gdm- why it is important. professor fidelma dunne md phd frcp frcpi consultant endocrinologist...

GDM- why it is important.

Professor Fidelma Dunne MD PhD FRCP FRCPI

Consultant Endocrinologist

Saolta University Hospital Group and National University of Ireland Galway Ireland.

Gestational Diabetes (GDM)

• GDM detects an at-risk pregnancy for mother.

• GDM detects an at risk pregnancy for the infant.

• GDM is associated with increased future maternal life-time risk of Type 2 DM (50%).

• GDM is associated with increased rates of obesity and pre-diabetes in adolescents and type 2 DM in adult life of the offspring.

• DIABETES BEGETS DIABETES.

Why are we concerned about GDM?

Mother

• PIH/PET

• CS delivery

• Future Diabetes

• Obesity

• MetS/CVS

Infant

• Macrosomia.

• Hypoglycaemia/NNU

• Future Diabetes

• Future Obesity

• Autism

• Fatty Liver

School Institute Name to go here

What global factors are contributing to increased GDM prevalence?

• Prevalence of Type 2 DM; NHANES 4.6% (18-44 y).

• Prevalence of pre-diabetes NHANES 26.4% (18-44 y).

• Prevalence of Obesity, 20-30% global estimates.

• Rising maternal age for pregnancy.


GDM- Can we make a difference?

• Screening is easy and not costly.

• Interventions are low key for the majority.

• Treatments make a difference.

• Future maternal Type 2 DM can be prevented.

• Future maternal CVS risk can be addressed.

• Family health can influence offspring health.


Macrosomia

Who should we screen?How should we screen?

Who?

• Universal

• Selective


How?

• IADPSG/ WHO 2014---Perinatal outcomes

• Carpenter & Coustan--- Future Diabetes Risk

• NICE 2015--- Cost


Socio-Economic Status

1. Womens’ addresses were ‘geocoded’.

Geocoding = Assigning geographic coordinates (longitude-latitude) to each address.

Distance from test hospital

• For every 10km required to travel, the probability of attending for screening is reduced by 2%

• e.g. If you live 50km away from hospital, you are 10% less likely to attend

• If you like 100km away you are 20% less likely to attend.

Deprivation Score

• Correlation study:

Relative to Deprivation score 1, ie ‘wealthiest’;

Score 2: 2.3% less likely to attend p=0.138



Score 5:14.5% less likely to attend p=0.0001

Results: Primary v Secondary uptake rates

• Secondary care group significantly more likely to attend at their randomised location (p < 0.001)

School of Medicine National University of Ireland, Galway

Preventing GDM


4 individual risk factors


Combining risk factors


Exercise pre-pregnancy


Exercise in early pregnancy


Treatment of GDM?

• MNT and Exercise (70%)

• Insulin (30%)

• Metformin (NICE)

• Glibenclamide (ACOG)


Is treatment beneficial?


Shoulder Dystocia


Macrosomia


Preeclampsia


What dietary intervention works?


Diet and Exercise interventions in GDM- does it work?

The Atlantic DIP dataset was utilized:

N = 567 women with GDM. (D+E)

N = 2499 with NGT.

Differences in Characteristics

GDMN = 567

NGTN = 2499

P value

Age(mean =/-sd)

33.4 (4.9) 31.5(5.2) <0.01

BMI(mean+/-sd)

30.5 (6.1) 26.7 (4.8) <0.01

BMI>30N (%)

279 (49%) 522 (21%) <0.01

SBP(mean+/-sd)

119.7 (13.3) 116.3 (17.1) <0.01


Differences in infant size

GDMN =567

NGTN = 2499

P value

LGA(>90th C)

BMI <25BMI 25-30BMI>30

9.4%10.4%15.1%

12.2%16.0%21.8%

0.40.060.02

Macrosomia(> 4kg)

BMI <25BMI 25-30BMI>30

7.5%11.0%17.6%

16.5%21.8%27.0%

0.020.010.01


Composite Poor Neonatal Outcome

• OR 0.79 (CI 0.64-0.98) P 0.03

• 21% less likely to have an adverse outcome


Gestational weight gain in GDM?

• Is it important?


Institute of Medicine Guidelines for Gestational Weight Gain

Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines; Rasmussen KM YA, editors: Weight Gain During Pregnancy: Reexamining the Guidelines. 2009.

57% women gained excessive weight (n=307).

Contrasts with prior studies in non-diabetic women (33%).1

1. Nohr et al. Am J Clin Nutr, 2008

57%

43%

Rate of excessive GWG

excessive GWG

non-excessive GWG

Glucophage ?

• Used in South Africa in Type 2 DM since 1970. Perinatal mortality similar.

• Used extensively with PCOS with no adverse outcomes (Tang 2010).

• 3 systematic reviews and meta analysis (Gutzin 2003; Gilbert 2006; Juan Gui 2013; favour metformin re GWG, LGA, PIH, PET.

• Less macrosomia in N/OW women (Ljas 2011).


What are the health risks post GDM?


Abnormal glucose tolerance status at follow-up

Glucose tolerance

status

Previous GDM

(n=270)

Previous NGT

(n= 388)

p value for

difference

IFG 12.2% 1.8%

IGT 5.9% 1.5%

IFG/IGT 5.6% 0.3%

DM 2.2% 0%

Total 25.9% 3.6% <0.001

Comparison of HbA1c and FPG to identify abnormal glucose post partum

Criteria Sensitivity

(95% CI)

Specificity

(95% CI)

PPV

(95% CI)

NPV

(95% CI)

not requiring OGTT

N(%)

HbA1c 5.7% 45

(32, 59)

84

(78,88)

39

(27,52)

87

(82,91)

206

(78)

FPG 5.6 mmol/l 80

(66, 89)

100

(98, 100)

100

(91, 100)

96

(92, 98)

224

(85)

HbA1c 5.7% and FPG 5.6mmol/L

90

(78, 96)

84

(78, 88)

56

(45, 66)

97

(94, 99)

184

(70)

Metabolic syndrome (MetS), obesity and insulin resistance indices at follow-up (mean 2.6 years)

Waist circum-ference

BP HDL Triglycerides Fasting glucose0

50

100

54.7

38.9

32.5

20.415.1

31.2

15.6 14.8

6.11.9

GDM by IADPSG criteria

NGT by IADPSG criteria

Pre

vale

nce

(%

)

Metabolic syndrome components (ATP-III) at follow-up (mean 2.6 years)

Feig D. PLOS medicine 2013

Can we prevent Type 2 DM?


Prevention Type 2 following GDMDPP Aroda VR. JCEM 04/2015

• DPP 3 year data; ILS reduced by 53%, metformin by 50%

• DPP 10 year data; ILS reduced by 35%, metformin by 40%

• Both ILS and metformin (850mg BD) are effective in reducing progression to Diabetes


Preventing Type 2 DM after GDMBao W. Diabetologia 03/2015 N =1695

• Over 18 year F/U period

• Each 5kg increase in weight after index GDM pregnancy associated with 27% higher risk of T2DM.

• Postpartum weight management essential


Summary

• GDM is common.

• Dietary intervention works.

• Breast feeding should be encouraged.

• Diabetes post GDM is a public health concern but can be prevented.

• Metabolic syndrome and future CVS risk post GDM is a public health concern and requires F/U.

• A strong screening programme is essential.

• Integrated care is required.


gdm- why it is important. professor fidelma dunne md phd frcp frcpi consultant endocrinologist...

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