Evidence-based Clinical Search PICOT question on pregnant women with diabetes

Evidence-based Clinical Search PICOT question on pregnant women with diabetes
The PICOT question
“How do pregnant women (P) newly diagnosed with diabetes (I) manage the disease process and perceive reporting their blood sugar levels (O) to their healthcare providers during their pregnancy and six weeks postpartum? (T)

Introduction

Diabetes acquired during pregnancy is referred to as gestational diabetes, and it is usually induced by the hormonal changes in pregnancy. There are potential short and long-term health consequences to the mother and the fetus associated with the condition. According to Craig et al. (2020), there is no global standard definition for gestational diabetes as it keeps changing. They conject that the instability in definition has “increased the incidence in some countries in recent years, with some research suggesting minimal clinical improvement in outcomes” (Craig et al., 2020). The purpose of this systemic review is to establish how pregnant women, who are newly diagnosed with diabetes manage the disease process and perceive reporting blood sugar levels to their healthcare provider during their pregnancy and six weeks postpartum.

Problem statement

Pregnancy is a vulnerable period in a woman’s life as their bodies undergo several physical and hormonal changes that can alter how they perceives themselves. Diabetes in pregnancy has not been treated with the seriousness it deserves yet the pregnancy complications related to it are a potential threat to maternal and child health. Some of the complications include hypertension, large birth weight, and obstructed labor among others. The global estimation of women living with diabetes is 223 million. it is predicted that this number will increase to 343 million by 2045. According to IDF (2020) “20 million or 16% live births had some form of hyperglycemia in pregnancy. An estimated 84% were due to gestational diabetes.” IDF (2020) further states that one out of six births were affected by gestational diabetes. Statistics indicate that nearly half of the women diagnosed with GDM develop type 2 diabetes within five to ten years postpartum.

Craig et al. (2020), exert that a diagnosis of diabetes in pregnancy could seriously affect a pregnant woman’s quality of life particularly due to the anxiety that the baby could be affected. “this has a potential of turning pregnancy, a natural process, into a condition associate with risks, ill-health and increased surveillance” (Craig et al., 2020). Once a diagnosis has been established, one has to undergo the appropriate management process to ensure better health outcome for the mother and the baby. Inconsistencies in the management process have significant negative impacts to the health of the mother and the baby, thus drifting away from the global, MDG, on ensuring excellent reproductive health.

Systematic review of the clinical question

Research tool Search terms Findings Relevant documents
Cochrane library Pregnant women, diabetes, blood sugar levels, perinatal, post-partum. 178 results 22 articles
PubMed Pregnant women, diabetes management, blood sugar levels reporting, post-partum. 166 16 articles

 

Review of literature

Author(s) of the study Problem Purpose and scope Design Reliability and validity Level of evidence
Utz et al., 2018 Delays in GDM testing and management in Morocco primary healthcare settings. To establish the effectiveness of implementation of early detection and initial management of GDM through primary healthcare services in Morocco. A cluster randomized control trial was conducted in two districts in Morocco. Ten health centers were randomly chosen for intervention and control purposes. The sample population used was 210, which is a good representative of the target population, contributing to the studies reliability.

Quantitative data analysis tests were applied in analyzing 210 women who were recruited, thus contributing to study validity.

 Level I evidence.
Martis et al., 2018 Negative health outcomes for pregnant women with GDM and their babies. To provide an inclusive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. A systemic review of Cochrane databases from 5th January, 2018, was done for treatment and management of women GDM. The validity of the study was ensured through the use of standard critical appraisal tools for systemic reviews such as AMSTAR, ROBIS, and GRADE.

The reliability of the study was ensured through use of relevant high-quality and low-risk reviews that covered a broad target population over a long time.

 Level I evidence.

 

Systematic review and an error analysis

The appropriate documents were retrieved from Cochrane and PubMed online sites by typing in the key words. The key words include, “diabetes in pregnancy”, “management of diabetes in pregnancy”, “postpartum”, and “blood sugar levels reporting”. Before typing in the key words, the settings on the sites were applied to be for either ‘random clinical trials’ or ‘systemic review’ to ensure that only relevant documents were retrieved. From Cochrane, 178 articled were retrieved, and 15 of them were relevant to this systemic review. Only one was picked for the purpose of this review. From PubMed, 166 articles were retrieved, out of which 16 were relevant to the study. For this assignment, one random controlled trial and one systemic review were identified and evaluated.

A cluster random controlled trial conducted by Utz et al. (2018) was done to establish the effectiveness of implementation of early detection and initial management of GDM through primary healthcare services in Morocco. 210 subjects from Ten hospitals, in two districts in Morocco were enrolled for the study. To ensure high likelihood of reliability of study results, the sample population was obtained from different health centers in two districts, therefore, the results can be applied to a wider population. Use of statistical analyses tests for the variables contributed towards study validity. The findings of the study suggest that the high prevalence of GDM in the area should be addressed by a “context-adapted screening and management approach to enable early interventions” (Utz et al., 2018).

A systemic review by Martis et al. (2018) was intended to provide an inclusive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. A systemic review of Cochrane databases from 5th January to August, 2018, was done for treatment and management of women GDM. Out of 14 reviews, 10 were relevant high-quality and low-risk of bias data as indicated by AMSTAR and ROBIS checklist tools. Using GRADE tool, 128 randomized controlled trials revealed a high to very low-quality. The analyses revealed that the most effective method for treating women with GDM is through effective lifestyle changes (Martis et al., 2018).

Some errors in the studies are not obvious. Possible errors in the studies, particularly the systematic review is the data entry errors. Analyzing over ten thousand variables is bound to have human errors such as transposition and data entry errors. Similarly, in the random controlled trial, there are possible transposition errors in the data analysis since they are processes done by human beings through technological software.

Random controlled trial article summary

The cluster random controlled trial was conducted in morocco, in two different districts, where the study areas were ten health centers in each district. 210 pregnant women who were attending antenatal clinic in these health centers and were eligible, and were enrolled to participate in the study. The intervention administered was “GDM screening by capillary glucose testing following International Association of Diabetes in Pregnancy Study Groups/WHO criteria” (Utz et al., 2018). Those who tested positive for GDM were counseled on nutrition and physical activity and follow up was done through their health centers. At control facilities, the standard routine practice as per the hospital was administered. Following the analyses of the continuous and categorical variables, the findings of the study implied that the high prevalence of GDM in the area should be addressed by a “context-adapted screening and management approach to enable early interventions” (Utz et al., 2018).

Application of the review to my practice

The findings and conclusions of the random controlled trial and the systematic reviews have a significant impact to my practice as they contribute to the knowledge base. The results from the systematic review by Martis et al. (2020) contribute to the knowledge in my practice through the application of the most effective interventions for women diagnosed with GDM. According to Martis et al. (2020), the most effective way of managing GDM is through lifestyle changes. I can apply this knowledge to my practice by encouraging mothers to have a regular physical activity routine, and consume a healthy diet. From the random controlled trial, I would apply the knowledge from the findings in my practice by having timely screening and intervention of gestational diabetes, from the first trimester.

Outcome evaluation

The internal external procedures in the studies were carefully conducted to ensure validity and reliability of the outcomes. In the random clinical trial, efforts to maximize reliability were made through the use of a sample size from two districts, with ten health centers each. This ensure that the results can be generalized to a wider population thus increasing the reliability. The study also used standard measurement tools for analyzing study variables. The tools have been used in other similar studies and have produced consistent results. Therefore, this contributes to increasing the study validity. In the systematic review, the use of standard checklist to conduct review of the research variable minimizes bias, thus increasing study internal validity. Also, the data was collected from reviews of a period of six months, with the analysis including 10 relevant high-quality and low-risk of bias data. From random controlled trials, 128 reviews were obtained and 27 comparisons were done. The total number of women in the RCTs reviewed was 17, 984 and the babies were 16,305, and 1441 children (Martis et al., 2018). The broad population analyzed implies that the results can be applied to a wider population. Therefore, there is high likelihood of study reliability. Measures put in ensuring the study validity and reliability of both studies ensured minimal bias.

 

 

 

 

References

Craig, L., Sims, R., Glasziou, P., & Thomas, R. (2020). Women’s experiences of a diagnosis of gestational diabetes mellitus: a systematic review. BMC pregnancy and childbirth, 20(1), 76.

International Diabetes Federation (IDF). (2020). Gestational Diabetes. Retrieved from https://www.idf.org/our-activities/care-prevention/gdm#:~:text=There%20were%20an%20estimated%20223,were%20due%20to%20gestational%20diabetes.

Martis, R., Crowther, C. A., Shepherd, E., Alsweiler, J., Downie, M. R., & Brown, J. (2018). Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews, (8).

Utz, B., Assarag, B., Smekens, T., Ennassiri, H., Lekhal, T., El Ansari, N., … & De Brouwere, V. (2018). Detection and initial management of gestational diabetes through primary health care services in Morocco: An effectiveness-implementation trial. PloS one, 13(12), e0209322.

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