# Presentation: 231023

## Native Women’s Health and MCH Conference

**Native Women’s Health ****and MCH Conference**

**GESTATIONAL DIABETES**

- Donald R. Coustan,
- August 16, 2006

## Definition of GDM

**Definition of GDM**

**Carbohydrate intolerance, of varying severity, with onset or first recognition during pregnancy**

## Significance of GDM

**Significance of GDM**

**To the mother**
**To the pregnancy**

## LONG-TERM FOLLOWUP  OF GDMs 17-23 YEARS AFTER INDEX PREGNANCIES

**LONG-TERM FOLLOWUP  OF GDMs 17-23 YEARS AFTER INDEX PREGNANCIES**

**14%**

**61%**

**5%**

**39%**

***FORMER GDMs***

***CONTROLS***

***NDDG CRITERIA***

***WHO CRITERIA***

**O’Sullivan: **_**Carb Metab Preg Newborn**_** NY:Springer-Verlag, 1978, 425**

## Gestational Diabetes

**Gestational Diabetes**

**Conclusion: The history of gestational diabetes is a powerful predictor for the subsequent development of overt diabetes. **

## Gestational Diabetes

**Gestational Diabetes**

**Implications to the pregnancy**
**	****Perinatal Mortality**
**	****Perinatal Morbidity**

## Perinatal Mortality

**Perinatal Mortality**

**Recent studies show no increase in perinatal mortality**
**Recent studies all involved some sort of intervention**

## PERINATAL MORTALITY IN GESTATIONAL DIABETES

***PERINATAL MORTALITY IN GESTATIONAL DIABETES***

- 			***PERINATAL MORTALITY***
***UNTREATED***			**12/187**
***GDMs***				**(6.4%)**
***NORMAL***				 **4/259**
***CONTROLS***			 **(1.5%)**

**O’Sullivan et al  **_**AJOG **_**116:901,**_** **_**1973**

## Perinatal Mortality vs 2 hr Glucose

**Perinatal Mortality vs 2 hr Glucose**

**Deaths per**
**1000 Live**
**Births**

**Plasma Glucose (mg/dl)**

**Pettitt et al  **_**Diab Care  **_**161:638, 1989**

## GESTATIONAL DIABETES

**GESTATIONAL DIABETES**

**PERINATAL MORBIDITY**

## MORBIDITY IN GESTATIONAL DIABETES

**MORBIDITY IN GESTATIONAL DIABETES**

**MACROSOMIA**
**TRAUMATIC DELIVERY**
**OPERATIVE DELIVERY**
**SHOULDER DYSTOCIA**
**?LONG TERM OBESITY AND DIABETES**
**NEONATAL HYPOGLYCEMIA**
**NEONATAL PLETHORA**
**NEONATAL JAUNDICE**
**RDS**

## GESTATIONAL DIABETES

**GESTATIONAL DIABETES**

**MACROSOMIA**

## Macrosomia vs 2 hr Glucose

**Macrosomia vs 2 hr Glucose**

**>4 kgs per 100**
**Births**

**Plasma Glucose (mg/dl)**

**Pettitt et al  **_**Diab Care  **_**161:638, 1989**

## GESTATIONAL DIABETES

**GESTATIONAL DIABETES**

**RISK FACTOR FOR CHILDHOOD AND ADULT OBESITY**

## Slide 16

## GESTATIONAL DIABETES

**GESTATIONAL DIABETES**

**DEVELOPMENT OF DIABETES IN THE OFFSPRING**

## PREGNANCY GTT: EFFECT ON OFFSPRING

**PREGNANCY GTT: EFFECT ON OFFSPRING**

**Pettitt et al: *****Diabetes*****  40(S2)126, 1991**

## Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes

**Caroline A. Crowther, F.R.A.N.Z.C.O.G., Janet E. Hiller, Ph.D., John R. Moss, F.C.H.S.E., Andrew J. McPhee, F.R.A.C.P., William S. Jeffries, F.R.A.C.P., Jeffrey S. Robinson, F.R.A.N.Z.C.O.G. and the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group**

**N Engl J Med**
**Volume 352;24:2477-2486**
**June 16, 2005**

## AUSTRALIAN CARBOHYDRATE INTOLERANCE 

**RANDOMIZED CLINICAL TRIAL**
**N=1000 WITH “GLUCOSE INTOLERANCE”**
**75 GM, 2-HR OGTT**
**FASTING <140 mg/dl and**
**2 HR 140-200 mg/dl**
**IF FASTING >140 OR 2 HR >200, DX’D AS GDM AND ****	****NOT INCLUDED IN STUDY**
**18 CENTERS (14 IN AUSTRALIA, 4 IN ENGLAND)**

**AUSTRALIAN CARBOHYDRATE INTOLERANCE **
**STUDY IN PREGNANT WOMEN (ACHOIS) TRIAL**

## AUSTRALIAN CARBOHYDRATE INTOLERANCE 

**INTERVENTION GROUP (n=490)**
**INFORMED OF GLUCOSE INTOLERANCE**
**DIET, SMBG 4x DAILY**
**INSULIN IF FBG>100 OR 2 HR PP >126 TWICE IN TWO WEEKS**

**AUSTRALIAN CARBOHYDRATE INTOLERANCE **
**STUDY IN PREGNANT WOMEN (ACHOIS) TRIAL**

## AUSTRALIAN CARBOHYDRATE INTOLERANCE 

**ROUTINE CARE GROUP (N=510)**
**TOLD THEY DID NOT HAVE GDM**
**AN ADDITIONAL 20% OF NORMAL GTT SUBJECTS ****	****WERE INCLUDED IN ROUTINE CARE GROUP TO ****	****HELP MAINTAIN BLINDING**
**CAREGIVER  HAD DISCRETION FOR FURTHER ****	****TESTING FOR GDM, AND TREATMENT**

**AUSTRALIAN CARBOHYDRATE INTOLERANCE **
**STUDY IN PREGNANT WOMEN (ACHOIS) TRIAL**

## AUSTRALIAN CARBOHYDRATE INTOLERANCE 

**INTERVENTION GROUP REPLICATED CLINICAL CARE IN WHICH UNIVERSAL SCREENING AND TREATMENT FOR GDM IS AVAILABLE**
**ROUTINE CARE GROUP REPLICATED CLINICAL CARE IN WHICH SCREENING  FOR GDM IS NOT AVAILABLE**

**AUSTRALIAN CARBOHYDRATE INTOLERANCE **
**STUDY IN PREGNANT WOMEN (ACHOIS) TRIAL**

## Primary Clinical Outcomes among the Infants and Their Mothers

**Crowther, C. et al. N Engl J Med 2005;352:2477-2486**

## Secondary Outcomes among the Infants

**Crowther, C. et al. N Engl J Med 2005;352:2477-2486**

## RESULTS

- Number needed to treat to prevent a serious outcome* in the infant was 34 (CI 20-103)
- (*death, shoulder dystocia, bone fracture or nerve palsy)

## CONCLUSIONS

- This large randomized trial of the treatment of gestational diabetes demonstrated that serious perinatal complications were significantly less common among the offspring of women who received dietary advice, blood glucose monitoring, and insulin therapy as needed to maintain glycemic control than among the offspring of women who received routine care

## Study Overview

- These findings provide strong support for the implementation of screening for and treatment of gestational diabetes

## THE EPIDEMIC OF DIABETES

**Prevalence of Diagnosed Diabetes by Age, United States, 1980–2004**
**For females, 0-44 years, 0.7% in 1980, 1.3% in 2004**

- CDC web site
- http://www.cdc.gov/diabetes/statistics/prev/national/figbyage.htm

## THE EPIDEMIC

**WE ARE IN THE MIDST OF A GROWING EPIDEMIC OF OBESITY AND TYPE 2 DIABETES**
**IS THERE A SIMILAR EPIDEMIC OF GESTATIONAL DIABETES?**

## THE EPIDEMIC

**WHY ARE CHANGES IN THE PREVALENCE OF GDM DIFFICULT TO ASCERTAIN?**

## THE EPIDEMIC

**NO UNIFORM GTT PROTOCOL**
**DIFFERENT CHALLENGES (50, 75, 100 GMS)**
**DIFFERENT THRESHOLDS**
**DIFFERENT DURATIONS (2 HR, 3 HR)**
**DIFFERENT MEDIA (CAPILLARY BLOOD, VENOUS PLASMA, ETC)**

## THE EPIDEMIC

**SHIFTS IN AGE AT CHILDBEARING**
**POPULATION VARIATIONS IN PREVALENCE**

## THE EPIDEMIC – POPULATION VARIANCES IN PREVALENCE

| Location | Ethnicity | Prevalence |
| --- | --- | --- |
| Providence | 88% white | 2.0% |
| Arizona | Tohono O’odham | 3.2% |
| Long Island | 61% black | 3.9% |
| Alaska | Yup’ik Eskimo | 5.8% |
| Los Angeles | Hispanic | 8.8% |
| New Mexico | Zuni | 14.3% |

- _Diabetes in America_, NIDDK, 19956

## THE EPIDEMIC

**Ferrara et al *****ObGyn***** 103:526, 2004**

**KAISER NORTHERN CALIF GDM REGISTRY**
**307,826 PREGNANCIES WITHOUT PRE-EXISTING DIABETES FROM 1991-2000**
**267,051 (87%) WERE SCREENED FOR GDM**
**SCREENING INCREASED OVER THE YEARS:**
**65% IN 1991**
**95% IN 1996**
**93% IN 2000**

## THE EPIDEMIC

**Ferrara et al *****ObGyn***** 103:526, 2004**

**16,918 PREGNANCIES IDENTIFIED WITH GDM (C&C)**
**CRUDE INCIDENCE:**
**1991 4.7%**
**1996 6.8%**
**2000 7.2%**
**AGE, ETHNICITY ADJUSTED INCIDENCE:**
**1991 5.1%**
**1996 6.8%**
**2000 6.9%**

## THE EPIDEMIC

**Ferrara et al *****ObGyn***** 103:526, 2004**

**AGE-ADJUSTED INCIDENCE OF GDM BY RACE AND ETHNICITY:**

|  | 1991 | 1996 | 2000 |
| --- | --- | --- | --- |
| WHITE | 3.9% | 5.4% | 5.7% |
| AFRICAN-AMERICAN | 4.1% | 5.6% | 6.4% |
| HISPANIC | 7.2% | 8.2% | 8.3% |
| ASIAN | 7.2% | 10% | 9.7% |

## THE EPIDEMIC

**Ferrara et al *****ObGyn***** 103:526, 2004**

**GESTATIONAL DIABETES IS INCREASING IN NORTHERN CALIFORNIA!**

## THE EPIDEMIC

**Dabelea et al *****Diab Care***** 28:579, 2005**

**KAISER OF COLORADO PERNATAL DATABASE**
**36,403 SINGLETON PREGNANCIES FROM 1994-2002**
**ALL THOSE WHO WERE SCREENED FOR GDM**
**EXCLUDED IF PRE-EXISTING DIABETES**
**USED NDDG CRITERIA FOR GDM**

## THE EPIDEMIC

**Dabelea et al *****Diab Care***** 28:579, 2005**

**1,183 PREGNANCIES IDENTIFIED WITH GDM (NDDG)**
**1994 2.1%**
**2002 4.1%**

## THE EPIDEMIC

**Dabelea et al *****Diab Care***** 28:579, 2005**

**AGE-ADJUSTED INCIDENCE OF GDM BY RACE AND ETHNICITY:**

|  | 1994-96 | 2000-02 |
| --- | --- | --- |
| WHITE | 1.9% | 3.4% |
| AFRICAN-AMERICAN | 2.5% | 4.6% |
| HISPANIC | 2.8% | 5.1% |
| ASIAN | 6.3% | 8.6% |

## THE EPIDEMIC

**Ferrara et al *****ObGyn***** 103:526, 2004**

**GESTATIONAL DIABETES IS INCREASING IN COLORADO!**

## IMPLICATIONS

**WILL THE GDM EPIDEMIC CONTRIBUTE TO, AND BE STIMULATED BY, THE RISE IN PREVALENCE OF OBESITY AND TYPE 2 DIABETES?**

## GESTATIONAL DIABETES

**GESTATIONAL DIABETES**

**SCREENING AND DIAGNOSTIC TESTING**

## ADA EXPERT COMMITTEE (1997)

**ADA EXPERT ****COMMITTEE (1997)**

**UNIVERSAL SCREENING, *****EXCEPT***
**LOW-RISK GROUP IN WHICH UNIVERSAL SCREENING MAY NOT BE COST EFFECTIVE**
**MUST MEET *****ALL***** OF THE FOLLOWING:**
**<25 YEARS OF AGE**
**NORMAL BODY MASS INDEX**
**NO FAMILY HX OF DM**
**NOT MEMBERS OF ETHNIC/RACIAL GROUP WITH HIGH PREVALENCE OF DM**
**THRESHOLD EITHER 130 MG/DL OR 140 MG/DL**

## ACOG (AS OF 2001)

**ACOG (AS OF 2001)**

**ACKNOWLEDGES UNIVERSAL SCREENING MOST SENSITIVE**
**THERE MAY BE LOW RISK GRAVIDAS LESS LIKELY TO BENEFIT FROM UNIVERSAL SCREENING**
**VERY HIGH RISK GROUPS MAY PROCEED DIRECTLY TO OGTT**
**CRITERIA SIMILAR TO ADA STATEMENT**

**ACOG PRACTICE BULLETIN 30, 2001**

## GESTATIONAL DIABETES

**GESTATIONAL DIABETES**

**GLUCOSE TOLERANCE TEST CRITERIA**

## O’SULLIVAN AND MAHAN CRITERIA

**FASTING****	****	**** 90 mg/dl**
**1 HOUR****	****	****	****165 mg/dl**
**2 HOURS****	****	****143 mg/dl**
**3 HOURS****	****	****127 mg/dl**

**VENOUS WHOLE BLOOD, SOMOGYI-NELSON**

## O’SULLIVAN AND MAHAN CRITERIA

**FASTING****	****	**** 90 mg/dl**
**1 HOUR****	****	****	****165 mg/dl**
**2 HOURS****	****	****145 mg/dl**
**3 HOURS****	****	****125 mg/dl**

**VENOUS WHOLE BLOOD, SOMOGYI-NELSON**

## NDDG CONVERSION

**FASTING****	****	****105 mg/dl**
**1 HOUR****	****	****	****190 mg/dl**
**2 HOURS****	****	****165 mg/dl**
**3 HOURS****	****	****145 mg/dl**

**VENOUS PLASMA OR SERUM**

## CARPENTER & COUSTAN CONVERSION

**FASTING****	****	**** 95 mg/dl**
**1 HOUR****	****	****	****180 mg/dl**
**2 HOURS****	****	****155 mg/dl**
**3 HOURS****	****	****140 mg/dl**

**VENOUS PLASMA, GLUCOSE OXIDASE**

## “HEAD-TO-HEAD” TEST RESULTS

**	****	****	****	*****SACKS******	******NDDG******	******C&C***
**FASTING****	****	**** ****96****	****	****105*****	****	****  95***
**1 HOUR****	****	****172****	****	****190****	****	****180***
**2 HOURS****	****	****152****	****	****165****	****	****155***
**3 HOURS****	****	****131****	****	****145****	****	****140***
**= ****VALUE WITHIN 95% CONFIDENCE LIMITS OF ****	****SACKS’ CONVERSIONS**

**SACKS ET AL  AJOG  161:638, 1989**

## HAPO STUDY

**~23,000 NON-DIABETIC GRAVIDAS**
**13 CENTERS**
**10 DIFFERENT COUNTRIES**
**BLINDED 75 GM OGTT 24-28 WEEKS**
**EXCLUDED IF FBS >105 MG/DL, **

**UNPUBLISHED DATA**

## HAPO STUDY

_**CONTINUOUS**_** RELATIONSHIP BETWEEN FBS, 1-HR AND 2-HR GLUCOSE ON 75 GM OGTT WITH:**
**MACROSOMIA**
**CESAREAN SECTION**
**NEONATAL HYPOGLYCEMIA**
**CORD BLOOD C-PEPTIDE**
**RELATIONSHIP HOLDS EVEN DOWN TO LOWER LEVELS OF GLUCOSE**

**UNPUBLISHED DATA**

## HAPO STUDY

**NEED FOR INTERNAITONAL AGREEMENT ON GTT CRITERIA**
**THIS WILL REQUIRE AGREEMENTN ON WHAT LEVEL OF “MORBIDITY” IS CONSIDERED WORTH PREVENTING**
**CONSENSUS CONFERENCE PLANNED**

**UNPUBLISHED DATA**