Oral Presentation Australian Diabetes in Pregnancy Society 2018

Obstetrician perspective. (#19)

Ian Fulcher 1
  1. Liverpool Hospital and Bathurst Base Hospital, Liverpool, NSW, Australia

The juxtaposition of the new IADPSG diagnostic criteria, increasing maternal obesity, advancing age at conception and background ethnic predisposition to diabetes has led to a significant increase in women being diagnosed with gestational diabetes.

The HAPO Study published in 2008 has provided us with the largest database on fetal outcomes in pregnancies complicated by hyperglycaemia of varying degrees of severity.  On the basis of this the IADPSG recommended the formulation of new consensus guidelines for the diagnosis of GDM.

These recommendations were endorsed by WHO and ADIPS as well as ADS but not by SOMANZ or ESA. In November 2013 RANZCOG convened a multidisciplinary working party to discuss the proposed pathway and criteria for diagnosis of GDM. Although invited, representation from ESA and RACGP was declined. This meeting recommended:

  1. A single step OGTT at 24-28 weeks’ gestation
  2. Adoption of WHO-2013 diagnostic criteria by 1 Jan 2015.

The increased workload has led some Obstetricians to question the validity of the GTT cut-offs determined by a RR of 1.75 based on the HAPO data. The concerns expressed include:

  1. Crowded clinics may result in higher risk patients being overwhelmed by lower risk patients.
  2. Doctor fatigue may result in warning signs of adverse outcome being missed.
  3. Being labelled “lower risk“ may alter perception of risk and alter compliance accordingly.
  4. Input and advice in the step-down clinic may vary from the high -risk clinic.

Discussion points:

  1. Have the new guidelines led to significant improvement in fetal outcomes?
  2. Should we maintain Australian guidelines rather than adhere to international guidelines to improve our flexibility to respond to local issues?
  3. Should we define a high-risk algorithm including obesity and advancing maternal age and ethnicity to select those at greater risk to optimise provision of appropriate levels of care?