1. Turkish Guidelines for the management of pregnancies with GDM
OLUS API
YedITEPE UNIVERSITY HOSPITAL, ISTANBUL, TURKEY

2. one of the largest health emergencies of the 21st century
1 in 11 adults have diabetes (415 million)
By 2040, 1 adult in 10 (642 million) will have diabetes
The prevalence of diabetes is increasing worldwide
IDF Diabetes Atlas, 7th Edition, 2015

3. 1 in 7 births is affected by gestational diabetes
16.2 % OF LIVE BIRTHS

4. HAPO: Incidence of Adverse Outcomes Increases Along Continuum
N Engl J Med May 8;358(19): doi: /NEJMoa
Hyperglycemia and adverse pregnancy outcomes.
HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, Coustan DR, Hadden DR, McCance DR, Hod M, McIntyre HD, Oats JJ, Persson B, Rogers MS, Sacks DA.
Source
Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
Abstract
BACKGROUND:
It is controversial whether maternal hyperglycemia less severe than that in diabetes mellitus is associated with increased risks of adverse pregnancy outcomes.
METHODS:
A total of 25,505 pregnant women at 15 centers in nine countries underwent 75-g oral glucose-tolerance testing at 24 to 32 weeks of gestation. Data remained blinded if the fasting plasma glucose level was 105 mg per deciliter (5.8 mmol per liter) or less and the 2-hour plasma glucose level was 200 mg per deciliter (11.1 mmol per liter) or less. Primary outcomes were birth weight above the 90th percentile for gestational age, primary cesarean delivery, clinically diagnosed neonatal hypoglycemia, and cord-blood serum C-peptide level above the 90th percentile. Secondary outcomes were delivery before 37 weeks of gestation, shoulder dystocia or birth injury, need for intensive neonatal care, hyperbilirubinemia, and preeclampsia.
RESULTS:
For the 23,316 participants with blinded data, we calculated adjusted odds ratios for adverse pregnancy outcomes associated with an increase in the fasting plasma glucose level of 1 SD (6.9 mg per deciliter [0.4 mmol per liter]), an increase in the 1-hour plasma glucose level of 1 SD (30.9 mg per deciliter [1.7 mmol per liter]), and an increase in the 2-hour plasma glucose level of 1 SD (23.5 mg per deciliter [1.3 mmol per liter]). For birth weight above the 90th percentile, the odds ratios were 1.38 (95% confidence interval [CI], 1.32 to 1.44), 1.46 (1.39 to 1.53), and 1.38 (1.32 to 1.44), respectively; for cord-blood serum C-peptide level above the 90th percentile, 1.55 (95% CI, 1.47 to 1.64), 1.46 (1.38 to 1.54), and 1.37 (1.30 to 1.44); for primary cesarean delivery, 1.11 (95% CI, 1.06 to 1.15), 1.10 (1.06 to 1.15), and 1.08 (1.03 to 1.12); and for neonatal hypoglycemia, 1.08 (95% CI, 0.98 to 1.19), 1.13 (1.03 to 1.26), and 1.10 (1.00 to 1.12). There were no obvious thresholds at which risks increased. Significant associations were also observed for secondary outcomes, although these tended to be weaker.
CONCLUSIONS:
Our results indicate strong, continuous associations of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels.
Metzger BE, et al. Hyperglycemia and Adverse Pregnancy Outcomes. NEJM 2008;358(19):

5. Why Diagnose and Treat GDM?
MATERNAL MORBIDITY
Short-term
Preterm labor
Preeclampsia
Traumatic labor
Caesarian section
Postoperative/postpartum infection
Postoperative/postpartum hemorrhage
Thromboembolism
Maternal morbidity and mortality
Hemorrhage
Post-partum & Long-Term
Failure to initiate and/or maintain breastfeeding
Infection
Weight retention
GDM in subsequent pregnancy
Future overt diabetes
Future cardiovascular diseasePrevent future risks for the mother (CVD, DM II)

6. Why Diagnose and Treat GDM?
FETAL/NEONATAL/CHILD MORBIDITY
Short-term
Stillbirth
Neonatal death
Shoulder dystocia
Respiratory distress syndrome
Excessive fetal growth (macrosomia, large for gestational age)
Cardiomyopathy
Neonatal hypoglycemia
Neonatal polycythemia
Neonatal hyperbilirubinemia
neonatal hypocalcemia
Erb’s palsy (as consequence of birth injury)
Long-Term
Programming and imprinting; fetal origins of disease: diabetes, obesity, hypertension, metabolic syndrome

7. DIABETES IN TURKEY
Diabetes has become one of the major public health issues also in Turkey
Rapid economic growth
Increase in life expectancy
Changes in lifestyle
According to the recent global estimates of the World Health Organization, there will be 300 million people with diabetes by the year 2025.
POSSIBLE CAUSES
World Health Organization. World health statistics Geneva: WHO Press; 2011.

8. > 12 %

9. 6-8%

10. EPIDEMIOLOGY OF DIABETES: TURKEY DATA
TURDEP STUDY-1 & TURDEP STUDY-2
Turkish Diabetes Epidemiology Study Group
Turkey was a country where awareness of diabetes was poor. Screening programs date back to the
1940s, and nearly 1 million people have been screened to date, but because of differing methodology and lack of standardization between studies, considerable variations in diabetes prevalence have been reported from one area to another and even in the same area over time
INCREASING PREVALANCE

11. Cross-sectional, population-based survey, 1997-1998
N = 24,788 subjects (age ≥ 20 years, women 55%, response 85%)
Glucose tolerance was classified according to WHO recommendations on the basis of 2-h blood glucose values
Satman I et al. Diabetes Care, 2002

12. *TURDEP-1 STUDY: Satman İ, Yılmaz T and TURDEP Study Group
TURDEP-1 STUDY RESULTS
(> 20 YEARS OF AGE)
Diyabet %
Yeni DM %
Bilinen D %
BGT %
DIABETES
UNDIAGNOSED DM
KNOWN DM
IGT
*TURDEP-1 STUDY: Satman İ, Yılmaz T and TURDEP Study Group

13. TURGEP-II STUDY
Cross-sectional, population-based survey, 15 January to 11 June 2010.
N = 26,499 subjects (age ≥ 20 years, response 87%)
Fasting glucose and biochemical parameters were measured in all; then a OGTT was performed.
amples from both urban and rural populations in five geographical regions corresponding to the first survey.
Three provinces from each region, six counties from each province, and three urban districts and three rural villages from each county were randomly selected.
Satman I et al. Eur J Epidemiol, 2013

14. *TURDEP-2 STUDY: Satman I and TURDEP Study Group
TURDEP-2 STUDY RESULTS
(> 20 YEARS OF AGE)
Diabetes 13.7%
(UNDIAGNOSED) 45.5%
IGT %
The crude prevalence of diabetes was 16.5 % (95 % CI: 16.1–17.0); of them 45.5 % had newly diagnosed (prevalence:
7.5 %; 95 % CI: 6.3–8.7) and 54.5 % previously known (9.0 %; 7.8–10.1) diabetes (p\0.001). Among previously known diabetes 85.5 % was on anti-diabetic medications (OAD: 71.9 %, insulin: 2.2 %, insulin ? OAD: 11.4 %).
*TURDEP-2 STUDY: Satman I and TURDEP Study Group

15. AGE-SPECIFIC DIABETES RATES
TURDEP-1 AND TURDEP-II
AGE GROUPS
OVERALL 13.7 %, MEN 12.4 %, WOMEN 14.6 %

16. TURKEY MINISTRY OF HEALTH, CHRONIC DISEASES & RISK FACTORS STUDY – PHYSICAL INACTIVITY
MEN
INADEQUATE
MODERATE
ADEQUATE
WOMEN
INADEQUATE
MODERATE
ADEQUATE
ANKARA, 2013

17. Obesity rates in women & men TURDEP-II
Obesity ; BMI

18. Rate of diabetes & prediabetes increasing in Turkey
Prevalance of Diabetes(%)
Percent Increase DM
%90
IGT
% 106
Obesity
% 40
Central Obesity
% 35
Hypertension
% 11 15
% 64,5
%90
13.7
(16.5) 10
1997
2010
% 49,8
7.2 5
Average age ↑ 4 years,
Women 6 kg,average waist 6 cm ↑
Men 8 kg, average waist 7 cm ↑
Onset of diabetes 5 years earlier
Satman I et al. Eur J Epidemiol, 2013
Satman I et al. Diabetes Care, 2002

19. CHALLENGES IN DIAGNOSIS OF GDM IN TURKEY

20. 1) DIAGNOSIS OF PREDIABETES
‘Isolated-IFG’ FPG levels = 5.6–6.9 mmol/L (100–125 mg/dL) but 2-hPG levels < 7.8 mmol/L ( < 140 mg/dL)
Isolated-IGT 2-hPG levels 7.8–11.0 mmol/L (140–199 mg/dL) but FPG levels < 5.6 mmol/L (<100 mg/dL)
Combined prediabetes (IFG + IGT) Both FPG levels 5.6–6.9 mmol/L (100–125 mg/dL) and 2-hPG levels 7.8–11.0 mmol/L (140–199 mg/dL)
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care. 2003;26:3160–7.

21. IMPAIRED FASTING GLUCOSE (IFG) IMPAIRED GLUCOSE TOLERANCE (IGT)
TURDEP-II: Prediabetes The crude prevalence of prediabetes was 30.8 % (isolated- IFG 14.7 %, isolated-IGT 7.9 %, and combined 8.2 %).
IMPAIRED FASTING GLUCOSE (IFG)
IMPAIRED GLUCOSE TOLERANCE (IGT)
COMBINED IFG + IGT
CRUDE RATE
STANDARDIZED RATE

22. 45.5 % for TURKEY according to TURDEP-II study

23. MARCH, 2017

24. M. Hod et al. International Journal of Gynecology and Obstetrics ; 2015

27. This clinical practice guideline was prepared by the
Diabetes and Pregnancy Study Group of Turkish
Perinatology Society to clarify controversial issues in
Turkey and facilitate clinical practice in the light of new
scientific data obtained on pregnancy and diabetes
recently.

29. Recommendations for screening GDM
All pregnant women should be screened for GDM at weeks of gestation [Grade C, Level3 3)
If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy [Grade D, Consensus].
If the initial screening is performed before 24 weeks of gestation and is negative, rescreen between weeks of gestation.

32. USING THE IADPSG criteria
The rate of diagnosed GDM cases increases to 18%.
More intervention
What is the impact on the patient and workload of increasing the prevalence of GDM?
Do we have sufficient evidence with respect to treatment benefit at the various thresholds to make an informed decision?