Diabetes in Pregnancy

Assessment
The assessment for this module has been divided into 2 sections.
The case study (1,000 words)
Written assignment (3,000 words)
Both sections must be submitted separately for marking and both sections must reach the pass standard in order to successfully complete the module. Please carefully read the marking criteria and the descriptors provided.

1. The Case study
The purpose of this assessment is to allow the student to apply theory to practice and is based around a case study. Please discuss the following case:

• Problems associated with diabetic retinopathy and pregnancy.

The Case
• Mrs Begum is 38 years old, married with 3 daughters (she experienced gestational diabetes in all three pregnancies and required insulin therapy during the last pregnancy). Following the birth of her last daughter (6 years ago) she was then found to have raised blood glucose levels and when an oral glucose tolerance test was performed diagnosed with type 2 diabetes mellitus.
• Her current medication is Lisinopril 20 mg, Simvastatin 40 mg, Metformin 500 mg twice daily. She does not always attend her appointments with the practice nurse and there has been some concerns regarding her concordance with medication.
• Her last retinal photography demonstrated background retinopathy. Microalbuminuria was found on one occasion, but further urine samples were not supplied by the patient.
• The last recorded HbA1c was 8.3% (67 mmol/mol), creatinine 90, total cholesterol 4, eGFR above 90. Last blood pressure recording 135/80. BMI 29.
• She attends the surgery complaining of vaginal thrush and in conversation says her husband wants her to have another baby. Mrs Begum has limited command of the English language, but fortunately the practice nurse can speak Mrs Begum’s native language.

Please add to the case study the critical appraisal of the following reference studies and add others as you see suitable.

Ref1. “Diabetes Control and Complications Trial (DCCT) 1993”

Ref2. “Maloney and Drury Am J Ophthalmol 1982”

Ref3. “Klein et al Diabetes Care 1990

Ref4. “Chew et al Diabetes Care 1995”

The case study should include the following sections:
• Introduction (very brief)
• Effect of pregnancy on retinopathy.
• Effect of retinopathy on pregnancy.
• What causes the deterioration in retinopathy?
• Management of retinopathy in pregnancy.
All according to a case study.

2. The Written Assignment
You are required to write a 3,000 assignment with the following options:
Option : Gestational Diabetes – a diagnosis not worth making?
Critically evaluate the screening strategies and treatment approaches you use at present. Identify an area you wish to change or update. Evidence-base your decided change and document how this change will be implemented. What will be the benefits to people with diabetes?

Please structure the Gestational Diabetes (GDM) assignment to include the following sections with brief discussion of each section:
1-Introduction
2- Symptoms
3-Epidemiology (How common)
4- Causes of GMD (pathoghysiology)
5-Who is at risk of GDM.
6-Diagnosis of GDM.
7-Treatmant of GDM A. medical treatment b. life style c. obstetric treatment.
8-Complications of GDM.

Then the following is the main part of the assignment you need to to concentrate on:
A. Current Screening strategies for GDM you use at present, with its benefits to people with diabetes and evidence base by critically appraise numbers of studies, and what suggested changes you wish and how will be implemented.
B. Current treatment approaches for GDM, with evidence base (critically appraise) with its benefits to people with diabetes, and what suggested changes you wish to do.

Then
Conclusion

Please include the following recommended reading with critical appraisal and add others, again with critical appraisal, up to 45 in total
.
Recommended reading
• Bell, R. et al. (2012). Peri-conception hyperglycaemia and nephropathy are associated with risk of congenital anomaly in women with pre-existing diabetes: a population-based cohort study. Diabetologia. 5(4). pp. 936-947. •
Bellamy, L. et al. (2009). Type 2 diabetes mellitus after gestational diabetes: A systematic review and meta-analysis. Lancet. 373(9677). pp. 1773-1779. •
Confidential Enquiry into Maternal and Child Health. (2005). Improving the health of mothers, babies and children. Pregnancy in women with type 1 and type 2 diabetes 2002–2003 England, Wales and Northern Ireland. London: CEMACH
• Department of Health (2003). National Service Framework for Diabetes – Delivery Strategy. London: DOH •
Inkster, M., Fahey, T. P., Donnan, P.T., Leese, G.P., Mires, G.J., and Murphy, D.J. (2006). Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: Systematic review of observational studies. BMC Pregnancy and Childbirth, 6(1), pp. 30
• Kim, S. et al. (2011). Gestational Diabetes Mellitus and risk of childhood overweight and obesity in offspring: A systematic review. Experimental Diabetes Research. Article ID 541308. doi:10.1155/2011/541308
• Landon et al, A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes, N Engl J Med 2009; 361:1339-1348, October 1, 2009
• Meltzer, S. (2010). Editorial: Prepregnancy care: A shared responsibility. Diabetes Care. 33(12). pp. 2713-2715. •
Miller, E., Hare, J. W., Cloherty, J. P., Dunn, P. J., Gleason, R. E., Soeldner, J. S. and Kitzmiller, J. L. (1981). Elevated maternal hemoglobin A1c in Early Pregnancy and Major Congenital Anomalies in Infants of Diabetic Mothers. New England Journal of Medicine, 304, pp. 1331 – 1334. •
Murphy, H. et al. (2010). Personal experiences of women with diabetes who do not attend pre-pregnancy care. Diabetic Medicine. 27(1). pp. 92-100.
• Murphy, H. et al. (2010). Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes. Diabetes Care. 33(12). pp. 2514-2520. •
National Institute for Clinical Excellence (2015). Diabetes in pregnancy: management of diabetes and its complications from conception to the postnatal period guideline. London: NICE https://www.nice.org.uk/guidance/ng3/resources/diabetes-in-pregnancy-management-ofdiabetes-and-its-complications-from-preconception-to-the-postnatal-period-51038446021 •
National Institute for Clinical Excellence. (2008). TAG151 Diabetes: Insulin Pump Therapy. London: NICE •
Pearson, D. W. M., Kernaghan, D., Lee, R. and Penney, G.C. (2006). The relationship between pre-pregnancy care and early pregnancy loss, major congenital anomaly or perinatal death in Type 1 diabetes mellitus. BJOG An international Journal of Obstetrics and Gynaecology, 114(1).pp. 104 – 107.
• Ray, J.G., O’Brien, T. E. and Chan, W. S. (2001). Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: A meta-analysis. Quarterly Journal of Medicine, 94(8). pp. 435 – 444.

• Saravanan, P. & Yajnik, C. (2010). Role of maternal vitamin B12 on the metabolic health of the offspring: a contributor to the diabetes epidemic? British Journal of Diabetes and Vascular Disease. 10(3). pp.109- 114 •
Scottish intercollegiate Guidelines Network (2010). Management of Diabetes: A National Clinical Guideline. SIGN. https://www.sign.ac.uk/guidelines/
Studies •
CEMACH report – Diabetes in pregnancy: Are we providing the best care? – Confidential Enquiry into Maternal and Child Health: Findings of a national enquiry: https://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/25.-February-2007Diabetes-in-Pregnancy-are-we-providing-the-best-care-Findings-from-a-national-projectMarch-2002-February-2003.pdf
• HAPO study https://www.ncbi.nlm.nih.gov/pubmed/18463375
• ACHOIS study https://www.nejm.org/doi/full/10.1056/nejmoa042973
Useful websites
• Global library of Women’s medicine https://www.glowm.com/
• Learn about diabetes using interactive tools https://diabetes.niddk.nih.gov/resources/HealthTools/index.htm
• National Service Framework https://www.nhs.uk/nhsengland/NSF/pages/Nationalserviceframeworks.aspx
• National Diabetes Support Team https://www.diabetes.nhs.uk/
• NHS Evidence – https://www.evidence.nhs.uk/
• NICE https://www.nice.org.uk/

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