Pragmatic Approach to GDM Screening, Diagnosis and Care in South Asia Region
Prof Dr V Seshiah MD, FRCP, D Sc.,(Hony) Former Professor of diabetology , MMC President- Diabetes In Pregnancy Study Group, India (DIPSI) Vice- Chairman- International Association of Diabetes Pregnancy Study Group (IADPSG) Member, Expert Review CommitteeGlobal Guidelines on Diabetes & Pregnancy, International Diabetes federation and WHO,
I.Detection and treatment of diabetes in pregnancy pose a variety of health policy, health service delivery and technically challenges across a spectrum of world wide health care contexts. II.Diabetes in Pregnancy relates to the background risk of diabetes in the population and contributes to future diabetes and cardiovascular risk in the mother and offspring. III.It is an important problem that all levels of economic development, but immediate and pragmatic considerations, may limit the resources devoted to this issue in developing countries. Matching diagnosis and management of diabetes in pregnancy to local prioritis and resources: An international approach.V.Seshiah,David McIntyre, Moshe hod etal .2009. IJGO.
CONCERN
GDM represents detection of chronic β cell dysfunction Buchanan TA et al. What is Gestational Diabetes. Fifth International Workshop Conference on Gestational Diabetes Mellitus. Diabetes Care. Vol 30 (suppl 2), July 2007, S 105 - 111
GDM is a stage in the evolution of Type 2 DM Carpenter MW. Gestational Diabetes, Pregnancy, Hypertension and late vascular disease. Fifth International Workshop Conference on Gestational Diabetes Mellitus. Diabetes Care, Vol 30 suppl 2 , July 2007, S 246 – 250.
IMPLICATIONS Women with a history of GDM are at increased risk of future diabetes, predominantly type 2 diabetes, as are their children. Risk and prevention of type 2 diabetes in women with gestational diabetes. Anne Dornhorst, Michela Rossi. Diabetes Care, Volume 21, Supplement 2, august 1998
Transgeneration Transmission Occurs Seshiah V, Balaji V, Madhuri S Balaji, Sanjeevi CB, Anders Green (2004) Gestational Diabetes Mellitus in India. J Assoc Physicians India 2:707. L. Aerts, 36th annual DPSG Meeting, Portugal, 2004
EPIDEMIOLOGY •In 2010 there were an estimated 22 million women with diabetes in the reproductive age group of 20-39 years. •An additional 54 million in this age group had IGT or pre diabetes with potential to develop gestational diabetes if they become pregnant. •Thus over 76 million women are at risk of their pregnancy being complicated with pre gestational (existing) diabetes or gestational diabetes (diabetes occurring or first recognized during pregnancy). International Diabetes Federation (Accessed 10.06.11).
Public Health Priority GDM may play a crucial role in the increasing prevalence of diabetes and obesity. Asslamira Ferrara. Increasing prevalence of GDM Diabetes Care 30 (2): 2007.S141- 146
This necessitates universal screening of all pregnant women for glucose intolerance.
Diagnosis The importance of any diagnostic procedure is not only to identify women with GDM but also to exclude Normal Glucose Tolerant [NGT] women
Comparison of Diagnostic criteria for Gestational diabetes mellitus (GDM) with a 75 gram oral glucose load [mg/dl (mmol/L)]
WHO
Nice (UK) Any One value
Fasting *Unfavored
ADA
IADPSG
Any two values
Any one value
126 (7.0)
95 (5.3)
92 (5.1)
1 hr
-
-
180 (10.0)
180 (10.0)
2 hr
140 (7.8)
140 (7.8)
155 (8.6)
155 (8.6)
Center-to-center differences occur in GDM frequency The 75-g OGTT, performed in pregnancy uses and the relative diagnostic importance of fasting, 1-h, and same threshold of 2-hour PG >140mg/dl 2-hsimilar glucose impact strategies(WHO). used for tolevels. that ofThis IGT may outside pregnancy Alberti K, Zimmett P. WHO Consultation, Definition, diagnosis and Classification the diagnosis of GDM of diabetes mellitus and its complications, 1: Diabetes Med 1998; 15 :539-53.
Frequency of gestational diabetes mellitus at collaborating centers based on IADPSG consensus panel-recommended criteria: the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Sacks DA. etal. Diabetes Care Mar;35(3):526-8 Mellitus: A fundamental and Clinical Text – Second edition.2012 Derek LeRoith etal.
*Diabetes 2000. Chapter Gestational Diabetes Mellitus. Page no.884(Robert E Ratner and Maureen D Passaro)
Global Differentials in Human Development
Performing OGTT (fasting, 1hr and 2hr) may not be feasible in less resource settings Source: UNDP Human Development Report, 2009
Practical Problems in Diagnosing GDM
All the diagnostic criteria require women to be in fasting, but most of the time pregnant women do not come in the fasting state because of commutation and belief not to fast for long hours (Our Field Experience).
The dropout rate is very high when a pregnant woman is asked to come again for the glucose tolerance test Magee S, Walden CE, Benedetti TJ et al, JAMA 1993: 269(3): 609-15. Luiz Guilherme Kraemer de Aguiar, Haroldo Jose de Matos, Marilia de Brito Gomes. Diabetes Care 2001: 24: 954-5. V Seshiah, V Balaji, Madhuri S Balaji, CB Sanjeevi, A Green. Gestational Diabetes Mellitus in India. JAPI 52, 2004.707-11
Attending the first prenatal visit in the fasting state is impractical in many settings International Association of Diabetes & Pregnancy Study Groups (IADPSG) Recommendations on the diagnosis and classification of hyperglycemia in pregnancy. IADPSG Consensus panel, Diabetes Care 33 (3), 2010
Hence, A prospective study was undertaken to find out whether glucose test performed irrespective of last meal timing would facilitate diagnosis of GDM Anjalakshi C, Seshiah V, Balaji V,, Madhuri S Balaji, Ashalatha S, Sheela Suganthi, Arthi T, Thamizharasi M, Acta Diabetologica 46 (1) : 51-54, March 2009.
BACKGROUND WHO recommendation of 2h PG ≼140mg/dl with75g oral glucose load administered without regard to the time of the last meal (non-fasting women) correctly identified subjects with GDM. {No need for further test} Pettitt DJ et al 1991, Diabetes 40(2):126-130
Conclusion From this Study 2 HR PG ≥140mg/ dl WITH 75G ORAL GLUCOSE ADMINISTERED IN PREGNANT WOMEN IN THE FASTING OR NON FASTING STATE, WITHOUT REGARD TO THE TIME OF THE LAST MEAL IS ABLE TO IDENTIFY WOMEN WITH GDM. V. SESHIAH, C. ANJALAKSHI, V. BALAJI, et al. A SINGLE STEP PROCEDURE TO DIAGNOSE GESTATIONAL DIABETES MELLITUS. ACTA DIABETOL. 46 (1) :51-54, March 2009.
ADVANTAGES Pregnant woman need not
be fasting.* Causes least disturbance in a
pregnant woman‟s routine activities.
Serves as both screening and diagnostic procedure (universal testing is possible). Paul W. Franks, Helen C. Looker, Sayuko Kobes, Leslie Touger, P. Antonio Tataranni, Robert L. Hanson, and William C. Knowler. Diabetes 2006 55: 460 -465.
Seshiah V, Balaji V, Anjalakshi C, Madhuri S Balaji, et al. A Single test procedure to diagnose GDM. Acta Diabetologica 46 (1) : 51-54, March 2009
Advantages of DIPSI Procedure This procedure requires one blood sample drawn at 2 hrs after 75g oral glucose load for estimating plasma glucose. Even if the test is to be repeated in each trimester, the cost in performing the procedure will be 66% less than the cost of performing IADPSG recommended procedure.
Thus, DIPSI procedure is feasible, sustainable, cost-effective and high impact best buy for less resource settings.
Diagnosis of GDM with 2-h PG ≼ 140 mg/dl and treatment is worthwhile with a decreased macrosomia rate, fewer emergency cesarean sections, serious perinatal morbidity and may also improve the women’s health-related quality life. Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus. N Engl J Med 2005; Vol. 352, No. 24, 2477-86. Gayle C, Germain S, Marsh MS, et al. Comparing pregnancy outcomes for intensive versus routine antenatal treatment of GDM based on a 75 gm OGTT 2- h blood glucose (>140 mg/dl). Diabetologia. 2010; Vol. 53, Suppl. No. 1, S435. Jitendra Singh et al .Prevalence of Gestational Diabetes Mellitus (GDM) and Its Outcomes in Jammu. JAPI (59): April 2011. Balaji V, Madhuri Balaji, Anjalakshi C, Cynthia A, Arthi T, Seshiah V. (2011). Diagnosis of gestational diabetes mellitus in Asian-Indian women. Indian J Endocrinol Metab. July 2011, Vol 15, Issue 3, pp. 187-190
Comparison of Performance of the IADPSG and WHO criteria for diagnosing GDM
The WHO 2 hour criteria appears to be sufficient to diagnose GDM. Obtaining three blood samples as required by IADPSG guidelines, can be a challenge(in less resource settings) S.Nallaperumal etal. Swami diabetes centre, Geetika diabetes centre, Institute of diabetology MMC , MDRF and Dr.Mohan’s diabetes specialties centre chennai
Diagnosis of GDM by three different criterias in a government hospital setting in Chennai
DIPSI criterion requires estimation of plasma glucose in one blood sample to diagnose GDM. It is cost effective and convenient. In this study the diagnostic accuracy of DIPSI Criteria is comparable to ADA and WHO criteria Dr. Anand Moses C.R etal. Institute of MMC & Rajiv Gandhi general hospital, chennai
Prevalence of GDM by IADPSG & DIPSI (WHO) Criteria (n = 1,463)
Diagnostic Criteria
IADPSG (3 blood tests)
DIPSI
(1 blood test)
N (%)
214 (14.6%) 196 (13.4%)
The difference was 1.2% - Not Significant ( p > 0.02) The discordant pair between the two criteria - No statistical significance (P = 0.21) - Mc Nemar Test A close agreement between these two procedures Seshiah V, Balaji V, Siddharth Shah, Shashank Joshi, AK Das, Sahay BK, Samar Banerjee, Zargar AH, Madhuri Balaji. Diagnosis of Gestational Diabetes Mellitus in the community , JAPI Aug 2012
New Diagnostic Criteria The WHO and the IADPSG criteria for GDM identified women at a increased risk for adverse FPG 1-hr PG 2-hr PG pregnancy outcomes. mg/dl mg/dl However, highmg/dl inconsistency was seen for those the IADPSG180 criteria. ADA with95 155 In settings other than HAPO require additional IADPSG 92 studies. 180 153 [HAPO]
.
Most Populous countries like India, China and less resource countries were not part clinical of the HAPO study In future practice,
American Diabetes Association: Clinical Practice Recommendations 2011. Dia Care Jan 2011; 34 (supplement 1): s1-98.
simpler more cost-effective The WHO and the IADPSG criteriaand for GDM identified women at a increased risk for adverse pregnancy outcomes. However,that high inconsistency was seen for those with strategies do not require the IADPSG criteria. In settings other than HAPO require additional studies. performing an OGTT on most Eliana M Wendland et. al, BMC Pregnancy Child birth 2012 Mar 31;12:23. women maystrategies be In future clinical practice,pregnant simpler and more cost-effective that do not require performing an OGTT on most pregnant women may be developed. developed. International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of
Hyperglycemia in Pregnancy. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. Boyd E. Metzger
“A single-step procedure with a single glucose value*” Modified WHO Criteria Diabetes In Pregnancy Study Group India (DIPSI) - GUIDELINES State Health Society Operational guidelines for Screening & Diagnosis of GDM in the Community
At the first visit to the antenatal clinic, a pregnant woman after undergoing preliminary clinical examination, has to be given a 75g oral glucose load, without regard to the time of the last meal. A venous blood sample is collected at 2 hours for estimating plasma glucose by the GOD-POD method. GDM is diagnosed if 2 hr PG is ≥ 140 mg/dl (7.8 mmol/ L)
*V Seshiah, B K Sahay, A K Das, Siddharth Shah, Samar Banerjee, P V Rao, A Ammini, V Balaji, Sunil Gupta, Hema Divakar, Sujatha Misra, Uday Thanwala, S K Sharma. Gestational Diabetes Mellitus- Indian Guidelines. JIMA(2009)107 (11); 799- 806
Universal Screening
Sub: 1) Screening of Glucose Intolerance during pregnancy to be made mandatory
MORE PEOPLE VISITING PRIMARY HEALTH CENTRES
An increase of 77.2% between April 2007 and Jan 2008 over corresponding period of 2006 - 07
Dr Muthulakshmi Reddy Maternity Welfare Scheme
24
Impact of our Diabetes In Pregnancy Awareness And25 Prevention [DIPAP] Project on Birth Weight of New born babies [DIPSI Criteria] Total Number of pregnant women followed-up = 8731
National Family Health Survey – SGA 17% & LGA 19%
10.45% {41.2 %}
7.26 % {63.2 %}
This single initiative of achieving birth weight of infants appropriate for gestational age, would have significant positive effect on the overall health of the family and the community. Data from Diabetes In Pregnancy Awareness & Prevention (DIPAP) PROJECT
Supply of glucometer to all sub centres One Step Test for Universal Screening during Pregnancy.
One Step Test is feasible as a routine test during ANC for all pregnant women when NPCDCS [National Programme for Prevention and Control of Cancer, Diabetes, Carddiovascular Disease and Stroke] expands its programme to all districts keeping all the above points in mind as is envisaged in the 12th FYP.
Prevention of Diabetes Preventive measures against Type 2 DM should start during INTRA UTERINE PERIOD and continue through out life from early childhood. Tuomilehto J. A paradigm shift is needed in the primary prevention of Type 2 DM, Prevention of DM, John Wiley & sons limited, 153-165; 2005
GDM offers an important opportunity for the development, testing and implementation of clinical strategies for diabetes prevention Thomas A Buchanan, Anny Xiang, Siri L Kjos, Richard Watanabe. “What is gestational diabetes?� Diabetes Care 30(2): S105-111, July 2007
FEMALE GENDER: THE KEY TO DIABETES PREVENTION? – Lise Kingo
It starts with a healthy pregnancy In adult life Low birth weight = elevated risk for
or large for gestational age birth weight
• • • •
Obesity Diabetes Hypertension CVD
Intergenerational transfer of risk
Maternal health – The link to the NCD epidemic
Public Health Priority The timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition and obtaining newborn weight appropriate for the gestational may prevent in all probability, the epidemic of diabetes. Seshiah V Project Advisor, Diabetes in Pregnancy Awareness and Prevention
“No single period In human development provides a greater potential (than pregnancy) for long–range „pay–off‟ via a relatively short–range Period of enlightened metabolic manipulation” Freinkel – Excerpta Medica 1979