European Board and College of Obstetrics and Gynaecology

1. European Board and College of Obstetrics and Gynaecology Global Challenges of Hyperglycaemia in Pregnancy and its Sequelae Dr Tahir Mahmood CBE, MD, FRCPI, MBA, FACOG, FRCPE,FRCOG President EBCOG 19th May International session Antalya, Turkey Global Challenges 190517

2. EPIDEMIOLOGY OF OBESITY Australia 67% of women and 52% of men are obese (BMI >30) (2.5 fold rise in obesity over the last 20 years) USA Overall 61% population have a BMI >30 UK Overall >30 % population have a BMI >30 (Indian = 20%; Pakistani origin = 24%) Mahmood TA. Obesity and Pregnancy. Br J Diab Vasc Dis.2009; 9(1):1-4 Global Challenges 190517

3. Epidemic of Obesity • Trebled in England from 1980s to 2000 • In 2004 24% of adults obese • A further 35% women and 46% of men overweight • 14% of children between 2-10year obese Global Challenges 190517

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6. 67.0 99.4 48% 46.5 80.3 73% 0 Global Projections for the DiabetesEpidemic: 2007-2025 (millions) 53.2 64.1 21% 28.3 40.5 43% 24.5 44.5 81% 16.2 32.7 102% 10.4 18.7 80% Diabetes 2007 = 246 million 2025 = 380 million Increase 55% IGT 2007 = 309 million 2025 = 419 million Increase 36% IDF Atlas 2006 Global Challenges 190517 Diabetes Atlas, 3rd edition, IDF 2006

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8. ~130 million live births Global Challenges 190517

9. Type 2 diabetes • GDM during Pregnancy • high blood pressure • high cholesterol levels • coronary heart disease • congestive heart failure • angina pectoris • stroke • bladder control problems Problems of Obesity in Women- Non Communicable Diseases asthma osteoarthritis musculoskeletal disorders gallbladder disease sleep apnea and respiratory problems gout Pelvic Floor Dysfunction Global Challenges 190517

10. oblems • Increased Risk of Cancer • uterus • breast • kidney • liver • pancreas • esophagus • colon and rectum Problems of Obesity in Women-NCDs • Poor female Reproductive Health • Complications of pregnancy • menstrual irregularities • infertility (PCOS) • irregular ovulation • Contraception Issues In a study involving 90,000 obese women, increased risk of death has been reported (JAMA, 2006) Global Challenges 190517

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16. Hyperglycaemia During Pregnancy Global Challenges 190517

17. Types of hyperglycemia in pregnancy Global Challenges 190517

18. Intrauterine exposure to maternal hyperglycemia Fetal and neonatal complications in the short term Global Challenges 190517

19. GDM and Challenges for the European Obstetric practice • Comparison between countries is very difficult due to different diagnostic strategies for GDM and subpopulations • A contributing factor for the large variation in practices is probably the differing recommendations by international and local scientific organizations • Migrants, ethnic diversity and national health policies Global Challenges 190517

20. Post Partum Follow Up Global Challenges 190517

21. Type 2 diabetes aftergestational diabetes – a systematic review and meta-analysisBellamy, Lancet 2009; 373: 1773–79 • The risk of type 2 diabetes after GDM has increased over the last 25 years (Lauenborg et al, Diab Care 2004) • GDM vs. normoglycemia during pregnancy RR 7.43 for subsequent type 2 diabetes within 10 Years: 95% CI 4.79–11.51 Global Challenges 190517

22. Prevalence of the metabolic syndrome 10 years after GDM Adj. OR 3.4 (95% CI 2.5-4.8) N=481 N=1000 Lauenborg et al. JCEM 2005 Global Challenges 190517

23. Intra-Uterine Environments , intra-Generational Obesity and Diabetes are inter-linked Global Challenges 190517

24. In Utero Exposure to MaternalHyperglycemia IncreasesChildhood Cardiometabolic Riskin OffspringDiabetes Care 2017;40:679–686 | DOI: 10.2337/dc16-2397 Global Challenges 190517

25. Pre-Pregnancy Weight (>30 BMI) was associated with offspring behavioural problems such as Attention deficit (Incidence risk 3.3: 95%CI 1.7-4.9) Global Challenges 190517

26. EBCOG Response • Two Prong Approach • Set up a European Wide group to develop EBCOG Position for GDM Screening • Publish Standards of Care for Obstetric Practice- including Care of Obese Women during Pregnancy Global Challenges 190517

27. EBCOG Response • Two Prong Approach • Set up a European Wide group to develop EBCOG Position for GDM Screening • Publish Standards of Care for Obstetric Practice- including Care of Obese Women during Pregnancy Global Challenges 190517

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30. Standards of Care for Women’s Health in Europe EBCOG has developed Standards of Care for Obstetrics and Neonatal Services Gynaecology Services STANDARDS OF CARE The Standards of Care are intended to address variations and inequities in access to care. They will lead to a clearer understanding about what standards of treatment and care patients can,and should, expect. The Standards of Care focus on the safety, care, dignity and treatment of patients. They reflect the Care that a Health Service and prudent Healthcare Professional should provide in order to be effective and safe for the patient. Global Challenges 190517

31. Standards of Care for Women’s Health in Europe The following is the complete list of the STANDARDS for OBSTETRIC and NEONATAL SERVICES: • STANDARD 1 Generic Standards of Care for Maternity Services • STANDARD 2 Pre-Pregnancy Services • STANDARD 3 Early Pregnancy Emergency Services • STANDARD 4 Antenatal Care • STANDARD 5 Antenatal Screening • STANDARD 6 Care of Pregnant Women with Pre-existing Medical Conditions and/or • Special Needs • STANDARD 7 Care of Pregnant Women with Mental Health Conditions • STANDARD 8 Care of Women Developing Medical Conditions during Pregnancy • STANDARD 9 Care of Obese Pregnant Women • STANDARD 10 Prevention of Preterm Birth • STANDARD 11 Intrapartum Care • STANDARD 12 Infection Prevention and Control • STANDARD 13 Maternal Mortality and Morbidity associated with Childbearing • STANDARD 14 Post-natal Care of the Mother • STANDARD 15 Neonatal Care • STANDARD 16 Rationalising Care of Babies Born Prematurely • STANDARD 17 Supporting Families who Experience Pregnancy Loss • STANDARD 18 Routine Data Collection for Pregnancy and Childbirth Global Challenges 190517

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33. Standardised Antenatal care • Pre Pregnancy advice- awareness campaign • Higher dose of Folic Acid ( 5mg) in the peri-conceptual period • Smoking cessation • Early access to antenatal care for risk assessment • Access to protocol based antenatal care • Screening for congenital malformations • One Step GDM Screening • Monitoring foetal growth and wellbeing Global Challenges 190517

34. A Case for Universal one step GDM Screening FIGO Initiative supported by EBCOG Global Challenges 190517

35. FIGO Box – Universal Testing • FIGO adopts and supports the IADPSG / WHO / IDF/EBCOG position that all pregnant women should be tested for hyperglycemia during pregnancy using a one-step procedure. • FIGO encourages all countries and its member associations to adapt and promote strategies to ensure universal testing of all pregnant women for hyperglycemia during pregnancy. Global Challenges 190517

36. FIGO Box – GDM management FIGO recognizes that management of diabetes in pregnancy should be made in accord with available national resources and infrastructure, even without high quality evidence, as it is preferable to the alternative of no or poor care. Global Challenges 190517

37. Options for Diagnosis of GDM Global Challenges 190517

38. FIGO Box – Postpartum FIGO supports the concept that the postpartum period in women with GDM provides an important platform to initiate early preventive health for both the mother and the child who are both at a heightened risk for future obesity, metabolic syndrome, diabetes, hypertension, and cardiovascular disorders. Global Challenges 190517

39. Key Messages • Obesity is a serious risk for women’s health • It not only effects reproductive outcomes but also have long term effects on the quality of life, increased morbidity and risk of Pre mature mortality. • Every women during Pregnancy should be offered screening for HIP • There should be a robust policy of following up these women post natally for weight management. Global Challenges 190517

40. Thank You Global Challenges 190517