Jane E. Hirst

Consequences of Gestational Diabetes in an Urban Hospital in Viet Nam: A Prospective Cohort Study

Jane Hirst and colleagues determined the prevalence and outcome of gestational diabetes mellitus in urban Vietnam and found that choice of criteria greatly affected prevalence, and has implications for the ability of the health system to cope with the number of cases.

Women with gestational diabetes in Vietnam: a qualitative study to determine attitudes and health behaviours.

BackgroundDiabetes is increasing in prevalence globally, notably amongst populations from low- and middle- income countries. Gestational Diabetes Mellitus(GDM), a precursor for type 2 diabetes, is increasing in line with this trend. Few studies have considered the personal and social effects of GDM on women living in low and middle-income countries. The aim of this study was determine attitudes and health behaviours of pregnant women with GDM in Vietnam.MethodsThis was a qualitative study using focus group methodology conducted in Ho Chi Minh City. Pregnant women, aged over 18 years, with GDM were eligible to participate. Women were purposely sampled to obtain a range of gestational ages and severity of disease. They were invited to attend a 1-hour focus group. Questions were semi structured around six themes. Focus groups were recorded, transcribed, translated and cross-referenced. Non-verbal and group interactions were recorded. Thematic analysis was performed using a theoretical framework approach.ResultsFrom December 2010 to February 2011, four focus groups were conducted involving 34 women. Median age was 31.5 years (range 23 to 44), median BMI 21.8 kg/m2. Women felt confusion, anxiety and guilt about GDM. Many perceived their baby to be at increased risk of death. Advice to reduce dietary starch was confusing. Women reported being ‘hungry’ or ‘starving’ most of the time, unaware of appropriate food substitutions. They were concerned about transmission of GDM through breast milk. Several women planned not to breastfeed. All felt they needed more information. Current sources of information included friends, magazines, a health phone line or the Internet. Women felt small group sessions and information leaflets could benefit them.ConclusionsThis study highlights the need for culturally appropriate clinical education and health promotion activities for women with GDM in Vietnam.

Early prediction of gestational diabetes mellitus in Vietnam: clinical impact of currently recommended diagnostic criteria.

OBJECTIVE We aimed to compare the discriminative power of prognostic models for early prediction of women at risk for the development of gestational diabetes mellitus (GDM) using four currently recommended diagnostic criteria based on the 75-g oral glucose tolerance test (OGTT). We also described the potential effect of application of the models into clinical practice. RESEARCH DESIGN AND METHODS A prospective cross-sectional study of 2,772 pregnant women was conducted at a referral maternity center in Vietnam. GDM was determined by the American Diabetes Association (ADA), International Association of the Diabetes and Pregnancy Study Groups (IADPSG), Australasian Diabetes in Pregnancy Society (ADIPS), and World Health Organization (WHO) criteria. Prognostic models were developed using the Bayesian model averaging approach, and discriminative power was assessed by area under the curve. Different thresholds of predicted risk of developing GDM were applied to describe the clinical impact of the diagnostic criteria. RESULTS The magnitude of GDM varied substantially by the diagnostic criteria: 5.9% (ADA), 20.4% (IADPSG), 20.8% (ADIPS), and 24.3% (WHO). The ADA prognostic model, consisting of age and BMI at booking, had the best discriminative power (area under the curve of 0.71) and the most favorable cost-effective ratio if implemented in clinical practice. Selective screening of women for GDM using the ADA model with a risk threshold of 3% gave 93% sensitivity for identification of women with GDM with a 27% reduction in the number of OGTTs required. CONCLUSIONS A simple prognostic model using age and BMI at booking could be used for selective screening of GDM in Vietnam and in other low- and middle-income settings.

A method for developing standardised interactive education for complex clinical guidelines

BackgroundAlthough systematic use of the Perinatal Society of Australia and New Zealand internationally endorsed Clinical Practice Guideline for Perinatal Mortality (PSANZ-CPG) improves health outcomes, implementation is inadequate. Its complexity is a feature known to be associated with non-compliance. Interactive education is effective as a guideline implementation strategy, but lacks an agreed definition. SCORPIO is an educational framework containing interactive and didactic teaching, but has not previously been used to implement guidelines. Our aim was to transform the PSANZ-CPG into an education workshop to develop quality standardised interactive education acceptable to participants for learning skills in collaborative interprofessional care.MethodsThe workshop was developed using the construct of an educational framework (SCORPIO), the PSANZ-CPG, a transformation process and tutor training. After a pilot workshop with key target and stakeholder groups, modifications were made to this and subsequent workshops based on multisource written observations from interprofessional participants, tutors and an independent educator. This participatory action research process was used to monitor acceptability and educational standards. Standardised interactive education was defined as the attainment of content and teaching standards. Quantitative analysis of positive expressed as a percentage of total feedback was used to derive a total quality score.ResultsEight workshops were held with 181 participants and 15 different tutors. Five versions resulted from the action research methodology. Thematic analysis of multisource observations identified eight recurring education themes or quality domains used for standardisation. The two content domains were curriculum and alignment with the guideline and the six teaching domains; overload, timing, didacticism, relevance, reproducibility and participant engagement. Engagement was the most challenging theme to resolve. Tutors identified all themes for revision whilst participants identified a number of teaching but no content themes. From version 1 to 5, a significant increasing trend in total quality score was obtained; participants: 55%, p=0.0001; educator: 42%, p=0.0004; tutor peers: 57%, p=0.0001.ConclusionsComplex clinical guidelines can be developed into a workshop acceptable to interprofessional participants. Eight quality domains provide a framework to standardise interactive teaching for complex clinical guidelines. Tutor peer review is important for content validity. This methodology may be useful for other guideline implementation.

Application of evidence‐based teaching in maternal and child health in remote Vietnam

To develop, implement, and evaluate an evidence‐based multidisciplinary teaching program to improve maternal and infant health in remote Vietnam.

Breastfeeding Practices in a Hospital-Based Study of Vietnamese Women

BACKGROUNDnThe benefits of breastfeeding to both maternal and infant health are vast and widely known. The aim of this study was to elicit the rates of exclusive breastfeeding, early initiation of breastfeeding, and colostrum feeding and to determine the attitudes, knowledge, and influences around breastfeeding in postpartum Vietnamese women.nnnMATERIALS AND METHODSnA cross-sectional study was conducted at the Hung Vuong Hospital in Ho Chi Minh City, Viet Nam, between December 2010 and January 2011. Postpartum women were randomly selected and interviewed within 48 hours of delivery.nnnRESULTSnOf the 223 women interviewed, 86% had initiated breastfeeding at the time of the interview. Modes of feeding included exclusive breastfeeding (7%), mixed feeding (79%), which included breastmilk and formula or water, and exclusive formula feeding (14%). Of the breastfeeding women, 14% had initiated breastfeeding within 60 minutes of delivery, 92% had initiated within 24 hours, and 8% had initiated after 24 hours of delivery. Of women who had initiated breastfeeding, 37% had discarded their colostrum. Factors that positively influenced breastfeeding were knowledge that breastfeeding is good for the infant, advice obtained from public information, and the influence of health professionals and family on the decision to breastfeed. Factors that influenced the decision not to initiate breastfeeding included pain or fever after cesarean section and perceived lack of breastmilk after delivery.nnnCONCLUSIONSnThe rate of exclusive breastfeeding at Hung Vuong Hospital in this study was lower than the national average of 17%. Specific interventions targeting this must be formulated to increase these rates.

Reducing the proportion of stillborn babies classified as unexplained in Vietnam by application of the PSANZ clinical practice guideline

Background:u2002 Over 2.6 million babies are stillborn every year mostly in low‐ and middle‐income countries, where cause of death remains often unexplained.

Post‐menopausal bleeding: Hydatidiform mole a rare cause

A 55-year-old nulliparous woman presented for investigation of breakthrough bleeding while on hormone replacement therapy. She had been on the combined oral contraceptive pill until age 53. Six months after ceasing the contraceptive pill she commenced cyclical combined hormone replacement therapy, switching to combined continuous therapy after 6 months and then owing to palpitations, changing to tibolone. In May 2002 she presented with a history of breakthrough bleeding for 5 weeks, after 6 months of treatment with tibolone. She also had generalised malaise including aching joints and palpitations. The patient was otherwise well and had no significant medical history. She had no personal or family history of gynaecological or other malignancy. She was a non-smoker and drank moderate amounts of alcohol. On examination she was a slim lady of stated age. The abdomen was soft. There was some bleeding from the cervix and the uterus was slightly bulky, but non-tender and there were no palpable adnexal masses. Haemoglobin was within the normal range and thyroid function tests were normal. Transvaginal and transabdominal pelvic ultrasound was performed and showed an anteverted uterus with a grossly abnormal endometrial echo pattern. The endometrium was heterogenous and 5 cm × 4 cm × 3 cm in size. There were areas of fluid echogenecity and loss of the boundary between the myometrium and endometrium. There was increased vascularity around the outside of this abnormal endometrium. No invasion outside the uterus was seen and the adnexae appeared normal. Owing to the high likelihood of endometrial malignancy, a hysteroscopy and curettage was performed. Standard saline hysteroscopy was carried out under general anaesthesia. Endometrial biopsy was performed, with profuse curettings obtained. Blood loss was not excessive and the patient was discharged home the same day. Histopathology of the curettings showed marked psuedo decidual change and Arias-Stella like change. These findings were thought to be consistent with exogenous hormone effect. No evidence of hyperplasia, neoplasia or endometritis was seen. One month later the patient represented to her general practitioner complaining of nausea and lumpy breasts, which had not improved since ceasing tibolone pre hysteroscopy. Her bleeding had also continued. Abdominal computed tomography scan was performed and showed a thick-walled mass associated with the upper portion of the fundus of the uterus, which was thought to be consistent with a large exophytic fibroid with possibly some central necrosis. A small granuloma was noted in the right lobe of the liver, but there were no other abnormal findings. Her symptoms were consistent with exogenous oestrogen production in the presence of a degenerating fibroid, within which malignant change could not be excluded. Laparoscopic assisted vaginal hysterectomy and bilateral salpingooophorectomy with pelvic node dissection was therefore recommended. At operation the uterus contained a large mass which had the appearance of necrotic and hydropic villi (Fig. 1). Frozen section confirmed the presence of chorionic villi. There was no evidence of macroscopic spread from the uterus. Beta human chorionic gonadotropin (βhCG) performed intraoperatively was 96463 IU/L. Histopathology confirmed the presence of a complete hydatidiform mole. Lymph nodes and peritoneal washings were clear of malignant spread. Since the operation, βhCG fell to negative levels over a period of 6 weeks and has remained negative for 12 months.

Early Prediction of Gestational Diabetes in Vietnam

OBJECTIVE We aimed to compare the discriminative power of prognostic models for early prediction of women at risk for the development of gestational diabetes mellitus (GDM) using four currently recommended diagnostic criteria based on the 75-g oral glucose tolerance test (OGTT). We also described the potential effect of application of the models into clinical practice. RESEARCH DESIGN AND METHODS A prospective cross-sectional study of 2,772 pregnant women was conducted at a referral maternity center in Vietnam. GDM was determined by the American Diabetes Association (ADA), International Association of the Diabetes and Pregnancy Study Groups (IADPSG), Australasian Diabetes in Pregnancy Society (ADIPS), and World Health Organization (WHO) criteria. Prognostic models were developed using the Bayesian model averaging approach, and discriminative power was assessed by area under the curve. Different thresholds of predicted risk of developing GDM were applied to describe the clinical impact of the diagnostic criteria. RESULTS The magnitude of GDM varied substantially by the diagnostic criteria: 5.9% (ADA), 20.4% (IADPSG), 20.8% (ADIPS), and 24.3% (WHO). The ADA prognostic model, consisting of age and BMI at booking, had the best discriminative power (area under the curve of 0.71) and the most favorable cost-effective ratio if implemented in clinical practice. Selective screening of women for GDM using the ADA model with a risk threshold of 3% gave 93% sensitivity for identification of women with GDM with a 27% reduction in the number of OGTTs required. CONCLUSIONS A simple prognostic model using age and BMI at booking could be used for selective screening of GDM in Vietnam and in other low- and middle-income settings.

Early Prediction of Gestational Diabetes in Vietnam Clinical impact of currently recommended diagnostic criteria

OBJECTIVE We aimed to compare the discriminative power of prognostic models for early prediction of women at risk for the development of gestational diabetes mellitus (GDM) using four currently recommended diagnostic criteria based on the 75-g oral glucose tolerance test (OGTT). We also described the potential effect of application of the models into clinical practice. RESEARCH DESIGN AND METHODS A prospective cross-sectional study of 2,772 pregnant women was conducted at a referral maternity center in Vietnam. GDM was determined by the American Diabetes Association (ADA), International Association of the Diabetes and Pregnancy Study Groups (IADPSG), Australasian Diabetes in Pregnancy Society (ADIPS), and World Health Organization (WHO) criteria. Prognostic models were developed using the Bayesian model averaging approach, and discriminative power was assessed by area under the curve. Different thresholds of predicted risk of developing GDM were applied to describe the clinical impact of the diagnostic criteria. RESULTS The magnitude of GDM varied substantially by the diagnostic criteria: 5.9% (ADA), 20.4% (IADPSG), 20.8% (ADIPS), and 24.3% (WHO). The ADA prognostic model, consisting of age and BMI at booking, had the best discriminative power (area under the curve of 0.71) and the most favorable cost-effective ratio if implemented in clinical practice. Selective screening of women for GDM using the ADA model with a risk threshold of 3% gave 93% sensitivity for identification of women with GDM with a 27% reduction in the number of OGTTs required. CONCLUSIONS A simple prognostic model using age and BMI at booking could be used for selective screening of GDM in Vietnam and in other low- and middle-income settings.