alexa The Challenge to Deliver Cost Effective Care for Patients with Gestational Diabetes Mellitus | Open Access Journals
ISSN: 2161-038X
Reproductive System & Sexual Disorders: Current Research
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

The Challenge to Deliver Cost Effective Care for Patients with Gestational Diabetes Mellitus

Julie A Quinlivan1,2,3*

1Department of Obstetrics and Gynaecology, Joondalup Health Campus, Joondalup, WA, Australia

2Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia

3Women’s and Children’s Medical Research Institute, University of Adelaide, Adelaide, SA, Australia

*Corresponding Author:
Professor Julie A Quinlivan
Suite 106 Private Consulting Suites
Joondalup Health Campus
Shenton Avenue Joondalup WA 6027, Australia
Tel: 61-8-94009400
E-mail: [email protected]

Received date: August 12, 2014; Accepted date: August 27, 2014; Published date: September 03, 2014

Citation: Quinlivan JA (2014) The Challenge to Deliver Cost Effective Care for Patients with Gestational Diabetes Mellitus. Reprod Syst Sex Disord 3:144. doi:10.4172/2161-038X.1000144

Copyright: © 2014 Quinlivan JA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Reproductive System & Sexual Disorders: Current Research

Abstract

The global rise in obesity and gestational weight gain, along with recent trials demonstrating improved pregnancy and neonatal outcomes associated with the treatment of mild hyperglycaemia, have resulted in a clinical challenge to deliver cost effective healthcare to manage the epidemic of Gestational Diabetes Mellitus (GDM). Whilst clinicians now have clear criteria by which to diagnose GDM, and the glycaemic targets to achieve, less clear are the pathways to achieve these outcomes in a cost effective manner. The value of using allied health providers such as dieticians compared to less trained patient educators, the effectiveness of individualised versus group dietician counselling, the role of antenatal investigations such as CTG and ultrasound, the degree of monitoring of maternal blood sugar level, the type of medications to complement dietary therapy, along with policies on delivery and postnatal care, all need to be refined through studies or audits. Having identified the problem and established diagnostic and treatment targets, the next challenge is to provide evidence-based, cost-effective care.

Keywords

Gestational diabetes mellitus; Gestational weight gain; Pregnancy; Cost effective; Public health

Mini-review

The rising tide of global obesity and diabetes has seen Gestational Diabetes Mellitus (GDM) assume increasing public health significance. More than a third of pregnant women in the developed world present for care with a body mass index consistent with overweight or obesity [1-3]. Many pregnant women also have gestational weight gain in excess of Institute of Medicine recommendations [1-4]. These changes have seen global rates of GDM soar.

Until recently, the diagnosis and management of GDM was based upon expert opinion. Following publication of the hypoglycaemiaand Adverse Pregnancy Outcomes (HAPO) trial in 2008, it became possible to conduct trials and evaluate clinical service against outcomes that could be directly linked to pregnancy hyperglycaemia [5].

The HAPO trial of 23,316 women documented clear associations between hyperglycaemia at 24-28 weeks gestation and adverse maternal and neonatal outcomes [5]. Results revealed a continuum across which glycaemia levels were associated with adverse outcomes. In the absence of a categorical cut off, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) panel recommended the diagnostic criteria should be blood sugar levels that were associated with an odds ratio of 1.75 for producing adverse outcomes compared to mean glucose levels [6].

Whilst no trial has specifically utilised these cut off points, randomised trials of intervention in women with mild hyperglycaemia in pregnancy have documented a broad range of benefits including reductions in birth weight >90th centile, caesarean section, neonatal hypoglycaemia and cord C-peptide >90th centile [7-9].

Following an evaluation of data from available trials, authorities recommended new criteria to diagnose GDM (Table 1). These targets are based upon blood sugar levels following a 75 g Oral Glucose Tolerance Test (OGTT) performed between 24-28 weeks gestation. Treatment targets have also been refined in line with results from these published trials and expert opinion (Table 2)[7-11].

New diagnostic criteria for Gestational Diabetes*
Fasting Blood Sugar Level (BSL): >5.0 mmol/l
1-hour BSL: >10mmol/l
2-hour BSL: >8.4mmol/l *Cut off points following a 75 gram oral glucose tolerance test performed between 24-28 weeks pregnancy
*One or more must be abnormal for a diagnosis of GDM

Table 1: Diagnosis of Gestational Diabetes Mellitus

New treatment targets for Gestational Diabetes
Fasting Blood Sugar Level (BSL): <5.1 mmol/l
1-hour BSL: <7.5 mmol/l
2-hour BSL: <6.8 mmol/l

Table 2: Treatment targets for Gestational Diabetes Mellitus

Unfortunately, achieving consensus in the diagnosis and treatment targets for GDM is only the starting point. Clinicians now face the challenge to deliver care for women whose pregnancy is complicated with GDM so that therapeutic outcomes are achieved in a cost effective way.

Since the aim of care is to achieve glycaemic control, dietary interventions are key. However, dietary interventions range in price. The cheapest models provide women with a written pamphlet. The next step up would be models of care where a patient educator provides patients with written information and dietary counselling, through to group sessions with a qualified dietician, to repeated individualised sessions with a dietician at the extreme price range. The cost of these interventions ranges from US$1 to US$300 per patient [2]. A direct comparison of the relative efficacy of these differing approaches, with other factors controlled, has not occurred.

The next question is drug therapy. Fortunately, nearly 70% of patients with GDM can be managed with dietary intervention alone. However, the remaining patients require medication. Until recently this was exclusively administered as insulin, but in recent years Metformin has been substituted for insulin with comparable outcomes [12,13]. However, patients with high blood sugar levels usually benefit from insulin or combined therapy [13].

The type of monitoring required in pregnancy complicated by GDM is also unclear. Fetal cardiotocography and ultrasound have been utilised to manage pregnancy but their ‘value add’ in management is unclear [7-9].

Likewise, the ideal time to deliver patients whose pregnancy is complicated by GDM is subjected to debate. When fetal compromise is present, timing of delivery is dependent upon fetal factors. However, it is less clear whether a pregnancy complicated by GDM but subsequently managed with good glycaemic control and normal fetal growth should warrant induction or be left to await natural labour.

Postnatal management is also diverse. Some centers monitor babies for 48 hours with serial blood sugar levels whilst others are happy for expedited discharge.

Strangely the one intervention that has a substantiated evidence base, a postnatal OGTT performed between 6-12 weeks postpartum to detect women with type 2 diabetes, seems to slip through the practice net. Studies show up to 16% and 6% of women with GDM will have ongoing glucose intolerance or type 2 diabetes respectively by three months postpartum. Therefore, this patient population represents a cohort where early diagnosis and intervention could achieve benefits in terms of long term chronic disease morbidity [14]. Yet follow up is inconsistent [15].

Clinicians need to streamline the management of GDM to ensure interventions are effective and efficient. Streamlined pathways are required to deliver dietary advice, monitor glycaemia and monitor fetal wellbeing without undue intervention secondary to antenatal tests and labour induction.

These are the next wave of challenges for clinicians.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • International Conference on Gynecology and Obstetrics Pathology
    October 23-24, 2017 Orlando, USA
  • 5th International Conference on HIV/AIDS, STDs and STIs
    Nov 13-14, 2017, Las Vegas, Nevada, USA

Article Usage

  • Total views: 11568
  • [From(publication date):
    December-2014 - Oct 21, 2017]
  • Breakdown by view type
  • HTML page views : 7800
  • PDF downloads :3768
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

[email protected]

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

[email protected]ine.com

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

[email protected]

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords