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Not So Good to be So Sweet: Pregnancy & Diabetes

Tausi Suedi, MPH

Mychelle Farmer, MD

Chandrakant Ruparelia, MD,MPH

Leah Hart, MSN, MPH

March 7, 2014

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Objectives

Describe the global burden of NCDs Define gestational diabetes List adverse maternal and newborn outcomes

associated with GDM Describe GDM screening and diagnosis

approaches Evaluate community based innovative model for

screening, diagnosis and management of GDM

Global Burden of Disease

65% of all deaths each year due to NCDs

NCDs leading cause of death globally for women

CAUSE %

Cardiovascular 33.2

Infections 13.9

Cancer 13.0

Chronic Respiratory Dis. 7.3

Respiratory Infxn, TB 6.6

Injuries 5.1

OB, Perinatal 5.0

GI 3.1

Diabetes 2.6

Neuro-psychiatric 2.3

World Health Organization, 2008

Global Burden of Diabetes

5Zimmet PZ, Medicographia, 2011

50% of diabetics are undiagnosed

Nearly 70% of diabetics in Africa

57% diabetics in Western Pacific

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Zimmet PZ, Medicographia, 2011

Diabetes Mellitus

It is a disease in which human body either does not produce or properly use insulin that regulates blood sugar resulting in increased blood glucose.

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There are two type of diabetes mellitus: Type 1 and Type 2

Types of Diabetes Mellitus

Type 1 Low or absent endogenous

insulin due to beta cell damage

Onset before 30 years Exogenous insulin required

for life Causes: Genetic, infection

Type 2 Insulin level is normal,

elevated or absent insulin resistance,

tissue sensitivity, & impaired beta cell function

Exogenous insulin may be required for management

Causes: family history, lifestyle, obesity and aging

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Understanding the Mechanism

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: Insulin, Closed Glucose Transporter, Open Glucose Transporter, Glucose, Insulin Receptor

Gestational Diabetes Mellitus (GDM)

Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance with recognition or onset during pregnancy’ irrespective of the treatment with diet or insulin.

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Blood glucose

Gestational DMInsulin secretion

Insulin resistance

Normal Pregnancy

Insulin secretion

Insulin resistance

Slide: Courtesy of Professor Peter Damm

GDM short-term outcomes

Babies Macrosomia Birth trauma such as

shoulder dystocia Stillbirth Neonatal

hypoglycemia

Mothers Birth trauma Increased rate of

C-section Increased risk for

post-partum hemorrhage and other causes of maternal deaths

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GDM out long-term outcomes

Babies Type 2 diabetes

(33% increased risk)

Mothers Type 2 diabetes (35-60% increased

risk)

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GDM and Type 2 Diabetes

http://www.thenews.com.pk/article-17375-Deaths-up-from-non-communicable-diseases

http://www.thehindu.com/sci-tech/health/medicine-and-research/novel-study-in-tn-to-know-gestational-diabetes-effects/article2970820.ece

Recommended Practices

IADPSG Diagnostic Guidelines

Based on Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study

Fasting glucose ≥ 5.1 mmol/L (92 mg/dl), 2 h 75 g OGTT in pregnancy One hour result of ≥ 10.0 mmol/L (180 mg/dl), Two hour result of ≥ 8.5 mmol/L (153 mg/dl).

Country Case Study: India

1. Prevalence of GDM in India

2. Purpose of Jhpiego’s assessment in two Indian states

3. Results

4. Proposed community-based approach to screening

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Urban Semi-urban Rural Average0

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4

6

8

10

12

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GDM Prevalence in India

17

% P

reva

lenc

e

17.8

13.8

9.9

13.9

V.Seshiah , V. Balaji , Madhuri S Balaji.A Paneerselvam, T Arthi, M Thamizharasi, Manjula Datta , (2008). Prevalence of GDM in Asian Indians- A community-based study. JAPI , Vol 56 , pp. 329-323.

Purpose of India assessment

To describe the current situation related to screening, diagnosis and management of diabetes in pregnancy at various health facility levels in the peri-urban regions of Mumbai, Maharashtra and Chennai, Tamil Nadu.

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http://www.mapsofindia.com/images2/india-map.jpg

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Inconsistent use of GDM guidelines Urine dipstick testing at sub-center levels with

referral Resource intensive follow up to positive urine

screen Inconsistent documentation of referral results

and birth complications related to GDM

Results of situational analysis

Challenges of Clinic-based GDM Screening

High volume of referral based on urine dipstick screen

Fasting required High clinic volume

due to 2-hour wait Up to 30% “no show”

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Community-based GDM Screening Approach

Begins at the doorstep of the pregnant woman

Cost-effective and integrated in existing services

Reduces healthcare facility burden while increasing detection

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Beyond diagnosis… a public health approach

Pregnant Woman in the

Community

12-16 weeks first ANC visit:

1st GDM Screening

24-28 weeks:2nd

GDM Screening

Screening using Glucose Challenge

Test (GCT)*

---

+

- Referred for diagnostic test and medical management- Meal plan and medication management- Community-based glucose monitoring- Birth preparedness and complication readiness

 

98%!

Summary

It is time to address GDM globally Community-based single test approach to

screening for GDM is the way to go No linkages for referral? Program will fail. Improved health outcomes is the goal, with 98% of

cases managed through healthy meals and lifestyle

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Thank You!

Mychelle Farmer, MD

Mychelle.farmer@jhpiego.org Tausi Suedi

Tausi.suedi@jhpiego.org Chandrakant Ruparelia, MD MPH

Chandrakant.ruparelia@jhpiego.org Leah Hart, MSN MPH

Leah.hart@jhpiego.org

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The Closing Session will begin at4pm in the Grand Ballroom.

Closing remarks will be followed bya 30-minute social gathering

(refreshments will be served). Comemeet new people and discuss the

highlights of the day!

Please fill out an evaluation by going

to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the

room.

Thank you!