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Gestational Diabetes: New Concepts, New Guidelines

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Gestational Diabetes: New Concepts, New Guidelines Thank you for attending Gestational Diabetes: New Concepts, New Guidelines A Live and Archived Webcast Sponsored by Community Health Association of Mountain/Plains States (CHAMPS) Presented by Dr. Linda Barbour on Wednesday, February 28, 2007 Supplementary Information Packet Contents: o Learning Objectives o AAFP o Biography of Dr. Linda Barbour o Description of CHAMPS o Presentation Slides o GDM Guidelines – Long o GDM Guidelines – Short Gestational Diabetes: New Concepts, New Guidelines Linda Barbour, MD, MSPH, February 28, 2007 Learning Objectives • Understand the existing controversies in the diagnosis and management of gestational diabetes • Interpret the findings from the most recent landmark trials which shaped the recommendations from the 5th International Workshop on Gestational Diabetes • Describe how to use a fetal-based strategy for the optimal treatment of GDM • Recognize the long term implications of GDM for both infant and mother and the appropriate postpartum recommendations AAFP This live webcast has been reviewed and is acceptable for up to 1.5 Prescribed credits by the American Academy of Family Physicians (AAFP). Application for 1.5 hours of Prescribed CME credit for the archived version of this webcast will be filed immediately after the live event. Linda Barbour has indicated that she has no relationships to disclose relating to the subject matter of his presentation. The AAFP invites comments on any activity that has been approved for AAFP CME credit. Please forward your comments on the quality of this activity to [email protected]. Biography of Linda Barbour, MD, MSPH Linda A. Barbour, MD, MSPH, is an Associate Professor of Medicine and Obstetrics and Gynecology in the divisions of Endocrinology, Metabolism, and Diabetes and Maternal- Fetal Medicine at the University of Colorado at Denver Health Sciences Center. She is Board Certified in Endocrinology and completed a second fellowship in Preventive Medicine and Biometrics. She is the Co-Director of the High Risk Obstetrics Clinic and Diabetes in Pregnancy Clinic. She chaired the Colorado Clinical Guidelines Collaborative on Gestational Diabetes and also co-authored the Endocrine Society Guidelines for Thyroid Disease in Pregnancy, soon to be published. Dr. Barbour is the past president of the North American Society of Obstetric Medicine, previous moderator and speaker for the Pregnancy and Reproductive Health Council for the American Diabetes Association, and the Director of Continuing Medical Education for the Department of Medicine. She is co-editor of the textbook, Medical Care of the Pregnant Patient, published in 2000, for which the 2nd edition is soon to be published. She is the principal investigator on a 5- year NIH grant which studies insulin signaling in gestational diabetes. Description of CHAMPS CHAMPS, the Community Health Association of Mountain/Plains States, is a non-profit organization dedicated to providing a coordinating structure of service to non-profit primary health care programs whose primary purpose is to serve the medically indigent and medically underserved of Region VIII (CO, MT, ND, SD, UT, and WY). CHAMPS also serves the Region VIII State Primary Care Associations that assist those nonprofit primary health care programs (CCHN, MPCA, CHAD, AUCH, and WYPCA). Currently, CHAMPS programs and services focus on education and training, collaboration and networking, policy and funding communications, and the collection and dissemination of regional data for Region VIII Community Health Centers and Primary Care Associations. For more information, please visit www.champsonline.org or call (303) 861-5165. Community Health Association of Mountain/Plains States Gestational Diabetes: CCGC Guidelines Committee New Concepts, Sponsored by Community Health Association of Mountain/Plains States Chair: Linda Barbour , MD, MSPH New Guidelines (CHAMPS) Reviewers: Linda Barbour MD, MSPH – Jill Davies MD, Mark Deutchman MD, Ronald Gibbs, MD, Oliver Associate Professor in Endocrinology Jones MD, Lisa Latts, MD, Richard Porreco MD, Robert Stettler Associate Professor in Endocrinology MD, Robert Wall MD, Marie Hastings-Tolsma PhD, CNM, Nancy and Maternal-Fetal Medicine, UCDHSC www.CHAMPSonline.org Nola NP, RN, Paula Stearns MSN, RN, Tanya Tanner CNM, MS Co-Director Diabetes in Pregnancy Clinic Committee: – Deborah Davis RNC, MS, Julie Gormley MS, RD, Teri This live webcast has been reviewed and is acceptable for up to 1.5 Prescribed credits by the Hernandez RN, MS, Bonnie Jortberg RD, MS, CDE, Linda Mattei American Academy of Family Physicians (AAFP). Application for 1.5 hours of Prescribed RN, MPH, CDE, Mandy McCulloch RD, Rhoda Rogers RN, BSN, CME credit for the archived version of this webcast is pending with AAFP. CDE, Pamela Spry PhD, CNM, Helen Stover RN, BSN, CDE Linda Barbour has indicated that she has no relationships to disclose relating to Gloria Vellinga, RD, CDE the subject matter of this presentation. CCGC Staff: Marjie Harbrecht MD, Cassidy Smith MPH This presentation was supported by Grant Number 5 H68CS00150-20-00 from the CCGC Staff: Marjie Harbrecht MD, Cassidy Smith MPH Department of Health and Human Services (DHHS) Health Resources and Services Administration (HRSA) Bureau of Primary Health Care (BPHC). Views of the presenter do not necessarily represent the official views of CHAMPS or HRSA/BPHC. Linda Barbour, MD, MSPH 5th International Workshop on GDM Objectives November 11-15, 2005 Chicago Appreciate the rapidly rising prevalence of GDM due (Metzger BE, Women’s Health 2006; 2(2):211-16) to obesity epidemic Understand the importance of GDM on long term maternal and childhood outcomes Cite landmark studies that shaped the guidelines and studies pending in 2007 Review the key elements of the guidelines Understand new management strategies including fetal-based approaches Underscore the importance of appropriate post partum management for both mother and infant Linda Barbour, MD, MSPH Linda Barbour, MD, MSPH What Is Gestational Diabetes (GDM)? What Causes It? Vast majority of women who develop GDM are Glucose intolerance recognized for the first overweight and insulin resistant time during pregnancy Placental hormones cause worsening insulin – Does not exclude women with pre-existing resistance in the late 2nd trimester intended to shunt diabetes previously undiagnosed nutrients to the fetus – Undiagnosed Type 2 with ↑A1C have risk for Moms are unable to produce enough insulin to major malformations overcome the overwhelming resistance to maintain euglycemia – Most women diagnosed before 24 weeks have Fetuses are exposed to high levels of glucose, TGs IGT (pre-diabetes) and are at very high risk for and FFAs. Fetal hyperglycemia→→hyperinsulinemia developing Type 2 postpartum →→pancreatic hyperplasia. Insulin is a growth hormone causing excess fat deposition Linda Barbour, MD, MSPH Linda Barbour, MD, MSPH 1 Percent of Women with Diabetes During Pregnancy, How Big Is the Problem? by Race/Ethnicity, 2002-2004 20 ~7.5% of mothers in Colorado have diabetic 18 pregnancies (CO PRAMs data) ~5000 16 women 14 women 12 Incidence has Doubled in the last 7-8 years 10 from 2-5% of population to ~4-12% 8 Percent (%) 6 10.7 A leading high risk complication of 8.3 pregnancy (after preterm birth and obesity) 4 6.7 2 5.8 Tremendous economic costs for mother and 0 infant White/Non- White/Hispanic Black Other Hispanic Self perpetuating cycle feeding the obesity and diabetes epidemic Data Source: Colorado PRAMS Linda Barbour, MD, MSPH Linda Barbour, MD, MSPH Percent of Women with Diabetes During Pregnancy, Percent of Women with Diabetes During Pregnancy, by Years of Education Received, 2002-2004 by Age Group, 2002-2004 14 16 12 14 12 10 10 8 8 6 6 11.2 10.7 Percent (%) Percent Percent (%) Percent 4 8.6 4 7.1 6.2 2 2 2.5 4.6 0 0 15-19 20-24 25-34 35+ < 12 years 12 years >12 years Age Group Years of Education Data Source: Colorado PRAMS Data Source: Colorado PRAMS Linda Barbour, MD, MSPH Linda Barbour, MD, MSPH 1996→2006 GDM Costs Why Is It a Problem Kitzmiller Diab Care 1998;21, Supp 2:B123 to Mother? Diet treated GDM ~$11,000 per pt ($6,000) Intensive monitoring of blood Insulin Treated GDM ~$20,000 ($11,000) glucoses, diet restrictions, insulin – 1/3 patient require meds injections or meds, increased frequency of – 8% require ~1-2 days in NICU ~$4000 ($2300) prenatal visits, financial burden 70,000 births X 7.5% = 5,250 births Higher risk of infections – 3,500 X $11,000 = $38.5 million Higher risk of C-section – 1,750 X $20,000 = $35 million 2006 costs state of CO = ~$80 million (6%) ~50% Maternal risk of developing Type 2 DM in 5-10 years!!! Linda Barbour, MD, MSPH Linda Barbour, MD, MSPH 2 What About the Baby??? Diabetic Effects on the Fetus Mother Fetus ↑ Glucose Î ↑Glucose Î ↑Insulin Î ↑Growth Amniotic Fetal fluid insulin Overgrowth Self Blood Measure of too ↑ Birth trauma Glucose much glucose ↑ C-sec Monitoring, getting to the ↑ Childhood Obesity/Diabetes Diet, Insulin baby Linda Barbour, MD, MSPH Linda Barbour, MD, MSPH What’s So Bad About a Fetal Programming: Big Baby??? Long Term Implications Babies have central obesity and can’t get through the Metabolic factors in the intrauterine environment birth canal→ → birth trauma have a profound effect on prenatal development and Babies at ↑ risk of stillbirth because they can outgrow enhanced susceptibility to later chronic disease their oxygen supply GDM→ ↑ fetal Insulin, neonatal fat, insulin resistance, and Babies develop hypoglycemia at birth due to inability
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