Wednesday, October 07, 2020

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


Diabetes in Pregnancy

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

Monday, October 05, 2020

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


GTG 38 gestational trophoblastic disease


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%

Tuesday, September 15, 2020

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!!


GTG 12 Breast Cancer Pregnancy


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

Friday, July 03, 2020

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


Mrcog exam modules rcog clinical governance teaching statistics

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
A guide to ATSM in Medical Education
Dr Tom
EMQ
Appraisal
TOG
RCOG
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
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
Reflective Practice
TOG
GMC
Miscellaneous
TOG

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
CGA
Good Practice Guidance
Kindly go through the blog post which covers this topic along with explanations: Click Medical Law and Ethics
Consent
TOG
RCOG
BlogPost
Legal Issues
TOG
Research
TOG
RCOG
Assessing evidence
TOG

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