Title: Diabetes Asia
1Screening and Diagnosis
2Objectives
- At the end of this session you will be able to
- Define GDM
- Identify the risks for development of GDM.
- State the prevalence of GDM locally
- Explain the reason for identifying and treating
GDM - Identify appropriate screening measures
- Identify who should be screened
- Identify diagnostic criteria
3Definition
- Glucose intolerance with onset or first
recognition during pregnancy - Characterized by ß-cell function that is unable
to meet the bodys insulin needs
Buchanan, Wiang, Kjos, Watanabe 2007
4Glucose regulation during pregnancy
- Insulin resistance begins in mid pregnancy and
progresses through the third trimester - A result of maternal adiposity and effects of
placental hormones - ß -cells usually make more insulin to compensate
for resistance when they cannot meet the needs
hyperglycemia occurs
5- GDM represents a state of chronic ß-cell
dysfunction in the face of insulin resistance - Insulin resistance and insulin levels are
different prior to pregnancy in women who develop
GDM and those who do not - Changes in insulin sensitivity are similar in
both groups during pregnancy - However in GDM women, insulin secretion does not
increase adequately
Buchanan, Wiang, Kjos, Watanabe 2007
6Prevalence
- The prevalence of GDM is estimated to be 10-16.9
in pregnant women depending on the diagnostic
criteria used. - Prevalence also varies by region and ethnicity.
- Highest prevalence is in South East Asia
- Lowest in North America and the Caribbean
- Prevalence higher
- in less physically active women.
- In older women
- In women with higher BMI
- In those with a strong family history of diabetes
WHO, 2013 IDF, 2013
7Discussion
- What are the risk factors for gestational
diabetes? - What risk factors do you see most often in your
setting?
8Risk factors for GDM
Low risk
- Obesity
- Diabetes in 1st degree relative
- Previous
- history of GDM or glucose intolerance
- complicated pregnancy
- infant with macrosomia gt 3.5 kg
- Older age
- High risk ethnic group South Asian, East Asian,
Indigenous American or Australian, Hispanic - PCOS
- Age less than 25 years
- No previous poor pregnancy outcomes
- No diabetes in 1st degree relatives
- Normal prepregnancy weight and weight gain during
pregnancy - No history of abnormal glucose tolerance
Perkins, Dunn, Jagastia, 2007
9Is Hypertension a risk factor?
- Hypertension prior to pregnancy or during 1st
trimester doubled the risk of GDM independent
of maternal weight - Hence all women with hypertension should be
screened for GDM
Hedderson, Ferrara, 2008
10Why diagnose and treat GDM?
- Short term risks for the mother
- Development of gestational hypertension,
worsening essential hypertension or development
of preeclampsia - Operative delivery - related to macrosomia
- Polyhydramnios
- Premature labour
- Long term risks for the mother
- Development of type 2 diabetes in next 10 years
(30-60 depending on population) - Development of cardiovascular disease
CDA, 2013 Metzger, Buchanan, et al. 2007
11Why diagnose and treat GDM?
- Short term risks for the baby
- Macrosomia
- Neonatal hypoglycemia
- Jaundice
- Preterm birth
- Birth injury
- Hypocalcemia/ hypomagnesimia
- Respiratory distress syndrome
- Long term risks for the baby
- Obesity
- Type 2 diabetes
12Importance of follow up
- Long term follow up studies have shown that most
women with GDM will develop diabetes within the
first decade after the pregnancy - Testing after pregnancy is important - more about
this later
Kim, Newton, Knopp 2002
13Screening
- Whom to screen
- When to screen
- How to screen
14Who to screen
- Some guidelines recommend screening all women at
the first visit to rule out pre-existing type 2
diabetes - Most guidelines recommend screening all women for
GDM at 24-28 weeks gestation.
ADA, 2015 CDA , 2013
15When to screen?First trimester
- Screening in 1st trimester
- - to rule out unidentified pre-existing
diabetes - Fasting plasma glucose gt126 mg/dl (7 mmol/L)
- or
- HbA1c gt6.5
- or
- Random gt200mg/dl (11.1 mmol/L)
- or
- 2hr value in OGTT gt200mg/dl (11.1 mmol/L)
- If overt diabetes is detected, it must be treated
appropriately.
ADA, 2015
16When to screenScreening for GDM
- Screening should be done at 24-28 weeks
- Diagnosis based on a 75 gm glucose load given in
fasting state - GDM diagnosed when one or more of the following
is present - Fasting 92 - 125 mg/dl (5.0 6.9 mmol/L)
- 1 hour post 75 gm load gt180 mg/dl (10 mmol/L)
- 2 hour post 75 gm load gt153mg/dl (8.5 mmol/L)
- If woman tests negative, screening at 32 weeks
also may be necessary in presence of high risks
World Health Organization, 2013
17Diagnostic criteria
WHO (2013) 1 or more IADPSG 1 or more ADA one step ADA two step
Fasting plasma glucose 5.1-6.9 mmol/L (92-125 mg/dl) gt5.1 mmol/L (92 mg/dl) gt5.1 mmol/L (92 mg/dl) 50-g glucose load (nonfasting) If 1 hour gt 7.8mmol/L (140mg/dl) Do 100 g OGTT GDM If 2 of 4 results high
1 hour PG after 75gm load gt10.0mmol/L (180mg/dl) gt10.0mmol/L (180mg/dl) gt10.0mmol/L (180mg/dl) 50-g glucose load (nonfasting) If 1 hour gt 7.8mmol/L (140mg/dl) Do 100 g OGTT GDM If 2 of 4 results high
2 hour PG after 75gm load 8.5-11.0 mmol/L (153-199 mg/dl) gt8.5 mmol/L (153 mg/dl) gt8.5 mmol/L (153 mg/dl) 50-g glucose load (nonfasting) If 1 hour gt 7.8mmol/L (140mg/dl) Do 100 g OGTT GDM If 2 of 4 results high
Diabetes Care 2015, WHO 2013
18How to screen
- Key considerations for screening in low resource
countries - Low cost
- No requirement for elaborate preparation
- High sensitivity and specificity
- Short turn-around time
- Be administered by health workers with minimal
training - Need little maintenance, calibration, or
refrigeration
Agarwal et al, 2007
19Venous or capillary
- The venous plasma is the gold standard
-
- Where laboratory facilities or technicians are
not available, capillary glucose estimations may
be done using a hand held glucose meter. - The glucose meter must be standardized with a lab
and calibrated against the lab on a regular
basis.
20Which of these women has GDM?
- All have had 75g glucose load at about 25 weeks
- Rupinder, overweight, 35 years old,
- fasting 90 mg/dl (5.0 mmol/L),
- 1 hr 170mg/d (9.4 mmol/L),
- 2hr 135mg/dl (7.5 mmol/L)
- Joanne, 3rd pregnancy, history of big babies,
- fasting 130 mg/dl (7.2 mmol/L),
- 1 hr 190mg/dl (10.5 mmol/L)
- 2 hr 220mg/dl (12.2 mmol/L)
- Maria, 1st pregnancy, 25 years old, obese,
- fasting 90mg/dl (5 mmol/L),
- 1 hr 168mg/dl (9.3mmol/L)
- 2 hr 160 mg/dl (8.8mmol/L)
21Giving the diagnosis
- Will my baby be ok? 1st question often asked
- Is this temporary? 2nd question
- Questions provide an opportunity for teaching
- Must answer truthfully
- Must convey importance of management during
pregnancy for healthy outcome but also for future
health of baby and mother - Risk of type 2 diabetes
- Risk of obesity
22References
- American Diabetes Association. Clinical Practice
Recommendations 2015. Diabetes Care. 201538(1) - Agarwal et al - Fasting plasma glucose as a
screening test for gestational diabetes mellitus,
Archives of Gynecology and Obstetrics 2007 - Buchanan T, Xiang A, Kjos S, Watanabe R. What is
gestational Diabetes? Diabetes Care
200730(2)S105-111. - Canadian Diabetes Association Clinical Practice
Guidelines Expert Committee. Canadian Diabetes
Association 2013 Clinical practice guidelines for
the prevention and management of diabetes in
Canada Diabetes and pregnancy. Can J of
Diabetes. 201337(suppl 1)S168-183. - Hedderson MM, Ferrara A. High blood pressure
before and during early pregnancy is associated
with an increased risk of gestational diabetes
mellitus. Diabetes Care. 200831(12)2362-2367. - IDF Diabetes Atlas 6th Ed, 2013
- Kim C. Newton KM, Knopp RH. Gestational diabetes
and the incidence of type 2 diabetes. Diabetes
Care 2002251862-1868 - Metzger BE, Buchanan TA, Coustan DR, De Leiva A,
Hadden DR, Hod M. Summary and recommendations of
the fifth international workshop-conference on
gestational diabetes mellitus, Diabetes Care.
200730(suppl 2)S251-260. - Perkins JM, Dunn JP, Jagastia SM. Perspectives
in gestational diabetes mellitus A review of
screening, diagnosis and treatment. Clinical
Diabetes. 200725(2)57-62 - WHO. Diagnostic Criteria and Classification of
Hyperglycaemia First Detected in Pregnancy , 2013