Native Womens Health and MCH Conference

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Native Womens Health and MCH Conference

• GESTATIONAL DIABETES

Donald R. Coustan, August 16, 2006
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Definition of GDM

• Carbohydrate intolerance, of varying severity,
  with onset or first recognition during pregnancy

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Significance of GDM

• To the mother
• To the pregnancy

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LONG-TERM FOLLOWUP OF GDMs 17-23 YEARS AFTER
INDEX PREGNANCIES

• FORMER GDMs

CONTROLS
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NDDG CRITERIA
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WHO CRITERIA
OSullivan Carb Metab Preg Newborn
NYSpringer-Verlag, 1978, 425
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Gestational Diabetes

• Conclusion The history of gestational diabetes
  is a powerful predictor for the subsequent
  development of overt diabetes.

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Gestational Diabetes

• Implications to the pregnancy
• Perinatal Mortality
• Perinatal Morbidity

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Perinatal Mortality

• Recent studies show no increase in perinatal
  mortality
• Recent studies all involved some sort of
  intervention

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PERINATAL MORTALITY IN GESTATIONAL DIABETES

• PERINATAL MORTALITY
• UNTREATED 12/187
• GDMs (6.4)
• NORMAL 4/259
• CONTROLS (1.5)

OSullivan et al AJOG 116901, 1973
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Perinatal Mortality vs 2 hr Glucose
Deaths per 1000 Live Births
Pettitt et al Diab Care 161638, 1989
Plasma Glucose (mg/dl)
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GESTATIONAL DIABETES

• PERINATAL MORBIDITY

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MORBIDITY IN GESTATIONAL DIABETES

• MACROSOMIA
• TRAUMATIC DELIVERY
• OPERATIVE DELIVERY
• SHOULDER DYSTOCIA
• ?LONG TERM OBESITY AND DIABETES
• NEONATAL HYPOGLYCEMIA
• NEONATAL PLETHORA
• NEONATAL JAUNDICE
• RDS

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GESTATIONAL DIABETES

• MACROSOMIA

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Macrosomia vs 2 hr Glucose
gt4 kgs per 100 Births
Pettitt et al Diab Care 161638, 1989
Plasma Glucose (mg/dl)
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GESTATIONAL DIABETES

• RISK FACTOR FOR CHILDHOOD AND ADULT OBESITY

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GESTATIONAL DIABETES

• DEVELOPMENT OF DIABETES IN THE OFFSPRING

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PREGNANCY GTT EFFECT ON OFFSPRING
Pettitt et al Diabetes 40(S2)126, 1991
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Effect of Treatment of Gestational Diabetes
Mellitus on Pregnancy Outcomes
Caroline A. Crowther, F.R.A.N.Z.C.O.G., Janet E.
Hiller, Ph.D., John R. Moss, F.C.H.S.E., Andrew
J. McPhee, F.R.A.C.P., William S. Jeffries,
F.R.A.C.P., Jeffrey S. Robinson, F.R.A.N.Z.C.O.G.
and the Australian Carbohydrate Intolerance Study
in Pregnant Women (ACHOIS) Trial Group
N Engl J Med Volume 352242477-2486 June 16, 2005
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AUSTRALIAN CARBOHYDRATE INTOLERANCE STUDY IN
PREGNANT WOMEN (ACHOIS) TRIAL
RANDOMIZED CLINICAL TRIAL N1000 WITH GLUCOSE
INTOLERANCE 75 GM, 2-HR OGTT FASTING lt140 mg/dl
and 2 HR 140-200 mg/dl IF FASTING gt140 OR 2 HR
gt200, DXD AS GDM AND NOT INCLUDED IN STUDY 18
CENTERS (14 IN AUSTRALIA, 4 IN ENGLAND)
Crowther, C. et al. N Engl J Med
20053522477-2486
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AUSTRALIAN CARBOHYDRATE INTOLERANCE STUDY IN
PREGNANT WOMEN (ACHOIS) TRIAL
INTERVENTION GROUP (n490) INFORMED OF GLUCOSE
INTOLERANCE DIET, SMBG 4x DAILY INSULIN IF
FBGgt100 OR 2 HR PP gt126 TWICE IN TWO WEEKS
Crowther, C. et al. N Engl J Med
20053522477-2486
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AUSTRALIAN CARBOHYDRATE INTOLERANCE STUDY IN
PREGNANT WOMEN (ACHOIS) TRIAL
ROUTINE CARE GROUP (N510) TOLD THEY DID NOT HAVE
GDM AN ADDITIONAL 20 OF NORMAL GTT SUBJECTS
WERE INCLUDED IN ROUTINE CARE GROUP TO HELP
MAINTAIN BLINDING CAREGIVER HAD DISCRETION FOR
FURTHER TESTING FOR GDM, AND TREATMENT
Crowther, C. et al. N Engl J Med
20053522477-2486
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AUSTRALIAN CARBOHYDRATE INTOLERANCE STUDY IN
PREGNANT WOMEN (ACHOIS) TRIAL

• INTERVENTION GROUP REPLICATED CLINICAL CARE IN
  WHICH UNIVERSAL SCREENING AND TREATMENT FOR GDM
  IS AVAILABLE
• ROUTINE CARE GROUP REPLICATED CLINICAL CARE IN
  WHICH SCREENING FOR GDM IS NOT AVAILABLE

Crowther, C. et al. N Engl J Med
20053522477-2486
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Primary Clinical Outcomes among the Infants and
Their Mothers
Crowther, C. et al. N Engl J Med
20053522477-2486
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Secondary Outcomes among the Infants
Crowther, C. et al. N Engl J Med
20053522477-2486
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RESULTS

• Number needed to treat to prevent a serious
  outcome in the infant was 34 (CI 20-103)
• (death, shoulder dystocia, bone fracture or
  nerve palsy)

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CONCLUSIONS

• This large randomized trial of the treatment of
  gestational diabetes demonstrated that serious
  perinatal complications were significantly less
  common among the offspring of women who received
  dietary advice, blood glucose monitoring, and
  insulin therapy as needed to maintain glycemic
  control than among the offspring of women who
  received routine care

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Study Overview

• These findings provide strong support for the
  implementation of screening for and treatment of
  gestational diabetes

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THE EPIDEMIC OF DIABETES

• Prevalence of Diagnosed Diabetes by Age, United
  States, 19802004
• For females, 0-44 years, 0.7 in 1980, 1.3 in
  2004

CDC web site http//www.cdc.gov/diabetes/statistic
s/prev/national/figbyage.htm
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THE EPIDEMIC

• WE ARE IN THE MIDST OF A GROWING EPIDEMIC OF
  OBESITY AND TYPE 2 DIABETES
• IS THERE A SIMILAR EPIDEMIC OF GESTATIONAL
  DIABETES?

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THE EPIDEMIC

• WHY ARE CHANGES IN THE PREVALENCE OF GDM
  DIFFICULT TO ASCERTAIN?

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THE EPIDEMIC

• NO UNIFORM GTT PROTOCOL
• DIFFERENT CHALLENGES (50, 75, 100 GMS)
• DIFFERENT THRESHOLDS
• DIFFERENT DURATIONS (2 HR, 3 HR)
• DIFFERENT MEDIA (CAPILLARY BLOOD, VENOUS PLASMA,
  ETC)

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THE EPIDEMIC

• SHIFTS IN AGE AT CHILDBEARING
• POPULATION VARIATIONS IN PREVALENCE

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THE EPIDEMIC POPULATION VARIANCES IN PREVALENCE
Diabetes in America, NIDDK, 19956
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THE EPIDEMIC

• KAISER NORTHERN CALIF GDM REGISTRY
• 307,826 PREGNANCIES WITHOUT PRE-EXISTING DIABETES
  FROM 1991-2000
• 267,051 (87) WERE SCREENED FOR GDM
• SCREENING INCREASED OVER THE YEARS
• 65 IN 1991
• 95 IN 1996
• 93 IN 2000

Ferrara et al ObGyn 103526, 2004
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THE EPIDEMIC

• 16,918 PREGNANCIES IDENTIFIED WITH GDM (CC)
• CRUDE INCIDENCE
• 1991 4.7
• 1996 6.8
• 2000 7.2
• AGE, ETHNICITY ADJUSTED INCIDENCE
• 1991 5.1
• 1996 6.8
• 2000 6.9

Ferrara et al ObGyn 103526, 2004
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THE EPIDEMIC

• AGE-ADJUSTED INCIDENCE OF GDM BY RACE AND
  ETHNICITY

Ferrara et al ObGyn 103526, 2004
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THE EPIDEMIC

• GESTATIONAL DIABETES IS INCREASING IN NORTHERN
  CALIFORNIA!

Ferrara et al ObGyn 103526, 2004
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THE EPIDEMIC

• KAISER OF COLORADO PERNATAL DATABASE
• 36,403 SINGLETON PREGNANCIES FROM 1994-2002
• ALL THOSE WHO WERE SCREENED FOR GDM
• EXCLUDED IF PRE-EXISTING DIABETES
• USED NDDG CRITERIA FOR GDM

Dabelea et al Diab Care 28579, 2005
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THE EPIDEMIC

• 1,183 PREGNANCIES IDENTIFIED WITH GDM (NDDG)
• 1994 2.1
• 2002 4.1

Dabelea et al Diab Care 28579, 2005
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THE EPIDEMIC

• AGE-ADJUSTED INCIDENCE OF GDM BY RACE AND
  ETHNICITY

Dabelea et al Diab Care 28579, 2005
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THE EPIDEMIC

• GESTATIONAL DIABETES IS INCREASING IN COLORADO!

Ferrara et al ObGyn 103526, 2004
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IMPLICATIONS

• WILL THE GDM EPIDEMIC CONTRIBUTE TO, AND BE
  STIMULATED BY, THE RISE IN PREVALENCE OF OBESITY
  AND TYPE 2 DIABETES?

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GESTATIONAL DIABETES

• SCREENING AND DIAGNOSTIC TESTING

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ADA EXPERT COMMITTEE (1997)

• UNIVERSAL SCREENING, EXCEPT
• LOW-RISK GROUP IN WHICH UNIVERSAL SCREENING MAY
  NOT BE COST EFFECTIVE
• MUST MEET ALL OF THE FOLLOWING
• lt25 YEARS OF AGE
• NORMAL BODY MASS INDEX
• NO FAMILY HX OF DM
• NOT MEMBERS OF ETHNIC/RACIAL GROUP WITH HIGH
  PREVALENCE OF DM
• THRESHOLD EITHER 130 MG/DL OR 140 MG/DL

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ACOG (AS OF 2001)

• ACKNOWLEDGES UNIVERSAL SCREENING MOST SENSITIVE
• THERE MAY BE LOW RISK GRAVIDAS LESS LIKELY TO
  BENEFIT FROM UNIVERSAL SCREENING
• VERY HIGH RISK GROUPS MAY PROCEED DIRECTLY TO
  OGTT
• CRITERIA SIMILAR TO ADA STATEMENT

ACOG PRACTICE BULLETIN 30, 2001
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GESTATIONAL DIABETES

• GLUCOSE TOLERANCE TEST CRITERIA

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OSULLIVAN AND MAHAN CRITERIA

• FASTING 90 mg/dl
• 1 HOUR 165 mg/dl
• 2 HOURS 143 mg/dl
• 3 HOURS 127 mg/dl

VENOUS WHOLE BLOOD, SOMOGYI-NELSON
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OSULLIVAN AND MAHAN CRITERIA

• FASTING 90 mg/dl
• 1 HOUR 165 mg/dl
• 2 HOURS 145 mg/dl
• 3 HOURS 125 mg/dl

VENOUS WHOLE BLOOD, SOMOGYI-NELSON
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NDDG CONVERSION

• FASTING 105 mg/dl
• 1 HOUR 190 mg/dl
• 2 HOURS 165 mg/dl
• 3 HOURS 145 mg/dl

VENOUS PLASMA OR SERUM
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CARPENTER COUSTAN CONVERSION

• FASTING 95 mg/dl
• 1 HOUR 180 mg/dl
• 2 HOURS 155 mg/dl
• 3 HOURS 140 mg/dl

VENOUS PLASMA, GLUCOSE OXIDASE
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HEAD-TO-HEAD TEST RESULTS

• SACKS NDDG CC
• FASTING 96 105 95
• 1 HOUR 172 190 180
• 2 HOURS 152 165 155
• 3 HOURS 131 145 140
• VALUE WITHIN 95 CONFIDENCE LIMITS OF SACKS
  CONVERSIONS

SACKS ET AL AJOG 161638, 1989
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HAPO STUDY

• 23,000 NON-DIABETIC GRAVIDAS
• 13 CENTERS
• 10 DIFFERENT COUNTRIES
• BLINDED 75 GM OGTT 24-28 WEEKS
• EXCLUDED IF FBS gt105 MG/DL,

UNPUBLISHED DATA
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HAPO STUDY

• CONTINUOUS RELATIONSHIP BETWEEN FBS, 1-HR AND
  2-HR GLUCOSE ON 75 GM OGTT WITH
• MACROSOMIA
• CESAREAN SECTION
• NEONATAL HYPOGLYCEMIA
• CORD BLOOD C-PEPTIDE
• RELATIONSHIP HOLDS EVEN DOWN TO LOWER LEVELS OF
  GLUCOSE

UNPUBLISHED DATA
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HAPO STUDY

• NEED FOR INTERNAITONAL AGREEMENT ON GTT CRITERIA
• THIS WILL REQUIRE AGREEMENTN ON WHAT LEVEL OF
  MORBIDITY IS CONSIDERED WORTH PREVENTING
• CONSENSUS CONFERENCE PLANNED

UNPUBLISHED DATA