NICE: Diabetes in Pregnancy

This post is a summary of NICE guideline NG23 “Diabetes in Pregnancy” which was published in 2015. This guideline contains recommendations for managing diabetes & its complications in women who are planning pregnancy /already pregnant.

This is one of ‘the must’ guideline for the MRCOG exams. I have extracted only the main points. It is recommended to read the full guideline to ensure that no important points are missed.

I hope this is helpful. Your feedback and suggestions to improve further posts are welcome.

Thanks

To download full guideline Click Here

To download all NICE guidelines Click Here

INTRODUCTION

• 5% pregnancies are complicated by diabetes
• 87.5% → gestational diabetes
• 7.5% → type1
• 5% → type 2
• Risks to woman & fetus
• Miscarriage, pre-eclampsia & preterm labour are more common with pre-existing diabetes
• Diabetic retinopathy can worsen rapidly during pregnancy
• Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality & postnatal adaptation problems are more common in babies born to women with pre-existing diabetes

PRECONCEPTION PLANNING AND CARE

• Good blood glucose control before conception & continuing it throughout pregnancy reduces the risk of miscarriage, congenital malformation, stillbirth & neonatal death
• Risks can be reduced but not eliminated
• Important to avoid unplanned pregnancies & effective contraception
• Provide information about how diabetes affects pregnancy and how pregnancy affects diabetes
• Make sure woman enters pregnancy in best optimum health in order to avoid complications
• BMI ≥27 offer advice on weight loss
• Prescribe folic acid 5 mg/day to reduce risk of baby with neural tube defects

Monitoring of blood glucose & ketones in the preconception period

• Offer monthly HbA1c to those diabetics planning to become pregnant
• Teach self-monitoring of blood sugar levels& use of glucometer

Target blood glucose and HbA1c levels

• Aim for same capillary plasma glucose target ranges as recommended for all people with type 1 diabetes
• Aim to keep HbA1c levels below 48 mmol/mol (6.5%)
• Advise against pregnancy if HbA1c level above 86 mmol/mol (10%)

Safety of medicine for diabetes before and during pregnancy

• Metformin can be used
• All other oral blood glucose-lowering agents should be discontinued before pregnancy & insulin substituted

GTG# 38 Management of Gestational Trophoblastic Disease

This post is the summary of green-top guideline GTG 38 “Management of Gestational Trophoblastic Disease” which was published in September 2020.  The new version of the guideline has some changes, so it is important to cover it. There are some important numbers which are tested repeatedly in exams. It is strongly encouraged to go through the original guideline to make sure that no point is missed. 

I hope this post is helpful. Suggestions to improve future posts are welcome.

To Download the Guideline 38: Click Here

All GreenTop Guidelines: Click Here

Definitions

Gestational trophoblastic disease (GTD) is a group of disorders ranging from premalignant (complete & partial mole also called hydatidiform mole) to malignant (invasive mole, choriocarcinoma, placental site specific trophoblastic tumour (PSTT) and epithelium trophoblastic tumour (ETT)

Gestational trophoblastic neoplasia (GTN): persistence of GTD after primary treatment (persistent elevation of HCG)

Histological confirmation for diagnosis

• Required for complete/partial mole
• Not required for GTN

Introduction & Background

Molar pregnancy subdivided into complete and partial mole 

Complete Mole	Partial Mole
Diploid & androgenic in origin	Triploid 90% Tetraploid or mosaic occasionally
No fetal tissue	Fetus or fetal RBCs present
75-80% arise due to duplication of single sperm after fertilisation of an ‘empty’ ovum	2 sets of paternal haploid & 1 set of maternal haploid chromosomes
20-25% due to dispermic fertilization of an ‘empty ovum’	Not all triploid or tetraploid pregnancies are partial moles Must have histopathological evidence of trophoblast hyperplasia for dx

GTD (Hydatidiform mole, Invasive mole, Choriocarcinoma, PSTT)

• Uncommon in UK
• Incidence 1 in 714 live births
• Ethnic variation Asian 1 in 387 live births Non-Asian 1 in 752 live births
• Associated with age at conception, higher in extremes of age
• <15 yrs 1 in 500 pregnancies >50 yrs 1 in 8 pregnancies 

GTN 

• May develop after molar/non-molar pregnancy or a live birth
• 1 in 50 000 after live birth 
• On average, a consultant O &G will deal with one new case every 2 years

Registration & Treatment Program UK

• Effective with cure rates of 98-100% 
• Chemotherapy Needed in 
• 0.5-1.0% after partial mole 
• 13-16% after complete mole
• Registration with GTD is a minimum standard of care

Presentation of Molar Pregnancy

• Most common presentation is irregular vaginal bleeding (60%), positive pregnancy test & supporting USG evidence (12%)
• Less common hyperemesis, excessive uterine enlargement, hyperthyroidism, early-onset pre-eclampsia (PET) & abdominal dissension due to theca lutein cysts
• Very rarely: haemoptysis or seizures— metastasis in lungs or brain

Role of USG

• USG use has lead to earlier diagnosis of molar. Reduction in mean gestation age of diagnosis from 16 to 9 weeks (over 1988- 2013)
• Majority of histologically proven molar → associated with USG diagnosis of delayed miscarriage or an-embryonic pregnancy
• Pre-removal accuracy of diagnosis increases with gestational age 
• 35-40% before 14wks
• 60% after 14 wks 
• USG correctly identified 56% of molar pregnancies with suspected missed miscarriage
• Unrecognised GTD prior to removal → 2.7%

GTG # 12 Pregnancy & Breast Cancer

This blogpost is a summary of GTG 12 Pregnancy and Breast Cancer. This is an old guideline which was last updated in 2011 but it is one of an important guidelines which is repeatedly tested in exam. This summary is from my personal notes which I prepared for the exam. My purpose to share these notes is to give you an idea “how to summarise a guideline without missing out important information”.

I hope it is helpful. To download full guideline : Click Here

Best wishes as always!!

Background

• Most common cancer in females
• Lifetime risk 1:9 in UK
• Leading cause of death aged 35-54yrs
• 15%→ dx before 45 yrs
• Almost 5000 women affected in reproductive age group in UK annually
• B/w 1991-1997→ 1.3-2.4 cases per 10 000 live births
• If diagnosed ≤30 yrs→ 10-20% may be associated with pregnancy + up to 1 yr postpartum
• Prognosis→ improving
• 5-yr survival→ 80% for under 50 yrs  (survival rate may be lower in very young)
• Fewer than 10% diagnosed will become pregnant
• Number of women seeking pregnancy after t/m is increasing

What is optimal management if diagnosed during pregnancy?

Prognosis

• Pregnancy itself doesn’t worsen the prognosis
• As pregnancy associated cancer occurs in younger→ so may have poor prognosis

Diagnosis

• Breast lump + pregnancy→ Refer to breast specialist team
• Any imaging or further tests must be in conjunction with MDT
• USG is used first for discrete lump but if cancer is confirmed, Mammography is necessary to assess extent of disease & contralateral breast
• Tissue diagnosis→ USG-guided biopsy for histology (*not cytology)
• Histology → similar to age-matched non-pregnant. Grade, receptor status & HER2 → for t/m planning
• Staging for metastasis→ only done if high clinical suspicion. Includes→ CXR + liver USG
• Not Recommended
• Gadolinium enhanced MRI
• Tumour marker CA125, CEA & CA15-3

MODULE 2-3: TEACHING-APPRAISAL-CLINICAL GOVERNANCE-RESEARCH

This blog post provides an outline of Modules 2 and 3. These are very important topics tested frequently in MRCOG exams. As these two modules are closely related so it is best to cover these together. Most of the exam candidates find themselves lost while thinking about these dry topics. It is very important to understand the basic principles which can be applied to ANY clinical scenario

• As I always advise the first step is to have a look at the details of modules on the RCOG website which will clarify what are you expected to demonstrate under these modules
• The best source for these modules is StratOG. It provides the most authentic information and can be subscribed by visiting this page StratOG Home
• You should first collect all the reading material and arrange/compile it as it suits your study needs
• The following tables may help you to collect and organize your study material in one place
• If you use gadgets (iPad/Laptop/Smartphone) its easier to arrange but if you prefer hard copies, you can get the printouts and arrange them as per your convenience
• I would suggest making ONE big folder and you can name it "Clinical Governance, Teaching & Statistics"
• Then make sub-folders based on the following outline. This will ensure that you do not miss any topic
• For each topic, you can make a ‘NOTE’ file which should be a summary of the points taken from all resources
• The format of your notes is very important. It should be concise and easy to retain information
• Keep practising SBAs and EMQs from different sources as these topics are tested in a variety of ways. You need to focus on EACH and EVERY word in the question to get the right answer
• I have made an outline just to give an idea about how these topics can be covered. If you find some topic is missing kindly modify your list 

I hope you find this compilation helpful and that it saves you precious time. Suggestions to improve future posts are welcome.

Thanks

Module 2: Teaching, Appraisal and Assessment Details RCOG

Teaching Role of clinical teacher Recent trends in Medical Education Principles of Adult Learning
TOG	The teacher, the learner and the method 2010 The key features of highly effective training units in ob/gyn 2020 Giving effective feedback in medical education 2017 Spotlight on education 2017 Providing an obstetric teaching programme in resource poor country 2014 Making simulation stimulating-how to set up a simulation workshop 2011 How can recruitment be improved in ob / gyn 2010 A guide to ATSM in Medical Education Article 1 - Principles of teaching and learning 2009  Article 2 - Assessment, feedback and evaluation 2010 Article 3 - Teaching and assessment in clinical setting 2010 Article 4 - Quality assurance and research in medical education 2010
Dr Tom	Education Answer
EMQ	Teaching Methods
Appraisal
TOG	A practical guide to appraisal and revalidation 2018
RCOG	Supporting information for appraisal and Revalidation: Guidance for Obstetrics and Gynaecology
Revalidation	Conducted by GMC to confirm that a doctor can retain license to practice in UK. Done every 5 years. GMC Website Link: Click Here
Assessment
TOG	Workplace-based assessment: a new approach to existing tools 2014
StratOG	RCOG eLearning Workplace Behavior and Skills tutorial on: Improving workplace behavior Step Up RCOG Communications Skills module
Mentoring
RCOG	RCOG eLearning case study on Leadership and Management Royal College of Mentorship and Support
Reflective Practice
TOG	Clinical Reflective Practice 2020
GMC	The reflective practitioner
Miscellaneous
TOG	Managing burnout in obstetrics and gynaecology 2019 The relevance of non-technical skills in ob/gyn 2013 Bullying in workplace-recognition and management 2012

Module 3: Information Technology, Clinical Governance & Research Details RCOG

Clinical Governance Main things to focus on are Quality improvement within a framework Patient Safety Consent Ethics Confidentiality Risk management Audit cycle Dealing with complains/legal matters Developing & applying clinical guidelines
TOG	The value of obstetric surveillance systems within NHS 2013 Implementation Strategies - moving guidance into practice 2013 What have maternity networks ever done for us? 2012 A practical guide to quality improvement 2017
CGA	Improving Patient Safety: Risk Management for Maternity and Gynaecology CGA 2 Presenting Information on Risk CGA 7 Understanding Audit CGA 5
Good Practice Guidance	Maternity Dashboard GP 7 Responsibility of Consultant On-Call GP 8 Gynaecology: Emergency Services Standards of Practice and Service Organization GP 9 Labour Ward Solutions GP 10 Improving Patient Handover GP 12  Reconfiguration of women's services in UK GP 15
Kindly go through the blog post which covers this topic along with explanations: Click Medical Law and Ethics
Consent
TOG	Understanding the Mental Capacity Act 2005 2010 Consent in Clinical Practice 2015 Medico-legal update on consent 'The Montgomery Ruling' 2016 Decision making framework in gynaecology for patients who lack mental capacity 2018
RCOG	Obtaining valid consent CGA 6 Obtaining valid consent for complex gynaecological surgery CGA 6b Obtaining Valid Consent to Participate in Perinatal Research CGA 6a
BlogPost	Consent Advice: Risk Figures Compilation
Legal Issues
TOG	Litigation in Gynaecology 2014 Dealing with serious incident requiring investigations in ob/gyn 2014 Surrogate Pregnancy: ethical and medico-legal issues in modern obstetrics 2013 Tackling female genital mutilation in the UK 2017
Research
TOG	A guide to RCOG Advanced Professional Module in Clinical Research 2018 A Practical introduction to medical statistics 2014 Participation in research as means of improving quality care 2015
RCOG	Understanding Audit CGA 5
Assessing evidence
TOG	The art of reviewing a paper 2014

You may also like:

Module 5,6,7: Core Surgical Skills, Post-op Care & Surgical Procedures

Module 8: Antenatal Care — Part 1

Module 8: Antenatal Care — Part 2

Module 9: Maternal Medicine

Module 10/11: Labour & Delivery 12: Puerperium

Module 13: General Gynaecology

Module 14: Subfertility

Module 15: Sexual and Reproductive Health

Module 16: Early Pregnancy Care

Module 17: Gynaecological Oncology

Module 18: Urogynaecology & Pelvic Floor Problems

Starting Point for MRCOG Part 2

3Ws and General Advice for MRCOG Part 2

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