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Foreign. Diabetes. Diabetes. Diabetes. Diabetes. Diabetes. Diabetes. Diabetes. Thank you, Wilford. Diabetes. Y' all remember that old guy, big mustache, sweet as can be. I mean, like your typical prototypical American grandpa, right? That was Wilford Brimley. But he took so much heat with his, you know, Diabetes. Diabetes. I'd like to talk to you about diabetes. Okay, fine. For a long time before I went to medical school, I thought it was called diabetes. It's actually diabetes. So regardless of whether you say diabetes or diabetes or like you have some. I have rural patients in the state of Texas. I mean like rural, rural country. And I love it. I mean, somebody's mother will come in and go, are you, you know, you're taking care of my daughter for her pregnancy? You know, are you gonna check her for the sugar? I'm like, well, what kind of sugar? Like granulated sugar, white sugar, brown sugar? What are we talking about here? Oh, you mean the diabetes. Yes, I will check her for the diabetes. But one thing we can agree on, whether it's diabetes or diabe that was so dumb, or diabetes, is that at Least in the US, BMIs and weights are kind of on the increase in general. I'm not trying to be mean to anyone, but in general, BMIs and patients weights are on the upswing. Surprise. I mean, we've known that for a while. It's just the way it is. And there's a variety of reasons for that. But because of that there's been increased calls for universal screening for pre existing diabetes in early pregnancy. Okay. Now especially under 20 weeks, where there's a chance to get in early. I mean, if they first present at 20 weeks, I mean, my goodness, you're just going to follow them up in four weeks to get their routine screening at 24 weeks anyway. So ideally they would come in under 20 weeks, or as in the publication that we're going to cover today, under 16 weeks to do a screen for diabetes. Now remember, diabetes found early on, before 24 weeks, and especially under 16 weeks in general, the pregnancy can't be blamed for that because human placental lactogen, as far as we know, doesn't really start to increase until after 20 weeks. So if they've got the diabetes in the first part of pregnancy, it's probably because they've got the diabetes, it's not the pregnancy that's doing that. So there is this call for a universal screening. Just they come in, if they're unusual, under 20 weeks, check them somehow, which is what we're going to talk about for everybody, however, right Now, ACOG does not say universal screen early. It says you can screen those with additional risk factors like a prior history of GDM, prior macrosomia, if their BMI is greater than 30, so classed as obesity, if they have a history of PCOS or a first degree relative with diabetes or they they're over the age of 40 because there's an increase insulin resistance, of course, as we all age then in those you could screen for pre existing diabetes before 20 weeks. That is ACOG stand. So it does say, hey, we don't really know what the best way to do that is. But especially for those with risk factors, you can do it, but not universal. So there is that debate. We're going to get into that. The debate is should we do universal or only do early screening those with risk factors. I'm a universal guy, why not? It's a low risk test and it can help with some kind of patient education and some kind of strategy for triage like we're going to discuss in this episode. Now, let me be very clear, it is very gray and we'll get into some of the specifics after the break. After the intro. There are some, some inconsistencies in the data or whether treating early diabetes so found, you know, in the first part of pregnancy, in the early part of pregnancy is that actually has a big impact in maternal and neonatal outcomes. We're going to give you that data, but I don't want to give any false illusion here as of right now as a whole, as an aggregate, it doesn't really seem to really move the needle for big bad things either on the mom or the baby side, although there is some benefit in terms of trends. All right, so there is this study that came out that showed, hey, if you've diagnosed it early and you get on top of it early, it can have a decreasing trend in that pregnancy for large registration age macrosomia. Great. So nobody has said that it hurts to check early. It's outside of the fact that they're checking their fingers, you know, finger sticks probably earlier on and maybe getting a little bit of anxiety. But it doesn't cause any physiological harm to make the diagnosis early. And potential can help, potentially can help, although the data is very unclear with the majority aggravate data saying probably not that big of a deal to find and diagnose it early. However, however it is an open discussion because not everybody agrees with that. There is a recent multicenter study that found that those randomized to early intervention, meaning before the standard 24 weeks those who were diagnosed as early GDM or as pre existing diabetics. If you get on top of it earlier, the babies tended to have a less respiratory depression, less respiratory distress at time of delivery. Now it wasn't like, you know, they were intubated for weeks otherwise. I mean it was still a minor kind of benefit, but still it did show at least some minor benefit in terms of respiratory function if you got on top of it before the 24 week traditional scan. Traditional screen. Okay, so the point I'm making here is that there's a move for universal screening for pre existing diabetes early on as long as they're under 20 weeks, whereas others use risk factors. ACOG right now says we should probably do that with risk factors, but not everybody agrees. There's also controversy if finding it early helps. But there seems to be a trend that it doesn't hurt outside of the maybe the cost of supplies, a little bit of anxiety, it doesn't cause any physiological, you know, negative impact and potentially could help. So that's what we're going here because there's a brand new publication out of the gray journal, hasn't officially come out yet. It was released ahead of print as a clinical opinion. So let me say that right here and we're going to say that again after the intro. This is not a guidance recommendation, but I'm covering this because they very nicely use the evidence at hand to kind of make a very nice algorithm which we're gonna cover very briefly here, guys. And the pitch for why we really should do universal screen on every prenatal visit patient when they arrive, ideally at or under 16 weeks. All right, so yes, these authors who are doing this clinical opinion on early screening as universal method for detection of impaired glucose tolerance in the first part of pregnancy, they're given a very nice proposal of what to do and how to test them based on their clinical opinions. So I'll be very clear. This is not smfm, it's not the Royal College of OBGYN from Canada, it's not sogc, I mean from the UK or SOGC from Canada. This is just great authors from Rochester from Montefiore. I've got great friends in Montefiore and also at Thomas Jefferson University. It's their interpretation of the data and making the pitch for we should really check universally before 16 weeks because patients BMIs are bigger. Okay. And they're gonna have some impaired glucose tolerance and we should probably get on top of that overall just for tuning up the body for pregnancy. Now that's my whole stance there. I agree with that. Whether it makes a big dent in maternal or neonatal outcomes, that's controversial maybe. No, but in tuning them up, they're just going to feel better. It can probably help a downward trend of large registrational age macrosomia. So something for you to consider if you want to wait until 24 to 28 weeks for a traditional screen. Nothing wrong with that. And we're going to talk about that in this episode. Which one you should do and which scale you should use for that interpretation though we've covered that many times before. We are going to get into that and you can just wait, that's fine. But again, there is a move and ACOG does say that in those with risk factors it is reasonable to screen them early for pre existing diabetes. The question is how should we do that? Because in ACOG's latest update, which was July of 2024 on screening for gestational diabetes, they said, yeah, it's fine, you should probably check in those with risk factors for pre existing diabetes. But we don't really know the best way to do that. Some use a hemoglobin A1C, some use a fasting plasma glucose as 126 or more as diagnostic of diabetes. Some use a glucose tolerance test with a two hour value greater than 200. We don't really know what the best one is. Well, these authors now kind of go through additional data and kind of give a proposal that I like. I think this is reasonable. I think it's also okay to wait till 24 to 28 weeks, but the needle is moving towards earlier screening, especially for those with risk factors. Or, or like these authors say, universal. So you don't miss anybody. Right? Just do a universal. And I'm gonna tell you what they recommend as a universal screen. So that's what we're gonna cover. We're gonna cover this brand new publication from the American Journal of Obgyn that has to do with this new proposal. A new way of looking at either pre existing diabetes, early gestational diabetes or traditional gestational diabetes. And I'm gonna tell you what those mean in this episode after the intro. So should you screen early? Sure. ACOG says it's reasonable with risk factors. These authors say, forget the risk factors, just do it. Universally there seems to be some benefit in terms of trending for better outcomes, not real outcomes, but trending for better outcomes. So I think it's fascinating, it's a good topic. I think I've set it up enough. Let's get out of the intro and we'll start talking about diabetes. That's diabetes to you and me. We'll be right back. This is Dr. Chapas, OB GYN, clinical pearls, no Spin podcast. Good morning, I'm Wilford Brimley and I'd like to talk to you for a few minutes about diabetes. I don't know why that went so like viral before viral was a thing while I talked to you about diabetes. I don't, I mean it wasn't like a comedy thing, it was a very serious discussion. Wilford Brinley had diabetes and he wanted to educate people and he was like the spokesperson for kind of for diabetes awareness. But I don't know, I just, he just said it's so daggone weird that it just kind of everyone focused on the diabetes versus the message. All right, none of that. I think we're done with that now. So as a reminder, July 2024. July 2024, that was when ACOG released its update on GDM and there were four big items. So we're going to start there just as a recap, just as a refresher to loosen up the cobwebs up in the cerebellum. Cerebellum? Yeah, cerebrum. No cerebellum. No cerebellum. So here we go. Number one, the first thing that it reminded us was that ACOG recommends a two step screening for GDM. Two step screening, in other words, 50 gram followed by a 100 gram. That's the first thing it reminded us. Although they did say based on some practices and some patient preferences, the 1 step 75 gram can be done. But ACOG does prefer the 2 step process 1 hour with the 50 gram, then the 3 hour as a 100 gram including a fasting value. Because the 1 step 75 gram tends to over call without really changing any having any neonatal benefit. Okay. The second thing is that it reminded us in July of 2024 that with the two step process there are two diagnostic scales. Remember there's a carbon Trcostin which is a little bit lower and then the National Diabetic Data Group which is about in general 10 points higher than Carpenter Costin. ACOG now recommends the lower threshold. Carpenter Costin versus National Diabetic Data Group. Now in the past, before July 2024 it was like, hey, just stick with one, just be consistent, whatever, it's up to you. But no, the data really does show there are some improved outcomes being tighter in the diagnostics. So a 1 hour for example, should use a cutoff of 130 on the carbon diocostin and then the 3 hour 100 gram should follow the lower cutoffs. And for again the same scale of the carbon diokostin criteria number three. The third thing it reminded us in July of 2024 is that it now is reasonable to do an immediate postpartum glucose tolerance test, a 75 gram glucose challenge and see what that looks like at the fasting and the two hour value before hospital discharge. But ideally after 24 hours because human placental lactogen in general is, has a big decline within the first 24 hours of delivery. So as an alternative to waiting for four or whatever, you know, eight weeks after she delivers to do a repeat screen. You can do an immediate screen and if it's negative it's very reassuring. And if it's positive, the positive value is not as great. So they will need a repeat screening as well. So it made, it opened up the door for immediate postpartum testing. We do that in our institution using a 75 gram oral glucose tolerance test. And remember that this 75 gram is the non pregnant scale. So in other words, a fasting value of greater than 126 is really off. That's diabetic. And then a two hour value after 75 gram of greater than 200 is definitely diabetes. That's a fail. Okay, so remember to use while it's the same 75 gram test, it's the different scale than when they were in pregnancy at 24 to 28 weeks. All right. The scale used to diagnose GDM with a 75 gram glucose tolerance test has lower cutoffs because we want to prevent maternal hyperglycemia. But when they're not pregnant, a traditional 75 gram glucose challenge is a fasting value greater than 126 that is abnormal or the two hour value greater than 200 that is abnormal. Okay, that's diabetes. So remember, the 75 gram glucose tolerance test has one interpretation of lower values. And when done at 24 to 28 weeks, everybody good. Okay, so there's two scales for 75 grams glucose tolerance with a 24 to 28 weeks as one step being lower values than postpartum. Fine. That was the third thing that was in the July 2024 update. And then here it is guys, number four is exactly what we're talking about here. It stated if we're gonna do early screening, which we're not looking for GDM in this case, we're looking for pre existing diabetes, it is reasonable to do that if in those with additional risk factors, like we talked about in the intro. However, ACOG says we don't know if it really changes anything and we don't know the best way to do that. Although some have used hemoglobin A1C, we're going to talk about it. Some have used fasting blood sugar. We will talk about it. Or the 75 glucose tolerance test, which we have just talked about. Okay, so these authors from the Gray Journal, again from Rochester Medical, from Monte Fior and Thomas Jefferson from February 2026, say, look, with all this kind of uncertainty, why don't we kind of make an algorithm? I'm gonna tell you what to do here so that we can get on top of this early, since basically Americans are getting fatter. Okay, they didn't really say that. They said it's a BMI issue. But, you know, it is what it is. So, yes, I'm all in favor for early screening. I am, and I like doing that. Universal ACOG right now says risk factors. But I'm with these authors. I think it's universal. And they have, they lay out a really nice plan here. Whether if we're going to do it universal before 20 weeks, then there's patients with risk factors, which means we're going to give them directly the 75 gram glucose tolerance test, or if they don't have risk factors, we can screen them with hemoglobin A1C and then the algorithm will branch based on each of those. All right, so that's what we're going to get into here. So unlike ACOG, which calls for selective screening before 20 weeks in those with risk factors, these authors say, let's just do it for everybody. But how we do that will depend on whether or not they have risk factors. With risk factors. Early 75 gram glucose tolerance test with a cutoff being greater than 126, fasting abnormal and greater than 200 as pre existing diabetes. And if it's normal, then they just get a routine screen like everywhere else. But if it's impaired glucose tolerance or frank diabetes, put them at least on diabetic checks, with diet, nutritional counseling, and then start medications as necessary. We're gonna break it down here in a minute. All right, we're gonna break it down in a minute. But the short thing I want you to remember right off the bat right here is that these authors are proposing universal screening. Again, that's at or under 16 weeks. And if they have risk factors, give them a glucose tolerance challenge. And I'm going to Tell you what to do based on each one of the possible results or if they don't have risk factors, just use hemoglobin A1C and I'm going to give you that branch of the algorithm based on those results. Okay, everybody good? Everybody with me? So, universal screen, either with or without risk factors. Either with the 75 gram challenge or with hemoglobin A1C. So let's start first, let's say they have no risk factors. Okay? No risk factors. And the patient presents, say at 14 weeks. Welcome aboard. Welcome to prenatal care. I'm gonna grab a hemoglobin A1C along with your routine initial enrollment ob labs. All right, so get a hemoglobin A1C. Because in early pregnancy, a hemoglobin A1C tends to not lose its validity later on. As pregnancy progresses, the hemoglobin amoet can get turned over quicker. So it's unclear know if hemoglobin A1C is that accurate. It may get chomped up earlier than usual, but under 20 weeks, the hemoglobin A1c has proven to have validity. All right, guys, so hemoglobin A1C is a pretty good screening tool, which ACOG recognizes as one of the options. So according to these authors, patients, no risk factors, universal screen, 16 weeks or less, get the hemoglobin A1C. Very easy. Let me knock out the three options here of what those results could be. Number one, if hemoglobin A1C is normal, remember, that's less than 5.7. All right, so less than 5.7 if it's normal, boom, you pass. We're going to do a routine screen at 24 to 28 weeks, check if it's borderline. So hemoglobin A1C is 5.7 up to 6.4. You're like, oh, that's called impaired glucose tolerance. Let's give them a 75 gram glucose tolerance. Tail test, tail test. Now let's work on this. Right, so it's borderline hemoglobin A1C. They get a challenge. If they fail that, like one of the values is off, then they get called early GDM and they're treated with diet, sugar checks and then meds are started as needed. Okay, so again, hemoglobin A1C normal nothing screen as usual, borderline early screen. And if they fail a value, you call them early gdm and then give them sugar checks, nutritional counseling and medications if needed based on these authors recommendation. Now, if they really fail that challenge, meaning the fasting is, you know, greater than 126 or the two hours greater than 200. Then you call them pre gestational diabetics. Remember, that is normal criteria for patients with diabetes anyway. And you give them treatment as if they were diabetic. Okay, so if you fail, how bad did you fail? If you really fail with the cutoffs that are diagnostic with or without pregnancy, then you treat them as pre gestational. And then the last option, of course, is that if they get the 75 gram challenge and they pass, well, then that's great. They move on to a regular screen at 24 to 28. All right, so let's recap. We're talking about universal screening at 16 weeks or less, no risk factors, hemoglobin A1C normal, go straight to 24 to 28. Borderline, you're going to get you a challenge. And if you pass, move on to 24 to 28. If you fail one of the values, then you're early gdm. And if you really fail, if you blow the test because it really sucks, fasting blood sugar greater than 26 or 2 hour greater than 200, you treat them as pre gestational diabetics. Okay, so that, all of that was when the hemoglobin A1C was borderline. All right, so borderline, get a challenge. Now, if the hemoglobin A1C is not normal and it's not borderline like we just talked about, if it's greater than 6.5, well, that's a no brainer. Hello. I mean, hemoglobin A1C of 6.5 and above is diagnostic of diabetes. Diabetes. So you treat them as a pre existing diabetic. All right, so that's it. We finished the universal screening under or at 16 weeks in patients with no risk factors. Remember, obesity is a risk factor. That's a lot of my patients. So mine wouldn't really fall into this. Mine would fall into with risk factors. I'm gonna tell you just about that in a minute. But for these authors who propose Universal screening under or at 16 weeks, hemoglobin A1C, if they have no risk factors, if it's normal, keep going. If it's borderline, give them a challenge and then treat them accordingly. And if the hemoglobin A1C is above 6.5, clearly they are already diabetic patients. Okay, now let's move on to universal screening with risk factors. Well, if they do have risk factors, these authors say, don't waste your time with hemoglobin A1C, they've already got some, some extra baggage. I mean, I don't mean that in a bad way, but I mean physiologic baggage on their system. Just give them straight challenge. And remember, the risk factors are as you would think. Obesity, advanced maternal age over 40, previous GDM diagnosis, previous macrosomia, first degree REL with GDM, some throw in there Native Americans or Hispanics just because of genetic influences. So it's pretty darn broad the list of risk factors. Okay, so if they have a risk factor, these authors say go straight to the 75 gram glucose tolerance test and treat them based on their results. So if they pass it early, then great, go on to 24 to 28 weeks knowing that you're gonna do a one step followed by a three step if needed. But at least they passed for now. If they fail badly again, that's a fasting greater than 126 or two hour greater than 200. That's just pre existing diabetes. But if they fail, but it's not grossly terrible, then you start sugar checks, you do nutritional counseling and you start medications as needed to keep their fasting blood Sugars ideally under 95 and a two hour postprandial under 100, 120. Okay, so isn't that easy? Isn't that nice? So as the US increases BMIs and weights, it is reasonable to either do screening for those with risk factors or like these authors say, universal, which I'm in that camp, just to do universal. And if those patients, if we agree we're going to do universal, then there's two ways to screen. If they have risk factors, just give them a challenge right away. 75 gram of glucose tolerance test. All right, guys, stick with me here. We're almost done. So that is if they've got risk factors. If they don't have risk Factors, use hemoglobin A1C and if it's totally normal, proceed to 24 to 28 weeks. If the hemoglobin A1C is greater than 6.5, clearly that's diabetic. And if it's anything borderline, then they get the 75 gram challenge and then you treat them accordingly. I like it. I like it. So here's a question. Does this really make a difference? Well, it's unclear and these authors are very open with that. We don't know. It is unclear if there's major benefits here for maternal and neonatal outcomes. But what they really hang on to, guys, is one really Good study. I mean it was well done. Out of the New England Journal of medicine in 2023, which was a multi center trial. Okay? Now this evaluated pregnancy outcomes comparing those screened early based on risk factors, let's be clear, and diagnosed using the one step method and who were treated compared to those who had standard testing and treatment at 24 to 28 weeks. They found less neonatal respiratory distress occurred when GDM was treated early compared to standard care with an odds ratio of 0.5. And the confidence interval was under 1. It was 0.3 to 0.7. All right, but it wasn't a major, it didn't, wasn't like a predictor prevention of stillbirth. It wasn't a big deal for shoulder dystocia. Really the benefit there, guys, was in respiratory distress and I'm not minimizing that, but it's not like the kid was on the vent for months. I mean it was maybe needed a little cpap, you know, oxygen, more than four hours. So it's a loose benefit. So and that's why it's okay if you don't want to screen early and you just want to do 24 to 28 weeks, that's okay too. But the needle is moving. Okay. This is very similar to our recent discussion on HPV in our last episode. You know, when HPV was starting to take the place of cytology. You know, I went to many conferences, guys, many conferences for education and they were like, well, I'm just taking, cytology is our standard. Well, guys, the needle was moving towards HPV and now look where we're at now. I mean, it's pretty much primary HPV screening and with genotyping and then molecular tests with dual stain with cytology thrown out of the mix. So it's kind of moving. All right. Right now there's, it's not going to move 24 to 28 weeks. That is solid. And ACOG recommends a two step process. But this issue of checking early as BMIs increase is reasonable and evidence based. So these authors, as we wrap this up, make the pitch for screening at or under 16 weeks. Over 16 weeks are like, just wait, man. I mean you're so Damn close to 24 weeks. Just WA. But ideally you get under 16 weeks and then those with risk factors, you go straight to the challenge. Test those without risk factors. You do a hemoglobin A1C. And I like their triage, which we have gone through piece by piece in this episode. All right, so there you go. Universal screen. Why not as long as they come in at or under 16 weeks. Hemoglobin A1C without risk factors. Do a 75 gram glucose challenge for those with risk factors and then treat them based on each respective result. Podcast Family as always, we're thankful for you. We're glad you're part of our podcast community. Thank you for your support. Thank you for all of your kind messages that have come in. And now that we've done all that and we've done talking about diabetes, Michael let's take it home right now. 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