Presentation on theme: "GESTATIONAL DIABETES FORUM 28/5/14. Hyperglycemia in Pregnancy Gestational Diabetes Mellitus Is GDM important? How should we screen for it? Does treatment."— Presentation transcript:
Hyperglycemia in Pregnancy Gestational Diabetes Mellitus Is GDM important? How should we screen for it? Does treatment make a difference? –What are the treatment options?
Medical Management of GDM Professor David McIntyre Approaching 100% consensus regarding diagnosis
Australian Consensus RANZCOG convened consensus conference Nov 1, 2013 Present: RANZCOG, ADIPS, RCPA, ADS, ADEA, ACM, SOMANZ Absent: ESA, RACGP Major recommendations: –Cease GCT July 2014 –Adopt IADPSG / WHO criteria Jan 2015
Australian Consensus NHMRC guidelines for Antenatal Care –First visit – assess risk of DM (Age, BMI, previous GDM, FH diabetes, PCOS, ethnicity) –Early test for hyperglycemia in women at higher risk –Test (or re – test) at 24 – 28 weeks if not known DM –Use WHO / IADPSG protocol and thresholds
Finer points Exactly who is “high risk”? Terminology: “Overt Diabetes” (IADPSG) vs. “Diabetes in Pregnancy” (WHO) vs. No specific comment (ADIPS) Role of HbA1c Remote areas ? Intensity of treatment?
GDM screening tests: One Step versus Two Step Process with a Glucose Challenge Test GCT lacks both sensitivity and specificity –Leeuwen BJOG 2012 –Systematic review of all studies with both GCT and OGTT in all women –Overall sensitivity for GDM diagnosis on OGTT ~0.74 Issues –25 % GDM missed with GCT –Need to return for OGTT if GCT positive –Loss of follow up –Diagnosis and therapy delayed Van Leeuwen et al. (BJOG 2012;119:393–401)
ADIPS GDM diagnostic criteria - 2013 1.Early testing for GDM with risk factors “Moderate risk factors” for GDM screened with either a random or a fasting glucose test followed by a pregnancy OGTT (POGTT) if clinically indicated “High risk” of GDM (one high RF or two moderate RF) should undergo a 75 g POGTT
ADIPS GDM diagnostic criteria - 2013 Moderate Risk factorsHigh Risk factors Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific, Islander, Maori, Middle Eastern, non ‐ white African BMI 25 – 35 kg/m2 Previous GDM Previously elevated BGL Maternal age ≥40 years Family history DM (1st degree relative with DM or a sister with GDM) BMI > 35 kg/m2 Previous macrosomia (baby with birth weight > 4500 g or > 90th centile) PCOS Medications: corticosteroids, antipsychotics
ADIPS GDM diagnostic criteria - 2013 2. Routine testing for GDM All women should have an 75 gm fasting POGTT at 24-28 weeks Diagnosis of GDM ( Recommended by RANZCOG to be adopted by Jan 2015) –one or more of the following glucose levels are elevated; Fasting glucose ≥ 5.1mmol/L 1 ‐ hr glucose ≥ 10.0mmol/L 2 ‐ hr glucose ≥ 8.5mmol/L
GDM ; Management - Multidisciplinary Dietician & Diabetes educator review Home Blood glucose monitoring – qid, fasting and 2 hour post prandial Lifestyle changes – diet and physical activity AN care continued in collaboration with midwives/obstetricians BGL Targets - little firm evidence regarding BG targets - Fasting <5.5mmol/L (<5.1 mmol/L) - 1hr post prandial <8.0 mmol/L(< 7.4 mml/L) - 2 hr post prandial <7 mmol/L(<6.7 mmol/L) Treatment options Insulin or metformin ( in some centres) if failing to meet glucose targets Suggested BG treatment targets based on 2SDs above the mean values for pregnant women without known risk factors. Current targets
Recommended targets Fasting mmol/L 1 hour PP mmol/L 2 hours PP mmol/L Old ADIPS5.58.07.0 New ADIPS5.07.46.7 USA5.36.7 Mean + 1 SD*184.108.40.206 Mean + 2 SD*220.127.116.11 * from:- Hernandez et al D Care, 2011
Medication use “Lifestyle” for all ? Availability of extra resources (e.g. dieticians / diabetes educators / exercise physiologists) Medication use –ACHOIS 20%, US MFMNU trial 10% (insulin) –MMH clinic 35 – 40 % (insulin + metformin) Accuracy of home glucose meters in the GDM range
Models of care Variable around Australia Groups vs. Individual RCT models of care vs. resources and reality Fetal monitoring GP based care Risk stratification
Supporting clinical care Use of IT – meters / decision support tools Telehealth to support isolated areas Educational packages Structure for post natal / inter pregnancy care –Link to mother and baby health checks
Metformin vs. Insulin Women entitled to explanation and choice of therapy Immediate pregnancy outcomes with metformin comparable to insulin therapy No suggestion teratogenicity Convenience of treatment Longer term outcomes for children.
Metformin vs. Insulin Metformin –Not quite as easy as it seems –GIT side effects may be troublesome –Officially “Category C” in Australia –Risk of “dumbing down” of high risk pregnancy care –Push to use metformin economic rather than clinical
Postnatal care of women with GDM Recommendations: –75 gr 2 hr OGTT 6-12 weeks postpartum to exclude diabetes –Follow up OGTT two yearly (possibly at time of cervical screening) or yearly if planning another pregnancy –Repeat OGTT early in subsequent pregnancy –Lower risk women consider fasting PG every 1-2 years –Follow up of impaired fasting glucose by regular checks for frank diabetes in addition to assessment of other risk factors of macrovascular disease
Other important issues Long term maternal health and opportunities for prevention –Risk of diabetes – 70 % lifetime risk of developing T2 DM –Risk of cardiovascular disease Long term health of children – increased risk Obesity and IGT Intergenerational transmission of diabetes and other risks
Heaven / Nirvana of Diabetes Prevention Population / Environment measures Early pregnancy testing “ Standard” GDM testing Pre conception testingHigher risk
Repercussions PERSONAL – Where we draw the line does matter GDM Pregnancy Maternal Health Baby Health Non - GDM Pregnancy Maternal Health Baby Health