In case you missed it: Here are the top 5 posts this month

September was a very busy month with lots of good research papers and systematic reviews published on various topics. We also saw many guidelines and recommendations updates from ACOG, ASRM and USPSTF. Here are the top 5 most read posts for the month of September.

USPSTF simplifies cervical cancer screening recommendations: Dual testing no longer advised

The US Preventive Services Task Force (USPSTF) has issued new draft recommendations for cervical cancer screening with a major change that it recommends either cervical cytology (CC) or high-risk HPV (hrHPV) test as a screening procedure every 3 years for women aged 30-65 years, and not both ( Grade A)  

https://obgynupdated.blogspot.com/2017/09/uspstf-simplifies-cervical-cancer.html

ACOG issues clinical practice guidelines for Gestational Diabetes Mellitus

The American College of Obstetricians and Gynecologists (ACOG) has issued clinical practice guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM).

Although prevalence of GDM is directly proportional to prevalence of type 2 DM in a given population, it is estimated that GDM accounts for 90% of cases diabetes in pregnancy. The prevalence of DM in pregnancy is around 6-9%.

https://obgynupdated.blogspot.com/2017/09/acog-issues-clinical-practice.html

ASRM guidelines update: Metformin alone is not the first line of treatment for ovulation induction in women with PCOS

Practice Committee of the American Society for Reproductive Medicine does not recommend Metformin alone for ovulation induction as a first line therapy in women with PCOS. The guidelines were published in Journal Fertility and Sterility Epub ahead of print.

Metformin is a biguanide used as an oral insulin lowering agent in type2 diabetes, but also used enthusiastically in women with PCOS because of shared pathophysiology of insulin resistance in both.

https://obgynupdated.blogspot.com/2017/09/asrm-guidelines-update-metformin-alone.html

Oral Nifedipine parallels IV hydralazine in lowering down BP in acute hypertensive emergency in pregnancy

Intravenous hydralazine and oral nifedipine both exhibit the same efficacy in lowering the blood pressure in acute hypertensive emergency of pregnancy reports the results of small randomized trial published online in journal American Journal of Obstetrics and Gynecology.

https://obgynupdated.blogspot.com/2017/09/oral-nifedipine-parallels-iv.html

Oral diclofenac potassium plus cervical lidocaine cream eases the pain during hysterosalpingography

Oral diclofenac potassium tab 30 minutes before hysterosalpingography (HSG) and cervical lidocaine cream 5% significantly relieves pain and eases patient anxiety during the procedure and for half an hour after reports the results of a randomized trial published in September issue of journal Fertility and Sterility.

https://obgynupdated.blogspot.com/2017/09/oral-diclofenac-potassium-plus-cervical.html 

ACOG issues clinical practice guidelines for Gestational Diabetes Mellitus

Courtesy: YouTube.

The American College of Obstetricians and Gynecologists (ACOG) has issued clinical practice guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM).

Although prevalence of GDM is directly proportional to prevalence of type 2 DM in a given population, it is estimated that GDM accounts for 90% of cases diabetes in pregnancy. The prevalence of DM in pregnancy is around 6-9%.

The prevalence of GDM globally is on the rise because of increasing obesity, delayed childbearing and sedentary lifestyle.

The document provides a brief overview of GDM, one of the most common complication of pregnancy, identifies the disease process, its diagnosis and management based on current research and identifies the lacunae for future research.

Screening for GDM is done by various methods and there is still no standardized method. ACOG supports the two-step process most commonly used in USA. It involves first screening with the administration of a 50-g oral glucose solution followed by a 1-hour venous glucose determination. 

Women whose glucose levels meet or exceed an institution’s screening threshold then undergo a 100-g, 3-hour diagnostic OGTT. Gestational diabetes mellitus is most often diagnosed in women who have two or more abnormal values on the 3-hour OGTT.

Other institutions and private practitioners use International Association of Diabetes and Pregnancy Study Group (IADPSG) recommended one step, universal 75-g, 2-hour OGTT to diagnose GDM.

The summary of recommendations by ACOG:

Recommendations based on good scientific evidence (Level A):

All women diagnosed with GDM should first be treated with adequate nutritional and exercise counselling, before starting any pharmacological treatment.

If lifestyle modifications fail to control glucose levels, Insulin is the first line of drug for controlling blood sugar in pregnancy.

Recommendations based on limited or inconsistent scientific evidence (Level B):

All pregnant women should be screened for GDM with a laboratory based blood glucose level testing.

Women who refuse to take insulin, or who are unable to safely administer insulin, metformin is a reasonable second-line choice.

Glyburide is not be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin.

All women should be counselled about limitations of safety data regarding oral hypoglycemic agents.

Women should also receive counselling regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 g or more.

Recommendations based primarily on consensus and expert opinion (Level C):

In the absence of clear evidence and comparative trials, no single value of blood glucose can be taken as cutoff over another for 1-hour glucose test nor one set of diagnostic criteria for the 3-hour OGTT can be clearly recommended over the other. Practitioners should select a single set of criteria and use it consistently with their patients.

Women should be advised dietary guidance and 30 minutes of moderate physical activity, 5 days a week or 150 minute/week.  

In women, whose GDM is well controlled by diet and exercise, delivery is not indicated before 39 weeks of gestation, in absence of other obstetric indication. She can be safely managed expectantly up to 40 6/7 weeks of gestation, with antepartum fetal surveillance.

In women, whose GDM is well controlled by medications, delivery is recommended at 39 0/7 to 39 6/7 weeks of gestation.

All women with GDM should be screened at 4–12 weeks postpartum to identify women with diabetes, impaired fasting glucose levels, or impaired glucose tolerance, with an appropriate referral to medical practitioner.

The American Diabetic Association (ADA) and ACOG recommend repeat testing every 1–3 years for women who had a pregnancy affected by GDM and normal postpartum screening test results.

Full Text 

Adverse pregnancy and neonatal outcomes seen in obese pregnant women even in the absence of chronic diseases.

According to a recent study published Ahead of Print in journal of obstetrics and gynecology, women who are obese have higher risk of adverse pregnancy and neonatal outcome.

The study was conducted as a retrospective cohort study using the medical records obtained from the Consortium on Safe Labor, from the year 2002-2008. 

Dr. Sung Soo Kim and her colleagues from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, examined records of singleton pregnancies among US women without any pre-pregnancy disease for obstetrics and neonatal complications based on prepregnancy BMI of mother.

The mothers were put into either of the 5 categories according to the BMI as normal weight (18.5-24.9 kg/m²), overweight (25-29.9), obese class I (30-34.9), obese class II (35-39.9), or obese class III (40 or greater).

The investigators looked in to 112,309 deliveries among 106,552 women.

The relative risk for developing gestational diabetes compared to normal weight women was 1.99 for overweight women, 2.94 for obese class I women, 3.97 for obese class II women, and 5.47 for obese class III women.

A similar risk profile was noted for gestational hypertensive disorders, gestational diabetes, cesarean delivery, and induction that increased in a dose response manner.

The neonatal risks also increase with increasing BMI like preterm birth at less than 32 weeks of gestation, large for gestational age (LGA), transient tachypnea, sepsis, and intensive care unit admission.

The percentage of LGA infants born to normal weight women was 7.9% that increased to 17.3% among obese class III women and relative risks increased to 1.52 (1.45-1.58), 1.74 (1.65-1.83), 1.93 (1.79-2.07), and 2.32 (2.14-2.52) as BMI category increased.

When all these adverse outcomes were grouped together and analyzed as a single composite variable, it was seen that obese women have a 18%-47% increased risk of any pregnancy complication than normal weight cohorts.

The researchers said “We found increased risks of relatively rare outcomes that other studies could not observe, including maternal acute cardiovascular events and neonatal transient tachypnea, necrotizing enterocolitis, peri- and intraventricular hemorrhage, and retinopathy of prematurity among deliveries to overweight or obese women.” 

References:

http://journals.lww.com/greenjournal/Abstract/publishahead/Obstetric_and_Neonatal_Risks_Among_Obese_Women.98718.aspx

Gestational Diabetes Mellitus Revisited

Gestational Diabetes Mellitus Revisited 

Today is world diabetes day. The International Diabetes Federation has released new data in support of its campaign against Diabetes quoting that “1 in 7 births is affected by gestational diabetes” and “One quarter of all births are affected by high blood glucose during pregnancy in South-East Asia.”

 This article is based on The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care.

• The International Diabetes Federation (IDF) estimates that one in six live births (16.8%) are to women with some form of hyperglycemia in pregnancy.

• While 16% of these cases may be due to diabetes in pregnancy (either preexisting diabetes—type 1 or type 2—which antedates pregnancy or is first identified during testing in the index pregnancy), the majority (84%) is due to gestational diabetes mellitus (GDM).

• The definition of GDM is still evolving.

• Hyperglycemia first detected at any time during pregnancy should be classified either as diabetes mellitus in pregnancy (DIP) or GDM.

• When the level of hyperglycemia first detected by testing at any time during the course of pregnancy meets the criteria for diagnosis of diabetes in the nonpregnant state, the condition is called DIP. Those criteria are:

      1) Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL); and/or

      2) 2-hour plasma glucose ≥11.1 mmol/L (200 mg/dL) following a 75-g oral glucose load; or

      3)Random plasma glucose ≥11.1 mmol/L (200 mg/dL) in the presence of diabetes   symptoms.

• DIP may either have been pre-existing diabetes (type 1 or type 2) antedating pregnancy, or diabetes first diagnosed during pregnanc.

• When hyperglycemia detected during routine testing in pregnancy (generally between 24 and 28 weeks) does not meet the criteria of DIP it is called GDM.

            To address the global burden of GDM, FIGO recommendations:

• Universal testing-- All pregnant women should be tested for hyperglycemia during pregnancy using a one-step procedure and FIGO encourages all countries and its member associations to adapt and promote strategies to ensure this.

• As per the recommendation of the IADPSG (2010) and WHO (2013), the diagnosis of GDM is made using a single-step 75-g OGTT when one or more of the following results are recorded during routine testing specifically between weeks 24 and 28 of pregnancy or at any other time during the course of pregnancy:

     1)Fasting plasma glucose 5.1−6.9 mmol/L (92−125 mg/dL);

     2)1-hour post 75-g oral glucose load ≥10 mmol/L (180 mg/dL);

     3)2-hour post 75-g oral glucose load 8.5–11.0 mmol/L(153−199 mg/dL)

• Asian Indians are considered to be at the highest risk of gestational diabetes. Based on studies from India and keeping in mind the already high burden and rising prevalence of diabetes and the realities of resource constraints within the health system in India, as well as the high rate of deliveries (27 million each year), the Diabetes in Pregnancy Study Group in India (DIPSI) developed the following guideline for diagnosis of GDM in the community. This guideline has been endorsed by the Ministry of Health, Government of India, the Federation of Obstetrics and Gynecological Societies of India (FOGSI), and the Association of Physicians of India (API)
• For Asian Indians Testing for GDM is recommended twice during prenatal care. The first testing should be done during first prenatal contact as early as possible in pregnancy. The second testing should be done ideally during 24−28 weeks of pregnancy if the first test is negative. If women present beyond 28 weeks of pregnancy, only one test is to be done at the first point of contact.

• The management of GDM should be in accordance with available national resources and infrastructure even if the specific diagnostic and treatment protocols are not supported by high-quality evidence, as this is preferable to no care at all.

• Life style modification is the corner stone in management of DIP and GDM.

• Nutritional therapy includes an individualized food plan to optimize glycemic control. Medical nutritional therapy in pregnancy can be described as “a carbohydrate-controlled meal plan that promotes adequate nutrition with appropriate weight gain, normoglycemia, and the absence of ketosis.

• Daily energy intake of approximately 2050 calories (minimum of 175 g carbohydrates/day) in all BMI categories in women with GDM was reported to reduce weight gain, maintain euglycemia, avoid ketonuria, and achieve average birth weights of 3542 g.

• Oral antidiabetic agents  Insulin, glyburide, and metformin are safe and effective therapies for GDM  during the second and third trimesters, and may be initiated as first-line treatment after failing to achieve glucose control with lifestyle modification. Among OADs, metformin may be a better choice than glyburide.

• Insulin should be considered as the first-line treatment in women with GDM who  are at high risk of failing on OAD therapy, including some of the following factors

       • Diagnosis of diabetes <20 weeks of gestation

             • Need for pharmacologic therapy >30 weeks

       • Fasting plasma glucose levels >110 mg/dL

       • 1-hour postprandial glucose >140 mg/dL

       • Pregnancy weight gain >12 kg

• The postpartum period is crucial, not only in terms of addressing the immediate perinatal problems, but also in the long term for establishing the basis for early preventive health for both mother and child, who are at a heightened risk for future obesity, metabolic syndrome, diabetes, hypertension, and cardiovascular disorders.

• Progression to diabetes is more common in women with a history of GDM compared with those without a GDM history. 
• Both “intensive lifestyle” and metformin have been shown to be highly effective in delaying or preventing diabetes in women with IGT and a history of GDM.

• The current EBCOG proposal is to screen women with a history of GDM at 6−12 weeks postpartum using the 2-hour 75-g OGTT with nonpregnancy diagnostic criteria. Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years.

     References:

• http://www.ijgo.org/article/S0020-7292%2815%2930033-3/pdf

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