Diabetes in Pregnancy

Burden of Disease

Diabetes in Pregnancy: Epidemiology

Type 1 Diabetes4% Type 2 Di-

abetes8%

Gestational Di-abetes Mellitus

88%

Diabetes in Pregnancy 1995 CDC Data1

• 2%-10% of pregnancies currently are complicated by gestational diabetes mellitus (GDM)

• New diagnostic criteria estimated to increase rate to 18%2,3,4

• The prevalence of both GDM and type 2 diabetes mellitus have increased as obesity and sedentary lifestyle have increased in the United States5

• Pregnancies complicated by preexisting diabetes have increased substantially; most likely due to increased prevalence of T2DM in younger patients6,7

1. Engelgau, MM, et al. Diabetes Care. 1995;18(7):1029-33. 2. CDC. National Diabetes Fact Sheet 2011. CDC. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. 2011. Accessed: April 26, 2012. 3. ADA. What is Gestational Diabetes? ADA.

http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html. 2010. Accessed: April 26, 2012. 4. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 5. Chitayat L, et al. Diabetes Technol Ther. 2009;11:S105-111.

6. Pinhas-Hamiel O, Zeitler P. Pediatric Diabetes. 2007;8(9):16-27. 7. National Diabetes Education Program. Overview of Diabetes in Children and Adolescents. NIH. http://ndep.nih.gov/media/Youth_factsheet.pdf. June 2011. Accessed: April 26, 2012.

Risks Associated With Diabetes in Pregnancy

Maternal Risks Fetal Risks • Preeclampsia1

• Increased caesarean delivery1

• Subsequent development of T2DM1

• 30% maternal mortality rate2

• Progression of chronic complications of diabetes4

• Gestational hypertension5

• Hypoglycemia1

• Infection (eg, pyelonephritis)6,7

• Ketoacidosis6,7

• Polyhydramnios6,7

• Preterm labor6,7

• Seizures4,6

• Doubled spontaneous abortion risk4

• Maternal birth weight <4 lbs 7 oz9

• Birth injuries1,7

• Childhood obesity1,7

• Hyperbilirubinemi1,7

• Hypoglycemia1,7

• Macrosomia1,7

• Shoulder dystocia1,7

• Respiratory distress syndrome1,7 • Premature birth1,7

• Increased cord-blood serum C-peptide levels1,7

• Abnormal birth weight (low or high)4

• Increased risk of T2DM and/or GDM later in life8

• Increased congenital malformations4

Morbidity and Mortality

1. Committee on Obstetric Practice. ACOG. 2011;504:1-3. 2. Jovanovic L. Insulin therapy in pregnancy. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc; 2002:139-151. 3. Jovanovic L, Peterson CM. Diabetes

Care. 1982;5(1):24-37. 4. AACE. Endocr Pract. 2011;17(2):1-53. 5. Metzger BE, et al. Diabetes Care, 2007;30(2):S251- 60.6. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 7. Castorino K et al. Curr Diab Rep, 2012;12:53-59.

8. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 9. Inness KE, et al. JAMA. 2002;287(19):2534-41.

GDM: Pathophysiology

Gestational diabetes mellitus (GDM)

Combination of:• Glucose

intolerance• Hyperglycemia• Beta-cell

dysfunction2

Insulin resistance due to placental secretion of anti-

insulin hormones1

Late pregnancy:• Maternal hepatic glucose

production increases by 15%-30% to meet fetal demand1

Pancreatic beta-cell dysfunction caused by:• Genetics• Autoimmune

disorders• Chronic insulin

resistance1,2

1. Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40:703-26. 2. Metzger BE, et al. Diabetes Care. 2007;30(2):S251- 60.

GDM: Etiology and Risk Factors• Hormonally induced insulin resistance• Resulting in hyperglycemia• Eventually progresses into diabetes

Etiology

• Obesity• Previous history of GDM• Prior delivery of a large baby (>9 lbs)• Glycosuria• Family history of diabetes in a first-degree relative

Gestational diabetes mellitus

(GDM) risk factors1,2

• 5%-10% of women with GDM develop T2DM immediately postpartum6

• 35%-60% chance of T2DM over next 10-20 years6

• Risk increased with uncontrolled blood sugar in pregnancy5

Risk of future T2DM

1. American Diabetes Association. Diabetes Care. 2004;27(1):S88-S90. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 3. Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40:703-26. 4. Metzger BE, et al. Diabetes Care. 2007;30(2):S251- 60. 5.

Committee on Obstetric Practice. ACOG. 2011;504:1-3. 6. CDC. National Diabetes Fact Sheet 2011. CDC. Http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. 2011. Accessed: April 26, 2012 .

Cost-Effectiveness of New Screening Criteria

• International Association of the Diabetes and Pregnancy Study Groups (IADPSG) has proposed new screening criteria for gestational diabetes mellitus (GDM)– For every 100,000 women screened under the updated

criteria, 6,178 quality-adjusted life-years (QALYs) will be gained at a cost of approximately $126 million

– Compared with current GDM screening practices, the new IADPSG strategy has an incremental cost-effectiveness ratio (ICER) of $20,336 per QALY gained

1. Werner EF, et al. Diabetes Care. 2012;35:529-35.