Society News

ISUOG Education Committee

Update on proposed minimum standards for ultrasound

training for residents in Ob/Gyn

dynamic focus digitization l gain compensation, acoustic output relationship (may be given in practical demonstration); (f) Artefacts, interpretation and avoidance l reverberation l side lobes l edge effects l registration l shadowing l enhancement; (g ) Measuring systems l linear, circumference, area and volume l Doppler ultrasound - flow, velocity, spectrum analysis; (h) Image recording, storage and analysis; (i) Interpretation of acoustic output information and its clinical relevance.
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INTRODUCTION

We would expect the trainee to have a basic knowledge of the following areas: embryology, dysrnorphology, genetics, the physiology and pathophysiology of pregnancy. The theoretical training program would expect the candidate to understand the full range of diagnostic possibilities of ultrasound. The practical training requirements are to ensure the candi(date develops sufficient skills to enable him to establish normal and abnormal fetal development with the objective to improve fetal outcome; to triage for gynecological emergencies and to make appropriate referrals to a tertiary (specialist) center for further investigations. There is a difference between the theoretical and practical training components. Residents do not have to accomplish in practice everything that is being taught in theory.

THEORETICAL

TRAINING

PROGRAM

The trainee to understand lowing:

and be able to discuss the fol-

Obstetrics
(1) Investigation of early pregnancy (4 Ultrasound features of normal early pregnancy, including gestational sac and yolk sac, simple and multiple pregnancy, chorionicity; (b) Development of fetal anatomy in early pregnancy including recognition of abnormalities such as nuchal translucency, cystic hygroma and fetal hydrops; (4 Embryonic-fetal biometry, e.g. crown-rump length; (4 Fetal viability; (4 Ultrasound features of early pregnancy failure including hydatidiform mole; (f) Ultrasound and biochemical investig,ation of ectopic pregnancy tumors in early pregnancy; M 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

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 and non-thermal; (3) Basic operating principles of medical instruments: (4 Pulse echo, scanning principles and 3-D; (b) Pulse echo instruments, including linear array, curvilinear, mechanical sector, transvaginal and rectal scanners; (4 Velocity ilmaging and recording: l Doppler principle continuous wave pulse wave color flow mapping power Doppler l Color velocity imaging l Pitfalls, artefacts; (4 Data acquisition; (4 Signal processing (may be g:iven in practical demonstration): l gray sc:ale l time gain compensation l dynamic range

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

spine: both longitudinally heart rate and rhythm, including lungs shape bladder, atrioventricular

and transversely four-chamber valves, view, tract outflow

(4 (4

Clinical prediction Clinical

applications

and limitations growth

in the

of intrauterine applications

retardation the

and pre-eclampsia in monitoring small-for-dates fetus and pregnancies

of the thorax stomach, abdominal

and abdomen liver, kidneys and urinary radius and wall and umbilicus humerus,

abdomen:

complicated by rhesus isoimmunization, diabetes and fetal cardiac arrhythymias; (10) Knowledge of invasive diagnostic and therapeutic chorionic villus procedures.

limbs: femur, shape,

tibia and fibula,

and ulna, hands

and feet - these to include of the long bones chorionicity; differential diagnosis, of

echogenicity

(i) (4)

movement multiple pregnancy:

procedures (a) Diagnostic: amniocentesis, sampling, cordocentesis (b) Therapeutic: shunting

and draining

To study the epidemiology, natural (a)

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history skeletal central

of abnormalities system nervous system disorders

and management

Structural

Gynecology
( 1) Normal (a) pelvic anatomy size, position, morphological shape and measurement changes1 in the thickness Uterus l uterine
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cardiovascular intrathoracic renal abdominal markers wall and diaphragm for chromosomal abnormalities hydrops, intravascular gastrointestinal

cyclical

endometrium measurement

of endometrial shape

(b)

Functional
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(b)

polyhydramnios, dysrhythmias

oligohydramnios, (including

Ovaries l size, position,

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and measurement changes1 and corpus fluid; luteum

cyclical

morphological of follicles of peritoneal

(c)

Prognosis therapy);

and treatment

measurement assessment

(5)

Fetal biometry (a) Measurements biparietal abdominal (b) Measurements to assess fetal size (including head circumference, femur length) of fetal circumference, diameter,

(2)

Gynecological (a) Uterus

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complications

fibroids adenomyosis endometrial endometrial polyps location hyperplasia cancer contraceptive abnorrnalities devices of the

to aid the diagnosis

anomalies: anterior/posterior horn of the lateral ventricle, transcerebellar diameter, nuchal skinfold; (b) (6) Estimation (a) of gestational and other age of limitation for of investigations Interpretation ultrasonic gestational (7) Assessment (a) and appreciation age assessment;

.
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of intrauterine and other tube

lubes
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hydrosalpinx Fallopian

(c)

Ovaries
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cysts: benign scoring endometriosis

and malignant,

morphological

of fetal growth
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systems

Ultrasonic assessment of fetal growth: interpretation and appreciation of limitations standard measurements estimation; interpretation and singly or serially Fetal weight

of

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ovarian carcinoma differential diagnosis

of pelvic masses;

(b) (8)

(3)

Biophysical appreciation (a) (b) (c)

scoring systems: of limitations

Infertility (a) Monitoring spontaneous l diagnosis

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of follicular

development

in

Fetal body movements Fetal breathing Heart rate and rhythm; of fetal and uteroplacental appropriate blood flow (4)

and stimulated cycles of hyperstimulation syndrome of polycystic ovaries

diagnosis

sonosalpingography; procedures retrieval of ovarian of ovarian cysts cysts device;

(9)

Evaluation (a) (b)

Invasive

Methodology investigation

to obstetric

Appreciation of problems in blood flow and velocity measurements and waveform analysis normal and complicated pregnancies

in

(4 (b) (c) (4
(4

Oocyte Injection

Aspiration

Drainage of pelvic abscesses Extraction of intrauterine contraceptive

364

Ultrasound in Obstetrics and Gynecology

Society News

(5)

Doppler in gynecology (a) Infertility and oncology.

(4 (f ) k) 04
control, computeri

Heart rate and rhythm, four-chamber view Size and morphology Shape of the thorax Abdomen: umbilical umbilicus diaphragm, vein, kidneys, femur,

size and position, of the lungs

Organization
Infrastructure, zation

of ultrasound
documentation,

unit
quality

and abdomen stomach, abdominal liver and wall and radius

and data storage.

6)
Medicolegal examination implications of ultralsound

Limbs: shape,

tibia and fibula,

humerus,

and ulna, feet and hands echogenicity pregnancy: twin-twin location of amniotic

- these to include and syndrome

and movement monochorionic transfusion fluid of vessels;

(i) (k) (1) (4

(3)

Multiple dichorionic, Amount Placental Cord

Ethics and patien.t information

and number

PRACTICAL

TR.AINING

Required
(1)

skills
to 'be able to identify gynecological and transabdominal early pregnancy by (4) ultrasound problems

The trainee transvaginal (a)

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Fetal biometry (a) Crown-rump length, biparietal diameter, length, head circumference, abdominal circumference, Activity: (a) (b) recognize interpretation and quantify: of growth

femur charts;

and emergency

Early pregnancy fetal viability description yolk sac

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Fetal movements Breathing movements Eye movements.

of the gestational gestation

sac, embryo, (chorionicity)

(c)

single and multiple early pregnancy ectopic pregnancy

(b)

Pathology
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failure :such as nuchal abnormalities

Certification
(1) scanning to include: One hundred h ours of supervised (a) 100 gynecological examinations and early pregnancy sonography required) (b) 200 obstetric scans covering obstetric conditions; the full spectrum of problems (principally but transabdominal by t ransvaginal experience also

gross fetal abnormalities translucency, hydropic mole pelvic tumors hydatidiform associated normal uterine

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(c)

Gynecology
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pelvic anatomy size and endometrial of ovaries e.g. fibroids,

thickness (2) cysts, Logbooks (a) 30 cases on one A4 page with ultrasound picture - at least 15 anomalies should be included;

measurement pelvic tumors, hydrosalpinx peritoneal intrauterine

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fluid contraceptive devices;

(3)

(2)

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

Examination (a) General guidelines: the examination Iwould be included as part of the normal Ob-G.yn training. The options are to have a multiple-choice examination scan, 30 minutes The candidate and interpret paper side, a transvaginal paper or short written On the practical fetal anatomy be recommended. ultrasound (3-4 cases). scan and a take

for bloth, would would the images.

and transversely

pictures

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