Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes
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Transcript of Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes
Postpartum Gestational Diabetes:
Screening Opportunities
for Type 2 DiabetesIris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Assoc Prof. 4, UP College of MedicineChief, UPCM Medical Informatics Unit
Section of Endocrinology, Diabetes & Metabolism Dept. of Medicine, Philippine General Hospital
“Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783
2012 Diabetes Philippines Annual ConventionEDSA Shangrila Hotel 14 Nov 2012
Sunday, November 18, 12
Is GDM the forme fruste of diabetes?
forme fruste partial, arrested or inapparent form of the disease
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
Natural History of Type 2 DiabetesDe Fronzo RA, Diabetes 2009
Sunday, November 18, 12
Women developing GDM had lower pregravid insulin sensitivity Landon et al 2001
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
GDM: increased fasting insulin concentrations in late gestation Landon et al 2001
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
GDM: decreased insulin response to glucose challenge in late pregnancy Xiang AH et al Diabetes 1999
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
GDM: lower insulin response for degree of insulin resistance Homko et al Diabetes 2001
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
GDM: Diabetes in Evolution
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
Gestational diabetes is an independent risk factor for diabetes in Filipino-Americans
Cuasay et al Diabetes Care 2001
Risk factor OR 95% CIAge (y)
35-44 10.79 1.00-16.8345-54 16.17 1.42-184.0355-64 14.65 1.09-97.70
65 and older 38.68 2.27-659.89
Gestational diabetes 21.65 6.73-69.67Delivery of baby >9 lb 1.51 0.39-5.84Family history of diabetes 2.22 0.92-5.35Obesity 2.85 0.53-15.4
Sunday, November 18, 12
“Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783
When & how to screen
Barriers to screening
Interventions to improve screening
Sunday, November 18, 12
Metabolic assessments recommended after GDM
Metzger BE et al, Summary & Recommendations of the 5th International Workshop on GDM. Diabetes Care 2007
Time Test Purpose
Post-delivery (1-3 days) Fasting or random plasma glucose
Detect persistent, overt diabetes
Early postpartum (around the time of postpartum visit)
75-g 2-h OGTT Postpartum classification of glucose metabolism
1 year postpartum 75-g 2-h OGTT Assess glucose metabolismAnnually Fasting plasma glucose Assess glucose metabolismTri-annually 75-g 2-h OGTT Assess glucose metabolismPrepregnancy 75-g 2-h OGTT Classify glucose metabolism
Sunday, November 18, 12
Postpartum Screening for Diabetes Among Women with a History of
Gestational DiabetesSystematic Review
Tovar A et al, Prev Chronic Dis 2011;8(6):A124
“paper” by v_g, http://www.sxc.hu/photo/77779
11 studies (2008-2010) on rates & results of postpartum screening
n = 32,240 GDM(1999-2008)
Sunday, November 18, 12
“dream graph” by iamwahid, http://www.sxc.hu/photo/1209643
Postpartum Screening for Diabetes Among
Women with a History of Gestational Diabetes
Systematic ReviewTovar A et al, Prev Chronic Dis 2011;8(6):A124
34%-73% (median 48%)
screened
Sunday, November 18, 12
Postpartum screening not improved over time
Postpartum Screening for Diabetes Among
Women with a History of Gestational Diabetes
Systematic ReviewTovar A et al, Prev Chronic Dis 2011;8(6):A124
50.3% within 3 mos 48.2-51% within 6 mos55.9% within 12 mos
“calendario” by malko, http://www.sxc.hu/photo/750005
Sunday, November 18, 12
Postpartum Screening for Diabetes Among
Women with a History of Gestational Diabetes
Systematic ReviewTovar A et al, Prev Chronic Dis 2011;8(6):A124
“Injection time” by adamci, http://www.sxc.hu/photo/250620
79-100% screened with FPG (4 studies)56-95% screened with OGTT (3 studies)
Sunday, November 18, 12
“Injection time” by adamci, http://www.sxc.hu/photo/250620
Using only FPG in postpartum screening
will miss up to 75% of women with IGT or type 2 diabetes
Kwong et al Diabetes Care 2009
Single FPG sensitivity of 16% to 89% vs OGTTTovar et al Prev Chronic Dis 2011
Isolated IGT 1/3 of GDM cohort with DM or prediabetesHunt & Conway Am J Obstet Gynecol 2008
Sunday, November 18, 12
“Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783
When & how to screen
Barriers to screening
Interventions to improve screening
Sunday, November 18, 12
Patient barriers Henderson et al The Open Diabetes J 2012
Time pressure as primary barrier
Cost or inconvenience
Unaware of risks
Unaware of proven methods to prevent or delay diabetes
“Time slipping away 1” by chriki7274, http://www.sxc.hu/photo/723865
Sunday, November 18, 12
Barriers & facilitators of postpartum follow-up care in previous GDMBennett et al J Women’s Health 2011
Barriers Baby’s health needsPersonal and family adjustment to baby (emotional stress/feeling overwhelmed, demands of baby’s schedule/lack of time for self-care, child care needs)
Concerns about postpartum and future health (perception of good health and not needing further care, fear of receiving bad news at follow-up appointment)
Experiences with medical care (dissatisfaction with care, logistics of accessing care)
“duckie 1” by ppreacher, http://www.sxc.hu/photo/299965
Sunday, November 18, 12
Barriers & facilitators of postpartum follow-up care in previous GDMBennett et al J Women’s Health 2011
Facilitators Availability of child careCheck-up and clearance for return to workConnection with clinical and office staffAddress specific concerns or questionsDiscuss family planning
“businesswoman 1” by CELALTEBER, http://www.sxc.hu/photo/1305802
Sunday, November 18, 12
Postpartum Screening for Diabetes Among Women with a History of
Gestational DiabetesSystematic Review
Tovar A et al, Prev Chronic Dis 2011;8(6):A124
“paper” by v_g, http://www.sxc.hu/photo/77779
21 studies (2008-2010)on predictors of & barriers to screening
Sunday, November 18, 12
“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902
Provider barriers Tovar et al Prev Chronic Dis 2011
lack of attendance at postpartum visithowever94% postpartum Pap smear vs 67% glucose testing (37% FPG or OGTT)
Sunday, November 18, 12
“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902
Provider barriers Henderson et al The Open Diabetes J 2012
clinician’s perception that screening guidelines were “inconsistent”
Sunday, November 18, 12
Postpartum screening recommendations for women with GDMCanadian Diabetes Association (2008)75-g OGTT 6 wks-6 mos postpartumPre-pregnancy screening for T2D
WHO75-g OGTT >6 wks postpartum
American Diabetes Association (2008)FPG or 75-g OGTT Annual repeat testing if IFG/IGT detected; q3 y if normal
American College of Obstetricians & Gynecologists (2009)FPG or OGTT
“worried man against white background” by bigevil600, http://www.sxc.hu/photo/1000622
Sunday, November 18, 12
“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902
Provider barriers Henderson et al The Open Diabetes J 2012
lack of documentation of GDM on problem listspoor communication between OB and primary care
Sunday, November 18, 12
Who should follow up GDM postpartum?
2008 ACOG survey: OB-GYNs self-report ordering follow-up testing for patients (74%)Gabbe et al Obstet Gynecol 2004
howeverReview of lab records: only 1/3 had undergone postpartum glucose screeningAlmario et al Obstet Gynecol 2008
Lack of clarity who in the clinical continuum should take
primary responsibilityDornhorst et al Diabetes Care 1998
Sunday, November 18, 12
“holding hands” by spekulator, http://www.sxc.hu/photo/835200
Multidisciplinary approach Khandelwal M, Current Diabetes Rep 2008
many overlaps to provide constant reminders and encouragement
Sunday, November 18, 12
Reluctance to order OGTT even in non-pregnantWilson et al BMC Health Serv Res 2009
Complexity and time required for OGTTUncertain value of intervening when IGT identifiedPerceived cost
“dislike button” by Sean McEntee, http://www.flickr.com/photos/smemon/5683562879/
Sunday, November 18, 12
Predictors of postpartum screening Ferrara et al Diabetes Care 2009
Older ageAsian or Hispanic race/ethnicityHigher educationAt least 2 prior birthsEarlier gestational age at GDM diagnosisUse of insulin or glyburide during pregnancyVisits to an IM or OB-Gyn during postpartum
Sunday, November 18, 12
“Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783
When & how to screen
Barriers to screening
Interventions to improve screening
Sunday, November 18, 12
Postal reminders Clark et al AJOG 2008
RCT Reminder sent to MD and patient, patient only, MD only, no reminders
Outcome: OGTT in 1 y (p<0.05)
MD only Patient only MD & Patient No reminders
16/3151.6%
42/7655.3%
49/8160.5%
5/3514.3%
“timbre poste” by gastonmag, http://www.sxc.hu/photo/504564
Sunday, November 18, 12
Lab requests & telephone reminders
Kwong et al Diabetes Care 2009
cohort of 1,006 GDM women attending a pregnancy diabetes clinic
48% (n=438) completed postpartum screening
Non-adherence to testing significantly associated with
higher parity & lack of insulin use
“old phone II” by bury-osiol, http://www.sxc.hu/photo/754394
Sunday, November 18, 12
Nurse managed care programFerrara et al Diabetes Care 2009
Proportion receiving OGTT 1995 - 5% 2005 - 16.6%2006 - 71.5% Greater attention to postpartum screening guidelines
cohort of 14,448 GDM between 1995 and 2006
“shaking hands” by bluegum, http://www.sxc.hu/photo/911615
Sunday, November 18, 12
Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009
Target women at high risk for postpartum glucose intolerance
“shot on target” by cobrasoft, http://www.sxc.hu/photo/1176209
Independent risk factorsPre-pregnancy BMI >30
<24 weeks AOG at diagnosis1h OGTT >200 mg/dL
Insulin therapy
Sunday, November 18, 12
Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009
Sunday, November 18, 12
Risk stratification to improve screening Schaefer-Graf et al Diabetes Care 2009
Sunday, November 18, 12
Interventions to improve postpartum
screening in GDM
Written information, individualized risk reduction advice, care from an
endocrinologist, diabetes educator or OB Morrison et al Aust NZ J Obs Gyn 2009
Provision of lab slip and preventive counseling Kim et al Diabetes Care 2007
One-on-one counseling session at 37-38 wks gestation Stasenko et al Am J Obstet Gynecol 2009
“writing hand” by tulp. http://www.sxc.hu/photo/877745
Sunday, November 18, 12
Promoting health after gestational diabetes: a National Diabetes Education Program
Call To Action Gabbe SG et al, Obstet Gynecol Jan 2012
http://ndep.nih.gov/am-i-at-risk/gdm/
Sunday, November 18, 12
Download from http://ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx
Sunday, November 18, 12
“Classical Windows” by theswedish, http://www.sxc.hu/photo/1344783
When & how to screen
Barriers to screening
Interventions to improve screening
Sunday, November 18, 12
Thank You!http://www.endocrine-witch.net
@endocrine_witchhttp://www.slideshare.net/isiptan
Sunday, November 18, 12