Gestational Diabetes- Tonga s Experiences, Screening & Challenges. Dr. Maake Tupou, Obstetrics & Gynaecology Unit, Vaiola Hospital, Tonga.

Transcription

1 Gestational Diabetes- Tonga s Experiences, Screening & Challenges. Dr. Maake Tupou, Obstetrics & Gynaecology Unit, Vaiola Hospital, Tonga.

2

3 Presentation Outline Introduction- What, Where, Who, Why, How, Tonga s Approach to NCD (Multidisciplinary Approach) Gestational Diabetes- History & Trends Future

4 Introduction Definition Significance Women at high risk for pregnancy and delivery complications Infant associated complications 7 fold increase risk of developing DM 2 Children likely to develop glucose intolerance leading to diabetes in the future. Identified risk factors

5 International Stats Prevalence of GDM 4.6%-9.2% in USA (PRAMS ) Australian Territories (2006 to 2009) - >5% had diabetes in pregnancy 0.6% pre-existing diabetes 4.7% GDM New Zealand up to 6.6%

6 Diabetes in Tonga The prevalence of diabetes was 34.4% in 2012 and can be up to 40%.*** Obesity No established DIP prevalence, evidence based screening & management program until now.

7 NCD Developments in Tonga National NCD strategy 2007-Autonomous body to address NCD 2011-TSDF Ⅰ, 2015-TSDFⅡ-a more progressive Tonga;enhanching our inheritance NCD specialist Nurses Establish GDM Taskforce**** 2015-National guidelines for GDM screening & management/ -National Strategy for prevention & control of NCD Est. of Secretariat (Tonga Health) Technology/e-Health/mDiabetes- RPM, First 1000 days campaign

8 NCD Stats 93% of aged 25-44y.o. are overweight & 77% are obese 99.9% adult Tongans age 25-64y.o. are at moderate to high risk of developing NCD 2012-Tonga ranked 3 rd most overweight country in the world % Tongan pop. with impaired FBS by 7% between

9 Traditional Diabetes in Pregnancy Screening In Tonga. Risk Factors- Selective modified OGTT screening test Obstetrician decides capillary OGTT test no multidiscipline approach WHO criteria

10 Current Program Prospective study to establish prevalence of DIP for Tonga (Feb Feb 2016), standardized screening and treatment framework for DIP patients, determine clinical outcome national integrated intervention for prevention of diabetes in this cohort of DIP patient September October EXPLORE possibly extension for another 3-5 years MOH to adopt and use

11 Unofficial Results 2700 deliveries 2000 in Tongatapu

12 Universal Screening IADPSG Protocol for the Evaluation of Diabetes in Pregnancy Pregnancies < 24/40s Pregnancies 24/40s Not Dx with GDM or Over Diabetes Perform FBS or RBS or A1c in women at High Risk for Diabetes FBS < 5.1 A1c < 6.5% RBS < 11.1 FBS FBS 7.0 A1c 6.5% RBS FBS or A1c 2 hr 75g GTT at 24-28/40 GDM, No further testing Overt Diabetes, No further testing 2 hr 75g GTT

13 Risk Factors For Diabetes In Pregnancy High Risk Grp. Age 35yrs FHx DM parents & siblings Previous GDM, sister w GDM Baby 4.5kg PCOS Persistant glycosuria BMI > 30 Previous unexplained perinatal loss or malformed Glucocorticoid use

14 Tonga screening for GDM High Risk Low Risk OGTT AT weeks Perform full OGTT at booking FBGL 5.3 mmol/l or 2 hr BGL 9 mmol/l (1 or more abnormal readings) **

15 Results-GDM Screening Sept 2015-May 2016 Screened 1102 we need another 898(900) to test 2000 in Tongatapu. Currently testing 50/week so we need to do 18 more weeks to last week of October (27 th, 28 th ).

16 Results Date Total Booked for OGTT Total Tested with OGTT Overt DM (Fasting 7, 2 hours 11mmol/L GDM (Fasting 5.3, 2 hours 9mmol/L Tot DIP Total No. Total %

17 Overt DM GDM (Fasting 7, (Fasting 2h 5.3, 2h 11mmol/L) 9mmol/L) Total DIP Diabetes in Pregnancy Overt DM (Fasting 7, 2h 11mmol/L) GDM (Fasting 5.3, 2h 9mmol/L) Total DIP Diabetes in Pregnancy No Booked No tested No Booked No tested Date for OGTT with OGTT Date for OGTT with OGTT 25 th Sep Feb CU nd Oct Feb24th th Oct Feb 25th th Oct Mar 3rd rd Oct Mar 4th th Oct Mar 10th th Nov Mar 11th th Nov Mar 17th No TESTING 20 th Nov Mar 18th No TESTING 27 th Nov Mar 24th th Dec Mar 25th No TESTING 11 th Dec Mar 31st th Dec April 1st th Dec No TESTING April 7th st Jan No TESTING April 8th th Jan April 14th th Jan April 15th th Jan April 21st st Jan April 22nd nd Jan April 28th th Jan April 29th th Jan May 5th th Feb May 6th th Feb May12th No TESTING 11th Feb May 13th No TESTING 12th Feb May 19th No TESTING 18th Feb May 20th No TESTING 19th Feb May 26th Subtotal May 27th Subtotal TOTAL %

18 Results- Unofficial Sep 25th 2015 May 27th 2016 Total Pregnant mothers tested with OGTT by age group Age Group Tot No % Teen Preg (<20yrs) yrs yrs yrs yrs yrs yrs No age

19 Able to Review 70 Case Notes out of 121 DIP

20 Risk Factors among 70 mothers with Age Group DIP Tot Patients PH-DM or GDM PH-BB BOH FH # Smoke Teen Preg (<20yrs) years years years yrs yrs Total % 12.90%

21 DIP by Age Group Age Group Overt GDM Tot No % Teen Preg (<20yrs) years years years yrs yrs

22 Unofficial Results BMI at Booking among 70 DIP Patients Age Group Normal Tot 18.5 Screened 24.9 OW Class1 Obese Class 2 Class No BMI Teen Preg (<20yrs) years years years yrs yrs Tot No (18.5) 21(30) 19(27.1) 11

23 Gravida Age Group G1 G2 G3 G4 G5 G6+ ToTAL Teen Preg (<20yrs) years years years yrs yrs

24 GA at Booking T1 T weeks weeks post-t3 No info ToTAL Teen Preg (<20yrs) yrs yrs yrs yrs yrs Tot No by GA at booking

25 Unofficial results-56 Babies delivered All at 37+ weeks (Term) 5 had LSCS, 51 NVD All had good Apgar Score at Birth BW Range grams 9 babies had BW 4000 grams 1 had BW of 4500 grams (4630) None had Postnatal Complications

26 Impact on the service Real diabetic picture Home monitoring possible Costly Expect increase in cases numbers combine weekly clinics with diabetic center team inpatient management of medicated patient (class A2 patient)

27 Important Lessons Learned ONE OF THE MOST VALUBLE ASSET IN IMPROVING DIABETES MANAGEMENT IN OUR SETTING ARE THE NURSES They can be the nurse advisor, counsellor, patient tracker, patient locator, patient confident, patient advocator, clinic data manager, diabetes educator and dietician

28 Future is here E-Health, mdiabetes program August 2016 First 1000 days text campaign June 2016 Continuation of the combined care with the Diabetic center enhanced emphasis on committed, continuous lifestyle/lifetime/sustained behavioral changes.

29 Acknowledge The GDM Taskforce MOH Tonga Late Dr. Semisi Latu Dr. Makameone Taumoepeau Malo Aupito Thank You All

30 References