Screening and Diagnosis

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Presentation transcript:

Screening and Diagnosis

Objectives 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

Definition Glucose intolerance with onset or first recognition during pregnancy Characterized by β-cell function that is unable to meet the body’s insulin needs Buchanan T, Xiang A, Kjos S, Watanabe R. What is gestational Diabetes? Diabetes Care 2007;30(2):S105-111. Buchanan, Wiang, Kjos, Watanabe 2007

Glucose 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 β -cells usually make more insulin to compensate for resistance – when they cannot meet the needs hyperglycemia occurs All women who are pregnant have increasing insulin resistance. Most women are able to increase the secretion of insulin to overcome the resistance and therefore they do not experience higher than normal blood glucose levels. Those women who cannot secrete more insulin develop gestational diabetes.

GDM represents a state of chronic β-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 While all women become insulin resistant and all increase their insulin secretion, studies have shown a difference in the women who develop GDM. This suggests that GDM is really a forerunner to type 2 diabetes, and may explain why so many women with GDM go on to develop type 2. Buchanan T, Xiang A, Kjos S, Watanabe R. What is gestational Diabetes? Diabetes Care 2007;30(2):S105-111. Buchanan, Wiang, Kjos, Watanabe 2007

Prevalence 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 Prevalence is the number of people said to have the condition at one point in time. Using the 1999 WHO criteria prevalence is approximately10% Using the 2008 IADPSG criteria the prevalence is approximately 15% IDF Atlas 6th Edition reports the global prevalence of hyperglycemia in pregnancy (women 20-49 years) to be 16.9% WHO. Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy , 2013 IDF Diabetes Atlas 6th Ed, 2013 WHO, 2013 IDF, 2013

Discussion What are the risk factors for gestational diabetes? What risk factors do you see most often in your setting? Facilitator: Stop you presentation here and ask the questions… You could write the answers on butcher paper or on a black/white board. If one risk factor is most commonly seen – such as obesity – you could ask why that is occurring.

Risk factors for GDM Low risk High risk Age less than 25 years Obesity Diabetes in 1st degree relative Previous history of GDM or glucose intolerance complicated pregnancy infant with macrosomia > 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 Now compare the list that you just developed from the participants with this list. Perkins JM, Dunn JP, Jagastia SM. Perspectives in gestational diabetes mellitus: A review of screening, diagnosis and treatment. Clinical Diabetes. 2007;25(2):57-62 Perkins, Dunn, Jagastia, 2007

Is 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 This question might result in some discussion… BP is not currently recommended as a screening tool, but is it something that should be considered. How many take the BP on the 1st pregnancy visit? Hedderson MM, Ferrara A. High blood pressure before and during early pregnancy is associated with an increased risk of gestational diabetes mellitus. Diabetes Care. 2008;31(12):2362-2367. Hedderson, Ferrara, 2008

Why 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 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy. Can J of Diabetes. 2013;37(suppl 1):S168-183. 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. 2007; 30(suppl 2):S251-260. CDA, 2013 Metzger, Buchanan, et al. 2007

Why 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 Neonatal hypoglycemia is directly proportional to the state of glycemia of the mother at the time of labour and delivery.

Importance 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 C. Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care 2002;25:1862-1868 Kim, Newton, Knopp 2002

Screening Whom to screen When to screen How to screen

Who 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. Screening at the first visit has become important as the prevalence of type 2 diabetes has increased in the younger population. Many women may not be aware they have type 2 diabetes when they become pregnant. ADA, 2015 CDA , 2013

When to screen? First trimester Screening in 1st trimester - to rule out unidentified pre-existing diabetes Fasting plasma glucose >126 mg/dl (7 mmol/L) or HbA1c >6.5% Random >200mg/dl (11.1 mmol/L) 2hr value in OGTT >200mg/dl (11.1 mmol/L) If overt diabetes is detected, it must be treated appropriately. Ask the participants – when do you usually see women for the 1st pregnancy visit? Do you think you should screen them before the 24-28 week period? Recommended that all women be screened at first visit. ADA. Standards of Medical Care in Diabetes 2015. Diabetes Care. 2015;38(Suppl 1):S13 ADA, 2015

When to screen Screening 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 >180 mg/dl (10 mmol/L) 2 hour post 75 gm load >153mg/dl (8.5 mmol/L) If woman tests negative, screening at 32 weeks also may be necessary in presence of high risks The recommended screen for gestational diabetes is to have the woman come to the lab or clinic fasting. A blood sample is drawn, then a 75 gm glucose load is given, this should be sipped and completed in 5-10 minutes. A blood samples are then drawn at 1 and 2 hours after the drink is taken. Gestational diabetes is diagnosed when one or more of the criteria is met. The reason there is a range of 92-125 mg/dl (5.0-6.9mmol/L) is that if the fasting level is over 126mg/dl or 7 mmol/L the woman would be diagnosed with diabetes – after a second confirming test. World Health Organization. About diabetes. Cited May 10, 2013 from http://www.who.int/diabetes/action_online/basics/en/index1.html World Health Organization, 2013

Diagnostic criteria Fasting plasma glucose 5.1-6.9 mmol/L WHO (2013) 1 or more IADPSG ADA “one step” “two step” Fasting plasma glucose 5.1-6.9 mmol/L (92-125 mg/dl) >5.1 mmol/L (92 mg/dl) 50-g glucose load (nonfasting) If 1 hour > 7.8mmol/L (140mg/dl) – Do 100 g OGTT GDM If 2 of 4 results high 1 hour PG after 75gm load >10.0mmol/L (180mg/dl) 2 hour PG after 75gm load 8.5-11.0 mmol/L (153-199 mg/dl) >8.5 mmol/L (153 mg/dl) This slide simply shows a comparison of different screening methods. Note: the 2015 NICE guidelines opted for a 5.6-mmol/L (101-mg/dL) cutoff using a one-step single fasted 75-g 2-hour oral glucose tolerance test [OGTT] (and/or 2-hour glucose of > 7.8 mmol/L). ADA 2 step method After the 100 g OGTT Fasting 95mg/dl(5.3(mmol/L) or Fasting 105 mg/dl(5.8 mmol/L) 1 hr 180 mg/dl (10 mmol/L) 1 hr 190 mg/dl (10.6 mmol/L) 2 hr 155 mg/dl (8.6 mmol/L) 2 hr 165 mg/dl (9.2 mmol/L) 3 hr 140 mg/dl (7.8 mmol/L) 3 hr 145 mg/dl (8 mmol/L) Mohan V, Mahalakshmi MM, Bhavadharini B, Maheswari K, Kalaiyarasi G, Anjana RM, Uma R, Usha S, Deepa M, Unnikrishnan R, Pastakia SD, Malanda B, Belton A, Kayal A. Comparison of screening for gestational diabetes mellitus by oral glucose tolerance tests done in the non-fasting (random) and fasting states. Acta Diabetologica. 2014;51:1007-1013. Diabetes Care 2015, WHO 2013

How 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 - Fasting plasma glucose as a screening test for gestational diabetes mellitus, Archives of Gynecology and Obstetrics 2007 Agarwal et al, 2007

Venous 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. If facilities are not available, a capillary sample should be taken but the result should be confirmed as soon as possible with a venous sample taken at an appropriate facility. There is no need to adjust the capillary result as meters have been adjusted to report venous levels in the factory. Das, V, Jain V, Afarwal A, Pandey A et al Glucometer screening of gestational diabetes. J Obs & Gyn of India. 2006;56(6):499-501. Bhavadharini B, Mahalakshmi MM, Maheswari K, Kalaiyarasi G, Anjana RM, Deepa M, Ranjani H, Priya M, Uma R, Usha S, Pastakia SD, Malanda B, Belton A, Unnikrishnan R, Kayal A, Mohan V. Use of capillary blood glucose for screening for gestational diabetes mellitus in resource-constrained settings. Acta Diabetologica. 2015 Apr 28. [Epub ahead of print].

Which 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) Rupinder does NOT have GDM as her results are all within range… she is however at risk as she is overweight, 35 years old – should she be retested? When? Answer : at about 32 weeks Manju – does NOT have GDM, she has diabetes – both her fasting level and 2 hr PG are above diagnostic levels for diabetes. Technically she would be said to have GDM because it was discovered during pregnancy, but what should be done once she has delivered? Ashima – DOES have GDM – her fasting level and 1 hour are normal but her 2 hr PG is above the diagnostic level of 153 mg/dl (8.5 mmol/L).

Giving 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

References American Diabetes Association. Clinical Practice Recommendations 2015. Diabetes Care. 2015;38(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 2007;30(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. 2013;37(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. 2008;31(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 2002;25:1862-1868 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. 2007;30(suppl 2):S251-260. Perkins JM, Dunn JP, Jagastia SM. Perspectives in gestational diabetes mellitus: A review of screening, diagnosis and treatment. Clinical Diabetes. 2007;25(2):57-62 WHO. Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy , 2013