postpartum gestational diabetes: opportunities for screening for type 2 diabetes

Postpartum Gestational Diabetes:

Screening Opportunities

for Type 2 DiabetesIris Thiele Isip Tan MD, MSc, FPCP, FPSEM

Assoc Prof. 4, UP College of MedicineChief, UPCM Medical Informatics Unit

Section of Endocrinology, Diabetes & Metabolism Dept. of Medicine, Philippine General Hospital

“Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783

2012 Diabetes Philippines Annual ConventionEDSA Shangrila Hotel 14 Nov 2012

Sunday, November 18, 12

http://www.sxc.hu/photo/1344783


Is GDM the forme fruste of diabetes?

forme fruste partial, arrested or inapparent form of the disease

“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563




Natural History of Type 2 DiabetesDe Fronzo RA, Diabetes 2009


Women developing GDM had lower pregravid insulin sensitivity Landon et al 2001







GDM: increased fasting insulin concentrations in late gestation Landon et al 2001







GDM: decreased insulin response to glucose challenge in late pregnancy Xiang AH et al Diabetes 1999







GDM: lower insulin response for degree of insulin resistance Homko et al Diabetes 2001







GDM: Diabetes in Evolution





Gestational diabetes is an independent risk factor for diabetes in Filipino-Americans

Cuasay et al Diabetes Care 2001

Risk factor OR 95% CIAge (y)

35-44 10.79 1.00-16.8345-54 16.17 1.42-184.0355-64 14.65 1.09-97.70

65 and older 38.68 2.27-659.89

Gestational diabetes 21.65 6.73-69.67Delivery of baby >9 lb 1.51 0.39-5.84Family history of diabetes 2.22 0.92-5.35Obesity 2.85 0.53-15.4



When & how to screen

Barriers to screening

Interventions to improve screening




Metabolic assessments recommended after GDM

Metzger BE et al, Summary & Recommendations of the 5th International Workshop on GDM. Diabetes Care 2007

Time Test Purpose

Post-delivery (1-3 days) Fasting or random plasma glucose

Detect persistent, overt diabetes

Early postpartum (around the time of postpartum visit)

75-g 2-h OGTT Postpartum classification of glucose metabolism

1 year postpartum 75-g 2-h OGTT Assess glucose metabolismAnnually Fasting plasma glucose Assess glucose metabolismTri-annually 75-g 2-h OGTT Assess glucose metabolismPrepregnancy 75-g 2-h OGTT Classify glucose metabolism


Postpartum Screening for Diabetes Among Women with a History of

Gestational DiabetesSystematic Review

Tovar A et al, Prev Chronic Dis 2011;8(6):A124

“paper” by v_g, http://www.sxc.hu/photo/77779

11 studies (2008-2010) on rates & results of postpartum screening

n = 32,240 GDM(1999-2008)




“dream graph” by iamwahid, http://www.sxc.hu/photo/1209643

Postpartum Screening for Diabetes Among

Women with a History of Gestational Diabetes

Systematic ReviewTovar A et al, Prev Chronic Dis 2011;8(6):A124

34%-73% (median 48%)

screened




Postpartum screening not improved over time




50.3% within 3 mos 48.2-51% within 6 mos55.9% within 12 mos

“calendario” by malko, http://www.sxc.hu/photo/750005







“Injection time” by adamci, http://www.sxc.hu/photo/250620

79-100% screened with FPG (4 studies)56-95% screened with OGTT (3 studies)




“Injection time” by adamci, http://www.sxc.hu/photo/250620

Using only FPG in postpartum screening

will miss up to 75% of women with IGT or type 2 diabetes

Kwong et al Diabetes Care 2009

Single FPG sensitivity of 16% to 89% vs OGTTTovar et al Prev Chronic Dis 2011

Isolated IGT 1/3 of GDM cohort with DM or prediabetesHunt & Conway Am J Obstet Gynecol 2008




Patient barriers Henderson et al The Open Diabetes J 2012

Time pressure as primary barrier

Cost or inconvenience

Unaware of risks

Unaware of proven methods to prevent or delay diabetes

“Time slipping away 1” by chriki7274, http://www.sxc.hu/photo/723865




Barriers & facilitators of postpartum follow-up care in previous GDMBennett et al J Women’s Health 2011

Barriers Baby’s health needsPersonal and family adjustment to baby (emotional stress/feeling overwhelmed, demands of baby’s schedule/lack of time for self-care, child care needs)

Concerns about postpartum and future health (perception of good health and not needing further care, fear of receiving bad news at follow-up appointment)

Experiences with medical care (dissatisfaction with care, logistics of accessing care)

“duckie 1” by ppreacher, http://www.sxc.hu/photo/299965




Barriers & facilitators of postpartum follow-up care in previous GDMBennett et al J Women’s Health 2011

Facilitators Availability of child careCheck-up and clearance for return to workConnection with clinical and office staffAddress specific concerns or questionsDiscuss family planning

“businesswoman 1” by CELALTEBER, http://www.sxc.hu/photo/1305802




Postpartum Screening for Diabetes Among Women with a History of

Gestational DiabetesSystematic Review

Tovar A et al, Prev Chronic Dis 2011;8(6):A124

“paper” by v_g, http://www.sxc.hu/photo/77779

21 studies (2008-2010)on predictors of & barriers to screening




“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902

Provider barriers Tovar et al Prev Chronic Dis 2011

lack of attendance at postpartum visithowever94% postpartum Pap smear vs 67% glucose testing (37% FPG or OGTT)





Provider barriers Henderson et al The Open Diabetes J 2012

clinician’s perception that screening guidelines were “inconsistent”




Postpartum screening recommendations for women with GDMCanadian Diabetes Association (2008)75-g OGTT 6 wks-6 mos postpartumPre-pregnancy screening for T2D

WHO75-g OGTT >6 wks postpartum

American Diabetes Association (2008)FPG or 75-g OGTT Annual repeat testing if IFG/IGT detected; q3 y if normal

American College of Obstetricians & Gynecologists (2009)FPG or OGTT

“worried man against white background” by bigevil600, http://www.sxc.hu/photo/1000622





Provider barriers Henderson et al The Open Diabetes J 2012

lack of documentation of GDM on problem listspoor communication between OB and primary care




Who should follow up GDM postpartum?

2008 ACOG survey: OB-GYNs self-report ordering follow-up testing for patients (74%)Gabbe et al Obstet Gynecol 2004

howeverReview of lab records: only 1/3 had undergone postpartum glucose screeningAlmario et al Obstet Gynecol 2008

Lack of clarity who in the clinical continuum should take

primary responsibilityDornhorst et al Diabetes Care 1998


“holding hands” by spekulator, http://www.sxc.hu/photo/835200

Multidisciplinary approach Khandelwal M, Current Diabetes Rep 2008

many overlaps to provide constant reminders and encouragement




Reluctance to order OGTT even in non-pregnantWilson et al BMC Health Serv Res 2009

Complexity and time required for OGTTUncertain value of intervening when IGT identifiedPerceived cost

“dislike button” by Sean McEntee, http://www.flickr.com/photos/smemon/5683562879/


http://www.flickr.com/photos/smemon/5683562879/

http://www.flickr.com/photos/smemon/5683562879/

Predictors of postpartum screening Ferrara et al Diabetes Care 2009

Older ageAsian or Hispanic race/ethnicityHigher educationAt least 2 prior birthsEarlier gestational age at GDM diagnosisUse of insulin or glyburide during pregnancyVisits to an IM or OB-Gyn during postpartum


Postal reminders Clark et al AJOG 2008

RCT Reminder sent to MD and patient, patient only, MD only, no reminders

Outcome: OGTT in 1 y (p<0.05)

MD only Patient only MD & Patient No reminders

16/3151.6%

42/7655.3%

49/8160.5%

5/3514.3%

“timbre poste” by gastonmag, http://www.sxc.hu/photo/504564




Lab requests & telephone reminders

Kwong et al Diabetes Care 2009

cohort of 1,006 GDM women attending a pregnancy diabetes clinic

48% (n=438) completed postpartum screening

Non-adherence to testing significantly associated with

higher parity & lack of insulin use

“old phone II” by bury-osiol, http://www.sxc.hu/photo/754394




Nurse managed care programFerrara et al Diabetes Care 2009

Proportion receiving OGTT 1995 - 5% 2005 - 16.6%2006 - 71.5% Greater attention to postpartum screening guidelines

cohort of 14,448 GDM between 1995 and 2006

“shaking hands” by bluegum, http://www.sxc.hu/photo/911615




Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009

Target women at high risk for postpartum glucose intolerance

“shot on target” by cobrasoft, http://www.sxc.hu/photo/1176209

Independent risk factorsPre-pregnancy BMI >30

<24 weeks AOG at diagnosis1h OGTT >200 mg/dL

Insulin therapy




Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009


Interventions to improve postpartum

screening in GDM

Written information, individualized risk reduction advice, care from an

endocrinologist, diabetes educator or OB Morrison et al Aust NZ J Obs Gyn 2009

Provision of lab slip and preventive counseling Kim et al Diabetes Care 2007

One-on-one counseling session at 37-38 wks gestation Stasenko et al Am J Obstet Gynecol 2009

“writing hand” by tulp. http://www.sxc.hu/photo/877745




Promoting health after gestational diabetes: a National Diabetes Education Program

Call To Action Gabbe SG et al, Obstet Gynecol Jan 2012

http://ndep.nih.gov/am-i-at-risk/gdm/




Download from http://ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx


http://ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx

http://ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx

Thank You!http://www.endocrine-witch.net

@endocrine_witchhttp://www.slideshare.net/isiptan


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postpartum gestational diabetes: opportunities for screening for type 2 diabetes

Health & Medicine