Screening naar diabetes tijdens de zwangerschap de nieuwe

Screening naar diabetes tijdens de zwangerschap: de nieuwe aanbevelingen Dr. Katrien Benhalima Endocrinologie, UZ Leuven 19 -10 -2012

Focus on two problems: Pregestational diabetes: *Increase of obesity and diabetes in younger adults *Increase of maternal age at first Pregnancy No uniformity in screening and diagnosis of Gestational diabetes (GDM)

Glucose challenge test for screening 50 g po glucose non fasting After 1 hour glycemia ≥ 130 mg/dl sensitivity 90% 60% more chance for need for extra testing glycemia ≥ 140 mg/dl Sensitivity 80% Specificity 90% 10% with GDM 130 -140 mg/dl

ADA en ACOG: 2 abnormal values necessary for diagnosis WHO: 1 abnormal value is necessary for diagnosis

HAPO study: Hyperglycemia and adverse pregnancy outcomes 25, 505 pregnant women, 15 centers in 9 countries Observational study: 2 -h 75 -g OGTT 24 -32 weeks Unblinded: fasting plasma glucose ≥ 105 mg/d, RPG ≥ 160 mg/dl or the 2 -h glucose ≥ 200 mg/dl The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358: 1991 -2002.

Frequency of Primary Outcomes across the Glucose Categories. The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358: 1991 -2002.

IADPSG: International Association of Diabetes & Pregnancy study groups (2008) International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnostic and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676 -682.

Prevalence GDM OR 25% 16. 1% 8. 8% 1. 5 1. 75 2. 0 FPG 90 92 95 1 -h PG 167 180 191 2 -h PG 142 153 162 26% 38% 36% mg/d. L % consensus

One step Universal screening with 75 g 2 -h OGTT without glucose challenge test (GCT) One abnormal value is enough for diagnosis

Overview of the different diagnostic criteria for GDM. NDDG ADA WHO IADPSG 3 h-100 g 2 h-75 g fasting ≥ 105 ≥ 95 ≥ 126 ≥ 92 1 h ≥ 190 ≥ 180 2 h ≥ 165 ≥ 155 3 h ≥ 145 ≥ 140 Prevalence 2 -4%* 3 -5%* ≥ 180 ≥ 140 ≥ 153 7 -11%† 16. 1%† GDM 2 abnormal values (--) 1 abnormal value

New IADPSG consensus screening strategy for overt diabetes and GDM

Important increase in prevalence of GDM: • Irish population: compared to WHO: 9, 4% --) 12, 4% • Norwegian population compared to WHO: 13% --) 31, 5% O’Sullivan EP et al, Atlantic Diabetes in pregnancy: the prevalence and outcomes of gestional diabetes mellitus using new diagnostic criteria. Diabetologia 2011; 54: 1670 -1675. Jenum Ak et al. Gestational diabeets with WHO and modified IADPSG criteria: impact of ethnicity. Eur, J, of Endocrinology, first online 11 -2011

• • • ADA: IADPSG since 12 -2010 ACOG: continue with 2 -step screening NIH en WHO: consensus in 2012 Europe: Germany, Austria and Italy: IADPSG le Groupement des Gynécologues Obstétriciens de Langue Française de Belgique’ (GGOLFB): IAPDPSG

VDV-VVOG-Domus Medica consensus meetings on 20 -12 -2011 and 05 -03 -2012 Gynecologists: • Prof. Roland Devlieger, prof. Johan Verhaeghe and prof. Liesbeth Lewi: UZ Leuven • Dr. Griet Vandenberghe: UZ Gent • Prof. Dr. Yves Jacquemyn and Dr. Paul Ramaekers : UZA • Dr. Monica Laubach: UZ Brussel • Dr. Anne Loccufier : AZ Sint-Jan Brugge Endocrinologists: • Dr. Katrien Benhalima and Prof. Dr. Chantal Mathieu: UZ Leuven • Prof. Johannes Ruige: UZ Gent • Prof Christophe De Block and prof Luc Van Gaal: UZA • Prof. Dr. Katelijn Decochez: UZ Brussel • Dr. Ann Verhaegen: ZNA Jan Palfijn • Dr. Sylva Van Imschoot: AZ Sint-Jan Brugge • Dr. Paul Van Crombrugge: OLVZ Aalst Domus Medica: Dr. Lieve Seuntjes and prof. Johan Wens: UA

VDV-VVOG-Domus Medica consensus 2012 Screening for pregestational diabetes at first prenatal contact

The VDV-VVOG-Domus Medica consensus recommendation: When pregnancy wish or at the latest at first prenatal contact: universal screening with Fasting Plasma Glucose Easy to perform and higher sensitivity than Hb. A 1 c

Hba 1 c: for diagnosis of pregestational diabetes, NOT for GDM!! Not reimbursed for screening in Belgium

FPG 100 -125 mg/dl (prediabetes)? Plan OGTT as soon as possible (before 24 weeks of pregnancy) Offer lifestyle advice (diet and physical activity) to every women with obesity already before pregnancy and to every women early in pregnancy to avoid excessive weight gain

VDV-VVOG-Domus Medica consensus 2012 Screening for GDM

Logistical problems: 2000 deliveries/year: 6 -8 OGTTs a day (at the hospital) Important increase in prevalence of GDM

A lot of debate: *Impact of obesity op the risk for LGA *Data on cost-benefit? *Data based on observational study *Low reproducibility of OGTT *Risk of type 2 diabetes after pregnancy?

Relation of OR for LGA comparing categories of BMI vs. categories of fasting plasma glucose in the HAPO study • en : BMI : nuchtere glucose BMI Ryan EA. Diabetologia 2011; 54: 480 -486.

Risk for LGA : 5 x higher in cat. 7 vs. cat. 1 (25% vs. 5%) But low in absolute numbers The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358: 1991 -2002.

Number needed to treat cat. 2: 33 cat. 6: 9 cat. 3: 25 cat. 7: 6 Prevention of 1 complication in cat. 1 will cost 8 x more than the prevention 1 complication in cat. 7 Waugh N et al. Best Practice & Research Clinical Endocrinology &Metabolism 2010; 24: 553 -571

In HAPO study: very broad range of prevalence of GDM: Israel: 9, 3% --) US 25% Sacks DA, Hadden DR, Maresh M, Deerochanawong C, Dyer AR, Metzger BE et al. Frequency of gestational diabetes mellitus at collaborating centers based on IADPSG consensus panel-recommended criteria. Diabetes Care 2010; 35: 526 -528.

The consensus on screening for GDM • for now NOT to implement the IADPSG strategy for screening for GDM but to continue with the two step screening: universal screening with 50 g GCT at 24 weeks of gestation (140 mg/dl) • 100 g OGTT (or 2 h 75 g OGTT) met Carpenter & Coustan criteria

VDV-VVOG-Domus Medica consensus 2012 At pregnancy wish or at first prenatal contact: universal screening FPG ≥ 126 mg/dl Hb. A 1 c ≥ 6. 5% RPG ≥ 200 mg/dl yes no Treat as pregestational DM yes FPG: ≥ 100 mg/dl and <126 mg/dl Plan an OGTT as soon as possible no 24 weeks of pregnancy : universal screening with 50 g GCT no Glycemia ≥ 140 mg/dl No GDM Yes: 3 -h 100 g (or 2 -h 75 g) OGTT FPG ≥ 95 mg/dl 1 -h ≥ 180 mg/dl 2 -h ≥ 155 mg/dl 3 -h ≥ 140 mg/dl ≥ 2 abnormal values Treat as GDM

What at diagnosis of GDM? start with dietary measures Registration ‘Zoet Zwanger’: www. zoetwanger. be Start monitoring glycaemia Glycaemic targets: 1 -h postprandial <140 mg/dl or 2 -h postprandial <120 mg/dl fasting plasma glucose <95 mg/dl 1 -2 weeks after start with dietary measures Targets achieved continue with dietary measures Targets not achieved Start with insulin and further follow up by endocrinologist

Follow up postpartum • Universal screening with 2 -h 75 g OGTT 6 -12 weeks postpartum • Yearly measurement of FPG and Hb. A 1 c by GP • Registration in ‘Zoet Zwanger’ normal Impaired glucose regulation diabetes fasting <100 mg/dl ≥ 100 en <126 mg/dl ≥ 126 mg/dl OGTT (75 g 2 u) <140 mg/dl ≥ 140 en < 200 mg/dl ≥ 200 mg/dl

Enquête screeningsstrategie naar zwangerschapsdiabetes in Vlaanderen Doel: 1 ingevulde enquête per verloskundig centrum Organiserend comité: Dr. Katrien Benhalima en prof Chantal Mathieu, dienst endocrinologie, UZ Leuven Prof. Johan Verhaeghe, prof. Roland Devlieger en prof. Liesbeth Lewi, dienst gynaecologie, UZ Leuven Dr. Paul Van Crombrugge, dient endocrinologie, OLV Aalst Correspondentieadres: Katrien. benhalima@uzleuven. be;