8/15/2019 GDM Full Presentation
1/37
+
GESTATIONALDIABETESEvidence For Universal Screening
Laura Andersen & Danielle Major Galasso
8/15/2019 GDM Full Presentation
2/37
+99 Topics - Objecties
8/15/2019 GDM Full Presentation
3/37
+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
8/15/2019 GDM Full Presentation
4/37
+.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
8/15/2019 GDM Full Presentation
5/37
+.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
8/15/2019 GDM Full Presentation
6/37
+.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]
8/15/2019 GDM Full Presentation
7/37
+.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
8/15/2019 GDM Full Presentation
8/37
+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
8/15/2019 GDM Full Presentation
9/37
+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 $"estational a"e) (etal
'5po"l5ce#ia) '5perbilirubine#ia) birt' ei"'t% StudentHs t-test as used to statisitcall5 co#pare "roups
and p J ==<
8/15/2019 GDM Full Presentation
10/37
+Grin, et al /===
6esults7
>20
8/15/2019 GDM Full Presentation
11/37
+Grin, et al /===
8/15/2019 GDM Full Presentation
12/37
+Grin, et al /===
Botto# line7
Universal screening is su$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
8/15/2019 GDM Full Presentation
13/37
+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.
@
8/15/2019 GDM Full Presentation
14/37
+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%
8/15/2019 GDM Full Presentation
15/37
+
Glucose ascate"oricalariableandpri#ar5outco#es
8/15/2019 GDM Full Presentation
16/37
+Glucose as continuous ariable and pri#ar5 & secondar5 outco#es
8/15/2019 GDM Full Presentation
17/37
8/15/2019 GDM Full Presentation
18/37
+HAPO group) /==2
alidit5
6ando#ied NA
8atient c'aracteristics si#ilar at baseline NA
Blindin" Groups ere treated euall5 NA
+ill t'ese results c'an"e #5 practice
T'res'old "lucose leels in GDM "uidelines based on O6/= (or pri#ar5 outco#e (ro# t'is stud5
8/15/2019 GDM Full Presentation
19/37
+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
8/15/2019 GDM Full Presentation
20/37
+Crowther et al, /==<
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
8/15/2019 GDM Full Presentation
21/37
+Crowther et al, /==<
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
8/15/2019 GDM Full Presentation
22/37
+
$SC-; R #easure o(#aternal 'ealt'
status%
8/15/2019 GDM Full Presentation
23/37
+
8/15/2019 GDM Full Presentation
24/37
8/15/2019 GDM Full Presentation
25/37
8/15/2019 GDM Full Presentation
26/37
+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
+ill t'ese results c'an"e #5 practice
In(or#ed .DA "uideline (or uniersal GDM screenin"
8/15/2019 GDM Full Presentation
27/37
+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
8/15/2019 GDM Full Presentation
28/37
+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
8/15/2019 GDM Full Presentation
29/37
+
8/15/2019 GDM Full Presentation
30/37
+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
8/15/2019 GDM Full Presentation
31/37
+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
8/15/2019 GDM Full Presentation
32/37
+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
8/15/2019 GDM Full Presentation
33/37
+.riteria (or uniersal screenin"
8/15/2019 GDM Full Presentation
34/37
+
8/15/2019 GDM Full Presentation
35/37
+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
8/15/2019 GDM Full Presentation
36/37
+
Questions
8/15/2019 GDM Full Presentation
37/37
+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/==