Obstetric and Gynecologic Ultrasound Curriculum and Competency Assessment in Residency Training Programs: Consensus Report

Special Report ajog.
org
Obstetric and gynecologic ultrasound curriculum

and competency assessment in residency
training programs: consensus report
Alfred Abuhamad, MD; Katherine K. Minton, MA, RDMS, RDCS; Carol B. Benson, MD;
Trish Chudleigh, PhD; Lori Crites, BS, RDMS; Peter M. Doubilet, MD, PhD; Rita Driggers, MD;
Wesley Lee, MD; Karen V. Mann, MD; James J. Perez, DO; Nancy C. Rose, MD;
Lynn L. Simpson, MD; Ann Tabor, MD; Beryl R. Benacerraf, MD
Introduction
Ultrasound imaging is integral to the Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With
practice of obstetrics and gynecology, as it increasing educational demands and limited hours in residency programs, dedicated time for
allows comprehensive anatomic and training and achieving competency in ultrasound has diminished substantially. The American
physiologic evaluation of the fetus and Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-
detailed assessment of the maternal pelvic based, standardized curriculum and competency assessment tools for obstetric and gyneco-
organs. Ultrasound imaging has signifi- logic ultrasound training in residency programs. The curriculum and competency assessment
cant advantages over other imaging mo- tools were developed based on existing national and international guidelines for the perfor-
dalities. The technology is portable, is mance of obstetric and gynecologic ultrasound examinations and thus are intended to represent
relatively inexpensive, and does not the minimum requirement for such training. By expert consensus, the curriculum was devel-
involve ionizing radiation. In the gyneco- oped for each year of training, criteria for each competency assessment image were generated,
logic patient, the real-time aspect of this the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound
images with pass score in each was deemed necessary for attaining each competency.
modality allows the operator to use
Given the current lack of substantial data on competency assessment in ultrasound training,
transducer pressure to palpate as the pa-
the task force expects that the criteria set forth in this document will evolve with time. The
tient is imaged, thus localizing
task force also encourages use of ultrasound simulation in residency training and expects
the anatomic source of pelvic pain, and to that simulation will play a significant part in the curriculum and the competency assessment
examine for the sliding of organs over each process. Incorporating this training curriculum and the competency assessment tools may
other and over the pelvic wall. Ultrasound promote consistency in training and competency assessment, thus enhancing the perfor-
imaging is also used widely in obstetrics, mance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.
with current data suggesting that pregnant
women in the United States receive on Key words: quality control, residency programs, simulation, sonographic images, ultrasound
average about 4.5 ultrasound examina- competency, ultrasound curriculum, ultrasound training
tions per pregnancy.1
To a much greater extent than
computed tomography or magnetic technical skills and a good understand- examination. The quality of ultrasound
resonance imaging, ultrasound imaging ing of anatomy are essential to the images is dependent on several factors,
is operator-dependent. Adequate performance of the ultrasound including the operator having a basic
From the Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Abuhamad); American Institute of Ultrasound in
Medicine, Laurel, MD (Ms Minton); Department of Radiology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA (Drs Benson,
Doubilet and Benacerraf); Department of Ultrasound, Cambridge University Hospitals, Cambridge, United Kingdom (Dr Chudleigh); Ultrasound
Education, Obstetrics and Gynecology Residency Program, Doctors Hospital OhioHealth, Columbus, OH (Ms Crites and Dr Perez); Department of
Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD (Dr Driggers); Department of Obstetrics and Gynecology, Division of Women’s and
Fetal Imaging, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX (Dr Lee); Division of Medical Education, Dalhousie University,
Halifax, Nova Scotia, Canada (Dr Mann); Reproductive Genetics, Intermountain Healthcare, Department of Obstetrics and Gynecology, University of
Utah, Salt Lake City, UT (Dr Rose); Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY (Dr Simpson); and
Department of Obstetrics, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark (Dr Tabor).
Disclosure: W.L. received honoraria from GE Healthcare as a faculty speaker, and limited research funding from Samsung. N.C.R. received support from
the National Institutes of Health as an investigator; honoraria for an ethics grant in prenatal development from the Hastings Center for Bioethics; and
compensation from the Texas Department of Health for lecture series for circulating cell-free DNA. The remaining authors report no conflicts of interest.
This paper is being simultaneously published in American Journal of Obstetrics & Gynecology, Journal of Ultrasound in Medicine, and Ultrasound in
Obstetrics and Gynecology.
Corresponding author: Alfred Abuhamad, MD. [email protected]
0002-9378/$36.00 ª 2017 jointly by the International Society of Ultrasound in Obstetrics and Gynecology, the American Institute of Ultrasound in Medicine, and Elsevier
Inc. All rights reserved. https://doi.org/10.1016/j.ajog.2017.10.016
JANUARY 2018 American Journal of Obstetrics & Gynecology 29

Special Report ajog.org
understanding of ultrasound physics and curriculum was developed based on competency assessment process. In a
familiarity with the ultrasound machine existing national and international recent study, the validity of an obstetric
control panel, as well as on their skills guidelines for the performance of ob- ultrasound simulator as a tool for eval-
and competency in performing the ex- stetric and gynecologic ultrasound ex- uating trainees following structured
amination. Obstetric ultrasound imag- amination4-6 and is intended to provide training was compared to using stan-
ing is particularly challenging, given the fundamental ultrasound education in dardized ultrasound planes obtained
small size of fetal organs and the variable the first and second years, with more from volunteers.9 Images obtained from
fetal position in the uterus, which occa- advanced ultrasound knowledge in the the simulator and from the volunteer
sionally obscures target anatomic third and fourth years, of residency subjects were scored according to previ-
regions. training. A competency assessment ously established quality criteria. Scores
With the increasing educational de- process was developed for obtaining obtained from the obstetric ultrasound
mands and limited hours in residency specific ultrasound images that are part simulator were significantly higher than
training programs, dedicated time for of the basic obstetric and gynecologic those obtained by volunteers. The study
training and achieving competency in ultrasound examinations. In addition, showed that an obstetric ultrasound
ultrasound has diminished substantially. writing an ultrasound report, assessing simulator is as effective as volunteer-
Data from the Accreditation Council for ultrasound components of the biophys- based examination for evaluating prac-
Graduate Medical Education on ultra- ical profile, and performing third- tical skills of trainees follow-
sound performance in obstetric and gy- trimester amniocentesis were included. ing structured training in obstetric
necologic residency programs indicate By expert consensus, the curriculum was ultrasound.9
that currently the number of ultrasound developed for each year of training, It is important to note that the com-
procedures performed as part of many criteria for each competency assess- petency assessment aspect of this docu-
training programs falls short of the ment image were generated, the pass ment requires the trainee to obtain
minimum threshold required for physi- score was established at or close to, personally the respective images for re-
cian qualification for the performance of 75% for each, and obtaining a set of 5 view and evaluation. For specialties and
obstetric and gynecologic ultrasound ultrasound images with pass score in practices such as radiology practices, in
examinations, as defined by the Amer- each was deemed necessary for attain- which the primary mode of ultrasound
ican Institute of Ultrasound in Medicine ing each competency. Some compe- training is based on interpretation of
(AIUM).2,3 tencies, such as measurement of the images acquired by sonographers, the
Given the clinical importance and uterus, require >1 image to be ob- competencies can be adapted to reflect
widespread use of ultrasound imaging in tained and the pass score was estab- this.
obstetrics and gynecology, the AIUM lished taking into account the criteria
assembled a multisociety task force to of all required images. The consensus Curriculum
develop a standardized consensus-based decision to establish competency on Objectives of the curriculum are
curriculum and competency assessment the basis of 5 image submissions was organized around essential topics,
tools for the performance of the basic supported by data (albeit limited) in including basic principles of medical
obstetric and gynecologic ultrasound the literature. In a study assessing ultrasound and characteristics of the
examination, intended to be used in performance measures and learning equipment, aspects of the ultrasound
residency programs. Task force partici- curves for use of an ultrasound simu- examination, and ultrasound exami-
pants included representatives from the lator, novices reached the level of an nation performance throughout the
AIUM, Society for Maternal-Fetal Med- expert with a median of 5 iterations.7 stages of pregnancy and in gynecology.
icine (SMFM), American Congress of In another prospective cohort study The objectives are presented within a
Obstetricians and Gynecologists on the usability of simulation training level-based framework that will
(ACOG), American College of Osteo- in obstetric ultrasonography, measure- allow trainees to progress along a
pathic Obstetricians and Gynecologists ments of crown-rump length, head continuum toward increasing
(ACOOG), American College of Radi- circumference, and femur diaphysis competence.
ology (ACR), International Society of length were attained consistently with
Ultrasound in Obstetrics and Gynecol- 5 iterations.8 Level 1 (year 1)
ogy (ISUOG), and Society of Radiolo- Given the current lack of substantial Basic principles of medical ultrasound
gists in Ultrasound (SRU). data on competency assessment in ul-
trasound training, the task force expects Basic principles of ultrasound
Procedure: curriculum and that the criteria set forth in this docu- physics.
competency development ment will evolve with time. The task Ultrasound modes (B-mode, M-
The process of developing the document force encourages use of ultrasound mode, Doppler, 2-dimensional [2D]
included multiple telephone conference simulation in residency training and and 3-dimensional [3D]).
calls and one face-to-face meeting be- expects that simulation will be a signifi- Bioeffects of ultrasound (mechanical
tween members of the task force. The cant part of the curriculum and the and thermal effects: as low as
30 American Journal of Obstetrics & Gynecology JANUARY 2018

ajog.org Special Report
reasonably achievable [ALARA] Gestational sac evaluation (intrauter- Methods for diagnosing
principle).10 ine location, discriminatory human oligohydramnios.
Ultrasound artifacts. chorionic gonadotropin levels, and Methods for diagnosing
Official statements from professional differentiation from endometrial polyhydramnios.
societies (AIUM, ACOG, ACOOG, fluid).
ACR, ISUOG, SMFM, and SRU). Yolk sac. Ultrasound examination of nonpreg-
Amnion. nant uterus
Basic characteristics of ultrasound Embryo/fetus (number).
Embryo/fetus cardiac activity; docu- Indications for pelvic sonography.
equipment (knobology)
ment with M-mode or movie clip. Sonographic features of the normal
Criteria for definitive diagnosis of uterus in relation to the menstrual cycle.
Ultrasound transducers: principles of
sound generation; compare trans- embryonic/fetal death in first
trimester. Ultrasound evaluation of adnexa
ducer characteristics and
applications. Components of sonographic dating in
first trimester. Sonographic features of normal
Sound penetration and bioeffect with ovary in relation to menstrual
Ultrasound evaluation of ampullary
consideration related to acoustic cycle.
tubal ectopic pregnancy.
power output. Characteristics of a simple cyst.
Subchorionic hematoma.
Effect of frequency on resolution and
Sonographic features of molar
penetration.
pregnancy. Level 2 (year 2)
Effect of depth settings on field of Association between thickened nuchal Ultrasound in the first trimester
view and image size. translucency and fetal chromosomal
Gain settings for optimal image bright- anomalies. Sonographic appearance of major
ness with minimum power output. fetal malformations in early gestation.
Focal zone depths to achieve best Ultrasound in the second and third Atypical locations of ectopic preg-
resolution of structures of interest. trimesters nancy, including interstitial, ovarian,
Image persistence settings to reduce cervical, abdominal, and cesarean scar
background noise. Components of basic second- and third- implantations.
Inputting patient information into trimester ultrasound examinations. Workup of pregnancy of unknown
ultrasound system before starting an Components of fetal biometry in location.
ultrasound examination. sonographic dating in second and
Ultrasound evaluation of twin
third trimesters.
Aspects of the ultrasound examination Predisposing factors for fetal macro- gestations
somia and fetal growth restriction in
Methods of determining twin
Effective positioning of patients and third trimester.
placentation by ultrasound.
application of coupling agents. Imaging parameters for placental
Role of ultrasound in follow-up of
Ergonomic practices that minimize localization.
twin gestations.
repetitive stress injuries (positioning Risks and indications for genetic
Role of ultrasound in serial evaluation
of operator and equipment). amniocentesis.
of discordant twins.
Correct transducer manipulation and
image orientation. Ultrasound evaluation of twin Sonographic findings of mono-
chorionic monoamniotic twins.
Ultrasound image labeling and gestations
storage.
Placental abnormalities
Appropriate communication of ul- Role of ultrasound in diagnosis of
trasound findings to other health twins.
Risk factors and sonographic diag-
professionals. Chorionicity and amnionicity in
nosis of vasa previa.
Protocol for transducer cleaning and multifetal pregnancies.
Risk factors and sonographic find-
disinfection. ings of placenta accreta.
Placental abnormalities
Role of ultrasound assessment of
Ultrasound in the first trimester
placental abruption.
Risk factors and sonographic diag-
Steps for performance of first- nosis of placenta previa and low-lying Amniotic fluid assessment
trimester transvaginal ultrasound placenta.
examination. Risk factors of placenta accreta. Ultrasound estimation of
Indications for first-trimester ultra- amniotic fluid volume in twin
sound examination. Amniotic fluid assessment gestations.

Cervix Normal fetal pelvic anatomy and Role of middle cerebral artery peak
common malformations. systolic velocity in screening for fetal
Ultrasound measurement of cervical Normal fetal skeletal anatomy and anemia.
length in second and third trimesters common malformations.
of pregnancy. Role of umbilical artery Doppler Ultrasound evaluation of twin
studies in evaluation of fetal growth gestations
Abnormalities of the nonpregnant restriction.
uterus Ultrasound diagnosis of Sonographic features of conjoined
hydrops. twins.
Ultrasound evaluation of anatomic Writing the ultrasound report. Role of ultrasound in diagnosis and
locations of leiomyomas. evaluation of twin reversed arterial
Ultrasound evaluation of endometrial Ultrasound evaluation of twin perfusion.
abnormalities. gestations
Competency assessment
Role of ultrasound in diagnosis and
Ultrasound evaluation of adnexa Competency is assessed by evaluation
management of twin-twin trans-
of still ultrasound images, movie clips,
fusion syndrome.
Sonographic characteristics of hem- real-time scanning, or a combination
Role of ultrasound in evaluation
orrhagic cysts and their evolution of methods, as determined by indi-
of twin anemia-polycythemia
(gray-scale and color Doppler). vidual programs. The pass score for
sequence and selective intrauterine
Sonographic characteristics of endome- competency assessment was established
growth restriction in monochorionic
triomas (gray-scale and color Doppler). at, or close to, 75%, and a set of 5
twins.
Sonographic characteristics of mature ultrasound images with pass score in
Role of umbilical artery Doppler
teratomas (gray-scale and color each was deemed necessary for attain-
studies in the evaluation of fetal twin-
Doppler). ing each competency. Missing the
twin transfusion syndrome.
Sonographic characteristics of specified criteria* fails the competency
pedunculated leiomyomas and for a particular image (or movie clip
Ultrasound examination of the
ovarian fibromas. when appropriate). The competencies
nonpregnant uterus
Sonographic characteristics of are listed in Table 1. Details of each
hydrosalpinx. competency assessment and corre-
Sonographic features of adenomyosis.
Sonographic characteristics of sponding images are provided in
Classification of congenital uterine
tubo-ovarian inflammatory Appendix.
malformations (2D and 3Dy
process (tubo-ovarian complex/
ultrasound).
abscess). Conclusion
Role of ultrasound in localization of
Sonographic characteristics of peri- This document, endorsed by the AIUM,
intrauterine contraceptive devices
toneal inclusion fluid. SMFM, ACOOG, ISUOG, and Society of
(2D and 3Dy ultrasound).
Sonographic characteristics of poly- Diagnostic Medical Sonography; recog-
cystic ovaries. nized by ACR and SRU; and supported
Evaluation of the adnexa
Sonographic characteristics of by ACOG and the Council on Resident
adnexal torsion. Role of color Doppler in evaluation of Education in Obstetrics and Gynecology
Sonographic characteristics of malig- adnexal masses. (CREOG), presents a consensus-based
nant adnexal masses. Prediction models for ovarian curriculum and competency assessment
cancer. tools for performance of the basic ob-
Level 3 (year 3) International Ovarian Tumor Anal- stetric and gynecologic ultrasound ex-
Ultrasound in the second and third ysis simple rules for classification of amination, and is intended to represent
trimesters adnexal masses.11 the minimum requirement for such
Sonographic features of training. Programs may choose to sup-
Normal fetal head anatomy and endometriosis. plement this curriculum with additional
common malformations. material on normal and abnormal con-
Normal fetal facial anatomy and Level 4 (year 4) ditions as they see fit. It is understood
Ultrasound in the second and third
common malformations. that individual training programs may
trimesters
Normal fetal thoracic anatomy and have different trajectories of curriculum
common malformations. and competency assessment as they fit
yNote that this does not imply that the trainee needs to
Normal fetal heart anatomy and
attain competency in 3D ultrasound, but rather explain
common malformations. the classification of uterine malformations and identify *Indicates criteria that are essential to passing a compe-
Normal fetal abdominal anatomy and location of intrauterine contraceptive devices based tency. Missing the asterisked criteria will fail the respec-
common malformations. upon 2D and 3D ultrasound. tive competency.

into other components of the training

and clinical practice requirements. Ulti- TABLE 1
mately, the composite curriculum and List of competencies assessed during levels 1e4 (years 1e4)
competency assessment should be ach- 1. Competency assessment: level 1 (year 1) (see Appendix Tables 1A to 1K)
ieved by the time of completion of resi- A. Mean sac diameter
B. Crown-rump length
dency training. C. Fetal presentation
This curriculum is also applicable to D. Fetal extremities
anyone who wants to learn how to E. Biparietal diameter
perform obstetric and gynecologic ul- F. Head circumference
trasound examinations, even if they G. Abdominal circumference
H. Femur diaphysis length
have already completed their formal I. Biophysical profile (ultrasound components)
training. J. Amniotic fluid index
In parallel to this task force, the AIUM K. Maximum vertical pocket
has established another collaborative 2. Competency assessment: level 2 (year 2) (see Appendix Tables 2A to 2G )
task force to develop narrated pre- A. Cervical length (transvaginal ultrasound)
B. Cervical length (transabdominal ultrasound)
sentations by expert sonologists on ul- C. Endometrial thickness
trasound topics in obstetrics and D. Uterine measurements
gynecology, covering all aspects of the E. Ovarian measurements
curriculum of this task force. F. Transvaginal pelvic examination: uterus
We recognize that residency program G. Transvaginal pelvic examination: ovaries
3. Competency assessment: level 3 (year 3) (see Appendix Tables 3A to 3P)
directors have the difficult task of A. Head: transventricular plane
balancing training requirements with B. Head: transthalamic plane
limited flexibility in residency schedules. C. Head: transcerebellar plane
Ideally, a structured rotation in ultrasound D. Face: upper lip and philtrum
during residency will facilitate ultrasound E. Four-chamber view
F. Left ventricular outflow tract
training and help in development of the G. Right ventricular outflow tract
technical skills required for the basic ob- H. Abdomen: abdominal circumference level
stetric and gynecologic ultrasound exam- I. Abdomen: kidneys
ination. A 2003 survey on obstetric J. Abdomen: cord insertion
sonography by CREOG noted that 41% of K. Number of cord vessels
L. Pelvis: bladder
residency programs had a required ultra- M. Spine: longitudinal
sound rotation and 64% had didactic ul- N. Spine: axial
trasound training.12 Although a O. Writing a report: obstetrics
structured ultrasound rotation is ideal, P. Writing a report: gynecology
task force members believe that ultra- 4. Competency assessment: level 4 (year 4) (see Appendix Tables 4A and 4B)
A. Face: facial profile
sound training can also be performed B. Amniocentesis to assess fetal lung maturity
during other residency rotations, given 5. Additional competencies (not currently part of basic obstetric and gynecologic ultrasound
that ultrasound is embedded in obstetric examination) (see Appendix Tables 5A to 5E)
and gynecologic clinical care. We hope A. Three vessels and trachea view
that the curriculum and competency B. Face: orbits
C. Umbilical artery Doppler
assessment tools provided here will sup- D. Nuchal translucency
port residency program directors and will E. Saline contrast sonohysterography
serve to facilitate ultrasound training in
Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.
residency programs. The aforementioned
accompanying narrated lecture series will
be made available to program directors competency assessment, as the simu- The task force believes that the cost of
among others, and the competency lation can be performed remotely and ultrasound simulation will drop sub-
assessment tools will serve to standardize does not require patient interaction. stantially over time.
training and track progress during the Standardized reports can be submitted Incorporating this training curricu-
residency program. electronically to program directors and lum and these competency assessment
We anticipate that simulation will the progress of ultrasound training and tools should promote consistency in
evolve to provide educational and competency assessment can be tracked training and competency assessment,
competency assessment products to over time. Local institutions should and thus enhance the performance
facilitate and accelerate residency evaluate the cost-effectiveness of ultra- and diagnostic accuracy of ultrasound
training in ultrasound. Ultrasound sound simulation, and how it would fit examination in obstetrics and
simulators allow for flexibility in into their respective residency training. gynecology. -

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APPENDIX TABLE 1A
Mean sac diameter
Pass grade: 7/9
Two images are required for this competency
Image 1:
Image magnified appropriately
Focal zone at appropriate level
Ultrasound plane at widest dimensions of gestational sac
Gestational sac measured in 2 orthogonal dimensions using inner-to-inner technique
Image 2:
Image magnified
Ultrasound plane of gestational sac perpendicular to that of image 1
Gestational sac measured at widest dimension using inner-to-inner technique
*Mean sac diameter appropriately calculated from mean of all 3 dimensions from images 1 and 2
APPENDIX FIGURE 1
Mean sac diameter
A, Gestational sac visualized in sagittal plane of uterus. Note length and height of gestational sac (measurements 1 and 2, respectively).
B, Maximum width of gestational sac measured in plane perpendicular to that of A. Mean sac diameter is calculated from mean of length, height
(A), and width (B). See Appendix Table 1A for corresponding competency list.
* Missing this criteria fails this competency.


APPENDIX TABLE 1B
Crown-rump length
Pass grade: 4/5
Embryo/fetus imaged in neutral position
Maximum length of embryo/fetus shown
Maximum length of embryo/fetus measured in straight line from cranial to caudal
APPENDIX FIGURE 2
Crown-rump length (CRL)
Midsagittal plane in fetus at 12 weeks and 5 days, showing CRL measurement. See Appendix Table 1B for corresponding competency list.
APPENDIX TABLE 1C
Fetal presentation
Pass grade: 2/3
Longitudinal view of lower uterine segment above level of maternal pubic bone
*Fetal presenting body part identified in relation to cervical area
APPENDIX FIGURE 3
Fetal presentation
Midsagittal plane of uterus in lower uterine segment, showing A, cephalic (fetal head) and B, breech (fetal buttocks) presentations. Note midsagittal
view of cervix. See Appendix Table 1C for corresponding competency list.


APPENDIX TABLE 1D
Fetal extremities
Pass grade: 5/7
4 Images are required for this competencya
Longitudinal view of extremity shown
Image 1:
Right upper extremity, showing hand if possible
Image 2:
Left upper extremity, showing hand if possible
Image 3:
Right lower extremity, showing foot if possible
Image 4:
Left lower extremity, showing foot if possible
APPENDIX FIGURE 4
Ultrasound images of fetal upper and lower extremities
A, Upper extremities. Note appearance of humerus, ulna, and radius. Small portion of radius is shown, due to orientation of upper extremity. B,
Lower extremities. See Appendix Table 1D for corresponding competency list.
a
<4 Images are acceptable if both extremities are displayed clearly.

APPENDIX TABLE 1E
Biparietal diameter
Pass grade: 10/13
*Axial plane of head
Symmetric appearance of cerebral hemispheres
Midline falx imaged
Thalami imaged
Cavum septi pellucidi imaged
Insula imaged
No cerebellum seen
Near caliper on outside edge of bone
Far caliper on inside edge of bonea
Measurement at widest diameter
Measurement perpendicular to falx
Passing this competency will also qualify for competency transthalamic plane in Table 3B
APPENDIX FIGURE 5
Biparietal diameter (BPD) - Transthalamic plane
A, Axial plane of fetal head at level of BPD, demonstrating falx cerebri, cavum septi pellucidi (CSP), thalami (T), third ventricle (V), and insula. Note,
BPD measurement in this image is from outside border of proximal parietal bone to inside border of distal parietal bone. B, Same image as in A.
BPD measurement in this image is from outside border of proximal parietal bone to outside border of distal parietal bone. See Appendix Table 1E
for corresponding competency list.
* Missing this criteria fails this competency; a Caliper may be placed on outer edge of bone based on existing practice patterns.

APPENDIX TABLE 1F
Head circumference
Pass grade: 7/10
Midline falx imaged
Thalami imaged
Insula imaged
No cerebellum seen
Measurement circumference ellipse on outside edge of bone
Passing this competency will also qualify for competency transthalamic plane in Table 3B
APPENDIX FIGURE 6
Head circumference (HC)
Axial plane of fetal head at biparietal diameter level (transthalamic), demonstrating falx cerebri, cavum septi pellucidi (CSP), thalami (T), third
ventricle (V), and insula. Measurement of HC is obtained using ellipse placed on outer edge of cranium. In this case, HC measures 21.74 cm,
corresponding to gestational age of 23 weeks and 6 days. See Appendix Table 1F for corresponding competency list.


APPENDIX TABLE 1G
Abdominal circumference
Pass grade: 8/11
*Axial plane of abdomen
Abdomen as circular as possible
Spine imaged in cross-section in 3- or 9-o’clock position if possible
Stomach bubble imaged
Intrahepatic portion of umbilical vein imaged in short segment
No more than one rib visible on each side laterally
Kidneys not visualized
Surrounding skin seen in entirety if possible
Measurement of circumference ellipse on outside edge of skin
Passing this competency will also qualify for competency abdominal circumference level in Table 3H
APPENDIX FIGURE 7
Abdominal circumference (AC)
Axial plane of fetal abdomen at level of AC. Note presence of intraabdominal portion of umbilical vein (UV), stomach (St), spine (Sp), descending
abdominal aorta (Ao), and inferior vena cava (IVC). Also note presence of large segments of individual ribs on each side laterally. See Appendix
Table 1G for corresponding competency list.


APPENDIX TABLE 1H
Femur diaphysis length
Pass grade: 5/7
*Whole femur diaphysis imaged
Ultrasound beam perpendicular to long axis of femur
Calipers placed at each end of ossified diaphysis
Longest visible diaphysis is measured
Spur artifacts on end of diaphysis not included in measurement
APPENDIX FIGURE 8
Femur diaphysis length (FL)
Longitudinal plane of femur, showing FL measurement. Note proximal and distal femoral epiphyses are not yet ossified and not included in FL
measurement. Also note presence of distal femoral spur, which should not be included in FL measurement. See Appendix Table 1H for
corresponding competency list.

APPENDIX TABLE 1I
Biophysical profile (ultrasound components)
Pass grade: 6/6
*Length of examination: 30 min maximum, or until all criteria are met
*Breathing, movement and tone documented by movie clips if available
*30-s period of fetal breathing imaged
*Three gross fetal body or limb movements imaged
*Episode of flexion and extension of fetal limb(s) imaged
*Amniotic fluid volume evaluated by amniotic fluid index, maximal vertical pocket, or qualitative assessment

APPENDIX TABLE 1J
Amniotic fluid index
Pass grade: 6/8
Image at appropriate depth
Sagittal orientation of ultrasound transducer
4 Images labeled, 1 for each quadrant
Calipers placed on each image from top to bottom of maximal vertical pocket
Fluid space measured is devoid of any cord or body part
Measurement is vertical with respect to transducer placement
4 Quadrant measurements are added for amniotic fluid index calculation
APPENDIX FIGURE 9
Amniotic fluid index (AFI)
Four images (Q1-Q4), obtained from each of 4 quadrants of uterus. Maximum vertical pocket (MVP) is measured in each quadrant (Q1-Q4). AFI is
calculated by adding MVP from all 4 quadrants. In this fetus, AFI is normal (13.7 cm). MVP is measured in amniotic fluid from top to bottom in a
vertical line. See Appendix Table 1J for corresponding competency list.

APPENDIX TABLE 1K
Maximal vertical pocket
Pass grade 4/6
Image at appropriate depth
Image displays maximal vertical pocket of amniotic fluid
Calipers placed from top to bottom of maximal vertical pocket
Fluid space measured is devoid of any cord or body parts
Measurement is vertical with respect to transducer placement
APPENDIX FIGURE 10
Maximal vertical pocket (MVP)
Ultrasound image of MVP for determination of amniotic fluid volume. MVP is determined by scanning all 4 quadrants of uterus and measuring MVP
in quadrant with largest amount of amniotic fluid. MVP is measured in amniotic fluid from top to bottom in vertical line. See Appendix Table 1K for

APPENDIX TABLE 2A
Cervical length (transvaginal ultrasound)
Pass grade: 7/10
Transvaginal ultrasound
Midsagittal plane of cervix
Anterior cervical width is equal to posterior cervical width
Maternal bladder empty
Internal os seen
External os seen
Cervical canal visible throughout
Caliper placement correct
APPENDIX FIGURE 11
Transvaginal cervical length measurement
Midsagittal plane of cervix obtained by transvaginal approach. Note cervical length is measured from internal to external cervical os (3.8 cm in this
example). Note anterior position of maternal bladder and presenting fetal head. See Appendix Table 2A for corresponding competency list.

APPENDIX TABLE 2B
Cervical length (transabdominal ultrasound)
Pass grade: 6/8
Transabdominal ultrasound
Midsagittal plane of cervix
Maternal bladder nondistended
Internal os seen
External os seen
Caliper placement correct
APPENDIX FIGURE 12
Transabdominal cervical length measurement
Midsagittal plane of cervix obtained by transabdominal approach. Note cervical length is measured from internal to external cervical os (4 cm in this
example). Fetal head is presenting. Note location of vaginal canal. Distention of maternal bladder may impact measurement of cervical mea-
surement on transabdominal approach. See Appendix Table 2B for corresponding competency list.

APPENDIX TABLE 2C
Endometrial thickness
Pass grade: 5/7
*Transvaginal ultrasound
Midsagittal plane of cervix and uterus, with magnification of endometrium as needed for endometrial measurement
Endometrial lining (echo) seen in its entirety from cervical canal to endometrial fundus
Cul-de-sac imaged posterior to cervix
Calipers placed in anteroposterior orientation, perpendicular to long axis of uterus, using outer-to-outer techniquea
Widest endometrial thickness measured using outer-to-outer technique
APPENDIX FIGURE 13
Endometrial thickness
Midsagittal plane of uterus obtained for measurements of endometrial thickness. Note midline endometrial lining (echo) is seen in its entirety from
cervical canal to endometrial fundus. Measurement of endometrial thickness is obtained by placing calipers in anteroposterior orientation,
perpendicular to long axis of uterus and using outer-to-outer technique. See Appendix Table 2C for corresponding competency list.
* Missing this criteria fails this competency; a In presence of endometrial fluid, measure anterior and posterior endometrial walls separately and add 2 measurements.

APPENDIX TABLE 2D
Uterine measurements
Pass grade: 7/10
Image 1:
Midsagittal plane of cervix and uterus
Endometrial lining seen in its entirety from cervical canal to endometrial fundus
Length of uterus measured from fundus to external os using outer-to-outer techniquea; alternate method for measurement of uterine length
includes measurement from fundal region, along endometrial lining and endocervical canal, using outer-to-outer technique
Anteroposterior diameter of uterus measured from anterior to posterior serosal surface at widest dimension perpendicular to long axis of uterus
using outer-to-outer technique
Image 2:
Transverse (axial) plane of uterus at widest dimension
Transverse diameter of uterus measured from left to right serosal surface at widest dimension using outer-to-outer technique
Passing this competency will also qualify for competency transvaginal pelvic examination: uterus in Table 2F.
APPENDIX FIGURE 14
Uterine measurements: midsagittal plane
A1 and A2, Midsagittal plane of uterus obtained for measurements of uterine length and height. Note endometrial lining (echo) is seen in its entirety
from cervical canal to endometrial fundus. Length of uterus (measurement 1) is measured from fundus to outer edge of cervix. In this midsagittal
plane, anteroposterior diameter of uterus is also measured at widest dimension (measurement 2), perpendicular to long axis of uterus. A2, Length
of uterus is measured following endometrial lining and endocervical canal, using outer-to-outer technique. This technique of uterine measurement
allows for more accuracy in presence of uterine flexion. B, Uterine measurements: transverse plane. Transverse plane of uterus, shown at its
widest dimension. Uterine width is measured from left to right at widest uterine dimension. See Appendix Table 2D for corresponding
competency list.
a
Morphological uterus sonographic assessment is another method that can be followed/used for uterine measurement.13

APPENDIX TABLE 2E
Ovarian measurements
Pass grade: 6/8
Perform for left and for right ovary
Image 1:
Plane of pelvis showing ovary with clear outline in longest dimension
Length of ovary measured from anterior to posterior at longest dimension
Anteroposterior diameter of ovary measured from left to right, orthogonal to length measurement
Image 2:
Plane of pelvis showing ovary with clear outline at right angles to image 1
Width of ovary measured from left to right at widest dimension
Passing this competency will also qualify for competency transvaginal pelvic examination: ovaries in Table 2G
APPENDIX FIGURE 15
Ovarian measurements: longitudinal and axial planes
A, Longitudinal plane of ovary, showing measurements of ovarian length and anteroposterior diameter. Anteroposterior diameter is measured
perpendicular to length measurement. B, Axial plane of ovary, perpendicular to longitudinal plane (A), showing ovarian width measurement.
See Appendix Table 2E for corresponding competency list.
APPENDIX TABLE 2F
Transvaginal pelvic examination: uterus
Pass grade: 5/7
Image 1: Longitudinal view
Midsagittal plane of cervix and uterus
Endometrial lining seen in its entirety from cervical canal to endometrial fundus
Image 2: Axial view
Axial plane of uterus at widest dimension
Competency for this plane can also be established as part of uterine measurement competency in Table 2D

APPENDIX TABLE 2G
Transvaginal pelvic examination: ovaries
Pass grade: 3/4
Perform for left and for right ovary
Image 1:
Parasagittal plane of pelvis showing ovary with clear outline in longest dimension
Image 2:
Axial plane of pelvis showing ovary with clear outline at right angles to image 1
Competency for this plane can also be established as part of ovarian measurement competency in Table 2E
APPENDIX TABLE 3A
Head: transventricular plane
Pass grade: 6/8
Midline falx imaged
Atrium and occipital horn of lateral ventricle clearly imaged
Measurement of atrium of lateral ventricle at level of parietooccipital groove
Calipers placed on medial and lateral walls of atrium of lateral ventricle perpendicular to long axis of ventricle using inner-to-inner technique
APPENDIX FIGURE 16
Transventricular plane
Axial view of fetal head at level of transventricular plane. Note that the choroid plexus does not extend into the occipital horns. Measurement of
lateral ventricle is obtained at atrium, at level of parietooccipital groove. Calipers are placed on medial and lateral walls, perpendicular to long axis
of ventricle, using inner-to-inner technique. Although cavum septi pellucidi (CSP) is seen in this figure, it does not have to be visualized as, on many
occasions, lateral ventricle can be seen in plane that is superior to CSP. See Appendix Table 3A for corresponding competency list.


APPENDIX TABLE 3B
Head: transthalamic plane
Pass grade: 7/9
Midline falx imaged
Thalami imaged
Insula imaged
No cerebellum seen
Competency for this plane can also be established as part of biparietal diameter measurement competency, as shown in Table 1E
APPENDIX TABLE 3C
Head: transcerebellar plane
Pass grade: 7/9
*Angled axial plane of head
Symmetric appearance of cerebellar hemispheres
Midline falx imaged
Thalami imaged
*Cerebellar vermis imaged
*Cisterna magna imaged
APPENDIX FIGURE 17
Transcerebellar plane
Angled axial plane of fetal head, showing posterior fossa. Note symmetric appearance of cerebellar hemisphere, cerebellar vermis, and
cisterna magna. In this plane, falx cerebri, cavum septi pellucidi (CSP), and thalami (T) are also seen. See Appendix Table 3C for corresponding
competency list.


APPENDIX TABLE 3D
Face: upper lip and philtrum
Pass grade: 3/4
Coronal view of upper lip and philtrum
*Soft tissue of upper lip, philtrum, and nares clearly imaged
APPENDIX FIGURE 18
Upper lip and philtrum
Coronal view of fetal face, showing upper lip and philtrum. Note appearance of soft tissue of upper lip, philtrum, and nares. See Appendix Table 3D
for corresponding competency list.


APPENDIX TABLE 3E
Four-chamber view
Pass grade: 5/7
*Transverse (axial) plane of fetal chest
No more than one rib seen on each side of chest laterally
Chest as circular as possible
Spine imaged in cross-section
*Four chambers imaged
APPENDIX FIGURE 19
Four-chamber view
Axial view of fetal chest at level of 4-chamber view of heart. Note appearance of 4 chambers with right ventricle (RV) as most anterior chamber, and
left atrium (LA) as most posterior chamber. Left ventricle (LV) and right atrium (RA) are also seen. Note location of descending thoracic aorta (Ao),
and spine (Sp) posteriorly. Note that apex of heart is towards fetal left side and note presence of large segments of individual ribs. See Appendix
Table 3E for corresponding competency list.


APPENDIX TABLE 3F
Left ventricular outflow tract
Pass grade: 4/5
Angled axial plane of fetal chest
*LVOT imaged with continuity of ascending aorta with ventricular septum
LVOT imaged with no division of ascending aorta (which excludes transposition)
APPENDIX FIGURE 20
Left ventricular (LV) outflow tract
Angled axial plane of fetal chest, showing LV outflow tract, aorta (Ao). Note Ao arising from LV, and continuity of Ao with ventricular septum. See
Appendix Table 3F for corresponding competency list.
LA, left atrium; RA, right atrium; RV, right ventricle.
LVOT, left ventricular outflow tract.


APPENDIX TABLE 3G
Right ventricular outflow tract
Pass grade: 3/4
Transverse or parasagittal plane of upper fetal chest
*RVOT imaged with pulmonary valve shown
APPENDIX FIGURE 21
Right ventricular (RV) outflow tract
Transverse plane of fetal upper chest at level of RV outflow tract. Note pulmonary artery (PA), superior to aorta (Ao). Also note pulmonary valve (PV).
See Appendix Table 3G for corresponding competency list.
RVOT, right ventricular outflow tract.


APPENDIX TABLE 3H
Abdomen: abdominal circumference level
Pass grade: 7/10
*Axial plane of abdomen
Abdomen as circular as possible
Spine imaged in cross-section in 3- or 9-o’clock position if possible
Stomach bubble imaged
Intrahepatic portion of umbilical vein imaged in short segment
No more than 1 rib visible on each side laterally
Kidneys not visualized
Surrounding skin seen in its entirety if possible
Competency for this plane can also be established as part of abdominal circumference measurement competency, as shown in Table 1G
APPENDIX TABLE 3I
Abdomen: kidneys
Pass grade: 3/4
Coronal, parasagittal, or axial view of abdomen
*Right and left kidneys imaged in 1 or 2 images
APPENDIX FIGURE 22
Kidneys: axial, coronal, and sagittal planes
A, Axial plane of fetal abdomen at level of kidneys. Note right and left kidneys and renal pelves, imaged in posterior aspect of fetal abdomen, lateral
to fetal spine. B, Coronal plane of fetal posterior abdomen. Note presence of right and left kidneys in coronal view. C, Sagittal plane of right side of
abdomen, showing right kidney. See Appendix Table 3I for corresponding competency list.


APPENDIX TABLE 3J
Abdomen: cord insertion
Pass grade: 3/4
Axial or midsagittal plane of abdomen
*Umbilical cord imaged inserting into anterior abdominal wall, outlined by amniotic fluid, with abdominal wall visualized clearly on both sides of
cord insertion
APPENDIX FIGURE 23
Abdominal cord insertion
Axial plane of fetal abdomen at level of cord insertion. Note insertion of umbilical cord into anterior abdominal wall. See Appendix Table 3J for


APPENDIX TABLE 3K
Number of cord vessels
Pass grade: 3/4
*Cross-sectional view of umbilical cord in amniotic fluid or axial view of fetal pelvis with color Doppler
*Presence of 2 fetal umbilical arteries around bladder
APPENDIX FIGURE 24
Number of cord vessels
A, Axial plane of fetal pelvis (color Doppler) at level of fetal bladder. Note presence of 2 umbilical arteries, lateral to bladder. B, Axial plane (gray-
scale) of free loop of umbilical cord in amniotic fluid, showing umbilical vein and 2 umbilical arteries. C, Axial plane (color Doppler) of free loop of
umbilical cord in amniotic fluid (B), showing umbilical vein and 2 umbilical arteries. Note that blood flow in umbilical vein is in reverse direction to
that of umbilical artery. See Appendix Table 3K for corresponding competency list.

APPENDIX TABLE 3L
Pelvis: bladder
Pass grade: 3/4
Coronal, sagittal, or axial view of abdomen/pelvis
*Bladder imaged in anterior aspect of pelvis
APPENDIX FIGURE 25
Bladder
Axial plane of the fetal pelvis showing the bladder. See Appendix Table 3L for corresponding competency list.


APPENDIX TABLE 3M
Spine: longitudinal
Pass grade: 5/7
Three images/sweeps are required for this competency
*Midsagittal plane of spine
*Overlying skin imaged outlined by amniotic fluid
Image 1:
*Entire length of cervical spine evaluated
Image 2:
*Entire length of thoracic spine evaluated
Image 3:
*Entire length of lumbosacral spine evaluated
APPENDIX FIGURE 26
Longitudinal spine
A, Midsagittal plane of fetal spine at level of cervical and thoracic region. Note that entire length of cervical and thoracic spine is shown, with normal
overlying skin and no spinal abnormalities. Spinous process and corresponding vertebral body is seen for each vertebra. B, Midsagittal plane of
fetal spine at level of thoracic region. Note that entire length of thoracic spine is shown, with normal overlying skin and no spinal abnormalities.
Spinous process and corresponding vertebral body is seen for each vertebra. C, Midsagittal plane of fetal spine at level of lumbosacral region. Note
that entire length of lumbosacral spine is shown, with normal overlying skin and no spinal abnormalities. Spinous process and corresponding
vertebral body is seen for each vertebra. See Appendix Table 3M for corresponding competency list.


APPENDIX TABLE 3N
Spine: axial
Pass grade: 5/7
Three images/sweeps are required for this competency
*Axial plane(s) of spine
Overlying skin imaged outlined by amniotic fluid
Image/sweep 1:
*Entire length of cervical spine evaluated
Image/sweep 2:
*Entire length of thoracic spine evaluated
Image/sweep 3:
*Entire length of lumbosacral spine evaluated
APPENDIX FIGURE 27
Axial spine
A, Axial plane of fetal spine at level of cervical spine. Note normal orientation of spinal lateral processes and normal overlying skin. B, Axial plane of
fetal spine at level of thoracic spine. Note normal orientation of spinal lateral processes and normal overlying skin. C, Axial plane of fetal spine at
level of lumbosacral spine. Note normal orientation of spinal lateral processes and normal overlying skin. Iliac bones are seen in pelvis laterally on
each side. See Appendix Table 3N for corresponding competency list.


APPENDIX TABLE 3O
Writing ultrasound report: obstetrics
Pass grade is assessed subjectively based on review of listed criteria
Ensure that essential criteria* are included as appropriate
Patient identification and pertinent characteristics:
*Patient name
*Identification numbers
*Examination date
Patient date of birth
Patient gravidity and parity if clinically relevant
Pregnancy dating as available
*Indication for ultrasound examination
Basic information:
*Presence or absence of cardiac activity
*Location of gestational sac
*Number of fetuses
*Location of fetuses in multiple pregnancy
*Placental location
*Type of placentation in multiple pregnancy
*Assessment of amniotic fluid
*Fetal lie and presentation
Fetal biometric measurements:
*Mean sac diameter (if no embryo/fetus)
*Crown-rump length
*Biparietal diameter
*Head circumference
*Abdominal circumference
*Femur diaphysis length
Fetal anatomy:
Described appropriate to setting and resources
*Basic anatomy
Detailed anatomy
*Estimated gestational age based on established guidelines
*Estimated fetal weight (>24 wk)
*Summary of examination and comments
Comparison with previous studies
Limitations of ultrasound examination
Recommendations for follow-up if necessary
* Essential criteria.

APPENDIX TABLE 3P
Writing ultrasound report: gynecology
Ensure that essential criteria (indicated by asterisk) are included as appropriate
Patient identification and pertinent characteristics:
*Patient name
*Identification numbers
*Date of examination
Patient date of birth
Patient gravidity and parity if clinically relevant
Mode of previous delivery(ies) if applicable
Date of last menstrual period
*Indication for ultrasound examination
Biometric information:
*Uterine height, length, and width
*Ovarian measurements in 3 dimensions are required part of imaging, but not of written report
*Cul-de-sac: fluid or abnormalities
Abnormalities:
*Uterine
*Adnexal
*Cul-de-sac
*Surrounding pelvic structures
Final diagnosis and follow-up:
*Summary of examination and comments
Comparison with previous studies
Limitations of ultrasound examination
Recommendations for follow-up if necessary
* Essential criteria.

APPENDIX TABLE 4A
Face: facial profile
Pass grade: 5/7
*Midsagittal view of face
Tip of nose imaged
Nasal bone imaged
Mandible imaged
Maxilla imaged
APPENDIX FIGURE 28
Fetal facial profile
Midsagittal plane of fetal face, showing facial profile. Note tip of nose, nasal bone, maxilla, and mandible. See Appendix Table 4A for corresponding
competency list.

APPENDIX TABLE 4B
Amniocentesis to assess fetal lung maturity
For obstetric and gynecologic residents only
Indication for amniocentesis
Written and oral information provided
Informed consent signed
Maternal blood type reviewed
Procedure
Timeout before procedure
Fetal viability established before procedure
Needle insertion performed under ultrasound guidance
Transplacental puncture avoided if possible
Needle gauge 22e20
Maximum of 2 insertions
Volume of amniotic fluid retrieved as needed for test
Fetal well-being: assessment of fetal heart rate after procedure
RhO(D) immune globulin administered if indicated

APPENDIX TABLE 5A
Three vessels and trachea view
Pass grade: 6/8
*Angled axial plane of fetal upper chest
Spine imaged in cross-section
Pulmonary artery/ductal arch imaged as anterior vessel
Ascending aorta/aortic isthmus imaged as middle vessel
Superior vena cava imaged in cross-section as posterior vessel
Ductal arch and aortic arch meet and both are shown to left of trachea
APPENDIX FIGURE 29
Three vessels and trachea view
A, Angled axial plane of the fetal upper chest, showing 3 vessels and trachea view. Note anterior location of pulmonary artery (PA), with ductus
arteriosus (DA) connecting with descending aorta (Ao). Ao and Ao isthmus are also seen connecting with descending Ao. Superior vena cava (SVC)
is seen in cross-section to right side of Ao. Note that DA and Ao isthmus are to left side of trachea, confirming presence of normal left Ao and DA.
Spine (Sp) is seen posteriorly. B, Three vessels and trachea view: color Doppler. Note that color Doppler shows blood flow in both DA and Ao
isthmus towards descending Ao. See Appendix Table 5A for corresponding competency list.


APPENDIX TABLE 5B
Face: orbits
Pass grade: 3/4
*Coronal or axial views of upper face, showing 2 orbits in same image
Bony edges of both orbits clearly imaged
APPENDIX FIGURE 30
Orbits
Axial view of upper face, showing 2 bony orbits. See Appendix Table 5B for corresponding competency list.


APPENDIX TABLE 5C
Umbilical artery Doppler
Pass grade: 7/9
A loop of umbilical cord imaged
Color Doppler applied if necessary
*Sample Doppler gate on umbilical artery
Wall filter sufficiently low to detect low-velocity flow
Scale and baseline set so waveforms occupy >50% of height of Doppler scale
Doppler velocimetry tracing demonstrates at least 5 consecutive similar waveforms
Doppler velocimetry tracing acquired in absence of fetal breathing and hiccups
Waveform(s) selected for measurements (pulsatility index, resistance index, or S/D ratio) are similar
APPENDIX FIGURE 31
Umbilical artery Doppler
Color and pulsed Doppler of umbilical artery obtained at level of placental cord insertion. Note that Doppler waveforms show forward flow during
diastole (D). Note also peak of waveforms, corresponding to peak systole (S). See Appendix Table 5C for corresponding competency list.
S/D ratio, Systolic / Diastolic ratio.


APPENDIX TABLE 5D
Nuchal translucency measurement
Pass grade: 7/9
Midsagittal plane of fetus
Image magnified with fetal head occupying majority of ultrasound image
Fetal head in neutral position
Fetus observed away from amnion
Margins of NT edges clear
Calipers (þ) used
Caliper horizontal cross bars are placed on NT line
Calipers placed perpendicular to long axis of fetus
Measurement is at widest NT space using on-to-on technique
NT measurement requires official certification before clinical practice
APPENDIX FIGURE 32
Nuchal translucency (NT)
Midsagittal plane of fetus in first trimester of pregnancy, showing measurement of NT. Note in this midsagittal plane, tip of nose, maxilla, and
midbrain are all visible. Also note that amnion is seen as separate membrane from NT. Measurement of NT is performed by placement of calipers at
widest NT space, using on-to-on technique. See Appendix Table 5D for corresponding competency list.
NT, nuchal translucency.


APPENDIX TABLE 5E
Saline contrast sonohysterography
Pass grade: review components with trainee
Preparation for procedure:
Review indication for procedure
Ensure no contraindications for procedure exist
Obtain informed consent
Evaluate for presence of sexually transmitted diseases and need for antibiotic prophylaxis
Prepare required equipment
Ensure timing of procedure is in early proliferative phase and when patient is not actively bleeding
Procedure:
Timeout performed before procedure
Patient in supine position
Transvaginal ultrasound used
Image criteria:
Long-axis view of endometrial cavity during fluid injection
Adequate endometrial cavity distension (probe pressure at internal os in sagittal orientation to maintain distension)
3-Dimensional volume if available: sagittal, transverse, and coronal views
2-Dimensional views:
Sagittal view: to include entire endometrial cavity
Transverse view: fundus, miduterine, and lower-uterine segments
Real-time evaluation of endometrial cavity with targeted image capture
Endometrial wall thickness: anterior and posterior walls measured separately
Define/describe endometrium: global/uniform, focal irregularity (mass, polyp, or fibroid)
APPENDIX FIGURE 33
Saline contrast sonohysterography
A, Saline contrast sonohysterography. Midsagittal plane of uterus obtained during sonohysterography. Note distended endometrial cavity and
sonohysterography catheter in isthmic portion of uterus. Note that cavity is normal without any visible abnormality. B, Sonohysterography: 3-
dimensional (3D) volume. 3D Ultrasound volume of uterus obtained during sonohysterography. A, Transverse, B, sagittal, and C, coronal
planes. 3D Coronal plane is also displayed in lower right quadrant. Note that coronal planes in 2-dimensional and 3D images show normal
endometrial cavity without any abnormality. See Appendix Table 5E for corresponding competency list.

Obstetric and Gynecologic Ultrasound Curriculum and Competency Assessment in Residency Training Programs: Consensus Report

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Special Report ajog.

Obstetric and gynecologic ultrasound curriculum

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into other components of the training

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REFERENCES ultrasound of the female pelvis. J Ultrasound opportunities. Am J Obstet Gynecol

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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LVOT, left ventricular outflow tract.

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RVOT, right ventricular outflow tract.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.

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* Missing this criteria fails this competency.