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Postpartum Gestational Diabetes: Opportunities for Screening for Type 2 Diabetes
1. “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
2. 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
Sunday, November 18, 12
3. Natural History of Type 2 Diabetes
De Fronzo RA, Diabetes 2009
Sunday, November 18, 12
4. “easter” by GiniMiniGi, http://
www.sxc.hu/photo/1162563
Women developing GDM had
lower pregravid insulin sensitivity
Landon et al 2001
Sunday, November 18, 12
5. “easter” by GiniMiniGi, http://
www.sxc.hu/photo/1162563
GDM: increased fasting insulin
concentrations in late gestation
Landon et al 2001
Sunday, November 18, 12
6. GDM: decreased insulin
response to glucose
challenge in late pregnancy “easter” by GiniMiniGi, http://
www.sxc.hu/photo/1162563
Xiang AH et al Diabetes 1999
Sunday, November 18, 12
7. “easter” by GiniMiniGi, http://
www.sxc.hu/photo/1162563
GDM: lower insulin response for
degree of insulin resistance
Homko et al Diabetes 2001
Sunday, November 18, 12
8. GDM: Diabetes in Evolution
“easter” by GiniMiniGi, http://www.sxc.hu/photo/1162563
Sunday, November 18, 12
9. 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
Sunday, November 18, 12
10. “Classical Windows” by theswedish,
http://www.sxc.hu/photo/1344783
When & how to
screen
Barriers to screening
Interventions to
improve screening
Sunday, November 18, 12
11. 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
Sunday, November 18, 12
12. 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
Sunday, November 18, 12
13. 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
34%-73%
(median 48%)
screened
“dream graph” by iamwahid, http://www.sxc.hu/photo/1209643
Sunday, November 18, 12
14. 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
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
Sunday, November 18, 12
15. 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
79-100% screened with FPG (4 studies)
56-95% screened with OGTT (3 studies)
“Injection time” by adamci, http://www.sxc.hu/photo/250620
Sunday, November 18, 12
16. 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
Sunday, November 18, 12
17. “Classical Windows” by theswedish,
http://www.sxc.hu/photo/1344783
When & how to
screen
Barriers to screening
Interventions to
improve screening
Sunday, November 18, 12
18. “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
Sunday, November 18, 12
19. 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
Sunday, November 18, 12
20. 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
Sunday, November 18, 12
21. 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
21 studies (2008-2010)
on predictors of
& barriers to screening
“paper” by v_g, http://www.sxc.hu/photo/77779
Sunday, November 18, 12
22. 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
Sunday, November 18, 12
23. Provider barriers
Henderson et al The Open Diabetes J 2012
clinician’s perception that
screening guidelines were
“inconsistent”
“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902
Sunday, November 18, 12
24. 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
Sunday, November 18, 12
25. Provider barriers
Henderson et al The Open Diabetes J 2012
lack of documentation of
GDM on problem lists
poor communication
between OB and primary
care
“medical doctor” by kurhan, http://www.sxc.hu/photo/1314902
Sunday, November 18, 12
26. 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
Sunday, November 18, 12
27. 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
Sunday, November 18, 12
28. 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/
Sunday, November 18, 12
29. Predictors of
postpartum screening
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
Sunday, November 18, 12
30. “Classical Windows” by theswedish,
http://www.sxc.hu/photo/1344783
When & how to
screen
Barriers to screening
Interventions to
improve screening
Sunday, November 18, 12
31. 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
Sunday, November 18, 12
32. 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
postpartum screening
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
Sunday, November 18, 12
33. 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
Sunday, November 18, 12
34. 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
Sunday, November 18, 12
35. Risk stratification
to improve screening
Schaefer-Graf et al Diabetes Care 2009
Sunday, November 18, 12
36. Risk stratification
to improve screening
Schaefer-Graf et al Diabetes Care 2009
Sunday, November 18, 12
37. “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
Sunday, November 18, 12
38. 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/
Sunday, November 18, 12
40. “Classical Windows” by theswedish,
http://www.sxc.hu/photo/1344783
When & how to
screen
Barriers to screening
Interventions to
improve screening
Sunday, November 18, 12
41. Thank You!
http://www.endocrine-witch.net
@endocrine_witch
http://www.slideshare.net/isiptan
Sunday, November 18, 12