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New Gestational Diabetes Guidelines

Acog Releases Updated Guidance On Gestational Diabetes

Acog Releases Updated Guidance On Gestational Diabetes

SUMMARY: ACOG has released updated guidance on gestational diabetes (GDM), which has become increasingly prevalent worldwide. Highlights and changes from the previous practice bulletin include the following: Fetal Monitoring Screening for GDM – One or Two Step? ACOG (based on NIH consensus panel findings) still supports the ‘2 step’ approach (24 – 28 week 1 hour venous glucose measurement following 50g oral glucose solution), followed by a 3 hour oral glucose tolerance test (OGTT) if positive Note: While the diagnosis of GDM is based on 2 abnormal values on the 3 hour OGTT, ACOG states, due to known adverse events, one abnormal value may be sufficient to make the diagnosis 1 step approach (75 g OGTT) on all women will increase the diagnosis of GDM but sufficient prospective studies demonstrating improved outcomes still lacking ACOG does acknowledge that some centers may opt for ‘1 step’ if warranted based on their population Who Should be Screened Early? ACOG has adopted the NIDDK / ADA guidance on screening for diabetes and prediabetes which takes in to account not only previous pregnancy history but also risk factors associated with type 2 diabetes. Screen early in pregnancy if: Patient is overweight with BMI of 25 (23 in Asian Americans), and one of the following: Physical inactivity Known impaired glucose metabolism Previous pregnancy history of: GDM Macrosomia (≥ 4000 g) Stillbirth Hypertension (140/90 mm Hg or being treated for hypertension) HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L) Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L) PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, morbid obesity and other conditions associated with insulin resistance Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose Cardiovascular disea Continue reading >>

Gestational Diabetes - Symptoms, Diagnosis, Treatment

Gestational Diabetes - Symptoms, Diagnosis, Treatment

Diabetes is diagnosed when a person has too much glucose (sugar) in the blood. Gestational diabetes is a variation of the disease that occurs during pregnancy, and is the result of the mother not being able to produce enough insulin. Gestational diabetes may not present obvious symptoms but may be diagnosed during routine pregnancy screening. The condition can adversely affect the pregnancy and health of the baby but can be managed with diet modification and exercise and, if necessary, medication. General information Diabetes mellitus (commonly known as diabetes) is a group of diseases characterised by high blood glucose levels over a prolonged period of time. This page deals with gestational diabetes. Other variations of diabetes include: Type 1 diabetes – usually diagnosed in childhood or adolescence. Type 2 diabetes – associated with a person being overweight. Gestational diabetes accounts for 90% of cases of diabetes in pregnancy, while pre-existing type 2 diabetes accounts for 8% of such cases. It usually develops during the second half of pregnancy but can occur as early as the 20th week. Gestational diabetes is common, with 3000–4000 women being diagnosed with the condition or its recurrence each year in New Zealand. The prevalence of gestational diabetes is increasing (8–9% per year) and is higher in Māori (5–10%), Pacific peoples (4–8%), and Asian Indians (4%) than in New Zealand Europeans (3%). The increasing rate of gestational diabetes appears to be related to increasing rates of obesity. Causes The exact cause of gestational diabetes is not known. However, pregnancy does affect how the body metabolises (breaks down) glucose. Glucose is absorbed into the bloodstream following a meal. The body then uses insulin (a hormone produced by the pancreas Continue reading >>

Diabetes And Pregnancy

Diabetes And Pregnancy

Key Messages Pregestational Diabetes All women with pre-existing type 1 or type 2 diabetes should receive preconception care to optimize glycemic control, assess complications, review medications and begin folate supplementation. Care by an interdisciplinary diabetes healthcare team composed of diabetes nurse educators, dietitians, obstetricians and diabetologists, both prior to conception and during pregnancy, has been shown to minimize maternal and fetal risks in women with pre-existing type 1 or type 2 diabetes. Gestational Diabetes Mellitus The diagnostic criteria for gestational diabetes mellitus (GDM) remain controversial; however, the committee has chosen a preferred approach and an alternate approach. The preferred approach is to begin with a 50 g glucose challenge test and, if appropriate, proceed with a 75 g oral glucose tolerance test, making the diagnosis of GDM if ≥1 value is abnormal (fasting ≥5.3 mmol/L, 1 hour ≥10.6 mmol/L, 2 hours ≥9.0 mmol/L). The alternate approach is a 1-step approach of a 75 g oral glucose tolerance test, making the diagnosis of GDM if ≥1 value is abnormal (fasting ≥5.1 mmol/L, 1 hour ≥10.0 mmol/L, 2 hours ≥8.5 mmol/L). Untreated GDM leads to increased maternal and perinatal morbidity, while treatment is associated with outcomes similar to control populations. Highlights of Revisions All recommendations have been updated and reorganized to clarify management considerations for women with pregestational or gestational diabetes in the prepregnancy period, during pregnancy, and in the intrapartum and postpartum periods. New criteria have been added for the screening and diagnosis of GDM (Figures 1 and 2). Figure 1 Preferred approach for the screening and diagnosis of gestational diabetes. Figure 2 Alternative approach f Continue reading >>

Screening And Diagnosis Of Gestational Diabetes Mellitus – Relevance To Low And Middle Income Countries

Screening And Diagnosis Of Gestational Diabetes Mellitus – Relevance To Low And Middle Income Countries

Abstract Gestational diabetes mellitus (GDM) is one of the most common metabolic complications of pregnancy. Ever since the first systematic evaluation of the oral glucose tolerance test by O’Sullivan and colleagues was carried out in 1964, there has been controversy with respect to the optimal screening and diagnostic criteria to detect GDM. The recently proposed International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for GDM has found fairly widespread acceptance, but it is still debated by several societies. This review intends to provide an overview of the evolution of the screening and diagnostic criteria for GDM. Debatable issues regarding optimal screening strategies, especially in the low resource settings of low and middle income countries are highlighted. The recent Women in India with GDM Strategy (WINGS) project carried out in Chennai, India tried to develop a Model of Care for GDM suitable for resource constrained settings. The findings related to screening and diagnosis of GDM based on WINGS are also highlighted in this review. Based on the WINGS experience we believe that despite the constraints in low and middle income countries at the present time, the IADPSG criteria appears to be the best. This will also help to bring out a uniform criteria for screening and diagnosis of GDM worldwide. Background The criteria for diagnosing diabetes outside of pregnancy, has evolved over time and have been largely accepted by major diabetes organizations worldwide. However, the screening and diagnosis of gestational diabetes mellitus (GDM) continues to be a contentious issue. Notwithstanding decades of research and several international workshops devoted to GDM, there is still no consensus among international bodies on a uniform global app Continue reading >>

Guidelines

Guidelines

There is now extensive evidence on the optimal management of diabetes, offering the opportunity of improving the immediate and long-term quality of life of those living with the condition. Unfortunately such optimal management is not reaching many, perhaps the majority, of the people who could benefit. Reasons include the size and complexity of the evidence-base, and the complexity of diabetes care itself. One result is a lack of proven cost-effective resources for diabetes care. Another result is diversity of standards of clinical practice. Guidelines are part of the process which seeks to address those problems. IDF has produced a series of guidelines on different aspects of diabetes management, prevention and care. The new IDF Clinical Practice Recommendations for managing Type 2 Diabetes in Primary Care seek to summarise current evidence around optimal management of people with type 2 diabetes. It is intended to be a decision support tool for general practitioners, hospital based clinicians and other primary health care clinicians working in diabetes. Pocket chart in the format of a Z-card with information for health professionals to identify, assess and treat diabetic foot patients earlier in the "window of presentation" between when neuropathy is diagnosed and prior to developing an ulcer. The content is derived from the IDF Clinical Practice Recommendations on the Diabetic Foot 2017. Available to download and to order in print format. The IDF Clinical Practice Recommendations on the Diabetic Foot are simplified, easy to digest guidelines to prioritize health care practitioner's early intervention of the diabetic foot with a sense of urgency through education. The main aims of the guidelines are to promote early detection and intervention; provide the criteria for Continue reading >>

12. Management Of Diabetes In Pregnancy

12. Management Of Diabetes In Pregnancy

For guidelines related to the diagnosis of gestational diabetes mellitus, please refer to Section 2 “Classification and Diagnosis of Diabetes.” Pregestational Diabetes Provide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. B Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examinations should occur before pregnancy or in the first trimester and then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. A Preferred medications in gestational diabetes mellitus are insulin and metformin; glyburide may be used but may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta, and all lack long-term safety data. A General Principles for Management of Diabetes in Pregnancy Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B Fasting, preprandial, and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and pregestati Continue reading >>

13.3 Gestational Diabetes Mellitus

13.3 Gestational Diabetes Mellitus

Clinical context Gestational diabetes, or GDM, is defined as glucose intolerance that begins or is first diagnosed during pregnancy. It may appear earlier, particularly in women with a high level of risk for GDM. GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy. GDM affects about 9.6–13.6% of pregnancies in Australia.245,246 The reported prevalence of GDM varies for a number of reasons. One reason is the use of different screening and diagnostic criteria. The prevalence is also affected by maternal factors such as history of previous gestational diabetes, ethnicity, advanced maternal age, family history of diabetes, pre-pregnancy weight and high gestational weight gain. Mothers of different ethnicity born in areas with high diabetes prevalence such as Polynesia, Asia and the Middle East, are three times as likely to have GDM as mothers born in Australia. Among Aboriginal and Torres Strait Islander mothers, GDM is twice as common, and pre-gestational diabetes affecting pregnancy is three to four times as common as in non-Indigenous mothers.245 In pregnancy, there is a natural increase in levels of hormones including cortisol, growth hormone, human placental lactogen, and progesterone and prolactin levels, causing two to three fold increases in insulin resistance. The action of these hormones is usually compensated by increased insulin release. In pregnant women with abnormal glucose tolerance or impaired β-cell reserve, the pancreas is unable to sufficiently increase insulin secretion in order to control BGLs. Potential maternal complications during pregnancy and delivery include pre-eclampsia and higher rates of caesarean delivery, maternal birth injury, postpartum haemorrhage. For the neonate, complications can inc Continue reading >>

Screening For Gestational Diabetes

Screening For Gestational Diabetes

Chairperson, Medical Disorders in Pregnancy Committee, FOGSI Pregnancy induces progressive changes in maternal carbohydrate metabolism. As pregnancy advances insulin resistance and diabetogenic stress due to placental hormones necessitate compensatory increase in insulin secretion. When this compensation is inadequate gestational diabetes develops. ‘Gestational Diabetes Mellitus’ [GDM] is defined as carbohydrate intolerance with onset or recognition during pregnancy. Women diagnosed to have GDM are at increased risk of future diabetes predominantly type 2 DM as are their children . Thus GDM offers an important opportunity for the development, testing and implementation of clinical strategies for diabetes prevention [ . Timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition may prevent in all probability, the vicious cycle of transmitting glucose intolerance from one generation to another. Screening & Diagnosis A number of screening procedures and diagnostic criteria (ADA, WHO, CDA, NDDG and Australasian criteria) are being followed in the same as well as in different countries. American Diabetes Association (ADA) recommends screening for selective (high risk) population. But compared to selective screening, universal screening for GDM detects more cases and improves maternal and neonatal prognosis [4,5]. Hence universal screening for GDM is essential, as it is generally accepted that women of Asian origin and especially ethnic Indians, are at a higher risk of developing GDM and subsequent type 2 diabetes. ADA procedure ADA recommends two step procedures. Step 1: A 50 g glucose challenge test (GCT) is used for screening without regard to the time of last meal or time of the day. St Continue reading >>

Updated Guidelines On Screening For Gestational Diabetes

Updated Guidelines On Screening For Gestational Diabetes

Go to: Introduction Gestational diabetes mellitus (GDM) has classically been defined as any glucose intolerance first identified during pregnancy.1 Recently, the American Diabetes Association (ADA) defined it as “Diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes”.2 However, as per IADPSG (International association of diabetes and pregnancy study groups) criteria, women can be diagnosed to have GDM even in the first trimester, if fasting plasma glucose (FPG) is ≥5.1 mmol/L (92 mg/dL), but <7 mmol/L (126 mg/dL).3 GDM is associated with an increased risk of complications for both mother and baby, during pregnancy as well as in the postpartum period. Screening and identifying these high-risk women is important to improve short and long-term maternal and fetal outcomes.4 However, there is lack of international uniformity in the approach to the screening and diagnosis of GDM.5 This is surprising, given that the strategies for making a diagnosis of diabetes mellitus are uniform across the world.2 The main reason for the diagnostic dilemma of GDM is the large number of procedures and glucose cutoffs proposed for the diagnosis of glucose intolerance in pregnancy.6 The first diagnostic criteria proposed by O’Sullivan in 1964 and its subsequent modifications (Carpenter and Coustan) were based on the maternal risk of developing type 2 diabetes, rather than on pregnancy outcomes. Recently, the recommendations from IADPSG attempt to redefine GDM in terms of adverse pregnancy outcomes, based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study results.6 But, we are still far from attaining a holistic criteria which is based on both short and long-term outcomes. The main purpose of this review is to provide an update on s Continue reading >>

Final Recommendation Statement

Final Recommendation Statement

Importance Gestational diabetes mellitus is glucose intolerance discovered during pregnancy. The prevalence of GDM in the United States is 1% to 25%, depending on patient demographics and diagnostic thresholds (1). Pregnant women with gestational diabetes are at increased risk for maternal and fetal complications, including preeclampsia, fetal macrosomia (which can cause shoulder dystocia and birth injury), and neonatal hypoglycemia. Women with GDM are also at increased risk for developing type 2 diabetes mellitus; approximately 15% to 60% of women develop type 2 diabetes within 5 to 15 years of delivery (2). Screening for GDM generally occurs after the 24th week of pregnancy. Screening before 24 weeks may identify women with glucose intolerance earlier in pregnancy. The USPSTF found adequate evidence that primary care providers can accurately detect GDM in asymptomatic pregnant women after 24 weeks of gestation. The most commonly used screening test in the United States is the 50-g oral glucose challenge test (OGCT). Other methods of screening include the fasting plasma glucose test and screening based on risk factors. However, there is limited evidence on these alternative screening approaches. The USPSTF found inadequate evidence to compare the effectiveness of different screening tests or thresholds for a positive screen result. Benefits of Detection and Early Treatment The USPSTF found adequate evidence that treatment of screen-detected GDM with dietary modifications, glucose monitoring, and insulin (if needed) can significantly reduce the risk of preeclampsia, fetal macrosomia, and shoulder dystocia. When these outcomes are considered collectively, there is a moderate net benefit for both mother and infant. The benefit of treatment on long-term metabolic outcomes Continue reading >>

Diabetes In Pregnancy: Managementdiabetes In Pregnancy: Management From Preconception To The Postnatalfrom Preconception To The Postnatal Periodperiod

Diabetes In Pregnancy: Managementdiabetes In Pregnancy: Management From Preconception To The Postnatalfrom Preconception To The Postnatal Periodperiod

© NICE 2017. All rights reserved. Subject to Notice of rights (rights). YYour responsibilityour responsibility The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Diabetes in pregnancy: management from preconception to the postnatal period (NG3) © NICE 2017. All rights reserved. Subject to Notice of rights (conditions#notice-of-rights). Page 2 of 67 ContentsContents Overview ..................................................................... Continue reading >>

Diabetes Management Guidelines

Diabetes Management Guidelines

Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including class of recommendation and level of evidence. Jump to a topic or click back/next at the bottom of each page Diabetes in Pregnancy (Gestational Diabetes) Glycemic Targets in Pregnancy Pregestational diabetes Gestational diabetes mellitus (GDM) Fasting ≤90 mg/dL (5.0 mmol/L) ≤95 mg/dL (5.3 mmol/L) 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) ≤140 mg/dL (7.8 mmol/L) 2-hr postprandial ≤120 mg/dL (6.7 mmol/L) ≤120 mg/dL (6.7 mmol/L) A1C 6.0-6.5% (42-48 mmol/L) recommended <6.0% may be optimal as pregnancy progresses Achieve without hypoglycemia Recommendations for Pregestational Diabetes Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM Spontaneous abortion Fetal anomalies Preeclampsia Intrauterine fetal demise Macrosomia Neonatal hypoglycemia Neonatal hyperbilirubinemia Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life Maintain A1C levels as close to normal as is safely possible Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia Discuss family planning Prescribe effective contraception until woman is prepared to become pregnant Women with preexisting type 1 or type 2 diabetes Counsel on the risk of development and/or progression of diabetic retinopathy Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum Management of Pregestational Diabetes Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin Insulin* management during pre Continue reading >>

Diabetes Mellitus In Pregnancy: Screening And Diagnosis

Diabetes Mellitus In Pregnancy: Screening And Diagnosis

INTRODUCTION Pregnancy is accompanied by insulin resistance, mediated primarily by placental secretion of diabetogenic hormones including growth hormone, corticotropin-releasing hormone, placental lactogen, and progesterone. These and other metabolic changes ensure that the fetus has an ample supply of nutrients. (See "Maternal adaptations to pregnancy: Endocrine and metabolic changes".) Gestational diabetes develops during pregnancy in women whose pancreatic function is insufficient to overcome the insulin resistance associated with the pregnant state. Among the main consequences are increased risks of preeclampsia, macrosomia, and cesarean delivery, and their associated morbidities. The approach to screening for and diagnosis of diabetes in pregnant women will be reviewed here. Management and prognosis are discussed separately: Continue reading >>

A Look At Two New Diabetes And Pregnancy Guidelines

A Look At Two New Diabetes And Pregnancy Guidelines

Gestational diabetes, if caught early, can be managed without causing harm to the mother or infant. The two new guidelines differ on how and when to screen pregnant women. Two medical organizations, The Endocrine Society and American Congress of Obstetricians and Gynecologists (ACOG), have slightly differing opinions on how to screen pregnant women for overt diabetes at the first prenatal visit and for gestational diabetes later during pregnancy, according to recently released guidelines from both associations. Diabetic Lifestyle spoke with authors of both guidelines to discuss how physicians should interpret the guidelines in clinical practice. Early Screening For Overt Diabetes: When and How? The Endocrine Society guidelines recommend that all pregnant women should be screened for overt diabetes using blood glucose testing at their first prenatal visit, either before 13 weeks’ gestation or as soon as possible thereafter, as reported in the November issue of the Journal of Clinical Endocrinology and Metabolism. This recommendation is in alignment with that of the International Association of Diabetes and Pregnancy Study Groups and the American Diabetes Association. The 2013 ACOG guidelines call for early screening for overt diabetes or gestational diabetes with blood glucose testing only in women identified as having risk factors for gestational diabetes (eg, a history of gestational diabetes, impaired glucose metabolism, or obesity). The ACOG guidelines were first published in the August issue of Obstetrics & Gynecology. “There is insufficient data at the present time to endorse universal testing for diabetes at the first prenatal visit. It does, however, seem reasonable to test for diabetes in early pregnancy in women with obvious risk factors,” said co-author Continue reading >>

Diabetes Criteria 'miss At-risk Women'

Diabetes Criteria 'miss At-risk Women'

New criteria for diagnosing diabetes during pregnancy could be missing thousands of at-risk women, a report suggests. Although the threshold introduced by health watchdog NICE earlier this year has been lowered, Cambridge University research says it is still too high. The WHO's threshold is lower and identifies more women at risk of pregnancy complications. Diabetes UK said it was vital that women received the right support. Diabetes that occurs for the first time during pregnancy is known as gestational diabetes. It is estimated to affect around 4%-5% of pregnant women in the UK and has becoming increasingly common in line with the rise in obesity. In some women, the condition occurs because the body cannot produce enough insulin to meet the extra needs of pregnancy. In others, diabetes may be found during the first trimester of pregnancy or may have existed before the pregnancy. If left untreated, the condition can be a risk to the health of the mother and baby, potentially leading to birth defects, babies being born overweight and emergency C-sections. Miscarriage is also a danger. The WHO criteria were not cost effective - their criteria did not provide enough benefit in relation to the increased costsProf Mark Baker, NICE Different thresholds The National Institute for Health and Care Excellence (NICE) brought in new guidelines in February, requiring two blood tests (one when fasting and another two hours after a sugary drink). A fasting blood sugar test reading of 5.6 mmol per litre or above is required for a diagnosis of gestational diabetes. The World Health Organization guidelines require three blood tests and a slightly lower reading of 5.1 mmol per litre for the fasting blood sugar test. Study author Dr Claire Meek from the Wellcome Trust-MRC Institute of Met Continue reading >>

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