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1 INTERVENTION STUDIES in GDM 관동의대제일병원산부인과 김문영

2 ISSUE Is it time to treat for mild GDM? Can the treatment of mild GDM prevent fetal death? Can the treatment of mild GDM prevent fetal over-growth? Justification of routine treatment of mild GDM Justification of universal screening for GMD

3 Intervention Studies & Related Articles Effect of treatment of GDM on pregnancy outcome (ACHOIS, Australian CHO intolerance study) Crowther CA et al 2005 A multicenter, randomized trial of treatment for mild GDM (NICDH, National institute child health human development) Landon MB et al 2009 A planned randomized clinical trial of treatment of mild GDM Landon MB et al 2002 Can the findings of recent randomized trials of treatment or no treatment of gestational diabetes be used for changing current treatment approaches? Moore TR 2010

4 Introduction Mild GDM 75gm or 100gm OGTT 로 GDM 진단받은경우 FBS <95mg/dl in 100gm OGTT FBS <99mg/dl in 75gm OGTT & 2hr mg/dl Mild GDM - metabolic heterogenecity? from a major health problem to a diagnosis still looking a disease Randomized clinical trial

5 Primary Pregnancy Outcome ACHOIS Perinatal death Shoulder dystocia Bone fracture Nerve palsy Admission NICU Jaundice requiring phototherapy NICHD Still birth or neonatal death Hypoglycemia Hyper-bilirubinemia Neonatal insulinemia Brachial palsy Fracture:clavicle,humerus,skull Induction of labor C/S

6 Secondary Pregnancy Outcome GA at delivery ACHOIS Birth wt : macrosomia, LGA, SGA NICHD Birth wt : macrosomia, LGA, SGA Admission of NICU RDS Wt.gain during pregnancy No of antenatal admission PIH C/S Induction of labor Shoulder dystocia Wt. gain during pregnancy PIH

7 Primary Clinical Outcomes in ACHOIS Crowther CA et al NEJM 2005;352:

8 Secondary Clinical Outcomes in ACHOIS Crowther CA et al NEJM 2005;352:

9 Primary Perinatal Outcome in NICHD Landon MB et al NEJM 2009;361:

10 Secondary Neonatal Outcome in NICHD Landon MB et al NEJM 2009;361:

11 Maternal Outcome in NICHD Landon MB et al NEJM 2009;361:

12 Comparison of Two Studies Study criteria Insulin Tx criteria Significant adverse outcome ACHOIS 16-30wks single & twin 50gm OGTT >140 and 75gm OGTT (24-34wks) FBS <99 & 2hr <35wks FBS>99, 2hr>126 >35wks FBS>99, 2hr>144 Random >162 Any serious perinatal Cx Perinatal death Shoulder dystocia Bone fracture Nerve palsy Macrosomia 24-30wks single NICHD 50gm OGTT and 100gm OGTT (+) & FBS<95 FBS>95 2hr>120 Random >160 Macrosomia C/S Shoulder dystocia Difference Primary outcome: Mortality Secondary outcome: Morbidity PIH

13 No recommendation d/t insufficient evidence. Harms of screening include short-term anxiety in some women with positive screening results Inconvenience to many women and medical practices because most positive screening test results are probably false positive. Until there is better evidence, clinicians should discuss screening for GDM with their patients and make case-bycase decisions. Ann Intern Med. 2008;148:

14 Prospective studies are needed to assess health outcomes in women with various glucose levels adjusted for obesity to help understand what level of glucose constitutes an important risk to the mother or fetus. Additional randomized trials are needed to compare health outcomes of lowering glucose with the health outcomes of not intervening in GDM. More definitive data are required regarding screening strategies for GDM including glucose load in timing. Ann Intern Med. 2008;148:

15 It is now time to consider how screening of the pregnant population can be performed in a timely and efficient manner how care of women with GDM can be better organized to provide in the maximum benefit in reducing the fetal and neonatal adiposity.

16 Discussion Points Fetal surveillance protocol in mild GDM Evaluation of risk of perinatal mortality & morbidity Shoulder dystocia ACHOIS primary outcome NICHD secondary outcome Serious birth injury Perinatal death

17 Fetal Surveillance Test for GDM Well controlled GDM (class A 1 ) Kick count from 28 wks NST from 40 wks US for fetal growth every 4 wks Delivery no later than 40 wks Insulin required without vasculopathy (class A 2 ) Kick count from wks NST from 32 wks If necessary CST, BPP US for fetal growth every 4 wks Delivery no later than 40 wks

$life Clavicle fracture : 38% Humeral fracture : 17%$

18 Shoulder Dystocia Incidence : % Brachial plexopathy : 2/3 of injury Half of brachial plexo-pathy from shoulder dystocia 88% resolved by 1yr of life Clavicle fracture : 38% Humeral fracture : 17% McRoberts maneuver Woods screw maneuver

19 Changing the Study View Fetal macrosomia shoulder dystocia-birth trauma high relation Macrosomia & shoulder dystocia : significant outcome in both studies evaluation of complication of birth trauma Only diet control group vs no treatment group of GDM

20 In treatment group of GDM, significantly reduced risk for perinatal morbidity Metabolic Cx, hypebilirubinemia, hypoglycemia, respiratory complication, shoulder dystocia, macrosomia, LGA, still birth, C/S

21 OGCT negative / OGCT positive, OGTT negative / OGCT OAV / GDM Definition of metabolic SD GDM or OAV or hyperinsulinemia : any one BP >140/90, TG >2SD, low HDL, BMI>30, waist >2SD: Metabolic SD in mid trimester can predictor macrosomia

22 Conclusion GDM, it is time to treat. ACHOIS trial Glycemic control in the form of dietary advice, blood glucose monitoring, and insulin therapy reduced the rate of serious perinatal complication without increasing the rate of C/S. NICHD trial Although Tx of mild GDM did not significant reduced the frequency of stillbirth or perinatal death, it did reduce the risks of fetal overgrowth, shoulder dystocia, cesarean section, and hypertensive disorders.

23 이미지를표시할수없습니다. 컴퓨터메모리가부족하여이미지를열수없거나이미지가손상되었습니다. 컴퓨터를다시시작한후파일을다시여십시오. 여전히빨간색 x 가나타나면이미지를삭제한다음다시삽입해야합니다. Thank you for your attention!

24 Case : Previous GDM with macrosomia 38 yrs old, Ht 160cm, Wt 52kg, BMI 21.1, Wt gain 16.5kg OBGY history G6 P2 L2 A3 NSVD 3.4kg(1992), NSVD 3.44kg(2007) Past history GDM(2007) 50gm OGTT gm OGTT 82/161/159/157 Present illness 50gm OGTT gm OGTT 81/141/171/117 at 25wks 69/140/121/117 at 28wks

25 Case (to be continued) Vacuum assisted vaginal delivery at wks Male / 4090gm / Apgar 1-6, 5-8 Postpartum 1&1/2 hr later BP 60/40, PR 110/min

26 The Point in this case Category in Mild GDM?? If the GDM was diagnosed in this case, the macrosomia would be prevented -?? If the macrosomia was not developed, the If the macrosomia was not developed, the obstetrical complication would be prevented -??

27 GDM 총산모군 Total delivery 603 LGA 22(3.64) GA at delivery(median) 38.5 SGA 69(11.44) PIH 25(4.15) Labor induction 45(7.46) V/D 298(49.5) Neonatal death 2 c/sec 294(48.76) NICU 입원 32(5.31) vacuum 11(1.82) hypoglycemia 5(0.83) Still birth 1 hyperbilirubinemia 145(24.05) Birth Wt 3175 Neonatal hyperinsulinemia TTN 153(25.4) RDS 13(2.16) Brachial palsy 0 Fracture(clavicle, humerus) Adverse NST 28(4.64) 0 1

28 GDM A1 Total delivery 537 LGA 19(3.54) GA at delivery(median) 38.5 SGA 64(11.92) PIH 23(4.28) Labor induction 43(8.00) V/D 263(48.97) Neonatal death 2 c/sec 263(48.97) NICU 입원 29(5.40) vacuum 11(2.05) hypoglycemia 5(0.93) Still birth 1 hyperbilirubinemia 127(23.65) Birth Wt 3107 Neonatal hyperinsulinemia TTN 141(26.26) RDS 11(2.05) Brachial palsy 0 Fracture(clavicle, humerus) Adverse NST 25(4.66) 0 1

29 Insulin Tx Total delivery 66 LGA 3(4.55) GA at delivery(median) 38.3 SGA 4(6.06) PIH 2(3.03) Labor induction 3(4.55) V/D 35(53.03) Neonatal death 0 c/sec 31(46.97) NICU 입원 3(4.55) vacuum 0 hypoglycemia 1(1.51) Still birth 0 hyperbilirubinemia 16(24.24) Birth Wt 3175 Neonatal hyperinsulinemia TTN 10(15.15) RDS 2(3.03) Brachial palsy 0 Fracture(clavicle, humerus) Adverse NST 3(4.55) 0 0

Microsoft PowerPoint - QUUBMRTOLPEO.pptx

Microsoft PowerPoint - QUUBMRTOLPEO.pptx 제 26 차대한당뇨병학회춘계학술대회 11 May, 2013 ICC, Jeju, Korea What are the appropriate screening and diagnostic methods for gestational diabetes in Korean women? 서울의대 분당서울대학교병원 내과장학철 임신성당뇨병 Gestational diabetes mellitus