Ultrasound and Screening in the First Trimester. Acute Gynaecology and Early Pregnancy

Transcription

1 Ultrasound Modules Appendix 1b Ultrasound modules are free standing, and in the new curriculum they can be undertaken as part of the relevant Advanced Training Skills Module as follows: Ultrasound Module Ultrasound and Screening in the First Trimester Ultrasound of Fetal Anatomy Ultrasound Assessment of Fetal Size, Fetal Wellbeing and Placenta Investigation of menstrual disorders, the postmenopause and pelvic pain Investigation of menstrual disorders, infertility and early pregnancy complications ATSM Title Acute Gynaecology and Early Pregnancy Fetal Medicine Advanced Antenatal Practice Menopause Sub-fertility and Reproductive Endocrinology Acute Gynaecology and Early Pregnancy

2 Curriculum module 1: Ultrasound and screening in the first trimester Learning outcomes The overall aim of this module is to ensure that the trainee is competent in TVS, independent scanning and reporting. Also to understand and demonstrate the appropriate knowledge skills and attitudes to undertake Screening procedures for the assessment of risk of aneuploidy in the first trimester Knowledge criteria Clinical competency Professional skills and Attitudes Training support Evidence/ Assessment Principles of ultrasound examination 1. Physics 2. Safety 3. Machine set-up 4. Patient care 5. Principles of report writing 6. Consent 7. Cultural Diversity Understand the principles of conducting a safe and appropriate transabdominal and transvaginal ultrasound examination. Use an ultrasound machine competently and independently Safe use of the ultrasound machine Appropriate care of the patient during examination Course including both: Theory Practical demonstration of machine use and reporting Certificate of attendance at course Case Discussion in Clinic

3 Knowledge criteria Clinical competency Professional skills and Attitudes Training support Evidence/ Assessment Documentation of scan OSAT: 1. Understand need for accurate documentation of scan 2. Record appropriate images To write a structured report of the scan findings and keep appropriate hard copy or video records of anomalies Communicate scan findings to other health professionals Supervised structured clinical learning sessions Ultrasound assessment of intrauterine pregnancy. Transabdominal Ultrasound assessment of adnexae in early pregnancy

4 Normal Ultrasound Findings 1. Recognise fetal heart beat 2. Know requirements for early pregnancy scanning RCOG guidelines 3. Know anatomical landmarks for performing standard fetal measurements: i.e. [CRL] [MGSD] 4. Recognise normal appearance of adenxal structures 5. Know the appropriate assessment of risks of aneuploidy using serum markers Identify fetal position within uterus Identify fetal number and chorionicity Be able to move probe with purpose to identify uterus and adnexae Be able to consistently and systematically identify the features of intra uterine and extra uterine gestation Be able to perform standard fetal measurements [CRL] [MGSD] Identify common adnexal abnormalities Recognise limits of competency Recall patients appropriately for further scans in cases of pregnancy of unknown location and interpret the findings with correlation to Serum bhcg Conduct scan to appropriate standard. Mandatory education and training sessions Theoretical course (local or RCOG) Supervised structured clinical learning sessions Attendance at first trimester scans and the Early Pregnancy Unit (EPA) unit Personal study Textbooks of obstetric ultrasound Relevant green top guidelines Guidance on Ultrasound Procedures in Early Pregnancy (published jointly with the Royal College of Radiologists) Certificate of course attendance Certificate of course attendance Log of experience Case Discussion in Clinic OSAT: Transabdominal ultrasound assessment of adnexae in early pregnancy Transvaginal ultrasound assessment of ectopic pregnancy Ultrasound assessment of early pregnancy complications Ultrasound assessment of intrauterine pregnancy.

5 Management of abnormalities of the first trimester 1. Recognise fetal heart beat 2. - Recognise signs of intra uterine gestation. - Assign gestational age, gestational number, and - Chorionicity in multiple pregnancy 2. Be aware of appropriate investigations Identify signs of normal and abnormal first trimester Advise appropriate investigations if abnormality identified Appropriate referral for more complex or detailed evaluation with ultrasound Appropriate management for risk assessment for screening Recognition and appropriate management or onward referral of abnormality Mandatory education and training sessions Theoretical course (local or RCOG) Supervised structured clinical learning sessions Personal study textbooks of fetal ultrasound Certificate of course attendance Log of experience Case Discussion in clinic OSAT: Ultrasound assessment of early pregnancy complications Transvaginal assessment of ectopic pregnancy Early pregnancy scan including recording images Counselling of abnormal scan findings with parents

6 Communication Provide parents with information about: 1. Provide parents with necessary information in a form they understand 2. Communicate scan findings and information given to parents to other health professionals 1. Normal scan findings 2. Screening 1. Counsel about serum and NT screening to include risks of invasive procedure 2. Counsel about scan abnormality 3. Discuss risks and benefits of invasive testing if appropriate 4. Counsel about termination of pregnancy if appropriate Communicate relevant information to parents and other health professionals Supervised structured clinical learning sessions Case discussion in clinic OSAT: Counselling of abnormal scan findings with parents

7 Objective structured assessment of technical skill Transabdominal ultrasound assessment of adnexae in early pregnancy Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection - transabdominal 3 Identify bladder and right/left orientation 4 Identify uterus and endometrium 5 Identify ovaries 6 Assess pouch of Douglas 7 Identify site of pregnancy and embryonic heartbeat 8 Measure CRL or [MGSD] 9 Interpret ultrasound findings in the context of the clinical setting 10 Communicate results to patient 11 Complete ultrasound report 12 Arrange appropriate follow up Comments Done independently Needs help Signed August

8 Objective structured assessment of technical skill Transvaginal ultrasound assessment of ectopic pregnancy Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection - transvaginal 3 Identify bladder and right/left orientation 4 Identify uterus and endometrium 5 Identify ovaries 6 Assess pouch of Douglas 7 Identify site of pregnancy and identify embryonic heartbeat 8 Identify gestation sac and/or embryo and measure sac diameter [MGSD] and/or crown rump length [CRL] 9 Interpret ultrasound findings in the context of the clinical setting In clinical setting interpret ultrasound findings 10 Communicate results to patient 11 Complete ultrasound report 12 Arrange appropriate follow up Comments Done independently Needs help Signed August

9 Objective structured assessment of technical skill Ultrasound assessment of early pregnancy Complications (Transabdominal and Transvaginal) Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection 3 Identify bladder and right/left orientation 4 Identify uterus and endometrium 5 Identify ovaries 6 Assess pouch of Douglas 7 Identify site of pregnancy and embryonic heartbeat 8 Identify gestation sac and/or embryo and measure MGSD and crown rump length [CRL] 9 Interpret ultrasound findings in clinical setting 10 Communicate results to patient 11 Complete ultrasound report 12 Arrange appropriate follow up Comments Done independently Needs help Signed August

10 Objective structured assessment of technical skill Ultrasound assessment of intrauterine Pregnancy (Including transvaginal scanning) Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure Done independently Needs help 2 Appropriate machine setup/probe selection 4 Determine fetal number 6 Measure CRL and/or MGSD transabdominally and transvaginally 5 Determine chorionicity 3 Identify fetal heart beat 7 Interpret ultrasound findings in the context of the clinical setting 8 Communicate results to patient 9 Complete ultrasound report 10 Arrange appropriate follow up Iif necessary Comments Signed August

11 MODULE 1 TOPIC : Ultrasound in the first trimester Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Safe use of US machine + correct settings Probe orientation, probe care and infection control (transabdominal and transvaginal) Confirmation of site of pregnancy Confirmation of fetal viability Accurate measurement of MGSD, CRL, (and NT). Adnexal assessment Accurate documentation of

12 measurements and observations, including chart plotting Producing written summary and interpretation of results Communicating normal results to parents Communicating abnormal results to parents Arranging appropriate follow up or intervention Working in a multi-disciplinary team Training Courses or sessions Title Signature of educational supervisor Date

13 Authorisation of Signatures please print your name and sign below Name (please print) Signature

14 Curriculum module 2: Ultrasound of fetal anatomy Learning outcomes To understand and demonstrate appropriate knowledge, skills and attitudes to perform a fetal anomaly scan, including perform a normal scan, recognise common abnormalities, communicate normal and abnormal results, know limits of competence, complete appropriate documentation Knowledge criteria Clinical competency Professional skills and Attitudes Training support Evidence/ Assessment Principles of ultrasound examination 1. Physics 2. Safety 3. Machine set-up 4. Patient care 5. Principles of report writing 6. Consent 7. Cultural Diversity Understand the principles of conducting a safe and appropriate ultrasound examination Use an ultrasound machine competently and independently Safe use of the ultrasound machine Appropriate care of the patient during examination Course including both: Theory Practical demonstration of machine use and reporting Certificate of attendance at course Case Discussion in clinic

15 Knowledge criteria Clinical competency Professional skills and Attitudes Training support Evidence/ Assessment Documentation of scan 1. Understand need for accurate documentation of scan 2. Record appropriate images Record scan findings clearly and accurately and keep appropriate hard copy or video records of anomalies. Communicate scan findings to other health professionals Supervised structured clinical learning sessions OSAT: Anomaly scan including recording images of fetus Counselling of normal scan findings with parents Counselling of abnormal scan findings with parents

16 Anomaly scan 1. Know requirements for minimal and optimal anomaly scan as defined in RCOG report 2000, Ultrasound screening 2. Know anatomical landmarks for performing standard fetal measurements (BPD, HC, AC, FL) 3. Recognise normal appearance of fetal structures and appreciate different appearance at different gestations 4. Know the detection rates of common anomalies Identify fetal position within uterus Be able to move probe with purpose to identify fetal structures Be able to consistently and systematically identify the features described in an optimal anomaly scan as described in RCOG report 2000, Ultrasound Screening Be able to perform standard fetal measurements (BPD, HC, AC, FL) Transcerebellar diameter, Ventricular atrium, nuchal pad, cisterna magna, renal pelvis AP diameter. Identify placental site Recognise limits of competency Recall patients appropriately for further scans if structures not seen clearly Conduct scan to appropriate standard. Mandatory education and training sessions Theoretical course (local or RCOG) Supervised structured clinical learning sessions Attendance at anomaly scans Personal study Textbooks of obstetric ultrasound RCOG/RCR report 2000 Ultrasound Screening RCOG/RCR report 1997 Ultrasound Screening for Fetal Abnormalities Relevant green top guidelines Certificate of course attendance Case discussion in clinic OSAT: Fetal Biometry Anomaly Scan including recording images of fetus

17 Management of anomalies 1. Recognise common anomalies 2. Be aware of appropriate investigations when an anomaly is identified Identify anomalies Advise appropriate investigations if anomalies identified Appropriate referral for more complex or detailed evaluation with ultrasound Recognition and appropriate management or onward referral of anomalies Mandatory education and training sessions Theoretical course (local or RCOG) Supervised structured clinical learning sessions Personal study textbooks of fetal ultrasound Log of experience Certificate of course attendance Case discussion in clinic OSAT: Anomaly Scan including recording images of fetus Communication 1. Provide parents with necessary information in a form they understand 2. Communicate scan findings and information given to parents to other health professionals Provide parents with information about: 1. Normal scan findings 2. Abilities and limitations of ultrasound If an anomaly is identified: 1. Counsel about ultrasound soft marker 2. Counsel about structural anomaly 3. Discuss risks and benefits of invasive testing if appropriate 4. Counsel about termination of pregnancy if appropriate and methods required at different gestation 5. Counsel about further in utero management. Communicate relevant information to parents and other health professionals Supervised structured clinical learning sessions Case discussion in clinic OSAT: Counselling of abnormal scan findings with parents

18 Objective structured assessment of technical skill FETAL BIOMETRY Trainee Name: Level of training: Grade/Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection 3 Confirm fetal heartbeat 4 Measure BPD, HC, TCD, AC, FL transabdominally 5 Demonstrate normal anatomy 6 Demonstrate Biometric anomalies detected on scan and note differences from normal 7 Communicate results to patient and uncertainties 8 Identify placental site or position in relation to the cervical canal if appropriate 9 Assess liquor volume 10 Discuss appropriate referral to other specialities, if indicated 11 Ensure images and video are recorded according to local protocol Comments Done Independently Needs help Signed August 2006

19 Objective structured assessment of technical skill ANOMALY SCAN INCLUDING RECORDING IMAGES OF FETUS Trainee Name: Level of training: Grade/Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection 3 Confirm fetal heartbeat 4 Demonstrate normal anatomy and normal biometry including BPD, HC (Atrial measurements lateral ventricle), TCD, AC, FL 5 Demonstrate anomaly(s) detected on scan and differences from normal 6 Communicate results to parents and uncertainties regarding diagnosis & prognosis 7 Identify placental site or placental position in relation to the cervical canal if appropriate 8 Assess liquor volume 9 Discuss appropriate referral to other specialities, if indicated 10 Ensure images and video are recorded according to local protocol Comments Done independently Needs help Signed August 2006

20 MODULE 2 TOPIC : Ultrasound of fetal anatomy Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Safe use of US machine + correct settings Accurate measurements of BPD, HC, FL, TCD and lateral atrial diameter of the cerebral ventricles Confirm normal anatomy of head and face Confirm normal anatomy of spine Confirm normal anatomy of heart and chest Confirm normal anatomy of abdomen Confirm normal anatomy of limbs Perform full anomaly scan

21 Recognise common structural anomalies Accurate documentation of measurements and observations, including chart plotting Producing written summary and interpretation of results Communicating normal results to parents Communicating abnormal results to parents Arranging appropriate follow up or intervention Working in a multi-disciplinary team Training Courses or sessions Title Signature of educational supervisor Date

22 Authorisation of Signatures please print your name and sign below Name (please print) Signature

23 Curriculum Module 3: Ultrasound assessment of fetal size, fetal wellbeing and placenta Learning outcomes To be able to carry out appropriate ultrasound assessment of fetal size and growth/lie/presentation To be able to carry out appropriate ultrasound assessment of fetal wellbeing To be able to carry out appropriate counselling and management of small and/or growth restricted fetus To be able to refer, where appropriate, cases with preterm fetal compromise To be able to carry out appropriate assessment, counselling and management of placenta praevia Knowledge criteria Clinical competency Professional skills and Attitudes Training support Evidence/ Assessment Principles of ultrasound examination 1. Physics 2. Safety 3. Machine set-up 4. Patient care 5. Principles of report writing 6. Consent 7. Cultural Diversity Understand the principles of conducting a safe and appropriate ultrasound examination Use an ultrasound machine competently and independently Safe use of the ultrasound machine Appropriate care of the patient during examination Course including both: Theory Practical demonstration of machine use and reporting Certificate of attendance at course Case discussion in clinic

24 Knowledge criteria Clinical competency Professional skills and Attitudes Training support Evidence/ Assessment Documentation of scan 1. Understand need for accurate documentation of scan Record scan findings clearly and accurately and keep appropriate hard copy or video records of anomalies. Communicate scan findings to other health professionals Supervised structured clinical learning sessions OSAT: Fetal Biometry Anomaly scan including recording images of fetus 2. Record appropriate images Counselling of normal scan findings with parents Counselling of abnormal scan findings with parents

25 Knowledge criteria Clinical competency Professional skills and Attitudes Biometry 8. Fetal growth Physiology Pathology - Maternal - Placental - Fetal 9. Fetal biometry Anatomical landmarks Reference charts Interpretation (including variability) Calculation and value of; - Ratios - Estimated fetal weight 10. SGA vs FGR Definition (fetal & neonatal) Outcome impact on mortality and morbidity Be able to perform and interpret standard fetal measurements: HC (BPD) AC FL EFW Manage a healthy SGA fetus including: Appropriate follow up Referral for further assessment Plan delivery Manage a compromised SGA fetus including: Appropriate follow up Referral for further assessment Plan delivery Conduct scan to assess fetal size / growth to appropriate standard Communicate scan findings to patient and other professionals Training support Mandatory education and training sessions Supervised structured clinical learning sessions Personal study Textbooks of obstetric ultrasound and relevant reviews/papers Green top guideline Investigation and management of the SGA fetus. The investigation and Management of the Smallfor-Gestational-Age Fetus (31) Nov 2002 Evidence/ Assessment Log of experience Fetal Biometry Case discussion in clinic OSAT: Anomaly scan including recording images of fetus Counselling of scan findings with parents

26 Knowledge criteria Clinical competency Professional skills and Attitudes Amniotic Fluid Training support Evidence/ Assessment 1. Amniotic fluid volume Physiology Change with gestation Pathology 2. Ultrasound measurement Subjective vs objective Max vertical pocket / AFI Reference charts Interpretation (including variability) 3. Oligohydramnios Definition Outcome Be able to perform and interpret assessment of AFV using ultrasound Be able to incorporate assessment of AFV into global assessment of fetal wellbeing and manage accordingly including: Appropriate follow up Referral for further assessment Plan delivery Conduct scan to assess amniotic fluid volume to appropriate standard Communicate scan findings to patient and other professionals Mandatory education and training sessions Supervised structured clinical learning sessions Personal study Textbooks of obstetric ultrasound and relevant reviews/papers Green top guideline Investigation and management of the SGA fetus. Log of experience Case discussion in clinic OSAT: Ultrasound assessment of maternal and fetal wellbeing 4. Polyhydramnios 5. Outcome

27 Knowledge criteria Clinical competency Professional skills and Attitudes Umbilical artery Doppler Training support Evidence/ Assessment 1. Fetoplacental circulation Anatomy Pathology in SGA and FGR 2. Ultrasound assessment Indices Reference charts Interpretation (including variability) 3. Abnormal UA Doppler Classification Outcome Be able to perform and interpret UA Doppler Be able to incorporate UA Doppler into global assessment of fetal wellbeing and manage accordingly including: Appropriate follow up Referral for further assessment Plan delivery Conduct scan to assess UA Doppler to appropriate standard Communicate UA Doppler result to patient and other professionals Mandatory education and training sessions Supervised structured clinical learning sessions Personal study Textbooks of obstetric ultrasound and relevant reviews/papers Green top guideline Investigation and management of the SGA fetus. Log of experience Case discussion in clinic OSAT: Ultrasound assessment of maternal and fetal wellbeing

28 Placenta and cervix 1. Ultrasound assessment of site Transabdominal ultrasound Transvaginal ultrasound - Indication - Interpretation 2. Placenta praevia Classification Management Outcome 3. Transvaginal assessment of the cervix Be able to perform and interpret ultrasound assessment of placental site - transabdominally - transvaginally Be able to manage placenta praevia including: Appropriate follow up Referral for further assessment (e.g. anterior PP with previous CS) Plan delivery Conduct transabdominal and, where appropriate, transvaginal scan to assess placental position. Communicate result to patient and other professionals Communicate results to patient and other professional(s) Mandatory education and training sessions Supervised structured clinical learning sessions Personal study Textbooks of obstetric ultrasound and relevant reviews/papers Green top guideline Placenta praevia: diagnosis and management. Log of experience Case discussion in clinic OSAT: Ultrasound assessment of placenta Be able to assess the cervix in relation to pre-term labour

29 Objective structured assessment of technical skill FETAL BIOMETRY Trainee Name: Level of training: Grade/Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection 3 Confirm fetal heartbeat 4 Measure BPD, HC, TCD, AC, FL transabdominally 5 Demonstrate normal anatomy 6 Demonstrate Biometric anomalies detected on scan and note differences from normal 7 Communicate results to patient and uncertainties 8 Identify placental site or position in relation to the cervical canal if appropriate 9 Assess liquor volume 10 Discuss appropriate referral to other specialities, if indicated 11 Ensure images and video are recorded according to local protocol Comments Done Independently Needs help Signed August 2006

30 Objective structured assessment of technical skill Ultrasound assessment of maternal and fetal wellbeing Trainee Name: Level of training: Grade/Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup / probe selection 3 Assess fetal movement and fetal lie 4 Measure BPD, HC, AC and FL transabdominally 5 Measure amniotic fluid volume 6 Record umbilical artery Doppler waveform 7 Measure umbilical artery indices 8 Interpret amniotic fluid volume AND umbilical artery Doppler 9 Communicate results to patient 10 Complete ultrasound report 11 Arrange appropriate follow up Comments Done independently Needs help Signed August 2006

31 Objective structured assessment of technical skill Ultrasound assessment of placenta Trainee Name: Level of training: Grade/Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup / probe selection 3 Determine placental position - transabdominally 4 - transvaginally 5 Determine cervical length and appearance (transvaginal) 6 Communicate results to patient 7 Complete ultrasound report 8 Arrange appropriate follow up Comments Done independently Needs help Signed.. August 2006

32 MODULE 3 TOPIC : Ultrasound assessment of fetal size, fetal wellbeing and placenta Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Safe use of US machine + correct settings Accurate measurement of BPD/HC, FAC, FL, EFW Accurate documentation of measurements and observations, including chart plotting Assessment of liquor volume Accurate measurement of AFI Assessment of placental position using the transabdominal and the transvaginal route Assessment of the cervix using the transvaginal route

33 Accurate acquisition and analysis of Doppler trace and indices. Producing written summary and interpretation of results Communicating normal results to parents Communicating abnormal results to parents Arranging appropriate follow up or intervention. Working in a multi-disciplinary team Training Courses or sessions Title Signature of educational supervisor Date

34 Authorisation of Signatures please print your name and sign below Name (please print) Signature

35 Training Ultrasound Skills Module: Gynaecology and the older woman Learning Outcomes: To develop knowledge and skills, which should enable the candidate to independently perform and report ultrasound to include transabdominal and transvaginal in the above patient group Knowledge criteria Clinical competency Professional skills and Attitudes Principles of ultrasound examination 1. Physics 2. Safety 3. Machine set-up 4. Patient care 5. Principles of report writing 6. Consent 7. Cultural Diversity Understand the principles of conducting a safe and appropriate transabdominal and transvaginal ultrasound examination. Use an ultrasound machine competently and independently Safe use of the ultrasound machine Appropriate care of the patient during examination Training support Course including both: Theory Practical demonstration of machine use and reporting Evidence/ Assessment Certificate of attendance at course Documentation of scan Understand need for accurate documentation of scan To write a structured report of the scan findings and keep appropriate hard copy or video records of anomalies Communicate scan findings to other health professionals Supervised structured clinical learning sessions OSAT: Ultrasound assessment of the normal female pelvis Record appropriate images

36 Knowledge Criteria Clinical Competency to be achieved Professional Skills and Attitudes Training support Evidence/ Assessment Knowledge of the normal ultrasound appearances of the uterus and the adnexal regions Knowledge of the ultrasound appearances of the physiological changes of aging/maturation of the endometrium, myometrium and adnexal regions Knowledge of the ultrasound assessment of the post menopausal endometrium including the standard measurement plane for measurement and the bilayer evaluation in the presence of endometrial fluid. Knowledge of the ultrasound assessment of the effect of HRT on the post menopausal endometrium Knowledge of the ultrasound appearances of simple thickening, hyperplasia, polyps and Ultrasound assessment of women with menstrual disorders via the TA and TV routes Ultrasound assessment of women with post menopausal bleeding via the TV route and if TV scan contra indicated via the TA route The transabdominal and transvaginal ultrasound assessment of adnexal masses and the Risk of malignancy index Ability to use ultrasound for differential diagnosis of menstrual disorders, postmenopausal bleeding and adnexal abnormalities Ability to chose appropriate additional diagnostic test/ interventions Ability to work within clinical protocols for management of ultrasound abnormalities in gynaecology Working a multidisciplinary team Collaboration with consultant colleagues and colleagues in other specialities and departments Ability to adhere to local protocols for the use of ultrasound in gynaecological problems Appropriate integration of ultrasound in the care pathway of patients Awareness of emotional implications for patient and family and staff Realistic recognition of own competence level Use of appropriate external protocols and guidelines Making appropriate onward referrals referrals Attendance of RCOG and other courses relevant to the subject Additional training in gynaecological ultrasound Useful Websites Local protocols Log book Audit projects RITA Certificates of course attendance OSATS Case based discussions Mini CEX Team observation

37 carcinoma. Knowledge of the normal ultrasound appearances of ovarian involution and the features of the normal post menopausal cyst and echogenic ovarian foci. Knowledge of the ultrasound appearances of the full spectrum of adnexal abnormalities: simple cysts, complex non malignant cysts and malignant ovarian lesions as well as the differential diagnoses in the female patient. Knowledge of the risk factors, epidemiology and aetiology of cancer of the endometrium. Knowledge of the risk factors, epidemiology and aetiology of cancer of the ovary Understanding of management issues in the provision of gynaecological care pathways

38 MODULE TOPIC : Ultrasound of the Older Woman Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Counsel patient prior to the scan TA/TV Perform TA/TV scan Abnormal endometrium Polyp to include doppler Endometrial cancer Myometrial abnormalities Fibroids Adenxal abnormalities Cysts Complex

39 Distant effects POD Bladder Training Courses or sessions Title Signature of educational supervisor Date

40 Authorisation of Signatures please print your name and sign below Name (please print) Signature

41 Training Skills Module: Ultrasound disorders of the premenopausal female to include: 1] Fertility, 2] Pregnancy related complications 3] Menstrual disorders Learning outcomes To develop knowledge and skills, which should enable the candidate to independently perform and report on transabdominal and transvaginal ultrasound Knowledge criteria Clinical competency Professional skills and Attitudes Principles of ultrasound examination 1. Physics 2. Safety 3. Machine set-up 4. Patient care 5. Principles of report writing 6. Consent 7. Cultural Diversity Understand the principles of conducting a safe and appropriate transabdominal and transvaginal ultrasound examination. Use an ultrasound machine competently and independently Safe use of the ultrasound machine Appropriate care of the patient during examination Training support Course including both: Theory Practical demonstration of machine use and reporting Evidence/ Assessment Certificate of attendance at course 1

42 Knowledge criteria Clinical competency Professional skills and Attitudes Documentation of scan 1. Understand need for accurate documentation of scan 2. Record appropriate images To write a structured report of the scan findings and keep appropriate hard copy or video records of anomalies Communicate scan findings to other health professionals Training support Supervised structured clinical learning sessions Evidence/ Assessment OSAT: Ultrasound assessment of the normal female pelvis Transabdominal Ultrasound assessment of adnexae in early pregnancy Ultrasound assessment of intrauterine pregnancy. 2

43 Knowledge criteria Clinical competency Professional skills and Attitudes Knowledge of ULTRASOUND FINDINGS 1. Knowledge of the ultrasound appearances of the uterus and adnexal regions throughout a normal and an abnormal cycle 2. Knowledge and understanding of the sequence of findings in the evolution of a normal intra uterine pregnancy 3. Knowledge and understanding of the spectrum of adnexal findings in a normal intra uterine pregnancy including the diagnosis and classification of multiple pregnancy Be able to perform a careful and systematic trans abdominal ultrasound scan of the female pelvis Be able to perform a careful and systematic transvaginal ultrasound scan of the female pelvis Ultrasound features of normal and abnormal cycles Ability to use ultrasound for assessment of the differential diagnosis of causes of subfertility Ability to use ultrasound for assessment of an early pregnancy Ability to use ultrasound for assessment of the differential diagnosis of early pregnancy complications Ability to chose between various conservative medical and surgical options in management of early pregnancy complications Ability to adhere to clinical protocols for management of pregnancies of unknown location Conduct scan to appropriate standard. Working in a multidisciplinary team Collaboration with consultant colleagues and colleagues in other specialities and departments Ability to work within local protocols for standards in ultrasound Appropriate report writing and the need for onward referral/ additional imaging Awareness of emotional implications for patient and family and staff Realistic recognition of own competence level Use of appropriate external protocols and guidelines Training support Mandatory education and training sessions Attendance at local or RCOG courses relevant to the subject Supervised structured clinical learning sessions Attendance at first trimester scans and the EPA unit Personal study Textbooks of obstetric ultrasound Relevant green top guidelines Guidance on Ultrasound Procedures in Early Pregnancy (published jointly with the Royal College of Radiologists) Evidence/ Assessment Certificate of course attendance Logbook of experience OSATS: Transabdominal ultrasound assessment of adnexae in early pregnancy Ultrasound assessment of intrauterine pregnancy. Transvaginal ultrasound assessment of ectopic pregnancy Ultrasound assessment of early pregnancy complications Case based discussions including attendance and presentation at relevant MDT meetings MiniCEX Team observation 3

44 Knowledge criteria Clinical competency Professional skills and Attitudes 4. Knowledge of anatomical landmarks for performing standard embryonic and pre embryonic measurements: i.e. [CRL] and [MGSD] 5. Knowledge and understanding of the spectrum of cystic and solid adnexal lesions 6. Knowledge and understanding of abnormalities of the myometrium and endometrium Making appropriate onward referrals Training support Useful Websites org.uk Local protocols Supervised structured clinical learning sessions Evidence/ Assessment 4

45 Knowledge criteria Clinical competency Professional skills and Attitudes Management of the abnormalities of the premenopausal female Training support Evidence/ Assessment 1. knowledge of epidemiology, aetiology, clinical features and diagnostic tests in early pregnancy complications 2. knowledge of options for managing early pregnancy problems 3. Management of recurrent miscarriage 4. Understanding of management issues in adnexal abnormalities 5. Understanding of management of abnormalities of the myometrium and endometrium 5

46 Objective structured assessment of technical skill Transabdominal ultrasound assessment of Adnexae in early pregnancy Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection - transabdominal and transvaginal 3 Identify bladder and right/left orientation 4 Identify uterus and endometrium 5 Identify ovaries 6 Assess pouch of Douglas 7 Identify site of pregnancy and embryonic heartbeat 8 Measure [MGSD] AND OR CRL 9 Interpret ultrasound findings in the context of the clinical setting 10 Communicate results to patient 11 Complete ultrasound report 12 Arrange appropriate follow up Comments Done independently Needs help Signed August

47 Objective structured assessment of technical skill Transvaginal ultrasound assessment of ectopic pregnancy Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection - transvaginal 3 Identify bladder and right/left orientation 4 Identify uterus and endometrium 5 Identify ovaries 6 Assess pouch of Douglas 7 Identify site of pregnancy and identify embryonic heartbeat 8 Identify gestation sac and/or embryo and measure sac diameter [MGSD] and/or crown rump length [CRL] 9 Interpret ultrasound findings in the context of the clinical setting 10 Communicate results to patient 11 Complete ultrasound report 12 Arrange appropriate follow up Comments Done independently Needs help Signed August

48 Objective structured assessment of technical skill Transvaginal and Transabdominal Ultrasound Assessment of Early Pregnancy Complications Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup and probe selection for TV and TA examination 3 Identify bladder and right/left orientation 4 Identify uterus and endometrium 5 Identify ovaries 6 Assess pouch of Douglas 7 Identify site of pregnancy and embryonic heartbeat 8 Identify gestation sac and/or embryo and measure MGSD and crown rump length [CRL] 9 Interpret ultrasound findings in the context of the clinical setting 10 Communicate results to patient 11 Complete ultrasound report 12 Arrange appropriate follow up Comments Done independently Needs help Signed August

49 Objective structured assessment of technical skill Transvaginal and Transabdominal Ultrasound assessment of intrauterine Pregnancy Trainee Name: Level of training: Grade/ Year Assessor Name: Post: Date: Clinical details of complexity/ difficulty of case Item under observation 1 Counsel patient about procedure 2 Appropriate machine setup/probe selection 3 Determine fetal number 4 Measure CRL and MGSD transabdominally and transvaginally 5 Determine chorionicity 6 Identify fetal heart beat 7 Interpret ultrasound findings in the context of the clinical setting 8 Communicate results to patient 9 Complete ultrasound report 10 Arrange appropriate follow up Done independently Needs help Comments Signed August

50 MODULE TOPIC : The Perimenopausal and Post Menopausal Woman Gynaecology and the older woman Skill Competence Level Observation Direct Supervision Independent Practice Date Signature Date Signature Date Signature Counsel patient prior to the scan TA/TV Perform TA/TV scan Myometrial abnormalities 1]Adenomyosis 2]Fibroids Simple Complicated Effects of HRT Adnexal abnormalities A] Cysts 1]Simple post menopausal cysts 2]Simple cysts

51 B] Complex cystic abnormalities 1]Haemorrhage including Endometrioma 2]Infection i.e. tubo ovarian abscess 3] Dermoid 4]Malignant change C]Solid adnexal abnormalities Pedunculated fibroid Fallopian tube masses Tubo ovarian abscess Ovarian Cancer Appendicitis

52 Pelvic kidney Recto sigmoid carcinoma Distant spread of ovarian malignancy 1] Ascites 2] Peritoneal deposits 3] Omental infiltration 4] Hepatic metastases 5] Pleural effusions Bladder Normal Bladder Outline Bladder wall thickening Loss of normal serosal outline

53 Training Courses or sessions Title Signature of educational supervisor Date Authorisation of Signatures please print your name and sign below Name (please print) Signature