critical evaluation of the diagnosis of gestational diabetes mellitus (gdm)

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Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM) Diabetes Mellitus (GDM) Simon Weitzman, MD, MPH Simon Weitzman, MD, MPH

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Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM). Simon Weitzman, MD, MPH. Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM). Diagnostic methods and criteria Screening strategies Maternal and offspring outcomes. - PowerPoint PPT Presentation

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Page 1: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)

Simon Weitzman, MD, MPHSimon Weitzman, MD, MPH

Page 2: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)

Diagnostic methods and criteriaDiagnostic methods and criteria

Screening strategiesScreening strategies

Maternal and offspring outcomesMaternal and offspring outcomes

Page 3: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)

Diagnostic methods and criteriaDiagnostic methods and criteria

Screening strategiesScreening strategies

Maternal and offspring outcomesMaternal and offspring outcomes

Page 4: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Diagnostic Methods for GDMDiagnostic Methods for GDM

1-hr. Oral Glucose Challenge Test 1-hr. Oral Glucose Challenge Test (GCT)(GCT)

Oral Glucose Tolerance Test (OGTT)Oral Glucose Tolerance Test (OGTT)World Health Organization (WHO)World Health Organization (WHO)

National Diabetes Data Group (NDDG)National Diabetes Data Group (NDDG)

Coustan ModificationCoustan Modification

Page 5: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Diagnostic criteria for GDMDiagnostic criteria for GDM

MethodMethod Criteria (mg/dl) Criteria (mg/dl) FPG 1 hr. 2 hr. 3 hr.FPG 1 hr. 2 hr. 3 hr.

WHO (75 gr)WHO (75 gr) 140 140 - 200 - - 200 -

NDDG (100 gr)NDDG (100 gr) 105 190 165 145 105 190 165 145

Coustan (100 gr) 95 180 155 140Coustan (100 gr) 95 180 155 140

FPG: Fasting plasma glucoseFPG: Fasting plasma glucose

Page 6: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)

Diagnostic methods and criteriaDiagnostic methods and criteria

Screening strategiesScreening strategies

Maternal and offspring outcomesMaternal and offspring outcomes

Page 7: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Screening strategies for GDMScreening strategies for GDM

The approachThe approach

One-step approachOne-step approach

Two-step approachTwo-step approach

Page 8: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

The 50 gr. GCT (Cutoff The 50 gr. GCT (Cutoff >>186 mg/dl)186 mg/dl)

Sensitivity: 38.2%Sensitivity: 38.2% Specificity: 93.3%Specificity: 93.3%

Positive Predictive Value: 78.6 %Positive Predictive Value: 78.6 % Negative Predictive Value : 70.0 %Negative Predictive Value : 70.0 %

Page 9: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

The 50 gr. GCT (Cutoff The 50 gr. GCT (Cutoff >>186mg/dl)186mg/dl)

Sensitivity: 38.2%Sensitivity: 38.2% Specificity: 93.3%Specificity: 93.3%

Positive Predictive Value:19.5%Positive Predictive Value:19.5% Negative Predictive Value: 97.2%Negative Predictive Value: 97.2%

Page 10: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Screening strategies for GDMScreening strategies for GDM

The populationThe population

Universal screeningUniversal screening

High risk groups screeningHigh risk groups screening

Page 11: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Universal versus high risk strategyUniversal versus high risk strategy

Universal screeningUniversal screening• 57.4% agreed to screening57.4% agreed to screening• 27.7 % GCT positive have abnormal 27.7 % GCT positive have abnormal

OGTTOGTT• Non-participants have more risk Non-participants have more risk

factorsfactors

High Risk Group ScreeningHigh Risk Group Screening•Would miss > 40% of GDMWould miss > 40% of GDM

Page 12: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Universal screening in the NegevUniversal screening in the Negev

70 % of Jewish and 57% of Bedouins 70 % of Jewish and 57% of Bedouins agreed to screeningagreed to screening

GCT only in 49% of womenGCT only in 49% of women OGTT only in 10%OGTT only in 10% Overall non- participation: 40%Overall non- participation: 40%

Page 13: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)

Diagnostic methods and criteriaDiagnostic methods and criteria

Screening strategiesScreening strategies

Maternal and offspring outcomesMaternal and offspring outcomes

Page 14: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Influence of GDM on the later Influence of GDM on the later development of diabetes in the childdevelopment of diabetes in the child

Hyperglycemia affects fetal beta-cell Hyperglycemia affects fetal beta-cell function in animalsfunction in animals

Intrauterine nutritional deprivation and Intrauterine nutritional deprivation and maternal hyperglycemia increase the maternal hyperglycemia increase the risk of diabetes in later liferisk of diabetes in later life

Page 15: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Maternal and offspring Maternal and offspring outcomesoutcomes

Characteristic Normal OGTT GDM Characteristic Normal OGTT GDM LGA (%)LGA (%) 34 34 38 38

Gestational age (w) 39Gestational age (w) 39 39.2 39.2

Hospital daysHospital days 3.7 3.9 3.7 3.9

Page 16: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Perinatal characteristics of women Perinatal characteristics of women with GDM, according to risk factorswith GDM, according to risk factors

Characteristic Risk Factors OR(Characteristic Risk Factors OR(95%CI) 95%CI) Yes NoYes No

Cesarean section (%) 38Cesarean section (%) 38 35 1.6 (0.7-3.7) 35 1.6 (0.7-3.7)

Macrosomia (%)Macrosomia (%) 33 33 17 17 2.4 (0.9-6.7) 2.4 (0.9-6.7)

Shoulder Dystocia (%) 7 13 0.5 (0.1-2.1)Shoulder Dystocia (%) 7 13 0.5 (0.1-2.1)

Insulin therapyInsulin therapy (%) 30 28 1.1 (0.4-2.7)(%) 30 28 1.1 (0.4-2.7)

Page 17: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Plasma glucose levels in non obese, and obese Plasma glucose levels in non obese, and obese women with previous GDM, after 5-10 years of women with previous GDM, after 5-10 years of follow-upfollow-up

0

5

10

15

0 30 60 90 120 150

Controls

NOpGDM

OpGDM

Time (min)

Plasma glucose (mmol/l)

Page 18: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Plasma insulin levels in non obese and obese Plasma insulin levels in non obese and obese women with previous GDM, after 5-10 years of women with previous GDM, after 5-10 years of follow-upfollow-up

0

200

400

600

800

0 30 60 90 120 150

Controls

NOpGDM

OpGDM

Time (min)

Plasma insulin (pmol/l)

Page 19: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Logistic regression analysis of factors relatedLogistic regression analysis of factors related to the to the development of diabetes in women with previous development of diabetes in women with previous GDMGDM

95% CIOddsratio

Factor

1.83-26.246.94Fasting glucose atdiagnosis

1.08-9.233.150-120 min glucose AUC atpostpartum OGTT

1.13-22.505.260-60 min insulin AUC atdiagnostic OGTT

Page 20: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Glucose tolerance at follow-up in women Glucose tolerance at follow-up in women with previous GDM and healthy controlswith previous GDM and healthy controls

Controls(n=27)

GDM(n=139)

Status atfollow-up

88.9 (24)64.7 (90)Normal OGTT

11.1 (3)20.1 (28)IGT

--------10.8 (15)Type 2 DM

--------4.3 (6)Type 1 DM

Page 21: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

ConclusionsConclusions

J. Nerup said that Type 1 diabetes is J. Nerup said that Type 1 diabetes is the nightmare of geneticists. the nightmare of geneticists. Paraphrasing his statement, we can say Paraphrasing his statement, we can say that GDM is the nightmare of that GDM is the nightmare of epidemiologists. There is controversy epidemiologists. There is controversy about its definition, the best diagnostic about its definition, the best diagnostic method, diagnostic criteria, and the method, diagnostic criteria, and the population to be screened.population to be screened.

Page 22: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Conclusions (2)Conclusions (2)

Despite this confusion, the management Despite this confusion, the management of the condition has greatly improved, of the condition has greatly improved, and the perinatal outcomes of and the perinatal outcomes of offspring's of GDM mothers are offspring's of GDM mothers are comparable to those of non-diabetic comparable to those of non-diabetic women, except for macrosomia.women, except for macrosomia.

Page 23: Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Conclusions(3)Conclusions(3)

There is an increasing body of evidence There is an increasing body of evidence supporting the risk of developing supporting the risk of developing diabetes mellitus (and particularly type 2 diabetes mellitus (and particularly type 2 diabetes) among women with previous diabetes) among women with previous GDMGDM

Among obese GDM women, even years Among obese GDM women, even years after delivery, features of insulin after delivery, features of insulin resistance can be foundresistance can be found