GDM Full Presentation

8/15/2019 GDM Full Presentation

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GESTATIONALDIABETESEvidence For Universal Screening

Laura Andersen & Danielle Major Galasso


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+99 Topics - Objecties


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+Bac!"round

Gestational diabetes #ellitus $GDM% is associated it'aderse #aternal and (etal outco#es

Screenin" is reco##ended but t'e best screenin"#et'od $"lucose load) blood "lucose leel cut-o*) etc%re#ains controersial

Accordin" to t'e +,O denition (or an acceptablescreenin" pro"ra##e) GDM does not (ulll t'e criteria

T'e reco##endations outlined in t'e .DA "uidelinesare Grade . leel o( eidence at best


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+.DA Guidelines

All pre"nant o#en s'ould be screened (or GDM at /01/2 ee!s o( "estation 3Grade C, Level 34

I( t'ere is a 'i"' ris! o( GDM based on #ultiple clinical(actors) screenin" s'ould be o*ered at an5 sta"e in t'epre"nanc5 3Grade D, Consensus4

I( t'e initial screenin" is per(or#ed be(ore /0 ee!s o("estation and is ne"atie) re-screen beteen /0 and /2

ee!s o( "estation 3Grade D, Consensus4


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+.DA Guidelines

6is! (actors7

8reious GDM

8re-diabetes

,i"' ris! populationet'nicit5

A"e : ;< 5ears

BMI : ;=

,istor5 o( 8.OSacant'osis ni"racans

.orticosteroid use

,istor5 o( #acroso#ic in(antcurrent #acroso#ia


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+.DA Guidelines

T'e pre(erred approac' (or t'e screenin" anddia"nosis o( GDM is t'e (olloin" 3Grade D,Consensus47

Screenin" (or GDM s'ould be conducted usin" t'e 'our ill be considered apositie screen and ill be an indication to proceed to

t'e @< " OGTT 3Grade C, Level 2]


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+.DA Guidelines

8G ?>>> ##olL can be considered dia"nostic o("estational diabetes and does not reuire a @< " OGTT(or conr#ation 3Grade C, Level 34

I( t'e G.T screen is positie) a @< " OGTT s'ould beper(or#ed as t'e dia"nostic test (or GDM usin" t'e(olloin" criteria ?> o( t'e (olloin" alues7

Castin" ? 'our ?>= ##olL / 'ours ?9= ##olL [Grade B, Level 14


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+Grin, et al /===

Fniersal ersus ris!-(actor based screenin" (or "estation diabetes#ellitus7 detection rates) "estation at dia"nosis) and outco#eDiabetic Medicine 17 /-;/

Ai#7 prospectie) rando#ied stud5 ai#ed to co#pare di*erencesin outco#es in eit'er uniersall5 screened "roups ersus ris!-based

screenin" "roups

Met'ods7

Stud5 conducted oer /0-#ont' period in Dublin) Ireland

Subjects ere rando#ied at boo!in" on t'e basis o( 'ic' da5 t'e5ca#e to clinic

I( > : #ore ris! (actor as present) o#en ere allocated to ris!"#asedgrou$ and underent a >==" OGTT at ;/ ee!s GA

Ot'er o#en ere allocated to t'e universal grou$ 'o ere screenedit' a >-'r


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+Grin, et al /===

Met'ods conHt7

Subjects dia"nosed it' GDM ere reieed b5 an OB andendocrinolo"5 /ee!s until ; ee!s) t'en ee!l5

t'erea(ter All subjects ere instructed on appropriate diabetics diets

or treated it' insulin i( indicated

SD as aaited until 0/ ee!s

Cetal outco#e data as recorded $"estational a"e) (etal

'5po"l5ce#ia) '5perbilirubine#ia) birt' ei"'t% StudentHs t-test as used to statisitcall5 co#pare "roups

and p J ==<


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+Grin, et al /===

6esults7

>20


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+Grin, et al /===


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+Grin, et al /===

Botto# line7

Universal screening is su$erior %o ris!"&ac%or #asedscreening in %'e de%ec%ion o& GD( in lo)"ris!,Caucasian $o$ula%ion

alidit57

6ando#ied

8atient de#o"rap'ics ere eual in bot' "roups

Sa#ple o( patients at si#ilar point in course o( disease

Objectie and un-biased outco#e criteria ere used

+ill t'ese results c'an"e #5 practice


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+HAPO group) /==2

,5per"l5ce#ia and aderse pre"nanc5 outco#es

8rospectie obserational stud5

Ai#7 to clari(5 ris!s aderse outco#es associated it'arious de"rees #aternal "lucose intolerance less seeret'an oer DM

Met'ods

8articipants 1 all pre"nant o#en in t'e centres $international%)

ecludin"7 A"e J>) uncertain dates) inabilit5 to co#plete OGTT b5 ;/!s

GA) #ultiple pre") (ertilit5 treat#ent) d DM durin" or prior tocurrent pre") ,I or ,ep B.

@


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+HAPO group) /==2

Met'ods contHd

+o#en) care"iers and ,A8O sta* $ecept lab personnel% blindedto OGTT and rando# BG unless "lucose leel dia"nostic o( DM)sa(et5 reasons $'5per- or '5po"l5ce#ia%

Onl5 data (ro# o#en 'o re#ained blinded included in stud5

In(ant cord-blood sa#ples at delier5 $.-peptide and BG%

.ollected data on prenatal care) ti#in" o( delier5) neonatal care

Outco#es

8ri#ar5 1 B+ :9=t' Kile) .S) clinical neonatal '5po"l5ce#ia)

(etal '5perinsuline#ia $.-peptide :9=t' Kile% Secondar5 1 pre#ature delier5 $J;@!s%) s'oulder d5stocia)

need (or intensie neonatal care) '5perbilli) preecla#psia

Statistical anal5sis7 #ultiple lo"istic re"ressions $incl #odelcontrollin" (or potential con(ounders%


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Glucose ascate"oricalariableandpri#ar5outco#es


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+Glucose as continuous ariable and pri#ar5 & secondar5 outco#es


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+HAPO group) /==2

alidit5

6ando#ied NA

8atient c'aracteristics si#ilar at baseline NA

Blindin" Groups ere treated euall5 NA


T'res'old "lucose leels in GDM "uidelines based on O6/= (or pri#ar5 outco#e (ro# t'is stud5


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+Crowther et al, /==<

A.,OIS stud5P 6.T

Ai#7 to assess 'et'er tt (or GDM ould reduceoerinata co#plications and to assess 'et'er t'ee*ects o( treat#ent on #aternal outco#e) #ood) andQOL

Met'ods

8opulation7 sin"leton or tin pre" >-;=!s GA) attended

antenatal clinics) 'ad one or #ore 6C (or GDM or positie'r BGJ@2 and /'r BG @2->>= $"lucose intolerance%

6ando#iation7 central) nu#ber "enerator into bloc!s

Blinded


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Met'ods $contHd%

Interentions

Interention "roup 1 receied on"oin" care b5 OBP

interentions included dietar5 adice) instructions on SMBG$QID until it'in tar"et ran"e%) and insulin i( appropriate

6eplicated clinical care in 'ic' uniersal screenin" andtreat#ent (or GDM aailable

6outine care "roup 1 replicated clinical care in 'ic'screenin" (or GDM not aailable

8ri#ar5 outco#es

In(ants7 co#posite #easure serious perinatal co#plications)ad#ission neonatal nurser5) and jaundice p'otot'erap5

+o#en7 IOL) .S) 'ealt' status) ps5c'olo"ical outco#es

Secondar5 outco#es7 in(ants and o#en


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Met'ods $contHd%

Statistics

Intention to treat

Adjusted (or con(ounders 8ri#ar5 outco#es7 66) NNT) NN, (or binar5 outco#esP

ANOA (or continuous ariables

8oer calculation


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$SC-; R #easure o(#aternal 'ealt'

status%


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+Crowther et al) /==<

Botto# line7 %rea%en% o& GD( reduced ra%e o&serious $erina%al or#idi%. and a. alsoi$rove )oen/s 'eal%'"rela%ed 0L

alidit5

6ando#ied

8atient c'aracteristics si#ilar at baseline

.ontrolled (or di*erences

Blindin" Groups ere treated euall5


In(or#ed .DA "uideline (or uniersal GDM screenin"


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+Landon) et al /==9

A #ulti-centre) rando#ied trial o( treat#ent (or #ild"estational diabetes. New England Journal of Medicine317 >;;9-02

Ai#7 to deter#ine i( treat#ent o( #ild "estational

diabetes i#proes pre"nanc5 outco#es i.e., anabnor!al result on an oral glucose"tolerance test but afasting glucose le#el below $% !g per deciliter &%.'!!ol per liter()

T'e pri#ar5 outco#e as a co#posite o( stillbirt' or

perinatal deat' and neonatal co#plications) includin"'5perbilirubine#ia) '5po"l5ce#ia) '5perinsuline#ia) andbirt' trau#a

Secondar5 outco#es included birt' ei"'t "reater t'an0===") LGA) SGA) ad#ission to NI.F) or respirator5 distresss5ndro#e


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+Landon) et al /==9

Met'ods7 Included o#en /0-;> ee!s GA it' #ild GDM

6ando#l5 assi"ned to usual pre-natal care $con%rol grou$% or ordietar5 interention) sel(-#onitorin" o( blood "lucose) and insulint'erap5) i( necessar5 %rea%en% grou$%

+o#en co#pleted a (astin") ;-'r >==" OGTT

Eclusion criteria7

preeistin" diabetes

an abnor#al result on a "lucose screenin" test be(ore /0 ee!so( "estation

prior "estational diabetes

a 'istor5 o( stillbirt'

#ulti(etal "estation) ast'#a) or c'ronic '5pertension

i( t'e5 ere ta!in" corticosteroids

i( t'ere as a !non (etal ano#al5


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+Landon) et al /==9

Met'ods contHd7

Statistical anal5sis7

Aut'ors reieed literature to deter#ine t'e eent rates (oreac' o( t'e pri#ar5 outco#es dened in o#en it' andit'out treat#ent (or GDM

+it' sa#ple sie o( n R 9


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+Landon) et al /==9

6esults7

T'ere as no statisticall5 si"nicant di*erences in pri#ar5outco#e #easures $perinatal and neonatal (actors%

T'e #ean birt' ei"'tneonatal (at #ass) and (reuence o(LGA babies as si"nicantl5 reduced in t'e treat#ent "roup

$p J ===>% In ter#s o( #aternal (actors) c-section as si"nicantl5 less

co##on in t'e treat#ent "roup $pR==/% as ell as t'eincidence o( s'oulder d5stocia $pR==/%

Botto# Line7 %rea%en% &or ild GD( did no%reduce $riar. $erina%al ou%coes #u% didsignican%l. reduce %'e ra%e o& c"sec%ion, s'oulderd.s%ocia, acrosoia5LG6, and $re"ecla$sia


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+Landon) et al /==9

alidit57

6ando#ied usin" t'e si#ple urn #et'od

8atient c'aracteristics ere si#ilar at baseline

Blindin" as ac'ieed

Groups ere not treated euall5 +ill t'ese results c'an"e #5 practice

.DA "uidelines currentl5 reco##end t'is7

+o#en it' GDM s'ould receie nutrition counselin" (ro#a re"istered dietitian durin" pre"nanc5 3Grade C, Level

3] and postpartu# 3Grade D, Consensus46eco##endations (or ei"'t "ain durin" pre"nanc5s'ould be based on pre"raid BMI [Grade D, Consensus4


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+.riteria (or uniersal screenin"


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+Su##ar5

All pre"nant o#en s'ouldbe screened (or GDM at /0-/2

ee!s o( "estation 3Grade .)Leel ; $>/>%4

I( t'ere is a 'i"' ris! o( GDM

based on #ultiple clinical(actors) screenin" s'ould beo*ered at an5 sta"e in t'epre"nanc5 3Grade D).onsensus4 I( t'e initial

screenin" is per(or#ed be(ore/0 ee!s o( "estation and isne"atie) rescreen beteen/0 and /2 ee!s o( "estation


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Questions


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+6e(erences ,A8O Stud5 .ooperatie 6esearc' Group ,5per"l5ce#ia and

aderse pre"- nanc5 outco#es N En"l Med /==2P;99>e/==/

.rot'er .A) ,iller E) Moss 6) et al E*ect o( treat#ent o("estational diabetes #ellitus on pre"nanc5 outco#es N En"l Med/==

Documents

GDM Full Presentation