President’s Report

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ADIPSA U S T R A L A S I A N D I A B E T E S I N P R E G N A N C Y S O C I E T Y

NEWSLETTER | APRIL 2007

Sponsored by TABLE OF CONTENTS

President’s Report 1

Editorial 2

Farewell from David Simmons 3

GDM in Austria and Australia 4-6

Istanbul GDM Conference 7-8

Flyer –ADIPS research grants 9

Meetings and miscellaneous 10

ADIPS Membership Application 11

ADIPS Membership Renewal 12

“Can I have a healthy baby” order form 13

For ADIPS, 2007 will be an important year. Firstly the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study will report its long awaited findings in Chicago at the American Diabetes Association meeting in June. This international NIH funded study will provide the data that will enable us to finally develop internationally accepted evidence based diagnostic criteria for gestational diabetes. Although it has been truly an international effort, it is important to acknowledge the major contributions of the Australian (ADIPS) contributors to this study including, in particular, Jeremy Oats who has been involved from the very beginning in the study design and implementation and David McIntyre and Annette Parry who have run the Australian study site at the Brisbane Mater Hospital.

Secondly, the MiG study results will be reported this year. This is a clinical trial of the use of metformin in the management of gestational diabetes. Of particular relevance to ADIPS, is that this study has been designed and run in New Zealand and Australia by ADIPS members with the major contributions being from our Newsletter Editor Janet Rowan and Bill Hague. Although it is not an ADIPS trial as such, much of the preliminary discussions and planning for the trial were undertaken at ADIPS meetings and many of the Centres that have contributed to the study are linked to ADIPS.

Both the HAPO and MiG study results will be presented at the ADIPS Annual Scientific Meeting to be held in Christchurch 7th and 8th September that immediately follows the ADS/ADEA/NZSSD meeting. While the major findings of both these studies will be presented in a combined ADS/ADEA/NZSSD/ADIPS session on the 7th September, there will be further sessions devoted to HAPO and MiG later in the ADIPS program to allow full discussion. Our international invited speaker to ADIPS this year is Sylvie Hauguel-DeMouzon. She will discuss the roles of diabetes, adipocytokines and placental imflammation with respect to fetal origins of obesity and metabolic syndrome.

The ADIPS Audit Program was rolled out in December last year with many sites showing an interest to be involved. David Simmons did most of the work developing the Audit Program prior to moving from NZ to a new position at the Cambridge University Hospital NHS Foundation. Jeff Flack, as with the ANDIAB Program, is generously assisting with computer analysis of the audit data. Thanks need to go to David and Jeff for all the work they have put in. The audit process is an important activity for ADIPS and will provide highly valuable data that will be of use at several levels (e.g. individual centres for bench marking, government policy, international debate, etc). It also gives us an opportunity to collect valuable data on the outcomes of pregnancies in which new treatments are being used. With the arrival of the new long acting insulin analogues on the PBS, many more women of child-bearing age will conceive on them. Their safety has not been established yet such that use of Lantus and Levemir insulins in pregnancy needs to be with considerable caution. Data from the audit will help in determining the safety of these new insulins.

For centres involved in the ADIPS Audit Program, I would like to remind you that we need completed forms for births from the 6 months up to the end of February by mid-April to compile a report by late April for the Dept of Health and Aging. For any queries relating to the Audit, please don’t hesitate to contact Trish Cohen at the ADIPS Secretariat, Jeff Flack or myself.

I wish to thank the new ADIPS council for their efforts so far, particularly Glynis Ross as Treasurer, Aidan McElduff as Secretary, Janet Rowan as Newsletter Editor and Harry Georgiou as Webmaster. I look forward to seeing many of you at the Annual Scientific Meeting in Christchurch in September.

Chris Nolan

Information about the society can

be found at: www.adips.org

Information about the International

Association of the Diabetes and

Pregnancy Study

Groups can be found at:

http://www.iadpsg.org

with links to ADIPS and other

regional study groups.

Australasian Diabetes in Pregnancy

WEBSITE

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Along with the new web-based format for the Newsletter, you have a new Editor. I personally think that having me as the Editor at this stage may lead to disaster, especially as I am particularly illiterate when it comes to web-based thingies, but there were not many applicants for the job! It seems that everyone is busier than everyone else. I obviously

did not sell my sob-story very well. Thank goodness I have been guided by Harry Georgiou, the previous Editor and Carol Gardener at Roche, who has formatted the contributions beautifully. Plus, the rest of the Council has been actively providing practical help and contributions.

You should have received a postcard to tell you the Newsletter was on our database. If your contact details change, please forward this information to the Secretariat either on the postcard or by email. If you did not receive a postcard and just stumbled across the Newsletter, please

let the Secretariat know as well (adips.pc@bigpond.net.

au).

The current plan is that we will continue to have two Newsletters a year. One is typically in October after the annual ADIPS meeting, so I will be asking volunteers to write up different sessions, particularly those who ask a question after every presentation.

The March/April Newsletter is bit trickier. Of course an important part is to remind everyone to come to the meeting in September and bring your colleagues. (Register

on www.asnevents.net.au/adips/)This year will be a real highlight for me personally, as we will be presenting MiG, which has consumed my life for the past 5 years. For many of us a key attraction will be hearing about HAPO, which has consumed other peoples’ lives for more than 15 years, I understand. HAPO will give us some data to base our debates on regarding the diagnosis of GDM.

I have been told that our guest speaker, Sylvie Hauguel-DeMouzon is a captivating speaker, and will make her talks on the placenta and diabetes fetopathy accessible to our mixed audience. The debate maestro, Aidan McElduff, is likely to generate some steam from the audience with our interactive session about type 2 diabetes in pregnancy. Tim Cundy will present interesting background data for this session. Rinki Singh will remind us that our pregnancy management may have long term influences in the offspring.

In each Newsletter I would like to provide contact information about other conferences that members may be interested to attend. If any of you come across a future meeting that you think is relevant, please email me details so I can share it in the next Newsletter.

We have had some important contributions. One is from David Simmons, who has left New Zealand and taken up a position in Cambridge, UK. We will miss his great enthusiasm, optimism and ability to take on projects and move them forwards. I asked him to leave us with a few thoughts. We also have a timely contribution from Willibald Zeck, who comes from Graz, Austria (of the

clock award). He has summarized his observations with respect to differences between Brisbane and Graz in the diagnosis and management of GDM, and put it into the context of our need for more information internationally.

Finally, a few of us went to Istanbul for the recent diabetes in pregnancy meeting and have provided a snapshot of meeting highlights.

I would be thrilled to receive articles, critiques, jokes, and especially photos of our ADIPS community. The Newsletter needs to be interesting, educational and I believe, entertaining!

My contact email is jrowan@internet.co.nz

Editorial Hello to all ADIPS members,

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The current plan is that we will continue to have two Newsletters a year. One is typically in October

after the annual ADIPS meeting, so I will be asking volunteers to write up different sessions,

particularly those who ask a question after every presentation.

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It is with a heavy heart that I leave Australasia, including my friends in ADIPS, to take up a position in Cambridge, England. I have now been in this part of the world for 17 years

and was introduced to the Society in the early 1990’s by Dr David Scott from Middlemore Hospital in South Auckland - surely an early front line in the fight against diabetes and its harm to the mother and baby. Having been introduced to a large number of ADIPS members (some now retired) I quickly learnt that here was a group of people from a range of disciplines, very knowledgeable as individuals and as a group and committed to achieving the best results from pregnancies complicated by diabetes; a group never afraid to debate the issues and to disagree, but working together to improve things. As a Society, I believe we should be proud of our achievements including the high quality of our annual meetings, our newsletter, our guidelines and statements, our audit programme, keeping a national committee in Australia to put diabetes in pregnancy on the table to Government, our links with other societies and of course our website! Above all, I believe it is our trans-Australia and trans-Tasman collegiality that we need to have pride in and maintain. We need to ensure that we keep our broad range of members and perhaps find ways to increase those currently under-represented such as paediatricians and neonataologists, basic scientists and obstetricians.

We have achieved an enormous amount, which has also made us a valuable member of the IADPSG, a forum for us to learn and also to give. Janet has asked me to comment on a few areas which I believe we should, perhaps, put effort into over the forthcoming years. There remains much to do. I believe that besides maintaining and extending our current activities there are a number of areas in which I think we can do better, and in which ADIPS can play a role. I will highlight four areas. The first three relate to the audit programme (in which I ask you all to participate). Firstly, it should allow us to monitor

the uptake and impact of the new insulins and perhaps oral agents as these are used. Secondly, I think the audit should be linked into follow up programmes for women with past GDM and their children. I know that different areas have developed follow up strategies, but perhaps the audit programme could facilitate this in a coordinated manner. Closer ties to the GPs, I feel, would be an important component of this. Thirdly, the audit should be helpful in facilitating ways to improve the pre-conceptual care of women with pre-existing diabetes. We still seem to see too many pregnant women with poor glucose control, without folate in place and without having had appropriate counselling/ family planning in place. I think this is an area in which a benchmark, and inclusion in the payment for

results approach, might stimulate an earlier achievement of what is needed. The fourth area will need to await the results to HAPO. Once these are available, Australia and New Zealand need to discuss what they mean to our populations (especially to our indigenous and other higher risk populations), to model different criteria and approaches, and agree on a simple comparable approach to implementation across Australasia. Hopefully this will be part of an international consensus on screening and diagnosis. There are many other areas-so much to do-I am confident that by working together, the Society will continue to improve the health of women and babies affected by diabetes in pregnancy.

Farewell from Professor David Simmons

Dear Friends and Colleagues

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We have achieved an

enormous amount, which has

also made us a valuable member

of the IADPSG, a forum for us to

learn and also to give.

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Gestational diabetes mellitus and pre-gestational diabetes pose risks to the mother and developing fetus. The number of cases of diabetes worldwide has increased significantly in the last decade and it is anticipated that the number of people with diabetes will double by 2030. This “diabetic epidemic” does also affect pregnant women on a large scale. However, the management of Type 1 diabetes (T1DM), and Type 2 diabetes (T2DM) in pregnancy as well as gestational diabetes mellitus (GDM), defined as glucose intolerance first detected in pregnancy, remains challenging.

Within the scope of cooperative research activities between the Medical University of Graz, Austria and the Mater Misericordiae Mothers’ Hospital in Brisbane, Australia, I was involved in diagnosis and treatment of pre-gestational and gestational diabetes at the Mater Misericordiae Mothers’ Hospital for 7 months. In various discussions, Prof. David McIntyre, Past President of ADIPS and Director of Obstetric Medicine at Mater Health Services in Brisbane, and I were able to identify both differences in diagnosing and treating diabetes in pregnancy and common ground in certain areas:

Notably, the management of pre-gestational diabetes is quite similar at the two obstetric centres, although Austria and Australia are geographically and culturally very different countries. (see table no. 1). However, we found that there is more variation in the management of GDM. The recommended week of gestation for GDM screening is identical in both centers and 75g of glucose is used for OGTTs in both centers (see table no. 2). Furthermore both centers recommend universal screening of all pregnant women and considers that one high value in OGTT justifies the diagnosis of GDM. There is, however, disagreement in the performance of screening per se: two stage screening (GCT followed by OGTT) is performed at the Mater Hospital, whilst one stage screening (OGTT only) is performed at the University Hospital of Graz. Cut off levels for diagnosing GDM are much lower in Graz than in Brisbane. The variation in the two centres

reflects the fact that screening of GDM remains the most divergent issue. The dilemma of disagreement in when and how to screen for GDM is known throughout the literature. Applying a one-stage or two-stage screening test as well as defining the cut off glucose levels for the diagnosis of GDM are very important for determining the prevalence of GDM as well as for the perinatal and maternal outcomes on a local or national level. Outcomes will be more favorable when OGTT diagnostic thresholds for GDM are set low, as more near - normoglycaemic pregnant women will be diagnosed with GDM. Hence comparing GDM prevalence across countries remains difficult. Inclusion criteria are inconsistent and numbers have to be interpreted carefully. Although the findings of the Australian Carbohydrate Intolerance Study in pregnant women (ACHOIS) have suggested that universal screening should be implemented, the precise level of hyperglycaemia that carries increased pregnancy risk remains to be defined. Results of the blinded prospective international epidemiological study HAPO (Hyperglycemia and Adverse Pregnancy Outcome) which are expected by mid-2007 may identify a clear cut point or threshold for the complications associated with GDM.

When it comes to diagnosing and monitoring GDM, the obstetric department in Graz uses amniocentesis extensively for insulin treatment decision making. In fact GDM management has been traditionally undertaken at the obstetric department in Graz on the basis of fetal hyperinsulinism resulting in diabetic fetopathy with associated consequences for the fetus. Amniocentesis is considered a reliable intervention to detect fetal hyperinsulinism at the obstetric department in Graz. Several studies have suggested that amniotic fluid insulin levels are a sensitive and representative fetal parameter, being more a direct measure of fetal metabolic consequences independent of placental function. However, amniocentesis in GDM pregnancies remains uncommon in other centres, including the Mater, as it involves an invasive procedure. In addition none of published practice guidelines in English language, which have been approved by national agencies, considers amniocentesis as a routine procedure in management of GDM. It might be a worthwhile option, however further trials are required before recommending this as a routine diagnostic intervention.

GDM in Austria and AustraliaDifferences and common ground in clinical diagnosis and treatment of diabetes in pregnancy at two obstetric centres in Australia and Austria

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Willibald Zeck, MD, MSc Department of Obstetrics and Gynaecology, Medical University of Graz, Austria

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Concerning pre-gestational diabetes, glucose target values vary slightly in the two centres. There is, however, broad agreement upon many aspects of pre conception management of existing diabetes, such as target HbA1c levels, reviews for retinopathy and nephropathy, fetal ultrasound - and CTG – surveillance (see table no. 2). The usage of glucose lowering agents differs between the centres. Whereas the Mater uses insulin analogues these agents are not used in Graz. Insulin analogues are increasingly used instead of human insulin. Although evidence is emerging that the use of insulin analogues is not associated with excess risk of fetal malformations there are still no recommendations from any guidelines. Metformin is sometimes used at the Mater Hospital in Brisbane in Type 2 diabetes only, but is not used in Graz. A randomized trial involving metformin (MiG study) is under way.

Finally we found that the timing of delivery differs: In Graz pregnancy is continued beyond term in uncomplicated and non insulin treated GDM pregnancies. At the Mater Hospital in Brisbane GDM – pregnancies are continued until term. The optimal time of delivery in pregnancies complicated by diabetes is rather hard to determine. It is likely that this will remain a domain where individual co - factors and risks have to be balanced.

In conclusion, GDM and pre-gestational diabetes are associated with increased feto-maternal morbidity including stillbirth, macrosomia and fetal malformations as well as long – term complications in mother and offspring. There is no internationally agreed approach and there are neither up-to-date WHO - recommendations nor fact sheets for diabetes in pregnancy in particular. The complexity of gestational and pre-gestational diabetes, its underlying pathogenic mechanism and recent insights into potential and far-ranging complications have justified the establishment of a considerable number of national guidelines recently. An enormous variation of treatment strategies has originated from different views, approaches and traditional management in obstetric clinics around the globe. In short, few areas in diabetes research have aroused such controversy as the concept and diagnosis of diabetes in pregnancy. The result is potential confusion not only among practitioners but also among women with diabetes in pregnancy. It is difficult to standardize the screening criteria and diagnostic methods for GDM and pre-gestational diabetes. National and international consensus has yet to be achieved in the management of Diabetes in Pregnancy.

Acknowledgements:

I want to thank Prof. David McIntyre, Past President of the Australasian Diabetes in Pregnancy Society and Director of the Centre for Diabetes in Pregnancy at the Mater Health Services in Brisbane, Australia, for his support and for inviting me to come to Brisbane for clinical experience and research.

Furthermore I want to thank Prof. Uwe Lang, head of the Obstetrics and Gynecology - department at the Medical University of Graz, Austria for supporting my intentions to come to Brisbane.

1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 Oct;27(10):2568-9; author reply 2569.

2. Hotu S, Carter B, Watson PD, Cutfield WS, Cundy T. Increasing prevalence of type 2 diabetes in adolescents J Paediatr Child Health 2004;40: 201-4.

3. Department of Health. National service framework for diabetes (England) standards. London: Stationery Office, 2001.

4. Metzger BE, Coustan DR. Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care. 1998 Aug;21 Suppl 2:B161-7.

5. Homko CJ, Reece EA. To screen or not to screen for gestational diabetes mellitus. The clinical quagmire. Clin Perinatol. 2001 Jun;28(2):407-17. Review.

6. McIntyre HD, Cheung N W, Oats J N, Simmons D. Gestational diabetes mellitus: from consensus to action on screening and treatment. Med J Aust. 2005 Sep 19;183(6):288-9.

7. HAPO Study Cooperative Research Group. The hyperglycemia and adverse pregnancy outcome (HAPO) study. Int J Gynaecol Obstet 2002; 78: 69–77.

8. Weiss PAM, Walcher W, Scholz HS. Der vernachlässigte Gestationsdiabetes: Risiken und Folgen. Geburtshilfe Frauenheilkd. 19999;59:535-544

9. Weiss PA, Lichtenegger W, Winter R, Purstner P. Insulin levels in amniotic fluid. Management of pregnancy in diabetes. Obstet Gynecol. 1978 Apr;51(4):393-8.

10. Weiss PA, Kainer F, Haeusler M, Purstner P, Haas J. Amniotic fluid insulin levels in nondiabetic pregnant women: an update. Arch Gynecol Obstet. 1998;262(1-2):81-6.

11. Weiss PA, Haeusler M, Tamussino K, Haas J. Can glucose tolerance test predict fetal hyperinsulinism? BJOG. 2000 Dec;107(12):1480-5.

12. Fraser RB, Bruce C. Amniotic fluid insulin levels identify the fetus at risk of neonatal hypoglycaemia. Diabet Med. 1999 Jul;16(7):568-72.

13. Simmons D. The utility and efficacy of the new insulins in the management of diabetes and pregnancy Curr Diab Rep. 2002 Aug;2(4):331-6.

14. Simmons D, Walters BN, Rowan JA, McIntyre HD. Metformin therapy and diabetes in pregnancy. Med J Aust. 2004 May 3;180(9):462-4

15. Feig DS, Palda VA, Lipscombe L; Canadian Task Force on Preventive Health Care. Screening for type 2 diabetes mellitus to prevent vascular complications: updated recommendations from the Canadian Task Force on Preventive Health Care. CMAJ. 2005 Jan 18;172(2):177-80.

16. Kjos SL, Buchanan TA. Gestational diabetes mellitus. N Engl J Med. 1999 Dec 2;341(23):1749-56.

17. Macintosh MC, Fleming KM, Bailey JA, Doyle P, Modder J, Acolet D, Golightly S, Miller A. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study.BMJ. 2006 Jul 22;333(7560):177. Epub 2006 Jun 16.

18. Cutchie WA, Cheung NW, Simmons D. Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes.Diabet Med. 2006 May;23(5):460-8. Review.

GDM in Austria and Australia...cont

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Center/ Organization

Antenatal Route and Timing of Delivery

Postpartum

Screening Abnormal OGTT values (mmol/l)

Abnormal values for diagnosis

Further management when abnormal

Monitoring/ glucose Targets(mmol/)

Further Management and indications for insulin therapy

Current Practice Medical University Graz, Obstetric Department

1 – Stage - screening: screen all between 24 and 28 weeks, use 75g Glu, screening performed by general practitioner, endocrinologist, diabetologist or gynecologist, screen high risk groups in 1. Trimenon

F ≥ 5.01h ≥ 8.92h ≥ 7.8

One or more Diet, Blood - glucose - self measuring up to 9 to 12 times daily, advice exercise

F < 5.01h < 7.82h < 6.7 and mean level < 5.3

If mean level is exceededrecommend amniocentesis, if amniotic fluid insulin level ≤ 13.6 diet remains the only therapy until deliveryorstart insulin therapy when amniocentesis is refused by patient or amniotic fluid insulin level ≥ 13.6obstetric check up every 2 weeks

In case of uncomplicated/ insulin dependent GDM deliver at term, in case of uncomplicated/ non - insulin dependent GDM continue pregnancy until 10 days beyond term

Determination of cord blood insulin, encourage breast feeding, blood glucose test in the newborn 30 min post partum, perform maternal OGTT 8 weeks post partum (75mg Glucose), if OGTT normal continue on a 2 -years basis

Current PracticeMater Misericordiae Mother’s Hospital Brisbane, Obstetric and Medical Department

2 – Stages - screening: screen all between 24 and 28 weeks, use 75g Glu, 1 - Stage Screening in high risk pregnancies, screening mainly performed by general practitioner standardized by laboratory

F ≥ 5.52h ≥ 8.0

One or more Multidisciplinary team approach, diet, blood - glucose - self measuring 4 times daily, advice exercise

F < 5.52h < 7.0

Start insulin therapy if goals are exceeded on two or more occasions within a 1 to 2 week interval, when macrosomia is suspected plan obstetric review every second week

Continue pregnancy until term when uncomplicated

Blood glucose testing in newborn 4 h after delivery,maternal OGTT 6 weeks postpartum then at least every 2 years, encourage breast feeding

Table 2 Summary of current practice for screening, diagnosis and management of gestational diabetes (GDM) at the Medical University Graz, Obstetric Department and Mater Misericordiae Motherʼs Hospital Brisbane, Obstetric and Medical Department.

Center/ Organization

Preconceptional Antenatal Route and Timing of Delivery

Postpartum

Glucose target values

Medical surveillance Obstetric surveillance Medication used

Current Practice Medical University Graz, Obstetric Department

Preconceptional counseling, strict control of blood glucose levels, supply folic acid 5 mg, cease hypoglycemia, diabetes complications screening, HbA1c level as close as possible to reference range

F < 5.01h < 7.82h < 6.7mean level ≤ 5.0 HbA1c < 6%

Screen for nephropathy and retinopathy (at least once in pregnancy), and thyroid disease, measure HbA1c every 3 - 4 weeks, glucose – self monitoring, fasting up to 9 to 12 times daily

Offer routine nuchal transparency screening (incl. PAPP-A and ß-HCG), fetal morphology USS at 18-20 weeks followed by fetal growth USS, review every 2 weeks, start CTG surveillance between 34. and 35 week

Human insulin Delivery at term when uncomplicated course, deliver at 38 weeks when control is poor or vascular disease is evident, measure regulary during labour

Close monitoring and adjustment of maternal insulin therapy

Current PracticeMater Misericordiae Mother’s Hospital Brisbane, Obstetric and Medical Department

Multidisciplinary team approach, counseling about risks and dangers by obstetrician or endocrinologist, strict control of blood glucose levels HbA1c < 6%

F < 4.0 - 5.52h < 7.0HbA1c < 6%

Screen for nephropathy and retinopathy (at least 3x times in pregnancy) and thyroid disease, measure HbA1c at least 3 times in pregnancy, medical review up to 15 times when uncomplicated course, glucose – self monitoring, fasting, 1h und 2h postprandial

Offer first trimester nuchal transparency screening (incl. PAPP-A and ß-HCG), fetal morphology USS at 18-20 weeks, fetal growth USS at 28-30 and 34-36 weeks, obstetric review up to 12 times when uncomplicated course, CTG monitoring from 36. week on

Human insulin,insulinanalogues, Metformin rarely used in T2DM

Delivery at term when uncomplicated course, deliver at 38 weeks when control is poor or vascular disease is evident, give insulin iv during labour in DMT1, measure regulary during labour in DMT2 (when blood glucose > 8 treat with insulin)

Close monitoring and adjustment of maternal insulin therapy 6 weeks post partum

Table 1 Summary of current practice for screening, diagnosis and management of pre-gestational diabetes at the Medical University Graz, Obstetric Department and Mater Misericordiae Motherʼs Hospital Brisbane, Obstetric and Medical Department.

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This is just a snapshot, written during a 12 hour stop over in Singapore, as the Newsletter is about to go to press. I am planning to elicit more detailed reports for the October Newsletter from some of the eight Australasians who attended this meeting along with a truly international lineup, though the Spanish, Italians and Israelis featured heavily on the delegate list.

This meeting convenes every two years and the next one is in Italy in 2009. So, what are the current hot topics?

PRE-GESTATIONAL DIABETES, GOALS OF CARE AND PREGNANCY OUTCOMES

The Confidential Enquiry into Maternal and Child Health (CEMACH) from the UK has looked at pregnancies in women with pre-existing diabetes, focusing on services and prepregnancy assessment. They reviewed over 500 pregnancies, including women who had poor outcomes (127 anomalies, 95 perinatal deaths). In women who had attended a clinic in the year prior to pregnancy, prepregnancy advice was given in 35%, an HbA1c was measured in 37% and preconceptual folic acid was prescribed in 39%. Women with bad outcomes were less likely to receive preconceptual care than women who had good outcomes. Health professionals’ documentation about contraception and pregnancy advice was poor.

Women who are seen for prepregnancy counseling are often advised to aim for an HbA1c <7%. Is this appropriate? In the Netherlands for example, where rates of prepregnancy care are high and HbA1c levels in early pregnancy are typically around 7%, there are still significantly increased risks of congenital anomalies. Should we be aiming for euglycaemia? If so, do we have the tools to help women achieve this without dangerous hypoglycaemia?

A SIGNIFICANT PORTION OF THE MEETING FOCUSED ON POSSIBLE WAYS OF IMPROVING OUTCOMES.

In women with type 1 diabetes it is recognized that the tools we have for managing blood glucose control are not perfect. Use of the continuous glucose monitor (CGMS), which provides 288 interstitial glucose readings over 24 hours, was demonstrated in several presentations. It showed that it can be useful for finding undetected periods of hyperglycaemia, which in turn can lead to changes in management and improved control. It also demonstrated that undetected nocturnal hypoglycaemia

was quite common (up to 40%). The use of insulin pumps (CSII) was promoted by one speaker, but some members of the audience had not found improved outcomes in the women they had managed using CSII. Selection of patients and education about the use of the pump may be important factors. There was a session about use of aspart insulin during pregnancy now the results of the ANA-1474 trial have been published in Diabetes Care. In this trial, 322 women were randomized to either Novorapid or Actrapid from prepregnancy or when they first presented during pregnancy. Overall pregnancy outcomes were the same, but there was improved post breakfast glycaemia in the Novorapid group (p<0.05) and trends towards fewer preterm deliveries, 20% vs 30% (p = 0.053), and fewer nocturnal hypoglycaemic episodes (p= 0.09). Many people in the audience are already using Novorapid or Humalog routinely.

In women with type 2 diabetes, the discussion focused on different approaches to management. The public health implications of the epidemic of “diabesity” was discussed, with the conclusion that the best way to improve pregnancy outcomes in type 2 diabetes would be to improve health of the population and reduce the prevalence of obesity and type 2 diabetes. Intergenerational effects of poor nutrition, fetal growth restriction and prematurity as well

as macrosomia were highlighted. Several speakers talked abut the adverse effect of obesity on pregnancy outcomes, but demonstrated the additional influence of type 2 diabetes (and GDM).

GESTATIONAL DIABETES

There were a number of presentations about the interrelationship between GDM, metabolic syndrome and later cardiovascular risk in women with GDM. Conclusions were that this population is a high risk group that may benefit from lifestyle and possibly pharmacological interventions to improve later health. There were no presentations about interventions, but maybe we will see that at the next meeting.

Istanbul GDM Conference4th International Symposium on Diabetes and Pregnancy, Istanbul, Turkey.

March 29th-31st 2007. Janet Rowan

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THE NEXT MEETING WILL BE HELD IN

ITALY, 2009

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Use of glibenclamide for treatment of GDM was “discussed” in the final session, but this was hijacked by opinions about this as a treatment option. In the United States, treatment with glibenclamide has become common in many centres. Since Langer’s original paper showing it was effective at improving glycaemic control and none was detected in cord blood, subsequent publications have reported its role within clinical practice, showing that obesity, early diagnosis and elevated fasting glucose levels over 6.0mmol/l are associated with need for insulin treatment. Neonatal outcomes have been similar in women treated with glibenclamide or insulin. Reservations about its use relate to the fact that some have demonstrated a small amount of glibenclamide does cross the placenta (about 4% over three hours). Is this negligible or could it have effect on the fetal pancreas? Follow up of the offspring would be a good way to settle this.

Metformin was not discussed, as we are awaiting reports of the MiG trial later this year. Newer data from South Africa showed that metformin in combination with glibenclamide was used safely in small numbers of women with GDM, but the combination was associated with increased prenatal losses in women with type 2 diabetes.

DIABETES AND OBSTETRIC ISSUES

Although there were several sessions dedicated to obstetric issues, there does not seem to be any good new data that help to answer the perennial questions about timing and mode of delivery.

Macrosomia was discussed, with most presenters using a single birth weight definition of macrosomia, though some talked about 90th percentile growth and customized birth weight charts were mentioned briefly. Can we improve antenatal fetal weight estimation or accurately identify the fetus that is at risk of shoulder dystocia? The answer still seems to be no and it is still true that the bigger the baby the more error is found in calculations of fetal weight based on ultrasound parameters. Measures of fetal fat were shown in several posters, but again did not seem to add useful information for management. Despite these limitations a number of obstetricians plan delivery by elective caesarean section (LSCS) based on ultrasound estimations of weight, for example, at one centre in Israel, elective LSCS is performed in women with an estimated fetal weight >4,000g. Variations in practice are still apparent and it was interesting to see the LSCS rate in women with pre-existing diabetes varied from about 50% - 80% at different centres. There was concern about the high rates because of the increased maternal risks

associated with LSCS, which are compounded in obese women and increased risks in a subsequent pregnancy.

A talk about ultrasound detection of anomalies showed the experience at one centre: over 20% of anomalies were not detected antenatally. Of the ones that were, half were detected on a scan between 12-14 weeks; renal and cardiac anomalies were typically not detected until later anatomy scans were performed.

The value of doppler estimations was the topic of one talk, but the speaker was unable to attend. It was mentioned by another speaker that routine doppler estimations were not helpful, but are recommended for the usual obstetric indications. There is work looking at middle cerebral artery dopplers, but details will have to await the next Newsletter.

The use of cardiotocographs (CTGs) to assess fetal well-being was reported in combination with CGMS readings. Initial data on small numbers of women (about 15 women) were shown. Most of these women had very tight glucose control over the monitoring period and no associations were seen between these maternal glucose levels and CTG recordings. However, in a few women who had an interstitial glucose reading >14 mmol/l, changes were seen on the CTG. This level of hyperglycaemia was associated with loss of fetal heart rate variability and fetal tachycardia. It was proposed that this may uncover a fetus at risk of sudden intrauterine fetal death. No adverse effects were

seen on the CTG during maternal hypoglycaemia.

The assessment of biophysical profile (BPP) was also discussed – increased fetal breathing movements can be seen in the fetus of

women with diabetes, which could relate to hypoxic stress. Liquor volume may also be altered in relation to maternal diabetes and potentially more difficult to interpret. No conclusions were made about BPP assessments (though I may have had a jet-lagged moment).

So, that is all for now, just a taster. We will report further and add details (and any corrections) in the next newsletter.

THE LSCS RATE IN WOMEN WITH PRE-EXISTING DIABETES

VARIED FROM ABOUT 50% - 80%

Istanbul GDM Conference...cont

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S P O N S O R E D B Y R O C H E D I A G N O S T I C S

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TAN

DEM

121

89 3

/07

These grants are encouragement awards in the field of Diabetes in Pregnancy. They may be suitable for pilot studies but are not intended to fund large scale projects or salaries. Priority will be given to new investigators, novel submissions, and proposals which are not additional studies within existing funded projects. It is expected that projects will be completed within one year and that the successful applicants should undertake to present their findings at the ADIPS Annual Scientific Meeting in the following 1–2 years.

The applicants must be financial members of ADIPS. For the membership application form go to the ADIPS website at: www.adips.org/

Submissions should be of no more than 2 pages. They must indicate:

Title Grant CategoryInvestigators Project detailsInstitution and contact Significance of the project

In addition, the following questions need to be answered:

• Is this proposal a component or substudy of a larger project with existing funding or where funding from another body has been sought?

• Name of the administering body.

Grant applications should be sent to: ADIPS RESEARCH GRANTS c/o ADIPS Secretariat Trish Cohen, 32 St. Georges Road, Toorak Vic 3142.

The 2007 ADIPS Research Grants are generously supported by Novo Nordisk Pharmaceuticals Pty Ltd.

Enquiries: Dr Glynis Ross, ADIPS Treasurer gpross@bigpond.net.au

a n n o u n c e m e n t

The 2007 ADIPS research grants

The ADIPS–Novo Nordisk Grantfor Scientific/Clinical Research $3000

The ADIPS–Novo Nordisk Grant for Education Research $3000

The Grant Review Committee reserves the right not to award a grant if there are no applications of adequate standard within the category. Adequacy of standard will be determined by the Committee. The Committee’s decision is final and no negotiation will be entered into.

CLOSING DATEFriday 30 June 2007

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S P O N S O R E D B Y R O C H E D I A G N O S T I C S

2nd International Congress on “prediabetes” and the metabolic syndrome April 25-28, 2007 (may be too late for this year, but one to watch out for next time) Barcelona, Spain www.kenes.com/prediabetes/registration.asp

American Diabetes Association (ADA) 67th Scientific Sessions June 22-26, 2007 McCormick Place Convention Centre Chicago, Illinois www.scientificsessions.diabetes.org

New Zealand Society for Study of Diabetes (NZSSD) and Australian Diabetes Society (ADS) joint meeting (which overlaps ADIPS on 7th and 8th at the same venue ) September 5-7, 2007 Christchurch, NZ www.ads-adea.org.au/

European Association for the Study of Diabetes (EASD) 43rd Annual Meeting September 17-21 Amsterdam, The Netherlands www.eadd.org/

Diabetic Pregnancy Study Group 39th Annual Meeting September 20-23, 2007 Ibiza, Spain bbjbonet@fhalcorcon.es

Developmental origins of Health and Disease (DOHAD) November 6 – 10, 2007 Perth Convention Exhibition Centre Perth, Western Australia www.congresswest.com.au/dohad/doahd.html

Society of obstetric medicine in Australia and New Zealand (SOMANZ) November 16-18th, 2007 Sydney…more details soon www.somanz.org/

Western Pacific IDF conference and NZSSD 32nd ASM 31 March – 4 April, 2008 Wellington, NZ

Meetings and miscellaneousA D I P S A P R I L 2 0 0 7

Andrew Hattersley receiving a gift from ADIPS - life is not all

work for our international speakers

Aidan, the MC of debates - is the wine suitable?

Miggers together ADIPS 2006 - is it the projector or face-paint, Bill?

Jeremy warming up for HAPO

Some members from the organising committee for ADIPS 2007 (and friends) – can you spot Peter, Rosemary, David and Ruth?

The Australasian Diabetes in Pregnancy Society 32 St. Georges Road, Toorak Vic 3142, Australia Phone/Fax: +61 3 9827 8263 E-mail: adips.pc@bigpond.net.au ABN: 79 371 815 899

APPLICATION FOR NEW MEMBERSHIP AUSTRALASIAN DIABETES IN PREGNANCY SOCIETY

Name of Applicant: ___________________________________________________

Address: ___________________________________________________

___________________________________________________

State ____________________ Post Code ____________

ProfessionalQualifications: ___________________________________________________

Phone No: Bus: _____________________ Fax: ________________

E-mail: ___________________________________________________ (please print clearly)

Nominated: ____________________ Seconded: _________________

Please Note: Nominators and Seconders must be financial Members of ADIPS. If you have no contact with financial members, please notify Secretary Dr Aidan McElduff, Royal North Shore Hospital Pacific Highway, St. Leonards, N.S.W. 2065 Tel: (02) 9926 8388, Fax (02) 9906 7525, E-mail: aidanmc@bigpond.com

For Australian Members: Membership fee is AU$66:00 (includes GST) For New Zealand Members: Membership fee is AU$60:00 (excludes GST)

Membership is based on a calendar year

Application form together with Membership fee should be forwarded toMrs. Trish Cohen ADIPS Secretariat 32 St. Georges Road Toorak, VIC 3142, Australia Fax: +61 3 9827 8263

� Cheque: Please make payable to “ADIPS” � Credit Card: � MasterCard � Visa

(other cards not accepted)

Card Number: ______________________ Expiry Date: _____________________

Name on Card: ______________________ Signature: _____________________

Privacy Note: ADIPS complies with National Privacy Legislation, Privacy Amendment (Private Sector) Act 2001, effective 21 December, 2001.

TAX INVOICE ABN 79 371 815 899

(If applicable, this becomes a Tax Invoice on payment)

For 2007 Calendar Year

SUBSCRIPTION FEE / RECORD UPDATE

Name: _____________________________________________________

Address: _____________________________________________________

_____________________________________________________

State __________________ Post Code _______________

Telephone No: BH ( )________________ AH ( )__________________

Fax: ( )________________

E-mail Address: __________________________________________________________ The address supplied will be used for all ADIPS correspondence

Annual Subscription Fee: Australian members AU$66:00 (includes GST)

New Zealand members AU$60:00 (excludes GST) (Payment only in AU$ is accepted)

Please send to: Mrs. Trish Cohen ADIPS Secretariat 32 St. Georges Road Toorak, VIC 3142, Australia Fax: +61 3 9827 8263

� Cheque: Please make payable to “ADIPS” � Credit Card: � MasterCard � Visa

(other cards not accepted)

Card Number: _____________________ Expiry Date: _____________________

Name on Card: ______________________ Signature: _____________________

Privacy Note: ADIPS complies with National Privacy Legislation, Privacy Amendment (Private Sector) Act 2001, effective 21 December, 2001.

The Australasian Diabetes in Pregnancy Society 32 St. Georges Road, Toorak Vic 3142 Phone/Fax: (03) 9827 8263 E-mail: adips.pc@bigpond.net.au ABN: 79 371 815 899

1 3 S P O N S O R E D B Y R O C H E D I A G N O S T I C S

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Please tell us what you think of the booklet, so we can improve future prints. ADIPS and DAVhave agreed to subsidize half the printing costs to help minimize costs to our consumers. Wehope Institutions will uphold the aim and provide this useful resource to women at no charge.An electronic copy of the booklet can be downloaded from the ADIPS webpage atwww.adips.org

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