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Update on proposed minimum standards for ultrasound training for residents in Ob/Gyn

INTRODUCTIONWe would expect the trainee to have a basic knowledge ofthe following areas: embryology, dysrnorphology, genetics,the physiology and pathophysiology of pregnancy.

The theoretical training program would expect the can-didate to understand the full range of diagnostic possibili-ties of ultrasound. The practical training requirements areto ensure the candi(date develops sufficient skills to enablehim to establish normal and abnormal fetal developmentwith the objective to improve fetal outcome; to triage forgynecological emergencies and to make appropriate refer-rals to a tertiary (specialist) center for further investiga-tions. There is a difference between thepractical training components. Residentsaccomplish in practice everything that istheory.

theoretical anddo not have tobeing taught in

THEORETICAL TRAINING PROGRAMThe trainee to understand and be able to discuss the fol-lowing:

Basic physical principles of medical ultrasound(1) The relevant principles of acoustics, attenuation,

absorption, reflection, speed of sound;(2) The effects on tissues of pulsed and continuous wave

ultrasound beams: biological effects, thermal andnon-thermal;

(3) Basic operating principles of medical instruments:(4(b)

(4

(4(4

Pulse echo, scanning principles and 3-D;Pulse echo instruments, including linear array,curvilinear, mechanical sector, transvaginal andrectal scanners;Velocity ilmaging and recording:l Doppler principle

continuous wavepulse wavecolor flow mappingpower Doppler

l Color velocity imagingl Pitfalls, artefacts;Data acquisition;Signal processing (may be g:iven in practicaldemonstration):l gray sc:alel time gain compensationl dynamic range

l dynamic focusl digitizationl gain compensation, acoustic output

relationship (may be given in practicaldemonstration);

(f) Artefacts, interpretation and avoidancel reverberationl side lobesl edge effectsl registrationl shadowingl enhancement;

(g ) Measuring systemsl linear, circumference, area and volumel Doppler ultrasound - flow, velocity,

spectrum analysis;(h) Image recording, storage and analysis;(i) Interpretation of acoustic output information

and its clinical relevance.

Obstetrics(1) Investigation of early pregnancy

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(b)

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Ultrasound features of normal early pregnancy,including gestational sac and yolk sac, simpleand multiple pregnancy, chorionicity;Development of fetal anatomy in earlypregnancy including recognition ofabnormalities such as nuchal translucency, cystichygroma and fetal hydrops;Embryonic-fetal biometry, e.g. crown-rumplength;Fetal viability;Ultrasound features of early pregnancy failureincluding hydatidiform mole;Ultrasound and biochemical investig,ation ofectopic pregnancy tumors in early pregnancy;Normal appearance of the cervix;

(2) Assessment of amniotic fluid and placenta(a) estimation of amniotic fluid volume(b) examination of the placenta and cord(c) placental location(d) number of cord vessels;

(3) Normal fetal anatomy at 18-20 weeks(a) shape of the skull: nuchal skinfold(b) facial profile(c) brain: cerebral ventricles, posterior fossa and

cerebellum; cysterna magna, choroid plexus cysts

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(4)

(4(4(f)k)0-4(i)

(i)

spine: both longitudinally and transverselyheart rate and rhythm, four-chamber view,including atrioventricular valves, outflow tractlungsshape of the thorax and abdomenabdomen: stomach, liver, kidneys and urinarybladder, abdominal wall and umbilicuslimbs: femur, tibia and fibula, humerus, radiusand ulna, hands and feet - these to includeshape, echogenicity of the long bones andmovementmultiple pregnancy: chorionicity;

To study the epidemiology, differential diagnosis,natural history of abnormalities and management of(a) Structural

l skeletal systeml central nervous systeml cardiovascularl intrathoracic disordersl renall abdominal wall and diaphragml gastrointestinall markers for chromosomal abnormalities

(b) Functionall polyhydramnios, oligohydramnios, hydrops,

dysrhythmias(c) Prognosis and treatment (including intravascular

therapy);(5) Fetal biometry

(a) Measurements to assess fetal size (includingbiparietal diameter, head circumference,abdominal circumference, femur length)

(b) Measurements to aid the diagnosis of fetalanomalies: anterior/posterior horn of the lateralventricle, transcerebellar diameter, nuchalskinfold;

(6) Estimation of gestational age(a) Interpretation and appreciation of limitation of

ultrasonic and other investigations forgestational age assessment;

(7) Assessment of fetal growth(a) Ultrasonic assessment of fetal growth:

interpretation and appreciation of limitations ofstandard measurements singly or serially(b) Fetal weight estimation;

(8) Biophysical scoring systems: interpretation andappreciation of limitations(a) Fetal body movements(b) Fetal breathing(c) Heart rate and rhythm;

(9) Evaluation of fetal and uteroplacental blood flow(a) Methodology appropriate to obstetric

investigation(b) Appreciation of problems in blood flow and

velocity measurements and waveform analysis innormal and complicated pregnancies

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(4

Clinical applications and limitations in theprediction of intrauterine growth retardationand pre-eclampsiaClinical applications in monitoring thesmall-for-dates fetus and pregnanciescomplicated by rhesus isoimmunization,diabetes and fetal cardiac arrhythymias;

(10) Knowledge of invasive diagnostic and therapeuticprocedures(a) Diagnostic: amniocentesis, chorionic villus

sampling, cordocentesis(b) Therapeutic: shunting and draining procedures.

Gynecology( 1) Normal pelvic anatomy

(a) Uterusl uterine size, position, shape and measurementl cyclical morphological changes1 in the

endometriuml measurement of endometrial thickness

(b) Ovariesl size, position, shape and measurementl cyclical morphological changes1l measurement of follicles and corpus luteuml assessment of peritoneal fluid;

(2) Gynecological complications(a) Uterus

l fibroidsl adenomyosisl endometrial hyperplasial endometrial cancer. polypsl location of intrauterine contraceptive devices

(b) lubesl hydrosalpinx and other abnorrnalities of the

Fallopian tube(c) Ovaries

l cysts: benign and malignant, morphologicalscoring systems

l endometriosisl ovarian carcinomal differential diagnosis of pelvic masses;

(3) Infertility(a) Monitoring of follicular development in

spontaneous and stimulated cyclesl diagnosis of hyperstimulation syndromel diagnosis of polycystic ovariesl sonosalpingography;

(4) Invasive procedures(4(b)(c)(4(4

Oocyte retrievalInjection of ovarian cystsAspiration of ovarian cystsDrainage of pelvic abscessesExtraction of intrauterine contraceptive device;

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(5) Doppler in gynecology(a) Infertility and oncology.

Organization of ultrasound unitInfrastructure, documentation, quality control, computerization and data storage.

Medicolegal implications of ultralsoundexamination

Ethics and patien.t information

PRACTICAL TR.AININGRequired skills(1) The trainee to ' beble to identify early pregnancy

and emergency gynecological problems bytransvaginal and transabdominal ultrasound(a) Early pregnancy

l fetal viabilityl description of the gestational sac, embryo,

yolk sacl single and multiple gestation (chorionicity)

(b) Pathologyl early pregnancy failurel ectopic pregnancyl gross fetal abnormalities :such as nuchal

translucency, hydropic abnormalitiesl hydatidiform molel associated pelvic tumors

(c) Gynecologyl normal pelvic anatomyl uterine size and endometrial thicknessl measurement of ovariesl pelvic tumors, e.g. fibroids, cysts,

hydrosalpinxl peritoneal fluidl intrauterine contraceptive devices;

(2) The trainee to be able to recognize the followingnormal fetal anatomical features from 18 weeksonwards by abdominal ultrasound(a) Shape of the skull; nuchal skinfold(b) Brain: ventricles and cerebellum, choroid plexus(c) Facial profile(d) Spine: both longitudinally and transversely

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6)

(i)(k)(1)(4

Heart rate and rhythm, size and position,four-chamber viewSize and morphology of the lungsShape of the thorax and abdomenAbdomen: diaphragm, stomach, liver andumbilical vein, kidneys, abdominal wall andumbilicusLimbs: femur, tibia and fibula, humerus, radiusand ulna, feet and hands - these to includeshape, echogenicity and movementMultiple pregnancy: monochorionic anddichorionic, twin-twin transfusion syndromeAmount of amniotic fluidPlacental locationCord and number of vessels;

(3) Fetal biometry(a) Crown-rump length, biparietal diameter, femur

length, head circumference, abdominalcircumference, interpretation of growth charts;

(4) Activity: recognize and quantify:(a) Fetal movements(b) Breathing movements(c) Eye movements.

Certification(1) One hundred h ours of supervised scanning to include:

(a) 100 gynecological examinations and earlypregnancy problems (principally by t ransvaginalsonography but transabdominal experience alsorequired)

(b) 200 obstetric scans covering the full spectrum ofobstetric conditions;

(2) Logbooks(a) 30 cases on one A4 page with ultrasound picture

- at least 15 anomalies should be included;(3) Examination

(a) General guidelines: the examination Iwould beincluded as part of the normal Ob-G.yn training.The options are to have a multiple-choice paperor short written examination paper (3-4 cases).On the practical side, a transvaginal scan and afetal anatomy scan, 30 minutes for bloth, wouldbe recommended. The candidate would takeultrasound pictures and interpret the images.

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