Gestational Diabetes: An Update on Testing Diabetes - Dr...gestational diabetes mellitus on...
Transcript of Gestational Diabetes: An Update on Testing Diabetes - Dr...gestational diabetes mellitus on...
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Kimberlee A McKay, M.D.
Avera Medical Group Ob/GYN
Gestational Diabetes: An Update on
Testing
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Gestational Diabetes
Increased risks of: Still Birth
Hydramnios
Should Dystocia
Prolonged Labor
Preeclampsia
Macrosomia
Habitual Abortions
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Gestational Diabetes :
“Carbohydrate intolerance that begins or
is first recognized during pregnancy.”
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The Beatles
Go-Go boots
Gestational Diabetes
1960s
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Positive 1-hour GTT:•140 mg/dl or higher
•Sensitivity of 80%
•15% of your patients may require 3-hr OGTT
•130 mg/dl or higher
•Sensitivity of 90%
•23% of your patients may require 3-hr OGTT
ACOG Practice Bulletin No. 30
Gestational Diabetes
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ACOG Diagnostic Criteria for GDM: 2 or
more thresholds must be exceeded
Serum Glucose by
Carpenter /Coustan
Conversion
Serum Glucose
level by National
Diabetes Data
Group
Conversion
Fasting 95 mg/dl 105 mg/dl
1-hour 180 mg/dl 190 mg/dl
2-hour 155 mg/dl 165 mg/dl
3-hour 140 mg/dl 145 mg/dl
Gestational Diabetes. ACOG Practice Bulletin No. 30. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2001;
98:535-38
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“Although a number of comparative studies of various treatments are available, there is little
information regarding the effectiveness of treatment versus no treatment.”
ACOG Practice Bulletin No. 30
Gestational Diabetes
American College of Obstetricians and Gynecologists. Obstet
Gynecol 2001; 98:535-38
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RCT to determine whether treating GDM affected perinataloutcomes
At the time, usual practice was no treatment in some centers
1000 pregnant women across 18centers in Australia and 2 centers in the UK
Positive 2 hour OGTT (FBS>99 mg/dl and 2-hour BS<198 mg/dl
ACHOIS Trial
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of treatment of
gestational diabetes mellitus on pregnancy outcomes. Australian carbohydrated intolerance study in
pregnant women (ACHOIS) trial group. NEJM 2005; 352: 2477-86
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ACHOIS Trial: 1000 patients
n=510
Positive 2-hour OGTT
Usual care
n=490
Positive 2-hour OGTT
Intervention
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of
treatment of gestational diabetes mellitus on pregnancy outcomes. Australian
carbohydrated intolerance study in pregnant women (ACHOIS) trial group. NEJM
2005; 352: 2477-86
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ACHOIS Trial: Outcome Measures
Primary Secondary
Maternal •Cesarean Delivery
•Need for labor induction
•#PN visits
•Mode of delivery
•Wt. Gain
•Antenatal Admits
•PIH
Neonatal •Perinatal complications
•Admission to NICU
•Jaundice requiring Photo therapy
•Gestational age
•Birth Weight
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of treatment of
gestational diabetes mellitus on pregnancy outcomes. Australian carbohydrated intolerance study
in pregnant women (ACHOIS) trial group. NEJM 2005; 352: 2477-86
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ACHOIS Trial: Neonatal Outcomes
Primary
Intervention
#(%) of
n=506
Routine Care
#(%) of n=534 RR
Death 7(1) 24(4) 0.32
Stillbirth 0 5(1)
Neonatal death0 3(<1)
Shoulder
Dystocia 7 (1) 16(3) 0.45
Bone
Fracture0 1(<1)
Nerve Palsy 0 3(1)
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of treatment of gestational
diabetes mellitus on pregnancy outcomes. Australian carbohydrated intolerance study in pregnant women
(ACHOIS) trial group. NEJM 2005; 352: 2477-86
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ACHOIS Trial: Neonatal Outcomes
SecondaryIntervention
n=506
Routine
n=524P-value
Birth Weight3335+/-551
gms
3482+/-660
gms<.0001
LGA 63(13%) 115 (22%) <.0001
EFW>4 kg 49 (10%) 110 (21%) <.0001
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of
treatment of gestational diabetes mellitus on pregnancy outcomes. Australian carbohydrated
intolerance study in pregnant women (ACHOIS) trial group. NEJM 2005; 352: 2477-86
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ACHOIS Trial: Maternal Outcomes
Primary Intervention
# (%) n=490
Routine
# (%) n=510
RR
Induction 189 (39) 150(29) 1.31
C/S Total 152 (31) 164(32) 0.96
C/S Emergent 80 (16) 103 (20) 0.81
C/S Elective 72 (15) 61 (12) 1.23
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of treatment of
gestational diabetes mellitus on pregnancy outcomes. Australian carbohydrated intolerance study
in pregnant women (ACHOIS) trial group. NEJM 2005; 352: 2477-86
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ACHOIS: Conclusions
Routine Care Group Increased risk of macrosomia and LGA
Increased risk of perinatal outcomes (shoulder dystocia, birth trauma)
Intervention Group Increased risk of labor induction
Increased risk of NICU Admission
Decreased neonatal body weight
Crowther, CA. Hiller JE. Moss JR. McPhee AJ, Jeffries WS, Robinson JJ. Effects of
treatment of gestational diabetes mellitus on pregnancy outcomes. Australian
carbohydrated intolerance study in pregnant women (ACHOIS) trial group. NEJM 2005;
352: 2477-86
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US Preventive Task Force 2008
“The USPTF concludes that the current evidence is
insufficient to asses the benefits and harms of screening
for GDM either before or after 24 weeks gestation.”
Screening for gestational diabetes mellitus: Us Preentitive
Services Task Force recommendations statement. Ann Intern Med
2008;148 (10): 759-65
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HAPO Study 2008
25,000 patients in 9 countries
75-g OGTT from 24-32 WGA
Looked at maternal glucose values as a continuum
to see what levels may be associated with an
increased risk of adverse perinatal outcomes.
The HAPO study cooperative research group.
Hyperglycemia and adverse pregnancy outcomes. NEJM
2008; 358(19): 1991-2001
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HAPO Study
Primary Outcomes Birth weight > 90%ile
Primary cesarean delivery
Clinical neonatal hypoglycemia
Cord-blood serum C-peptide level > 90%ile
Secondary Outcomes Premature delivery
Shoulder dystocia or birth injury
NICU admissions
Hyperbilirubinemia
PreecampsiaThe HAPO study cooperative research group. Hyperglycemia and adverse pregnancy
outcomes. NEJM 2008; 358(19): 1991-2001
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HAPO Study
Glc >200
• = Overt Diabetes
• Unblindedfrom study
Glc >105
• GDM
• Unblindedfrom study
Glc= 2 abnomalvalues
• Mild hyperglycemia
The HAPO study cooperative research group. Hyperglycemia and adverse pregnancy
outcomes. NEJM 2008; 358(19): 1991-2001
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HAPO Study
Plasma glucose levels were divided in to 7 categories
Adjusted Odds Ratios were calculated for both primary and
secondary outcomes
Then they made some really complicated graphs that I am not
going to reproduce because, let’s face it, I am just not that
smart.
The HAPO study cooperative research group. Hyperglycemia and
adverse pregnancy outcomes. NEJM 2008; 358(19): 1991-2001
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HAPO Study: Birth weight>90th%ile
FBS OR 1-hr OR 2-hr OR
1 1.0 1.0 1.0
2 1.37 1.21 1.11
3 1.72 1.65 1.51
4 1.95 2.27 2.15 (126-139)
5 2.73 (90-94) 2.66 (172-193) 2.10
6 3.0 3.5 2.68
7 5.01 4.49 4.46
The HAPO study cooperative research group. Hyperglycemia and adverse pregnancy
outcomes. NEJM 2008; 358(19): 1991-2001
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HAPO Study: Cord-blood serum C-
peptide >90%ile
FBS OR 1-hr OR 2-hr OR
1 1.0 1.0 1.0
2 1.41 1.07 1.06
3 1.75 1.62 1.44
4 2.36 (85-89) 1.95 (156-171) 1.72 (140-157)
5 3.62 2.76 (172-193) 2.21 (140-157)
6 4.46 2.91 2.86
7 7.65 4.65 3.48
The HAPO study cooperative research group. Hyperglycemia and adverse
pregnancy outcomes. NEJM 2008; 358(19): 1991-2001
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HAPO Study: Secondary outcomes
Positive associationsPreeclampsia
Shoulder dystocia
Birth Injury
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HAPO Study: Conclusions
“Our results indicated strong, continuous
associations of maternal glucose levels below those
diagnostic of diabetes with increased birth weight
and increased cord-blood serum C-peptide levels.”
The HAPO study cooperative research group. Hyperglycemia and
adverse pregnancy outcomes. NEJM 2008; 358(19): 1991-2001
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Carpenter-Coustan criteria Vs. National
Diabetes Data Group Thresholds
2009 retrospective cohort study of patients in California
delivering from 1988-2001
14, 500 patients 753 (5.1%) patients meeting criteria for GDM by both NDDG and C-C criteria.
480 (3.3%) by NDDG
272 (1.9%) by C-C
Hypothesized that using the C-C criteria would decrease
undesirable perinatal complications.
Cheng, WC, Block-Kurbisch, I. and Caughey, A. Carpenter-Coustan Criteria
Compared with the National Diabetes Data Group Thresholds for Gestational
Diabetes Mlitus. Obstet and Gynecol. 2009; 114(2)326-332
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273 (1.9 %)
LGA (5.1%)
Macrosomia (4.0%)
Shoulder dystocia (3.3%)
Birth Trauma(4.4%)
Operative Vaginal delivery (18.8%)
C-section (22.7%)
Post Partum Hemorrhage (26.7%)
Neonatal Hypoglycemia (1.8%)
480 (3.3%)
LGA (2.9%)
Macrosomia (1.0%)
Shoulder Dystocia (1.1%)
Birth Trauma (2.7%)
Operative Vaginal Delivery (14.3%)
C-Section (26.1%)
Post Partum Hemorrhage (31.9%)
Neonatal Hypoglycemia (4.4%)
Cheng, WC, Block-Kurbisch, I. and Caughey, A. Carpenter-Coustan Criteria
Compared with the National Diabetes Data Group Thresholds for Gestational
Diabetes Millitus. Obstet and Gynecol. 2009; 114(2)326-332
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Carpenter-Coustan criteria Vs. National
Diabetes Data Group Thresholds
Suggested that NDDG threshold was missing a subgroup of
women who had mild hyperglycemia
Suggested that treatment of this subgroup of patients may lower
the risk of complications
Cheng, WC, Block-Kurbisch, I. and Caughey, A. Carpenter-Coustan
Criteria Compared with the National Diabetes Data Group Thresholds
for Gestational Diabetes Millitus. Obstet and Gynecol. 2009; 114(2)326-
332
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IADPSG 2010
Made considerable changes to recommendations for screening
based primarily on the HAPO Study. Goal:
Achieve international consensus
Translate the HAPO data as it relates to improving perinatal morbidity
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IADPSG Recommendations 2010
Fasting Plasma
Glucose>92 mg/dl
1-Hour Plasma Glucose > 180 mg/dl
2-Hour plasma Glucose > 153 mg/dl
**One or more values must be exceeded.
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IADAPSG Screening
Recommendations
First prenatal visit
Measure FPG, A1C, or random plasma glucose on all or only high-risk women
1. If results indicate overt diabetes
Treatment and follow-up as for preexisting diabetes
2. If results not diagnostic of overt diabetes:
--and fasting plasma glucose ≥92 mg/dl but <126 mg/dl,
diagnose as GDM.
--and fasting plasma glucose <92 mg/dl, test for GDM from
24 to 28 weeks' gestation with a 75-g OGTT
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IADAPSG Screening
Recommendations
24–28 weeks' gestation: diagnosis of GDM
2-h 75-g OGTT: perform after overnight fast on all women not previously found to have overt diabetes or GDM during testing earlier in this pregnancy
1. Overt diabetes if fasting plasma glucose 126 mg/dl
2. GDM if one or more values equals or exceeds thresholds
3. Normal if all values on OGTT less than thresholds
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No evidence that these changes will lead to clinically significant improvements in maternal and neonatal outcomes.
Could significantly increase costs without improving perinatal, neonatal and maternal outcomes.
DO NOT recommend changing from the current 2-step process until more research is available.
ACOG Committee Opinion No. 504
Screening and Diagnosis of Gestational Diabetes Mellitus. Committee
Opinion Number 504. ACOG. Obstet Gynecol 2011; 118: 751-53
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Why do we care (clinical
relevance)?
• Fewer shoulder dystocias
• Fewer NICU admissions
• Decreased childhood and potentially adult obesity
• Less “Birth Trauma.”
• More inductions
• More interventions
• Potentially increased cost
• More patients who will be forced to eat a healthy and balanced diet