Gestational Diabetes

5/19/2018 Gestational Diabetes

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Your name


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Introduction

The basic cause of type 2 diabetes, whose prevalence is

rapidly increasing worldwide, is genetic factors, with the

addition of such acquired factors as lack of exercise,

obesity caused by a high-fat diet, stress, and aging

impairing insulin action, leading to the onset of diabetes


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Introduction cont.

!n "apan, there is a clear trend towards delayed

marriage and childbirth, and in future the number ofwomen with decreased carbohydrate tolerance who

develop gestational diabetes mellitus #$%&' during

pregnancy is expected to increase more and more

!t is a fact that it is known that the incidence of $%&

increases by approximately ( times for pregnant women

aged )* years and over compared with women aged 2*

years or under


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Gestational Diabetes Mellitus +riginally, $%& was defined as decreased carbohydrate

tolerance that develops or is first identified during

pregnancy,

but in 2010 the definition was changed as following.

Thus, $%& is a carbohydrate intolerance that is not

diabetes that has developed or been discovered for the firsttime during pregnancy

The $%& definition therefore does not include overt

diabetes in pregnancy ccordingly, hyperglycemic

disorders that are thought to have been overlooked until thepregnancy are excluded from the definition of $%& and are

instead diagnosed as overt diabetes in pregnancy.


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hy


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Diagnostic Criteria for GDM

The first evidence that screening, diagnosis and treatment of

hyperglycaemia in women not previously known to have

diabetes improve outcomes was provided by +./ullivan et al in

the 013s fter investigating the distribution of plasma glucose

values of pregnant women, these authors proposed diagnosticcriteria for gestational diabetes based on a )-h 033g +$TT

hen the 2-h 4*g +$TT was established in 0141-01(3 by

international panels as the diagnostic test for diabetes and

glucose intolerance05, the 6+ extended this recommendation

to pregnant women0* The 7/ 8ational %iabetes %ata $roup#8%%$' continued to use the )-h 033g +$TT because the 2-h

4*g +$TT had been little investigated during pregnancy

History


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&ost commonly used guidelines for the

diagnosis of $%&

OrganisationFastingPlasmaglucose

GlucoseChalleng

e

1-hplasmaglucose

2-hplasmaglucose

3-hplasmaglucose

WHO 19993* 7.0 75g OGTTNot

required 7.8

Notrequired

American

Congress ofOstetriciansan!G"necologists21**

5.3100gOGTT

10.0 8.6 7.8

Cana!ian

#iaetesAssociation22** 5.3 75g OGTT 10.6 8.9

Not

required

$A#P%G19* 5.1 75g OGTT 10.0 8.5Not

required

*one value is sufient !or diagnosis

** t"o or #ore values are required !ordiagnosis


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The diagnostic criteria for hyperglycaemia in pregnancy

recommended by the orld 6ealth +rgani9ation #6+'

in 0111 were not evidence-based and needed to be

updated in the light of previously unavailable data The

update follows the 6+ procedures for guidelinesdevelopment /ystematic reviews were conducted for

key questions, and the $rading of :ecommendations

ssessment, %evelopment and ;valuation #$:%;'

methodology was applied to assess the quality of theevidence and to determine the strength of the

recommendation on the diagnostic cut-off values for

gestational diabetes

Need to update


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1*? @! 3)5-3*',

= large for gestational age #3*4> 1*?> @! 354-340' and

= shoulder dystocia #350> 1*? @! 322-34'

dditionally the risks for, perinatal mortality, neonatal

intensive care admission and birth trauma were reduced

in treated women, but the magnitude of these effects did

not reach statistical significance


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Classification of

Hyperglycaemia First

Detected During Pregnancy


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Recommendation 1

Hyperglycaemia first detected at any

time during pregnancy sould be

classified as eiter!

diabetes mellitus in pregnancy

gestational diabetes mellitus


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The classification of abnormalities of glucose

intolerance first detected during pregnancy

continues to be debated

!n non-pregnant adults the distinction is madebetween diabetes and intermediate

hyperglycaemia = impaired glucose tolerance

#!$T' and impaired fasting glucose #!A$' The

6+ 0111 report defines $%& as eitherdiabetes or !$T first recogni9ed in pregnancy


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@oncern has been expressed about the inclusion of such

a wide range of glucose abnormalities in the one

definition, especially including those with more severe

hyperglycaemia which defines diabetes in non-pregnant

adults This concern centres on special considerationsabout management during pregnancy and post-partum

follow-up in women with more severe hyperglycaemia

Dra"ing conclusions about tis group is particularly difficult because of te lac#

of good $uality data at tis le%el of yperglycaemia.


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The large multinational 6B+ study which examined the

association between maternal glycaemia and maternal

and infant outcomes excluded women with

Aasting glucose levels above *(mmolCl #035 mgCdl' and

2-h post load glucose levels above 000mmolCl #233

mgCdl'

/imilarly, the two recent high quality randomised studies

on treatment of $%& also excluded these types of

patients


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The @6+!/ study 50 excluded women with a

Aasting plasma glucose of 43 mmolCl #02 mgCdl' or

more and 2-h post-load glucose above 003 mmolCl #233 mgCdl'

The study by Landon et al excluded women with a

fasting glucose of *) mmolCl #1* mgCdl' or more


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&at is ne" in te classification of

yperglycaemia in pregnancy'

%istinguishing between diabetes in pregnancy and $%&

was first proposed by !%B/$ and the $%$ updating the

6+ recommendations accepted this distinction, but

proposes slightly different terminology = DdiabetesE, rather

than Dovert diabetesE proposed by !%B/$

This distinction between diabetes and $%& is a new

recommendation and there is lack of published data on

the implications of using this classification

( i i l f f di b i d


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(e principles of management of diabetes in pregnancy and

GDM are similar. Ho"e%er) tere are some differences in

te approac to management of "omen "it diabetes in

pregnancy compared "it GDM) as outlined in e*isting

e%idence+based guidelines) suc as tose of NIC, !

A detailed assessment for the presence of diabetes related

complications is recommended at diagnosis of diabetes,

especially complications which can affect pregnancy or beaggravated by it, such as retinopathy and renal impairment

During pregnancy a more intensive monitoring and treatment of

hyperglycaemia is recommended and pharmacotherapy is

much more likely to be reuired to control the hyperglycaemia

!ollowing the pregnancy there is need for closer follow"up and

ongoing monitoring and treatment of women with diabetes


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Recommendation -

Diabetes mellitus in pregnancy sould be diagnosedby te -/ &H0 criteria for diabetes if one or more

of te follo"ing criteria are met!

Fasting plasma glucose . . mmol2l 31-/ mg2 dl4

-+plasma glucose . 11.1 mmol2l 3- mg2dl4

follo"ing a 5g oral glucose load

Random plasma glucose . 11.1 mmol2l 3- mg2 dl4 in

te presence of diabetes symptoms.


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&at is ne" in tese diagnostic

criteria for diabetes in pregnancy

These diagnostic criteria for diabetes are

universally accepted in non-pregnant individuals,

but pregnant women with these cut-off valueswere classified as having $%& when first

detected during pregnancy


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Recommendation 6

The diagnosis of gestational diabetes mellitus at anytime during pregnancy should be based on any one of

the following valuesF

Aasting plasma glucose G *0-1 mmolCl #12 -02*mgCdl'

0-h post 4*g oral glucose load HG033 mmolCl #0(3

mgCdl'I

2-h post 4*g oral glucose load (* = 003 mmolCl #0*)-011 mgCdl'

Ithere are no established criteria for the diagnosis of diabetes based on the 0-hour post-load value


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&at is ne" in te diagnostic

criteria for GDM' The recommended glucose cut-off values for $%&

correspond to those proposed by !%B/$ and are lower

than those recommended by earlier guidelines 7nlike

earlier guidelines, they are based on the association of

plasma glucose and adverse maternal 53 and neonataloutcomes during pregnancy, at birth and immediately

following it

The difference from !%B/$ guidelines is that thesenew 6+ guidelines set a range of plasma glucose

levels to distinguish diabetes in pregnancy and $%&


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Implications


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Implications

The implications of these recommendations should be

considered in the context of each health setting hile

international consensus about the diagnostic criteria for

hyperglycaemia detected during pregnancy is growing,

implementation may be difficult in some countries Thus,consideration will need to be given to efficient detection

strategies !n addition, adaptation for some ethnic groups

or geographical regions might be required as the 6B+

study did not include participants from all regions !nsome ethnic groups fasting plasma glucose values may

not be adequate to diagnose $%&


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Recommendations for future

researc


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Recommendations for future

researc Brevalence of $%& and diabetes according to the new

criteria

;valuation of the new diagnostic criteria in diverse settings

and ethnic groupsF costs, acceptability

:andomi9ed trials #eg country or region specific' comparing

different strategies for the detection of $%&

;valuation of a Dsingle step procedureE in diagnosing $%&

@ost-effectiveness studies with different detection strategies Jong term risks related to $%& in mother and child and

impact of $%& treatment on long-term outcomes in mother

and child


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(H7N8 90: 7;;

Gestational Diabetes

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