Gestational Diabetes

1
Gestational Diabetes Mellitus Prevalence,
Risk Factors Maternal and Infant Outcomes
Professor Bagher Larijani Professor of
Internal Medicine Endocrinology Head of EMRC
Endocrine and Metabolism Research Center
(EMRC) Tehran University of Medical Sciences(TUMS)
2
Classification of Diabetes Mellitus

• Type 1
• - Immune mediated
• - Idiopathic

Type 2 - Insulin resistance - Relative insulin
deficiency

• Other specific types
• - Genetic defect of beta-cell function or in
  insulin action
• - Diseases of the exocrine pancreas,
  endocrinopathies
• - Induced Drug, Infections, uncommon
  immune-mediated diabetes
• - Other genetic syndromes

Gestational Diabetes Mellitus
American Diabetes Association Economic
consequences of diabetes mellitus in the US in
1997. Diabetes Care 21296, 1998
EMRC
3
GDM
Gestational Diabetes Mellitus (GDM) is defined
as Carbohydrate intolerance of varying severity
with the first recognition of onset occurring
during pregnancy
American Diabetes Association Clinical practice
Recommendations, Diabetes Care, 21, 1, S60, 1988
4
GDM
Gestational Diabetes Mellitus is a common
metabolic abnormality affecting pregnant women
5
Pathogenesis of GDM

• Decreased tissue sensitivity to insulin
• Impaired insulin insulin receptor binding
  
• Impaired intracellular insulin signaling
• Increased insulin degradation
• Impaired ?-cell function
• Autoimmune destruction of pancreatic
• ?-cells

Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000
6
Reasons for Varying frequency of GDM around the
world
Ethnicity Pattern of NIDDM Screening
strategy Screening Diagnostic
criteria Environment Lifestyle
7
GDM Prevalence In Different Populations
Country /population Prevalence U.S
All ethnicities 4
Zuni Indian 14.3
Chinese 7.3
Hispanics 4.2 Australia
Australian-born 4.3
Indian-born 15
Vietnam born 7.3
8
Prevalence of GDM as a percentage of all
pregnancies
Percent
Epidemiology of glucose intolerance and GDM in
women of child bearing age, Diabetes Care, 21,
1998
9
Frequency of GDM Regarding Ethnicity, Screening
Method, And Diagnosis Criteria

• The frequency of GDM according to ethnic group
  diagnosed using a50-g OGTT ,and 75-g OGTT (WHO
  criteria)

Diabetes Care Vol 21 Suppl 2 B43 1998
10
Screening for GDM
Much controversy exists regarding the screening
strategy and diagnostic thresholds of GDM
Increasing health care cost
Limited resources
Must pay attention to the
11
Screening Strategy
Universal
Selective
based on
Performing GCT in all pregnant women
Obesity
Age ? 25 years
familial diabetes
poor obstetric outcome
abnormal glucose metabolism
High GDM prevalence ethnic groups
Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000
12
Sensitivity of Various Screening Protocols
ACOG The American college of obstetricians and
Gynecologists Screening of high risk and general
population for GDM, Clinical application and cost
analysis. Diabetes, 34, 2, 24-27, 1985
13
Diagnostic Criteria for GDM
Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000
14
Complications
Maternal
Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000 Obstetrical complications
with GDM. Effect of maternal weight. Diabetes,
40, 279, 1991
15
Complications
Fetal Neonatal Macrosomia Organomegaly Prenatal
mortality Neonatal hypoglycemia Hypocalcaemia Hype
r bilirubinemia Polycythemia Transient
tachypnea RDS Poor Apgar LGA infants Still
birth Abortion
16
Complications

• Recurrent GDM
• 30 - 60
• Diabetes type 2
• 5 to 16 years
• 17 - 63

• Impaired glucose tolerance in the offspring
• Age IGT
• 5 years 1.2
• 5 - 9 years 5.4
• 10 - 16 years 19.6

17
Monitoring

• Daily SMBG
• Urine ketone (insufficient caloric or
  carbohydrate intake)
• Urine glucose (is not useful in GDM)
• Urine protein BP (Hypertensive disorders)
• Glycohemoglobin
• Fructosamine or Glycated albumin (in patients
  with hemoglobinopathies)
• Maternal serum a-fetoprotein (after 16 wk)

• Daily fetal movement counting by mother (after
  28 wk)
• Biophysical testing (after 34 wk)
• 2 weekly NST.
• or weekly CST.
• or weekly biophysical profile.
• Amniocentesis delivery
• phosphatidy glycerol
• L/S ( gt 2 the patient suffer HMD)

Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000
EMRC
18
Management
Antepartum
Peripartum
Medical Nutrition Therapy (MNT)

• Cesarean Section
• GDM alone dose not mandate C/S
• Macrosomic fetus (prevent shoulder dystocia)
• Maternal glucose levels should be controlled
• Targeted blood glucose 80-110mg/dl
• Insulin
• . Usual insulin dose on the evening before
  induction.
• . Omit morning insulin dose on day of delivery.
• . On day of delivery dextrose infusion if
  necessary, an intravenous insulin infusion

FBS lt 95mg/dl more likely to achieve good
glycemic control after 2 weeks of dietary
therapy. BMI gt 30 we should recommend 30 33
calorie restriction (25kcal/kg 35-40
carbohydrates)
Exercise
Start or continue a program of moderate exercise.
Insulin

• Human Insulin should be used
• SMBG should guide the dose timing of the
  Insulin regimen.
• The use of insulin analogs has not been
  adequately tested in GDM.
• Based on previous studies, oral glucose-lowering
  agents are not recommended during pregnancy.
• Fructosamine levels correlated significantly
  with both fasting mean glucose levels over
  2-week intervals.

Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000
19
Multicenter Survey of GDM

• 2416 pregnant women
• Five hospital clinics in Tehran
• Universal Screening
• GCT ? 130 mg /dl (Positive)
• GTT100-gr 3-hour (diagnostic test)

Glucose Challenge Test
Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
EMRC
20
Multicenter Survey of GDM

• Carpenter Coustan criteria
• Obstetrics Family history
• Complete physical examinations
• Followed up until delivery
• OGTT 75-gr 6-12 weeks after delivery

Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
EMRC
21
Universal Screening

• Performing blood glucose testing
• At 24 - 28 wk all pregnant women
• Before 24 wk high risk pregnant women
• Repeat after 32 wk
• - Age gt 30 years
• - Impaired GTT in one of the venous
• plasma concentrations
• - Symptoms of hyperglycemia

Screening for GDM optimum timing and criteria
for retesting. Diabetes 34, 221-23, 1985
Clinics in laboratory medicine, 21.1 March 2001,
173-192 Diabetes Care 23.1, ADA clinical practice
recommendation 2000
EMRC
22
Universal Screening
GCT 50 g (first visit with RF) GCT
50 g OGTT 100 g At 24 28 wk
all Pregnant women GDM OGTT 100
g GCT at 32 36 wk GDM OGTT No GDM
-

-

-

High risk
-
High risk


-

-
Screening for GDM optimum timing and criteria
for retesting. Diabetes 34, 221-23, 1985
Diabetes Care 23.1, ADA clinical practice
recommendation 2000
23
Results of Multicenter study in Tehran
24
Multicenter Survey The prevalence of IGT and GDM
Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
25
Risk Factors for Gestational Diabetes Mellitus
26
Association of Risk Factors with GDM

• Risk factors
• Obesity
• Family Hx. Of DM
• Age ? 25
• History of poor obstetric outcome
• History of abnormal glucose metabolism

Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
27
Symptoms Associated With GDM and Normal Pregnancy
Symptoms Polyuria, Hyperhidrosis, Polydipsia,
Polyphagia
31 of GDM patients were Asymptomatic
52 of Normal pregnant women were symptomatic
Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
EMRC
28
Universal Screening
Threshold
130 mg/dL
140 mg/dL
15.7 Cost
12 sensitivity
29
Selective Screening
14
Sensitivity
130 mg/dL
Cost
28.6
Threshold
Sensitivity
23
140 mg/dL
Cost
37
30
Pregnancy Outcome in Women with GDM and Controls
31
Maternal outcome
OGTT 75-gr 6-12 weeks after delivery
Postpartum Diabetes Mellitus 7.3 Impaired
Glucose Tolerance 18.4
32
The best predictors of postpartum diabetes and
IGT

• Fasting blood glucose level
• Maternal obesity
• Early gestational age at GDM diagnosis
• Gestational requirement for insulin

33
Conclusion
34
The Prevalence of DM and IGT in Different Areas
of IRAN (WHO Criteria 1985)
35
Prevalence of Diabetes Mellitus in IRAN
14.5 - 22.5 of the people over 30 years have
IGT or DM.
25 of people with IGT will lead to Diabetes.
EMRC
36
Prevalence of GDM as a percentage of all
pregnancies
Percent
Epidemiology of glucose intolerance and GDM in
women of child bearing age, Diabetes Care, 21,
1998
37
Sensitivity and Cost of Various Screening
Protocols
38
Cost-Effectiveness
For every dollar spent on the Slightly more
expensive postprandial monitoring strategy
,approximately 3 would be saved in adverse
outcome costs
39
For every additional dollar spent on
preconception care of diabetes
1.86 could be saved in direct medical cost
for the offspring

40
The rate of risk factors show significant
difference between GDM patients and normal
pregnant women
But
High Prevalence of GDM among pregnant women
without any risk factor suggests revision in
the Risk Factors for GDM screening.
41
Approximately one fourth of GDM patients were
experienced IGT or overt diabetes in the early
postpartum period.
42
As conclusion

• GDM is prevalent in Iran
• The Burden of GDM is significant and needs more
  attention
• Universal screening seems more cost effective in
  Iran
• We need a national strategy to manage this
  disease

43
National program of GDM

• Large cohort study designed and conducted by EMRC
  with cooperation of CDC,Undersecretary for Health
  of MOH
• Target areas include Tehran, Mazandaran, Ardabil,
  Boushehr, and Esfahan Provinces.

44
Objectives of program

• Determine the prevalence of GDM in Iran
• Evaluate the risk factors for GDM
• Evaluate the complications of GDM
• Recommend the most appropriate method for
  screening and treatment of GDM (based on ethnic
  and economic condition of Iran)
• Compare different methods for the screening,
  diagnosis and treatment of GDM
• Establishment of combined GDM clinics in all
  provinces

45
Summary of EMRC activities about diabetes

• Performing 27 research projects
• Performing 19 graduate thesis
• Publishing 24 papers
• Presenting 95 abstracts in seminars
• Editing 5 books
• Publishing 30 educational pamphlets
• Publishing the Iranian Journal of Diabetes and
  Lipid Disorders
• Conducting 4 workshops for physicians
• Conducting 4 seminars
• Conducting 4 educational camps for diabetic
  children

46
Summary of EMRC activities about diabetes

• Establishment of diabetes polyclinic with 1200
  registered patients
• Establishment of GDM clinic
• Establishment of Diabetes Hotline
• Strategic planning for NCDs including diabetes
• Establishment of National Diabetes Network
• National program of GDM
• National program of pancreas and islet
  transplantation