(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) 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 guidelines. Liaise effectively with the wider MDT. 1,2,3 1,2,3 1,2,3 evidence must be based upon more than one case in which you have been directly involved. Suitable evidence includes, Reflective Practice, log of 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 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 contraception options and the management future pregnancies. 1,2,3 1,2,3 (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 / diabetes clinics. STRATOG Advanced, Maternal Medicine eLearning: Gestational
diabetes mellitus (2016). STRATOG Advanced, Maternal Medicine eLearning: 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 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. (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 (10.08) Prior thromboembolism 1,2 1,2 (10.07-10.08) Understand how to quantify thromboembolism risk and how best to mitigate that risk. 1,2 (10.07-10.08) Manage a case of thrombophilia and / or previous VTE in pregnancy, arrange and interpret appropriate investigations. 1,2,3 (10.07-10.08) RCOG Patient information (2015). Diagnosis and treatment of venous thrombosis in 1,2,3
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 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 1,2,3 1,2,3 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. Review the pharmacology of (cyclizine, metoclopramide) antacids (magnesium trisilicate) and antagonists (ranitidine). Understand the place of endoscopy, steroid use and parental nutrition. 1,2 1,2 1,2 1,2 (11.07-11.08) STRATOG Advanced, Maternal Medicine eLearning: Gastrointestinal Disease (2016). Endocrine (11.09) Hypothyroidism 1,2 (11.09 -11.10) 1,2 (11.09 -11.10)
postnatal care in a manner that is easy to understand. 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 appropriate, for further assessment. 1,2,3 (11.15) NICE Guideline (2012) Psoriasis assessment and management. STRATOG Advanced, Maternal Medicine eLearning: Dermatological problems in pregnancy (2016). Malignant Disease (11.17) History of breast or malignancy. (11.18) Active breast or other malignancy 1,2 (11.17- 11.18) Know the maternal & fetal effects of cancer 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 1,2 1,2 1,2 (11.17-11.18) Take an appropriate history from 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. 1,2,3 (11.17-11.18) RCOG Green top guideline No.12 Pregnancy and breast cancer. NICE CG90 (2009) Guideline Early and locally advanced breast cancer: diagnosis and treatment.
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 Act with empathy, honesty and sensitivity when breaking bad news. 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, corticosteroids, chloroquine, sulphasalazine, azothiaprine and penicillamine). 1,2 1,2 (11.19-11.21) Take an appropriate history and examination from a with connective tissue disorders (SLE, RA). Be able to explain the fetal and maternal risks, arrange and interpret appropriate investigations, institute/modify drug therapy, Plan delivery and postnatal care referring appropriate for further assessment and treatment. Be able to pre-pregnancy advice of the risks for future pregnancies and how these may be minimised. 1,2,3 (11.19) STRATOG Advanced, Maternal Medicine eLearning: SLE (2016). 1,2,3 1,2,3 1,2,3
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 Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/ assessment Hypertension and Renal (12.01) Acute renal failure (12.02) Renal transplant recipient 1,2 (12.01-12.02) These conditions build upon the knowledge developed 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 1,2 1,2 (12.01 -12.02) 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 antenatally and postpartum on the investigation, treatment and obstetric management of these conditions. Deliver information in a manner that is straightforward to understand. (12.01-12.02) 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). (12.01-12.09) 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, 1,2,3
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 potential adverse effects of (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 1,2 1,2 Be able to plan suitable treatment and monitoring strategies upon both the maternal and fetal risks. Understand the benefits of MDT working for complex cases. Liaise appropriately with primary case and hospital physicians as appropriate to the patient’s needs. 1,2 1,2,3 1,2,3 General medical clinics and MDT antenatal clinics. Obstetric anaesthesia ITU/HDU. STRATOG Advanced, Maternal Medicine eLearning: Chronic hypertension (2016). 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) 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. 1,2,3 (12.04-12.05) RCOG Patient information (2015). Diagnosis and treatment of venous thrombosis in pregnancy and birth. Attendance at
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 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 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 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 (12.06) Pre-existing diabetes with chronic complications (nephropathy, retinopathy, neuropathy, vascular disease.) (12.07) Ketoacidosis 1,2 (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 1,2,3 (12.06) NICE Guideline NG3 (2015) Diabetes in Pregnancy: management from preconception to the postnatal period. Medical ward and clinic
minimising the risk of further episodes. 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 6. Management of the Key Obstetric Medical Conditions. (6.09) ASM 10 Key intrapartum obstetric medical disorders). (10.01, 10.02, 10.05). ASM 11. Skills covering the full of maternal medical conditions Review the cardiovascular, respiratory, metabolic, psychiatric and neurological causes of altered consciousness and how they may present during pregnancy or postpartum. 1,2 (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 investigations, institute/modify drug therapy. Plan delivery and postnatal care, liaise and refer where appropriate. 1,2,3 1,2,3 1,2,3 (12.08) Green top guideline No.68 Epilepsy in pregnancy. No.56 Maternal collapse in pregnancy. Haematological disorders (12.09) Sickle cell crisis 1,2 (12.09) This builds upon the knowledge developed from: (12.09) In collaboration with haematology services be able to interpret results, manage acute sickling crises and (12.09- RCOG Patient information (2014) Sickle cell
Authorisation of signatures (to be completed by the clinical trainers) Name of clinical trainer (please print) Signature of clinical trainer 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. ASM 13: Communication and Clinical Governance Skills for Obstetric Medicine Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/ assessment (13.01) Restrictive cardiac or lung disease Explain the implications of pregnancy and childbirth. (13.02) Abnormal renal function Explain the results and implications. (13.03) Pre-pregnancy counselling for medical disorder 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. 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. 1,3,4 1,3,4 1,3,4 (13.01-13.05) RCOG Clinical Governance Advice No.7 (2008) Presenting information on risk. (13.06) (13.01-13.07) are competencies in which effective communication is being assessed. The evidence for these competencies should be work