- Email: [email protected]
260: Insulin doses and gestational weight gain in pregnant women treated with insulin detemir
www.AJOG.org
Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging
QALYs. The cost-effectiveness threshold was set to $100,000 per QALY. RESULTS: Treating patients in Glucose Category 5 was the dominant strategy. Treatment was more expensive ($11,491.75 with treatment vs $10,734.42 without treatment) but more effective (56.914924 QALYs with treatment vs 56.897791 without treatment), with an incremental cost of $44203.00/QALY. In a one-way sensitivity of analysis of the degree of treatment efficacy, treatment remained cost-effective as long as it met 64% of its reported efficacy. CONCLUSION: Treating patients in Glucose Category 5 of the HAPO Trial is cost-effective in terms of improving maternal and neonatal outcomes. How the health care system will provide this expanded care to this group of women will need to be examined.
Poster Session II
RESULTS: 55% of the patients had a 1st trimester HbA1c ⱕ 7%, 48% of
the population was Caucasian and 34% Hispanic, the type 1 to type 2 PGDM ratio was 40:60, the mean enrollment BMI (SD) in kg/m2 was 31.7 (8.17), and the overall LGA outcome was 34.1%. Patients with type 2 PGDM and a first trimester HbA1c ⱕ 7% were found to have a significantly lower rate of LGA (20% vs. 41%, p⫽0.0203) than all other subjects combined. Final multivariate analysis revealed higher third trimester HbA1c and higher weekly maternal weight gain were associated with LGA outcome. For every 1% increase in third trimester HbA1c (e.g. from 6% to 7%), the risk of LGA increased 53.3%, p⫽0.0277; and for every 0.1 kg increase in maternal weekly weight gain, the risk of LGA increased 19.9%, p⫽0.0267. ROC (Figure 1) indicates HbA1c of 5.9% maximizes sensitivity and specificity for LGA risk. CONCLUSION: Increasing weekly maternal weight gain and increasing 3rd trimester HbA1c are independent predictors of increased risk for an LGA neonate in pregnancies affected by type 1 or type 2 PGDM. Using univariate analysis, we found that pregnancies affected by type 2 PGDM with a first trimester HbA1c ⱕ 7% were at lower risk of LGA neonate outcome; however this result was not seen in the multivariate model. Maintaining a 3rd trimester HbA1c ⱕ 5.9% and restricting weekly maternal weight gain to ⱕ 0.1 kg may reduce the incidence of LGA neonates in pregnancies affected by pregestational diabetes mellitus.
260 Insulin doses and gestational weight gain in pregnant women treated with insulin detemir Katarzyna Suffecool1, Barak Rosenn1, Brianne Bimson1, Janelle Foroutan1, Sophia Scarpelli1, Oded Langer1 1 St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, NY
259 Factors associated with fetal overgrowth in pregnancies affected by type 1 and type 2 pregestational diabetes mellitus Kami M. Dixon1, Karen B. Lesser1, Martin Feuerman2, Hayley M. Roylance3, Kathryn L. Reed1 1 University of Arizona, Obstetrics and Gynecology, Tucson, AZ, 2Winthrop University Hospital, Health Outcomes Research -Biostatistics, Mineola, NY, 3University of Arizona, Public Health/Pre-medicine, Tucson, AZ
OBJECTIVE: Evaluate the association between first trimester glycemic control and fetal overgrowth in pregnancies affected by type 1 and type 2 diabetes. STUDY DESIGN: 135 women with pregestational diabetes mellitus (PGDM) and singleton live births were retrospectively studied between 1/2001 and 1/2011. Patients were categorized by first trimester glycosylated hemoglobin (HbA1c) ⱕ 7% and ⬎7%. Independent associations between HbA1c values, demographics, and diabetes type were analyzed to estimate the risk of a large-for-gestational age (LGA) neonate using multiple regression models.
OBJECTIVE: Insulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnancy. Several studies have reported that treatment with ID in people with type 2 diabetes has a weight-sparing effect compared with other basal insulins. The purpose of this study was to test the hypothesis that use of ID during pregnancy is associated with less weight gain compared to treatment with NPH. STUDY DESIGN: This is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. In women treated with ID, the initial insulin dose was calculated based on current body weight and divided into 50% ID and 50% aspart. Patients were instructed to check the glucose levels 4-7 times a day and insulin doses were adjusted throughout pregnancy based on the level of glycemic control. Maternal weight was documented at each visit, every 1-2 weeks. Insulin doses and maternal weight gain were compared
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S127
Poster Session II
Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging
www.AJOG.org
between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Chi-square and Student’s t-test were used, as appropriate. RESULTS: Thirty women were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean ( SD) Insulin doses and maternal weight gain are presented in the table. CONCLUSION: Insulin dosages in pregnant women treated with ID and aspart appear to be comparable to dosages in women treated with NPH and aspart. However, use of ID is associated with significantly higher weight gain during pregnancy.
262 Glycated albumin and hemoglobin A1c: an alternate screen for first trimester gestational diabetes Kristina Milan1, D. Ware Branch2, T. Flint Porter3, Tracy Manuck4 1
University of Utah, Obstetrics and Gynecology, Salt Lake City, UT, University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT, 3Intermountain Healthcare and University of Utah, Obstetrics and Gynecology, Salt Lake City, UT, 4University of Utah Health Sciences Center and Intermountain Healthcare, Obstetrics and Gynecology, Salt Lake City, UT 2
261 Does insulin detemir improve pregnancy outcome in pregnant women with diabetes? Katarzyna Suffecool1, Barak Rosenn1, Brianne Bimson1, Janelle Foroutan1, Sophia Scarpelli1, Oded Langer1 1 St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, NY
OBJECTIVE: Insulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnant women. The purpose of this study is to describe our experience with ID compared to NPH in pregnancy. STUDY DESIGN: This is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. Patients were instructed to check glucose levels 4-7 times a day with the fasting glucose target set at 60-90mg/dL and the 2-hours post-prandial target set at ⬍120mg/dL. Glucose control and outcome of pregnancy were compared between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Statistical analysis was performed using Chi-square and Student’s t-test, as appropriate. RESULTS: The study included 60 women: 30 were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean glucose concentrations, percent values within targets, rates of hyperglycemia and hypoglycemia, birthweight, rates of LGA and macrosomia are presented in the table. CONCLUSION: Insulin Detemir does not appear to have any advantage over NPH with respect to glucose control, maternal hypoglycemia and birth weight in pregnant women with diabetes.
S128
OBJECTIVE: Glycated albumin has a half-life of 15-20 days and may be a better short-term marker of glycemic control than hemoglobin A1C (half-life 120 days). Our objective was to determine whether first trimester hemoglobin A1C (A1C) or glycated albumin (GA) levels correlate with a simultaneous 50-gram glucola screen (OGTT) and a 1st trimester diagnosis of gestational diabetes mellitus (GDM) in a high risk population. STUDY DESIGN: Prospective cohort of women recruited during their first prenatal visit at a local Health Department. Women with no known history of type 1 or 2 diabetes were enrolled 95/180/165/140 mg/dL or if the OGTT was ⱖ200mg/dL, GDM was diagnosed. Data were analyzed by Chi-square, Students t-test, and receiver operating curve/area under the curve as appropriate. RESULTS: 65 women were enrolled; the majority (88%) of whom were Hispanic. 51 (78%) were overweight/obese (mean 1st trimester measured BMI 29.3). 25 (38%) had a first-degree relative with diabetes, and 2 (3%) had a history of GDM in a prior pregnancy. 8 (12%) had an elevated OGTT, including one with an OGTT ⬎200mg/dL. 3 (5%) were diagnosed with GDM. A1C and GA results were significantly higher among women with abnormal glucola and a diagnosis of GDM (see Table 1). The A1C value was highly correlated with the 50g OGTT result (r⫽0.41, p⬍0.001), but the GA less so (r⫽0.22, p⫽0.08). The area under the curve (AUC) for A1C was 0.99 (p⫽0.42), not significantly different from the 50g OGTT in predicting DM (p⫽0.42). The AUC for GA performed slightly worse (AUC 0.83, p⫽⬍0.001). CONCLUSION: In this cohort of women at high risk for GDM, the A1C and GA were highly correlated with the first trimester OGTT screen results. These tests may provide alternate screening options in high risk women unable to tolerate a first trimester GTT. The threshold for A1C as a diagnostic tool for 1st trimester GDM may be lower than originally speculated as adapted from American Diabetes Association guidelines in the non-pregnant adult (⬎/⫽6.5%).
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging
QALYs. The cost-effectiveness threshold was set to $100,000 per QALY. RESULTS: Treating patients in Glucose Category 5 was the dominant strategy. Treatment was more expensive ($11,491.75 with treatment vs $10,734.42 without treatment) but more effective (56.914924 QALYs with treatment vs 56.897791 without treatment), with an incremental cost of $44203.00/QALY. In a one-way sensitivity of analysis of the degree of treatment efficacy, treatment remained cost-effective as long as it met 64% of its reported efficacy. CONCLUSION: Treating patients in Glucose Category 5 of the HAPO Trial is cost-effective in terms of improving maternal and neonatal outcomes. How the health care system will provide this expanded care to this group of women will need to be examined.
Poster Session II
RESULTS: 55% of the patients had a 1st trimester HbA1c ⱕ 7%, 48% of
the population was Caucasian and 34% Hispanic, the type 1 to type 2 PGDM ratio was 40:60, the mean enrollment BMI (SD) in kg/m2 was 31.7 (8.17), and the overall LGA outcome was 34.1%. Patients with type 2 PGDM and a first trimester HbA1c ⱕ 7% were found to have a significantly lower rate of LGA (20% vs. 41%, p⫽0.0203) than all other subjects combined. Final multivariate analysis revealed higher third trimester HbA1c and higher weekly maternal weight gain were associated with LGA outcome. For every 1% increase in third trimester HbA1c (e.g. from 6% to 7%), the risk of LGA increased 53.3%, p⫽0.0277; and for every 0.1 kg increase in maternal weekly weight gain, the risk of LGA increased 19.9%, p⫽0.0267. ROC (Figure 1) indicates HbA1c of 5.9% maximizes sensitivity and specificity for LGA risk. CONCLUSION: Increasing weekly maternal weight gain and increasing 3rd trimester HbA1c are independent predictors of increased risk for an LGA neonate in pregnancies affected by type 1 or type 2 PGDM. Using univariate analysis, we found that pregnancies affected by type 2 PGDM with a first trimester HbA1c ⱕ 7% were at lower risk of LGA neonate outcome; however this result was not seen in the multivariate model. Maintaining a 3rd trimester HbA1c ⱕ 5.9% and restricting weekly maternal weight gain to ⱕ 0.1 kg may reduce the incidence of LGA neonates in pregnancies affected by pregestational diabetes mellitus.
260 Insulin doses and gestational weight gain in pregnant women treated with insulin detemir Katarzyna Suffecool1, Barak Rosenn1, Brianne Bimson1, Janelle Foroutan1, Sophia Scarpelli1, Oded Langer1 1 St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, NY
259 Factors associated with fetal overgrowth in pregnancies affected by type 1 and type 2 pregestational diabetes mellitus Kami M. Dixon1, Karen B. Lesser1, Martin Feuerman2, Hayley M. Roylance3, Kathryn L. Reed1 1 University of Arizona, Obstetrics and Gynecology, Tucson, AZ, 2Winthrop University Hospital, Health Outcomes Research -Biostatistics, Mineola, NY, 3University of Arizona, Public Health/Pre-medicine, Tucson, AZ
OBJECTIVE: Evaluate the association between first trimester glycemic control and fetal overgrowth in pregnancies affected by type 1 and type 2 diabetes. STUDY DESIGN: 135 women with pregestational diabetes mellitus (PGDM) and singleton live births were retrospectively studied between 1/2001 and 1/2011. Patients were categorized by first trimester glycosylated hemoglobin (HbA1c) ⱕ 7% and ⬎7%. Independent associations between HbA1c values, demographics, and diabetes type were analyzed to estimate the risk of a large-for-gestational age (LGA) neonate using multiple regression models.
OBJECTIVE: Insulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnancy. Several studies have reported that treatment with ID in people with type 2 diabetes has a weight-sparing effect compared with other basal insulins. The purpose of this study was to test the hypothesis that use of ID during pregnancy is associated with less weight gain compared to treatment with NPH. STUDY DESIGN: This is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. In women treated with ID, the initial insulin dose was calculated based on current body weight and divided into 50% ID and 50% aspart. Patients were instructed to check the glucose levels 4-7 times a day and insulin doses were adjusted throughout pregnancy based on the level of glycemic control. Maternal weight was documented at each visit, every 1-2 weeks. Insulin doses and maternal weight gain were compared
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S127
Poster Session II
Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging
www.AJOG.org
between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Chi-square and Student’s t-test were used, as appropriate. RESULTS: Thirty women were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean ( SD) Insulin doses and maternal weight gain are presented in the table. CONCLUSION: Insulin dosages in pregnant women treated with ID and aspart appear to be comparable to dosages in women treated with NPH and aspart. However, use of ID is associated with significantly higher weight gain during pregnancy.
262 Glycated albumin and hemoglobin A1c: an alternate screen for first trimester gestational diabetes Kristina Milan1, D. Ware Branch2, T. Flint Porter3, Tracy Manuck4 1
University of Utah, Obstetrics and Gynecology, Salt Lake City, UT, University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT, 3Intermountain Healthcare and University of Utah, Obstetrics and Gynecology, Salt Lake City, UT, 4University of Utah Health Sciences Center and Intermountain Healthcare, Obstetrics and Gynecology, Salt Lake City, UT 2
261 Does insulin detemir improve pregnancy outcome in pregnant women with diabetes? Katarzyna Suffecool1, Barak Rosenn1, Brianne Bimson1, Janelle Foroutan1, Sophia Scarpelli1, Oded Langer1 1 St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, NY
OBJECTIVE: Insulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnant women. The purpose of this study is to describe our experience with ID compared to NPH in pregnancy. STUDY DESIGN: This is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. Patients were instructed to check glucose levels 4-7 times a day with the fasting glucose target set at 60-90mg/dL and the 2-hours post-prandial target set at ⬍120mg/dL. Glucose control and outcome of pregnancy were compared between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Statistical analysis was performed using Chi-square and Student’s t-test, as appropriate. RESULTS: The study included 60 women: 30 were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean glucose concentrations, percent values within targets, rates of hyperglycemia and hypoglycemia, birthweight, rates of LGA and macrosomia are presented in the table. CONCLUSION: Insulin Detemir does not appear to have any advantage over NPH with respect to glucose control, maternal hypoglycemia and birth weight in pregnant women with diabetes.
S128
OBJECTIVE: Glycated albumin has a half-life of 15-20 days and may be a better short-term marker of glycemic control than hemoglobin A1C (half-life 120 days). Our objective was to determine whether first trimester hemoglobin A1C (A1C) or glycated albumin (GA) levels correlate with a simultaneous 50-gram glucola screen (OGTT) and a 1st trimester diagnosis of gestational diabetes mellitus (GDM) in a high risk population. STUDY DESIGN: Prospective cohort of women recruited during their first prenatal visit at a local Health Department. Women with no known history of type 1 or 2 diabetes were enrolled 95/180/165/140 mg/dL or if the OGTT was ⱖ200mg/dL, GDM was diagnosed. Data were analyzed by Chi-square, Students t-test, and receiver operating curve/area under the curve as appropriate. RESULTS: 65 women were enrolled; the majority (88%) of whom were Hispanic. 51 (78%) were overweight/obese (mean 1st trimester measured BMI 29.3). 25 (38%) had a first-degree relative with diabetes, and 2 (3%) had a history of GDM in a prior pregnancy. 8 (12%) had an elevated OGTT, including one with an OGTT ⬎200mg/dL. 3 (5%) were diagnosed with GDM. A1C and GA results were significantly higher among women with abnormal glucola and a diagnosis of GDM (see Table 1). The A1C value was highly correlated with the 50g OGTT result (r⫽0.41, p⬍0.001), but the GA less so (r⫽0.22, p⫽0.08). The area under the curve (AUC) for A1C was 0.99 (p⫽0.42), not significantly different from the 50g OGTT in predicting DM (p⫽0.42). The AUC for GA performed slightly worse (AUC 0.83, p⫽⬍0.001). CONCLUSION: In this cohort of women at high risk for GDM, the A1C and GA were highly correlated with the first trimester OGTT screen results. These tests may provide alternate screening options in high risk women unable to tolerate a first trimester GTT. The threshold for A1C as a diagnostic tool for 1st trimester GDM may be lower than originally speculated as adapted from American Diabetes Association guidelines in the non-pregnant adult (⬎/⫽6.5%).
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012