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Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes
 

Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes

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Presentation at the 2012 Diabetes Phillippines annual convention at the EDSA Shangrila Hotel.

Presentation at the 2012 Diabetes Phillippines annual convention at the EDSA Shangrila Hotel.

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    Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes Presentation Transcript

    • “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 Postpartum Gestational Diabetes: Screening Opportunities for Type 2 Diabetes Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM Assoc Prof. 4, UP College of Medicine Chief, UPCM Medical Informatics Unit Section of Endocrinology, Diabetes & Metabolism Dept. of Medicine, Philippine General Hospital 2012 Diabetes Philippines Annual Convention EDSA Shangrila Hotel 14 Nov 2012Sunday, November 18, 12
    • Is GDM the forme fruste of diabetes? forme fruste partial, arrested or inapparent form of the “easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563 diseaseSunday, November 18, 12
    • Natural History of Type 2 Diabetes De Fronzo RA, Diabetes 2009Sunday, November 18, 12
    • “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 Women developing GDM had lower pregravid insulin sensitivity Landon et al 2001Sunday, November 18, 12
    • “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 GDM: increased fasting insulin concentrations in late gestation Landon et al 2001Sunday, November 18, 12
    • GDM: decreased insulin response to glucose challenge in late pregnancy “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 Xiang AH et al Diabetes 1999Sunday, November 18, 12
    • “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 GDM: lower insulin response for degree of insulin resistance Homko et al Diabetes 2001Sunday, November 18, 12
    • GDM: Diabetes in Evolution “easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563Sunday, November 18, 12
    • Gestational diabetes is an independent risk factor for diabetes in Filipino-Americans Cuasay et al Diabetes Care 2001 Risk factor OR 95% CI Age (y) 35-44 10.79 1.00-16.83 45-54 16.17 1.42-184.03 55-64 14.65 1.09-97.70 65 and older 38.68 2.27-659.89 Gestational diabetes 21.65 6.73-69.67 Delivery of baby >9 lb 1.51 0.39-5.84 Family history of diabetes 2.22 0.92-5.35 Obesity 2.85 0.53-15.4Sunday, November 18, 12
    • “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screeningSunday, November 18, 12
    • Metabolic assessments recommended after GDM Metzger BE et al, Summary & Recommendations of the 5th International Workshop on GDM. Diabetes Care 2007 Time Test Purpose Fasting or random Detect persistent, overt Post-delivery (1-3 days) plasma glucose diabetes Early postpartum Postpartum classification (around the time of 75-g 2-h OGTT postpartum visit) of glucose metabolism 1 year postpartum 75-g 2-h OGTT Assess glucose metabolism Annually Fasting plasma glucose Assess glucose metabolism Tri-annually 75-g 2-h OGTT Assess glucose metabolism Prepregnancy 75-g 2-h OGTT Classify glucose metabolismSunday, November 18, 12
    • Postpartum Screening for Diabetes Among Women with a History of Gestational Diabetes Systematic Review Tovar A et al, Prev Chronic Dis 2011;8(6):A124 11 studies (2008-2010) on rates & results of postpartum screening n = 32,240 GDM (1999-2008) “paper” by v_g, http://www.sxc.hu/photo/77779Sunday, November 18, 12
    • Postpartum Screening for Diabetes Among Women with a History of Gestational Diabetes Systematic Review Tovar A et al, Prev Chronic Dis 2011;8(6):A124 34%-73% (median 48%) screened “dream graph” by iamwahid, http://www.sxc.hu/photo/1209643Sunday, November 18, 12
    • Postpartum Screening for Diabetes Among Women with a History of Gestational Diabetes Systematic Review Tovar A et al, Prev Chronic Dis 2011;8(6):A124 Postpartum screening not improved over time 50.3% within 3 mos 48.2-51% within 6 mos 55.9% within 12 mos “calendario” by malko, http://www.sxc.hu/photo/750005Sunday, November 18, 12
    • Postpartum Screening for Diabetes Among Women with a History of Gestational Diabetes Systematic Review Tovar A et al, Prev Chronic Dis 2011;8(6):A124 79-100% screened with FPG (4 studies) 56-95% screened with OGTT (3 studies) “Injection time” by adamci, http://www.sxc.hu/photo/250620Sunday, November 18, 12
    • 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 OGTT Tovar et al Prev Chronic Dis 2011 Isolated IGT 1/3 of GDM cohort with DM or prediabetes Hunt & Conway Am J Obstet Gynecol 2008 “Injection time” by adamci, http://www.sxc.hu/photo/250620Sunday, November 18, 12
    • “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screeningSunday, November 18, 12
    • “Time slipping away 1” by chriki7274, http://www.sxc.hu/photo/723865 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 diabetesSunday, November 18, 12
    • Barriers & facilitators of postpartum follow-up care in previous GDM Bennett et al J Women’s Health 2011 Barriers Baby’s health needs Personal 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/299965Sunday, November 18, 12
    • Barriers & facilitators of postpartum follow-up care in previous GDM Bennett et al J Women’s Health 2011 Facilitators Availability of child care Check-up and clearance for return to work Connection with clinical and office staff Address specific concerns or questions Discuss family planning “businesswoman 1” by CELALTEBER, http://www.sxc.hu/photo/1305802Sunday, November 18, 12
    • Postpartum Screening for Diabetes Among Women with a History of Gestational Diabetes Systematic Review Tovar A et al, Prev Chronic Dis 2011;8(6):A124 21 studies (2008-2010) on predictors of & barriers to screening “paper” by v_g, http://www.sxc.hu/photo/77779Sunday, November 18, 12
    • Provider barriers Tovar et al Prev Chronic Dis 2011 lack of attendance at postpartum visit however 94% postpartum Pap smear vs 67% glucose testing (37% FPG or OGTT) “medical doctor” by kurhan, http://www.sxc.hu/photo/1314902Sunday, November 18, 12
    • Provider barriers Henderson et al The Open Diabetes J 2012 clinician’s perception that screening guidelines were “inconsistent” “medical doctor” by kurhan, http://www.sxc.hu/photo/1314902Sunday, November 18, 12
    • Postpartum screening recommendations for women with GDM Canadian Diabetes Association (2008) 75-g OGTT 6 wks-6 mos postpartum Pre-pregnancy screening for T2D WHO 75-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/1000622Sunday, November 18, 12
    • Provider barriers Henderson et al The Open Diabetes J 2012 lack of documentation of GDM on problem lists poor communication between OB and primary care “medical doctor” by kurhan, http://www.sxc.hu/photo/1314902Sunday, November 18, 12
    • 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 however Review of lab records: only 1/3 had undergone postpartum glucose screening Almario et al Obstet Gynecol 2008 Lack of clarity who in the clinical continuum should take primary responsibility Dornhorst et al Diabetes Care 1998Sunday, November 18, 12
    • Multidisciplinary approach Khandelwal M, Current Diabetes Rep 2008 many overlaps to provide constant reminders and encouragement “holding hands” by spekulator, http://www.sxc.hu/photo/835200Sunday, November 18, 12
    • Reluctance to order OGTT even in non-pregnant Wilson et al BMC Health Serv Res 2009 Complexity and time required for OGTT Uncertain value of intervening when IGT identified Perceived cost “dislike button” by Sean McEntee, http://www.flickr.com/photos/smemon/5683562879/Sunday, November 18, 12
    • Predictors of postpartum screening Ferrara et al Diabetes Care 2009 Older age Asian or Hispanic race/ethnicity Higher education At least 2 prior births Earlier gestational age at GDM diagnosis Use of insulin or glyburide during pregnancy Visits to an IM or OB-Gyn during postpartumSunday, November 18, 12
    • “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screeningSunday, November 18, 12
    • 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 16/31 42/76 49/81 5/35 51.6% 55.3% 60.5% 14.3% “timbre poste” by gastonmag, http://www.sxc.hu/photo/504564Sunday, November 18, 12
    • 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/754394Sunday, November 18, 12
    • Nurse managed care program Ferrara et al Diabetes Care 2009 cohort of 14,448 GDM between 1995 and 2006 Proportion receiving OGTT 1995 - 5% 2005 - 16.6% 2006 - 71.5% Greater attention to postpartum screening guidelines “shaking hands” by bluegum, http://www.sxc.hu/photo/911615Sunday, November 18, 12
    • Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009 Target women at high risk for postpartum glucose intolerance Independent risk factors Pre-pregnancy BMI >30 <24 weeks AOG at diagnosis 1h OGTT >200 mg/dL Insulin therapy “shot on target” by cobrasoft, http://www.sxc.hu/photo/1176209Sunday, November 18, 12
    • Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009Sunday, November 18, 12
    • Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009Sunday, November 18, 12
    • “writing hand” by tulp. http://www.sxc.hu/photo/877745 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 2009Sunday, November 18, 12
    • 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/Sunday, November 18, 12
    • Download from http://ndep.nih.gov/am-i-at-risk/gdm/take-action.aspxSunday, November 18, 12
    • “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screeningSunday, November 18, 12
    • Thank You! http://www.endocrine-witch.net @endocrine_witch http://www.slideshare.net/isiptanSunday, November 18, 12