The Ever-Changing Approaches to Diabetes in Pregnancy

Transcription

1 The Ever-Changing Approaches to Diabetes in Pregnancy Kirsten E. Salmeen, MD Assistant Professor Obstetrics, Gynecology & Reproductive Sciences Maternal-Fetal Medicine I have nothing to disclose. Approaches are Ever-Changing Due To: Type 1 Diabetes GDMA1 GDMA2 Relative lack of very high-quality data Disagreement about definitions of disease Type 2 Pre-Diabetes Wide variability in resources 1

2 What is the average fasting glucose for healthy pregnant woman who do not have diabetes? The Data We Have A mg/dl 31% 35% B mg/dl 23% C mg/dl D mg/dl 11% m g / d L m g / d L m g / d L m g / d L What is the average 1-hour postprandial glucose for healthy pregnant woman who do not have diabetes? Normal Glucose In Pregnancy: Non Diabetics A mg/dl 48% B mg/dl 37% C mg/dl D mg/dl 12% 2% m g / d L m g / d L m g / d L m g / d L Hernandez et al. Diabetes Care. 2011;34(7):

3 HAPO Results Increasing maternal glycemia is associated with increased risk of maternal and fetal complications. Blinded study of ~25,000 women at 15 centers, 9 countries Primary predictor: Levels of hyperglycemia Primary outcomes: Birth weight > 90%ile, primary CD, neonatal hypoglycemia, cord-blood C-peptide level HAPO Study Cooperative Research Group. N Engl J Med. 2008;358(19): HAPO Study Cooperative Research Group. N Engl J Med. 2008;358(19): Outcome (%) Birth weight 4000 g Birth weight 4500 g Fasting < 74 Fasting Fasting Fasting 83 Odds Ratio 95% CI LGA PIH/PreE Shoulder Dystocia Hyperglycemia & Pregnancy Outcomes Outcome (%) Birthweight 4000 g Birthweight > 4500 g 2 hour < hour hour hour 130 Odds Ratio 95% CI LGA PIH/PreE Shoulder Dystocia Hyperglycemia & Pregnancy Outcomes Jensen AJOG 2001 Jensen AJOG

4 Landon Trial of Treatment for GDM Crowther Trial of Treatment for GDM Intervention Group N = 485 (%) Control Group N = 473 (%) Relative Risk p-value NICU Admission ( ) 0.19 *Any serious perinatal complication Intervention Group N= 490 (%) Routine Care N= 510 (%) Adjusted RR or Treatment Effect Adjusted p-value ( ) 0.01 Macrosomia ( ) < Neonatal Hypoglycemia ( ) 0.32 Shoulder Dystocia ( ) 0.02 Cesarean Delivery ( ) 0.02 Admission to NICU ( ) 0.04 Macrosomia ( ) < Neonatal hypoglycemia ( ) 0.16 Preeclampsia ( ) 0.02 Preeclampsia or GHTN Landon et al. N Eng J Med. 2009;361: ( ) 0.01 Cesarean Delivery ( ) 0.73 * One or more of: death, shoulder dystocia, bone fracture, nerve palsy Crowther et al. N Engl J Med. 2005;352: Rowan - Metformin versus Insulin Moore Metformin versus Glyburide Composite Outcome** Any neonatal blood glucose < 28.8 mg/dl Rowan et al. N Engl J Med. 2008;358: Metformin* Group N = 363 (%) Insulin Group N = 370 (%) Relative Risk p-value 116 (32.0) 119 (32.2) 0.99 ( ) (3.3) 30 (8.1) 0.41 ( ) Birth weight - g / / Birth weight > 90%ile 70 (19.3) 69 (18.6) 0.83 * 168 patients received metformin PLUS insulin ** Composite: neonatal hypoglycemia, respiratory distress, need for phototherapy, birth trauma, 5 min Apgar < 7, birth < 37 weeks 150 women randomized to Metformin or Glyburide Outcomes: EGA at delivery, NICU admission, neonatal & maternal hypoglycemia were the same Birthweight was ~ 200g larger in the Glyburide group Cesarean delivery was higher in the Metformin group 34.7% of women in the Metformin group versus 16.2% of women in the Glyburide group did not achieve adequate glycemic control Moore et al. Obstet Gynecol. 2010;115:

5 Nachum Glyburide vs Metformin and Their Combination Randomized trial of ~ 100 women 53 started with Glyburide: 6 (11%) failed due to hypoglycemia 12 (23%) failed due to inadequate control 51 started with Metformin 1 (2%) failed due to GI side-effects 14 (28%) failed due to inadequate control Treatment success after 2 nd therapy was higher in the metformin group (87%) vs the Glyburide group (50%) The combination of the drugs reduced the need for insulin from 33% to 11% Nachum et al. Diabetes Care 2017 Wouldes: Neurodevelopmental Outcomes for Metformin & Insulin 2-yr follow-up of 211 children whose mothers were treated with insulin or metformin No differences in neurodevelopmental scores examined using Bayley Scales Wouldes et al. Arch Dis Child Fetal Neonatal Ed 2016 Wang RCT of Exercise 300 overweight/obese Chinese women, randomized to exercise (3 times per week of 30 min cycling or control (usual daily activities) Primary outcome was incidence of GDM Women in the exercise group were diagnosed with GDM 22% versus 41% in the control group Induction of Labor Rosenstein: Infant mortality rates at 39 weeks are lower than overall mortality risk of expectant management. Wang et al. AJOG 2017 Rosenstein et al. Am J Obstet Gynecol. 2012;206:309.e1-7. 5

6 Things we really don t know The best diets for women with GDM The best treatment options Risks associated with mild, isolated fasting hyperglycemia Risk of poor outcomes by overall sugar control Attributable long-term risks for mothers and infants Approaches are Ever-Changing Due To: Relative lack of very high-quality data Disagreement about definitions of disease Wide variability in resources What constitutes disease? What primary cesarean section rate defines a bad outcome from disease? Dichotomization of a continuous process is bound to result in disagreement HAPO Study Cooperative Research Group. N Engl J Med. 2008;358(19):

7 What birth weight defines a bad outcome from disease? Who Decides? HAPO Study Cooperative Research Group. N Engl J Med. 2008;358(19): Lack of unambiguous evidence that aggressive diagnosis improves clinically important pregnancy outcomes The Landon study included women with 2 abnormal values on a 3-hour All pregnant patients should be screened for GDM, whether by the patient s medical history, clinical risk factors, or laboratory screening test results to determine blood glucose levels. Studies of treatment are within the confines of strict clinical trials No study has compared outcomes between women who rule-in by 1-step approach but rule out by 2-step approach 7

8 You Decide! Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness has not been proved with randomised controlled trials. Patient population: Risk Health literacy Willingness & ability to make changes Relative degree of concern about GDM Resources: Nutrition Education Provider capacity The Nature of Screening Tests One-Step vs. Two-Step Testing Screening is the identification of an asymptomatic disease, harmful condition or risk factor. When deciding how to screen, the following must be considered: - Burden of suffering caused by the condition - Therapeutic interventions available - Performance of available screening tests One-Step Fasting, 75 g, 1 & 2 hr serum glucose measurement 1+ abnormal value GDM GDM prevalence ~ 20% Two-Step Step 1: Non-Fasting, 50 g, 1 hr serum glucose measurement 130/140 mg/dl Step 2 Step 2: Fasting, 100 g, 3 hr glucose test 2+ abnormal values GDM GDM prevalence ~ 5-10% Fletcher et al. Clinical Epidemiology: The Essentials, 5 th Ed, Lippincott Williams & Wilkins

9 Early Screening National Diabetes Data Group Carpenter- Coustan Criteria Carpenter-Coustan v. NDDG Fasting (mg/dl) 1 hr (mg/dl) 2 hr (mg/dl) 3 hr (mg/dl) GDM Prevalence % % Detecting women with pre-existing diabetes or glucose intolerance (pre-diabetes) ACOG: History of GDM, known impaired glucose metabolism, obesity ADA: Severe obesity, strong family history, personal history of GDM, impaired glucose metabolism, glucosuria Hemoglobin A1c Diagnosing Type 2 DM: A1c 6.5 DM2 A1c Glucose Intolerance A1c < 5.7 Normal Pregnancy Outcomes for Women with 1 Abnormal Value on 3 hour Average HbA1c Values Non-Diabetic Women Non- Pregnant 1 st Trimester 2 nd Trimester 3 rd Trimester HbA1c % (5.2) (5.0) (4.9) (5.1) O Connor et al. Clin Chem Lab Med 2012;50(5): McLaughlin et al AJOG 2006;194:e

10 Treatment for Patients With 1 Abnormal Value In your practice, for which of the following patients do you check a fasting glucose in the third trimester? A. All patients B. No patients 27% 41% 32% C. High-risk patients only Fassett et al. AJOG 2007;196:597.e1-597.e4 A l l p a t i e n t s N o p a t i e n t s H i g h - r i s k p a t i e n t s o n l y Costs v Benefits Approaches are Ever-Changing Due To: Relative lack of very high-quality data Disagreement about definitions of disease Wide variability in resources 1-step screening strategy would: Increase frequency of GDM 2-3 fold 15-20% Annually Add: 450,000 patient education visits 1 million prenatal testing appointments 1 million clinic visits Increase cost of care for GDM by > $1 billion 10

11 What I Think You Should Do Worry about the over-medicalization of pregnancy and increased anxiety about diagnosis What I Think You Should Do What I Think You Should Do Pre-conception planning Easy access to laboratory services Universal access to nutritional counseling High health-literacy Ample time and access to exercise facilities Appropriate emotional support Long-term follow up 11

12 Talk to Your Patients Where Do Women Get Advice About Weight, Eating and Physical Activity During Pregnancy? 183 normal weight women & 172 overweight/obese women in the Fit for Delivery trial in Rhode Island Questionnaires at 6 week postpartum visit 60.6% received information from a book, 58% from the internet 56% received information from a doctor, 34% from a nurse Acknowledge What Is NOT Controversial Health risks go up with increasing blood sugar. There is no risk of harm from encouraging women to follow a healthy diet and get regular physical activity. SOME portion of women will change their behavior after being made aware of an increased risk of disease. Mercado et al. Where do women get advice about weight, eating and physical activity during pregnancy? J Womens Health May, 2017 What I Think You Should Do - Testing Determine what testing strategy fits your circumstances best Have flexibility for different situations Modify as needed to identify the most women with significant hyperglycemia when it occurs What I Think You Should Do: Treatment Exercise prescriptions (30+ minutes daily) Nutritional counseling avoid ketosis Achieve glycemic control while avoiding lows Metformin or Glyburide (and maybe both) are appropriate Use insulin as needed encourage self-titration Consider Lantus or Levemir for some challenges 12

13 What I Think You Should Do Delivery & Postpartum Induction at 39 weeks, but there is room for flexibility Consider primary CD for EFW > 4500g Determine what postpartum testing regimen works and help patients to do it 2 hour glucose tolerance at 6 weeks OR fasting/hba1c between weeks Encourage ongoing healthy diet & exercise Contraception!!!! Help encourage pre-conception testing It changes all the time, but it also really stays the same! Identify patients with hyperglycemia Manage hyperglycemia Individualize care Thank You 13