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Obstetric Medicine (2018) – approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018AimTo prepare the clinician working within a MDT for the recognition and management of medical problems in pregnancy.

PrerequisitesSuccessful completion of an Obstetric Emergency Course, for example a MOET course or equivalent.

Key componentsThe ATSM comprises 5 Advanced Skills Modules (ASM). All 5 ASM are required to award the ATSM as part of CCT. Outwith CCT, individual ASM may be recognised separately as part of continuing professional development towards your CPD programme.

ASM 6. Management of Key Obstetric Medical Conditions. Identical to the ASM of the same name in the High-Risk Pregnancy ATSM.

ASM 10. Key intrapartum Obstetric Medical disorders. Identical to the ASM of the same name in Advanced Labour Ward Practitioner ATSM.

ASM 11. Skills covering the full range of Maternal Medical Conditions.ASM 12. Key maternal conditions involving the multidisciplinary team.ASM 13. Communication and Clinical Governance Skills for Obstetric Medicine.

Educational SupportAttendance at the annual RCOG/BMFMS Maternal Medicine 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 also provided by the RCOG.

Clinical SupportThe ATSM should be undertaken under the supervision of an identified Obstetric Consultant 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 relevant to the ATSM are listed in the module.

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

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

ASM 6 Management of Key Obstetrical Medical Conditions

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

assessment

Hypertension(6.01) Chronic hypertension

Renal(6.02) Hydronephrosis

Gastrointestinal(6.03) Obstetric cholestasis(6.04) Hyperemesis gravidarum

Endocrinology(6.05) Pre-existing diabetes without complications

(6.06) Gestational diabetes

Respiratory(6.07) Asthma

Dermatology(6.08) Eczema

Neurological(6.09) Headache

(6.10) Epilepsy

Haematological(6.11) Thrombocytopenia

1,2

1,2

1,2

1,2

1,2

1,2

1,2

1,2

1,2

(6.01-6.12)Detailed knowledge of the aetiology, incidence, recurrence risks, obstetric, medical & neonatal complications of these key medical problems in pregnancy

Take an appropriate history and conduct an examination in a woman presenting with the symptom / sign / abnormality.

Arrange appropriate investigations counsel re maternal and fetal risks plan pregnancy, delivery and postnatal care

Understand the pathophysiology, presentation and implications for maternal &/or fetal health of common late pregnancy complication.

Know the aetiology, incidence, pathophysiology, diagnosis, management, obstetric, medical & neonatal complications, and recurrence risks of each condition.

(6.13- 6.15)Understand the interpretation of each of these investigations and how they are influenced by pregnancy.

1,2

1,2,3,4

1,2,3,4

1,2

1,2

1,2

(6.01-6.12) Able to make a thorough assessment of a presenting problem with appropriate investigation and consideration of differential diagnoses

Consider effects on fetus or neonate when prescribing drugs for mother

Liaise with midwives and other health professionals to optimise patient management

Use appropriate referral pathways and local protocols

1,2

1,2

1,2,3

1,2

(6.01)NICE (2011) Hypertension in Pregnancy diagnosis and management (CG07).

(6.06) Scientific impact paper No. 23 Diagnosis and treatment of Gestational Diabetes.

NICE Guideline NG3 (2015) Diabetes in Pregnancy: management from preconception to the postnatal period. RCOG Clinical Green Top Guidelines:10A (Management of preeclampsia/

These represent the core medical conditions with which you should have a thorough knowledge based upon direct clinical experience.

The evidence should support this and may include the full range of work placed based assessments along with a record of any relevant clinics courses or meetings attended.

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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(6.12) Previous thromboembolic disease

Investigations(6.13) ECG interpretation

(6.14) CXR interpretation

(6.15) Blood gas interpretation

1,2

eclampsia)

20a (External cephalic version and reducing the incidence of breech presentation)

No. 20 (Breech presentation, management)

No.27 (Placenta Praevia and Placenta Praevia Accreta: Diagnosis and Management)

No. 43 (Obstetric cholestasis)

RCOG Clinical Green Top Guideline 31 (Small for gestational age: fetus: investigation and management)

ASM 6. Management of Key Obstetric Medical Conditions.

Part of the High Risk Obstetrics ATSM and the Obstetric Medicine ATSM

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LogbookCompetence level Not required

Level 1 Level 2 Level 3

ASM 6. Management of key obstetric medical conditions

Date Signature Date Signature Date Signature

HypertensionChronic hypertension

RenalHydronephrosis

GastrointestinalObstetric cholestasis

GastrointestinalHyperemesis gravidarum

EndocrinologyPre-existing diabetes without complications

EndocrinologyGestational diabetes

RespiratoryAsthma

DermatologyEczema

NeurologicalHeadache

NeurologicalEpilepsy

HaematologicalThrombocytopenia

HaematologicalPrevious thromboembolic disease

4





ASM 6. Management of key obstetric medical conditions


ECG interpretation

CXR interpretation

Blood gas interpretation

Training Courses or sessions

Title Signature of educational supervisorDate

5



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

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

Completion of ASM 6: Management of Key Obstetric Medical Conditions Date Signature

Appropriate management of the key obstetric medical conditions in each trimester to the level expected within secondary care and liaison with the tertiary centre when appropriate.

ASM 10 Key Intrapartum Obstetric Medical Disorders

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

(10.01) Severe preeclampsia

(10.02) Eclampsia

1,2

1,2

(10.01-10.3)Understand best practice for the management of severe pre-eclampsia. Including its definition, diagnosis, acute

1,2,3(10.01)Take an appropriate medical history and examination of a woman with symptoms of severe

1,2,3,4

(10.01-10.03)RCOG Green to guideline N0.10a Pre-eclampsia

(10.01-10.12)Each condition within ASM.10 is core to the

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(10.03) HELLP syndrome 1,2 management and associated complications.

Understand the pathophysiology and pharmacology for the condition. Be able to interpret investigations

Understand the acute and long-term maternal and fetal risks associated with the condition.

1,2

1,2

disease.

Be able to interpret and act appropriately upon investigations.

Be able to construct a differential diagnosis and recognise symptom and signs of co-existing maternal disease (HELLP, chronic hypertension, pre-existing renal damage.)

(10.01-10.02)Manage cases of complex severe pre-eclampsia with:(a) HELLP(b) eclampsia(c) pulmonary oedema(d) acute renal failure

(10.01-10.02) Institute / modify drug therapies, plan delivery and postnatal care refer, where appropriate, for further assessment / treatment.

Be able to give accurate advice for future pregnancies.

(10.02 -10,3)Be proficient in the acute management of eclampsia and HELLP according to best practice

1,2,3

1,2

1,2,3

1,2,3

1,2,3,4

1,2,3

/eclampsia management.

RCOG Patient information (2012) Pre-eclampsia.

understanding of medical problems during labour.

For each of the 12 conditions your supporting evidence must be based upon more than one case in which you have been directly involved.

Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.

In addition to direct exposure, CBD with your supervisor are particularly useful for those areas in which your exposure to cases has not been sufficient to cover

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guidelines. Liaise effectively with the wider MDT.

the breadth of the condition.

(10.04) Diabetes Mellitus

(10.05) Gestational Diabetes

1,2

1,2

(10.04) Understand how pregnancy influences diabetes and how diabetes can impact upon the pregnancy for both complicated and uncomplicated diabetes.

Pre-existing diabetes: pathogenesis & classification, prevalence, complications (metabolic, retinopathy, nephropathy, neuropathy, vascular disease).

Know how to undertake pre-pregnancy assessment and screening for complications.

Know how to monitor and optimise glucose control in pregnancy and postpartum.

Know how to manage hypoglycaemia and ketoacidosis in pregnancy.

Know how to appropriately monitor the fetal condition at all stages of pregnancy.

(10.05)Understand how GDM is identified in pregnancy, its impact and how to mitigate its effects. Understand its short and long term implications.

1,2

1,2

1,2

1,2

1,2

1,2

1,2

(10.04) Perform, under supervision, appropriate assessment and management of women with pre-gestational diabetic complications

Ability to take an appropriate history and conduct an examination to assess a woman with pre-gestational diabetes.

Ability to perform and interpret appropriate investigations formulate, implement and where appropriate modify a multi-disciplinary management plan.

(10.04-10.05)Liaise with diabetologists, diabetic nurse specialists, dieticians, and other specialists where appropriate, counsel, maternal and fetal risks, importance of good glycaemic control (including use of insulin in GDM)

Discuss long-term risks, contraception options and the management future pregnancies.

1,2,3

1,2,3,4

1,2,3

1,2,3,4

1,2,3,4

(10.04 -10.05)RCOG Scientific impact paper No. 23 Diagnosis and treatment of Gestational diabetes.

NICE Guideline NG3 (2015) Diabetes in Pregnancy: management from preconception to the postnatal period. RCOG Patient information (2013). Gestational diabetes.

Attendance at Obstetric Medical clinics / adult diabetes clinics.

STRATOG Advanced,

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Maternal Medicine eLearning: Gestational diabetes mellitus (2016).

STRATOG Advanced, Maternal Medicine eLearning: Pre-existing diabetes without complications (2015).

(10.06) Known haemoglobinopathy 1,2 (10.06)Understand how haemoglobinopathy impacts upon the antenatal and intrapartum care of the woman.Understand the risks to the fetus and how these may be monitored.Understand the genetic basis for the common haemoglobinopathies and what prenatal testing is available.

1,2

1,2

10.06)Manage thalassaemia or other haemoglobinopathy. Counsel on fetal and maternal risks, arrange and interpret appropriate investigations liaise regarding therapy, plan delivery and postnatal care.

Be able to explain the option of prenatal diagnosis.

1,2,3,4

1,2,3,4

(10.06)Green top guideline No.66 Thalassemia in pregnancy.

RCOG patient information (2015). Beta Thalassemia and pregnancy.

(10.07) High risk for venous thromboembolism

1,2 (10.07-10.08)Understand how to quantify 1,2

(10.07-10.08)Manage a case of thrombophilia 1,2,3

(10.07-10.08)RCOG Patient

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(10.08) Prior thromboembolism 1,2

thromboembolism risk and how best to mitigate that risk.

and / or previous VTE in pregnancy, arrange and interpret appropriate investigations.

Be able to accurately risk score for thromboembolism, and to communicate that risk effectively.

Discuss and plan treatment accordingly. Institute/modify VTE prophylaxis where appropriate.

1,2,3,4

1,2,3,4

information (2015). Diagnosis and treatment of venous thrombosis in pregnancy and after birth.

STRATOG Advanced, Maternal Medicine eLearning: Previous venous thromboembolism (2016).

(10.09) Renal disease in labour 1,2(10.09)Have an understanding of the effects of labour and the immediate postpartum period on chronic renal disease.

1,2 (10.09)Perform, under supervision, appropriate assessment and management of a labouring woman with renal disease.

Arrange and interpret appropriate investigations, formulate, implement and where appropriate modify a multi-disciplinary management plan with appropriate liaison where necessary.

1,2,3,4

1,2,3

(10.09)STRATOG Advanced, Maternal Medicine eLearning: Kidney Disease in Pregnancy.

(10.10) HIV including MDT approach to minimising potential sequelae.

1,2(10.10)Understand how HIV impacts upon the antenatal, intrapartum and postpartum care of the woman.

1,2(10.10)Manage a case of HIV in labour: plan mode of delivery and suitable treatment to minimise

1,2,3(10.10)RCOG Patient information (2013) HIV in pregnancy.

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Understand the risks to the fetus and how these may be reduced.

Understand the transmission of HIV and how viral load may be monitored and the treatments available.

1,2

neonatal transmission.

(10.11) Intrapartum pyrexia 1,2(10.11)

Understand the causes of pyrexia in labour, their investigation and treatment as well as the potential impact upon mother and baby.

1,2(10.11)Manage intrapartum pyrexia, coordinating midwifery, neonatal and microbiology assistance as required.

1,2,3(10.11)RCOG Green top guideline No.64 Sepsis in pregnancy.No.64b Sepsis following pregnancy.

(10.12) Increased risk to new-born from Group B Haemolytic Streptococcus

1,2 (10.12)Understand which groups are at increased risk of GBS and how to mitigate this increased risk. Understand the features of early and late onset neonatal GBS infection.

1,2(10.12)Explain risks and implement local policy to reduce risks of GBS in the new-born.

Liaise appropriately with neonatal team.

1,2,3,4

1,2,3

(10.02)RCOG Patient information (2013). Group B streptococcus infection in new-born babies.

ASM 10: Intrapartum Obstetric Medical Disorders Part of the Maternal Medicine ATSM and the Advanced Labour Ward Practitioner ATSM.



ASM 10: Key Intrapartum Obstetric Medical Disorders Date Signature Date Signature Date Signature

Severe preeclampsia

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ASM 10: Key Intrapartum Obstetric Medical Disorders Date Signature Date Signature Date Signature

Eclampsia

HELLP syndrome

Diabetes Mellitus

Gestational Diabetes

Known haemoglobinopathy

High risk for venous thromboembolism

Prior thromboembolism

Renal disease in labour

HIV including MDT approach to minimising potential sequelae.

Intrapartum pyrexia

Increased risk to new-born from Group B Haemolytic Streptococcus

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Completion of ASM 10: Key Intrapartum Obstetric Medical Disorders Date Signature

Safe and effective management of these maternal medical conditions has been achieved through direct exposure and decision making for a range of clinical cases including timely liaison with the MDT and tertiary services if appropriate.

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ASM 11: Skills covering the full range of Maternal Medical conditions


Hypertension and Renal(11.01) Glomerulonephritis

(11.02) Reflux nephropathy

1,2(11.01-11.02)Understand the functional and anatomical changes of the renal tract in normal pregnancy. Be able to interpret the normal changes in renal function during pregnancy.

For pre-existing renal disease (typically, reflux nephropathy, glomerulonephritis, polycystic kidney disease) understand their pathology, prevalence and pre-pregnancy assessment and pregnancy management.

1,2

1,2

(11.01-11.02)Be able to interpret and explain renal function testing in the presence of chronic renal disease.Where the diagnosis is unclear be able to construct a differential diagnosis, investigate and liaise appropriately.

Be able to advise on the likely impact that pregnancy will have upon the renal condition and how the condition may impact upon the pregnancy.

1,2,3,4

1,2,3,4

(11.01 -11.21)Your supporting evidence should be based upon at least one case in which you have been directly involved.

Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.

It is recognised that you may not have the opportunity to be directly involved with each condition.

In this case you will need to supply supportive evidence such as

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Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/assessmentCBD, attendance at a suitable case reviews or other relevant clinical meetings and completion of eLearning such as TOG and STRATOG.

Cardiac and Respiratory(11.03) Congenital heart disease

(11.04) Ischaemic heart disease

(11.05) Pregnancy with artificial heart valve.

(11.06) Peripartum cardiomyopathy.

1,2(11.03)Review the effects of pregnancy on the cardiovascular system and the risks this creates for co-existing ischaemic heart disease and the main forms of adult congenital heart disease. Understand how each may present in pregnancy and how the pregnancy should be monitored.

(11.06)Understand how peripartum cardiomyopathy presents, is investigated and treated. Understand the implications for any future pregnancies.

1,2

1,2

(11.03-11.06)Take an appropriate history for each condition.

Be able to perform a thorough cardiovascular examination.

Be able to interpret ECHO and ECG findings.

Be able to offer pre-pregnancy and booking advice, suitable antenatal monitoring, intrapartum and postpartum care plans.

Liaise appropriately to cardiologists, haematologists, anaesthetists for further assessment and treatment.

Recognise and act promptly if there are signs of deterioration.

1,2,3,4

1,2,3

1,2

1,2,3,4

1,2,3

1,2

(11.03-11.06)RCOG Good practice guideline No.13 (2011) Cardiac disease and pregnancy.

Attend Adult Cardiac Clinics, Adult Congenital Heart Disease Clinics.

MDT meetings on ITU/HDU, Obstetric anaesthesia reviews.

STRATOG Advanced, Maternal Medicine eLearning:

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Peripartum cardiomyopathy (2015).

Gastrointestinal(11.06) Acute fatty liver of pregnancy

1,2(11.06) Review the symptoms and signs of AFLP; in particular consider how these may mimic other hypertensive and renal conditions in pregnancy.

Understand the systemic implications of the condition, the immediate risks and the long-term implications.

Understand the management options, including the management of acute liver failure.

1,2

1,2

1,2

(11.06)Be able to rapidly assess the seriousness of the clinical situation.

Appropriately investigate and construct a differential diagnosis.

With support plan the acute care and delivery.

Liaise with hepatologists where appropriate.

Debrief providing accurate information including details on future risks.

1,2,3

1,2,3

1,2,3

1,2,3

1,2,3,4

(11.06)MDT meetings on ITU/HDU, Obstetric anaesthesia reviews.

STRATOG Advanced, Maternal Medicine eLearning: Acute fatty liver of pregnancy (2016).

Gastrointestinal(11.07) Crohn’s disease

(11.08) Ulcerative colitis

1,2(11.07-11.08)Review the effects of pregnancy on the gastrointestinal system and how this may impact upon Crohn’s disease and Ulcerative colitis.

Understand how these conditions may present, their differential diagnosis, treatment and management during pregnancy.

1,2

1,2

(11.07-11.08) STRATOG Advanced, Maternal Medicine eLearning: Gastrointestinal Disease (2016).

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Review the pharmacology of anti-emetics (cyclizine, metoclopramide) antacids (magnesium trisilicate) and H2-receptor antagonists (ranitidine).

Understand the place of endoscopy, steroid use and parental nutrition.

1,2

1,2

Endocrine(11.09) Hypothyroidism

(11.10) Hyperthyroidism

1,2(11.09 -11.10)Understand the endocrinology of the thyroid during pregnancy;

Review the prevalence, pathogenesis, diagnosis, monitoring and treatment (including the pharmacology of thyroxine and thionamides) for thyroid disorders.

Understand the risk and management of adverse of fetal outcomes including neonatal hypo/hyperthyroidism and developmental delay.

1,2

1,2

1,2

(11.09 -11.10)Take an appropriate history and examination to screen for endocrine dysfunction in pregnancy.

Manage cases of thyroid dysfunction both during and after pregnancy.

Explain test results and offer accurate counselling explaining both fetal and maternal risks in a manner that is straightforward to understand.

Liaise with endocrinologist, and other specialists where appropriate.

1,2,3,4

1,2,3

1,2,3,4

1,2,3

Neurology(11.11) Multiple sclerosis

(11.12) Bell’s Palsy

1.2(11.11-11.12)Understand the neurological examination, the information it provides and suitable tests to follow up any suspicion of

1,2

(11.11-11.12)Be able to carry out a neurological examination. 1,2,3

(11.11-11.12)STRATOG Teaching materials, Maternal

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underlying pathology.

Review the management of women with neurological disease in pregnancy with specific emphasis on pre-existing (multiple sclerosis) or new (Bell’s palsy) neurological diseases.

1,2

With support, be able to plan the assessment and management of women with pre-existing (multiple sclerosis) or new (Bell’s palsy) neurological disease.

Be able to explain the fetal and maternal risks, arrange and interpret appropriate investigations, institute/modify drug therapy.

Plan delivery and postnatal care, liaise and refer where appropriate.

1,2,3

1,2,3,4

1,2,3

Medicine: Neurological disorders –teaching resource, Case Studies.

Haematological disorders(11.13) Sickle cell disease

1,2(11.13)Review the genetics, presentation and management of sickle cell disease in pregnancy with particular emphasis on treatment options and the potential for sickle cell crises.

(11.13)Understand the role of the haematologist in managing the conditions.

1,2

1,3

(11.13)With appropriate liaison manage women with sickle cell disease demonstrating an understanding of how risks may be minimised both antenatally and intrapartum.

Be able to explain these risks in a manner that is easy to understand.

1,2,3

1,2,3,4

(11.13)RCOG Patient information (2014) Sickle cell disease in pregnancy.

STRATOG Advanced, Maternal Medicine eLearning: Sickle Cell Disease (2016)

Haematological disorders(11.14) Thrombophilia

1,2(11.14)Understand the genetic basis pathogenesis investigation and diagnosis of congenital

1,2(11.14)Conduct an appropriate history and examination from a woman

1,2,3,4

(11.14)RCOG Green top guideline No. 37a

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and acquired thrombophilias

Be able to quantify the risk of venous thromboembolism. Understand the risks secondary to thrombosis, both fetal and maternal.

Understand how risks may be minimised and monitored.

1,2

1,2

with known thrombophilia or suspected venous thromboembolism in pregnancy.

Be able to liaise appropriately, arrange and interpret suitable investigations and plan subsequent care.

Be able to explain the condition and plan antenatal and postnatal care in a manner that is easy to understand.

1,2,3

1,2,3,4

and No 37b. (2015) Thrombosis and embolism in pregnancy. No.40 (2010) Venous thromboembolism and hormonal contraception.

Dermatological disease(11.15) Psoriasis

(11.16) Pemphigoid gestationis

1,2(11.15 -11.16)Review the common (pre-existing) skin diseases (eczema, psoriasis, acne) in light of the impact that pregnancy may have on them and the treatments available.

Understand how new skin conditions may present, diagnosed and treated in pregnancy with particular emphasis on pemphigoid gestationis, polymorphic eruptions, prurigo and pruritic folliculitis of pregnancy.

1,2

1,2

(11.15-11.16)Take an appropriate history from a woman with pre-existing or pregnancy induced skin disease.

Perform an examination in a woman with skin disease.

Interpret appropriate investigations institute/modify drug therapy, liaise where appropriate, for further assessment.

1,2,3,4

1,2,3,4

1,2,3

(11.15)NICE Guideline CG153 (2012) Psoriasis assessment and management.

STRATOG Advanced, Maternal Medicine eLearning: Dermatological problems in pregnancy (2016).

Malignant Disease(11.17) History of breast or other malignancy.

1,2(11.17- 11.18)Know the maternal & fetal effects of cancer 1,2

(11.17-11.18)Take an appropriate history from 1,2,3,

(11.17-11.18)RCOG Green top

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(11.18) Active breast or other malignancy

therapies both radiotherapy and chemotherapy.

Understand the pathology, prevalence, maternal and fetal risks, management during pregnancy and postnatal and best advice for breastfeeding & contraception.

Review the prognosis and recurrence risks for breast cancer, gynaecological cancer, melanoma and haematological malignancy. Consider how the needs of the fetus and the treatment options available for the pregnant woman may be reconciled.

Understand the role of primary care, palliative care, surgeons and oncologists to optimise patient management.

Understand the principles and practice of palliative care.

1,2

1,2

1,2

1,2

a woman with suspected or prior malignancy.

Perform breast examination in pregnancy.

With appropriate liaison provide individualised care sensitive to the individual’s wishes hopes and expectations for the pregnancy.

Act with empathy, honesty and sensitivity when breaking bad news.

4

1,2,3

1,2,3,4

1,2,3,4

guideline No.12 Pregnancy and breast cancer.

NICE CG90 (2009) Guideline Early and locally advanced breast cancer: diagnosis and treatment.

STRATOG Advanced, Clinical Case Studies eLearning: Neoplasia in pregnancy: case study (2016).

Connective Tissue Disorders

(11.19) Systemic lupus erythematous

(11.20) Antiphospholipid syndrome (with complications, fetal growth restriction, stillbirth, pre-eclampsia or thrombosis.

(11.21) Rheumatoid arthritis

1,2(11.19-11.21)Understand how SLE and rheumatoid arthritis interact with pregnancy. Understand the range of complications that may accompany SLE how they are monitored and how these risks may be reduced.

Review the treatments available including any potential for adverse effects during pregnancy (aspirin, NSAIDs,

1,2

1,2

(11.19-11.21)Take an appropriate history and examination from a woman with connective tissue disorders (SLE, RA).

Be able to explain the fetal and maternal risks, arrange and interpret appropriate investigations, institute/modify drug therapy,

1,2,3,4

1,2,3,4

(11.19)STRATOG Advanced, Maternal Medicine eLearning: SLE (2016).

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corticosteroids, chloroquine, sulphasalazine, azothiaprine and penicillamine).

Plan delivery and postnatal care referring where appropriate for further assessment and treatment.

Be able to offer pre-pregnancy advice of the risks for future pregnancies and how these may be minimised.

1,2,3

1,2,3,4

ASM 11: Skills covering the full range of maternal medical conditions

Part of the Maternal Medicine ATSM


Level 1 Level 2


Date Signature Date Signature

Hypertension and RenalGlomerulonephritis

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Level 1 Level 2



Hypertension and RenalReflux nephropathy

Cardiac and RespiratoryCongenital heart disease

Cardiac and RespiratoryIschaemic heart disease

Cardiac and RespiratoryPregnancy with artificial heart valve

Cardiac and RespiratoryPeripartum cardiomyopathy

GastrointestinalAcute fatty liver of pregnancy

GastrointestinalCrohn’s disease

GastrointestinalUlcerative colitis

EndocrineHypothyroidism

EndocrineHyperthyroidism

NeurologyMultiple sclerosis

NeurologyBell’s palsy

Haematological disordersSickle cell disease

22




Level 1 Level 2



Haematological disordersThrombophilia

Dermatological diseasePsoriasis

Dermatological diseasePemphigoid gestations

Malignant DiseaseHistory of breast or other malignancy

Malignant DiseaseActive breast or other malignancy

Connective Tissue DisordersSystemic lupus erythematous

Connective Tissue DisordersRheumatoid arthritis

Connective Tissue DisordersAntiphospholipid syndrome (i.e. APL with complications, FGR/Stillbirth/PET or thrombosis)



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Completion of ASM 11: Skills covering the full range of maternal medical conditions Date Signature

A thorough understanding of these medical conditions has been achieved through attendance at specialist clinics both within and outwith the obstetric setting. Liaison with tertiary services has been timely and appropriate

ASM 12: Key maternal medical conditions involving the multidisciplinary team


Hypertension and Renal(12.01) Acute renal failure

1,2 (12.01-12.02)These conditions build upon the knowledge (12.01 -12.02) (12.01-12.02) (12.01-12.09)

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(12.02) Renal transplant recipientdeveloped from:

ASM 6. Management of the Key Obstetric Medical Conditions. (6.02)

ASM 10 Key intrapartum obstetric medical disorders. (10.09)

ASM11 Skills covering the full range of medical conditions (11.01, 11.02)

(12.01) Understand the presentation, investigation differential diagnosis, management and outcome of acute renal failure in pregnancy.

(12.02)For renal transplant recipients understand their pre-pregnancy assessment and the influence of pregnancy upon the condition both in the short and long term.

Be familiar with the monitoring of renal function during and after pregnancy, identification of deteriorating function and rejection.Understand the pharmacology of commonly used agents including their adverse effects: cyclosporine, tacrolimus, azothiaprine and corticosteroids.

1,2

1,2

1,2

Understand how the MDT may be effective in optimising the outcome and underpinning effective renal supportive measures.

Work effectively within the MDT to offer advice pre-pregnancy antenatally and postpartum on the investigation, treatment and obstetric management of these conditions.

Deliver information in a manner that is straightforward to understand.

1,2,3

1,2,3

1,2,3,4

Attendance at sessions in: General medical clinics and MDT antenatal clinics. Obstetric anaesthesia ITU/HDU.

STRATOG Advanced, Maternal Medicine eLearning: Kidney disease in pregnancy (2016).

These competencies are based upon knowledge skills and attitudes gained through MDT working for complex cases.

Each requires a deeper understanding of each condition with a holistic approach the each women rather than an entirely obstetric focus.

For this, time spent working with allied specialities, understanding the management both before during and after pregnancy is crucial.

Where evidence cannot be based on direct involvement with obstetric cases

25



Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/assessment(OSATs CBD, reflective practice) supplement evidence based upon OSAT and CBD of non-obstetric cases through exposure to allied specialties.

Include evidence of eLearning and skills drills.

Hypertension and Renal(12.03) Chronic hypertension

1,2 (12.03)This builds upon the knowledge developed from:


ASM 10 Key intrapartum obstetric medical disorders). (10.01-10.03)

Understand the physiological changes in pregnancy and how they impact upon chronic hypertension and its measurement.

Understand the pathophysiology of primary and secondary chronic hypertension their screening, diagnosis, management and the impact of pregnancy.

Understand the pharmacology including

1,2

1,2

1,2

(12.03)Be able to optimise the pre-pregnancy management of chronic hypertension.

Be able to differentiate between chronic hypertension, superimposed pre-eclampsia, HELLP,

Be able to plan suitable treatment and monitoring strategies based upon both the maternal and fetal risks.

Understand the benefits of MDT working for complex cases.

Liaise appropriately with primary case and hospital based

1,2,3

1,2

1,2

1,2,3

1,2,3

(12.03)NICE Guideline CG107 (2010). Hypertension in pregnancy.

Attendance at sessions in: General medical clinics and MDT antenatal clinics. Obstetric anaesthesia ITU/HDU.

STRATOG Advanced, Maternal Medicine eLearning: Chronic

26




potential adverse effects of anti-adrenergics (e.g. propranolol, labetolol, oxprenolol), calcium channel blockers (e.g. nifedipine), vasodilators e.g. hydralazine, ACE inhibitors (e.g. lisonopril).

Be able to advise on long-term cardiovascular risks.

1,2,3

physicians as appropriate to the patient’s needs.

hypertension (2016).

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Cardiac and Respiratory

(12.04) Pulmonary embolism

(12.05) Acute chest pain

1,2(12.04-12.05)Understanding these conditions building upon the knowledge developed from:

ASM 6. Management of the Key Obstetric Medical Conditions. (6.11, 6.12, 6.13, 6.14. 6.15)

ASM 10 Key intrapartum obstetric medical disorders. (10.07, 10.08)

(12.04)Understand the presentation of pulmonary embolism and recognise the potential for co-existing lung disease (asthma, sarcoidosis, cystic fibrosis, tuberculosis], restrictive lung disease)

(12.05)Construct a differential diagnosis for breathlessness, tachypnoea and acute hypoxemia bearing in mind all acute lung disease that can present in pregnancy (ARDS, pneumothorax, pneumonia) as well as cardiovascular conditions.

Understand the benefits of an MDT approach including the range of respiratory support and treatment options (oxygen therapy, the principles of ventilatory support antibiotic therapy).

1,2

1,2

1,2

(12.04-12.05)Ability to take an appropriate history and conduct an examination to assess a woman with acute respiratory disease.

Manage a case of acute lung disease in pregnancy, counsel re fetal and maternal risks.

Arrange and interpret appropriate investigations & fetal monitoring refer to respiratory physicians / intensivists for further assessment / treatment.

Plan delivery and postnatal care in liaison with respiratory physicians.

1,2,3,4

1,2,3,4

1,2,3

1,2,3

(12.04-12.05)RCOG Patient information (2015). Diagnosis and treatment of venous thrombosis in pregnancy and after birth.

Attendance at sessions in obstetric anaesthesia and ITU/HDU.

Medical ward attendance for a wider experience of (non pregnant) management for acute chest pain and pulmonary embolism.

Endocrine 1,2

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(12.06) Pre-existing diabetes with chronic complications (nephropathy, retinopathy, neuropathy, vascular disease.)

(12.07) Ketoacidosis

(12.06 – 12.07)Understanding the condition built upon the knowledge developed from:

ASM 6. Management of the Key Obstetric Medical Conditions. (6.05, 6.06)

ASM 10 Key intrapartum obstetric medical disorders (10.04 10.05).

(12.06 -12.07)Liaise effectively with the MDT and be able to explain the risks of pregnancy where there is established chronic diabetes with complications.

(12.07) Liaise effectively for the acute recognition and management of ketoacidosis in pregnancy.

Be able to debrief after diabetic ketoacidosis and advice of minimising the risk of further episodes.

1,2,3,4

1,2,3

1,2,3,4

(12.06)NICE Guideline NG3 (2015) Diabetes in Pregnancy: management from preconception to the postnatal period.

Medical ward and clinic attendance for a wider experience of (non pregnant) the management end organ disease secondary to diabetes.

Neurology(12.08) Altered consciousness

1,2(12.08)This builds upon the knowledge developed from:


ASM 10 Key intrapartum obstetric medical disorders). (10.01, 10.02, 10.05).

ASM 11. Skills covering the full range of maternal medical conditions (11.111-

(12.08)Be able to carry out a neurological examination.

Be able to construct a differential diagnosis and liaise appropriately with the MDT according to the suspected underlying causation.

Be able to explain any fetal and maternal risks, arrange and interpret appropriate

1,2,3

1,2,3

1,2,3,4

(12.08)Green top guideline No.68 Epilepsy in pregnancy.

No.56 Maternal collapse in pregnancy.

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11.12).

Review the cardiovascular, respiratory, metabolic, psychiatric and neurological causes of altered consciousness and how they may present during pregnancy or postpartum.

1,2 investigations, institute/modify drug therapy.

Plan delivery and postnatal care, liaise and refer where appropriate.

1,2,3

Haematological disorders(12.09) Sickle cell crisis

1,2(12.09)This builds upon the knowledge developed from:


ASM 10 Key intrapartum obstetric medical disorders). (11.13)

Understand how and why a sickle cell crises may present during pregnancy or postpartum. Understand its monitoring and the potential for fetal and maternal sequelae.

Understand how the risk of a crisis may be minimised.

1,2

1,2

(12.09)In collaboration with haematology services be able to interpret results, manage acute sickling crises and debrief afterwards in a manner that is easily understood.

1,2,3,4

(12.09-RCOG Patient information (2014) Sickle cell disease in pregnancy.

STRATOG Advanced, Maternal Medicine eLearning: Sickle Cell Disease (2016).



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Competence level

Level 1 Level 2


Hypertension and RenalAcute renal failureHypertension and RenalRenal transplant recipientHypertension and RenalChronic hypertensionCardiac and RespiratoryPulmonary embolismCardiac and RespiratoryAcute chest painEndocrinePre-existing diabetes with chronic complications (nephropathy, retinopathy, neuropathy, vascular disease.)EndocrineKetoacidosisNeurologyAltered consciousnessHaematological disordersSickle cell crisis

31







Completion of ATSM 12: Key maternal medical conditions involving the MDT Date Signature

A thorough understanding of these medical conditions has been achieved through attendance at specialist clinics both within and outwith Obstetrics within an MDT team setting, Liaison with tertiary services has been timely and appropriate.

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ASM 13: Communication and Clinical Governance Skills for Obstetric Medicine


(13.01) Restrictive cardiac or lung diseaseExplain the implications of pregnancy and childbirth.

(13.02) Abnormal renal functionExplain the results and their implications.

(13.03) Pre-pregnancy counselling for medical disorder where pregnancy carries significant maternal risk.

(13.04) Pre-pregnancy counselling for medical disorder where pregnancy carries significant fetal risk.

(13.05) Communication of the risks versus benefits of medication during pregnancy.

(13.06) Debrief after adverse pregnancy outcome.

(13.07) MDT liaison and co-ordination of care for admission to intensive care unit.

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

(13.01-13.06)The knowledge component of these competencies will have been acquired through ASM 10, 11 and 12 modules.

This section is where you are able to put into practice this knowledge under challenging circumstances.

To do this more effectively, develop an understanding of techniques for effective communication.

Review techniques for breaking bad news.

1,3,4

(13.01-13.06)Demonstrate the ability to summarise and explain complex medical conditions in a way that is easy to understand.

To respond to the woman’s hopes and expectations for the pregnancy.

To be able to balance the risks to the fetus with those to the mother.

To be able to advise on the short term and the long-term consequences of the clinical scenario.

To know your limitations and seek further advice when appropriate.

1,3,4

1,3,4

1,3,4

1,3,4

1,2,3,4

(13.01-13.05)RCOG Clinical Governance Advice No.7 (2008) Presenting information on risk.

(13.06)RCOG Green top guideline No.55 (2010) Late intrauterine death and stillbirth.

(2012). When your baby dies before birth.

STRATOG Advanced, Maternal Medicine eLearning: Cystic Fibrosis (2015).

STRATOG Advanced, Maternal

(13.01-13.07)These are competencies in which effective communication is being assessed. The evidence for these competencies should be work placed based assessments where you have been supervised delivering direct patient care.

Reflective practice

Log of cases, record of eLearning

33




Medicine eLearning: Asthma (2015).

Clinical Governance

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

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

(13.10) Lead Risk Management case review.

(13.11) Work effectively within the MDT team.

(13.12) Know when and how to refer to support services (for example, medical, diabetologists, endocrinologists, cardiologists pre-pregnancy counselling).

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

1,2,3

1,2

1,2,3

1,2,3

1,2,3

1,2,3

(13.08)Understand the definition of reflective practice, and those models that may be used to support reflection.

Understand the benefits and limitations of reflective practice.

(13.10 -13.13)Knowledge of team working and dynamics, those influences, both positive and negative that may impact on team development.

Support, mentoring and motivation.

Implementing changes and progressing as a team.

1,2

1

1,2,3

1,2,3,41,2,3

(13.08)Ability to use reflective practice to lead to positive changes learnt as a consequence of challenging clinic encounters.

(13.10-13.13)Understand and reflect upon the impact and effectiveness (or otherwise) of different leadership styles and behaviours.

1,2,3,4

1,3

(13.08-13.13)RCOG Clinical Governance Advice:

No.1c Producing a clinical practice guideline.

No.2 Improving patient safety. Risk management for maternity and gynaecology.

No.5 Understanding Audit.

No.6 Obtaining valid consent.

GMC: Leadership and Management for all doctors (2012)

GMC Good Medical Practice (2013).

(13.08)Reflective practice

(13.09)Attach quality improvement project to ePortfolio.

(13.10)Log of risk management meeting and cases discussed.

(13.11-13.13)OSATs and CBD from Obstetricians and allied specialities for complex medical cases.

Reflective Practice

NOTTS

34









Restrictive cardiac or lung diseaseExplain the implications of pregnancy and childbirth.

Abnormal renal functionExplain the results and their implications.

Pre-pregnancy counselling for medical disorder where pregnancy carries significant maternal risk.

Pre-pregnancy counselling for medical disorder where pregnancy carries significant fetal risk.

Communication of the risks versus benefits of medication during pregnancy.

Debrief after adverse pregnancy outcome.

MDT liaison and co-ordination of care for admission to intensive care unit.

Governance

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

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

Lead Risk Management case review.

35







Work effectively within the MDT team.

Know when and how to refer to support services (for example, medical, diabetologists, endocrinologists, cardiologists pre-pregnancy counselling).

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

36







Completion of ASM 13: Communication and Clinical Governance Skills for Obstetric Medicine

Date Signature

The full range of communication, professionalism and governance skills have been demonstrated within specialist obstetric medical clinic incorporating adequate liaison with the wider MDT team and tertiary services as required.

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