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“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 2012
Sunday, 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


    disease
Sunday, November 18, 12
Natural History of Type 2 Diabetes
                                        De Fronzo RA, Diabetes 2009




Sunday, November 18, 12
“easter” by GiniMiniGi, http://
                                             www.sxc.hu/photo/1162563




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


Sunday, November 18, 12
“easter” by GiniMiniGi, http://
                                              www.sxc.hu/photo/1162563




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


Sunday, 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 1999


Sunday, 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 2001


Sunday, November 18, 12
GDM: Diabetes in Evolution




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




Sunday, 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     0.53-15.4




Sunday, November 18, 12
“Classical Windows” by theswedish,
                          http://www.sxc.hu/photo/1344783




                                                                When & how to
                                                                screen

                                                                Barriers to screening

                                                                Interventions to
                                                                improve screening



Sunday, 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 metabolism




Sunday, 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/77779

Sunday, 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/1209643


Sunday, 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/750005

Sunday, 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/250620

Sunday, 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/250620

Sunday, November 18, 12
“Classical Windows” by theswedish,
                          http://www.sxc.hu/photo/1344783




                                                                When & how to
                                                                screen

                                                                Barriers to screening

                                                                Interventions to
                                                                improve screening



Sunday, 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 diabetes



Sunday, 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/299965

Sunday, 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/1305802

Sunday, 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/77779

Sunday, 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/1314902

Sunday, 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/1314902

Sunday, 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/1000622

Sunday, 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/1314902

Sunday, 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 1998




Sunday, 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/835200

Sunday, 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 postpartum




Sunday, November 18, 12
“Classical Windows” by theswedish,
                          http://www.sxc.hu/photo/1344783




                                                                When & how to
                                                                screen

                                                                Barriers to screening

                                                                Interventions to
                                                                improve screening



Sunday, 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/504564

Sunday, 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/754394

Sunday, 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/911615

Sunday, 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/1176209


Sunday, November 18, 12
Risk stratification
       to improve screening
       Schaefer-Graf et al Diabetes Care 2009




Sunday, November 18, 12
Risk stratification
       to improve screening
       Schaefer-Graf et al Diabetes Care 2009




Sunday, 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 2009
Sunday, 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.aspx




Sunday, November 18, 12
“Classical Windows” by theswedish,
                          http://www.sxc.hu/photo/1344783




                                                                When & how to
                                                                screen

                                                                Barriers to screening

                                                                Interventions to
                                                                improve screening



Sunday, November 18, 12
Thank You!
                          http://www.endocrine-witch.net




                                         @endocrine_witch
                             http://www.slideshare.net/isiptan




Sunday, November 18, 12

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Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes

  • 1. “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 2012 Sunday, November 18, 12
  • 2. 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 disease Sunday, November 18, 12
  • 3. Natural History of Type 2 Diabetes De Fronzo RA, Diabetes 2009 Sunday, November 18, 12
  • 4. “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 Women developing GDM had lower pregravid insulin sensitivity Landon et al 2001 Sunday, November 18, 12
  • 5. “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 GDM: increased fasting insulin concentrations in late gestation Landon et al 2001 Sunday, November 18, 12
  • 6. GDM: decreased insulin response to glucose challenge in late pregnancy “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 Xiang AH et al Diabetes 1999 Sunday, November 18, 12
  • 7. “easter” by GiniMiniGi, http:// www.sxc.hu/photo/1162563 GDM: lower insulin response for degree of insulin resistance Homko et al Diabetes 2001 Sunday, November 18, 12
  • 8. GDM: Diabetes in Evolution “easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563 Sunday, November 18, 12
  • 9. 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 0.53-15.4 Sunday, November 18, 12
  • 10. “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screening Sunday, November 18, 12
  • 11. 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 metabolism Sunday, November 18, 12
  • 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/77779 Sunday, November 18, 12
  • 13. 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/1209643 Sunday, November 18, 12
  • 14. 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/750005 Sunday, November 18, 12
  • 15. 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/250620 Sunday, November 18, 12
  • 16. 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/250620 Sunday, November 18, 12
  • 17. “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screening Sunday, November 18, 12
  • 18. “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 diabetes Sunday, November 18, 12
  • 19. 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/299965 Sunday, November 18, 12
  • 20. 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/1305802 Sunday, November 18, 12
  • 21. 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/77779 Sunday, November 18, 12
  • 22. 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/1314902 Sunday, November 18, 12
  • 23. 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/1314902 Sunday, November 18, 12
  • 24. 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/1000622 Sunday, November 18, 12
  • 25. 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/1314902 Sunday, November 18, 12
  • 26. 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 1998 Sunday, November 18, 12
  • 27. 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/835200 Sunday, November 18, 12
  • 28. 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
  • 29. 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 postpartum Sunday, November 18, 12
  • 30. “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screening Sunday, November 18, 12
  • 31. 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/504564 Sunday, November 18, 12
  • 32. 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 Sunday, November 18, 12
  • 33. 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/911615 Sunday, November 18, 12
  • 34. 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/1176209 Sunday, November 18, 12
  • 35. Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009 Sunday, November 18, 12
  • 36. Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009 Sunday, November 18, 12
  • 37. “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 2009 Sunday, November 18, 12
  • 38. 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
  • 40. “Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783 When & how to screen Barriers to screening Interventions to improve screening Sunday, November 18, 12
  • 41. Thank You! http://www.endocrine-witch.net @endocrine_witch http://www.slideshare.net/isiptan Sunday, November 18, 12