A. Complications of Pregnancy

I. First and second trimester bleeding

With respect to:

1. Threatened abortion

2. First and second trimester incomplete abortion

3. First or second trimester intrauterine death (missed abortion)

4. Complete abortion

5. Ectopic pregnancy

6. Septic abortion

7. Gestational trophoblastic disease

8. Incompetent cervix.

The student will be able to:

1. Define the above conditions.

2. Describe the signs and symptoms of each condition.

3. Give the etiology of each condition.

4. Describe the methods used to achieve a diagnosis.

5. Describe emergency and definitive treatments.

6. Discuss the emotional impact of pregnancy loss and the relationship to future pregnancies.

B. Pregnancy and Hypertension

The student will be able to:

1. Define and classify hypertensive disorders in pregnancy.

2. Explain the pathophysiology of hypertensive disorders in pregnancy.

3. Describe the signs and symptoms of these disorders.

4. List the methods to confirm the diagnosis.

5. Discuss the principles of management and follow-up.

6. Describe the maternal and fetal complications, which can occur.

7. Describe the prognosis for subsequent pregnancies.

C. Antepartum Hemorrhage (second and third trimester bleeding)

The student will be able to:

1. Explain the mechanisms of the following causes of third trimester bleeding:

- placental abruption

- placenta previa

- ectropion of the cervix

- bloody show

- carcinoma of the cervix

- vasa previa

2. Describe the appropriate method of investigation for each condition.

3. Describe the appropriate mode of management for each condition.

4. Describe the maternal and fetal outcomes for each condition.

D. Pre-term Labor

The student will be able to:

1. Define pre-term labor.

2. List the criteria necessary to make a diagnosis of pre-term labor.

3. Describe available methods to identify women at high risk for pre-term deliver.

4. Describe methods, which may prevent pre-term delivery in women at high risk for this complication.

5. Outline the management including the possible use of tocolytic agents and corticosteroids.

E. Premature Rupture of the Membranes

The student will be able to:

1. Describe the methods available to confirm the diagnosis of premature rupture of the membranes.

2. Outline the management of premature rupture of the membranes including indications and contraindications for induction of labor.

3. List the maternal and fetal risks associated with premature rupture of the membranes.

4. Describe the management regarding group B hemolytic streptococcus maternal colonization and the prevention of neonatal infection.

F. Isoimmunization

Facing a case of blood incompatibility in the fetus, the student will be able to:

1. Describe the pathophysiology of isoimmunization.

2. List the indications for immunoprophylaxis.

3. Describe the mechanisms of action of immunoprophylaxis.

4. Describe the methods used to detect maternal isoimmunization and determine the severity of fetal disease.

5. Describe the methods of treatment available pre and post natally.

G. Risk Assessment and Evaluation of Pregnancy

The student will be able to:

1. Recognize factors in a woman's lifestyle or personal or family medical history which indicate increased risk of an unfavorable outcome and strategies to ameliorate these factors.

2. Recognize factors in the history and physical examination of the pregnant woman at the first antenatal visit, or which appear during the antenatal period, which indicate an increased risk of an unfavorable outcome for the fetus or mother.

3. Describe the assessment of fetal growth, well being and maturity.

4. Define and discuss the significance of stillbirth rate, neonatal death rate, perinatal death and maternal death rates.

5. Describe the methods of audit used in your community in the assessment and improvement of healthcare delivery, (e.g. perinatal and maternal morbidity and mortality review).

H. Multiple Pregnancy

The student will be able to:

1. List the risks for the mother and fetuses associated with a multiple gestation.

2. Describe the etiology of multiple gestation.

3. List the physiological changes associated with multiple pregnancies.

4. Outline the correct management during the antepartum course, labor and postpartum period.

I. Intrauterine Growth Restriction (IUGR)

The student will be able to:

1. Define intrauterine growth restriction and small for gestational age.

2. Describe the use of the menstrual history and ultrasound to determine the gestation age.

3. List the known etiological factors associated with intrauterine growth restriction.

4. Describe the fetal risks associated with intrauterine growth restriction.

5. List the appropriate ancillary diagnostic tests.

6. Describe the surveillance of fetal growth and well being.

7. Describe how to recognize the difference between symmetrical and asymmetrical types of growth restriction and explain the significance of this distinction.

8. Describe the management of the pregnancy associated with intrauterine growth restriction.

9. Predict the outcome for future pregnancies for specific cases of intrauterine growth restriction.

J. Prolonged Pregnancy

The student will be able to:

1. Define a term pregnancy, pre-term pregnancy and post term pregnancy.

2. Describe the accuracy of methods for gestational dating, using available clinical data, physical

examination and ancillary tools.

3. Describe how to evaluate fetal well being in the post term pregnancy.

4. Outline the options for management of the post term pregnancy.

K. Fetal Death

The student will be able to:

1. Describe the clinical and ultrasonographic features leading to the diagnosis of fetal death.

2. Describe the possible emotional reactions of parents and the appropriate physician responses including the conduct of postpartum care in this situation.

3. Discuss the common reactions of physicians to fetal death and techniques for dealing with these feelings.

4. For your own community, list the hospital and community resources available to assist grieving families.

5. Outline the possible etiologies of intrauterine death and the preventative measures for future pregnancies.

6. List the maternal complications associated with fetal death.

7. Describe the methods for pregnancy termination, including their complications.

8. List the investigations to be carried out in situations of fetal death.

L. Congenital Anomalies

The student will be able to:

1. List the risk factors in the history and physical examination of the pregnant patient at her initial visit, which may increase her changes of having a baby with a congenital anomaly.

2. Describe the basic principles of pre-pregnancy counseling, including the options available to a couple after completion of the counseling.

3. List environmental factors in the antepartum period, which could have teratogenic effects on the fetus (maternal disease, substance abuse, infections, drugs, and radiation, etc).

4. Describe the methods of investigation for prenatal detection of congenital anomalies.

5. Discuss the significance of hydramnios and oligohydramnios associated with congenital anomalies.

M. Hyperemesis Gravidarum

The student will be able to:

1. Outline the theories of etiology of nausea and vomiting in pregnancy, including consideration of pregnancy complications associated with increased nausea and vomiting.

2. Describe how to assess the seriousness of the vomiting, including recognition of dehydration.

3. Describe the principles of treatment including fluid replacement, and the use of anti-emetic drugs.

N. Abnormalities of Labor and Delivery

I. The student will be able to:

1. Recognize abnormal patterns of labor and classify them as to whether they are protraction or arrest disorders, in descent or dilatation, and in the latent, or active phase of labor.

2. List the causes of abnormal labor.

3. Describe the factors important in the evaluation of the patient with abnormal labor.

4. List the indications and contra-indications of oxytocin administration.

5. List the indications for operative vaginal delivery and the prerequisites for the application of forceps or a vacuum extractor.

6. List the indications for caesarian section.

7. Describe the risk factors for and clinical presentation of shoulder dystocia and list the maneuvers needed for successful delivery in cases of shoulder dystocia.

8. Describe the patients who are appropriate for trial of labor after caesarian section (VBAC) and compare the advantages and risks of repeat caesarian section with VBAC.

9. Discuss the use of analgesic and anaesthetic techniques in cases of abnormal labor or operative delivery.

II. The student will be able to:

1. Identify the pregnancies where acute or chronic fetal distress is more likely to occur.

2. Describe the features of the biophysical profile score, which would indicate chronic hypoxia.

3. Describe the cord blood gas pattern in an asphyxiated fetus.

4. Define abnormal variability and deceleration patterns in the fetal heart tracing.

5. Outline management of a patient with a fetus in acute distress.

6. Discuss the significance of meconium stained amniotic fluid.

7. Outline the management of the neonate born with meconium stained amniotic fluid.

O. Abnormalities of the Post-Partum Period

I. The student will be able to:

1. List the causes of post-partum hemorrhage.

2. Describe the pre-disposing factors for post-partum hemorrhage.

3. Outline the appropriate management of post-partum hemorrhage.

4. List the impact of complications of this kind on the mother and the baby.

II. The student will be able to:

1. List the symptoms, signs, predisposing factors, appropriate investigations and management of the following post-partum complications:

- delayed post-partum hemorrhage

- infections (including endometritis, pelvic abscess formation, infected episiotomy)

- breast problems (including mastitis, galactocele)

- thrombo-embolic disease

2. List the bacteria commonly involved in post-partum infections, suitable antibiotic choices, and their compatibility with breast-feeding.

3. Describe the "post-partum blues" and management of depressive illness in the post-partum period.

P. Medical and Surgical Diseases Affecting Pregnancy

The student will be able to:

1. Describe the alterations in maternal carbohydrate metabolism in pregnancy.

2. Describe the maternal and fetal/neonatal consequences of uncontrolled pre-existing or gestational diabetes, including:

- congenital anomalies

- macrosomia

- hydramnios

- preterm labor

- fetal/neonatal and maternal trauma

- delayed fetal lung maturity

- neonatal hypoglycemia and hypocalciuria

3. Outline the protocols for routine screening of pregnant women for carbohydrate intolerance and the rationale for such screening.

4. List the risk factors for gestational diabetes and the diagnostic test for the disease.

5. Outline the principles of management including diet, blood sugar monitoring and insulin therapy.

6. Describe the methods of surveillance of the fetus in pregnancies complicated by diabetes.

7. Describe the obstetrical management of the patient with diabetes in pregnancy.

I. With respect to:

- Anemia and hemoglobinopathies

- Cardiac diseases

- Pulmonary diseases

The student will be able to:

1. Describe the important historical, physical and laboratory findings needed for a differential and final diagnosis.

2. Describe the effects of pregnancy on the disease and the effects of the disease on pregnancy.

3. Describe the fetal risks associated with these conditions.

4. Outline the principles of management for pregnancies associated with these conditions.

II. With respect to:

- Urinary tract diseases (infections, calculi, chronic diseases)

- Appendicitis

The student will be able to:

1. Outline the important physical and laboratory findings.

2. Describe the effects of pregnancy on the disease and the effects of the disease on the pregnancy.

3. Describe the teratogenic risks of infection and drugs used for these clinical problems during pregnancy.

4. Outline the principles of management for these clinical problems during pregnancy.

The student will be able to:

1. Describe the consequences of the following infections in pregnancy for the mother and fetus:

- herpes

- rubella

- parvovirus

- human immunodeficiency virus

- tuberculosis

- varicella

- hepatitis

- cytomegalovirus

- toxoplasmosis

- syphilis

2. In reference to the above infections, describe the important historical, physical and laboratory findings needed for a differential and final diagnosis.

3. Discuss the principles and possible complications of vaccination during pregnancy.

4. In reference to the above infectious diseases, describe the principles of management with reference to the pregnancy.

The student will be able to:

1. List the gastro-intestinal diseases which are specific to pregnancy.

2. Describe how common gastro-intestinal illnesses are altered by pregnancy.

3. Discuss the differential diagnosis and management for jaundice in pregnancy.

The student will be able to:

1. Describe the management of thyroid disease in pregnancy, including the effects on the fetus.

Q. The Newborn

The student will be able to:

1. List the steps in initial assessment of the neonate.

2. Describe the immediate resuscitative measures for a depressed newborn.

3. Interpret cord blood results.

4. Describe management of the neonate if there has been meconium staining of the amniotic fluid.

5. Describe the identification, differential diagnosis, pathophysiology, complications and principles of management of neonatal:

- hypoglycemia

- hypothermia

- infection

- respiratory problems

- hyperbilirubinemia