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Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM). Simon Weitzman, MD, MPH. Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM). Diagnostic methods and criteria Screening strategies Maternal and offspring outcomes. - PowerPoint PPT Presentation
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Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)
Simon Weitzman, MD, MPHSimon Weitzman, MD, MPH
Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)
Diagnostic methods and criteriaDiagnostic methods and criteria
Screening strategiesScreening strategies
Maternal and offspring outcomesMaternal and offspring outcomes
Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)
Diagnostic methods and criteriaDiagnostic methods and criteria
Screening strategiesScreening strategies
Maternal and offspring outcomesMaternal and offspring outcomes
Diagnostic Methods for GDMDiagnostic Methods for GDM
1-hr. Oral Glucose Challenge Test 1-hr. Oral Glucose Challenge Test (GCT)(GCT)
Oral Glucose Tolerance Test (OGTT)Oral Glucose Tolerance Test (OGTT)World Health Organization (WHO)World Health Organization (WHO)
National Diabetes Data Group (NDDG)National Diabetes Data Group (NDDG)
Coustan ModificationCoustan Modification
Diagnostic criteria for GDMDiagnostic criteria for GDM
MethodMethod Criteria (mg/dl) Criteria (mg/dl) FPG 1 hr. 2 hr. 3 hr.FPG 1 hr. 2 hr. 3 hr.
WHO (75 gr)WHO (75 gr) 140 140 - 200 - - 200 -
NDDG (100 gr)NDDG (100 gr) 105 190 165 145 105 190 165 145
Coustan (100 gr) 95 180 155 140Coustan (100 gr) 95 180 155 140
FPG: Fasting plasma glucoseFPG: Fasting plasma glucose
Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)
Diagnostic methods and criteriaDiagnostic methods and criteria
Screening strategiesScreening strategies
Maternal and offspring outcomesMaternal and offspring outcomes
Screening strategies for GDMScreening strategies for GDM
The approachThe approach
One-step approachOne-step approach
Two-step approachTwo-step approach
The 50 gr. GCT (Cutoff The 50 gr. GCT (Cutoff >>186 mg/dl)186 mg/dl)
Sensitivity: 38.2%Sensitivity: 38.2% Specificity: 93.3%Specificity: 93.3%
Positive Predictive Value: 78.6 %Positive Predictive Value: 78.6 % Negative Predictive Value : 70.0 %Negative Predictive Value : 70.0 %
The 50 gr. GCT (Cutoff The 50 gr. GCT (Cutoff >>186mg/dl)186mg/dl)
Sensitivity: 38.2%Sensitivity: 38.2% Specificity: 93.3%Specificity: 93.3%
Positive Predictive Value:19.5%Positive Predictive Value:19.5% Negative Predictive Value: 97.2%Negative Predictive Value: 97.2%
Screening strategies for GDMScreening strategies for GDM
The populationThe population
Universal screeningUniversal screening
High risk groups screeningHigh risk groups screening
Universal versus high risk strategyUniversal versus high risk strategy
Universal screeningUniversal screening• 57.4% agreed to screening57.4% agreed to screening• 27.7 % GCT positive have abnormal 27.7 % GCT positive have abnormal
OGTTOGTT• Non-participants have more risk Non-participants have more risk
factorsfactors
High Risk Group ScreeningHigh Risk Group Screening•Would miss > 40% of GDMWould miss > 40% of GDM
Universal screening in the NegevUniversal screening in the Negev
70 % of Jewish and 57% of Bedouins 70 % of Jewish and 57% of Bedouins agreed to screeningagreed to screening
GCT only in 49% of womenGCT only in 49% of women OGTT only in 10%OGTT only in 10% Overall non- participation: 40%Overall non- participation: 40%
Critical evaluation of the Critical evaluation of the diagnosis of Gestational diagnosis of Gestational Diabetes Mellitus (GDM)Diabetes Mellitus (GDM)
Diagnostic methods and criteriaDiagnostic methods and criteria
Screening strategiesScreening strategies
Maternal and offspring outcomesMaternal and offspring outcomes
Influence of GDM on the later Influence of GDM on the later development of diabetes in the childdevelopment of diabetes in the child
Hyperglycemia affects fetal beta-cell Hyperglycemia affects fetal beta-cell function in animalsfunction in animals
Intrauterine nutritional deprivation and Intrauterine nutritional deprivation and maternal hyperglycemia increase the maternal hyperglycemia increase the risk of diabetes in later liferisk of diabetes in later life
Maternal and offspring Maternal and offspring outcomesoutcomes
Characteristic Normal OGTT GDM Characteristic Normal OGTT GDM LGA (%)LGA (%) 34 34 38 38
Gestational age (w) 39Gestational age (w) 39 39.2 39.2
Hospital daysHospital days 3.7 3.9 3.7 3.9
Perinatal characteristics of women Perinatal characteristics of women with GDM, according to risk factorswith GDM, according to risk factors
Characteristic Risk Factors OR(Characteristic Risk Factors OR(95%CI) 95%CI) Yes NoYes No
Cesarean section (%) 38Cesarean section (%) 38 35 1.6 (0.7-3.7) 35 1.6 (0.7-3.7)
Macrosomia (%)Macrosomia (%) 33 33 17 17 2.4 (0.9-6.7) 2.4 (0.9-6.7)
Shoulder Dystocia (%) 7 13 0.5 (0.1-2.1)Shoulder Dystocia (%) 7 13 0.5 (0.1-2.1)
Insulin therapyInsulin therapy (%) 30 28 1.1 (0.4-2.7)(%) 30 28 1.1 (0.4-2.7)
Plasma glucose levels in non obese, and obese Plasma glucose levels in non obese, and obese women with previous GDM, after 5-10 years of women with previous GDM, after 5-10 years of follow-upfollow-up
0
5
10
15
0 30 60 90 120 150
Controls
NOpGDM
OpGDM
Time (min)
Plasma glucose (mmol/l)
Plasma insulin levels in non obese and obese Plasma insulin levels in non obese and obese women with previous GDM, after 5-10 years of women with previous GDM, after 5-10 years of follow-upfollow-up
0
200
400
600
800
0 30 60 90 120 150
Controls
NOpGDM
OpGDM
Time (min)
Plasma insulin (pmol/l)
Logistic regression analysis of factors relatedLogistic regression analysis of factors related to the to the development of diabetes in women with previous development of diabetes in women with previous GDMGDM
95% CIOddsratio
Factor
1.83-26.246.94Fasting glucose atdiagnosis
1.08-9.233.150-120 min glucose AUC atpostpartum OGTT
1.13-22.505.260-60 min insulin AUC atdiagnostic OGTT
Glucose tolerance at follow-up in women Glucose tolerance at follow-up in women with previous GDM and healthy controlswith previous GDM and healthy controls
Controls(n=27)
GDM(n=139)
Status atfollow-up
88.9 (24)64.7 (90)Normal OGTT
11.1 (3)20.1 (28)IGT
--------10.8 (15)Type 2 DM
--------4.3 (6)Type 1 DM
ConclusionsConclusions
J. Nerup said that Type 1 diabetes is J. Nerup said that Type 1 diabetes is the nightmare of geneticists. the nightmare of geneticists. Paraphrasing his statement, we can say Paraphrasing his statement, we can say that GDM is the nightmare of that GDM is the nightmare of epidemiologists. There is controversy epidemiologists. There is controversy about its definition, the best diagnostic about its definition, the best diagnostic method, diagnostic criteria, and the method, diagnostic criteria, and the population to be screened.population to be screened.
Conclusions (2)Conclusions (2)
Despite this confusion, the management Despite this confusion, the management of the condition has greatly improved, of the condition has greatly improved, and the perinatal outcomes of and the perinatal outcomes of offspring's of GDM mothers are offspring's of GDM mothers are comparable to those of non-diabetic comparable to those of non-diabetic women, except for macrosomia.women, except for macrosomia.
Conclusions(3)Conclusions(3)
There is an increasing body of evidence There is an increasing body of evidence supporting the risk of developing supporting the risk of developing diabetes mellitus (and particularly type 2 diabetes mellitus (and particularly type 2 diabetes) among women with previous diabetes) among women with previous GDMGDM
Among obese GDM women, even years Among obese GDM women, even years after delivery, features of insulin after delivery, features of insulin resistance can be foundresistance can be found