Diabetes Care solution in india

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Our aim is to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. From 2002 to March 2017, the World Diabetes Foundation provided USD 130 million in funding to 511 projects in 115 countries. For every dollar spent, the Foundation raises approximately 2 dollars in cash or as in-kind donations from other sources.

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Screening and Diagnosis:

Screening and Diagnosis

Objectives:

Objectives At the end of this session you will be able to: Define GDM Identify the risks for development of GDM. State the prevalence of GDM locally Explain the reason for identifying and treating GDM Identify appropriate screening measures Identify who should be screened Identify diagnostic criteria

Definition:

Definition Glucose intolerance with onset or first recognition during pregnancy Characterized by β-cell function that is unable to meet the body’ s insulin needs Buchanan, Wiang , Kjos , Watanabe 2007

Glucose regulation during pregnancy:

Glucose regulation during pregnancy Insulin resistance begins in mid pregnancy and progresses through the third trimester A result of maternal adiposity and effects of placental hormones β -cells usually make more insulin to compensate for resistance – when they cannot meet the needs hyperglycemia occurs

Slide 5:

GDM represents a state of chronic β-cell dysfunction in the face of insulin resistance Insulin resistance and insulin levels are different prior to pregnancy in women who develop GDM and those who do not Changes in insulin sensitivity are similar in both groups during pregnancy However in GDM women, insulin secretion does not increase adequately Buchanan, Wiang , Kjos , Watanabe 2007

Prevalence:

Prevalence The prevalence of GDM is estimated to be 10-16.9% in pregnant women depending on the diagnostic criteria used. Prevalence also varies by region and ethnicity. Highest prevalence is in South East Asia Lowest in North America and the Caribbean Prevalence higher in less physically active women. In older women In women with higher BMI In those with a strong family history of diabetes WHO, 2013 IDF, 2013

Discussion:

Discussion What are the risk factors for gestational diabetes? What risk factors do you see most often in your setting?

Risk factors for GDM:

Risk factors for GDM High risk Obesity Diabetes in 1 st degree relative Previous history of GDM or glucose intolerance complicated pregnancy infant with macrosomia > 3.5 kg Older age High risk ethnic group; South Asian, East Asian, Indigenous American or Australian, Hispanic PCOS Low risk Age less than 25 years No previous poor pregnancy outcomes No diabetes in 1 st degree relatives Normal prepregnancy weight and weight gain during pregnancy No history of abnormal glucose tolerance Perkins, Dunn, Jagastia , 2007

Is Hypertension a risk factor?:

Is Hypertension a risk factor? Hypertension prior to pregnancy or during 1 st trimester – doubled the risk of GDM – independent of maternal weight Hence all women with hypertension should be screened for GDM Hedderson , Ferrara, 2008

Why diagnose and treat GDM?:

Why diagnose and treat GDM? Short term risks for the mother Development of gestational hypertension, worsening essential hypertension or development of preeclampsia Operative delivery - related to macrosomia Polyhydramnios Premature labour Long term risks for the mother Development of type 2 diabetes in next ~10 years (30-60% depending on population) Development of cardiovascular disease CDA, 2013 Metzger, Buchanan, et al. 2007

Why diagnose and treat GDM?:

Why diagnose and treat GDM? Short term risks for the baby Macrosomia Neonatal hypoglycemia Jaundice Preterm birth Birth injury Hypocalcemia / hypomagnesimia Respiratory distress syndrome Long term risks for the baby Obesity Type 2 diabetes

Importance of follow up:

Importance of follow up Long term follow up studies have shown that most women with GDM will develop diabetes within the first decade after the pregnancy Testing after pregnancy is important - more about this later Kim, Newton, Knopp 2002

Screening:

Screening Whom to screen When to screen How to screen

Who to screen:

Who to screen Some guidelines recommend screening all women at the first visit to rule out pre-existing type 2 diabetes Most guidelines recommend screening all women for GDM at 24-28 weeks gestation. ADA, 2015 CDA , 2013

When to screen? First trimester:

When to screen? First trimester Screening in 1 st trimester - to rule out unidentified pre-existing diabetes Fasting plasma glucose >126 mg/dl (7 mmol /L) or HbA1c >6.5% or Random >200mg/dl (11.1 mmol /L) or 2hr value in OGTT >200mg/dl (11.1 mmol /L) If overt diabetes is detected, it must be treated appropriately. ADA, 2015

When to screen Screening for GDM:

When to screen Screening for GDM Screening should be done at 24-28 weeks Diagnosis based on a 75 gm glucose load given in fasting state GDM diagnosed when one or more of the following is present Fasting 92 - 125 mg/dl (5.0 – 6.9 mmol /L) 1 hour post 75 gm load > 180 mg/dl (10 mmol /L) 2 hour post 75 gm load >153mg/dl (8.5 mmol /L) If woman tests negative, screening at 32 weeks also may be necessary in presence of high ris ks World Health Organization, 2013

Diagnostic criteria:

Diagnostic criteria WHO (2013) 1 or more IADPSG 1 or more ADA “one step” ADA “two step” Fasting plasma glucose 5.1-6.9 mmol /L (92-125 mg/dl) > 5.1 mmol /L (92 mg/dl) > 5.1 mmol /L ( 92 mg/dl) 50-g glucose load ( nonfasting ) If 1 hour > 7.8mmol/L (140mg/dl) – Do 100 g OGTT GDM If 2 of 4 results high 1 hour PG after 75gm load > 10.0mmol/L (180mg/dl) > 10.0mmol/L (180mg/dl) > 10.0mmol/L (180mg/dl) 2 hour PG after 75gm load 8.5-11.0 mmol /L (153-199 mg/dl) > 8.5 mmol /L (153 mg/dl) > 8.5 mmol /L (153 mg/dl) Diabetes Care 2015, WHO 2013

How to screen :

How to screen Key considerations for screening in low resource countries Low cost No requirement for elaborate preparation High sensitivity and specificity Short turn-around time Be administered by health workers with minimal training Need little maintenance, calibration, or refrigeration Agarwal et al, 2007

Venous or capillary:

Venous or capillary The venous plasma is the gold standard Where laboratory facilities or technicians are not available, capillary glucose estimations may be done using a hand held glucose meter. The glucose meter must be standardized with a lab and calibrated against the lab on a regular basis.

Which of these women has GDM?:

Which of these women has GDM? All have had 75g glucose load at about 25 weeks Rupinder , o verweight, 35 years old, fasting 90 mg/dl (5.0 mmol /L), 1 hr 170mg/d (9.4 mmol /L), 2hr 135mg/dl (7.5 mmol /L) Joanne, 3 rd pregnancy, history of big babies, fasting 130 mg/dl (7.2 mmol /L), 1 hr 190mg/dl (10.5 mmol /L) 2 hr 220mg/dl (12.2 mmol /L) Maria, 1 st pregnancy, 25 years old, obese, fasting 90mg/dl (5 mmol /L), 1 hr 168mg/dl (9.3mmol/L) 2 hr 160 mg/dl (8.8mmol/L)

Giving the diagnosis:

Giving the diagnosis Will my baby be ok? – 1 st question often asked Is this temporary? – 2 nd question Questions provide an opportunity for teaching Must answer truthfully Must convey importance of management during pregnancy for healthy outcome but also for future health of baby and mother Risk of type 2 diabetes Risk of obesity

References:

References American Diabetes Association. Clinical Practice Recommendations 2015. Diabetes Care. 2015;38(1) Agarwal et al - Fasting plasma glucose as a screening test for gestational diabetes mellitus, Archives of Gynecology and Obstetrics 2007 Buchanan T, Xiang A, Kjos S, Watanabe R. What is gestational Diabetes? Diabetes Care 2007;30(2):S105-111. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy. Can J of Diabetes. 2013;37( suppl 1):S168-183. Hedderson MM, Ferrara A. High blood pressure before and during early pregnancy is associated with an increased risk of gestational diabetes mellitus. Diabetes Care. 2008;31(12):2362-2367. IDF Diabetes Atlas 6 th Ed, 2013 Kim C. Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care 2002;25:1862-1868 Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007;30( suppl 2):S251-260. Perkins JM, Dunn JP, Jagastia SM. Perspectives in gestational diabetes mellitus: A review of screening, diagnosis and treatment. Clinical Diabetes. 2007;25(2 ):57-62 WHO . Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy , 2013

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