1. GDM- why it is important.
Professor Fidelma Dunne MD PhD FRCP FRCPI
Consultant Endocrinologist
Saolta University Hospital Group and National University of Ireland Galway Ireland.

2. Gestational Diabetes (GDM)
GDM detects an at-risk pregnancy for mother.
GDM detects an at risk pregnancy for the infant.
GDM is associated with increased future maternal life-time risk of Type 2 DM (50%).
GDM is associated with increased rates of obesity and pre- diabetes in adolescents and type 2 DM in adult life of the offspring.
DIABETES BEGETS DIABETES.

3. Why are we concerned about GDM?
Mother
Infant
PIH/PET
CS delivery
Future Diabetes
Obesity
MetS/CVS
Macrosomia.
Hypoglycaemia/NNU
Future Diabetes
Future Obesity
Autism
Fatty Liver
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4. What global factors are contributing to increased GDM prevalence?
Prevalence of Type 2 DM; NHANES 4.6% (18-44 y).
Prevalence of pre-diabetes NHANES 26.4% (18-44 y).
Prevalence of Obesity, 20-30% global estimates.
Rising maternal age for pregnancy.
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5. GDM- Can we make a difference?
Screening is easy and not costly.
Interventions are low key for the majority.
Treatments make a difference.
Future maternal Type 2 DM can be prevented.
Future maternal CVS risk can be addressed.
Family health can influence offspring health.
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6. 6 6

7. Macrosomia

12. Who should we screen? How should we screen?

13. Who?
Universal
Selective
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14. How? IADPSG/ WHO 2014---Perinatal outcomes
Carpenter & Coustan--- Future Diabetes Risk
NICE Cost
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18. Socio-Economic Status
Womens’ addresses were ‘geocoded’.
Geocoding = Assigning geographic coordinates (longitude-latitude) to each address.

19. Distance from test hospital
For every 10km required to travel, the probability of attending for screening is reduced by 2%
e.g. If you live 50km away from hospital, you are 10% less likely to attend
If you like 100km away you are 20% less likely to attend.

20. Deprivation Score Correlation study:
Relative to Deprivation score 1, ie ‘wealthiest’;
Score 2: 2.3% less likely to attend p=0.138
Score 3: 4.3% less likely to attend p=0.008
Score 4: 7.6% less likely to attend p=0.0001
Score 5:14.5% less likely to attend p=0.0001

21. School Institute Name to go here

22. Results: Primary v Secondary uptake rates
Secondary care group significantly more likely to attend at their randomised location (p < 0.001)
School of Medicine
National University of Ireland, Galway

23. Preventing GDM
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24. 4 individual risk factors
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25. Combining risk factors
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26. School Institute Name to go here

27. Exercise pre-pregnancy
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28. Exercise in early pregnancy
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29. Treatment of GDM? MNT and Exercise (70%) Insulin (30%)
Metformin (NICE)
Glibenclamide (ACOG)
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32. Is treatment beneficial?
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33. Shoulder Dystocia
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34. Macrosomia
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35. Preeclampsia
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36. What dietary intervention works?
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37. School Institute Name to go here

38. Diet and Exercise interventions in GDM- does it work?
The Atlantic DIP dataset was utilized: N = 567 women with GDM. (D+E) N = 2499 with NGT.

39. Differences in Characteristics
GDM
N = 567
NGT
N = 2499
P value
Age
(mean =/-sd)
33.4 (4.9)
31.5(5.2)
<0.01
BMI
(mean+/-sd)
30.5 (6.1)
26.7 (4.8)
BMI>30
N (%)
279 (49%)
522 (21%)
SBP
119.7 (13.3)
116.3 (17.1)
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40. Differences in infant size
GDM
N =567
NGT
N = 2499
P value
LGA
(>90th C)
BMI <25
BMI 25-30
BMI>30
9.4%
10.4%
15.1%
12.2%
16.0%
21.8%
0.4
0.06
0.02
Macrosomia
(> 4kg)
7.5%
11.0%
17.6%
16.5%
27.0%
0.01
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41. Composite Poor Neonatal Outcome
OR (CI ) P 0.03
21% less likely to have an adverse outcome
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42. Gestational weight gain in GDM?
Is it important?
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43. Institute of Medicine Guidelines for Gestational Weight Gain
Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines; Rasmussen KM YA, editors: Weight Gain During Pregnancy: Reexamining the Guidelines

45. 57% women gained excessive weight (n=307).
Contrasts with prior studies in non-diabetic women (33%).1
1. Nohr et al. Am J Clin Nutr, 2008

47. Glucophage ?
Used in South Africa in Type 2 DM since Perinatal mortality similar.
Used extensively with PCOS with no adverse outcomes (Tang 2010).
3 systematic reviews and meta analysis (Gutzin 2003; Gilbert 2006; Juan Gui 2013; favour metformin re GWG, LGA, PIH, PET.
Less macrosomia in N/OW women (Ljas 2011).
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50. What are the health risks post GDM?
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55. Abnormal glucose tolerance status at follow-up
Previous GDM
(n=270)
Previous NGT
(n= 388)
p value for difference
IFG
12.2%
1.8%
IGT
5.9%
1.5%
IFG/IGT
5.6%
0.3% DM
2.2% 0%
Total
25.9%
3.6%
<0.001

56. Comparison of HbA1c and FPG to identify abnormal glucose post partum
Criteria
Sensitivity
(95% CI)
Specificity
PPV
NPV
not requiring OGTT
N(%)
HbA1c 5.7% 45
(32, 59) 84
(78,88) 39
(27,52) 87
(82,91)
206
(78)
FPG 5.6 mmol/l 80
(66, 89)
100
(98, 100)
(91, 100) 96
(92, 98)
224
(85)
HbA1c 5.7% and FPG 5.6mmol/L 90
(78, 96)
(78, 88) 56
(45, 66) 97
(94, 99)
184
(70)

58. Metabolic syndrome (MetS), obesity and insulin resistance indices at follow-up (mean 2.6 years)

59. Metabolic syndrome components (ATP-III) at follow-up (mean 2.6 years)

60. Feig D. PLOS medicine 2013

61. Can we prevent Type 2 DM?
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62. Prevention Type 2 following GDM DPP Aroda VR. JCEM 04/2015
DPP 3 year data; ILS reduced by 53%, metformin by 50%
DPP 10 year data; ILS reduced by 35%, metformin by 40%
Both ILS and metformin (850mg BD) are effective in reducing progression to Diabetes
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63. Preventing Type 2 DM after GDM Bao W. Diabetologia 03/2015 N =1695
Over 18 year F/U period
Each 5kg increase in weight after index GDM pregnancy associated with 27% higher risk of T2DM.
Postpartum weight management essential
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65. 65 65

66. Summary GDM is common. Dietary intervention works.
Breast feeding should be encouraged.
Diabetes post GDM is a public health concern but can be prevented.
Metabolic syndrome and future CVS risk post GDM is a public health concern and requires F/U.
A strong screening programme is essential.
Integrated care is required.
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