Screening and Diagnosis of Diabetes Mellitus during
Pregnancy
Prof. Recep Has Istanbul University
Ob&Gyn and Perinatology
Controversies in Gestational Diabetes
• Screen or not?
• Selective or universal screening?
• One or two step testing?
• Criteria for diagnosis?
• Criteria for the use of insulin?
• Role of oral hypoglycaemic drugs?
Diabetes in Pregnancy
• Prevalence: 3-14%
• Predisposition to Type 2 DM
– 50% > type 2 DM
• Recurrence in future pregnancies: 30-84%
Gestational diabetes
Diabetes diagnosed first time in pregnancy
•15-20% pregestational
•More complications
•Screening at first visit (B)
Albrecht SS, 2010Diabetes in Pregnancy:
Epidemiology
Albrecht SS, 2010
Diabetes in Pregnancy 6-7%
of GDM 90%
O Total GDM
Type 2
Type 1
Hyperglicemia
Shoulder dystocia
LGA
Why Diagnose and Treat GDM?
Mother Fetus Newborn Childhood/
Addult
Dystosia Macrosomia RDS Obesity
C/S Shoulder dystocia
and nerve injury
Hypoglicemia Type II diabetes
Preeclampsia Cardiomyopathy Hypocalcemia Metabolic syndrome Type II diabetes Preterm delivery Hyperbilirubinemia
Metabolic syndrome
Policytemia
What happened in recent years with gestational diabetes?
• Studies showed that
– mild hyperglicemia have adverse effects on pregnancy results, – and treatment is beneficial
• One step screening with 75 gr OGTT is recommended (IADPSG)
• Oral antidiabetics are in use
Studies
• HAPO. Hyperglycemia and adverse pregnancy outcomes.
– HAPO Study. N Engl J Med 2008;358:1991
• ACHOIS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.
– Crowther CA, et al. N Engl J Med 2005;352:2477
• MFMUN. A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes
– Landon MB, et al. N Engl J Med 2009;361:1339
HAPO
– NEJM, 2008
– Prospective, blinded
– Multicenter, different etnic groups
• 25.505 women
• 24 – 32 w. 75 gr GTT – Exclusion:
Fasting >105 mg/dL or 2. h ≥200 mg/dL or
Random ≥160 mg/dL
• Aim;
– To investigate maternal mild hyperglicemia related
pregnancy risks
• Fasting glucose levels divided 7 groups (5 mg/dl intervals)
HAPO: Incidence of Adverse Outcomes Increases Along Continuum
Metzger BE, et al. Hyperglycemia and Adverse Pregnancy Outcomes. NEJM 2008;358(19):1991-2002.
HAPO-Result:
• With increasing glocose levels;
– Birth weight
– Cord C-Peptid levels – C/S
– Neonatal
• Hypoglicemia
• Subcutaneus adipous tissue
– Complications are increasing
• There is no critical treshold
– Biological condition – Definition of GDM is
difficult
ACHOIS
Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.
Crowther CA, N Engl J Med.2005 Jun 16;352(24):2477-86.
Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group
Screenig: 75 g (Cases with a fasting 105-WHO criteria interval are included)
MFMUN-GDM
• 24-31 w
– 50 g+100 g OGTT – Fasting<95 mg
• Randomization
– 485 case (Diet + insulin if needed) – 473 control
• Primary results;
– fetal or perinatal death – birth trauma
– neonatal complications
• Results
• Composit results:
– 32.4% vs 37.0% ; (p: 0.14)
– No perinatal death
• Birth weight
– 3302 vs. 3408 g (p: 0.001)
• LGA
– 7.1% vs. 14.5% (p: 0.001)
• Shoulder dystocia
– 1.5% vs. 4.0% (p: 0.02)
• C/S
– 26.9% vs. 33.8% (p: 0.02)
• PIH
– 8.6% vs. 13.6%; (p: 0.01)
A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes.
Mark B. Landon. N Engl J Med. 2009 October 1; 361(14): 1339–1348.
Eunice Kennedy Shriver National Institute
GDM Screening
• Universal
– Endocrine Society, 2013 – ACOG, 2011
– ADA, 2011 – SOGC, 2002 – AACE, 2007 – WHO, 1999
• Risk based
– NICE 2008
– US Preventive Task Force 2008*
• *(2013) now recommends universal screening
GDM Screening Based on Risk Assessment
Risk category Recommendation
High risk Obesity
Strong family history of type 2 diabetes Previous history of GDM,
Impaired glucose metabolism, or glucosuria.
Ethnic group with a low prevalence of GDM Age ≥35 years
Polycystic ovarian syndrome Acanthosis nigricans
Testing as soon as feasable and Testing at 24 to 28 weeks
Moderate risk Testing at 24 to 28 weeks
Low risk
Ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives Age < 25 years
Weight normal before pregnancy Weight normal at birth
No history of abnormal glucose metabolism No history of poor obstetrical outcome
Testing not routinely required NICE
US Preventive Services Task Force
Standarts of Medical Care in Diabetes. Diabetes Care, 2012
GDM Screening All Women
• First visit • 24-28 w
IAPDPSG; 2010, ADA 2011
Standarts of Medical Care in Diabetes. Diabetes Care, 2012 The Endocrine Society Clinical Practice Guideline, 2013 US Preventive Task Force, 2013
First visit
Fasting, HbA1c, Random PG*
Fasting ≥126 mg/dL HbA1c ≥6.5 %
Random PG ≥200 mg/dL
Overt Diabetes
Fasting ≥92<126 mg/dL
GDM
Fasting <92 mg/dL HbA1c <6.5%
PG <200 mg/dL
24 – 28. w screening
IADPSG, 2010 ADA, 2012 ES, 2013
Screening 24-28 weeks
• Two Step
– 50g
– 100g or 75g OGTT
• One step
– 100 or 75g OGTT
Two step
1.H PG 140 135 130
Sensitivity % 79 98 100
Specificity % 87 80 78
Positive test % 13 20 22 50 g
Plasma glucose (mg/dl) National
Diabetes Data Group
(1979)1
The Fourth International
Workshop- Conference on
Gestational Diabetes2
Fasting 105 95
1.h 190 180
2.h 165 155
3.h 145 140
100 g OGTT
1. National Diabetes Group. 1979
2. Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 1998
GDM: 3-8%
2 ≥ values
One Step-75 g OGTT
Abnorm.
Result
Plasma glucose level (mg/dl) Prevalance (%)
CDA >2 F: 95, 1 h: 190, 2h: 160 7.9 EASD >1 F: 108, 2 h: 162 9.7 ADA >2 F: 95, 1 h: 180, 2 h: 155 10.6 NZSSD >1 F: 99, 2 h: 162 17.6 WHO >1 F: 126, 2 h: 140 19.6 ADIPS >1 F: 99, 2 h: 144 24.9
ADA: American Diabetes Association, ADIPS, Australasian Diabetes in Pregnancy Society; CDA, Canadian Diabetes Association; EASD, European Association for the Study of Diabetes; NZSSD, New Zealand Society for the Study of Diabetes; WHO, World Health Organization
Diabetes Care 2010;22:676-682
IADPSG
June 2008, Pasadena, California.
225 conferees from 40 countries reviewed (HAPO) study
HAPO: Incidence of Adverse Outcomes for Glucose Categories (OR 1.75 or 2.0 )
Metzger BE, et al. HAPO. NEJM 2008;358(19):1991-2002.
IADPSG Kriterleri
Coustan DR, Paving the way for new diagnostic criteria for GDM, 2010
HAPO
One step
Plasma Glucose Fasting 92 mg/dl
1 h 180 mg/dl
2 h 153 mg/dl
75 G OGTT
GDM 16.1%
Single value
IADPSG, 2010 ADA, 2012 ES, 2013
Obesity and diabetes in USA
South East Asia &
Pacific Region Nauru 78%
Tonga 70%
Samoa 63%
Niue 46%
French Polynesia 44%
Africa
Seychelles 28%
South Africa 28%
Ghana 20%
Mauritania 19%
Cameroon (urban) 14%
South Central America
Panama 36%
Paraguay 36%
Peru (urban) 23%
Chile (urban) 23%
Dominican Republic 18%
North America USA 33%
Barbados 31%
Mexico 29%
St Lucia 28%
Bahamas 28%
Eastern
Mediterranean Jordan 60%
Qatar 45%
Saudi Arabia 44%
Israel 43%
Lebanon 38%
European Region Albania 36%
Malta 35%
Turkey 29%
Slovakia 28%
Czech Republic 26%
% Obese 0-9.9%
10-14.9%
15-19.9%
20-24.9%
25-29.9%
≥30%
Obesity– Global prevalance
Diabesity epidemy, 2000 and 2030
Hossain et al NEJM, 2007
TURDEP I and II * studies in Turkey
• DM and Obesity in 12 years
1,2– DM 90% increased
– DM age 5 years earlier
– Women 6 kg & Men 8 kg increased
- Obesity 40% increased (22.3% 31.2%) 1998
2010
D. M. Prevalance (%)
0 5 10 15
13.7 7.2
90
%
*
TURDEP I and II: 1998 and 2010, population based, cross sectional, n: 24.7881 Satmanİ, TURDEP Group. Diabetes Care 2002;25:1551-6
2 Satman İ, Dinccag N. TURDEP-II Group 33. Natıonal Congress of Endocrinology 12-16 Oct 2011, Antalya
Istanbul Medical Faculty GDM prevalance
Year Deliveries GDM GDM
Prevalance (%)
1996- 1998 9.544 227 2
1999- 2004 16.007 688 4.3
2005- 2010 12.579 732 5.8
N. Dinççağ, R. Has, et al. 6th International Symposium on Diabetes and Pregnancy ,24-26 March Salzburg-Austria 2011
CONCLUSION
GDM SCREENING 2015: All Women
• First visit
– Standart methods
• Fasting
• HbA1C
• Random
(Level B evidence)
• 24-28 w
– Two step
• 50 and 100mg or
– One step
• 75 gr GTT
• >92/180/153
IAPDPSG; 2010, ADA 2011
Standarts of Medical Care in Diabetes. Diabetes Care, 2012 The Endocrine Society Clinical Practice Guideline, 2013
