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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
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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.
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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.
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Macrosomia
Who should we screen?How should we screen?
Who?
• Universal
• Selective
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How?
• IADPSG/ WHO 2014---Perinatal outcomes
• Carpenter & Coustan--- Future Diabetes Risk
• NICE 2015--- Cost
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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 3: 4.3% less likely to attend p=0.008
Score 4: 7.6% less likely to attend p=0.0001
Score 5:14.5% less likely to attend p=0.0001
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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
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4 individual risk factors
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Combining risk factors
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Exercise pre-pregnancy
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Exercise in early pregnancy
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Treatment of GDM?
• MNT and Exercise (70%)
• Insulin (30%)
• Metformin (NICE)
• Glibenclamide (ACOG)
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Is treatment beneficial?
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Shoulder Dystocia
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Macrosomia
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Preeclampsia
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What dietary intervention works?
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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
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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
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Composite Poor Neonatal Outcome
• OR 0.79 (CI 0.64-0.98) P 0.03
• 21% less likely to have an adverse outcome
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Gestational weight gain in GDM?
• Is it important?
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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).
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What are the health risks post GDM?
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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?
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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
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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
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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.
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