Gestational Diabetes
-
Upload
tanvir-ahmed -
Category
Documents
-
view
25 -
download
0
description
Transcript of Gestational Diabetes
-
5/19/2018 Gestational Diabetes
1/28
Your name
-
5/19/2018 Gestational Diabetes
2/28
Introduction
The basic cause of type 2 diabetes, whose prevalence is
rapidly increasing worldwide, is genetic factors, with the
addition of such acquired factors as lack of exercise,
obesity caused by a high-fat diet, stress, and aging
impairing insulin action, leading to the onset of diabetes
-
5/19/2018 Gestational Diabetes
3/28
Introduction cont.
!n "apan, there is a clear trend towards delayed
marriage and childbirth, and in future the number ofwomen with decreased carbohydrate tolerance who
develop gestational diabetes mellitus #$%&' during
pregnancy is expected to increase more and more
!t is a fact that it is known that the incidence of $%&
increases by approximately ( times for pregnant women
aged )* years and over compared with women aged 2*
years or under
-
5/19/2018 Gestational Diabetes
4/28
Gestational Diabetes Mellitus +riginally, $%& was defined as decreased carbohydrate
tolerance that develops or is first identified during
pregnancy,
but in 2010 the definition was changed as following.
Thus, $%& is a carbohydrate intolerance that is not
diabetes that has developed or been discovered for the firsttime during pregnancy
The $%& definition therefore does not include overt
diabetes in pregnancy ccordingly, hyperglycemic
disorders that are thought to have been overlooked until thepregnancy are excluded from the definition of $%& and are
instead diagnosed as overt diabetes in pregnancy.
-
5/19/2018 Gestational Diabetes
5/28
-
5/19/2018 Gestational Diabetes
6/28
hy
-
5/19/2018 Gestational Diabetes
7/28
Diagnostic Criteria for GDM
The first evidence that screening, diagnosis and treatment of
hyperglycaemia in women not previously known to have
diabetes improve outcomes was provided by +./ullivan et al in
the 013s fter investigating the distribution of plasma glucose
values of pregnant women, these authors proposed diagnosticcriteria for gestational diabetes based on a )-h 033g +$TT
hen the 2-h 4*g +$TT was established in 0141-01(3 by
international panels as the diagnostic test for diabetes and
glucose intolerance05, the 6+ extended this recommendation
to pregnant women0* The 7/ 8ational %iabetes %ata $roup#8%%$' continued to use the )-h 033g +$TT because the 2-h
4*g +$TT had been little investigated during pregnancy
History
-
5/19/2018 Gestational Diabetes
8/28
&ost commonly used guidelines for the
diagnosis of $%&
OrganisationFastingPlasmaglucose
GlucoseChalleng
e
1-hplasmaglucose
2-hplasmaglucose
3-hplasmaglucose
WHO 19993* 7.0 75g OGTTNot
required 7.8
Notrequired
American
Congress ofOstetriciansan!G"necologists21**
5.3100gOGTT
10.0 8.6 7.8
Cana!ian
#iaetesAssociation22** 5.3 75g OGTT 10.6 8.9
Not
required
$A#P%G19* 5.1 75g OGTT 10.0 8.5Not
required
*one value is sufient !or diagnosis
** t"o or #ore values are required !ordiagnosis
-
5/19/2018 Gestational Diabetes
9/28
Diagnostic Criteria for GDM
-
5/19/2018 Gestational Diabetes
10/28
Diagnostic Criteria for GDM
The diagnostic criteria for hyperglycaemia in pregnancy
recommended by the orld 6ealth +rgani9ation #6+'
in 0111 were not evidence-based and needed to be
updated in the light of previously unavailable data The
update follows the 6+ procedures for guidelinesdevelopment /ystematic reviews were conducted for
key questions, and the $rading of :ecommendations
ssessment, %evelopment and ;valuation #$:%;'
methodology was applied to assess the quality of theevidence and to determine the strength of the
recommendation on the diagnostic cut-off values for
gestational diabetes
Need to update
-
5/19/2018 Gestational Diabetes
11/28
1*? @! 3)5-3*',
= large for gestational age #3*4> 1*?> @! 354-340' and
= shoulder dystocia #350> 1*? @! 322-34'
dditionally the risks for, perinatal mortality, neonatal
intensive care admission and birth trauma were reduced
in treated women, but the magnitude of these effects did
not reach statistical significance
-
5/19/2018 Gestational Diabetes
12/28
Classification of
Hyperglycaemia First
Detected During Pregnancy
-
5/19/2018 Gestational Diabetes
13/28
Recommendation 1
Hyperglycaemia first detected at any
time during pregnancy sould be
classified as eiter!
diabetes mellitus in pregnancy
gestational diabetes mellitus
-
5/19/2018 Gestational Diabetes
14/28
The classification of abnormalities of glucose
intolerance first detected during pregnancy
continues to be debated
!n non-pregnant adults the distinction is madebetween diabetes and intermediate
hyperglycaemia = impaired glucose tolerance
#!$T' and impaired fasting glucose #!A$' The
6+ 0111 report defines $%& as eitherdiabetes or !$T first recogni9ed in pregnancy
-
5/19/2018 Gestational Diabetes
15/28
@oncern has been expressed about the inclusion of such
a wide range of glucose abnormalities in the one
definition, especially including those with more severe
hyperglycaemia which defines diabetes in non-pregnant
adults This concern centres on special considerationsabout management during pregnancy and post-partum
follow-up in women with more severe hyperglycaemia
Dra"ing conclusions about tis group is particularly difficult because of te lac#
of good $uality data at tis le%el of yperglycaemia.
-
5/19/2018 Gestational Diabetes
16/28
The large multinational 6B+ study which examined the
association between maternal glycaemia and maternal
and infant outcomes excluded women with
Aasting glucose levels above *(mmolCl #035 mgCdl' and
2-h post load glucose levels above 000mmolCl #233
mgCdl'
/imilarly, the two recent high quality randomised studies
on treatment of $%& also excluded these types of
patients
-
5/19/2018 Gestational Diabetes
17/28
The @6+!/ study 50 excluded women with a
Aasting plasma glucose of 43 mmolCl #02 mgCdl' or
more and 2-h post-load glucose above 003 mmolCl #233 mgCdl'
The study by Landon et al excluded women with a
fasting glucose of *) mmolCl #1* mgCdl' or more
-
5/19/2018 Gestational Diabetes
18/28
&at is ne" in te classification of
yperglycaemia in pregnancy'
%istinguishing between diabetes in pregnancy and $%&
was first proposed by !%B/$ and the $%$ updating the
6+ recommendations accepted this distinction, but
proposes slightly different terminology = DdiabetesE, rather
than Dovert diabetesE proposed by !%B/$
This distinction between diabetes and $%& is a new
recommendation and there is lack of published data on
the implications of using this classification
( i i l f f di b i d
-
5/19/2018 Gestational Diabetes
19/28
(e principles of management of diabetes in pregnancy and
GDM are similar. Ho"e%er) tere are some differences in
te approac to management of "omen "it diabetes in
pregnancy compared "it GDM) as outlined in e*isting
e%idence+based guidelines) suc as tose of NIC, !
A detailed assessment for the presence of diabetes related
complications is recommended at diagnosis of diabetes,
especially complications which can affect pregnancy or beaggravated by it, such as retinopathy and renal impairment
During pregnancy a more intensive monitoring and treatment of
hyperglycaemia is recommended and pharmacotherapy is
much more likely to be reuired to control the hyperglycaemia
!ollowing the pregnancy there is need for closer follow"up and
ongoing monitoring and treatment of women with diabetes
-
5/19/2018 Gestational Diabetes
20/28
Recommendation -
Diabetes mellitus in pregnancy sould be diagnosedby te -/ &H0 criteria for diabetes if one or more
of te follo"ing criteria are met!
Fasting plasma glucose . . mmol2l 31-/ mg2 dl4
-+plasma glucose . 11.1 mmol2l 3- mg2dl4
follo"ing a 5g oral glucose load
Random plasma glucose . 11.1 mmol2l 3- mg2 dl4 in
te presence of diabetes symptoms.
-
5/19/2018 Gestational Diabetes
21/28
&at is ne" in tese diagnostic
criteria for diabetes in pregnancy
These diagnostic criteria for diabetes are
universally accepted in non-pregnant individuals,
but pregnant women with these cut-off valueswere classified as having $%& when first
detected during pregnancy
-
5/19/2018 Gestational Diabetes
22/28
Recommendation 6
The diagnosis of gestational diabetes mellitus at anytime during pregnancy should be based on any one of
the following valuesF
Aasting plasma glucose G *0-1 mmolCl #12 -02*mgCdl'
0-h post 4*g oral glucose load HG033 mmolCl #0(3
mgCdl'I
2-h post 4*g oral glucose load (* = 003 mmolCl #0*)-011 mgCdl'
Ithere are no established criteria for the diagnosis of diabetes based on the 0-hour post-load value
-
5/19/2018 Gestational Diabetes
23/28
&at is ne" in te diagnostic
criteria for GDM' The recommended glucose cut-off values for $%&
correspond to those proposed by !%B/$ and are lower
than those recommended by earlier guidelines 7nlike
earlier guidelines, they are based on the association of
plasma glucose and adverse maternal 53 and neonataloutcomes during pregnancy, at birth and immediately
following it
The difference from !%B/$ guidelines is that thesenew 6+ guidelines set a range of plasma glucose
levels to distinguish diabetes in pregnancy and $%&
-
5/19/2018 Gestational Diabetes
24/28
Implications
-
5/19/2018 Gestational Diabetes
25/28
Implications
The implications of these recommendations should be
considered in the context of each health setting hile
international consensus about the diagnostic criteria for
hyperglycaemia detected during pregnancy is growing,
implementation may be difficult in some countries Thus,consideration will need to be given to efficient detection
strategies !n addition, adaptation for some ethnic groups
or geographical regions might be required as the 6B+
study did not include participants from all regions !nsome ethnic groups fasting plasma glucose values may
not be adequate to diagnose $%&
-
5/19/2018 Gestational Diabetes
26/28
Recommendations for future
researc
-
5/19/2018 Gestational Diabetes
27/28
Recommendations for future
researc Brevalence of $%& and diabetes according to the new
criteria
;valuation of the new diagnostic criteria in diverse settings
and ethnic groupsF costs, acceptability
:andomi9ed trials #eg country or region specific' comparing
different strategies for the detection of $%&
;valuation of a Dsingle step procedureE in diagnosing $%&
@ost-effectiveness studies with different detection strategies Jong term risks related to $%& in mother and child and
impact of $%& treatment on long-term outcomes in mother
and child
-
5/19/2018 Gestational Diabetes
28/28
(H7N8 90: 7;;