- Email: [email protected]
HD3-2 Screening and follow-up for gestational diabetes in the Torres strait Islands
DIABETES RESEARCH A N D CLINICAL PRACTICE
profile and assess three validated instruments that measure self management, locus of control and well being to assess their clinical value in day to day patient care. Design: A quantitative and qualitative study using three validated instruments and two newly constructed scales. All statistical tests were performed using SPSS version V14 23 A two tailed p-value below 0.05 was regarded as significant. Qualitative data were analysed thematically. Subject and settings: Forty-eight people with diabetes, three rural solo general practitioners, two diabetic educators and two practice nurses from the same three private solo practices. Results: This unique study combining the quantitative biological parameters of diabetic care with the qualitative analysis derived from interviews with the patient and their health providers, has shown a significant correlation between good diabetes control and the GPs assessment of the patients motivation (0.48 p=0.001). The perceived self-management scale also correlated with good diabetes control (-.29 p<0.05), which in turn correlated with the GPs assessment of the patients (0.31 p<0.05). The interviews reflected these quantitative results and revealed people fully understand the consequences of poorly controlled diabetes and have in general a good relationship with their health care providers and that they in turn are aware of the individuals psychosocial and self management needs but often do not have resources to respond. Conclusion: Tools exist which can supplement health providers understanding of patient’s motivation and self management. In the case of rural solo practitioners these tools do not add to the existing understanding of individual patient’s psychosocial challenges. Patients are fully aware of the consequences of diabetes and understand what they need to do to have good diabetic control. We readily accept the role of dietitian and podiatrist in our diabetic management team, perhaps it is time that we also consider the role of the psychologist, life coach or case manager for a select group identified by either the routine GP or by use of the PDSMS scale.
HD3-1 GDM estimates: what is the current picture in Australia? Mardi Templeton, Louise Catanzariti, Lynelle Moon, Indrani Pieris-Caldwell, Claire Ryan Australian Institute of Health and Welfare, Canberra, Australia Background/Aims: Gestational diabetes mellitus (GDM) is a serious but transient condition occurring in pregnancy and women with GDM are at an increased risk of developing Type 2 diabetes later in life. This condition substantially increases the risk of morbidity and adverse outcomes among affected women and their babies. In 1999–2000, the Australian Diabetes, Obesity and Lifestyle Study found that 3.6% of women who had ever been pregnant reported having ever been told they had gestational or pregnancy-related diabetes. However, a detailed national analysis on the current incidence of this condition has not been done
S47
79 (2008) S1 – S127
before in Australia. This study aims to provide a current picture of GDM among Australian women. Methods: This study analyses data from the National Hospital Morbidity Database (NHMD) on the proportion of women giving birth in hospital who have also been diagnosed with gestational diabetes. Comparisons of GDM incidence rates over time and between age-groups are also presented. Findings: The incidence rate of GDM in 2004–05 was 4.2 per 100 women giving birth in hospital. This is an increase of 17% from the rate of 3.6 per 100 women giving birth in hospital in 2000–01. At least part of this increase is likely to be due to the increase in the average age of women giving birth, as GDM is more common in older mothers. In 2004–05 about a third of GDM cases (33%) were among women over the age of 35 years, however only 20% of births occurred in this age-group. Conclusions/Comments: Hospitalisation data provides a good estimate of national GDM incidence. The data show that GDM is increasing over time and that the burden appears to be among women giving birth at an older age. Complete, accurate and regular national estimates of GDM incidence are necessary to better understand the magnitude of GDM among Australian women, and can be sourced from the national hospital data.
HD3-2 Screening and follow-up for gestational diabetes in the Torres strait Islands Ashim Sinha 1 , Henrik Falhammar, Bronwyn Davis 1 , Dianne Bond 1 , Deirdre Frost 2 , Marissa Arnot 2 , Edna Sambo 2 , Alexandra Raulli 3 1 Cairns Diabetes Centre, 2 Torres Strait Island Health Service District, 3 Cairns Tropical Public Health Unit, Australia Background: Research shows that diabetes in pregnancy has important and sometimes adverse outcomes for both mother and child. Both animal and human studies suggest that diabetes, like many other chronic adult diseases originates in foetal life. The prevalence of Type 2 diabetes in women of childbearing age in the Torres Strait Islands is already at 49%. As indigenous people are at such high risk of developing diabetes it is crucial that women with gestational diabetes (GDM)/diabetes in pregnancy (DIP) are managed aggressively to reduce the incidence of Type 2 diabetes in future generations. In an effort to overcome this problem the Torres Strait Island Health Service District has implemented routine screening and management protocols driven by Midwives and Health Workers. Aims: An audit was undertaken to: 1. Assess the effectiveness of routine screening and management protocols for women with GDM/DIP 2. Assess pregnancy outcomes and follow-up of women who have had GDM Methodology: A chart audit was undertaken using the Australasian Diabetes in Pregnancy (ADIPS) audit tool, of all women from the Torres Strait Islands who delivered in 1999 and 2005-
Abstract HD3-2 – Table 1 1999
2005/2006
Diabetic mothers† Non-diabetic mothers*† P value Diabetic mothers† Non-diabetic mothers*† P value (n=11) (n=248) (n=25) (n=170) Maternal age, yrs, mean (SD) Booking weight, kg, mean (SD) Parity, mean (SD) Birth weight, g, mean (SD) Gestational age at birth, weeks, mean (SD) Major congenital malformation, n (%) Neonatal hypoglycaemia, n (%) Respiratory distress syndrome, n (%)
33.1 (1.6) 94.0 (4.7) 4.5 (0.8) 4014 (127) 39.1 (0.4) 0 2 (25) 2 (22)
24.6 (0.3) 71.3 (1.5) 1.9 (0.1) 3314 (36) 38.9 (0.1) 3 (1) 7 (4) 7 (4)
0.00 0.00 0.00 0.00 0.74 1.00 0.04 0.05
32.6 (1.3) 89.6 (3.9) 2.2 (0.4) 3650 (182) 38.8 (0.4) 2 (9) 10 (45) 3 (14)
25.8 (0.5) 76.1 (1.4) 2.2 (0.2) 3300 (47) 39.1 (0.2) 5 (3) 2 (1) 8 (5)
0.00 0.00 0.84 0.02 0.64 0.20 0.00 0.12
S48
DIABETES RESEARCH A N D CLINICAL PRACTICE
2006 to assess compliance with screening and management protocols over two time periods. The percentage of women who received GDM followed-up was also assessed. Results: From Jan 1st 1999 to Dec 31st 1999 there were 249 pregnant women identified, of which 39 were not screened for GDM. From July 1st 2005 to June 30th 2006 there were 196 pregnant women identified of which only one woman was not screened for GDM. Thirty one percent of women who had GDM were followed up with either an OGTT or fasting blood glucose. The data will be discussed in more detail at presentation. Conclusions: In a remote indigenous community in Far North Queensland, Australia with high prevalence of Type 2 Diabetes a diabetes in pregnancy programme driven by trained indigenous health workers and midwives has resulted in: 1 Universal screening of all pregnant women; 2. Implementation of evidenced based treatment protocols and follow-up; 3. A trend towards reduction in birth weight; 4. The establishment of guidelines for follow up of women with GDM and diabetes in pregnancy and surveillance of children born to these mothers. With such culturally appropriate and locally developed programmes we would anticipate a reduction in the incidence of diabetes in pregnancy and the future development of Type 2 diabetes in children.
HD3-3 Microalbuminuria and hypertension in pregnancy in women with Type 1 and Type 2 diabetes Matthew Farrant 1 , Greg Gamble 2 , Tim Cundy 1,2 Diabetes Pregnancy Clinic, National Women’s Health, Auckland City Hospital, 2 Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand 1
Microalbuminuria (MA) detected in early pregnancy of women with Type 1 diabetes (T1D) is reported to increase in quantity throughout pregnancy and to be associated with a high risk of preeclampsia. However, the natural history and significance of microalbuminuria in women with Type 2 diabetes (T2D) has not been studied. We measured sequentially the albumin excretion rate (AER, estimated from the albumin/creatinine ratio) in 100 women (50 T1D, 50 T2D) from ≤20 weeks’ through to ≥32 weeks’ gestation (≥4 measurements per subject). MA was defined as an AER of 30-300 mg/day. Half of each group had MA on the initial test and half were normoalbuminuric (NA - <30mg/day). Preeclampsia was defined as a BP >140/90, plus at least one of: 2+ proteinuria (or, in subjects with MA, a doubling of AER), creatinine >90umol/l, AST >40u/l or platelets <150 x103 /mm3 . In early pregnancy, women with MA had similar systolic and diastolic blood pressure to NA women. Women with NA (both T1D and T2D) showed a significant fall in mean blood pressure in mid-pregnancy (20-24 weeks), that was not seen in women with MA (p value for difference <0.005, for both systolic and diastolic). In women with early pregnancy MA, the increment in AER at term was significantly greater in T1D than in T2D (p<0.0001), although early pregnancy levels were greater in the latter (p=0.047). Early pregnancy MA was predictive of preeclampsia in both T1D and T2D. However, a substantial number of NA women with T1D also developed preeclampsia - these subjects typically showed
Type 1 - NA Type 1 - MA Type 2 - NA Type 2 - MA Early AER (med, range) Term AER (med, range) Early BP (mean) Term BP (mean) Preeclampsia (%)
9 (2-22) 12 (3-160) 121/72 131/82 24
50 (30-299) 244 (29-2564) 122/74 138/85 48
8 (2-29) 13 (4-517) 118/71 120/78 0
98 (32-286) 156 (32-2692) 120/75 135/86 24
79 (2008) S1 – S127
exponential rises in AER in late pregnancy - and the proportion of MA women with T2D developing preeclampsia was only half that of MA women with T1D. We conclude that women with microalbuminuria in pregnancy do not show the usual physiologic mid-pregnancy blood pressure drop. Although microalbuminuria is a strong predictor of preeclampsia in women with T1D, it is less strongly predictive in T2D.
HD3-4 Maternal and fetal predictors of neo-natal hypoglycaemia, an audit related to diabetes in pregnancy Mohammad Mohiuddin 1 , Carl Eagleton 2 1 Department of Endocrinology & Diabetes, Middlemore Hospital, 2 Counties Manukau District Health Board, Otahuhu, South Auckland, New Zealand Aim: To identify maternal and fetal factors that would predict risk of neonatal hypoglycemia. These factors could then be used as valuable monitoring tool in the Antenatal clinic. Ultimate aim is to improve care of women with diabetes in pregnancy, thereby to reduce perinatal morbidity and to improve women’s health-related quality of life. Methods: A retrospective case control study of obstetric and medical notes of 106 women from 171 women with diabetes in pregnancy who gave live birth over a time period of one year at Middlemore Hospital in South Auckland. Group 1 consisted of 48 mothers whose babies required admission to the neonatal unit post partum due to hypoglycaemia. Group 2 consisted of 58 randomly selected mothers whose babies did not require admission. Maternal glycaemic control was assessed by antenatal HbA1c, mean fasting and post prandial blood glucose in the weeks prior to delivery. Fetal & neonatal characteristics analyzed were fetal abdominal circumference on growth scan, birth weight, and mode of delivery. New born’s capillary blood glucose <2.2 mmol/L at birth was considered as hypoglycaemia. Results: Glycaemic control, measured by HbA1c between the groups was different with statistical significance. Despite apparent difference, mean fasting & postprandial BGLs did not reach statistical significance. Insulin requirement at term did not reach statistical significance. Mode of delivery was statistically significant, Caesarean section predominant MOD in Gr1 (58%), normal vaginal delivery predominant in Gr2 (72%). Fetal abdominal circumference on growth scan showed statistically significant difference between the groups, more babies from group1 mothers had higher than normal abdominal circumference. Table 1. Maternal characteristics, no significant difference Characteristics Mean Age Mean BMI Diabetes Type GDM Type 2 Type 1 Mean FBG Mean pp BG Mean Insulin at term
Group 1
Group 2
33 36.7
32 36.1
34 12 2 5.1 8.3 87.4u/d
44 13 1 4.8 6.6 105u/d
Table 2. Maternal characteristics, significant difference Characteristics Mean HbA1c MOD Normal Vaginal C-section Other
Group 1
Group 2
p-value
6.6
6.1
0.01
14 28 6
23 7 2
0.01
profile and assess three validated instruments that measure self management, locus of control and well being to assess their clinical value in day to day patient care. Design: A quantitative and qualitative study using three validated instruments and two newly constructed scales. All statistical tests were performed using SPSS version V14 23 A two tailed p-value below 0.05 was regarded as significant. Qualitative data were analysed thematically. Subject and settings: Forty-eight people with diabetes, three rural solo general practitioners, two diabetic educators and two practice nurses from the same three private solo practices. Results: This unique study combining the quantitative biological parameters of diabetic care with the qualitative analysis derived from interviews with the patient and their health providers, has shown a significant correlation between good diabetes control and the GPs assessment of the patients motivation (0.48 p=0.001). The perceived self-management scale also correlated with good diabetes control (-.29 p<0.05), which in turn correlated with the GPs assessment of the patients (0.31 p<0.05). The interviews reflected these quantitative results and revealed people fully understand the consequences of poorly controlled diabetes and have in general a good relationship with their health care providers and that they in turn are aware of the individuals psychosocial and self management needs but often do not have resources to respond. Conclusion: Tools exist which can supplement health providers understanding of patient’s motivation and self management. In the case of rural solo practitioners these tools do not add to the existing understanding of individual patient’s psychosocial challenges. Patients are fully aware of the consequences of diabetes and understand what they need to do to have good diabetic control. We readily accept the role of dietitian and podiatrist in our diabetic management team, perhaps it is time that we also consider the role of the psychologist, life coach or case manager for a select group identified by either the routine GP or by use of the PDSMS scale.
HD3-1 GDM estimates: what is the current picture in Australia? Mardi Templeton, Louise Catanzariti, Lynelle Moon, Indrani Pieris-Caldwell, Claire Ryan Australian Institute of Health and Welfare, Canberra, Australia Background/Aims: Gestational diabetes mellitus (GDM) is a serious but transient condition occurring in pregnancy and women with GDM are at an increased risk of developing Type 2 diabetes later in life. This condition substantially increases the risk of morbidity and adverse outcomes among affected women and their babies. In 1999–2000, the Australian Diabetes, Obesity and Lifestyle Study found that 3.6% of women who had ever been pregnant reported having ever been told they had gestational or pregnancy-related diabetes. However, a detailed national analysis on the current incidence of this condition has not been done
S47
79 (2008) S1 – S127
before in Australia. This study aims to provide a current picture of GDM among Australian women. Methods: This study analyses data from the National Hospital Morbidity Database (NHMD) on the proportion of women giving birth in hospital who have also been diagnosed with gestational diabetes. Comparisons of GDM incidence rates over time and between age-groups are also presented. Findings: The incidence rate of GDM in 2004–05 was 4.2 per 100 women giving birth in hospital. This is an increase of 17% from the rate of 3.6 per 100 women giving birth in hospital in 2000–01. At least part of this increase is likely to be due to the increase in the average age of women giving birth, as GDM is more common in older mothers. In 2004–05 about a third of GDM cases (33%) were among women over the age of 35 years, however only 20% of births occurred in this age-group. Conclusions/Comments: Hospitalisation data provides a good estimate of national GDM incidence. The data show that GDM is increasing over time and that the burden appears to be among women giving birth at an older age. Complete, accurate and regular national estimates of GDM incidence are necessary to better understand the magnitude of GDM among Australian women, and can be sourced from the national hospital data.
HD3-2 Screening and follow-up for gestational diabetes in the Torres strait Islands Ashim Sinha 1 , Henrik Falhammar, Bronwyn Davis 1 , Dianne Bond 1 , Deirdre Frost 2 , Marissa Arnot 2 , Edna Sambo 2 , Alexandra Raulli 3 1 Cairns Diabetes Centre, 2 Torres Strait Island Health Service District, 3 Cairns Tropical Public Health Unit, Australia Background: Research shows that diabetes in pregnancy has important and sometimes adverse outcomes for both mother and child. Both animal and human studies suggest that diabetes, like many other chronic adult diseases originates in foetal life. The prevalence of Type 2 diabetes in women of childbearing age in the Torres Strait Islands is already at 49%. As indigenous people are at such high risk of developing diabetes it is crucial that women with gestational diabetes (GDM)/diabetes in pregnancy (DIP) are managed aggressively to reduce the incidence of Type 2 diabetes in future generations. In an effort to overcome this problem the Torres Strait Island Health Service District has implemented routine screening and management protocols driven by Midwives and Health Workers. Aims: An audit was undertaken to: 1. Assess the effectiveness of routine screening and management protocols for women with GDM/DIP 2. Assess pregnancy outcomes and follow-up of women who have had GDM Methodology: A chart audit was undertaken using the Australasian Diabetes in Pregnancy (ADIPS) audit tool, of all women from the Torres Strait Islands who delivered in 1999 and 2005-
Abstract HD3-2 – Table 1 1999
2005/2006
Diabetic mothers† Non-diabetic mothers*† P value Diabetic mothers† Non-diabetic mothers*† P value (n=11) (n=248) (n=25) (n=170) Maternal age, yrs, mean (SD) Booking weight, kg, mean (SD) Parity, mean (SD) Birth weight, g, mean (SD) Gestational age at birth, weeks, mean (SD) Major congenital malformation, n (%) Neonatal hypoglycaemia, n (%) Respiratory distress syndrome, n (%)
33.1 (1.6) 94.0 (4.7) 4.5 (0.8) 4014 (127) 39.1 (0.4) 0 2 (25) 2 (22)
24.6 (0.3) 71.3 (1.5) 1.9 (0.1) 3314 (36) 38.9 (0.1) 3 (1) 7 (4) 7 (4)
0.00 0.00 0.00 0.00 0.74 1.00 0.04 0.05
32.6 (1.3) 89.6 (3.9) 2.2 (0.4) 3650 (182) 38.8 (0.4) 2 (9) 10 (45) 3 (14)
25.8 (0.5) 76.1 (1.4) 2.2 (0.2) 3300 (47) 39.1 (0.2) 5 (3) 2 (1) 8 (5)
0.00 0.00 0.84 0.02 0.64 0.20 0.00 0.12
S48
DIABETES RESEARCH A N D CLINICAL PRACTICE
2006 to assess compliance with screening and management protocols over two time periods. The percentage of women who received GDM followed-up was also assessed. Results: From Jan 1st 1999 to Dec 31st 1999 there were 249 pregnant women identified, of which 39 were not screened for GDM. From July 1st 2005 to June 30th 2006 there were 196 pregnant women identified of which only one woman was not screened for GDM. Thirty one percent of women who had GDM were followed up with either an OGTT or fasting blood glucose. The data will be discussed in more detail at presentation. Conclusions: In a remote indigenous community in Far North Queensland, Australia with high prevalence of Type 2 Diabetes a diabetes in pregnancy programme driven by trained indigenous health workers and midwives has resulted in: 1 Universal screening of all pregnant women; 2. Implementation of evidenced based treatment protocols and follow-up; 3. A trend towards reduction in birth weight; 4. The establishment of guidelines for follow up of women with GDM and diabetes in pregnancy and surveillance of children born to these mothers. With such culturally appropriate and locally developed programmes we would anticipate a reduction in the incidence of diabetes in pregnancy and the future development of Type 2 diabetes in children.
HD3-3 Microalbuminuria and hypertension in pregnancy in women with Type 1 and Type 2 diabetes Matthew Farrant 1 , Greg Gamble 2 , Tim Cundy 1,2 Diabetes Pregnancy Clinic, National Women’s Health, Auckland City Hospital, 2 Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand 1
Microalbuminuria (MA) detected in early pregnancy of women with Type 1 diabetes (T1D) is reported to increase in quantity throughout pregnancy and to be associated with a high risk of preeclampsia. However, the natural history and significance of microalbuminuria in women with Type 2 diabetes (T2D) has not been studied. We measured sequentially the albumin excretion rate (AER, estimated from the albumin/creatinine ratio) in 100 women (50 T1D, 50 T2D) from ≤20 weeks’ through to ≥32 weeks’ gestation (≥4 measurements per subject). MA was defined as an AER of 30-300 mg/day. Half of each group had MA on the initial test and half were normoalbuminuric (NA - <30mg/day). Preeclampsia was defined as a BP >140/90, plus at least one of: 2+ proteinuria (or, in subjects with MA, a doubling of AER), creatinine >90umol/l, AST >40u/l or platelets <150 x103 /mm3 . In early pregnancy, women with MA had similar systolic and diastolic blood pressure to NA women. Women with NA (both T1D and T2D) showed a significant fall in mean blood pressure in mid-pregnancy (20-24 weeks), that was not seen in women with MA (p value for difference <0.005, for both systolic and diastolic). In women with early pregnancy MA, the increment in AER at term was significantly greater in T1D than in T2D (p<0.0001), although early pregnancy levels were greater in the latter (p=0.047). Early pregnancy MA was predictive of preeclampsia in both T1D and T2D. However, a substantial number of NA women with T1D also developed preeclampsia - these subjects typically showed
Type 1 - NA Type 1 - MA Type 2 - NA Type 2 - MA Early AER (med, range) Term AER (med, range) Early BP (mean) Term BP (mean) Preeclampsia (%)
9 (2-22) 12 (3-160) 121/72 131/82 24
50 (30-299) 244 (29-2564) 122/74 138/85 48
8 (2-29) 13 (4-517) 118/71 120/78 0
98 (32-286) 156 (32-2692) 120/75 135/86 24
79 (2008) S1 – S127
exponential rises in AER in late pregnancy - and the proportion of MA women with T2D developing preeclampsia was only half that of MA women with T1D. We conclude that women with microalbuminuria in pregnancy do not show the usual physiologic mid-pregnancy blood pressure drop. Although microalbuminuria is a strong predictor of preeclampsia in women with T1D, it is less strongly predictive in T2D.
HD3-4 Maternal and fetal predictors of neo-natal hypoglycaemia, an audit related to diabetes in pregnancy Mohammad Mohiuddin 1 , Carl Eagleton 2 1 Department of Endocrinology & Diabetes, Middlemore Hospital, 2 Counties Manukau District Health Board, Otahuhu, South Auckland, New Zealand Aim: To identify maternal and fetal factors that would predict risk of neonatal hypoglycemia. These factors could then be used as valuable monitoring tool in the Antenatal clinic. Ultimate aim is to improve care of women with diabetes in pregnancy, thereby to reduce perinatal morbidity and to improve women’s health-related quality of life. Methods: A retrospective case control study of obstetric and medical notes of 106 women from 171 women with diabetes in pregnancy who gave live birth over a time period of one year at Middlemore Hospital in South Auckland. Group 1 consisted of 48 mothers whose babies required admission to the neonatal unit post partum due to hypoglycaemia. Group 2 consisted of 58 randomly selected mothers whose babies did not require admission. Maternal glycaemic control was assessed by antenatal HbA1c, mean fasting and post prandial blood glucose in the weeks prior to delivery. Fetal & neonatal characteristics analyzed were fetal abdominal circumference on growth scan, birth weight, and mode of delivery. New born’s capillary blood glucose <2.2 mmol/L at birth was considered as hypoglycaemia. Results: Glycaemic control, measured by HbA1c between the groups was different with statistical significance. Despite apparent difference, mean fasting & postprandial BGLs did not reach statistical significance. Insulin requirement at term did not reach statistical significance. Mode of delivery was statistically significant, Caesarean section predominant MOD in Gr1 (58%), normal vaginal delivery predominant in Gr2 (72%). Fetal abdominal circumference on growth scan showed statistically significant difference between the groups, more babies from group1 mothers had higher than normal abdominal circumference. Table 1. Maternal characteristics, no significant difference Characteristics Mean Age Mean BMI Diabetes Type GDM Type 2 Type 1 Mean FBG Mean pp BG Mean Insulin at term
Group 1
Group 2
33 36.7
32 36.1
34 12 2 5.1 8.3 87.4u/d
44 13 1 4.8 6.6 105u/d
Table 2. Maternal characteristics, significant difference Characteristics Mean HbA1c MOD Normal Vaginal C-section Other
Group 1
Group 2
p-value
6.6
6.1
0.01
14 28 6
23 7 2
0.01