fetal medicine atsm 2018 · web viewconfirming normality and management of fasp conditions. asm 3....

Colour key: Common competency framework competencies Medical leadership framework competencies Health inequality framework competencies

Fetal Medicine (2018) – approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018AimTo underpin the management at Consultant level of pregnancy where there are fetal concerns.

PrerequisitesThe Basic and Intermediate Obstetric Ultrasound modules must be completed prior to starting the ATSM.

ComponentsThe ATSM contains 5 Advanced Skills Modules (ASM). ASM 1-4 are required for the awarding of the ATSM for CCT, ASM is optional 5. Outwith CCT, individual ASM may be recognised separately as part of continuing professional development towards your CPD programme.

ASM 1. Advanced Obstetric Ultrasound. Identical to the ASM of the same name in the High-Risk Pregnancy ATSM.

ASM 2. Confirming normality and management of FASP Conditions.ASM 3. Managing the range of fetal conditions.ASM 4. Communication and Governance skills for fetal concerns.

ASM 5. Amniocentesis This is an optional module for those wishing to undertake invasive procedures.

Educational SupportAttendance at the RCOG/BMFMS Advanced Ultrasound Course or an equivalent course prospectively approved by your Regional Preceptor.Attendance at the course must be after registering for the ATSM and no more than three years prior to completing the module.TOG, STRATOG and e-portfolio support is provided by the RCOG.

Clinical SupportThe ATSM should be undertaken under the supervision of an identified fetal medicine supervisor, who must be in a position to directly supervise and assess competence as well as approve appropriate professionals to train for the wider curriculum components.An average of least two sessions per week is required to work towards the targets. Additional, specific themed sessions are listed in the module.

Work intensityFor pre-CCT trainees the ATSM has been allocated a work intensity score of 2.0.

ASM 1 Advanced Obstetric Ultrasound

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GMC Good Medical Practice (GMP) Domains: Domain 1: Knowledge, skills and Performance Domain 2: Safety and quality Domain 3: Communication, Partnership and Teamwork. Domain 4: Maintaining Trust


Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/assessment

(1.01) Effective and safe use of imaging modalities

(1.02) Optimise image for 2D ultrasound.

(1.03) Optimise image for Doppler ultrasound.

(1.04) Understand benefits of and indications for other imaging modalities, 3D, 4D, and MRI.Uterine artery Doppler

(1.05) Umbilical artery Doppler

(1.06) Middle Cerebral artery Doppler, including vMax

(1.07) Ductus Venosus Doppler

(1.08) Cervical lengthUltrasound competency for the screening, diagnosis and management including timely

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(1.01)Understand the risks associated with the different ultrasound modalities and how to limit them. Understand mechanical index (MI) and thermal index (TI).

(1.02-1.03)Be familiar with the full range of optimisation controls including, Power, gain, focal length, magnification, sector width, frame rate, pulse repetition frequency, colour and power Doppler modes.

(1.04)Be familiar with local policies for the use and interpretation of 3D/4D ultrasound and fetal MRI.

(1.05- 1.07)Doppler ultrasound: understand when to use Doppler ultrasound and its interpretation

Understand how these assessments are used to monitor growth restriction.

Understand how fetal anomalies may influence the waveforms (for example cardiac arrhythmias, fetal anaemia, hydrops, and twin-twin transfusion syndrome).

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(1.01-1.04)Appreciates the limitations of antenatal ultrasound.

Understands the appearances of artefacts and how these might be misinterpreted.

Able to explain the use of antenatal ultrasound and the benefits of the different modalities along with the transabdominal and transvaginal route.

(1.05-1.12)Able to apply ultrasound finding to local and Regional guidelines, referring as appropriate.

(1.14)Able to liaise appropriately to explore option of amniodrainage for polyhydramnios.

(1.09-1.15)Able to explain ultrasound findings and management options in a manner that is non-judgemental and easy to understand.

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(1.09-1.10)RCOG Green top guideline No. 57 (2011) Reduced fetal movements.

No.31 (2013) Small for gestational age fetus, investigation and management.

(1.13)Scientific impact paper No.33 Preterm labour, antibiotics and cerebral palsy.

(1.16)RCOG Green top guideline No. 20a ECV to reduce breech presentation.

(1.11-1.12)NICE Clinical Guideline CG 129 Management of twin and triplet pregnancies in the antenatal period.

(1.01-1.16)These are the ultrasound competencies for high-risk pregnancy (rather than for fetal anomaly which is covered in ASM2.)

Your evidence should be supported by a log of sessions attended and work-placed based assessments demonstrating good communication skills, documentation and recording of growth and anatomy.

(1.05-1.5)Work-placed based assessments should include abnormal values and explore the antenatal management.

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referral of:

(1.09) Severe early onset fetal growth restriction

(1.10) Late onset fetal growth restriction

(1.11) Twin pregnancy with growth discordance

(1.12) Twin-twin transfusion syndrome

(1.13) Suspected preterm ruptured membranes

(1.14) Polyhydramnios

(1.15) Low lying placenta

(1.16) Ultrasound guided procedures: ECV for Breech

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Understand how MCA vMax is used to monitor for signs of anaemia

(1.08)Cervical length: transcervical measurement of cervical length, the criteria for accurate and reproducible measurement.

Recognises when cervical length should be offered.

(1.09-1.10)Management of growth restriction according to National Guidelines. When to refer to the Tertiary Centre.

(1.11-1.12)Multiple pregnancies: able to recognise and manage growth discordance. Understand the influence of chorionicity.For monochorionicity to be able to monitor for signs of TTTS and refer to the tertiary centre in accordance with local guidelines.Aware of the ultrasound features of TRAP (Twin reverse arterial perfusion sequence) and conjoined twins.

(1.13)Aware of the role and limitations of ultrasound in the management of suspected preterm ruptured membranes.

(1.13-1.14)

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(1.09-1.16)Able to formulate a suitable management plan, liaising where appropriate and always considering the individuals hopes and expectations for the pregnancy.

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RCOG Green top guideline N0.51 Monochorionic twin pregnancy.

STRATOG Advanced, Clinical Case Studies eLearning: Management of the SGA fetus (2016).

These are common findings and should be based upon direct patient care.

OSAT

CBD

Reflective Practice

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Able to accurately and reproducibly estimate liquor volume using maximum vertical pocket.

Understands the associations of polyhydramnios with poor maternal glucose control, fetal anomalies, and its significance in monochorionic pregnancies.

(1.15)Able to identify the lower edge of the placenta and measure the distance from the internal cervical os.

Recognises when there is an increased risk of morbidly adherent uterus (such as previous scar to uterus with overlying placenta).

(1.16)Practical experience of performing successful ECV according to local guidelines. Aware of contraindications to ECV.

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ASM 1 - Advanced Obstetric Ultrasound Part of the Fetal Medicine ATSM and the High Risk Pregnancy ATSM

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LogbookCompetence level Not required

Level 1 Level 2 Level 3ASM 1. Advanced Obstetric Ultrasound Date Signature Date Signature Date Signature

Effective and safe use of imaging modalities

Optimise image for 2D ultrasound.

Optimise image for Doppler ultrasound.

Understand benefits of and indications for other imaging modalities, 3D, 4D, and MRI.

Uterine artery Doppler

Umbilical artery Doppler

Middle Cerebral artery Doppler, including vMax

Ductus Venosus Doppler

Cervical length

Ultrasound competency for the screening, diagnosis and management including timely referral of:

Severe early onset fetal growth restriction

Late onset fetal growth restriction

Twin pregnancy with growth discordance

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Level 1 Level 2 Level 3ASM 1. Advanced Obstetric Ultrasound Date Signature Date Signature Date Signature

Twin-twin transfusion syndrome

Suspected preterm ruptured membranes

Polyhydramnios

Low lying placenta

Ultrasound guided procedures:

ECV for Breech

Training Courses or sessions

Title Signature of educational supervisorDate

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Authorisation of signatures (to be completed by the clinical trainers)

Name of clinical trainer (please print) Signature of clinical trainer

Completion of ASM 1: Advanced Obstetric Ultrasound Date Signature

Comprising the safe and effective use of imaging modalities, the screening, diagnosis and management of the at risk fetus. Level 3 is to the level expected within Secondary Care and includes timely liaison with the MDT and Tertiary Centre when appropriate.

ASM 2 Confirming normality and management of key fetal conditions

Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/

assessment(2.01) Demonstrate normal structural findings in all trimesters and recognise if normality cannot be demonstrated for:

(2.02) Central nervous system

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(2.01-2.10)Understand the embryology as listed below and how it is revealed in the ultrasound image.

(2.02)Embryology of brain & spinal cord (incl.

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(2.01-2.08)Understand the strengths and limitations of ultrasound for each system within each trimester.

Ability to perform and record appropriately a detailed,

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(2.01-2.08)STRATOG Advanced, Clinical Case Studies eLearning: Fetal Medicine – major congenital

(2.01-2.10)For the first part of this ASM focus on the normal anatomy so that variations from normal can be

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assessment(2.03) Face and neck

(2.04) Thorax

(2.05) Cardiovascular system

(2.06) Abdominal wall and gastrointestinal tract

(2.07) Urogenital system

(2.08) Skeleton and extremities

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early postnatal development).

Recognise normal ultrasound appearance of: head shape, biometry, cavum, thalami, cortex, ventricles, choroid plexus, cerebellum, cisterna magna.

Measurement of: head circumference, lateral ventricle, transcerebellar diameter, cisterna magna, nuchal fold.

(2.03)Embryology of: face and neckRecognise normal ultrasound appearance of: head shape & biometry, lip, palate, neck, jaw.Measurement of nuchal fold, Internal and external orbital distances.

(2.04)Embryology of trachea, lungs, diaphragm & functional adaptations after birth.Recognise normal ultrasound appearance of: chest size and shape -mediastinal shift, ribs, lung parenchyma, and diaphragm.

(2.05)Embryology of: heart and cardiovascular system, understand circulatory adaptations at birth.

Recognise normal ultrasound appearance of: cardiac size, position and axis, atria &

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systematic ultrasound assessment of each system for the entire fetus.

Explain normal anatomy views to patient.

Document and record normal anatomy views.

Understand local protocol for follow up if any after an incomplete anatomy scan.

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anomaly (2015).

National Screening Committee publications on normality at the 18-20 week scan.

Direct supervision from sonographers and senior clinicians

identified.

For this you need to provide evidence of regular ultrasound hands on sessions accompanied by work-placed based assessments as competencies are achieved.

(2.11-2.13)Evidence of attendance at genetics clinic and laboratory testing.

(2.14-2.25)You need to supply evidence showing a full understanding based on direct clinical care for these core fetal medicine anomalies.Evidence of attendance at fetal medicine clinics with involvement of paediatric

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assessmentventricles, outflow tracts, 3 vessels and trachea view.

Measurement of: heart rate, atrial and /ventricular rates.

(2.06)Embryology of: Abdominal wall, and gastrointestinal tract.

Recognise normal ultrasound appearance of: abdomen, abdominal wall / cord insertion, stomach, small & large bowel, liver, gallbladder, intrahepatic vein & ductus venosus.

Measurement of: abdominal circumference.

(2.07)Embryology of: genitor-urinary system (incl. physiology of fetal urinary system), functional adaptations after birth.

Recognise normal ultrasound appearance of: renal size, renal parenchyma & collecting system ureters & bladder, external genitalia.

Measurement of, liquor volume

(2.08)Embryology of: normal skeletal system

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surgeons, neurologists, nephrologists and neonatologists.Their screening is part of the NSC committee standards for the 18-20week scan.

(2.05-2.21) OSATS of Fetal Echocardiography

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assessmentincluding spin and cranial vault.Recognise normal ultrasound appearance of: bone shape, echogenicity (mineralisation), joint position, movements, tone. Identify digits.Measurement of long bones, foot length.

(2.09) Umbilical artery, middle cerebral artery, and ductus venous Doppler waveforms.

(2.10) Determine amnionicity and chorionicity

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(2.09)Understand the physiological basis for each Doppler waveform both normal and abnormal. Understand when they should be examined and their implications if abnormal.

(2.10)Embryology of: monozygotic & dizygotic twinning, placentation, chorionicity / amnionicity.

Recognition of: T-sign and the lambda sign for chorionicity.

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(2.09)Explain and document normal findings in a way that can be easily understood.

(2.10) arrange appropriate pregnancy surveillance once chorionicity and amnionicity determined.

(2.20)Explain finding in a way that can be easily understood. Describe how findings influence subsequent antenatal management.

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(2.10) NICE CG:129 (2011) Multiple pregnancy: antenatal care for twin and triplet pregnancies.

Management of the key fetal anomalies

(2.11) Suspected and confirmed Trisomy 21

(2.12) Suspected and confirmed Trisomy 18 / Trisomy 13

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(2.12-2.14)Understand the genetic basis for trisomy 21, 18 and 13. Recognise the ultrasound features associated with screening for the common trisomies.

Understand the organisation & role of Clinical Genetics Services in the diagnosis of trisomies including invasive and non-

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(2.12-2.14)Take an appropriate history and construct, where appropriate, a family tree in patients with or at risk of genetic disease.

Recommend genetic testing appropriately.

(2.12-2.14)NSC publications and parent information leaflets.

RCOG Scientific impact paper No.15 (2014) Non-

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assessment(2.13) Suspected and confirmed Turner’s syndrome

1,2 invasive testing.

Understand any implications for the current pregnancy and the long term prognosis for each condition with any implications for future pregnancies.

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Reflection upon the ethical & societal issues of antenatal diagnosis.

Be able to give information in a non-judgemental way that is easy to understand.

Liaise appropriately with the Tertiary centre and MDT.

invasive prenatal testing for chromosomal abnormality using maternal plasma DNA.

(2.14) Anencephaly

(2.15) Spina bifida

(2.16) Renal agenesis

(2.17) Facial cleft

(2.18) Exomphalos

(2.19) Gastroschisis

(2.20) Diaphragmatic hernia

(2.21) Hypoplastic left or right heart

(2.22) Lethal skeletal dysplasia

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(2.14-2.22)Recognise diagnostic features of each condition their differential diagnosis and risk of associated structural, chromosomal and syndromic associations.

Understand antenatal management, intrapartum care and immediate postnatal management of each condition.

Be able to state when tertiary referral opinion is required, when and where delivery is recommended and the most appropriate mode of delivery based on the condition and individual’s circumstances.

For each condition, understand the recurrence risk and management plan for future pregnancies.

(2.15)Spina bifida, Understand surgical options, long term prognosis. Be able to accurately

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(2.14-2.22)Liaise with fetal medicine specialist, neonatologists, surgeons (including appropriate referral for second opinion).

In collaboration with specialists, formulate, implement and where appropriate modify management plan.

Counsel women and their partners regarding the fetal risks, long term outcome, postnatal or post mortem findings and the recurrence risks.

Support parent(s) using shared decision making.

Provide appropriate support and follow up of ongoing pregnancy.

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(2.14-2.22)NSC publications and parent information leaflets.

Direct supervision from sonographers and senior clinicians including fetal medicine subspecialists.

(2.16)Observation of Paediatric neurosurgical counselling.

(2.17)Observation of paediatric

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assessmentidentify the features of open and closed spina bifida.

(2.16)Renal agenesis, understand antenatal and neonatal implications for both unilateral and bilateral renal agenesis.

(2.17)Understand limitations of ultrasound for cleft palate. Understand role of 2D and 3D ultrasound. Be able to distinguish between unilateral, bilateral and midline cleft lip.

(2.18)Exomphalos, identify size and contents and implications of each. Understand local monitoring policy and when to seek advice from tertiary centre.

(2.19)Gastroschisis, understand local monitoring policy and when to seek advice from tertiary centre.

(2.20)Diaphragmatic hernia: understand local pathway following identification of diaphragmatic hernia, role of MRI options for antenatal treatment.

(2.21)Understand implications of a univentricular

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Plan delivery and appropriate neonatal support in collaboration with fetal medicine specialist


Understand whether the option of termination of pregnancy is appropriate for each condition both in isolation and in combination with other anomalies.


Formulate management plan for future pregnancy in collaboration with specialists

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nephrologist counselling.

(2.17)Cleft liaison team where available,CLAPA website.

(2.18-2.19)GEEPS website.

(2.20)MBRRACE-UK (2014) Perinatal confidential enquiry - diaphragmatic hernia.

(2.21)Observe paediatric cardiologist counsellingLittle heart matters, British Heart Foundation (BHF) websites.

(2.22)Counselling of clinical geneticists.

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assessmentheart, staged operative palliation and long-term outcomes. Understand local pathway of care and antenatal surveillance.

(2.22)Be able to accurately describe the skeletal anomaly.

Understand the common forms of skeletal dysplasia their most recognisable features and why some forms are lethal. (Including thanatophoric dysplasia, achondrogenesis, osetogenesis imperfect type II, campomelic dysplasia.)

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OMIM: Online Mendelian inheritance in man.


(2.23) Observe amniocentesis

(2.24) Observe chorionic villus biopsy.

(2.25) Observe feticide

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(2.23-2.24)Understand when it is appropriate to offer invasive testing.

Understand the contraindications to invasive testing.Understand the role of non-invasive testing.

(2.26) Understand the legal framework under which termination of pregnancy by feticide may be offered.

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(2.23-2.24)Be able to explain the risks of each procedure and any alternatives.

Be aware of how the sample is processed, when and how the result is given.

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(2.23-2.25)Antenatal Results and Choices (ARC)

(2.25)Abortion Act (1967)

(2.25)This may be achieved to level 1 under other methodologies

ASM 2 Confirming Normality and Management of Fetal Anomaly Screening Programme (FASP) Conditions.

Part of the Fetal Medicine ATSM

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Level 1 Level 2 Level 3

ASM 2. Confirming normality and management of (FASP) Conditions.

Date Signature Date Signature Date Signature

Demonstrate normal structural findings in all trimesters and recognise if normality cannot be demonstrated for:

Central nervous system

Face and neck

Thorax

Cardiovascular system

Abdominal wall and gastrointestinal tract

Urogenital system

Skeleton and extremities

Umbilical artery, middle cerebral artery, and ductus venous Doppler waveforms.

Determine amnionicity and chorionicity

Management of the key fetal anomalies

Suspected and confirmed Trisomy 21

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Suspected and confirmed Trisomy 18 / Trisomy 13

Suspected and confirmed Turner’s syndrome

Anencephaly

Spina bifida

Renal agenesis

Facial cleft

Exomphalos

Gastroschisis

Diaphragmatic hernia

Hypoplastic left or right heart

Lethal skeletal dysplasia


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Observe amniocentesis

Observe chorionic villus biopsy

Observe feticide



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Completion of ASM 2: Confirming normality and management of key fetal conditions Date Signature

Demonstration of normal anatomy within the limitations of each trimester. Management the Fetal Anomaly Screening Programme (FASP) fetal conditions where level 3 incorporates timely liaison with the tertiary centre as required.

ASM 3 Managing the range of fetal conditions


assessment

(3.01) Cerebral ventriculomegaly

(3.02) Dandy Walker spectrum

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(3.01-3.22)Recognise diagnostic features of each condition their differential diagnosis and risk of associated structural, chromosomal

1,2(3.01-3.22)Liaise with fetal medicine specialist, neonatologists, and surgeons (including appropriate

1,2,3STRATOG Ultrasound scanning of fetal anomaly, Teaching

(3.01-3.22)In order to cover the full range of fetal anomalies it is

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assessment(3.03) Red cell alloimmunisation

(3.04) Non-immune hydrops

(3.05) Congenital lung malformation

(3.06) Bowel atresia (including oesophageal / duodenal)

(3.07) Hyperechogenic bowel

(3.08) Fetal arrhythmia

(3.09) Ventriculoseptal defects

(3.10) Cardiac outflow tract anomalies

(3.11) Lower urinary tract obstruction

(3.12) Hydronephrosis

(3.13) Multicystic kidney

(3.14) Talipes

(3.15) Limb reduction defect

(3.16) Non-lethal skeletal dysplasia

(3.17) Sex chromosome aneuploidy

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and syndromic associations.

Understand antenatal management, intrapartum care and immediate postnatal management of each condition.

Be able to state when tertiary referral opinion is required, when and where delivery is recommended and the most appropriate mode of delivery based on the condition and individual’s circumstances.

For each condition, understand the recurrence risk and management plan for future pregnancies.

(3.01) Accurately measure lateral ventricles and distinguish between, mild, moderate and severe ventriculomegaly measurements.

Understand the role of MRI for CNS lesions.

(3.02) Distinguish between Dandy Walker malformation, DW Variant and Mega cisterna magna. Understand the implications of each.

Understand the role of MRI for CNS lesions.

(3.03 and 3.21) Red cell alloimmunisation: understand the Blood group systems, pathophysiology and laboratory testing for

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referral for second opinion).

In collaboration with specialists, formulate, implement and where appropriate modify management plan.

Counsel women and their partners regarding the fetal risks, long term outcome, postnatal or post mortem findings and the recurrence risks.

Support parent(s) using shared decision making.

Provide appropriate support and follow up of ongoing pregnancy.

Plan delivery and appropriate neonatal support in collaboration with fetal medicine specialist


Understand whether the option of termination of pregnancy is appropriate for each condition both in isolation and in combination with other anomalies.

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resource.

BMFMS

ARC

(3.01-3.21)OMIM: Online Mendelian inheritance in man.

(3.08-3.10)Little heart matters.

British Heart Foundation (BHF) website.

(3.14)STEPS website.

(3.17-3.21)RCOG Scientific impact paper No.15 (2014) Non-invasive prenatal testing for chromosomal abnormality using maternal plasma

accepted that you may have limited direct experience of some of the conditions. You need to demonstrate, however, that you are fully conversant with the diagnosis and management of each anomaly.

Therefore if direct clinical exposure for a condition has been limited please supplement this with a record of CBD, eLearning and fetal medicine clinic attendances.

Mini-CEX

Case-based discussionsOSAT

Fetal Medicine ECHO OSAT

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assessment

(3.18) Cystic fibrosis

(3.19) Muscular dystrophy

(3.20) Fragile X

(3.21) Recognition and monitoring of alloimmune disease

(3.22) CMV, Toxoplasmosis,Parvovirus and Varicella

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rhesus and other red cell antigens. Role of DNA analysis from maternal plasma. The neonatal implications of anaemia, hyperbilirubinaemia and hydrops.

The organisation & effectiveness of screening and prevention programmes. The pharmacology of Anti-D immunoglobulin administration.

Ability to perform and interpret MCA Doppler.

(3.04) Non-immune Hydrops: Investigate appropriately, determine severity, understand role of fetal echo , MCA, Umbilical Doppler, Ductus Venosus and Amniotic fluid assessment.

Be able to construct a full differential diagnosis.

(3.05) Cystic adenomatoid malformation: recognise and the monitor condition, liaising with Tertiary centre as appropriate.

Ensure local pathway for postnatal management is followed.

(3.06) Recognise the different ultrasound features of the GI atresia their associations and surgical options following delivery.

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Formulate management plan for future pregnancy in collaboration with specialists.

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DNA.

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assessment(3.07) Hyperechogenic bowel: understand the spectrum of ultrasound finding and that it may be associated with chromosomal anomalies, Cystic Fibrosis, growth restriction and viral infections.

(3.08) Recognise the common tachy- and brady – arrhythmias.Understand the role of the paediatric cardiologist in their management.

(3.09) Ventriculoseptal defects: Be able to identify the different types of VSD and appreciate their association with cardiac, extracardiac and chromosomal anomalies. Understand the role of the paediatric cardiologist in their management.

(3.10) Cardiac outflow anomalies: Be able to identify when the outflow tracts are not normally formed or related.

Be familiar with the ultrasound features of transposition of the great arteries, atresia of either outflow tract, stenosis of either outflow tract, double outlet right ventricle or a common outflow tract (truncus arteriosus).

Appreciate their association with further cardiac, extracardiac and chromosomal anomalies. Understand the role of the paediatric cardiologist in their

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assessmentmanagement.

(3.11-3.13) Urinary tract obstruction and MCDK: understand its aetiology, spectrum of severity postnatal investigation and the likely short and long term impact of these conditions.

(3.14) Talipes: Understand the local pathway for postnatal referral and the Ponsetti approach to treatment.

(3.15) Limb reduction defects: Understand associations and the wide aetiology.

(3.16)Non-lethal skeletal dysplasia: Be able to accurately describe skeletal anomalies.

Be familiar with the features of the more common non –lethal dysplasias, particularly certain types of osteogenesis imperfecta and achondroplasia.

(3.17-3.20) Common genetic disorders: understand the implications of: Kleinfelter syndrome (47 XXY) and 47 XXX, cystic fibrosis, muscular dystrophy and fragile X. Understand laboratory testing /screening for these conditions.

Be able to construct an appropriate family tree.

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assessment(3.22) Understand the screening for these conditions, ultrasound features, monitoring strategies and role of the clinical virologist.Understand the limitations of any antenatal treatment options, their postnatal management, short term and long term prognosis.

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ASM 3: Managing the range of fetal conditions Part of the Fetal Medicine ATSM

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Level 1 Level 2

ASM 3: Managing the range of fetal conditions Date Signature Date Signature

Cerebral ventriculomegaly

Dandy Walker spectrum

Red cell alloimmunisation

Non-immune hydrops

Cystic adenomatoid malformation

Bowel atresia (including oesophageal / duodenal)

Hyperechogenic bowel

Fetal arrhythmia

Ventriculoseptal defects

Cardiac outflow tract anomalies

Lower urinary tract obstruction

Hydronephrosis

Multicystic kidney

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Level 1 Level 2

ASM 3: Managing the range of fetal conditions Date Signature Date Signature

Talipes

Limb reduction defect

Non-lethal skeletal dysplasia

Sex chromosome aneuploidy

Cystic fibrosis

Muscular dystrophy

Fragile X

Recognition and monitoring of alloimmune disease

CMV, Toxoplasmosis, Parvovirus and Varicella



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Completion of ASM 3: Managing the range of fetal conditions Date Signature

A thorough understanding of the breadth of fetal conditions has been achieved, their initial diagnosis, management and common associations. This has included time spent with geneticists, neonatologists, paediatric surgeons and cardiologists. Where exposure to clinical cases has been limited this has been supplemented by evidence through other methodologies to confirm a thorough knowledge base. Liaison with tertiary services has been timely and appropriate.

ASM 4 Communication and Governance for Fetal Concerns


assessment

(4.01) Counsel for previous structural fetal anomaly.

1,2,3,4

(4.01-4.04)Fetal anomaly knowledge base accrued 1

(4.01-4.03)Ability to: reach a definitive 1,2

(4.01-4.11)RCOG Green

(4.01-4.11)Log of experience:

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assessment

(4.02) Counsel following suspected structural fetal anomaly.

(4.03) Counsel following fetal anomaly with a significant risk of severe handicap.

(4.04) Conduct postnatal review following termination of pregnancy for fetal anomaly.

(4.05) Construction and explanation of family tree for genetic anomaly.

(4.06) Explain common modes of Mendelian inheritance.

(4.07) Counsel for previous aneuploidy.

(4.08) Counsel where there is an uncertain prognosis and the need for expert opinion.

(4.09) Explain the risk and benefits of prenatal non-invasive fetal screening

(4.10) Explain the risks and benefits of invasive prenatal testing.

(4.11) Explain the role of post-

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,

through ASM1, 2 and 3.

(4.05-4.10)Understand: Gene structure & function DNA as genetic material replication, transcription & translation mechanisms & effects of mutation. The inheritance & susceptibility patterns of single genes, genetic heterogeneity, how new mutations cause single gene disorder, expression & penetrance multifactorial inheritance, mitochondrial inheritance.

(4.11)Familiarity with the consent procedure for post-mortem (& option of tissue retention) the conduct of the examination and information that it provides.

1

1,2

diagnosis of major fetal anomaly (where possible).

Assess risks of death and/or handicap, counsel women and their partners regarding option of termination of pregnancy and of feticide.

(4.01-4.11)Ability to: liaise with fetal medicine specialists, midwives, neonatologists and pathologists where appropriate

Recognise when further counselling or support is needed.

Ability to deliver what is often complex information in a way that is easily understandable.

Avoid the use of jargon, and if medical terms are required provide an explanation of their meaning.

(4.12)Understand the role of clinical governance in the delivery of service.

1,2,3,4

1,2,3

1,2,3,4

1,2,3,4

1,2,3,4

1,2

top Guidance on Late TOP for Fetal Anomaly.

RCOG Working Party Report (20110) Termination of pregnancy for fetal abnormality in England Scotland and Wales

SANDS (stillbirth and neonatal death charity): Guide for Postmortem takers.

SANDSPregnancy loss and the Death of a Baby: guidelines for professionals 4th edition 2016.

sessions in: fetal medicine, perinatal pathology and genetics.

Work based assessments should highlight he communication aspects of each competency.

Mini-CEX

Case-based discussions

OSATs

(4.12)Reflective practice covering a range of clinical scenarios.

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assessmentmortem.

Clinical Governance:(4.12) Demonstrate effective reflective practice across a range of scenarios (attach supporting evidence).

4

1,2,3

Recognise the benefits of effective reflection practice.

1,2,3 The Bereavement Care Network

ARC website

ASM 4: Communication and Governance for Fetal Concerns Part of the Fetal Medicine ATSM

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ASM 4: Communication and governance for fetal concerns


Counsel for previous structural fetal anomaly

Counsel following suspected structural fetal anomaly.

Counsel following fetal anomaly with a significant risk of severe handicap.

Conduct postnatal review following termination of pregnancy for fetal anomaly.

Construction and explanation of family tree for genetic anomaly.

Explain common modes of Mendelian inheritance.

Counsel for previous aneuploidy.

Counsel where there is an uncertain prognosis and the need for expert opinion.

Explain the risk and benefits of prenatal non-invasive fetal screening

Explain the risks and benefits of invasive prenatal testing.

Explain the role of post-mortem.

Governance

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ASM 4: Communication and governance for fetal concerns


Demonstrate effective reflective practice across a range of scenarios (attach supporting evidence).

Produce a relevant Audit, Guideline or other Quality Improvement Project (attach supporting evidence).

Lead Risk Management case review.

Work effectively within the MDT lead and support obstetric sonographers.

Know when and how to refer to support services (genetics, paediatric, neonatal, surgical, bereavement, counselling).

Demonstrate awareness of own limitations, when to refer and how best to share care and monitoring.



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Completion of ASM 4: Communication skills for Fetal Concerns Date Signature

The full range of communication, professionalism and governance skills has been demonstrated within the context of fetal anomaly and high-risk pregnancy for fetal concerns.

ASM 5 Amniocentesis


assessment

(5.01) Counsel prior to amniocentesis.

(5.02) Perform amniocentesis in singleton pregnancy

1,2,3,4

1,2

(5.01)Understand the indications for offering invasive testing, its risk and benefits.Recognise the potential for sensitisation - Rhesus alloimmunisation - and the

1,2(5.01)Ensure written information has been received and understood prior to performing amniocentesis.

1,2,3,4

(5.01-5.03)RCOG Green Top Guideline No8. on amniocentesis (2010)

(5.02)Your level 3 competency requires a log consisting of a

30




assessment

(5.03) Counsel following abnormal amniocentesis result.

1,2,3,4

importance of maternal blood group.

Understand the implications of maternal blood born viruses.

Understand the types of analysis that may be applied: QF-PCR analysis, full karyotyping, array analysis and targeted molecular genetic examination for family history of genetic conditions.

Understand when sample should be stored in case of further analysis.

(5.02) Understand aseptic technique, how to optimize the ultrasound image, when amniocentesis is not likely to be straightforward and the options available.

(5.03) Understand what the test is not able to show, the significance of the result and the options available following an abnormal result.Understand the options following test failure, mosaicism, and the role of parental karyotyping in the interpretation of results.

1,2

1,2

1,2

1,2

1,2

Ensure valid consent is taken for the procedure.

Explain in an easily understandable manner the risks and benefits of the test and other options that may be available.

(5.02)Conduct the test in a safe manner followed by the appropriate labelling of specimens and request form, transportation to the laboratory and plan made for communicating the results according to local guidelines.

Accurately document the procedure, including use of anti-D where appropriate.

Debrief and provide advice following procedure

(5.03)Counsel following amniocentesis for both normal and abnormal results.

Counsel following a normal amniocentesis result in the presence of a structural fetal

1,2,3,4

1,2,3,4

1,2,3

1,2,3

1,2,3,4

1,2,3,4

1,2,3,4

RCOG Patient information leaflet on amniocentesis.

NSC patient information leaflets.

Guidance on written consent (DOH, 2009)

NHSFASP standards and protocols, (2008)

BCSH (2014) guideline of anti-D.

NICE anti-D prophylaxis for women who are Rhesus D negative (2008)

minimum of 30 or more recorded procedures.

Participation in your departmental continuous audit of procedures as recommended by RCOG (2010) and NSC (2007)

OSATS

31




assessmentanomaly.

ASM 5 Amniocentesis Part of the Fetal Medicine ATSM

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ASM 5. Amniocentesis Date Signature Date Signature Date Signature

Counsel prior to amniocentesis.

Perform amniocentesis in singleton pregnancyNote that level 3 requires a log consisting of a minimum of 30 procedures.Counsel following abnormal amniocentesis result.

Sessions attended Signature of educational supervisor DateFetal echocardiography clinic

Fetal echocardiography clinic



Clinical genetics clinic




Cytogenetics - Molecular genetics

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Neonatal ward round / clinic




Fetal post-mortem

Fetal post-mortem

Regional Fetal Medicine Unit





Title Signature of educational supervisor DateFetal medicine theoretical course



34





Completion of ASM 5 - Invasive procedures: Amniocentesis Date Signature

Completion of the skills required to safely counsel, perform and explain the results of amniocentesis when appropriate to the clinical situation.

35


fetal medicine atsm 2018 · web viewconfirming normality and management of fasp conditions. asm 3....

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