east coast working group on diabetes in pregnancy

7/27/2019 East Coast Working Group on Diabetes in Pregnancy

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Screening & Diagnosis



ACHOIS (2005) : treating mild hyperglycemia(glucose intolerance) in pregnant women leadsto reduction in the composite endpoint of perinatal death, shoulder dystocia, bonefracture and nerve palsy



Landon et al (2009) : similarly demonstrated areduction in macrosomia, shoulder dystocia,cesarean delivery, and hypertensive disorderswith treatment.



HAPO (2008) a prospective, blinded, multinationalobservational study

a continuous association between rising maternal glucose concentrations and large for gestational

age, pre-eclampsia, and primary cesarean section.positive association between maternal hyperglycemia and neonatal hypoglycemia, cordblood serum c-peptide, premature delivery,

intensive neonatal care, and hyperbilirubinemia



1. Treatment of GDM will improve perinataloutcome (not perinatal mortality)

2. Glucose levels for diagnosis of GDM (after GTT)

are lower than previously thought.



Screening methods: selective vs universalScreening protocol : timing

Classification of diagnosis

Diagnostic threshold



Organization Screening

ACOG (2001) American

College of Obstetricians

and Gynecologists

Risk assessment or perform universal screening at 24 –28

wks.

Low risk patients may be excluded from screening.

Screen with 50-g 1-h GCT.

Positive if 1-h > 7.2 mmol/l (130 mg/dl) or 7.8 mmol/l (140mg/dl)

Diagnose with 100-g OGTT.

SOGC (2002) Society of

Obstetricians and

Gynaecologists of Canada

Each of the following approaches is acceptable:

Routine screening at 24 –28 wks with 50-g GCT, using

threshold of 7.8 mmol/l (140 mg/dl) except in low risk

patients.Non-screening is also acceptable.

Consider the recommendations given by the Fourth

International Workshop-Conference for screening women

at high riskfor GDM early in pregnancy and again at 24 –28

wks if initial results are negative




5th International

Workshop-Conference

on Gestational

Diabetes Mellitus(2007)

Risk assessment should be performed at the first prenatal

visit.

Low risk women do not require any routine testing.

High risk women should undergo screening as soon aspossible (as below).

All other women should have screening at 24 –28 wks.

Screening can be done as 50-g GCT followed by diagnostic

OGTT if abnormal.

Abnormal if 1-h 7.8 mmol/l (140 mg/dl)

Or proceed directly to a diagnostic OGTT.




USPSTF (2008) U.S.

Preventive Services

Task Force

No recommendation made for routine screening due to

insufficient evidence.

Until there is better evidence, clinicians should discussion

screening with patients and make case-by-base decisions.

If a decision is made to screen for gestational diabetes, they

cite most screening is done between 24 and 28 wks and the50-g GCT is the most common test used in the United States

followed by the 100-g OGTT for confirmation.

NICE UK (2008) National

Institute for Health and

Clinical Excellence, UnitedKingdom

Perform risk assessment at the initial visit.

Women with any risk factors should be offered testing for

GDM.If a woman has had GDM in a prior pregnancy, she should be

offered SMBG at 16 –18 wks and repeat OGTT at 28 wks if

initial testing is normal.

Women without risk factors should be offered an OGTT at

24 –28 wks. Screen using the 75-g OGTT




ADA (2010) American

Diabetes Association

Risk assessment should take place at the first prenatal visit.

Do not screen low risk women.Screen high-risk women at the initial visit to identify pre-gestational

diabetes.

If negative at first visit, high risk women should be retested at

24 and 28 wks.Women of average risk should be universally screened

between 24 and 28 wks.Initial screening:

-hemoglobin A1c by NGSP-certified, standardized method, fasting

plasma glucose, 1 step 75-g OGTT with 2-h glucose level, or random

plasma glucose in a patient with classic symptoms of hyperglycemia2-step approach: Perform a 50-g glucose challenge test and if 1-h

plasma or serum glucose move on to either the 100-g OGTT or the 75-

g OGTT for diagnosis.

1-step approach: 75-g OGTT; this approach may be cost-effective in

high-risk>130 mg/dL or > 140 mg/dl, populations



Pregnant women should be screened if they have any of the following risk factors:

BMI >27kg/m

Previous macrosomic baby weighing 4kg or above

Previous gestational diabetes mellitus (GDM)

First-degree relative with diabetes

Bad obstetric history

Glycosuria at the first prenatal visitCurrent obstetric problems (essential hypertension,pregnancy induced hypertension, polyhydramnios andcurrent use of steroids)

Age above 25



Screening is done using the 75g OGTT andperformed at least once at >24 weeks of gestation

Screening at an earlier stage of gestationdepends on the degree of suspicion and at thephysician’s/obstetrician’s request.



Screen for risk

factor(s)

MGTT after 12-14 weeks or

as soon as risk identifiedRepeat test at 28-30 weeks

of gestation



Screen for risk factor(s)

75 gm OGTT

At or after 28-30 weeks of

gestation

Normal

Gestational

Diabetes

mellitus

present

absent

positive

positive

negative

negative

75gm OGTT



Selective vs Universal



Organisation Selective Universal

ACOG (2001) American College of Obstetriciansand Gynecologists

SOGC (2002) Society of Obstetricians and

Gynaecologists of Canada

X X/

5th International Workshop-Conference

on Gestational Diabetes Mellitus (2007)

USPSTF (2008) U.S. Preventive Services

Task Force

X X

NICE UK (2008) National Institute for Health and

Clinical Excellence, United Kingdom

ADA (2010) American Diabetes Association *

CPG Management of Type 2 DM 2009

Perinatal Care Manual



> 7.0 mmol/l

Overt Diabetes inPregnancy

>5.1 mmol/l but

<7.0 mmol/l

75-g OGTT at 24 to28 weeks’ gestation

GestationalDiabetes

<5.1 mmol

At booking

Measure FPG, HbA1C, or random plasma glucoseon all or only women high-risk



Selective screening: risk assessmentOGTT upon identification of risk factor



• GDM complicates approx 7% of all pregnanciesin US (Nicholson W, 2009)

• NICE (2008) = average prevalence in Englandand Wales is approximately 3.5%



Study Prevalance

Fuziah Paimin et al, 2011(unpub)

19.4%

Idris N et al, 2009 18.4%

Shamsuddin K, 2001 24.9%

Chan S, 1993 12.5%



Idris N et al (2009), screening of GDM asrecommended by Malaysian CPG 2009/ADA willresult in 90% of patient being screened




75 gm OGTT


gestation

Normal

Gestational

Diabetes

mellitus

present

absent

positive

positive

negative

negative

75gm OGTT



Timing



OGTT should be prescribed once risk factorsidentified

If at risk

repeat GTT.



Organization Screening design

ADIPS (1998) The Australasian Diabetes in

Pregnancy Society

Screen at 26 –30 wks.

WHO (1999) World Health

Organization

If high risk, screen in first trimester.

All others, screen at 24 –28 wks.

ACOG (2001) American College of

Obstetricians and Gynecologists

Risk assessment or perform universal

screening at 24 –28 wks.

SOGC (2002) Society of Obstetricians and

Gynaecologists

of Canada

Routine screening at 24 –28 wks with 50-g GCT

Japan (2002) The Committee of the Japan

Diabetes Society

Screen all at 24 –28 wks.



Organization Screening design

Austrian (2004) Screen all at 24 –28 wks.

Joslin Diabetes Center (2005) Screen average-risk women at 24 –28 wks.

AACE (2007) American Association of Clinical

Endocrinologists

Screen low-risk women at 24 –28 wks.

NICE UK (2008) National Institute for Health

and Clinical Excellence,United Kingdom

Women without risk factors should be offered

an OGTT at 24 –28 wks.

ADA (2010) American Diabetes

Association

High risk women should be retested at 24 and

28 wks

Average risk should be universally screened

between 24 and 28 wks




75 gm OGTT


gestation

Normal

Gestational

Diabetes

mellitus

present

absent

positive

positive

negative

negative

75gm OGTT



PPVs for risk factors :First-degree relative with type 2 diabetes 6.7%,

First-degree relative with type 1 diabetes 15%,

Previous macrosomic baby (more than 4500 g)

12.2%

Glycosuria in current pregnancy 50%

Macrosomia in current pregnancy 40%

Polyhydramnios in current pregnancy 40%

Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening

for gestational diabetes mellitus: detection rates, gestation at diagnosis and

outcome. Diabetic Medicine 2000;17(1):26–

32



OR for GDMPrevious gestational diabetes (OR 23.6, 95% CI 11.6to 48.0)

Previous macrosomic baby (OR 5.59, 95% CI 2.68 to

11.7)Family history of diabetes (OR 2.74, CI 1.47 to 5.11)

Age 25 years or more (OR 3.37, 95% CI 1.45 to 7.85)

Ostlund I and Hanson U. Occurrence of gestational diabetes mellitus and the value of

different screening indicators for the oral glucose tolerance test. Acta Obstetricia et

Gynecologica Scandinavica 2003;82(2):103–

8



Prescribe 75 gm OGTT in presence of (any of thefollowing risk factors)

BMI >27kg/m

Previous macrosomic baby weighing 4kg or above

Previous gestational diabetes mellitus (GDM)First-degree relative with diabetes

Bad obstetric history (recurrent miscarriages,unexplained stillbirth, diabetic related birth defect)*

Glycosuria at the first prenatal visitCurrent obstetric problems (essential hypertension,pregnancy induced hypertension, polyhydramnios andcurrent use of steroids)

Age above 25



The International Workshop-Conferences on GDM(2007) have defined the condition as “any degreeof glucose intolerance with onset or firstrecognition during pregnancy”

While this facilites screening and diagnosis,management of undetected glucose intoleranceantedated the pregnancy might be misjudged.



Current practice1. Gestational diabetes mellitus – diagnosed in

pregnancy

2. Established DM – diagnosed before pregnancy

*DM – diagnosed in pregnancy

*GDM – managed as established DM



Increased risk of congenital anomalies inoffspring (Schaefer et al, 1997).

Risk of diabetes complications (nephropathyand retinopathy) requiring treatment during

pregnancy (Omori & Jovanovic, 2005).Need for rapid treatment and close follow-upduring pregnancy to ensure prompt restorationof normal glycemia (Bartha et al, 2000; Maegawa et al,

2003).Need to ensure confirmation and appropriatetreatment of diabetes after pregnancy.



•Increasing prevalence of T2DM in Malaysiayounger female (in reproductive agegroup)higher risk of overt diabetes inpregnancy

• In Metabolic Study In Malaysia (May 2010) prevalence of T2DM in Malaysia (based on

OGTT) is 22.3%



Classification of diabetes mellitus in pregnancy

1. Established diabetes mellitus

2. Overt diabetes in pregnancy (1st

diagnosed inpregnancy, but probably pre-pregnancy DM)

3. Gestational diabetes mellitus



Time

Venous plasma glucose level (mmol/l)

Normal Diabetes mellitus

Fasting <5.6 >5.6

2 hours <7.8 >7.8



IADPSG, 2010



Overt diabetes in pregnancy = fasting plasmaglucose > 7 mmol/L

Gestational diabetes mellitus = at least one of the following

FPG = > 5.1 mmol/L

1 hour PG = > 10.0 mmo/L

2 hours PG = > 8.5 mmol/L



75 gm oral glucose tolerance test3 days of normal diet

Fasting for at least 8 hours before the test

75gm glucose in 250 mls water to be finished in 10-15minutes

Rest during the 2 hours (of test procedure)



75 gm OGTT Overt DM

GDM

Normal

75 gm OGTT Overt DM

GDM

Normal

……………………………………………………………………………………………………..

Antenatal

booking& all visits

24-28

weeks

gestation



1. Screen the high risk women for diabetes in pregnancy atthe first and every antenatal encounters

2. Women at risk should undergo a 75 gm OGTT andplasma venous glucose testing at 0 (fasting state), 1 and2 hours post glucose load

3. Any one of the abnormal readings can be used in thediagnosis (of gestational diabetes mellitus)

4. Overt diabetes in pregnancy is diagnosed base on fastingplasma glucose

5. Those at risk and tested negative (for diabetes inpregnancy) on the initial encounter, should be re-testedat 24-28 weeks of gestation



Dr Norhayati Yahaya

Dr Nurain Mohd Noor

Prof Mohd Shukri OthmanDr Iskandar Firzada Osman

Dr Khatijah Abd Rahman

AP Dr. Che Anuar Che Yaakob

Dr Zahar Azuar ZakariaDr Jusoh Senik

Dr Kamilah Mohamed

Dr Yazeed Zainal AbidinDr Nik Norashikin Nik AbdulRahman

Dr Jumizah Abd Kadir



1. Detection rate2. Cost

3. Human resource

4. Training



• Schaefer UM, Songster G, Xiang A, Berkowitz K, Buchanan TA,

Kjos SL. Congenital malformations in offspring of women withhyperglycemia first detected during pregnancy. Am J ObstetGynecol 1997;177:1165 –1171

• Omori Y, Jovanovic L. Proposal for the reconsideration of the

definition of gestational diabetes. Diabetes Care 2005; 28:2592 –2593

• Bartha JL, Martinez-Del-Fresno P, CominoDelgado R. Gestational

diabetes mellitus diagnosed during early pregnancy. Am JObstet Gynecol 2000;182:346 –350

• Maegawa Y, Sugiyama T, Kusaka H, Mitao M, Toyoda N.Screening tests for gestational diabetes in Japan in the 1st and2nd trimester of pregnancy. Diabetes Res Clin Pract 2003;62:47 –



• Ostlund I and Hanson U. Occurrence of gestational diabetesmellitus and the value of different screening indicators forthe oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103– 8

• Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk

factor-based screening for gestational diabetes mellitus:detection rates, gestation at diagnosis and outcome.Diabetic Medicine 2000;17(1):26– 32

• Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM,

Casey B et al. A multicenter, randomized trial of treatmentfor mild gestational diabetes. N Engl J Med 2009; 361(14):1339 –1348.



• Nicholson W, Bolen S, Witkop CT, Neale D, Wilson L, Bass E.

Benefits and risks of oral diabetes agent compared with insulin inwomen with gestational diabetes: a systematic review. ObstetGynaecol 2009; 113:193-205

•Crowther CA, Hiller JE, Moss JR, et al.; Australian CarbohydrateIntolerance Study in Pregnant Women (ACHOIS) Trial Group.Effect of treatment of gestational diabetes mellitus on pregnancyoutcomes. New England Journal of Medicine2005;352(24):2477 – 86.

• O'Sullivan JB & Mahan CM. Criteria for the oral glucose tolerancetest in pregnancy. Diabetes 1964; 13: 278 –285



• HAPO Study Cooperative Research Group. Hyperglycemia andadverse pregnancy outcomes. N Engl J Med 1991-2002; 2008:358

• International Association of Diabetes and Pregnancy Study

Groups. International Association of Diabetes and PregnancyStudy Groups recommendations on the diagnosis andclassification of hyperglycemia in pregnancy. Diabetes Care 2010;33(3): 676 –682

• N Idris, CH Che Hatikah, MZ Murizah, MN Rushdan. UniversalVersus Selective Screening For Detection Of Gestational DiabetesMellitus In A Malaysian Population, Malaysian Family Physician2009; Volume 4, Number 2



• Shamsuddin K, Mahdy ZA, Rafiaah SI, Jamil MA. Risk Factorscreening for abnormal glucose tolerance in pregnancy.International Journal of Gynecology and Obstetric 2001;75:27-32

• Chan S. Prevalence of GDM in Malaysia. ASGODIP Report:

ASEAN, 7th Congress of ASEAN Federation of Endocrine Society,1993

• Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey

B et al. A multicenter, randomized trial of treatment for mildgestational diabetes. N Engl J Med 2009; 361(14): 1339 –1348

east coast working group on diabetes in pregnancy

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