Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes

“Classical Windows” by theswedish,
http://www.sxc.hu/photo/1344783

Postpartum
Gestational Diabetes:
Screening
Opportunities
for Type 2 Diabetes
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Assoc Prof. 4, UP College of Medicine
Chief, UPCM Medical Informatics Unit
Section of Endocrinology, Diabetes & Metabolism
Dept. of Medicine, Philippine General Hospital

2012 Diabetes Philippines Annual Convention
EDSA Shangrila Hotel 14 Nov 2012
Sunday, November 18, 12

Is GDM the
forme fruste of diabetes?

forme fruste
partial, arrested or
inapparent form of the “easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563

disease

Natural History of Type 2 Diabetes
De Fronzo RA, Diabetes 2009


“easter” by GiniMiniGi, http://
www.sxc.hu/photo/1162563

Women developing GDM had
lower pregravid insulin sensitivity
Landon et al 2001



GDM: increased fasting insulin
concentrations in late gestation
Landon et al 2001


GDM: decreased insulin
response to glucose
challenge in late pregnancy “easter” by GiniMiniGi, http://

Xiang AH et al Diabetes 1999



GDM: lower insulin response for
degree of insulin resistance
Homko et al Diabetes 2001


GDM: Diabetes in Evolution

“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563


Gestational diabetes is an independent risk
factor for diabetes in Filipino-Americans
Cuasay et al Diabetes Care 2001

Risk factor OR 95% CI
Age (y)
35-44 10.79 1.00-16.83
45-54 16.17 1.42-184.03
55-64 14.65 1.09-97.70
65 and older 38.68 2.27-659.89
Gestational diabetes 21.65 6.73-69.67
Delivery of baby >9 lb 1.51 0.39-5.84
Family history of diabetes 2.22 0.92-5.35
Obesity 2.85 0.53-15.4


“Classical Windows” by theswedish,
http://www.sxc.hu/photo/1344783

When & how to
screen

Barriers to screening

Interventions to
improve screening


Metabolic assessments
recommended after GDM
Metzger BE et al, Summary & Recommendations of the
5th International Workshop on GDM. Diabetes Care 2007

Time Test Purpose
Fasting or random Detect persistent, overt
Post-delivery (1-3 days)
plasma glucose diabetes
Early postpartum Postpartum classiﬁcation
(around the time of 75-g 2-h OGTT
postpartum visit) of glucose metabolism
1 year postpartum 75-g 2-h OGTT Assess glucose metabolism
Annually Fasting plasma glucose Assess glucose metabolism
Tri-annually 75-g 2-h OGTT Assess glucose metabolism
Prepregnancy 75-g 2-h OGTT Classify glucose metabolism


Postpartum Screening for Diabetes
Among Women with a History of
Gestational Diabetes
Systematic Review
Tovar A et al, Prev Chronic Dis 2011;8(6):A124

11 studies (2008-2010) on
rates & results of
postpartum screening

n = 32,240 GDM
(1999-2008)

“paper” by v_g, http://www.sxc.hu/photo/77779


Postpartum Screening
for Diabetes Among
Women with a History of
Systematic Review

34%-73%
(median 48%)
screened

“dream graph” by iamwahid, http://www.sxc.hu/photo/1209643


for Diabetes Among
Systematic Review

Postpartum screening
not improved over time

50.3% within 3 mos
48.2-51% within 6 mos
55.9% within 12 mos

“calendario” by malko, http://www.sxc.hu/photo/750005


for Diabetes Among
Systematic Review

79-100% screened with FPG (4 studies)
56-95% screened with OGTT (3 studies)

“Injection time” by adamci, http://www.sxc.hu/photo/250620


Using only FPG
in postpartum screening
will miss up to 75% of women
with IGT or type 2 diabetes
Kwong et al Diabetes Care 2009

Single FPG
sensitivity of 16% to 89% vs OGTT
Tovar et al Prev Chronic Dis 2011

Isolated IGT
1/3 of GDM cohort with DM or prediabetes
Hunt & Conway Am J Obstet Gynecol 2008

“Injection time” by adamci, http://www.sxc.hu/photo/250620


“Time slipping away 1” by chriki7274, http://www.sxc.hu/photo/723865

Patient barriers
Henderson et al The Open Diabetes J 2012

Time pressure as
primary barrier
Cost or inconvenience
Unaware of risks
Unaware of proven
methods to prevent or
delay diabetes


Barriers & facilitators of postpartum
follow-up care in previous GDM
Bennett et al J Women’s Health 2011

Barriers
Baby’s health needs
Personal and family adjustment to baby
(emotional stress/feeling overwhelmed, demands of
baby’s schedule/lack of time for self-care, child care
needs)
Concerns about postpartum and future health
(perception of good health and not needing further care, fear of
receiving bad news at follow-up appointment)
Experiences with medical care (dissatisfaction with care,
logistics of accessing care)

“duckie 1” by ppreacher, http://www.sxc.hu/photo/299965


Barriers & facilitators of postpartum
follow-up care in previous GDM
Bennett et al J Women’s Health 2011

Facilitators
Availability of child care
Check-up and clearance for return to work
Connection with clinical and office staff
Address specific concerns or questions
Discuss family planning

“businesswoman 1” by CELALTEBER, http://www.sxc.hu/photo/1305802


Postpartum Screening for Diabetes
Among Women with a History of
Systematic Review

21 studies (2008-2010)
on predictors of
& barriers to screening

“paper” by v_g, http://www.sxc.hu/photo/77779


Provider barriers
Tovar et al Prev Chronic Dis 2011

lack of attendance at
postpartum visit
however
94% postpartum Pap
smear vs 67% glucose
testing (37% FPG or
OGTT)

“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902


Provider barriers

clinician’s perception that
screening guidelines were
“inconsistent”



Postpartum screening recommendations
for women with GDM
Canadian Diabetes Association (2008)
75-g OGTT 6 wks-6 mos postpartum
Pre-pregnancy screening for T2D

WHO
75-g OGTT >6 wks postpartum

American Diabetes Association (2008)
FPG or 75-g OGTT
Annual repeat testing if IFG/IGT detected; q3 y if normal

American College of Obstetricians & Gynecologists (2009)
FPG or OGTT

“worried man against white background” by bigevil600, http://www.sxc.hu/photo/1000622


Provider barriers

lack of documentation of
GDM on problem lists
poor communication
between OB and primary
care


Who should follow up
GDM postpartum?
2008 ACOG survey: OB-GYNs self-report
ordering follow-up testing for patients (74%)
Gabbe et al Obstet Gynecol 2004

however
Review of lab records: only 1/3 had undergone
postpartum glucose screening
Almario et al Obstet Gynecol 2008

Lack of clarity who in the
clinical continuum should take
primary responsibility
Dornhorst et al Diabetes Care 1998


Multidisciplinary approach
Khandelwal M, Current Diabetes Rep 2008

many overlaps to provide constant
reminders and encouragement

“holding hands” by spekulator, http://www.sxc.hu/photo/835200


Reluctance to order OGTT
even in non-pregnant
Wilson et al BMC Health Serv Res 2009

Complexity and time required for OGTT
Uncertain value of intervening when IGT identified
Perceived cost

“dislike button” by Sean McEntee, http://www.ﬂickr.com/photos/smemon/5683562879/


Predictors of
Ferrara et al Diabetes Care 2009

Older age
Asian or Hispanic race/ethnicity
Higher education
At least 2 prior births
Earlier gestational age at GDM diagnosis
Use of insulin or glyburide during pregnancy
Visits to an IM or OB-Gyn during postpartum


Postal reminders
Clark et al AJOG 2008

RCT
Reminder sent to MD and patient,
patient only, MD only, no reminders

Outcome: OGTT in 1 y (p<0.05)

MD only Patient only MD & Patient No reminders
16/31 42/76 49/81 5/35
51.6% 55.3% 60.5% 14.3%

“timbre poste” by gastonmag, http://www.sxc.hu/photo/504564


Lab requests &
telephone reminders
Kwong et al Diabetes Care 2009

cohort of 1,006 GDM women
attending a pregnancy diabetes clinic
48% (n=438) completed
Non-adherence to testing
significantly associated with
higher parity & lack of insulin use

“old phone II” by bury-osiol, http://www.sxc.hu/photo/754394


Nurse managed
care program
Ferrara et al Diabetes Care 2009

cohort of 14,448 GDM
between 1995 and 2006

Proportion
receiving OGTT
1995 - 5%
2005 - 16.6%
2006 - 71.5%
Greater attention to postpartum
screening guidelines
“shaking hands” by bluegum, http://www.sxc.hu/photo/911615


Risk stratification
to improve screening
Schaefer-Graf et al Diabetes Care 2009

Target women at high risk
for postpartum glucose intolerance

Independent risk factors
Pre-pregnancy BMI >30
<24 weeks AOG at diagnosis
1h OGTT >200 mg/dL
Insulin therapy

“shot on target” by cobrasoft, http://www.sxc.hu/photo/1176209


Risk stratification
to improve screening
Schaefer-Graf et al Diabetes Care 2009


“writing hand” by tulp. http://www.sxc.hu/photo/877745

Interventions to
improve postpartum
screening in GDM

Written information, individualized risk
reduction advice, care from an
endocrinologist, diabetes educator or OB
Morrison et al Aust NZ J Obs Gyn 2009

Provision of lab slip and preventive
counseling Kim et al Diabetes Care 2007
One-on-one counseling session
at 37-38 wks gestation Stasenko et al Am J Obstet Gynecol 2009

Promoting health after gestational diabetes:
a National Diabetes Education Program
Call To Action
Gabbe SG et al, Obstet Gynecol Jan 2012
http://ndep.nih.gov/am-i-at-risk/gdm/


Download from http://ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx


Thank You!
http://www.endocrine-witch.net

@endocrine_witch
http://www.slideshare.net/isiptan


Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes

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Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes