Medical News Blog Information

MERS-CoV in South Korea - other data formats for data provided by WHO...

The following links take you to different version of the PDF if you want to harvest those data...

  1. Excel version, Office 2010
    https://drive.google.com/open?id=0B5sEcTjB5Aila3c5WXI4bzlkLWc&authuser=0
  2. MS DOS CSV file
    https://drive.google.com/open?id=0B5sEcTjB5AilTHRub1FRZnhpQmM&authuser=0
  3. Original WHO PDF
    https://drive.google.com/open?id=0B5sEcTjB5AilWlo0UDZwVzRpdVE&authuser=0
Its taken a week to get these data, and its unclear why detail data dried up from the 12th June to the 19th, or why the data have appeared now, but they are here at last and that's great.

Cancer Care in Botswana

Hello from Gabarone,

I am now half way into my trip and I thought this might be a good time to sit and reflect on the things I have learned/experienced so far.  The major lesson I learned is that more questions arise than there were answers.  The choice to come Botswana stemmed from an already established collaboration between the Oncology department at MGH and two hospitals in the city of Gaborone (one public/government run) and one private which services government insured patients for certain aspects of care mainly with regards to oncology. The objectives were a few fold help establish breast cancer guidelines in hopes of standardizing treatment of breast cancer patients. Additionally, I hoped to assist with setting up a multi disciplinary breast clinic to make the transition for patient much easier.

Both have come with challenges as well as some progress. In trying to adapt the breast cancer guidelines used in the US, I had to get input from physicians who practice here in Botswana. Immediately you realize that cancer in the US is very different from Cancer in Botswana. For example where as we have screening guidelines and yearly mammography to detect early and occult malignancies, one of the physician�s quotes that 99% of breast cancer patients that they encounter self palpated a mass.  This essentially means that the breast cancer is locally advanced and diagnosed at a much later stage. This also means that things like breast conserving surgeries which is a viable option in the US is not an option in Botswana i.e women who come to attention for management of breast cancer, get mastectomies. So the questions: why are women diagnosed so late?  Why is there no capacity for screening, is it an acceptable fact young women are dying of potentially curable malignancies? In a country where breast are associated with femininity, is late stage disease resulting in mastectomies the best that can be done? There are so many questions�

Back to the guidelines, even though currently the guidelines are a skeleton compared to the one used in the US, it leaves a lot of room for improvement, which is a major positive. Also all the physicians were on board that these guidelines were in deed important and were mostly willing to contribute from their perspectives so that care can be standardized.  

With regard to the multi disciplinary clinic, the major limitation currently is finding an adequate space that would allow all the participating physicians to evaluate the patients� together.   Also hiring a nurse that could staff that clinic full time has been a challenge. Even though the government has the capacity, I have learned is that cancer is not quite as high a priority as infectious disease for example. The nation wide campaign against HIV and TB has been remarkable partly because the percentages of both are so high and there were enough interested parties to highlight the toll these diseases were taking on the population. Being an optimist though, I think there are enough interested parties that want to change the thinking about cancer; I believe the break through is just around the corner, at least I hope.   


In terms of helping the to stream line the process for patients, I am setting up a meeting with a physician who works with the ministry of health to discuss efforts to educate local providers and health care workers to recognize warning signs and symptoms and also to focus on age appropriate screening as part of their general check up, stayed tuned for the results of that meeting on the next post.


New medicine could help diabetics save Rs 10,000 per year


MUMBAI: A new anti-diabetes drug from the 'gliptin' family soon to be launched in India promises to lower treatment cost for patients by 55-60%. 

The launch of 'Teneligliptin' by Mumbai-based Glenmark Pharma under Ziten and Zita Plus brands at an affordable price could prove to be a game-changer with savings of over Rs 10,000 per year for diabetics. Treatment cost for the debilitating disease which gradually attacks and weakens all body organs may come down further over months, with possibly more domestic companies entering the market, experts said. 

Teneligliptin, a third-generation oral anti-diabetic drug manufactured by Gl
enmark, has received regulatory approval and is priced aggressively at nearly Rs 20 for a day's therapy (Rs 7,263 per year). As against this, all gliptins being sold in the market are priced around Rs 45 for a day, taking the cost of treatment for patients to nearly Rs 16,500 per year. (See chart) 

Most gliptins launched by MNCs in the country are currently imported. While manufacturing the drug entirely in the country, the pharma company has sought to connect its innovation to the Narendra Modi government's 'Make in India' programme. 


Diabetes is fast gaining the status of a potential epidemic in India with over 67 million individuals currently diagnosed with the disease (source: IDF 2014), while there is a huge undiagnosed diabetes population estimated around 35.4 million. 


The economic burden of diabetes is high in India as most patients pay out of their pocket for treatment due to the lack of medical reimbursement. The cost of treatment includes consultation, investigations, drugs and monitoring, and, due to the nature of the disease, the complications related to the disease may increase it substantially. 

Due to the high cost of therapy, patients from the lower socio-economic class tend to neglect it, or at times are forced to take loans, mortgage or sell property. 

Though the new class of drugs, gliptins (also called DPP-4 inhibitors), are increasingly emerging as a highly popular therapy, it is prescribed to only one in 10 diabetics in cities. Doctors say the price, particularly for economically-constrained patients, has always been an area of concern. 

"Cost of conventional treatment of diabetes is often prohibitive for most Indians; and addition of newer drugs (gliptins, SGLT-2 inhibitors), often needed to control blood sugar and prevent complications, makes it higher. In this respect, any drug of new category (gliptins) at half the price of available drugs of similar category is welcome in India," said Dr Anoop Misra, chairman Fortis-C-DOC Hospital for Diabetes. 


Overall, the oral anti-diabetic market in which Teneligliptin is the new entrant, is valued at approximately Rs 4,800 crore, increasing at 19% per annum (source: ORG-IMS MAT April 2015), while the gliptin family is at Rs 1,200 crore, growing at 27%. 

However, since the molecule has not been used extensively right now, its safety data needs more scrutiny, doctors say. "In general, gliptins tend to do well in Indians as we eat more carbohydrates and need lower doses. But we need more safety and outcome data on Teneligliptin coming from India," said Dr Shashank Joshi, endocrinologist and diabetologist. 

The drug, originally developed by Mitsubishi Tanabe Pharma, is approved for use mainly in Japan and Korea, and will be available in the country soon, said a Glenmark official. The company received approval from DCGI after conducting clinical trials on the molecule for over two years in India, he added. 

Globally, a recent study has dissipated a cloud that had been hanging over one of the gliptins, where it was found that there was no cardiovascular problems like heart failure associated with the use of these drugs, including Merck's Januvia. 


Annual event working to combat Peel’s climbing diabetes rates

PEEL – One in 10 Peel residents currently lives with Type 2 diabetes, says Peel Public Health, and, if nothing is done to fight some of the risk factors, that number could climb to one in six, or 17 per cent, of the region’s population over the next decade.
As well, Peel has a large population of people of South Asian and Caribbean descent, whom experts believe are more likely to develop diabetes than those from many other countries.
One group trying to shrink the risks is The Stop Diabetes Foundation, founded by Dr. Harpreet Bajaj, which works to educate the community about diabetes and healthy eating. The organization will host its yearly awareness event for June 21 from 9 a.m. to 4 p.m. at the Mississauga Convention Centre.
The free event will have Dr. Bajaj, along with diabetes specialists, doctors, pharmacists and dieticians, conducting seminars on a number of subjects including diet and health. A free healthy lunch will also be provided.
In addition, Dr. Bajaj will hold a media conference in the afternoon to talk about some new initiatives to fight the rise of diabetes in Peel. They include a social media campaign directed at South Asian youth, an awareness initiative aimed at adults who are stationary at their jobs and have low levels of physical activity, restaurant and Gurdwara campaigns to provide healthy meal and snack options and a women’s preventative health initiative, among others.
Bollywood singer Harshdeep Kaur of Heer fame will attend the event.
More than 500 people are expected to attend and the foundation has arranged for free bus service from locations in Malton and Brampton.

Youngster with Type 1 diabetes to run in St Albans Half Marathon to raise money for Diabetes UK

A young runner who suffers from diabetes will be setting the pace in a fun run in aid of Diabetes UK.
Darcy McBride, of Kimpton Bottom near Hitchin was diagnosed with Type 1 diabetes in January 2007 just three years after his father Kevin was told he had the condition aged 44.
The 10-year-old will be completing a three-mile fun run event at the St Albans Half Marathon on Sunday – the first day of Diabetes Week.
Darcy's mum, 39-year-old Nikki McBride, said: "Darcy is an amazing little boy who has never let his condition get in the way of anything he wants to do.
"He has chosen to run the fun run on his own and he is desperate to raise money so that in the future children do not have to live the life he does.
"He never moans about his condition but he knows that his life is different to others and can sometimes be scary and awkward."
The Beechwood Park School pupil was hoping to raise £500 but has already exceeded his expectations and has collected more than £800.
He is now aiming to raise around £1,000 for the charity.
Darcy, who is busy training for the event by running to the corner shop and back, said: "I love all kinds of sports and diabetes doesn't stop me doing anything so I really wanted to do this to show people and help raise money.
"If my money could help pay for some research to find a cure or even kinder ways of testing blood I would be really happy."
As well as running Darcy represents Hertfordshire in the under 11 County Badminton Team, and competes for his school in rugby, football, tennis, cricket, table tennis and badminton.
His mother added: "Darcy's school has been amazingly supportive often going above and beyond to make sure he is looked after.
"Kevin also deals with his diabetes in a very matter of fact way not letting it affect his life and he has been a great inspiration to Darcy."
Mrs Mcbride told the Mercury Darcy and the family had been overwhelmed by the support from his teachers, many of whom had personally donated towards his fundraising efforts.
Sharon Roberts, eastern regional manager for Diabetes UK, said: "Darcy is a wonderful example of how you can live life to the full with the condition and for him to do something to help others and prove what can be achieved is fantastic."

Young Kalispell brothers with diabetes headed for D.C. to 'fix' things

KALISPELL – Lots of people have set out for Washington, D.C., to try to “fix” things.
Maybe a pair of Kalispell brothers, ages 8 and 5, will have better luck than most.
Taite and Trevor Hammer certainly seem to have the personalities for winning others over, judging by videos of each posted by the Juvenile Diabetes Research Foundation.
The boys have been selected to represent Montana at the JDRF Children’s Congress in Washington on July 13-15. The Children’s Congress, held every two years since 1999, is designed to help U.S. senators and representatives understand what it’s like to live with the condition, and the importance of funding research on Type 1 diabetes.
In his video, 8-year-old Taite tells about a day at school where an older boy warned other students to steer clear of young Mr. Hammer.
“Stay away from him because you could get diabetes and die,” Taite remembers the older boy saying.
“I’m not contagious,” Taite says, breaking into a grin, “but my smile is.”
Trevor, the 5-year-old, says, “I can’t wait to get a cure – I just can’t wait.”
Taite was diagnosed when he was 1 1/2. Trevor says he was 3 when his diagnosis came.
“Trevor was raised around a pump and all that goes into caring for someone with T1D,” the boys’ mother, Shana Hammer, says. “When he was diagnosed, he thought it was cool to be like his brother.”
***
The family works hard to raise money for the Juvenile Diabetes Research Foundation – in 2013, they raised $11,000.
The foundation, in turn, says it funds the most promising research that may turn “Type One into Type None.”
Type 1 diabetes in an autoimmune disease in which a person’s pancreas stops producing insulin, a hormone necessary for people to get energy from food.
It strikes both children and adults, has nothing to do with diet or lifestyle, and there is nothing anyone can do to prevent it.
“Just to survive, people with T1D must frequently test their blood sugar and inject insulin, or continually infuse it with a pump, every day,” according to the foundation. “Taking insulin does not cure T1D, nor does it prevent the possibility of the disease’s devastating effects: kidney failure, blindness, nerve damage, heart attack, stroke and pregnancy complications.”
According to JDRF, another 30,000 people in the United States are diagnosed with Type 1 diabetes every year, joining the 26 million who suffer from all types of diabetes. There was a 23 percent increase in the prevalence of Type 1 diabetes in people under the age of 20 from 2001 to 2009.
Participants in the Children’s Congress range in age from 4 to 17. When his schedule permits, they've even met with the president.
The idea was inspired by a youngster in Massachusetts, who one day asked his mother, “Why can’t kids go to Washington and tell their representatives about what it is like to have Type 1 diabetes and let them know that we want scientists to find a cure?”
It’s a message Taite and Trevor will hammer home next month.

Gestational diabetes

Gestational diabetes (or gestational diabetes mellitusGDM) is a condition in which women without previously diagnoseddiabetes exhibit high blood glucose (blood sugar) levels during pregnancy (especially during their third trimester). Gestational diabetes is caused when insulin receptors do not function properly. This is likely due to pregnancy-related factors such as the presence of human placental lactogen that interferes with susceptible insulin receptors. This in turn causes inappropriately elevated blood sugar levels.
Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied.
As with diabetes mellitus in pregnancy in general, babies born to mothers with untreated gestational diabetes are typically at increased risk of problems such as being large for gestational age (which may lead to delivery complications), low blood sugar, andjaundice. If untreated, it can also cause seizures or stillbirth. Gestational diabetes is a treatable condition and women who have adequate control of glucose levels can effectively decrease these risks. The food plan is often the first recommended target for strategic management of GDM.
Women with unmanaged gestational diabetes are at increased risk of developing type 2 diabetes mellitus (or, very rarely, latent autoimmune diabetes or Type 1) after pregnancy, as well as having a higher incidence of pre-eclampsia and Caesarean section; their offspring are prone to developing childhood obesity, with type 2 diabetes later in life. Most women are able to manage their blood glucose levels with a modified diet and the introduction of moderate exercise, but some require antidiabetic drugs, includinginsulin.

Classification

Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy". This definition acknowledges the possibility that a woman may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether symptoms subside after pregnancy is also irrelevant to the diagnosis. A woman is diagnosed with gestational diabetes when glucose intolerance continues beyond 24–28 weeks of gestation.
The White classification, named after Priscilla White, who pioneered research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and pregestational diabetes (diabetes that existed prior to pregnancy). These two groups are further subdivided according to their associated risks and management.
The two subtypes of gestational diabetes under this classification system are:
  • Type A1: abnormal oral glucose tolerance test (OGTT), but normal blood glucose levels during fasting and two hours after meals; diet modification is sufficient to control glucose levels
  • Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required
Diabetes which existed prior to pregnancy is also split up into several subtypes under this system:
  • Type B: onset at age 20 or older and duration of less than 10 years.
  • Type C: onset at age 10-19 or duration of 10–19 years.
  • Type D: onset before age 10 or duration greater than 20 years.
  • Type E: overt diabetes mellitus with calcified pelvic vessels.
  • Type F: diabetic nephropathy.
  • Type R: proliferative retinopathy.
  • Type RF: retinopathy and nephropathy.
  • Type H: ischemic heart disease.
  • Type T: prior kidney transplant.
An early age of onset or long-standing disease comes with greater risks, hence the first three subtypes.
Two other sets of criteria are available for diagnosis of gestational diabetes, both based on blood-sugar levels.
Criteria for diagnosis of gestational diabetes, using the 100 gram Glucose Tolerance Test, according to Carpenter and Coustan:
  • Fasting 95 mg/dl
  • 1 hour 180 mg/dl
  • 2 hours 155 mg/dl
  • 3 hour 140 mg/dl
Criteria for diagnosis of gestational diabetes according to Indian National Diabetes Data group:
  • Fasting 105 mg/dl
  • 1 hour 190 mg/dl
  • 2 hours 165 mg/dl
  • 3 hour 145 mg/dl

Risk factors

Classical risk factors for developing gestational diabetes are:
  • Polycystic Ovary Syndrome
  • A previous diagnosis of gestational diabetes or prediabetesimpaired glucose tolerance, or impaired fasting glycaemia
  • family history revealing a first-degree relative with type 2 diabetes
  • Maternal age - a woman's risk factor increases as she gets older (especially for women over 35 years of age).
  • Ethnicity (those with higher risk factors include African-AmericansAfro-CaribbeansNative AmericansHispanicsPacific Islanders, and people originating from South Asia)
  • Being overweightobese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively.
  • A previous pregnancy which resulted in a child with a macrosomia (high birth weight: >90th centile or >4000 g (8 lbs 12.8 oz))
  • Previous poor obstetric history
  • Other genetic risk factors: There are at least 10 genes where certain polymorphism are associated with an increased risk of gestational diabetes, most notably TCF7L2.
In addition to this, statistics show a double risk of GDM in smokersPolycystic ovarian syndrome is also a risk factor, although relevant evidence remains controversial. Some studies have looked at more controversial potential risk factors, such as short stature.
About 40-60% of women with GDM have no demonstrable risk factor; for this reason many advocate to screen all women. Typically, women with GDM exhibit no symptoms (another reason for universal screening), but some women may demonstrate increased thirst, increased urinationfatiguenausea and vomitingbladder infectionyeast infections and blurred vision.

Prevention

Theoretically, smoking cessation may decrease the risk of gestational diabetes among smokers.
Physical exercise has not been found to have a significant effect of primary prevention of gestational diabetes in randomized controlled trials. It may be effective as tertiary prevention for women who have already developed the condition.

Pathophysiology

The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is increased insulin resistance. Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to the insulin receptor. The interference probably occurs at the level of the cell signaling pathway behind the insulin receptor. Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin is needed to overcome this resistance; about 1.5-2.5 times more insulin is produced than in a normal pregnancy.
Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which in cases of GDM progresses thereafter to levels seen in a non-pregnant person with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance that they cannot compensate for with increased production in the β-cells of the pancreas. Placentalhormones, and to a lesser extent increased fat deposits during pregnancy, seem to mediate insulin resistance during pregnancy. Cortisoland progesterone are the main culprits, but human placental lactogenprolactin and estradiol contribute, too. Multivariate stepwise regression analysis reveals that, in combination with other placental hormones, leptin, tumor necrosis factor alpha, and resistin are involved in the decrease in insulin resistance occurring during pregnancy, with tumor necrosis factor alpha named as the strongest independent predictor of insulin sensitivity in pregnancy. An inverse correlation with the changes in insulin sensitivity from the time before conception through late gestation accounts for about half of the variance in the decrease in insulin sensitivity during gestation: in other words, low levels or alteration of TNF alpha factors corresponds with a greater chance of, or predisposition to, insulin resistance or sensitivity. GABBE,STEVEN G; sixth Edition page 890.
It is unclear why some women are unable to balance insulin needs and develop GDM; however, a number of explanations have been given, similar to those in type 2 diabetes:autoimmunity, single gene mutations, obesity, along with other mechanisms.
Though the clinical presentation of gestational diabetes is well characterized, the biochemical mechanism behind the disease is not well known. One proposed biochemical mechanism involves insulin-producing β-cell adaptation controlled by the HGF/c-MET signaling pathway. β-cell adaption refers to the change that pancreatic islet cells undergo during pregnancy in response to maternal hormones in order to compensate for the increased physiological needs of mother and baby. These changes in the β-cells cause increased insulin secretion as a result of increased β-cell proliferation. HGF/c-MET has also been implicated in β-cell regeneration, which suggests that HGF/c-MET may help increase β-cell mass in order to compensate for insulin needs during pregnancy. Recent studies support that loss of HGF/c-MET signaling results in aberrant β-cell adaptation.
c-MET is a receptor tyrosine kinase (RTK) that is activated by its ligand, hepatocyte growth factor (HGF), and is involved in the activation of several cellular processes. When HGF binds c-MET, the receptor homodimerizes and self-phosphorylates to form an SH2 recognition domain. The downstream pathways activated include common signaling molecules such as RAS and MAPK, which affect cell motility, cell motility, and cell cycle progression.
Studies have shown that HGF is an important signaling molecule in stress related situations where more insulin is needed. Pregnancy causes increased insulin resistance and so a higher insulin demand. The β-cells must compensate for this by either increasing insulin production or proliferating. If neither of the processes occur, then markers for gestational diabetes are observed. It has been observed that pregnancy increases HGF levels, showing a correlation that suggests a connection between the signaling pathway and increased insulin needs. In fact, when no signaling is present, gestational diabetes is more likely to occur.
The exact mechanism of HGF/c-MET regulated β-cell adaptation is not yet known but there are several hypothesizes about how the signaling molecules contribute to insulin levels during pregnancy. c-MET may interact with FoxM1, a molecule important in the cell cycle, as FOXM1 levels decrease when c-MET is not present. Additionally, c-MET may interact with p27 as the protein levels increase with c-MET is not present. Another hypothesis says that c-MET may control β-cell apoptosis because a lack of c-MET causes increases cell death but the signaling mechanisms have not been elucidated.
Although the mechanism of HGF/c-MET control of gestational diabetes is not yet well understood, there is a strong correlation between the signaling pathway and the inability to produce an adequate amount of insulin during pregnancy and thus it may be the target for future diabetic therapies.
Because glucose travels across the placenta (through diffusion facilitated by GLUT1 carrier), which is located in the syncytiotrophoblast on both the microvillus and basal membranes, these membranes may be the rate-limiting step in placental glucose transport. There is a two- to three-fold increase in the expression of syncytiotrophoblast glucose transporters with advancing gestation. Finally, the role of GLUT3/GLUT4 transport remains speculative. If the untreated gestational diabetes fetus is exposed to consistently higher glucose levels, this leads to increased fetal levels of insulin (insulin itself cannot cross the placenta). The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia). After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia).

Screening

WHO diabetes diagnostic criteria
Condition2 hour glucoseFasting glucoseHbA1c
Unitmmol/l(mg/dl)mmol/l(mg/dl)mmol/molDCCT %
Normal<7.8 (<140)<6.1 (<110)<42<6.0
Impaired fasting glycaemia<7.8 (<140)≥6.1(≥110) & <7.0(<126)42-466.0–6.4
Impaired glucose tolerance≥7.8 (≥140)<7.0 (<126)42-466.0–6.4
Diabetes mellitus≥11.1 (≥200)≥7.0 (≥126)≥48≥6.5
Tests for gestational diabetes
Non-challenge blood glucose test
  • Fasting glucose test
  • 2-hour postprandial (after a meal) glucose test
  • Random glucose test
Screening glucose challenge test
Oral glucose tolerance test (OGTT)
A number of screening and diagnostic tests have been used to look for high levels of glucose inplasma or serumin defined circumstances. One method is a stepwise approach where a suspicious result on a screening test is followed by diagnostic test. Alternatively, a more involved diagnostic test can be used directly at the first antenatal visit for a woman with a high-risk pregnancy. (for example in those with polycystic ovarian syndrome or acanthosis nigricans).
Non-challenge blood glucose tests involve measuring glucose levels in blood samples without challenging the subject with glucose solutions. A blood glucose level is determined when fasting, 2 hours after a meal, or simply at any random time. In contrast, challenge tests involve drinking a glucose solution and measuring glucose concentration thereafter in the blood; in diabetes, they tend to remain high. The glucose solution has a very sweet taste which some women find unpleasant; sometimes, therefore, artificial flavours are added. Some women may experience nausea during the test, and more so with higher glucose levels.

Pathways

Opinions differ about optimal screening and diagnostic measures, in part due to differences in population risks, cost-effectiveness considerations, and lack of an evidence base to support large national screening programs. The most elaborate regimen entails a random blood glucose test during a booking visit, a screening glucose challenge test around 24–28 weeks' gestation, followed by an OGTT if the tests are outside normal limits. If there is a high suspicion, a woman may be tested earlier.
In the United States, most obstetricians prefer universal screening with a screening glucose challenge test. In the United Kingdom, obstetric units often rely on risk factors and a random blood glucose test. The American Diabetes Association and the Society of Obstetricians and Gynaecologists of Canada recommend routine screening unless the woman is low risk (this means the woman must be younger than 25 years and have a body mass index less than 27, with no personal, ethnic or family risk factors) TheCanadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening. The U.S. Preventive Services Task Forcefound there is insufficient evidence to recommend for or against routine screening.
Some pregnant women and careproviders choose to forgo routine screening due to the absence of risk factors, however this is not advised due to the large proportion of women who develop gestational diabetes despite having no risk factors present and the dangers to the mother and baby if gestational diabetes remains untreated.

Non-challenge blood glucose tests

When a plasma glucose level is found to be higher than 126 mg/dl (7.0 mmol/l) after fasting, or over 200 mg/dl (11.1 mmol/l) on any occasion, and if this is confirmed on a subsequent day, the diagnosis of GDM is made, and no further testing is required. These tests are typically performed at the first antenatal visit. They are simple to administer and inexpensive, but have a lower test performance compared to the other tests, with moderate sensitivity, low specificity and high false positive rates.

Screening glucose challenge test

The screening glucose challenge test (sometimes called the O'Sullivan test) is performed between 24–28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). No previous fasting is required for this screening test, in contrast to the OGTT. The O'Sullivan test involves drinking a solution containing 50 grams of glucose, and measuring blood levels 1 hour later.
If the cut-off point is set at 140 mg/dl (7.8 mmol/l), 80% of women with GDM will be detected. If this threshold for further testing is lowered to 130 mg/dl, 90% of GDM cases will be detected, but there will also be more women who will be subjected to a consequent OGTT unnecessarily.

Oral glucose tolerance test

The OGTT should be done in the morning after an overnight fast of between 8 and 14 hours. During the three previous days the subject must have an unrestricted diet (containing at least 150 g carbohydrate per day) and unlimited physical activity. The subject should remain seated during the test and should not smoke throughout the test.
The test involves drinking a solution containing a certain amount of glucose, usually 75 g or 100 g, and drawing blood to measure glucose levels at the start and on set time intervals thereafter.
The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes.
The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:
  • Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
  • 1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
  • 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
  • 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)
An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify fewer women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test.
The glucose values used to detect gestational diabetes were first determined by O'Sullivan and Mahan (1964) in a retrospective cohort study (using a 100 grams of glucose OGTT) designed to detect risk of developing type 2 diabetes in the future. The values were set using whole blood and required two values reaching or exceeding the value to be positive. Subsequent information led to alterations in O'Sullivan's criteria. When methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed.

Urinary glucose testing

Women with GDM may have high glucose levels in their urine (glucosuria). Although dipstick testing is widely practiced, it performs poorly, and discontinuing routine dipstick testing has not been shown to cause underdiagnosis where universal screening is performed. Increased glomerular filtration rates during pregnancy contribute to some 50% of women having glucose in their urine on dipstick tests at some point during their pregnancy. The sensitivity of glucosuria for GDM in the first 2 trimesters is only around 10% and the positive predictive value is around 20%.

Management

The goal of treatment is to reduce the risks of GDM for mother and child. Scientific evidence is beginning to show that controlling glucose levels can result in less serious fetal complications (such as macrosomia) and increased maternal quality of life. Unfortunately, treatment of GDM is also accompanied by more infants admitted to neonatal wards and more inductions of labour, with no proven decrease incesarean section rates or perinatal mortality. These findings are still recent and controversial.
A repeat OGTT should be carried out 6 weeks after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised.
If a diabetic diet or G.I. Diet, exercise, and oral medication are inadequate to control glucose levels, insulin therapy may become necessary.
The development of macrosomia can be evaluated during pregnancy by using sonography. Women who use insulin, with a history of stillbirth, or with hypertension are managed like women with overt diabetes.

Lifestyle

Counselling before pregnancy (for example, about preventive folic acid supplements) and multidisciplinary management are important for good pregnancy outcomes. Most women can manage their GDM with dietary changes and exercise. Self monitoring of blood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy.
Any diet needs to provide sufficient calories for pregnancy, typically 2,000 - 2,500 kcal with the exclusion of simple carbohydrates. The main goal of dietary modifications is to avoid peaks in blood sugar levels. This can be done by spreading carbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources—known as the G.I. Diet. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more. Ingesting more fiber in foods with whole grains, or fruit and vegetables can also reduce the risk of gestational diabetes.
Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM.
Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low. Target ranges advised by the Australasian Diabetes in Pregnancy Society are as follows:
  • fasting capillary blood glucose levels <5.5 mmol/L
  • 1 hour postprandial capillary blood glucose levels <8.0 mmol/L
  • 2 hour postprandial blood glucose levels <6.7 mmol/L
Regular blood samples can be used to determine HbA1c levels, which give an idea of glucose control over a longer time period.
Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child.

Medication

If monitoring reveals failing control of glucose levels with these measures, or if there is evidence of complications like excessive fetal growth, treatment with insulin might be necessary. This is most commonly fast-acting insulin given just before eating to blunt glucose rises after meals. Care needs to be taken to avoid low blood sugar levels due to excessive insulin. Insulin therapy can be normal or very tight; more injections can result in better control but requires more effort, and there is no consensus that it has large benefits.
There is some evidence that certain oral glycemic agents might be safe in pregnancy, or at least, are less dangerous to the developing fetus than poorly controlled diabetes. The oral medication metformin is better than glyburide. While metformin and insulin if needed may be better than just insulin.
Metformin being available by mouth oral is preferred to injections. Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels.
Almost half of the women did not reach sufficient control with metformin alone and needed supplemental therapy with insulin; compared to those treated with insulin alone, they required less insulin, and they gained less weight. With no long-term studies into children of women treated with the drug, here remains a possibility of long-term complications from metformin therapy. Babies born to women treated with metformin have been found to develop less visceral fat, making them less prone to insulin resistance in later life.

Prognosis

Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy, if you had GDM in your first pregnancy, are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence.
Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women who needed insulin treatment, hadantibodies associated with diabetes (such as antibodies against glutamate decarboxylaseislet cell antibodies and/or insulinoma antigen-2), women with more than two previous pregnancies, and women who were obese (in order of importance). Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years. Depending on the population studied, the diagnostic criteria and the length of follow-up, the risk can vary enormously. The risk appears to be highest in the first 5 years, reaching a plateau thereafter. One of the longest studies followed a group of women from Boston, Massachusetts; half of them developed diabetes after 6 years, and more than 70% had diabetes after 28 years. In a retrospective study in Navajo women, the risk of diabetes after GDM was estimated to be 50 to 70% after 11 years. Another study found a risk of diabetes after GDM of more than 25% after 15 years. In populations with a low risk for type 2 diabetes, in lean subjects and in women with auto-antibodies, there is a higher rate of women developing type 1 diabetes.
Children of women with GDM have an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life. This risk relates to increased maternal glucose values. It is currently unclear how much genetic susceptibility and environmental factors each contribute to this risk, and if treatment of GDM can influence this outcome.
There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37962 women were reported to have GDM, and there was a tendency towards more breast and pancreatic cancer, but more research is needed to confirm this finding.

Complications

GDM poses a risk to mother and child. This risk is largely related to uncontrolled high blood glucose levels and its consequences. The risk increases with higher blood glucose levels. Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably.
The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit. Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic) in unmanaged GDM, and small for gestational age and Intrauterine growth retardation in managed GDM. Macrosomia in turn increases the risk of instrumental deliveries (e.g. forcepsventouse and caesarean section) or problems during vaginal delivery (such as shoulder dystocia). Macrosomia may affect 12% of normal women compared to 20% of women with GDM. However, the evidence for each of these complications is not equally strong; in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study for example, there was an increased risk for babies to be large but not small for gestational age in women with uncontrolled GDM. Research into complications for GDM is difficult because of the many confounding factors (such as obesity). Labelling a woman as having GDM may in itself increase the risk of having an unnecessary caesarean section.
Neonates born from women with consistently high blood sugar levels are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia). Untreated GDM also interferes with maturation, causing dysmature babies prone torespiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis.
Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown to be an independent risk factor for birth defects. Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy, whereas GDM gradually develops and is least pronounced during the first and early second trimester. Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations. A large case-control study found that gestational diabetes was linked with a limited group of birth defects, and that this association was generally limited to women with a higher body mass index (≥ 25 kg/m²). It is difficult to make sure that this is not partially due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy.
Because of conflicting studies, it is unclear at the moment whether women with GDM have a higher risk of preeclampsia. In the HAPO study, the risk of preeclampsia was between 13% and 37% higher, although not all possible confounding factors were corrected.

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