When Hyperglycemia Strikes Pregnancy: Criteria for Diagnosis

1,651 views

Published on

Presentation at the 2011 annual convention of Diabetes Philippines, Inc.

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,651
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
102
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

When Hyperglycemia Strikes Pregnancy: Criteria for Diagnosis

  1. 1. WHEN HYPERGLYCEMIA STRIKES PREGNANCY: CRITERIA FOR DIAGNOSIS Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General HospitalTuesday, November 8, 11
  2. 2. UNITE for Diabetes CPG on screening & International diagnosis of GDM Association of Diabetes Hyperglycemia in Pregnancy Study Adverse Pregnancy Groups (IADPSG) Outcomes (HAPO)Tuesday, November 8, 11
  3. 3. Hyperglycemia Adverse Pregnancy Outcomes HAPOTuesday, November 8, 11
  4. 4. HAPO NEJM 2008; 358:1991-2002 Cord blood serum BW>90th %ile C-peptide >90 %ile 75-g OGTT 24-32 wks AOG 23,316 pregnant 15 centers 9 countries Primary CS Neonatal hypoglycemia http://www.flickr.com/photos/mikewade/3267336862/ http://www.flickr.com/photos/clairity/1385780317/ http://www.flickr.com/photos/j2dread/4501366303/ http://www.flickr.com/photos/tessawatson/379265818/Tuesday, November 8, 11
  5. 5. OR for adverse pregnancy outcomes 1 level SD increase FPG 6.9 mg/dL (0.4 mmol/L) 1 h PG 30.9 mg/dL (1.7 mmol/L) 2 h PG 23.5 mg/dL (1.3 mmol/L) HAPO NEJM 2008; 358:1991-2002Tuesday, November 8, 11
  6. 6. HAPO NEJM 2008; 358:1991-2002 BW>90th %ile 1h PG 1.46 (95%CI 1.39,1.53) Fasting 1.38 OR for (95%CI 1.32,1.44) 2h PG adverse 1.38 pregnancy (95%CI 1.32,1.44) outcomes http://www.flickr.com/photos/mikewade/3267336862/Tuesday, November 8, 11
  7. 7. HAPO NEJM 2008; 358:1991-2002 Cord blood serum C-peptide >90 %ile 1h PG 1.46 (95%CI 1.38,1.54) Fasting 1.55 OR for (95%CI 1.47,1.64) 2h PG adverse 1.37 pregnancy (95%CI 1.30,1.44) outcomes http://www.flickr.com/photos/clairity/1385780317/Tuesday, November 8, 11
  8. 8. HAPO NEJM 2008; 358:1991-2002 Primary CS 1h PG 1.10 (95%CI 1.06,1.15) Fasting 1.11 OR for (95%CI 1.06,1.15) 2h PG adverse 1.08 pregnancy (95%CI 1.03,1.12) outcomes http://www.flickr.com/photos/j2dread/4501366303/Tuesday, November 8, 11
  9. 9. HAPO NEJM 2008; 358:1991-2002 Neonatal hypoglycemia 1h PG 1.13 (95%CI 1.03,1.26) Fasting 1.08 OR for (95%CI 0.98,1.19) 2h PG adverse 1.10 pregnancy (95%CI 1.00,1.12) outcomes http://www.flickr.com/photos/tessawatson/379265818/Tuesday, November 8, 11
  10. 10. No obvious threshold at which risks increased HAPO NEJM 2008; 358:1991-2002Tuesday, November 8, 11
  11. 11. No obvious threshold FPG mg/dL at which risks increased Category 1 <75 2 75-79 3 80-84 4 85-89 5 90-94 6 95-99 7 >100 HAPO NEJM 2008; 358:1991-2002Tuesday, November 8, 11
  12. 12. No obvious threshold 1h PG mg/dL at which risks increased Category 1 <105 2 106-132 3 133-155 4 156-171 5 172-193 6 194-211 7 >212 HAPO NEJM 2008; 358:1991-2002Tuesday, November 8, 11
  13. 13. No obvious threshold 2h PG mg/dL at which risks increased Category 1 <90 2 91-108 3 109-125 4 126-139 5 140-157 6 158-177 7 >178 HAPO NEJM 2008; 358:1991-2002Tuesday, November 8, 11
  14. 14. Macrosomia C-section Hypoglycemia C-peptide HAPO NEJM 2008; 358:1991-2002Tuesday, November 8, 11
  15. 15. “... the relationship between maternal glucose levels and fetal growth and outcome appear to be a basic biologic phenomenon, and not a clearly demarcated disease state ...” Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  16. 16. International Association of Diabetes in Pregnancy Study Groups IADPSGTuesday, November 8, 11
  17. 17. IADPSG encourage and facilitate research and advance education facilitate an international approach to enhancing the quality of care for women with diabetes in pregnancy http://www.sxc.hu/photo/358002 Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  18. 18. IADPSG workshop/conference June 2008 (220 delegates approx 40 countries) consensus development session (50 delegates) Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  19. 19. OR for increased neonatal body fat, LGA and cord serum C-peptide Mean glucose as reference Positive Predictive Value % for >90th %ile OR Subjects > Birth Threshold C-peptide % Body fat weight 1.75 16.1 16.2 17.5 16.6 2.0 8.8 17.6 19.7 18.8 Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  20. 20. IADPSG recommendation for diagnosis of GDM FBS 92 mg/dL Diagnosis requires only one 1h 180 mg/dL threshold value exceeded 2h 153 mg/dL Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  21. 21. IADPSG recommendation for diagnosis of GDM FBS 92 mg/dL Diagnosis requires only one 1h 180 mg/dL threshold value exceeded 2h 153 mg/dL ADA FBS 95 mg/dL 1h 180 mg/dL 2h 155 mg/dL Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  22. 22. First prenatal visit Measure FPG, A1c or random plasma glucose in all or only in high-risk Overt Diabetes in Gestational Order a 75-g Pregnancy Diabetes OGTT at 24-28 FPG > 7 mmol/L wks AOG A1c > 6.5% FPG Random PG > 5.1-6.9 mmol/L FPG 11.1 mmol/L (92-125 mg/dL) <5.1 mmol/L IADPSG Consensus Panel. Diabetes Care Mar 2010;33(3):676-82Tuesday, November 8, 11
  23. 23. IADPSG recommendation for diagnosis of GDM FBS 92 mg/dL 24-28 wks AOG 1h 180 mg/dL Diagnosis requires only one threshold value exceeded 2h 153 mg/dL Overt diabetes FPG >7.0 mmol/L (126 mg/dL) Coustan et al. AJOG 2010; 202(6):654.e1-654.e6Tuesday, November 8, 11
  24. 24. Use of IADPSG criteria http://www.flickr.com/photos/kkoshy/4334413228/ More women will be diagnosed with GDM 17.8% of pregnant women Ryan EA. Diabetologia 2011; 54:480-6Tuesday, November 8, 11
  25. 25. Using HAPO data + 1,702 women with GDM of 23,316 pregnancies Nurses, dietitians & physicians Glucose monitoring Therapy of diabetes Ryan EA. Diabetologia 2011; 54:480-6Tuesday, November 8, 11
  26. 26. Diagnosis of GDM identifies women at risk of type 2 diabetes IADPSG criteria may overestimate high rates of diabetes in women with GDM historyTuesday, November 8, 11
  27. 27. X 140 cases of LGA X 21 cases of shoulder dystocia X 16 cases of birth injury Ryan EA. Diabetologia 2011; 54:480-6 http://www.sxc.hu/photo/249796Tuesday, November 8, 11
  28. 28. X 140 cases of LGA X 21 cases of shoulder dystocia X 16 cases of birth injury Modest outcomes? Ryan EA. Diabetologia 2011; 54:480-6 http://www.sxc.hu/photo/249796Tuesday, November 8, 11
  29. 29. 78% of LGA born to FBS undiagnosed women 92 mg/dL 1h 180 mg/dL 2h X 153 mg/dL BW>90th %ile Ryan EA. Diabetologia 2011; 54:480-6Tuesday, November 8, 11
  30. 30. report used an adjustment (Model 1) for many of the expected confounders (age, alcohol, smoking, sex etc.), and Greater impact of maternal BMI on also a model (Model 2) that adjusted for fasting plasma OR for LGA than maternal glucose except highest glucose category a b 8,000 5 ● 6,000 Model 1 BMI Women (n) 4 ▲ 4,000 Model 2 BMI OR 3 2 ◆ Maternal FG 2,000 1 0 0 1 2 3 4 5 6 7 1 2 3 Glucose category Glucos <22.6 22.6− 28.5− 33.0− 37.5− 42.0 28.4 32.9 37.4 41.9 BMI category (Kg/m2) Fig. 1 a Relationship of the OR for an infant of birthweight >90th Model 1: Adjusted for age, alcohol, smoking, sex, etc. HAPO Model 2: Adjusted for mean FG and MAP 2 percentile vs the BMI in categories (reference group BMI <22.6 kg/m Ryan EA. Diabetologia 2011; 54:480-6 [4]) or maternal fasting glucose in categories from HAPO (diamonds;Tuesday, November 8, 11
  31. 31. icular glucose category; the category incorporating the mean glucose level. This isr the glucose range. also true for the 1 and 2 h post-load challenge (ESM roup examined the role Fig. 3). It is also noteworthy that at category 5 (equivalent Majority of women IADPSG cut-off criteria, accepting that some cases inmary outcomes [4]. This to the had Most cases of LGA occur l 1) for many oflevels category 5 will lie abovenormal maternal glucose the < Cat. 3 in these cut-offs within category 5) smoking, sex etc.), and women below these cut-offs who had LGA represented (mean glucose level) glycemiasted for fasting plasma 78% of all women giving birth to LGA. b c 8,000 700 600 6,000 500 Women (n) Women (n) 400 4,000 300 2,000 200 100 0 0 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Glucose category Glucose category ☐ Participants infant of birthweight >90th (see text for details). The relationship for maternal fasting glucose ■ Participants with LGA infantsnce group BMI <22.6 kg/m2 ies from HAPO (diamonds; categories is also shown (black diamonds). b Number of participants in each category of glucose in HAPO (white bars), with number of HAPO lucose [2]). a The BMI c Number of participants in mothers with LGA infants (black bars).Ryan EA. Diabetologia 2011; 54:480-6cles) or model 2 (triangles) each category of glucose who had LGA infants Tuesday, November 8, 11
  32. 32. Proposed IADPSG diagnostic criteria are based on LGA, cord-C peptide and fetal adiposity. Treatment reduces perinatal ACHOIS morbidity Landon et al Crowther et al. NEJM 2009; NEJM 2005; 361:1339-48. 352:2477-86.Tuesday, November 8, 11
  33. 33. ACHOIS Crowther et al. NEJM 2005; M 352:2477-86. O Randomized controlled I Serious trial perinatal P Intervention complications (n=490) death diet CBG insulin shoulder dystocia vs bone fracture nerve palsy routine care (n=510) GDM 24-28 wks AOG Crowther CA et al. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. NEJM 2005; 352:2477-86.Tuesday, November 8, 11
  34. 34. Any serious perinatal complication ACHOIS Adj RR 0.33 (95% CI 0.14-0.75), p=0.01 Crowther et al. NEJM 2005; M 352:2477-86. O Randomized controlled I Serious trial perinatal P Intervention complications (n=490) death diet CBG insulin shoulder dystocia vs bone fracture nerve palsy routine care (n=510) GDM 24-28 wks AOG Crowther CA et al. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. NEJM 2005; 352:2477-86.Tuesday, November 8, 11
  35. 35. Landon et al NEJM 2009; M 361:1339-48. O Randomized Composite of controlled I stillbirth/ trial perinatal P Intervention death and (n=485) neonatal diet CBG insulin complications vs hyperbilirubinemia routine care hypoglycemia (n=473) hyperinsulinemia birth trauma “mild” GDM 24-31 wks AOG Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.Tuesday, November 8, 11
  36. 36. Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14 Landon et al NEJM 2009; M 361:1339-48. O Randomized Composite of controlled I stillbirth/ trial perinatal P Intervention death and (n=485) neonatal diet CBG insulin complications vs hyperbilirubinemia routine care hypoglycemia (n=473) hyperinsulinemia birth trauma “mild” GDM 24-31 wks AOG Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.Tuesday, November 8, 11
  37. 37. Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14 Landon et al NEJM 2009; M 361:1339-48. O Randomized controlled I trial P Intervention (n=485) diet CBG insulin vs routine care (n=473) “mild” GDM 24-31 wks AOG Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.Tuesday, November 8, 11
  38. 38. Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14 Landon et al NEJM 2009; M 361:1339-48. O Randomized LGA infants controlled I RR 0.49 trial P Intervention (95%CI 0.32-0.76) p<0.001 (n=485) diet CBG insulin BW >4000 g vs RR 0.41 routine care (95%CI 0.26-0.66) (n=473) p<0.001 “mild” GDM 24-31 wks AOG Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.Tuesday, November 8, 11
  39. 39. OGTT is poorly reproducible Diagnosis based on a single test, on a single abnormal value Ryan EA. Diabetologia 2011; 54:480-6 http://www.flickr.com/photos/craigoneal/4084388198/Tuesday, November 8, 11
  40. 40. HAPO data collected at 24-28 wks AOG Fasting glucose 5.1 mmol/L at 7 wks AOG = GDM Ryan EA. Diabetologia 2011; 54:480-6Tuesday, November 8, 11
  41. 41. IADPSG ACOG recommends against IADPSG consensus 1. All pregnant women should be screened for GDM by patient history, clinical risk factors or a 50-g, 1-hour loading test to determine blood glucose levels. ACOG Committee on Obstetric Practice. Screening & Diagnosis of http://www.sxc.hu/photo/358002 Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3Tuesday, November 8, 11
  42. 42. IADPSG ACOG recommends against IADPSG consensus 2. The diagnosis of GDM can be made based on the result of the 100-g, 3h OGTT. Carpenter & Coustan or NDDG criteria ACOG Committee on Obstetric Practice. Screening & Diagnosis of http://www.sxc.hu/photo/358002 Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3Tuesday, November 8, 11
  43. 43. ACOG recommends IADPSG against IADPSG consensus 3. Diagnosis of GDM based on the 1-step screening and diagnosis test outlined in the IADPSG guidelines is not recommended at this time because there is no evidence that diagnosis using these criteria leads to clinically significant improvement in maternal or newborn outcomes, and it would lead to a significant increase in healthcare costs. ACOG Committee on Obstetric Practice. Screening & Diagnosis of http://www.sxc.hu/photo/358002 Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3Tuesday, November 8, 11
  44. 44. UNITE for Diabetes CPG on screening & diagnosis of GDMTuesday, November 8, 11
  45. 45. 6.1 Should universal screening for diabetes be done among pregnant women? Recommendation: All pregnant women should be screened for gestational diabetes (Level 2, Grade B).Tuesday, November 8, 11
  46. 46. 6.2 For pregnant women, when should screening be done? Recommendations: 1. All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Level 4, Grade C).Tuesday, November 8, 11
  47. 47. Risk Factors for Gestational Diabetes Prior history of GDM (OR 23.6 [95%CI 11.6, 48.0])3 Glucosuria (OR 9.04 [95%CI 2.6, 63.7]2; PPV 50% 4) Family history of diabetes (OR 7.1 [95%CI 5.6, 8.9]1; OR 2.74 [95%CI 1.47, 5.11]3) First-degree relative with type 2 diabetes (PPV 6.7%)4 First-degree relative with type 1 diabetes (PPV 15%)4 Prior macrosomic baby (OR 5.59 [95%CI 2.68, 11.7])3 Age >25 years old (OR 1.9 [95%CI 1.3, 2.7]1; OR 3.37 [95%CI 1.45, 7.85]3) 1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21. ! ! 2 Schytte T, Jorgensen LG, Brandslund I, et al. The clinical impact of screening for gestational diabetes. Clinical Chemistry and Laboratory Medicine 2004;42(9):1036–42. 3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8. 4 Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32.Tuesday, November 8, 11
  48. 48. Risk Factors for Gestational Diabetes Diagnosis of polycystic ovary syndrome (OR 2.89 [95%CI 1.68, 4.98])5 Overweight or obese before pregnancy (BMI >27 kg/m2 OR 2.3 [95%CI 1.6, 3.3]1; BMI>30 kg/m2 OR 2.65 [95%CI 1.36, 5.14]3 Macrosomia in current pregnancy (PPV 40% 4) Polyhydramnios in current pregancy (PPV 40% 4) Intake of drugs affecting carbohydrate metabolism 1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21. 3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8. 4 Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32. 5 Toulis KA, Goulis DG, Kolibiankis EM, Venetis CA, et al. Risk of gestational diabetes mellitus in women with polycystic ovary syndrome: a systematic review and a meta-analysis. Fertil Steril 2009;92(2):667–77.Tuesday, November 8, 11
  49. 49. 6.2 For pregnant women, when should screening be done? Recommendations: 2. High-risk women should be tested at the soonest possible time (Level 3, Grade B).Tuesday, November 8, 11
  50. 50. 6.2 For pregnant women, when should screening be done? Recommendations: 3. Routine testing for gestational diabetes is recommended at 24-28 weeks age of gestation for women with no risk factors (Level 3, Grade B).Tuesday, November 8, 11
  51. 51. 6.2 For pregnant women, when should screening be done? Recommendations: 4. Testing for gestational diabetes should still be carried out in women at risk, even beyond 24 to 28 weeks age of gestation (Level 3, Grade C).Tuesday, November 8, 11
  52. 52. 6.3 Which tests should be used to screen pregnant women for gestational diabetes? Recommendation: An oral glucose tolerance test (OGTT), preferably the 75-g OGTT, should be used to screen for gestational diabetes (Level 3, Grade B).Tuesday, November 8, 11
  53. 53. 6.4 What criteria will be used to interpret the 75-g OGTT? Recommendation: The criteria put forth by the International Association of Diabetes & Pregnancy Study Groups (IADPSG) will be used to interpret the 75-g OGTT (Level 3, Grade B). International Association of Diabetes and Pregnancy Study Groups Consensus Panel. IADPSG Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care 2010; 33(3):676-82.Tuesday, November 8, 11
  54. 54. UNITE for Diabetes CPG on screening & International diagnosis of GDM Association of Diabetes in Pregnancy Study Hyperglycemia Groups (IADPSG) Adverse Pregnancy Outcomes (HAPO)Tuesday, November 8, 11
  55. 55. Thank You! http://www.endocrine-witch.net You are all invited to the 19th UPCM Grand Scientific Symposium Training the Clinical Eye: Making the Essential Visible Hyatt Hotel Manila Jan 27-28, 2012 19thgss@gmail.comTuesday, November 8, 11

×