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New Gestational Diabetes Guidelines

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 >>

Diagnosis Of Gestational Diabetes Mellitus (gdm) In Australia

Diagnosis Of Gestational Diabetes Mellitus (gdm) In Australia

For over 20 years, the diagnosis of GDM in Australia has been derived from an ad hoc consensus, based on very limited data available at that time.1 The landmark observation trial HAPO, 20082 and other important randomised trials (Crowther et al. 20053; Langdon et al. 20094) have led to recommendations for new criteria for the diagnosis of GDM5, which have been endorsed by the World Health Organisation (WHO). Locally, these criteria have been endorsed by the Australasian Diabetes in Pregnancy Society (ADIPS) and the Australian Diabetes Society (ADS) but not by the Endocrine Society of Australia (ESA) or the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ). The result is that there are currently two sets of GDM diagnostic criteria in use – causing significant confusion amongst obstetricians, midwives, pathologists and patients. On 1 November 2013, RANZCOG convened a multidisciplinary working party to progress the issue of variation in diagnosis of GDM (the Australian Multidisciplinary Gestational Diabetes Working Party). This working party included representation from: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), The Australasian Diabetes in Pregnancy Society (ADIPS), The International Association of the Diabetes and Pregnancy Study Groups (IADPSG), The Royal College of Pathologists of Australasia (RCPA), The Australian College of Midwives (ACM), The Australian Diabetes Educators Association (ADEA), The Australian Diabetes Society (ADS), The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ), and Consumer representation. Representatives from the Endocrine Society of Australia (ESA), The Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Pra Continue reading >>

Acog Guidelines At A Glance: Gestational Diabetes Mellitus

Acog Guidelines At A Glance: Gestational Diabetes Mellitus

Committee on Practice Bulletins—Obstetrics ACOG Practice Bulletin 137: Gestational Diabetes Mellitus, August 2013 (Replaces Practice Bulletin Number 30, September 2001, Committee Opinion Number 435, June 2009, and Committee Opinion Number 504, September 2011). Obstet Gynecol. 2013;122:406-16. Full text of ACOG Practice Bulletins is available to ACOG members at _Bulletins_--_Obstetrics/Gestational_Diabetes_Mellitus. Gestational diabetes mellitus Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. Debate continues to surround both the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purpose of this document is to 1) provide a brief overview of the understanding of GDM, 2) provide management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed. Used with permission. Copyright the American College of Obstetricians and Gynecologists. By Haywood L. Brown, MD Dr. Brown is Roy T. Parker Professor and Chair, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke Medicine, Durham, NC. He is also a member of the Contemporary OB/GYN Editorial Board. Practice Bulletin 137 on gestational diabetes mellitus provides a rationale for current screening guidelines for a pregnancy population in which prevalence of obesity and Type 2 diabetes has increased over the past several decades. Review of the bulletin underscores several questions pertinent to diagnosis and management, which are reflected by and addressed similarly in the evidence-based recommendations in the document.1 Is GDM overdiagnosed or underdiagnosed? Obviously, the prevalence of gest Continue reading >>

New Figo Guidelines On Gestational Diabetes [24p]

New Figo Guidelines On Gestational Diabetes [24p]

INTRODUCTION: Gestational diabetes mellitus is one of the most common medical disorders found in pregnancy. Clinical recognition of GDM is important because timely intervention by dietary measures or insulin and fetal surveillance can reduce the well described associated maternal and fetal complications. METHODS: This observational study was done over a period of one year. Single step test using 75 gms oral glucose was used as screening and diagnostic test for GDM. A total of 500 pregnant women attending antenatal clinic were selected randomly for the study at less than 16 weeks POG. All the selected women were given a 75 gm anhydrous glucose powder dissolved in a glass of water, to be consumed over 5 minutes, irrespective to the time of last meal. A venous blood sample was collected at 2 hours for estimating plasma glucose by the glucose oxidase peroxidase (GOD-POD) method. GDM was diagnosed if 2 hrs plasma glucose is >140 mg/dl. RESULTS: Prevalence of GDM was found to be 7% in present study. Age ≥25 years, obesity, multigravidity and family history of diabetes mellitus were major risk factors for developing GDM. Maternal and fetal outcomes were poor in GDM group as compared to the control group. In GDM group common maternal complications were polyhydramnios and recurrent vaginal infections. CONCLUSION: Present study concurs with the WHO recommendation of 2-hr 75 gms OGTT as single step procedure for both screening as well as diagnosis of GDM. Hence we suggest the adaptation of 75 gms glucose single step test for screening and diagnosis of GDM. Financial Disclosure: The authors did not report any potential conflicts of interest. © 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. 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 >>

The Impact Of Potential New Diagnostic Criteria On The Prevalence Of Gestational Diabetes Mellitus In Australia

The Impact Of Potential New Diagnostic Criteria On The Prevalence Of Gestational Diabetes Mellitus In Australia

Summary Objective: The International Association of Diabetes and Pregnancy Study Groups (IADPSG) has proposed new criteria for the diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to compare the prevalence of GDM when IADPSG criteria were used with the prevalence when the current Australasian Diabetes in Pregnancy Society (ADIPS) criteria were used. Design, setting and participants: This was a prospective study over a 6-month period, examining the results of all glucose tolerance tests (GTTs) conducted for the diagnosis of GDM in Wollongong, a city using the public and private sectors. Main outcome measures: The prevalence of GDM using the existing (ADIPS) and the proposed (IADPSG) criteria. Results: There were 1275 evaluable GTTs (571 public and 704 private). Using the current ADIPS diagnostic criteria, the prevalence of GDM was 8.6% (public), 10.5% (private) and 9.6% (overall). Using the proposed IADPSG criteria, the prevalence of GDM was 9.1% (public), 16.2% (private) and 13.0% (overall). Conclusions: The proposed IADPSG criteria would increase the prevalence of GDM from 9.6% to 13.0% (P < 0.001). In our study in the Wollongong area, which has a population with a predominantly white background, this increase came mainly from older women attending a private pathology provider. Data from both the public and private sectors need to be included in any discussion on the change in prevalence of GDM. 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 >>

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 >>

Monitoring Diabetes Before, During And After Pregnancy

Monitoring Diabetes Before, During And After Pregnancy

View / Download pdf version of this article What is new? All pregnant women should be tested for undiagnosed diabetes using HbA1c prior to 20 weeks’ gestation Pregnant women with HbA1c ≥ 50 mmol/mol should be referred to a diabetes in pregnancy clinic Pregnant women with HbA1c 41 – 49 mmol/mol should be offered lifestyle advice to reduce risks of adverse maternal and fetal outcomes; local protocols may recommend that these women are also referred to a diabetes in pregnancy clinic At 24 to 28 weeks’ gestation, women are recommended to undergo an oral glucose tolerance testing regimen, which is dependent on their initial HbA1c result HbA1c is used to monitor glycaemia postpartum in women who have had gestational diabetes, beginning at three months after birth Pregnancy is a time of significant metabolic change when a woman’s physiology adapts to meet the challenges of gestation. Insulin sensitivity is decreased by as much as 50 to 60% during pregnancy, a level comparable to that seen in people with type 2 diabetes or impaired glucose tolerance.1 This change in insulin sensitivity is thought to be caused by endocrine signals from the growing placenta, and has evolved to aid fetal development.2 During pregnancy the mother’s pancreas typically responds with beta-cell and islet hyperplasia to enable greater insulin production and regulate blood glucose levels.1 Women who do not produce enough insulin to compensate for this transitory increase in insulin resistance develop gestational diabetes. These women often have risk factors for the development of type 2 diabetes and a higher level of insulin resistance before pregnancy.1 After childbirth, the insulin resistance associated with pregnancy usually resolves, as does the need for treatment, if this has been requir Continue reading >>

Gestational Diabetes

Gestational Diabetes

What risk factors are associated with GDM? Factors that may impact a woman’s GDM diagnoses during pregnancy include: Obesity and being overweight A family history of type 2 diabetes (including parent or sibling) Cultural backgrounds can influence your risk including Aboriginal or Torres Strait Islanders, Indian, Vietnamese, Chinese, Middle Eastern or Polynesian Gestational diabetes occurred during previous pregnancies Your age – you are at greater risk of GDM if you are 30 years old or older Unexplained stillbirth or neonatal deaths or having a very large infant previously could put the mother at greater risk When will I be tested for GDM? A test called an oral glucose tolerance test (OGTT) is used to diagnose GDM and involves a blood test before breakfast, then again two hours after a glucose drink. This test generally occurs in the 24th – 28th week of pregnancy. Usually gestational diabetes goes away after your baby is born and you should be able to cease taking any associated medication (tablets or insulin). Before you are discharged to the care of your GP, your blood will be tested to make sure the glucose levels have returned to normal. You should have a fasting blood test six weeks after your baby is born and then every year. Looking after gestational diabetes is important to prevent complications during pregnancy and childbirth. Management for GDM includes: A dietitian who will help you with a healthy eating plan that meets the nutritional requirements of pregnancy and is appropriate for your blood glucose levels An exercise physiologist or local doctor will recommend regular physical activity to help your body’s insulin work better. It also helps manage blood glucose levels Frequent blood glucose monitoring will help manage blood glucose levels to stay i 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 >>

Screening And Diagnosis Of Gestational Diabetes Mellitus, Where Do We Stand

Screening And Diagnosis Of Gestational Diabetes Mellitus, Where Do We Stand

Go to: Any degree of glucose intolerance with the onset or first recognition during pregnancy is defined as Gestational Diabetes Mellitus (GDM) [1]. Women with history of GDM are at an increased risk of adverse maternal and perinatal outcome and also at increased risk of future diabetes predominantly Type II including their children and therefore there are two generations at risk [2]. Any degree of glucose intolerance during pregnancy is associated with adverse maternal and fetal outcome. The adverse maternal complications include hypertension, preeclampsia, urinary tract infection, hydramnios, increased operative intervention and future DM. In the fetus and neonates it is associated with macrosomia, congenital anomalies, metabolic abnormalities, RDS, etc. and subsequent childhood and adolescent obesity [3]. Therefore, it is important to diagnose early and treat promptly to prevent complications. GDM is a topic of considerable controversy when it comes to its screening, diagnosis and its cost-effectiveness. Precise level of glucose intolerance characterizing GDM has been controversial over three decades. High prevalence of DM and genetic predisposition to metabolic syndrome among Asians, particularly in Indian women, predisposes women to develop GDM and its complications. So, there is a need for cost-effective universal screening and diagnostic method. Unfortunately there is no international consensus on the screening and diagnostic criteria for GDM. The rationale of this review is to provide recent updates and to discuss the controversies of screening and diagnosis of GDM. It affects 7% of all pregnancies worldwide and in India it ranges from 6 to 9% in rural and 12 to 21% in urban area [4]. The high rate implies that Indian population has a higher incidence of DM and Continue reading >>

Natural Selection? The Evolution Of Diagnostic Criteria For Gestational Diabetes

Natural Selection? The Evolution Of Diagnostic Criteria For Gestational Diabetes

Gestational diabetes is a common pregnancy disorder which is generally managed with diet, exercise, metformin or insulin treatment and which usually resolves after delivery of the infant. Identifying and treating gestational diabetes improves maternal and fetal outcomes and allows for health promotion to reduce the mother’s risk of type 2 diabetes in later life. However, there remains considerable controversy about the optimal method of identification and diagnosis of women with gestational diabetes. The NICE-2015 diagnostic criteria (75 g oral glucose tolerance test (OGTT) 0 h ≥5.6 mmol/L; 2 h ≥7.8 mmol/L) are based upon cost-effectiveness estimates using observational data, while the WHO-2013 criteria (75 g OGTT 0 h ≥5.1 mmol/L; 1 h ≥10.0 mmol/L; 2 h ≥8.5 mmol/L) identify women and infants at risk of adverse outcomes according to prospective data. There is also considerable controversy about testing for gestational diabetes using universal or risk factor-based screening, and when and how testing should be performed. The aim of this review is to provide a summary of the clinical biochemistry aspects to these debates and to highlight the importance of appropriate identification of gestational diabetes and subsequent type 2 diabetes in this population. 1. Metzger, BE, Coustan, DR. Summary and recommendations of the fourth international workshop – conference on gestational diabetes mellitus. The Organizing Committee. Diabetes Care 1998; 21(Suppl 2): B161–B167. Google Scholar, Medline 2. World Health Organization. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy, Geneva: WHO, 2013. Google Scholar 3. Simmons D. Epidemiology of diabetes in pregnancy. In: McCance DR, Maresh M and Sacks DA (eds) Practical Management of Diabet 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 >>

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