Good afternoon, and welcome to Florida, for those of you who want to come and enjoy our sun. I am actually a nurse practitioner in a medical clinic for a health department-based endocrine clinic for women that experience diabetes-complicated pregnancy. Most of the women that I see have either Medicaid or are uninsured. So, I have a real passion for this topic, and I'm just so glad that you're here to talk today. I want to take this talk into three segments. I want to talk about, first, what is gestational diabetes, and what are the impacts of diabetes on pregnancy. Just kind of do a quick overview on that. Talk very importantly about screening for diabetes in pregnancy. And then, finally, to finish off with the transitions of care and why this is actually a very important life event for any woman that has had diabetes. These are my disclosures. Okay. Gestational diabetes prevalence. This is a growing problem. There's been a 30% increase in the prevalence of gestational diabetes in probably about the past five years, if you look between 2016 and 2020. Over 280,000 births each year are affected by gestational diabetes, and that accounts for at least almost 8% of all births in the U.S. Characteristics of women who are going to be affected by gestational diabetes vary by their demographics, age, et cetera. So, it's most prevalent, believe it or not, in non-Hispanic Asian women, and it's more prevalent in women over the age of 40. But, importantly, one of the fastest growing groups of women that we're seeing, and I absolutely see this in my practice, is women between the ages of 20 and 24. So, you see these women that are just very, very young coming in now with gestational diabetes, and we'll talk about why that's an issue. It's more prevalent in women with elevated body mass index, and we see greater prevalence in women with multiple pregnancies. The data show that, geographically, the prevalence of gestational diabetes varies. However, there may be under-reporting for that, so the data may not be really accurate in showing us where this actually occurs. So, it's important to define what is dysglycemia in pregnancy because there's different degrees of it. When we're talking about gestational diabetes, for many of us, the definition of this has changed. When I began my career, it was diabetes that was first recognized when a woman was pregnant, regardless of if it was at their first prenatal visit or their last prenatal visit. The Society of Maternal Fetal Medicine now defines it as diabetes that is diagnosed in the second half of pregnancy, and we'll talk about why that's important later. Or, it's diabetes diagnosed early in pregnancy that does not meet non-pregnant diagnostic criteria for diabetes, but does meet criteria for gestational diabetes. That's kind of women that are in the middle. Pre-gestational diabetes is a glucose elevation that is consistent with diabetes that predates the pregnancy. For many of us, we would think about the women that were discussed previously as having pre-gestational diabetes. What's the big issue with pre-gestational diabetes every time I see one of my patients that comes in early? It's, did this diabetes predate the pregnancy, and they were undiagnosed? Were they in that window of not being picked up with diabetes, and we're only getting the first glimpse of it because we actually screened early in their pregnancy? When we see women early in pregnancy, they potentially have undiagnosed type 1, well, usually it's type 2 diabetes, or what I think I see a lot is actually prediabetes that's been unrecognized. It's important to know that diagnostic criteria for women early in pregnancy are identical to those used for making diagnosis of non-pregnant individuals. The next kind of dysglycemia that we'll see in pregnancy, and I see this one all the time, is early abnormal glucose metabolism. These are women that have a fasting glucose threshold of 110 milligrams per deciliter, or an A1C of less, around 5.9%. This is important because it's associated with gestational diabetes later in pregnancy. Very importantly, cardiovascular, preeclampsia, macrosomia, shoulder dystocia, and potentially even a loss in pregnancy. And finally, we need to look at why does early identification in hyperglycemia in pregnancy matter? Because in the United States, 50% of babies are whoops babies, okay? 50% of these pregnancies are unplanned. And interestingly, among women with diabetes, the unplanned pregnancy rates are higher than those in the general population. Many women enter into pregnancy with diabetes risk or undiagnosed preexisting hyperglycemia. And very importantly, this is a potential predictor of future prediabetes and type 2 diabetes, which we'll discuss in a few minutes. So why does it matter? At the time a pregnancy is confirmed, organogenesis is often complete, or at least it's well under its way. And sadly, I had this reminder this week. I had a woman come in to me who has type 1 diabetes. We've seen her for a prior pregnancy, and she actually had stillbirth with that prior pregnancy. And I actually got to see her delivery record, and it showed that that baby had been affected. I think she came in initially with a 10A1C. That baby had a major congenital anomaly. That fetus had a major congenital anomaly. It had renal anomaly, and it had a limb anomaly. So what we have to do is look at this diagram, and you can see exactly where that happened, that by the time we saw her, there was really not a lot we could do because that baby was already formed. So when we look at the consequences of perinatal hyperglycemia, these vary by diabetes type. What becomes important is when women have gestational diabetes, that they do have increased risk for preeclampsia. They also have increased risk for surgical delivery and infection. And you can see that there are other types of issues that are faced by women that have preexisting diabetes. When you start looking at the perinatal consequences to the fetus or to the infant, though, really they become very similar. If we consider that gestational diabetes is diagnosed after the fetus is formed, you see that other than that, these infants face many of the same risks that other fetuses do of women that have type 1 or type 2 diabetes. And I really want to point out the bottom ones, the early childhood obesity risk that goes with that, and early onset of type 2 diabetes among the women that are affected, and we'll talk about that. So why does it happen? Well, we know that insulin requirements change during pregnancy, and this is a very nice graphic. And thank you, Laura shared this with me, but I had one that was very similar. And it shows us that in the early stages of pregnancy, insulin levels, even among non-pregnant women, are, if you will, normal. There's not a lot of change. And for those of us that work with women in pregnancy, we know that 24 weeks, the rocket's going to take off, and that blood sugar is going to go up. And what we see, and I explained to the ladies that I work with, is that all women who are pregnant have an increase in their insulin needs that escalates with every week of their pregnancy. What is different with them is that they cannot keep up and produce the extra insulin that's required to keep their blood glucose regulated into a normal range during pregnancy, and that's why 24 to 28 weeks become so important for screening. We also see that it's the big old placenta that's causing the problem, and the minute that the placenta leaves the body, the blood sugar actually starts to potentially normalize. Actually, this is an important time for women that have pre-existing diabetes, especially if they're on insulin, because they become very at risk for hypoglycemia. You'll also notice that in the postpartum period, pretty quickly, that that blood glucose normalizes, and that's going to become another issue that we'll discuss. Not to go through a lot about hormones, but just know that every one of these hormones affects and creates insulin resistance, and so that is the driver of what we're seeing with blood glucose elevation later in pregnancy. So moving on, early pregnancy glucose screening for some women is essential. There has been some discussion as to should we just be that glucose screening in pregnancy is easy to do, it's inexpensive, it can be done point of care in the office, and should we just be screening every single pregnant woman that comes in for diabetes as part of routine lab work or within their first prenatal visit? That's not a current guideline. Current guidelines are to screen women who are at risk while they're planning their pregnancy. What was the problem with that? 50% of those pregnancies are unplanned. Yes, so the cart is out of the barn when we see them. So based upon risk, there's recommendations to screen before 15 weeks of gestation in women with risk, and we consider those women at risk women that have prenatal overweight obesity, if they have a first-degree relative with diabetes, so getting that history is so critical, if they are black, Latino, Native American, or Asian, if they're hypertensive, if they have a history of dyslipidemia, very importantly polycystic ovarian syndrome, I see a lot of these ladies, if they're physically inactive, well that would almost suggest probably for many of our patients, most of them, other signs of insulin resistance that you might see, such as acanthosis nigrans, history of prediabetes, and a prior history of a gestational diabetes pregnancy is very important because they may have converted to persistent diabetes in the interim period. So the ADA 2023 recommendation is, and it's a B-grade recommendation, is to screen for early glucose metabolism using the fasting glucose or the A1C in at-risk individuals. So how do we diagnose a blood sugar problem at that point in pregnancy? We use the diagnostic criteria that are consistent with diagnosing diabetes for anybody else, being the fasting blood sugar being greater than 126, an abnormal glucose tolerance test with a 75-gram oral glucose tolerance test of greater than 200 at the two-hour mark, and an A1C greater than or equal to 6.5%. And it's important to recognize that that's in the absence of unequivocal hyperglycemia. The diagnosis requires two abnormal tests from the same sample. So it could be both the fasting plasma glucose and the A1C, or two separate times of the same test that are abnormal. What about when a woman has that fasting plasma glucose that sits elevated but is not quite diabetes? What are we thinking? We call that early abnormal glucose metabolism. I think I write that on 50% of the charts that I see for the women that I'm working with. And those really meet almost the criteria. The fasting is a little bit higher, but they're almost towards criteria towards prediabetes. So what do you do about it when you find somebody that has elevated blood glucose that's not diabetes, that's not consistent with a diagnosis of diabetes once they're pregnant? What do you do with these women that are in the middle? We don't know. And so that's actually a big issue that's under study right now. Within Australia, the International Association for the Study of Diabetes and Pregnancy Group, study group, they are currently producing work to look at what do you do with women that present early in their pregnancy with abnormal glucose screening? Do you treat them or do you not treat them? And so there's a very large study being done in there. They had actually, we'll talk about this in a second, but the results are not yet available. But what they're doing in the study is they are doing early screening for women at risk. They're considering a positive screen at 75 milligram to our oral glucose tolerance test. And then they're initiating treatment protocols, including group education, referral to the dietician, self-monitored blood glucose or metformin and insulin in the treatment group. So the pilot findings of this study, and there was only 21 women in the pilot, 11, I think, in treatment and 10 in control. They showed that in the untreated group, so these women had abnormal blood glucose early in pregnancy and half of them were provided the treatment protocol. The others were untreated. In the untreated group, 89% progressed to type 2 diabetes by their 24 to 28-week screenings. NICU admissions were actually greater in the treated group, and the treated group had smaller gestational age babies. Now, I don't know. I didn't go in and look in detail and see how those babies were treated, how those moms were treated if they were treated with insulin or metformin, but that could be an issue. And the large gestational age was seen in the untreated group. So right now there's a large study going. It's actually completed. The findings are still pending. I understand that they are in final report right now, final writing of some of these initial reports. And the large study will include 4,000 women. So what we know is when we have, if a woman has an early normal screening, she needs to be rescreened at 24 to 28 weeks, and all women need to be screened at 24 to 28 weeks. There are multiple methodologies to do this, and there's a lot of controversy into how you handle this. So at 24 to 28 weeks, the one-step method includes, and this is the one that's approved by the international group, is a 75-gram oral glucose tolerance test. And then they have the, you can see the values that are considered to be suggestive of gestational diabetes. This type of testing has been found to be able to capture almost three times more women with gestational diabetes diagnoses than prior methods. And what's important with this is that women that have an abnormal screen here have a 3.4-fold greater risk for pre-diabetes or type 2 diabetes. And in watching their children, their children up to 11 years, because this is how long they've followed them so far, have an increased risk of metabolic issues relative to excessive weight. So what we're seeing is gestational diabetes is not just a mom problem, it is now a baby-child problem and it follows this child into early childhood. The ADA currently recommends the one-step method because these criteria are the only ones that have been able to show pregnancy outcomes rather than endpoints that are predictive of maternal diabetes and again this is the international standard of care. The traditional way that we've screened for diabetes has been the two, for gestational diabetes has been the two-step strategy proposed by Carpenter and Coustan. In this one you start with a 50 gram glucose screening which is non-fasting and if that is positive and there's different values, I'm going to, I just listed the 130 but you'll see some literature say 130, 135, 140, then the woman goes on for 100 gram three-hour glucose tolerance test and then these are the cut points and if two values are positive in this particular method then that's considered a positive screen for gestational diabetes. Recent studies have found that twice the number of women meet GDM criteria with the one-step method which brings to mind are we capturing the right women, are we not capturing the right women, are we missing women, are we finding too many women, are we over-diagnosing it? I don't have the answers to that. Despite this there's no difference in complications based upon the screening processes that are used and the one-step method may be better for identifying people with prediabetes risk in the future and their child risk for adiposity differences but there's been no data on treatment differences in these women when we find them. The NIH panel in 2013 recommended the two-step method. The U.S. Preventative Service Task Force says there's greater likelihood of finding gestational diabetes with one-step but no differences in outcomes and the 2018 ACOG practice bulletin supports a two-step approach with preference for diagnosing gestational diabetes with one abnormal value and the A1C, it's always important to remember this becomes unreliable later in pregnancy due to the cardiovascular and hematologic changes that accompany pregnancy. Relative to my practice, we are using two-step, we're actually following ACOG guidelines and that's the preference of the obstetricians that I happen to work with and the rationale for that is that I work in a clinic where the women may not come back for that full glucose tolerance test screening, they may miss it and we can at least get that one value on them to drive us to know that at least they passed or didn't pass. So it's really up to you but in order to do the glucose tolerance test does require a fasting state, it requires a test, a trip to the lab and one of the issues that we especially dealt with in COVID is that we all of a sudden didn't have gestational diabetes in our clinic because the women would not sit in there for a three-hour glucose tolerance test, they didn't want to be in the lab that long, one, and two, they had their kids at home and they couldn't be away for three hours because they had to do homeschool and stuff so we've seen all kinds of issues relative to that. So as we move on, why does all of this matter from a long-term perspective and this just feeds into Dr. Wells' lecture on cardiovascular, it's so important. Our goal really is to mitigate pregnancy risks and that's one of the issues we've seen is that providers, especially maternal child providers, they focus on the pregnancy and they miss the impact of this on the woman's health risk for the rest of their lives and this is a marker, this is an important health marker for the rest of these women's lives. So our goal within the diabetes community really needs to be to mitigate pregnancy and lifetime risks associated with abnormal glucose metabolism. The transition from maternity care to primary care is awful, just saying it, okay. Maternal records do not follow women to, many women to their primary care doctors, many women will have lapses in primary care in between their babies, maternal health is the best place, I mean their well-woman provider may be a best place for them to actually get follow-up for this but it's a very important missed care transition and as such it's important as we already talked about getting that diabetes history, when a woman presents for any pregnancy or preventative, non-pregnancy or episodic or preventative care. If you think about a medical record when you do an intake visit, do they ask the woman, if they ask these women do they have diabetes, what will they respond? No, okay. If they respond, no and does your health record in your clinic, maybe because you're diabetes providers but if you're in a general practice setting, does it ask the woman what was your history of preeclampsia and what was your history of gestational diabetes, do you even consider that as a potential problem and I would just think about what you need to do relative to practice change for that. Why does this matter, history of gestational diabetes, we already said that today, increases the risk for progression to type 2 diabetes by seven fold but when does it happen? It happens in the first six years after they have their baby is when their greatest risk is. They are still having more babies, they are young, they are in their reproductive life cycle and they are now going to have long duration of type 2 diabetes so that's my soapbox, okay. So that's why all of this becomes so important. We are looking at a young adult problem that becomes a lifetime problem in the future. So as providers it's important for us to start educating women during a gestational diabetes complicated pregnancy about how to mitigate their future health risks. This includes telling them about their, increasing their awareness of type 2 diabetes risk, teaching them to self advocate for screening in the future and recognizing breastfeeding is a diabetes preventive strategy and that is a new guideline in this year's diabetes ADA standards. Consider including gestational diabetes on an active problem list, not just why she's pregnant but for her life, okay. Breastfeeding support and again lifestyle diabetes prevention strategies. Focusing on postpartum contraception is important because I'm always telling the women I work with, every baby needs to be planned and we want to make sure that if you did convert to diabetes that we attend to that and that we can have a healthy baby in the future and so reproductive life planning is very important and assessment for type 2 diabetes before they conceive ideally. So when should you screen these women? The current guidelines are that we should screen all women who have had gestational diabetes within 4 to 12 weeks following their delivery. How many of them do it? Less than 50%, okay and many of them never come back for a postpartum appointment, believe it or not. When doing the screening we need to use non-pregnant cut points and a recent study by the Society for Maternal Fetal Medicine looked at, compared 2 day testing after delivery for glucose, giving an oral glucose tolerance test at 2 days versus the 4 to 12 weeks and they found out that they were equally predictive for type 2 diabetes risk within the first year. So maybe in the future that will guide some changing that this testing is done in the hospital before they go home. These women should be screened annually for type 2 diabetes. I tell them to do it when they go in for their well woman exam and they should be screened prior to attempting another pregnancy. Interconception care is very important and why? Because we have risk for major fetal anomaly and that's directly associated with the glycemic levels in preconception care. And then the anomalies we see are horrible. As I said that one baby that was lost was a congenital heart defect, a renal defect and also a skeletal defect. So with that we'll kind of do a couple really quick cases. So my first case, Brittany, 31 year old. She's grabbed 2 pair of 0's. She had a miscarriage at, actually she had a, she had, actually this lady had hiatus de formant at 12 weeks. She has past medical history of a molar pregnancy 6 months ago. She was found to have an elevated blood sugar during that time but did not get any follow-up care. And she was told she had pre-diabetes as a teenager. She has a prior history of a 40 pound weight loss with regain. She has family history of type 2 diabetes. Her menarche was at age 14. She's had irregular cycles regulated by oral contraceptives and she has polycystic ovarian syndrome. Okay. Physical exam, she's 332 pounds. You can see her blood pressure is mildly elevated. She did have hirsutism, acne and acanthosis nigrans. Thyroid was okay. First audience response, would you screen her? Yes or no? Early, early. Would you do early screening on her? Wow. Great. Yes, clearly. So this is her early screening results. Her fasting blood sugar was 103 and her A1C was 5.5. I don't have the second faxing on her. I have a question about, is she on metformin? She was not on metformin when she, no, that's a good question. Yeah, no, she was not on metformin. No, she didn't tolerate it. So she was not on it when she conceived. Okay. All right. Now what do you do with her? First of all, what are you going to call this? And that's an audience response question. Would you call it normal early pregnancy glucose screen? Would you call it early abnormal glucose metabolism, prediabetes or pre-gestational type 2? How would you classify her? That's a poll question. Okay. So you're saying, most of you are saying it's early abnormal glucose metabolism and that is true. So what are you going to do? What are you going to do with her? Would you rescreen her at 24 to 28 weeks? Would you initiate home glucose monitoring, refer her for diabetes self-management education? Or would you prescribe metformin? Hmm. This is an audience response question too. I think it's reasonable to initiate home glucose monitoring, refer her, and that's actually what they did. I worked with her. We did start early monitoring on her. She eventually wound up on insulin. And I'm happy to say she was one of the most delightful patients I have ever worked with. Delivered a very healthy little baby boy at term, appropriate weight with no complications. So, and was just thrilled to death. She was very easy to work with because she wanted a healthy baby and she had done so much with having done Atkins and ketones and every kind of diet in the world that she, I mean she took right to it and whatever she needed to have done she did. So she did really, really well and the baby was healthy and perfect. Okay. We, you know, the study that's coming out of Australia may change how we manage her. So we'll have to see what happens with those results. So now we have Esmeralda and probably about half of the ladies I see are Latinas and she's a 34-year-old. Gravid a four, para three, term three, live three. She's now nine weeks pregnant. We've seen her before for gestational diabetes. She has a history of, a little history of macrosomia, 10-pounder plus, a 9-pounder. I think maybe her baby before that was a little bit macrosomic. But I think we took two or three pounds off the baby. So I think we're doing a little bit better than what she had. Those babies were delivered and the ones that were large were delivered in Guatemala. She is married. She immigrated from Guatemala and she lacks insurance and her menstrual history is unremarkable. She did no post-delivery follow-up relative to gestational diabetes. Here's her vitals. She did have acanthosis nigrans, otherwise she had a normal early pregnancy exam. Would you screen her? Audience response question. Yes, thank you. And how would you, let me get, there's her findings. How would you interpret that? Audience response question. Right, that's a normal early pregnancy screen. Very good. So even though we used different cut points later in pregnancy, she's being considered with what would be a normal blood sugar for a non-pregnant person because she's early in pregnancy. So what's your plan for her? And that's an audience response question. Really the right, she doesn't have gestational diabetes yet. You could be proactive and start her with screening and monitoring if you wanted to. You don't have a diagnosis yet to support getting testing equipment, but she's uninsured so you're going to be providing that anyway. But absolutely she should be rescreened at 24 to 28 weeks. And there she is. That's what happens between week 8 and week 25. So she had a screen of almost 200 and then repeat. She went up to, she has at least two values, three values that exceeded criteria. And so she was treated for gestational diabetes. So to conclude, history of diabetes is associated with heightened risk for prediabetes and diabetes why these women are still in their reproductive years and places them at risk for long-duration diabetes. Long-duration diabetes, type 2 diabetes, is a cardiometabolic risk factor. History of GDM is associated with future reproductive risks. And also don't forget the risk for obesity and metabolic dysfunction in offspring. So this is truly a transgenerational health problem. Remember that not just GDM, but pregnancy is a window into a woman's future health risks and opportunity for focused health prevention in the future. And there's some questions. That's my little baby David.

gestational diabetes

pregnancy

screening process

transitions of care

prevalence

risk factors

dysglycemia