies              • diaphragm                                       Ability to                                                                   Case-based
                                                                                                    • liaise with fetal medicine specialist,                                     discussions
Screening / diagnosis                         Be able diagnose to the following:                      neonatologists, surgeons (including appropriate   Sessions in;
-   ultrasound appearance of normal               •     CAML                                          referral for second opinion)                      •   fetal medicine
    embryonic/fetal thorax                        •     diaphragmatic hernia                        • in collaboration with specialists, formulate,     •   neonatology
-   ultrasound appearances of major               •     pleural effusion                              implement and where appropriate modify            •   paediatric
    pulmonary anomalies (incl. differential                                                           management plan                                       surgery
    diagnosis)                                Manage a case of CAML, diaphragmatic hernia           • counsel women and their partners accordingly      •   perinatal
                                              including:                                                -    fetal risks                                    pathology
Management / outcome                          •    counsel regarding fetal / infant risks               -    long term outcome
-   cystic adenomatoid malformation of        •    arrange appropriate fetal investigations             -    postnatal or post mortem findings          Personal study
    lung (CAML)                               • refer to fetal medicine centre for further
                                                                                                        -    recurrence risks
-   diaphragmatic hernia                           counselling / management
                                                                                                    • formulate management plan for future
-   pleural effusion                           •    discuss and offer termination if appropriate
                                                                                                        pregnancy in collaboration with specialists
                                               •    provide appropriate support / follow up of
                                                                                                    support parent(s)
Recurrence risks                                    ongoing pregnancy
-   major pulmonary anomalies                 • plan delivery / appropriate neonatal support in
                                                   collaboration with fetal medicine specialist /
                                                   neonatologist / paediatric surgeon




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

Knowledge criteria                             Clinical competency                                     Professional skills and Attitudes              Training                 Evidence/
                                                                                                                                                      support                  Assessment
Embryology                                     Take an appropriate history                             Ability to take an appropriate history         Observation of and       Log of experience
-   Abdominal wall                                                                                                                                    discussion with senior   and competence
-   Gastrointestinal tract                     Perform ultrasound scan to assess:                      Ability to                                     medical staff
                                                   • abdominal shape & biometry                        • perform detailed ultrasound assessment of
                                                                                                                                                                               Mini-CEX
Pathology / Epidemiology                           • abdominal wall / cord insertion                        fetal AW and GI tract                     Appropriate
-   pathology of AW and GI anomalies               • stomach, small & large bowel                      • reach a differential diagnosis               postgraduate courses
-   incidence of AW and GI anomalies               • liver, gallbladder                                • perform and interpret appropriate            e.g. Fetal Medicine      Case-based
-   risk factors                                   • intrahepatic vein & ductus venosus                  investigations                                                        discussions
-   associated chromosomal anomalies                                                                                                                  Sessions in;
                                               Be able to diagnose the following:                      Ability to                                     •   fetal medicine
Screening / diagnosis                              •     gastroschisis / body wall defect              • formulate, implement and where               •   neonatology
-   ultrasound appearance of normal                •     umbilical hernia / exomphalos                   appropriate modify management plan           •   paediatric
    embryonic/fetal AW and GI tract                •     absent / enlarged stomach                     • liaise with fetal medicine specialists,          surgery
-   ultrasound appearances of AW and GI            •     bowel atresia                                   neonatologists, paediatric surgeons          •   perinatal
    anomalies (incl. differential diagnosis)       •     echogenic bowel                                 (including appropriate referral for second       pathology
                                                   •     ascites                                         opinion)
Management / outcome                                                                                   • counsel women and their partners             Personal study
-   gastroschisis                              Manage a case of AW defect, bowel atresia,                accordingly
-   umbilical hernia / exomphalos              echogenic bowel including:                                  -    fetal risks
-   bowel atresia (incl. oesophageal &         •   counsel regarding fetal / infant risks (including       -    long term outcome
    duodenal atresia)                              long term health implications)                          -    postnatal or post mortem findings
-   echogenic bowel                            •   arrange / perform appropriate fetal
                                                                                                           -    recurrence risks
                                                   investigations
                                                                                                       • formulate management plan for future
Recurrence risks                               • refer to fetal medicine centre where appropriate
                                                                                                           pregnancy in collaboration with
-   major AW and GI anomalies                      for further counselling / management
                                                                                                           specialists
                                               •    discuss and offer termination if appropriate
                                                                                                       • support parent(s)
                                               •    provide appropriate support / follow up of
                                                    ongoing pregnancy
                                               • plan delivery / appropriate neonatal support in
                                                   collaboration with fetal medicine specialist /
                                                   paediatric surgeon



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

Knowledge criteria                               Clinical competency                                Professional skills and Attitudes                  Training                 Evidence/
                                                                                                                                                       support                  Assessment
Embryology                                       Take an appropriate history                        Ability to take an appropriate history             Observation of and       Log of experience
-   Fetal face                                                                                                                                         discussion with senior   and competence
-   Fetal neck                                   Perform ultrasound scan to assess:                 Ability to                                         medical staff
                                                     • head shape & biometry (incl. orbital         • perform detailed ultrasound assessment of
                                                                                                                                                                                Mini-CEX
Pathology / Epidemiology                                diameters)                                       fetal neck & face                             Appropriate
-   pathology of neck and facial anomalies           • face and palate                              • reach a differential diagnosis                   postgraduate courses
-   incidence of neck and facial anomalies           • neck                                         • perform and interpret appropriate                e.g. Fetal Medicine      Case-based
-   risk factors                                                                                      investigations                                                            discussions
-   associated chromosomal anomalies             Be able to diagnose the following:                                                                    Sessions in;
                                                     •     cystic hygroma                           Ability to                                         •   fetal medicine
Screening / diagnosis                                •     facial cleft                             • liaise with fetal medicine specialists, facial   •   neonatology
-   ultrasound appearance of normal fetal neck       •     micrognathia                               cleft team, neonatologists, paediatric           •   paediatric
    and face                                                                                          surgeons, facial cleft team (including               surgery
-   ultrasound appearances of neck and facial    Manage a case of cystic hygroma, facial cleft        appropriate referral for second opinion)         •   perinatal
    anomalies (incl. differential diagnosis)     including:                                         • in collaboration with specialists, formulate,        pathology
                                                 •    counsel regarding fetal / infant risks          implement and where appropriate modify
Management / outcome                                  (including long term health implications)       management plan                                  Personal study
-   cystic hygroma                               •    arrange / perform appropriate fetal           • counsel women and their partners
-   facial cleft                                      investigations                                  accordingly
-   micrognathia                                 • refer to fetal medicine centre where                  -    fetal risks
                                                      appropriate for further counselling /              -    long term outcome
Recurrence risks                                      management                                         -    postnatal or post mortem findings
-   Neck and facial anomalies                     •    discuss and offer termination if
                                                                                                         -    recurrence risks
                                                       appropriate
                                                                                                    • formulate management plan for future
                                                  •    provide appropriate support / follow up of
                                                                                                         pregnancy in collaboration with
                                                       ongoing pregnancy
                                                                                                         specialists
                                                 • plan delivery / appropriate neonatal support
                                                                                                    • support parent(s)
                                                      in collaboration with the fetal medicine
                                                      specialist / cleft team




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7            Skeletal anomalies
Learning Outcomes        To be able to carry out appropriate assessment, counselling and management of a fetus with a skeletal anomaly
                         To understand the management, complications and outcomes of neonates with skeletal anomalies

Knowledge criteria                                 Clinical competency                                      Professional skills and                      Training                 Evidence/
                                                                                                            Attitudes                                    support                  Assessment
Embryology                                         Take an appropriate history                              Ability to take an appropriate history       Observation of and       Log of experience
-   Fetal skeleton and spine                                                                                                                             discussion with senior   and competence
                                                   Perform ultrasound scan to assess:                       Ability to                                   medical staff
Pathology / Epidemiology                               • long bone shape & biometry                         • perform detailed ultrasound
                                                                                                                                                                                  Mini-CEX
-   pathology of skeletal anomalies                    • ribs & spine                                         assessment of fetal skeleton               Appropriate
-   incidence of skeletal anomalies                    • mineralisation of skeleton                         • reach a differential diagnosis             postgraduate courses
-   associated chromosomal anomalies                   • feet and hands                                                                                  e.g. Fetal Medicine      Case-based
                                                       • joints                                             Ability to                                                            discussions
Screening / diagnosis                                  • fetal tone and movements                           • liaise with fetal medicine specialists,
-   ultrasound appearance of normal fetal                                                                     geneticists, neonatologists, orthopaedic   Sessions in;
    skeleton                                       Be able to diagnose the following:                         surgeons where appropriate (including      •   fetal medicine
-   ultrasound    appearances      of   skeletal       •     micromelia (due to lethal and non-lethal         appropriate referral for second opinion)   •   neonatology
    anomalies (incl. differential diagnosis)                 dysplasias)                                    • in collaboration with specialists,         •   paediatric
                                                       •     limb reduction defect                            formulate, implement and where                 surgery
Management / outcome                                   •     talipes                                          appropriate modify management plan         •   perinatal
-   lethal skeletal dysplasias (incl.                  •     polydactyly                                    • counsel women and their partners               pathology
    thanatophoric dysplasia, achondrogenesis,                                                                 accordingly
    osteogenesis imperfecta)                       Manage a case of lethal skeletal dysplasia, limb             -    fetal risks                         Personal study
-   achondroplasia                                 reduction defect, talipes including:                         -    long term outcome
-   talipes                                        •   counsel regarding likely fetal diagnosis and fetal       -    postnatal or post mortem
-   limb reduction defect                              / infant risks                                                findings
-   polydactyly                                    •   arrange appropriate fetal & maternal
                                                                                                                -    recurrence risks
                                                       investigations
                                                                                                            • formulate management plan for future
Recurrence risks                                   • refer to fetal medicine centre where appropriate
                                                                                                                pregnancy
-   Skeletal anomalies                                 for further counselling / management
                                                                                                            • support parent(s)
                                                   •    discuss and offer termination if appropriate
                                                   •    provide appropriate support / follow up of
                                                        ongoing pregnancy
                                                   • plan delivery / appropriate neonatal support in
                                                       collaboration with fetal medicine specialist /
                                                       neonatologist



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

Knowledge criteria                                 Clinical competency                                  Professional skills and                     Training                 Evidence/
                                                                                                        Attitudes                                   support                  Assessment
Pathology / Epidemiology                           Take an appropriate history                          Ability to take an appropriate history      Observation of and       Log of experience
-   pathology of fetal hydrops (incl. immune and                                                                                                    discussion with senior   and competence
    non-immune causes)                             Perform ultrasound scan to assess:                   Ability to                                  medical staff
-   incidence of fetal hydrops                         •    cause of hydrops (incl. echocardiography    • perform detailed ultrasound
                                                                                                                                                                             Mini-CEX
-   risk factors                                            and middle cerebral artery Doppler            assessment of fetal hydrops               Appropriate
-   associated chromosomal / genetic /                 • severity of hydrops (incl. amniotic fluid      • reach a differential diagnosis            postgraduate courses
    syndromic anomalies                                   volume                                                                                    e.g. Fetal Medicine      Case-based
                                                       • fetal condition                                Ability to                                                           discussions
Diagnosis                                                                                               • liaise with fetal medicine specialists,   Sessions in;
-   ultrasound appearance of fetal hydrops         Be able to diagnose the following:                     and neonatologists (including referral    •   fetal medicine
    (incl. differential diagnosis)                     •     immune hydrops (see also 4.8)                for second opinion)                       •   genetics
-   role of, echocardiography (see 3.2), MCA           •     non-immune hydrops                         • in collaboration with specialists,        •   neonatology
    doppler and fetal blood sampling                                                                      formulate, implement and where            •   perinatal
                                                   Manage a case of fetal hydrops including:              appropriate modify management plan            pathology
Management / outcome                               •   counsel regarding fetal / infant risks           • counsel women and their partners
-   red cell alloimmunisation                      •   arrange appropriate fetal and maternal             accordingly                               Personal study
-   cardiac arrhymthmias                               investigations                                       -    fetal risks
-   fetal infection                                • refer to fetal medicine centre for further             -    maternal risks
                                                       counselling / management                             -    long term outcome
-   other non-immune causes of hydrops
                                                   •    discuss and offer termination if appropriate
                                                                                                            -    postnatal or post mortem
                                                   •    provide appropriate support / follow up of
Recurrence risks                                                                                                 findings
                                                        ongoing pregnancy
-   immune and non-immune hydrops                                                                           -    recurrence risks
                                                   • plan delivery / appropriate neonatal support in
                                                                                                        • formulate management plan for
                                                       collaboration with fetal medicine specialist /
                                                                                                            future pregnancy in collaboration
                                                       neonatologist
                                                                                                            with specialists
                                                                                                        • support parent(s)




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9            Multiple pregnancies
Learning Outcomes        To be able to carry out appropriate assessment, counselling and management of abnormalities in multiple pregnancies
                         To understand the management, complications and outcomes of abnormalities in twins
Knowledge criteria                                   Clinical competency                                  Professional skills and                  Training                 Evidence/
                                                                                                          Attitudes                                support                  Assessment
Embryology                                           Take an appropriate history                          Ability to take an appropriate history   Observation of and       Log of experience
-   mono- & di-zygous twinning                                                                                                                     discussion with senior   and competence
-   placentation – chorionicity / amnionicity        Perform ultrasound scan in multiple pregnancy to     Ability to                               medical staff
                                                     assess:                                              • perform detailed ultrasound
                                                                                                                                                                            Mini-CEX
Pathology / Epidemiology                             •   chorionicity and amnionicity                       assessment of a multiple pregnancy     Appropriate
-   pathology of abnormalities related to twinning   •   fetal anatomy                                     with a fetal anomaly or discordant      postgraduate courses
    and twin placentation (incl. twin-to-twin        •   fetal growth (see 4.3)                           growth                                   e.g. Fetal Medicine      Case-based
    transfusion syndrome [TTTS], twin reversed                                                            • reach a differential diagnosis                                  discussions
    arterial perfusion [TRAP] and conjoining.        Be able to diagnose the following:                                                            Sessions in;
-   incidence of abnormalities related to twinning       •     Multiple pregnancy with discordant fetal   Ability to                               •   fetal medicine
-   risk factors for twinning and related                      abnormality                                • liaise with fetal medicine             •   neonatology
    anomalies                                            •     Multiple pregnancy with discordant fetal     subspecialists, neonatologists where   •   perinatal
                                                               growth                                       appropriate (including appropriate         pathology
Screening / diagnosis                                    •     TRAP sequence                                referral for second opinion)
-   ultrasound determination of zygosity /               •     Conjoined twin                             • in collaboration with specialists,     Personal study
    chorionicity                                         •     TTTS                                         formulate, implement and where
-   chorionicity and amnionicity                                                                            appropriate modify management
-   ultrasound appearances of abnormalities          Manage a case of multiple pregnancy with fetal         plan
    related to twinning (incl. differential          abnormality/ TTS including:                          • counsel women and their partners
    diagnosis)                                       •   counsel regarding fetal / infant risks (incl.      accordingly
                                                         selective feticide, amnio reduction & laser          -    fetal risks (incl. invasive
Management / outcome                                     ablation)                                                 procedures) neonatal
-   Triplet & higher order multiple pregnancy        •   arrange / perform appropriate fetal and                   management
-   Discordant anomalies in multiples                    maternal investigations
                                                                                                              -    long term outcome
-   TRAP sequence                                    • refer to fetal medicine centre where appropriate
-   Conjoined twins                                      for further counselling / management
                                                                                                              -    postnatal or post mortem
                                                                                                                   findings
-   TTTS                                             •    provide appropriate support / follow up of
-   Discordant fetal growth                               ongoing pregnancy                                   -   delivery
                                                     • plan delivery / appropriate neonatal support in    •   support parent(s)
                                                         collaboration with fetal medicine specialist /
                                                         neonatologist




            09/02/2007
            Advanced Training Skills Module



 10       Disorders of amniotic fluid (AF)
Learning Outcomes       To be able to carry out appropriate assessment, counselling and management of a pregnancy with abnormal AF


Knowledge criteria                              Clinical competency                                                 Professional skills and                  Training          Evidence/
                                                                                                                    Attitudes                                support           Assessment
Embryology / Physiology                         Take an appropriate history                                         Ability to take an appropriate history   Observation of    Log of experience
-   placenta and membranes                                                                                                                                   and discussion    and competence
-   formation / function of amniotic fluid      Perform ultrasound scan to assess AF volume                         Ability to                               with senior
                                                                                                                    • perform detailed ultrasound            medical staff
                                                                                                                                                                               Mini-CEX
Pathology / Epidemiology                        Be able to diagnose and identify cause of:                               assessment of AF
-   pathology of disorders of AF (incl.             •     oligo/an-hydramnios (incl ROM, renal anomaly, FGR,        • reach a differential diagnosis         Appropriate
    secondary effects of early amnion                     postmaturity.                                             • perform and interpret appropriate      postgraduate      Case-based
    rupture & oligohydramnios)                      •     Hydramnios (incl. GI anomaly, neuromuscular anomaly,        investigations                         courses           discussions
-   incidence of AF disorders                             maternal diabetes)                                                                                 e.g. Fetal
-   risk factors                                                                                                    Ability to                               Medicine
-   associated chromosomal anomalies            Manage a case of oligo/an-hydramnios including:                     • liaise with fetal medicine
                                                •   counsel regarding fetal / infant risks                            specialists, neonatologists where      Sessions in;
Diagnosis                                       •   arrange / perform appropriate fetal investigations                appropriate (including appropriate     •   fetal
-   ultrasound measurement of AF                •    institute appropriate maternal and fetal monitoring              referral for second opinion)               medicine
-   diagnosis   of    oligohydramnios     and   •   refer to fetal medicine where appropriate for further           • in collaboration with specialists      •   neonatology
    hydramnios (incl. differential diagnosis)        counselling /management                                          formulate, implement and where         •   genetics
                                                •   plan delivery / appropriate neonatal support in collaboration     appropriate modify management          •   perinatal
Management / outcome                                 with fetal medicine specialist                                   plan                                       pathology
-   oligo/an-hydramnios                                                                                             • counsel women and their partners
-   hydramnios                                                                                                        accordingly                            Personal study
                                                Manage a case of hydramnios including
-   indications for / risks of:                 •   counsel regarding fetal/infant risks (incl. preterm                 -    fetal and neonatal risks
    •    amnioinfusion (see 3.3)                    delivery)                                                           -    maternal risks
    •    amnioreduction                         •   arrange / perform appropriate fetal & maternal                      -    postnatal or post mortem
                                                    investigations                                                           findings
Pharmacology                                    •   refer to fetal medicine centre where appropriate for                -    recurrence risks
-   prostaglandin synthase inhibitors               further counselling                                             • support parent(s)
                                                •    institute appropriate maternal and fetal monitoring
                                                •    institute, where appropriate, maternal medical
                                                     therapy
                                                •    plan delivery / appropriate neonatal support in
                                                     collaboration with fetal medicine specialist



            09/02/2007
            Advanced Training Skills Module



 11.      Termination of pregnancy
Learning Outcomes       To be able to carry out counselling and management of families undergoing TOP for fetal anomaly

Knowledge criteria                                 Clinical competency                                   Professional skills and                      Training                 Evidence/
                                                                                                         Attitudes                                    support                  Assessment
Law / Ethics                                                                                                                                          Observation of and       Log of experience
-   abortion law                                   Manage a case of major fetal anomaly:                 Ability to:                                  discussion with senior   and competence
-   ethics issues relating to TOP for fetal        •   counsel regarding:                                •    reach a definitive diagnosis of major   medical staff
    anomaly                                            - risk / impact of handicap associated with            fetal anomaly (where possible)
                                                                                                                                                                               Mini-CEX
-   guidance on use of feticide                             anomaly                                      •    assess risks of death and/or            Appropriate
Epidemiology                                           - feticide                                             handicap                                postgraduate courses
-   incidence of & indications for TOP for fetal       - methods of TOP (medical & surgical)             •    counsel women and their partners        e.g. Fetal Medicine      Case-based
    anomaly                                            - complications of TOP                                 regarding:                                                       discussions
-   rates of TOP for fetal anomalies and               - post-mortem                                          -    risks of death / handicap          Sessions in:
    factors influencing decision                       - aftercare                                            -    option of TOP ± feticide           •   fetal medicine
Pathology                                          •   plan TOP and post-TOP care                                                                     •   perinatal
-   consent for post-mortem (& tissue              •   arrange appropriate fetal (and maternal)          Ability to                                       pathology
    retention)                                         investigations incl. post-mortem                  • formulate, implement and where             •   genetics
-   conduct of post-mortem examination             •   refer, where appropriate, for further               appropriate modify management plan
Management (incl. methods, complications)              counselling                                         for TOP (incl. post-TOP review)            RCOG Guidance of
-   medical TOP                                    •   conduct post-TOP counselling                      • liaise with fetal medicine specialists,    Late TOP for Fetal
-   surgical TOP (incl. suction aspiration and     •   refer to fetal medicine specialist for feticide     midwives, neonatologists and               Anomaly
    dilatation & evacuation)                                                                               pathologists where appropriate
-   feticide                                       Perform:                                              • counsel women and their partners           Personal study
-   impact of gestational age on complications     •   medical TOP or refer, where appropriate, for        accordingly;
    (physical and psychological)                       same                                                   -    procedure & risks of TOP
Pharmacology                                       •   vacuum aspiration and dilatation / evacuation          -    post-mortem
-   mifepristone                                       or refer, where appropriate, for same             • support women and their partners
-   prostaglandin analogues (incl. cervagem,       •   supportive counselling
                                                                                                         • refer, where appropriate, for further
    misoprostol [see 4.1]                          •   post-TOP counselling incl:
                                                                                                              counselling / support
-   potassium chloride                                 -    postmorterm findings (where appropriate)
Bereavement                                            -    recurrence risks
-   Process and milestones                             -    management plan for future pregnancy
-   Management




            09/02/2007
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12.         Genetic disorders
Learning Outcomes               To be able to carry out appropriate counselling and management in families with a previous genetic disorder


Knowledge criteria                                          Clinical competency                              Professional skills and                     Training                 Evidence/
                                                                                                             Attitudes                                   support                  Assessment
Genetics                                                    Take an appropriate history and construct,       Ability to identify patients with, or at    Observation of and       Log of
-   gene structure & function                               where appropriate, a family tree in patients     risk of a genetic condition                 discussion with senior   experience and
    •    DNA as genetic material                            with or at risk of genetic disease.                                                          medical staff            competence
    •    replication, transcription & translation                                                            Ability to
    •    mechanisms & effects of mutation                   Manage a case with a personal / family history   • liaise with and refer to clinical         Appropriate
-   inheritance & susceptibility                            of:                                                                                          postgraduate courses
                                                                                                                                                                                  Mini-CEX
                                                                                                               geneticist, fetal medicine specialist,
    •    patterns of inheritance of single genes            •    genetic disease (incl. cystic fibrosis,       and associated laboratory disciplines     e.g. Fetal Medicine
    •    genetic heterogeneity (locus & allele)                  muscular dystrophy, haemoglobinopathy,        (incl. cyto- and molecular genetics)
                                                                                                                                                                                  Case-based
    •    new mutations causing single gene disorder              haemophilia)                                • in collaboration with clinical            Sessions in;             discussions
    •    expression & penetrance                            including:                                         geneticists and other specialists,        •   fetal medicine
    •    multifactorial inheritance (incl. summation /      •    counsel about:                                formulate, implement and where            •   genetics
         interaction gene effects, polymorphisms)                -     risk and impact of disease              appropriate modify management plan        •   laboratory
    •    mitochondrial inheritance                               -     information sources & support         • counsel women and their partners              specialties (incl.
                                                                       groups                                  about;                                        cyto- / molecular
Service & Laboratory aspects                                     -     prenatal diagnostic options (incl.    -    genetics in an understandable &            genetics
-   organisation & role of Clinical Genetics Services                  risks timing of tests / results,                                                  •   neonatology
                                                                                                                  non-directive way
-   DNA testing in clinical practice                                   accuracy)                                                                         •   perinatal
                                                                                                             -    fetal risks
    •    ethical & societal issues                               -     management options after testing                                                      pathology
    •    diagnostic, predictive & carrier testing                      (incl. termination of pregnancy)      -    prenatal screening / diagnostic
    •    uses & limitations                                 • refer to Clinical Geneticist or fetal               options (incl. limitations of tests)   Personal study
    •    diagnostic pitfalls                                     medicine centre for further specialist      -    treatment, management
-   indications, methods and limitations (incl. failure /        and/or genetic counselling / management     -    reproductive options
    error rates) of:                                        • plan care of ongoing pregnancy / delivery      • in collaboration with specialists,
    •    cytogenetics                                            in collaboration with fetal medicine             formulate management plan for
    •    FISH                                                    specialist / geneticist                          ongoing and future pregnancies
    •    Mutation detection / PCR                                                                            • support parent(s)
    •    Gene tracking using RFLPs                                                                           • respect confidentiality

                                                                                                             Ability to use genetic testing
                                                                                                             appropriately




            09/02/2007
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Knowledge criteria                                  Clinical competency                           Professional skills and   Training   Evidence/
                                                                                                  Attitudes                 support    Assessment
Methods of prenatal diagnosis (incl. indications,   Perform:
techniques, complications)                          •   detailed ultrasound:
    •    ultrasound                                     -    at appropriate gestation
    •    amniocentesis                                  -    using appropriate technique (incl.
    •    chorion villus sampling (CVS)                       transvaginal, Doppler)
                                                    •   amniocentesis
 Single gene defects
-    epidemiology & inheritance
-    effects of mutation & associated pathology
-    clinical / pathological features
-    prognosis
-    recurrence risks
-    prenatal diagnosis
of the following defects:
    •    cystic fibrosis
    •    muscular dystrophy
    •    haemoglobinopathies
    •    haemophilias




            09/02/2007
             Advanced Training Skills Module



13. Chromosomal disorders
 Learning Outcomes              To be able to carry out appropriate counselling and management in families with a previous chromosomal disorder
                                To be able to carry out appropriate counselling and management of fetal chromosome anomaly
                                To be able to carry to appropriate counselling and management of rarer cytogenetic anomalies including translocations, markers and mosacism.


 Knowledge criteria                                    Clinical competency                                      Professional skills and                     Training                 Evidence/
                                                                                                                Attitudes                                   support                  Assessment
 Chromosomes                                           Take an appropriate history                              Ability to take an appropriate              Observation of and       Log of
 -   structure & function (see 3.2/3.3)                                                                         history                                     discussion with senior   experience and
 -   cell division                                     Manage a case with a personal / family history of a                                                  medical staff            competence
 -   types of abnormality (incl. structural            chromosomal anomaly (incl. structural alterations)       Ability to;
     rearrangements, trisomies, sex chromosome         including:                                               •    counsel women and partners             Appropriate
     anomalies, extra markers, mosaicism)              •    counsel about:                                                                                  postgraduate courses
                                                                                                                                                                                     Mini-CEX
                                                                                                                     -    before screening test
 Screening / diagnosis                                      -     risk and impact of anomaly                         -    after positive result             e.g. Fetal Medicine
 -   biochemical markers (incl. AFP, uE3, hCG,              -     prenatal diagnostic options                   •    formulate, implement and where
                                                                                                                                                                                     Case-based
     PAPP-A, inhibin-A)                                     -     management options after testing                   appropriate modify management          Sessions in;             discussions
 -   ultrasound markers                                •    arrange appropriate fetal & parental                     plan in a woman at ‘higher’ risk of    •   fetal medicine
     •     11-14 weeks (incl. nuchal translucency,          investigations                                           chromosomal anomaly                    •   genetics
           nasal bone, ductus venosus Doppler,         • refer where appropriate for further specialist                                                     •   laboratory
           tricuspid regurgitation)                         and/or genetic counselling / management             Ability to                                      specialties (incl.
     •     18-21 weeks (incl. nuchal oedema,           • plan subsequent care of ongoing pregnancy              • formulate, implement and where                cyto- / molecular
           clinodactyly,       echogenic      bowel,                                                              appropriate modify management                 genetics, serum
           pyelectasis, choroid plexus cysts, nasal    Counsel women about screening for / diagnosis of           plan in a case with a chromosomal             screening)
           bone, short femur/humerus)                  chromosomal anomalies in pregnancy including:              anomaly                                   •   neonatology
 -   Likelihood ratios & risk calculation              •   screening options (biochemistry & ultrasound)        • liaise with fetal medicine specialist,    •   paediatric
 -   screening strategies                              •   diagnostic tests (incl. laboratory methods, risks,     clinical geneticist and cytogenetics          surgery
     •     accuracy     (incl. detection rate, false       accuracy and timing of results)                        and refer where appropriate.              •   perinatal
           positive rate)                                                                                       • counsel women and their partners              pathology
     •     service / cost implications                 Manage a case of chromosomal anomaly diagnosed in          about;
 -   laboratory diagnosis (incl. methods, failure /    pregnancy including;                                     -    fetal risks                            Personal study
     error rates)                                      •   counsel about fetal / infant risks and long term     -    prenatal screening / diagnostic
     •     cytogenetic analysis                            outcome of the following anomalies:                       options (incl. limitations of tests)
     •     FISH                                            -    trisomy 21 (Down syndrome)                      -    reproductive options
     •     PCR                                             -    trisomy 18 (Edward syndrome)
                                                           -    trisomy 13 (Patau syndrome)
                                                           -    45X (Turner syndrome)




             09/02/2007
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Knowledge criteria                                   Clinical competency                                   Professional skills and              Training                  Evidence/
                                                                                                           Attitudes                            support                   Assessment
-   mosaicism       (incl.    classification   and       -    triploidy                                    • formulate management plan for      National Screening
    management)                                          -    common sex chromosome anomalies (incl.           ongoing and future pregnancies   Committee Guidance
-   principles & organisation of screening /                  47XXY (Kleinfelter syndrome), 47XXX)         • support parent(s)                  on Down syndrome
    diagnostic programme for chromosomal             •   counsel about management options (incl. TOP)      • respect confidentiality            screening
    anomalies                                        •   refer where appropriate for further counselling
    •    National Screening Committee                    / support                                         Ability to use chromosomal testing   RCOG Guideline No 8
    •    role of regional screening coordinators     •   plan care of ongoing pregnancy / delivery         appropriately                        Amniocentesis and
    •    quality control & audit                     Perform:                                                                                   chorion villus sampling
                                                     •   Ultrasound screening for chromosomal anomaly
Chromosomal anomalies                                    at:
-    epidemiology                                        -    10-14 wk including:
-    pathology                                           •    nuchal translucency
-    clinical / pathological features                    -    18-21 wk including:
-    prognosis                                           •    nuchal oedema
-    recurrence risks                                    •    echogenic bowel
-    prenatal diagnosis                                  •    ventriculomegaly
of the following chromosomal anomalies                   •    major structural defect
    •    trisomy 21                                  •   risk calculation for trisomy 21 based on
    •    trisomy 18                                      ultrasound (+/- biochemical) markers
    •    trisomy 13                                  •   amniocentesis

    •    Turner syndrome
    •    Kleinfelter syndrome
    •    XXX
    •    triploidy




            09/02/2007
             Advanced Training Skills Module



14. Red cell alloimmunisation
             Learning Outcomes           To understand the principles and practical aspects of screening for and prevention of red cell alloimmunisation
                                         To be able to carry out appropriate assessment and management of a woman with a red cell alloimmunisation
                                         To understand the management, complications and outcome of a neonate with haemolytic disease of the newborn (HDN)
      Knowledge criteria                                              Clinical competency                   Professional skills and                Training support         Evidence /
                                                                                                            attitudes                                                       Assessment
      Blood group systems / pathophysiology                           Take an appropriate obstetric         Ability to take an appropriate         Observation of and       Log of
      -   rhesus (incl. gene structure and prediction of genotype)    history                               history                                discussion with senior   experience &
      -   other red cell antigens causing HDN                         •   past obstetric history                                                   medical staff            competence
      -   fetal pathology in HDN                                      •   timing / method of                Ability to;
      Epidemiology                                                        sensitisation                     •   perform and interpret              Appropriate              Mini-CEX
      -   incidence (alloimmunisation & complications)                                                          appropriate investigations in      postgraduate courses
      -   risk factors (sensitizing events)                           Manage a case of red cell                 fetus at risk of haemolytic                                 Case-based
      Laboratory methods                                              alloimmunisation                          anaemia (incl. MCA Doppler)        Attachments:             discussions
                                                                      •    institute appropriate            •   liaise with fetal medicine         •   fetal medicine
      -   Antibody detection (antiglobulin tests)
      -   Kleihauer testing / flow cytometry for FMH fetomaternal
                                                                           maternal and fetal monitoring        specialists, neonatologists and    •   neonatology
          haemorrhage (FMH)                                           •    assess risk of fetal anaemia         laboratory (haematology/blood
      -   DNA analysis (incl. use of fetal DNA in maternal plasma)         (incl. perform & interpret           transfusion)                       Personal study
      Prevention                                                           MCA Doppler)                     •   in collaboration with fetal
                                                                      •    refer to fetal medicine              medicine specialists, formulate,   RCOG Guideline No22
      -   FMH
      -   organisation & effectiveness of screening and prevention         specialist where appropriate,        implement and where                Anti-D immunoglobulin
          programmes                                                       for further counselling /            appropriate modify a               for rhesus prophylaxis
      Management                                                           management                           management plan for a woman
                                                                      •    plan mode / place / timing of        with red cell antibodies
      -   screening and diagnosis fetal anaemia (incl. MCA Doppler)
      -   hydrops                                                          delivery in collaboration with   •   counsel women and their
      Outcome                                                              specialists                          partners accordingly
                                                                                                                -    prevention of
      -   Neonatal complications of HDN (incl. hyper-
                                                                                                                     alloimmunisation
          bilirubinaemia, anaemia)
      -   Management of complications (incl. exchange transfusion)
                                                                                                                -    fetal / neonatal risks of
      Pharmacology                                                                                                   red cell antibodies
                                                                                                                -    recurrence risks and
      -   Anti-D immunoglobulin
                                                                                                                     management plan for
                                                                                                                     future pregnancy




             09/02/2007
             Advanced Training Skills Module



15.          Fetal growth disorders
             Learning Outcomes            To be able to carry out appropriate assessment and management of the SGA / growth restricted fetus
                                          To be able to understand the management, complications and outcomes of growth restricted neonates
                                          To be able to carry out appropriate assessment and management fetal macrosomia
                                          To understand the management, complications and outcome of neonates with growth disorders
      Knowledge criteria                                            Clinical competency                         Professional skills and attitudes          Training           Evidence /
                                                                                                                                                           support            Assessment
      Fetal growth                                                  Take an appropriate history and perform     Ability to take an appropriate history     Observation of     Log of
                                                                    an exam to screen for fetal growth          and conduct an examination to assess       and discussion     experience &
      -   pattern (incl. organ-specific growth)
                                                                    disorders (incl. use of customized growth   fetal size                                 with senior        competence
      -   causes (incl. fetal, placental & maternal factors)
                                                                    chart)
      Definitions                                                                                                                                          medical staff
                                                                                                                Abilty to                                                     Mini-CEX
      -   small for gestational age (SGA) / FGR                     Perform and interpret the following;
      -   large for gestational age (LGA) / macrosomia                                                          •   perform and interpret ultrasound
                                                                    •   ultrasound morphometry
      Screening / diagnosis                                                                                         in fetus with suspected growth         Sessions in
                                                                    •   umbilical artery Doppler
                                                                                                                    disorder                               •   fetal
      -   previous history                                          •   middle cerebral artery Doppler
                                                                                                                •   formulate, implement and where             medicine
      -   clinical exam (incl. symphysis fundal distance)           •   ductus venosus Doppler
      -   ultrasound morphometry – basic and derived
                                                                                                                    appropriate modify a                   •   neonatology
                                                                    •   biophysical profile (incl. AFV,
          measurements (incl. estimated fetal weight)                                                               management plan
                                                                        CTG)
      -   customised growth charts                                                                              •   liaise where appropriate with          Personal study
      Tests of fetal wellbeing                                                                                      fetal medicine specialists,
                                                                    Manage a case of SGA /FGR
                                                                                                                    neonatologists (incl. appropriate      RCOG Guideline
      Technique, indications for & interpretation of;               •  arrange appropriate
                                                                                                                    referral for second opinion)           No 31 Small-for-
      -   Doppler (umbilical artery (UA), middle cerebral artery       investigations to identify cause
                                                                                                                •   counsel women and their partners       gestational age
          (MCA), ductus venosus (DV))                               •  institute appropriate monitoring
                                                                                                                    accordingly                            fetus
      -   amniotic fluid volume (AFV)                               •  plan time / mode of delivery (incl.
                                                                                                                    -    fetal and neonatal risks (incl.
      -   cardiotocography (incl. computerized analysis)               TOP where appropriate)
      -   biophysical profile                                                                                            consideration, where
                                                                    •  refer to fetal medicine specialist
      Management                                                                                                         appropriate, of TOP)
                                                                       where appropriate for further
                                                                                                                    -    long term health implications
      -   strategy for monitoring                                      counselling / management
                                                                                                                         for infant
      -   timing / mode of delivery
      -   management of FGR in pre-viable/extremely preterm
                                                                                                                    -    recurrence risks and
                                                                    Manage a case of LGA/macrosomia
          fetus & in multiple pregnancy                                                                                  management plan for future
                                                                    •  arrange appropriate
      Outcome                                                                                                            pregnancy
                                                                       investigations to identify cause
      -   neonatal complications of SGA/LGA infant                  •  plan time / mode of delivery
      -   long term health implications of fetal growth disorders



             09/02/2007
             Advanced Training Skills Module



16.          Preconception counselling
             Learning Outcomes           To be able to carry out preconception counselling in families at increased risk of fetal anomaly (including those with family history, prior anomaly, medical
                                         disorder or exposure to teratogenic drugs)


      Knowledge criteria                                       Clinical competency                             Professional skills and attitudes                  Training               Evidence /
                                                                                                                                                                  support                Assessment
      Preconception counselling                                Take an appropriate history                     Ability to take an appropriate history             Observation of         Log of
      -   assessment of risk of fetal anomaly                                                                                                                     and discussion         experience &
          •    personal / family history of genetic disorder   Counsel ‘at risk’ woman/family pre-             Abilty to                                          with senior            competence
          •    prior chromosomal disorder / advanced age       conception                                      •   assess risks of fetal anomaly                  medical staff
          •    prior structural anomaly                        •   risks of fetal anomaly                      •   liaise with clinical geneticists, fetal                                Mini-CEX
          •    current medical disorder e.g. diabetes          •   screening / diagnostic options                  medicine specialists, physicians,
          •    teratogen exposure                              •   refer, where appropriate, to                    teratologists and refer where                  Sessions in            Case-based
      -   investigations (incl. genetic testing)                   clinical geneticist or fetal medicine           appropriate                                    •   clinical           discussions
      -   methods of screening / diagnosis
                                                                   specialist                                  •   counsel women and their partners                   genetics
      -   alternative options (incl. assisted conception /
          preimplantation diagnosis)                                                                               accordingly
                                                                                                                   -    screening / diagnostic options            Personal study
      Teratogenicity                                                                                               -    management plan for future
                                                                                                                        pregnancy
      -   mechanisms of teratogenicity
      -   information sources (including National
          Teratology Centre)
      -   teratogenetic effects of commonly used drugs
          incl:
          •     lithium
          •     warfarin
          •     anti-epileptic drugs
          •     ACE inhibitors
          •     anti-neoplastic drugs
      -   teratogenic effects of radiological investigations




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Advanced Training Skills Module




                                  Competence Level
Skill : Case Management
                                          Observation   Direct Supervision          Independent Practice
                                  Date    Signature     Date     Signature   Date    Signature

CNS anomalies

Anencephaly

Spina bifida

Ventriculomegaly

Choroid plexus cyst

Dandy Walker spectrum

Cardiac anomalies

Septal defects

Hypoplastic heart

Outflow tract anomalies




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Arrhythmia

Genitourinary anomalies

Renal agenesis

Hydronephrosis-renal pelvis ≤ 15mm

                   - renal pelvis > 15mm

Multicystic kidney

Megacystis/LUTO

Thoracic anomalies

Cystic adenomatoid malformation

Diaphragmatic hernia

Pleural effusion

Abdominal wall and gastrointestinal
anomalies
Gastroschisis

Exomphalos

Echogenic bowel




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Advanced Training Skills Module



Bowel atresia (incl.oesophageal / duodenal)

Ascites

Face and neck anomalies

Nuchal oedema / increased nuchal
translucency
Cystic hygroma

Facial cleft

Skeletal anomalies

Lethal skeletal dysplasia

Non-lethal skeletal dysplasia

Talipes

Limb reduction defect

Hydrops

Immune hydrops

Non-immune hydrops

Multiple pregnancy




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Advanced Training Skills Module



Twins with discordant anamaly

Twins with growth discordance

Twin-to-twin transfusion syndrome

Disorders of amniotic fluid volume

Oligohydramnios

Hydramnios

Chromosomal anomalies

Previous - trisomy
         - sex chromosome aneuploidy
Affected fetus – trisomy 21
                - trisomy 18/13
                - 45X
                 -47XXX/47XXY
Genetic anomalies (Previous/family
history/current)
Cystic fibrosis

Muscular dystrophy

Fragile X

Haemoglobinopathy




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Advanced Training Skills Module



Haemphilia / other bleeding disorder

Inborn error of metabolism

Fetal growth disorders

Fetal growth restriction – singleton > 32
weeks
   - singleton ≤ 32 weeks

Macrosomia

Alloimmunisation (non-transfusion
dependent)
Red cell alloimmunisation – anti-D, c

                           - anti-Kell




Procedures                                  Observed      Performed          Performed
                                                       Under supervision   independently
Procedures
20 weekly anomaly scan

11-14 week anomaly scan (including NT)

Umbilical artery Doppler

Middle cerebal artery Doppler



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Ductus venous Doppler

Biophysical profile

Ultrasound assessment of chorionicity

Amniocentesis

Construction of family tree

Pre-conception counselling




Sessions Attended                       Date   Supervisors signature


Fetal echocardiography clinic
Fetal echocardiography clinic
Fetal echocardiography clinic
Fetal echocardiography clinic
Clinical genetics clinic
Clinical genetics clinic
Clinical genetics clinic
Clinical genetics clinic
Neonatal ward round / clinic
Neonatal ward round / clinic
Neonatal ward round / clinic


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Advanced Training Skills Module



Neonatal ward round / clinic
Fetal postmortem
Fetal postmortem
Other sessions (list)
Cytogenetics
Molecular genetics




Regional Fetal Medicine Unit
Regional Fetal Medicine Unit




Written reports                   Date   Supervisors signature


Audit
Title
Guideline
Title




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Advanced Training Skills Module




Training Courses or sessions

                      Title                                                                           Date
                                                                Signature of educational supervisor




Authorisation of Signatures – please print your name and sign below

Name (please print)                                                    Signature




09/02/2007
Advanced Training Skills Module




Completion of Module
I confirm that all components of the module have been successfully completed



Date

Name of Educational Superviser

Signature of Educational Superviser




09/02/2007

				
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