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Volume 6, No. 4, April 2008
From Your Colleagues
Burt Attico. Phoenix
Current management of gestational diabetes mellitus
Diabetes mellitus is one of the most common medical complications of pregnancy; gestational diabetes mellitus (GDM) accounts for approximately 90-95% of all cases. GDM is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. It has been demonstrated that good metabolic control maintained throughout pregnancy can reduce maternal and fetal complications in diabetes. Diet is the mainstay of treatment in GDM, but physical activity is a helpful adjunctive therapy when euglycemia is not achieved by diet alone. When diet and exercise fail to maintain euglycemia, exogenous insulin is used and the new insulin currently available on the market may help. Traditionally, insulin therapy has been considered the gold standard for management. The American College of Obstetricians and Gynecologists and the American Diabetes Association do not currently recommend oral hypoglycemic agents as a treatment for GDM. Concerns regarding safety demand further well-designed studies.
This accompanying sidebar summarizes the key issues in this excellent review article:
- Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy (5-10%) and has short- and long-term implications for both mother and child.
- Diet is the mainstay of treatment in GDM; physical activity could be a helpful adjunctive therapy when euglycemia is not achieved by diet alone.
- Exogenous insulin is used when diet and exercise fail to maintain euglycemia. Some recently developed insulin analogues, like aspart and lispro, may be considered a valuable treatment option in patients with GDM.
- Oral hypoglycemic agents are not currently recommended as a treatment for GDM.
- There are no indications to pursue delivery before 40 weeks of gestation in patients with good glycemic control, unless other maternal or fetal indications are present.
- For insulin-treated GDM patients there is no universal recommendation to labor induction at approximately 38-39 weeks.
- Patients with diet-controlled diabetes will not require intrapartum insulin or monitoring of blood glucose levels.
- Patients with insulin-requiring diabetes need intrapartum capillary hourly monitoring of blood glucose levels and maintaining glycemic values between 80 and 110 mg/dl during labor.
- Postpartum periodic glucose tolerance tests need to previously identify glucose abnormalities and, consequently, to begin strategies for the prevention of diabetes.
The article also cautions against the use of ultra-long acting insulin until further studies are done and suggests that the use of glyburide or metformin is unlikely to be harmful.
Guido Menato; Simona Bo; Anna Signorile; Marie-Laure Gallo; Ilenia Cotrino; Chiara Botto Poala; Marco Massobrio Current Management of Gestational Diabetes Mellitus Expert Rev of Obstet Gynecol. 2008;3(1):73-91. http://www.medscape.com/viewarticle/568728
David Gahn, Tahlequah
Afghanistan Update
On January 12 th, 2007, and Indian Health Service team deployed to Kabul, Afghanistan as part of the HHS Afghanistan Health Initiative. Dr. Pat O’Connor, MD (Pediatrics, Tuba City, AZ), Dr. Brandon Taylor, Pharm. D. (Tahlequah), and I endured 6 weeks of a brutal Afghanistan winter working at Rabia Balkhi Women’s Hospital (RBH).
We encountered what we expected – a hospital staff overwhelmed with pathology in the face of lack of supplies and training. We all tackled our problem lists and worked on providing sustainable training, bedside teaching, and making recommendations to the Office of Global Health Affairs (OGHA) and the Centers for Disease Control and Prevention (CDC) on equipment needs, staffing, and training while providing epidemiological data on the patients.
Two non-governmental organizations (NGO’s) are currently working at RBH under cooperative agreements with HHS. International Medical Corps is focused on providing training to the hospital staff is general areas (i.e. infection prevention) as well as specific clinical training to physicians, nurse midwives, laboratory personnel, et al. Cure International is responsible for developing the administration of RBH as well as the supply chain issues. The NGO’s are experts at what they do and, partnering with OGHA, CDC and IHS, they have made a significant impact on the morbidity and mortality occurring at RBH.
Dr. O’Connor, Dr. Taylor, and I spent a majority of our time at the bedside with the physicians and pharmacists conducting clinical teaching and modeling the team approach to patient care. As I mentioned in a previous article, RBH houses an Ob/Gyn residency training program. The residents lack a strong foundation in basic sciences, but have superb clinical skills due mainly to the amount of pathology that presents to the hospital. The focus of the project is developing the residency training program, but naturally that involves the entire hospital from housekeeping to the blood bank. Each system presents challenges for improvement, but the hospital staff is eager to move forward.
In January 2008, OGHA and IHS entered into an interagency agreement to allow for IHS clinicians to deploy to Kabul. Money has been identified by OGHA to reimburse individual service units through IHS headquarters. I have been assigned to work on the project full time, and we are assembling another team to deploy in June 2008 to continue the work. We are currently searching for an Ob/Gyn physician to deploy for four weeks, and have identified potential candidates in anesthesia, pediatrics, and an operating room nurse.
If you are interested in the project or have any questions, please contact david.gahn@IHS.gov . The work is exciting, incredibly rewarding, and very challenging.
OB/GYN CCC Editorial
You can make a huge difference
Participating in the Rabia Balkhi Women’s Hospital project could change your life. Make no mistake, Rabia Balkhi Hospital does not compare to a modern U.S. hospital. However, since HHS began its involvement with the hospital, it “ is cleaner and provides better care since the project began, experts agree.” RBH is considered the best hospital in Kabul. It is clean, and it offers good health care to the people of Afghanistan.
RBH has become one of the best hospitals in Afghanistan. Its reputation draws an increasing number of patients, including many with very poor health and nutritional status, which has the unintended impact of stressing an already overburdened facility.
All HHS staff who have visited Afghanistan and who have been involved in this project have a heartfelt desire to do something to help the women and children who so desperately need our assistance in gaining access to basic medical care.
As HHS embarked on this project, no one underestimated the incredible challenge, and we fully recognized that much more would be needed from other sources, but doing something to get started was better than standing by and doing nothing.
What HHS has already accomplished at RBH exceeded our initial expectations, and created the hope that, with more investments and time, sustainable improvements can occur. HHS is proud of the work we have done in extremely challenging circumstances in Afghanistan. Everyone agrees there is much more that we can do, and many challenges to meet.
The challenges of providing health care in a war zone are enormous. Security restrictions have made it consistently difficult to deploy our personnel to Afghanistan.
Furthermore, in the short amount of time since we began the Afghanistan Health Initiative, the Afghan Government has had two different Health Ministers, each with very different approaches to conducting business; multiple Deputy Health Ministers; and two directors of RBH.
The newness and fragility of the Afghan Government has not always made decision-making and the flow of financial support for the project a simple matter.
But true to our tradition, if Indian Health is asked to help, we always do our best to contribute.
Scott Giberson, HQE
Women and HIV
Please review this 2 part series which is very well referenced as well as presenting classic artworks involving women through the ages. It is important to remember that although IHS/AIDS is a medical condition, women with addictions, depression and other mental illnesses, and most especially, women struggling with violence in their lives or who have been victims of violence as children are at greater risk of HIV/AIDS infection.
Part 1
http://www.hivandhepatitis.com/recent/women/womenandhiv/WomenHIV_part_1.pdf
Part 2
http://www.hivandhepatitis.com/recent/women/womenandhiv/WomenHIV_part_2a.pdf
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
