Objectives To compare the cost-effectiveness (CE) of the National Institute for Health and Care Excellence (NICE) 2015 and the WHO 2013 diagnostic thresholds for gestational diabetes mellitus (GDM). Setting The analysis was from the perspective of the National Health Service in England and Wales. Participants 6221 patients from four of the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study centres (two UK, two Australian), 6308 patients from the Atlantic Diabetes in Pregnancy study and 12 755 patients from UK clinical practice. Primary and secondary outcome measures planned The incremental cost per quality-adjusted life year (QALY), net monetary benefit (NMB) and the probability of being cost-effective at CE thresholds of £20 000 and £30 000 per QALY. Results In a population of pregnant women from the four HAPO study centres and using NICE-defined risk factors for GDM, diagnosing GDM using NICE 2015 criteria had an NMB of £239 902 (relative to no treatment) at a CE threshold of £30 000 per QALY compared with WHO 2013 criteria, which had an NMB of £186 675. NICE 2015 criteria had a 51.5% probability of being cost-effective compared with the WHO 2013 diagnostic criteria, which had a 27.6% probability of being cost-effective (no treatment had a 21.0% probability of being cost-effective). For women without NICE risk factors in this population, the NMBs for NICE 2015 and WHO 2013 criteria were both negative relative to no treatment and no treatment had a 78.1% probability of being cost-effective. Conclusion The NICE 2015 diagnostic criteria for GDM can be considered cost-effective relative to the WHO 2013 alternative at a CE threshold of £30 000 per QALY. Universal screening for GDM was not found to be cost-effective relative to screening based on NICE risk factors.
A multidisciplinary team operating in a secondary- or tertiary-care setting is a commonly adopted model for the provision of pregnancy care to women with diabetes. This chapter suggests important characteristics of a multidisciplinary team. It also presents simple practical advice on how to provide a diabetes-in-pregnancy service meeting the standards recommended in the UK National Institute for Health and Care Excellence (NICE) guidelines. The overall aims of multidisciplinary joint antenatal diabetes care are to allow the mother to have a good experience of pregnancy, excellent glycemic control, and a normal delivery of a healthy baby. In order to maintain and improve the standard of pregnancy care, there is the need for regular, simple standard audits conducted at local, regional, and national levels. The ability of individual hospitals and care providers to be able to benchmark against regional/national performance is very useful in driving improvements in care, particularly as a method of securing additional resources.
Today we are all expected to practice evidence-based medicine. However, there are many problems with regard to this in gynaecology, as in many areas, because the evidence base is sadly lacking. Obstetrics is much more advanced, with evidence based on randomized controlled trials being promoted heavily by Iain Chalmers, particularly in 1989 with the publication of Effective Care in Pregnancy and Childbirth.
A fine needle on a syringe was introduced through the cyst wall, and air under pressure pushed the syringe barrel outwards.At this point the surgeon and the anaesthetist realised that this pharyngocele had resulted from the inflated cuffof the laryngeal mask used.It was more prominent through the head having been turned to the opposite side.The "diagnostic" puncture of the cuff resulted in a slow deflation, which eventually necessitated the replacement of the mask owing to the development of laryngeal spasm.The surgeon was relieved ofthe need for further investigation of the swelling.
The diagnosis of and criteria for gestational diabetes mellitus (GDM) continue to divide the scientific and medical community, both between and within countries. Many argue for universal adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and feel that further clinical trials are unjustified and even unethical. However, there are concerns about the large increase in number of women who would be diagnosed with GDM using these criteria and the subsequent impact on health care resources and the individual. This Perspective reviews the origins of the IADPSG consensus and points out some of its less well-known limitations, particularly with respect to identifying women at risk for an adverse pregnancy outcome. It also questions the clinical and cost-effectiveness data often cited to support the IADPSG glycemic thresholds. We present the argument that adoption of diagnostic criteria defining GDM should be based on response to treatment at different diagnostic thresholds of maternal glycemia. This will likely require an international multicenter trial of treatment.
Excessive childhood adiposity is a risk factor for adverse metabolic health. The objective was to investigate associations of newborn body composition and cord C-peptide with childhood anthropometrics and explore whether these newborn measures mediate associations of maternal midpregnancy glucose and BMI with childhood adiposity.Data on mother/offspring pairs (N = 4,832) from the epidemiological Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study and HAPO Follow-up Study (HAPO FUS) were analyzed. Linear regression was used to study associations between newborn and childhood anthropometrics. Structural equation modeling was used to explore newborn anthropometric measures as potential mediators of the associations of maternal BMI and glucose during pregnancy with childhood anthropometric outcomes.In models including maternal glucose and BMI adjustments, newborn adiposity as measured by the sum of skinfolds was associated with child outcomes (adjusted mean difference, 95% CI, P value) BMI (0.26, 0.12-0.39, <0.001), BMI z-score (0.072, 0.033-0.11, <0.001), fat mass (kg) (0.51, 0.26-0.76, <0.001), percentage of body fat (0.61, 0.27-0.95, <0.001), and sum of skinfolds (mm) (1.14, 0.43-1.86, 0.0017). Structural equation models demonstrated significant mediation by newborn sum of skinfolds and cord C-peptide of maternal BMI effects on childhood BMI (proportion of total effect 2.5% and 1%, respectively), fat mass (3.1%, 1.2%), percentage of body fat (3.6%, 1.8%), and sum of skinfolds (2.9%, 1.8%), and significant mediation by newborn sum of skinfolds and cord C-peptide of maternal glucose effects on child fat mass (proportion of total association 22.0% and 21.0%, respectively), percentage of body fat (15.0%, 18.0%), and sum of skinfolds (15.0%, 20.0%).Newborn adiposity is independently associated with childhood adiposity and, along with fetal hyperinsulinemia, mediates, in part, associations of maternal glucose and BMI with childhood adiposity.
Prenatal screening is a routine procedure within contemporary maternity care and most women opt for prenatal testing and become involved in various aspects of such tests. Evidence to date suggests that the level of the practitioner's knowledge can impinge upon their communication skills and create barriers to information giving. A number of studies have identified that evaluations and monitoring of this aspect of antenatal care around information giving, staff training and guideline awareness, is minimal. Therefore, this study aimed to explore midwives’ and obstetricians’ perceptions of their roles, training needs, guideline awareness and their views of the local prenatal service. The study was undertaken between 1996 and 1997 across seven maternity units and involved 245 midwives and obstetricians. In developing the method, published standards and guidelines for practice were used to underpin the approach chosen. The findings suggest that a lack of guideline awareness exists, as well as dissatisfaction with local prenatal screening services and an identified need for further training among midwives and obstetricians.
This chapter focuses on problems that are encountered more frequently in women with type 1 diabetes mellitus (T1DM) than type 2 diabetes mellitus (T2DM). It also includes hypoglycemia. This complication is also encountered in women with T2DM who are on insulin. Hypoglycemic unawareness is of major concern to the clinician trying to optimize glycemic control in pregnancy. Maternal hyperglycemia, as associated with an increased risk of stillbirth and adverse pregnancy outcomes. Antenatal death in utero remains the most feared of all outcomes for women with T1DM and the clinicians who care for them. It is recommended that all patients with T1DM should be offered structured education in carbohydrate counting. The UK Dose Adjustment for Normal Eating (DAFNE) course is a structured education program of proven benefit in which patients with T1DM are empowered to adjust insulin based on the carbohydrate content of their meals or snacks.
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