The FIGO Initiative Setting out a global vision to address hyperglycemia in pregnancy Anil Kapur MD

79% 88% Global Diabetes Burden People with diabetes live in the Middle and Low Income Countries 79% Deaths attributable to diabetes occur in the same regions 88%

Hyperglycemia and Pregnancy – Why it is relevant? High risk of maternal and perinatal morbidity and mortality and poor pregnancy outcome Identifies women at high future risk of diabetes and CVD, offers opportunity of primary prevention Offspring of GDM pregnancy at high risk of metabolic problems including type 2 diabetes MNCH NCD Diabetes and Pregnancy is very relevant because screening and identifying women with diabetes or GDM provides us an opportunity to make significant contributions on three fronts which have great public health relevance. Because hyperglycaemia increases the risk of poor maternal and perinatal outcome as shown in the next slide and identifying and treating women with diabetes or GDM helps us improve these outcomes and lower morbidity and mortality related to pregnancy as we will see later. Diagnosis of GDM helps us identify women at very high risk of future diabetes and CVD as shown in subsequent slides and by offering preventive care provides us the opportunity to prevent or delay diabetes and CVD and their complications including premature mortality. At a third level it also helps identify individuals – offsprings of GDM pregnancy, who are at considerable high risk of diabetes and other NCDs as described in subsequent slides, and offer them early preventive care to break the rising curve of NCD and prevent intergenerational transfer of risks.

Hyperglycemia and Pregnancy Why it is relevant?

Maternal Health & NCD Interaction

Contributors to maternal morbidity and foetal programing

The Challenge ~127 Million Pregnancies/Year ~21 million /year complicated by hyperglycaemia ~3 to 4 million detected and treated ? Receive Post partum follow up and lifestyle advice

Hyperglycemia in Pregnancy is Grossly Neglected

FIGO Guidelines FIGO GDM Expert Group established Dec 2013 Oct 2015 FIGO GDM Expert Group established Guideline on diagnosis, management and care Articulates a vision & call for action Provides options according to resource setting Identifies key points of intervention The International Federation of Gynecology and Obstetrics (FIGO) Initiative on Gestational Diabetes Mellitus: A Pragmatic Guide for Diagnosis, Management and Care which as published in the International Journal of Gynecology and Obstetrics (IJGO) in October 2015, Also created a set of infographics which are now in english, french, spanish, chinese and more coming

Highlights Significance for Global Health

Advocates for Universal Testing Using One Step Procedure

Offers Pragmatic Options for Diagnosis

Provides Standards for Lab Testing Describes technical considerations in laboratory and point of care (POC) testing in different settings

Describes Care for Women with GDM

Recommends and Promotes Pre-conception and Inter-pregnancy Care

Recommends and Promotes Postpartum care

Prevent pregnancy complications and save mothers and new-borns; and Window of Opportunity Testing women during pregnancy for diabetes opens a window of opportunity to provide maternal care services Prevent pregnancy complications and save mothers and new-borns; and Identify women and children at highest future risk of diabetes, obesity and CVD and offer them early preventive care

UN High Level Political Declaration on NCDs New York on 19th September 2011 “Maternal and child health is inextricably linked with non-communicable diseases and their risk factors, specifically such as prenatal malnutrition and low birth weight create a predisposition to obesity, high blood pressure, heart disease and diabetes later in life, and that pregnancy conditions, such as maternal obesity and gestational diabetes, are associated with similar risks in both the mother and her offspring.” Advocates for “the inclusion of non-communicable disease prevention and control within sexual and reproductive health and maternal and child health programs, especially at the primary health-care level, as well as other programs, as appropriate, and also integrate interventions in these areas into non-communicable disease prevention programs.”

Diabetes Policy Brief Studies show that the prevalence of GDM is increasing. Throughout the EU, screening and policy varies because of a lack of consensus on testing, diagnostic procedures, and screening efforts. GDM increases the risk of perinatal complications for both mother and child. These women and their infants are at heightened risk of developing type 2 diabetes and cardiovascular disease Half of women with GDM will develop type 2 diabetes within 5 to 10 years after pregnancy.

We, Hereby Agree To undertake actions in our various capacities to support efforts to address the link between maternal health obesity and diabetes as a public health priority To accelerate the implementation of the FIGO GDM initiative (http://www.ijgo.org/issue/S0020-7292(15)X0015-4) in Europe, including by pursuing supportive policy actions and mobilizing resources for its implementation. To support efforts to increase public awareness about hyperglycemia in pregnancy and its impact on maternal and child health, encourage preconception counseling, antenatal care and post-natal follow up. To promote and celebrate a National GDM Awareness Day as an instrument to bring public attention and raise awareness of the problem To support and encourage task shifting, role based training to build capacity for prevention, early diagnosis, and treatment of HIP and continued engagement with the high risk mother child pair over a prolonged time period.

To advocate for access to uninterrupted diagnostic supplies, medications and trained manpower for diagnosis and appropriate management for HIP at all levels of care at affordable costs keeping the pregnant women's convenience in mind. To ensure that as a minimum, all pregnant women in Europe attending health facilities are tested for hyperglycemia using a single-step procedure, as advocated by FIGO. To make all efforts to support post-partum follow up and engagement of the high risk mother child pair post-GDM pregnancy linked to the child's vaccination program by engaging and collaborating with other health care professionals. To help develop, support and carry out a robust research agenda that fuels both the discovery of new tools and procedures to improve point of care diagnostics, monitoring and management of HIP and the ability to engage, counsel and track the mother-child pair over the long term; as well as carry out operational research to improve collaboration and efficacy in existing programs, keeping in mind the health care delivery realities in different parts of Europe.