ObesityType 2 Diabetes

ObesityDiabetes

. Macrosomia

. Malformations

. Fœtal Mortality

Neo-natalmorbidity

INFANT

DiabetesHypertensionPreeclampsiaSleep Apnea

ThromboembolismInfections

PreconceptionPregnancy

PostPartum

Cesarean

MOTHER (Obesity)

Maternal BMI and Hypertension

0

2

4

6

8

10

Underweight

Normalweight

Over-weight

Obesity Severeobesity

Garbaciak et al Galtier-Dereure et al Rode et al 2005

Preeclampsia (OR)1.7 2.7

Maternal BMI and Gestational diabetes

0

5

10

15

20

25

Underweight

Normalweight

Over-weight

Obesity Severeobesity

Garbaciak et al Galtier Dereure et al Rode et al 2005

Changes in BMI between the 2 firstpregnancies influence the rate ofgestational diabetes during G2

Villamer E, 2006

+ 100 %

+ 200 %

= 0 + 1+ 3 kg

+ 2

+ 6 kg

+ 7

+ 20 kg

+ 30 %

//

63 kg/165 cm

(BMI 23 kg/m²) BMI > 30

Changes in BMI units (kg/m²) between G1 et G2)

Mean blood glucose values of pregnant women with gestational diabetes

• n

• FBG (mg/dl)

• 2 h postprandial (mg/dl) BreakfastLunchDinner

1.188

97.3 + 11.4

110.9 + 15.5130.5 + 14.8123.7 + 13.8

2.030

82.9 + 7.3

96.1 + 9.9102.4 + 13.4106.5 + 8.0

< 0.001

< 0.001< 0.001< 0.001

Blood glucosenot controlled

Blood glucosecontrolled p

Victor Hugo Gonzalez-Quintero et al, Diabetes Care 2007

Data are means + SD (number of blood glucose measurements : 27000 to 36000 for each mean

Neonatal outcomes

• n

• Birth weight (g)• Macrosomia (%)

• Cesarean delivery• Neonatal intensive care• Neonatal hypoglycemia

• Composite outcome

1.188

3.491 + 53215.7

48.510.69.3

33.1

2.030

3.364 + 4819.3

37.47.37.1

24.0

0.0010.001

< 0.0010.0020.031

< 0.001

Blood glucosenot controlled

Blood glucosecontrolled p

Victor Hugo Gonzalez-Quintero et al, Diabetes Care 2007

Maternal characteristics

• n

• Maternal age (years)

• Prepregnancy BMI (kg/m²)

• Obese BMI (%) (> 35 kg/m²)

• Received insulin (%)

1.188

31.3 + 5.5

32.0 + 8.2

29.1

58.4

2.030

31.0 + 5.7

28.0 +6.8

13.4

23.7

0.571

< 0.001

< 0.001

< 0.001

Blood glucosenot controlled

Blood glucosecontrolled p

Victor Hugo Gonzalez-Quintero et al, Diabetes Care 2007

Respective influences of maternal weight and gestational diabetes on macrosomia

0

5

10

15

20

25

Normal weight Obeses

Langer O, Am J Obstet Gynecol 2005, 192, 1768

Diet

%

0

5

10

15

20

25

Normal weight Obeses

Insulin

%

GoodBad

CONTROL

Respective influences of maternal weight and gestational diabetes on cesarean section rates

15

20

25

30

35

Normal weight Obeses

Langer O, Am J Obstet Gynecol 2005, 192, 1768

Dietn = 1744

15

20

25

30

35

Normal weight Obeses

Insulinn = 2254

GoodBad

CONTROL

% %

Maternal effects of weight increaseduring pregnancy in obese womentolerant to glucose

Jensen, Diabetes Care, 2005

10

20

30

40%

10

20

30

40%

10

20

30

40%

< 5kg 5–9.9kg 10-14.9kg > 15 kg

< 5kg 5–9.9kg10-14.9kg > 15 kg

Hyp

ert

en

sio

nC

esare

an

secti

on

Ind

uced

lab

ou

r

Gestational weight increase

Gestational weight increase

10 1217

20.5

15

35

27 28

20

3228

36

Jensen, Diabetes Care, 2005

10

20

30

40%

10

20

30

40% 10

15

20%

< 5kg 5–9.9kg 10-14.9kg > 15 kg

< 5kg 5–9.9kg 10-14.9kg> 15 kg

Weig

ht

> 4

kg

Macro

som

ia

Int r

a u

teri

ne

gro

wth

ret a

rdat i

on

Gestational weight increase

Gestational weight increase

29

19

3335

33

2325

13

42

13

Foetal effects of weight increaseduring pregnancy in obese womentolerant to glucose

OBESITY

AND

MALFORMATIONS

Maternal obesity and central nervous system malformations

Anderson JL, Epidemiology 2005, 16, 87

Malformations

Neural tubeAnencephaliaSpina bifidaHydrocephalia

N

25497

157103

Adjusted OR

2.62.32.82.7

95 % IC

1.7 - 41.2 - 4.31.7 - 4.51.5 - 5

BMI ≥ 30 kg/m² versus 18.5 – 24.9 kg/m²

Maternal obesity, gestational diabetesand SNC malformations

0

1

2

3

4

5

Normal weight Obeses

Anderson JL, Epidemiology 2005, 16, 87

OR

SPINA BIFIDA

Gestational diabetes Yes No

Pregestational BMI predicts the risk of malformations in infants born from mothers with gestational diabetes

Martinez-Frias ML, Diabet Med, 2005, 22, 775

0

1

2

3

Controls < 21 21 - 25 25 - 30 > 30

OR

BMI (Kg/m²)

Prepregnancy management of obese women

Complications infertility metabolic : diabetes ? cardiovascular

Eating disorders ? Target weight Exercice and dietary

recommandations ? Treatments ? Bariatric surgery ?

Motivation ?

Pre-pregnancy gastric banding

D'après Skull et al, Obes Surg 2004

0

5

10

15

20

25

30

Rate

(%

)

Gestationaldiabetes

Hypertension NeonatalComplications

AGControls

Dixon et al, Obstet Gynecol 2005

PREGNANCY AFTER GASTRIC BANDING

Obese women

After banding Paired Previous pregnancyControls (before banding)

N

Initial BMI (kg/m²)Weight loss (before)

Weight gain (pregnancies)

Gestational Diabetes (%)Hypertension (%)Preeclampsia (%)

Macrosomia (%)

N = 79

46- 28 + 14 kg+ 9.6 + 9 kg

6.3105

11

N = 79

44

+ 15.5 + 9 kg

193825

18

N = 40

45

+ 14.4 + 9 kg

154528

11

Offspring Weights before and after maternal by-pass surgery by duodenal switch

Weight Group

Normal weight, n (%)

Overweight, n (%)

Obese, n (%)

Underweight, n (%)

Before surgery(n = 45)

16 (36)

9 (20)

18 (40)

2 (4.4)

After surgery(n = 172)

98 (57)

28 (16)

33 (19)

13 (7.5)

p = 0.006

Kyal JG, Pediatrics, 2007

Management during pregnancy

Diagnosis of diabetes : optimal intervals for fasting and 2 hours post prandialblood glucose ? For OGTT tests ?

Cardiovascular and respiratory assessment

Weight increase (# 5 kg)

Ultrasonographic follow-up

Optimal diagnosis of gestational diabetes in obese women ?

Which OGTT ?

.Oral glucose 50g, 75g, 100 g ?

. Times for samples ?

. Venous or capillary blood ? Units ?

. Various tresholds depend on types of morbidity

- fœtal- maternal- long term outcomes

When ?At 24th week ?

Too soon Gestational diabetes

Too late Type 2 diabetes

Frequency of glycemic control ?

. Fasting BG : 95 mg/100 ml

. Post prandial BG : 120 mg/100 ml (2 hrs)

Obese need tests abbleto be repeated at leastmonthly…

Risk of underestimate

Gestational diabetes prevalence

and risk of macrosomia

IMPACT OF DIAGNOSTIC CRITERIA

Gestational Diabetes%

Risk of Macrosomia%

Canadian

EASD

ADA

New Zealand

WHO

Australian

6.3

7.6

8.4

17

15

23

2.01

1.57

2.09

1.92

1.26

1.53

Agarwal MM, Diabetic Medicine 2005

Prepregnancy BMI has a greater population impact on pregnancy outcomes than gestational hyperglycemia

(n = 9270)

Population attribuable risks of pregnancy outcomes

BMI > 26 kg/m²(upper quartile)

Gestational Hyperglycemia

Macrosomia Hypertension

23 %

3.8 %

50 %

9.1 %

Ripart W. Diabetologia 2005

For BMI or GDM