australasian diabetes in pregnancy society april2008.pdf · women with a high test will be eligible...

1 S P O N S O R E D B Y R O C H E D I A G N O S T I C S

ADIPSA u s t r A l A s i A n D i A b e t e s i n P r e g n A n c y s o c i e t y

Newsletter | APrIl 2008

Sponsored by tAble of coNteNts

President’s Report 1

HAPO update 2

Editor’s Comment 3

Early screening for diabetes: 4 the STEP study

Journal Club: weight gain in pregnancy 6

IDF- Western Pacific Region Meeting 7

ADIPS President’s Report April 2008The HAPO (Hyperglycemia and Adverse Outcomes) study and the MiG (Metformin in Gestational Diabetes) clinical trial have both had first papers accepted for publication and should appear in press in the near future. We congratulate all the ADIPS members from Australia and New Zealand who were involved in these two very important studies, particularly Jeremy Oats (HAPO) and Janet Rowan (MiG). The results of both studies are likely to result in changes in practice in the diagnosis (HAPO) and management (MiG) of hyperglycaemic disorders in pregnancy and ADIPS will be very involved in developing position statements relating to both in the coming months.

The International Association of Diabetes in Pregnancy Study Groups (IADPSG) will be conducting an International Workshop Conference on Gestational Diabetes: Diagnosis and Classification, Pasadena California USA June 11th to 13th 2008. This International meeting has been set up essentially to translate the findings of the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study into clinical practice guidelines. ADIPS will be given an opportunity to make a submission to this meeting. In order to prepare our combined submission, ADIPS is holding a one-day workshop on the 3rd of May 2008 at the Royal North Shore Hospital in Sydney; a number of you have registered and I will see you there. The outcomes of the Sydney meeting and Pasadena meetings will undoubtedly create much debate and discussion in the second half of this year.

The 2008 ADIPS Annual Scientific Meeting will be held together with the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) in Adelaide, 31st October to 2nd November. We are pleased to announce that Peter Damm, an obstetrician with an international reputation for his clinical research relating to diabetes in pregnancy, has accepted to be our international keynote speaker this year. He is the Director of the Obstetric Clinic at the Center for Pregnant Women with Diabetes, Copenhagen University Hospital, Denmark. He will give two talks relating to Type 1 and Type 2 diabetes in pregnancy

Information about the society can

be found at: www.adips.org

Information about the International

Association of the Diabetes and

Pregnancy Study

Groups can be found at:

http://www.iadpsg.org

with links to ADIPS and other

regional study groups.

Australasian Diabetes in Pregnancy

Website


A D I P S A P R I l 2 0 0 8

and gestational diabetes. Bill Jeffries is working hard in Adelaide with SOMANZ representatives to make this a very enjoyable and successful meeting.

ADIPS members are actively involved in various projects including the development of educational materials for women that have had GDM and of educational videos relating to Type 1 and Type 2 diabetes in pregnancy. I thank all for their efforts.

Due to unforseen circumstances, the ADIPS audit has stalled for now. We apologise for the work of some centres that have not received processed data from their contributions. Extra funding needs to be found to re-establish a mechanism for processing the data and this is being sought. Once operating again, we will recontact the membership about how to proceed and the forms that we have received already will be processed. ADIPS considers the audit as an important activity that needs to be supported in the longer term.

I look forward to catching up with many of you at the Workshop meeting in Sydney early May and the Combined ADIPS/SOMANZ meeting later in the year.

Chris Nolan

President’s report cont...

We are pleased to announce that Peter Damm, an obstetrician with an international reputation for his clinical research relating to diabetes in pregnancy, has

accepted to be our international keynote speaker this year.

The first paper from HAPO, which reports on the associations between maternal glucose and the primary outcomes (birth weight greater than the 90th centile, primary caesarean delivery, clinical neonatal hypoglycaemia and cord C-peptide above the 90th centile) and secondary outcomes (premature birth, shoulder dystocia/birth injury, pre-eclampsia, intensive neonatal care and neonatal hyperbilirubinaemia) has been accepted for publication. A second paper about associations with neonatal anthropometrics is currently being prepared for submission.

Analyses of the interrelationships between pregnancy and neonatal outcome and various combinations of the fasting 1 hour and 2 hour GTT levels is underway and these will be presented at the ADIPS pre-Pasadena Meeting in Sydney May 3rd.

The programme of the Pasadena meeting, June 11th and 12th 2008 is on the iadpsg.org website. Following the 2 day meeting, representatives from the member organizations of IADPSG and other key Diabetes organizations will meet to commence the process of drafting the recommendations for criteria to be used for the classification of abnormal glucose tolerance in pregnancy. This document will be circulated widely for comment and feedback and it is anticipated that at least one further version will be circulated before endorsement and adoption.

Jeremy Oats for HAPO Steering Committee

the HAPo study update

3S P O N S O R E D B Y R O C H E D I A G N O S T I C S

A D I P S A P R I l 2 0 0 8

We are all hoping that the HAPO meetings this year will pave the way towards consensus about the diagnosis of GDM. However, there will still be many unanswered questions surrounding the diagnosis of GDM. Some of these relate to the fact that women diagnosed with GDM are a heterogeneous population and we all have a proportion of women

in our clinics with previously undiagnosed glucose intolerance/type 2 diabetes. Are we able to accurately identify these women when they present in pregnancy? Should we perform early screening in “high risk” women to identify them as soon as possible? Should high risk women just have an early OGTT, or do we have a cost-effective alternative? Should we still say these women have GDM?

I am sure that many centres have their own algorithms for identifying the “GDM, but really undiagnosed type 2 diabetes.” However, as the epidemic of obesity and type 2 diabetes grows, we should be sorting out the best approach in order to answer these questions appropriately.

In New Zealand, a Working Party was established in 2006 to address the key issues about screening for and managing women with GDM. A Technical Report has recently been published in the NZ Medical Journal, which summarises the main points. The full report is on the ADIPS website. The area of early screening is reviewed and recommendations are made within the report, recognising that more data are required. Ruth Hughes and colleagues have just initiated a study addressing the question of early screening. She has provided a summary of the study protocol for the Newsletter and we hope to hear regular updates as they obtain data.

I have asked the HAPO team representatives (Jeremy Oats and David McIntyre) whether they are ready to supply some answers to questions that were posed by Aidan McElduff in the last Newsletter, but we will have to wait until the next Newsletter, when further data have been analysed and released by the HAPO headquarters. Jeremy Oats has given us an outline of where things are at present.

Recently, the International Diabetes Federation – Western Pacific Region (IDF-WPR) had a meeting in Wellington. Some ADIPS members were there and I have included some relevant commentary from one of our diabetes midwives, Andrea Dawe. Of note, it appears that the IDF is becoming more involved with the Public Health issues surrounding the obesity epidemic. It may be a good idea for ADIPS to consider our stance with respect to the regulation of the food industry. Do we need to be more proactive with respect to protecting the next generation? Should energy-dense, nutrient-poor food have warnings on it “Not recommended for women planning pregnancy or during pregnancy?” Certainly food for thought….

As a final contribution, I hope you have all seen the articles published in Obstetric and Gynecology in October 2007. They provide the best data I have seen about recommended weight gain during pregnancy in women who have an elevated BMI. I know many of us are comfortable for women with GDM or type 2 diabetes to gain little weight or even lose weight during pregnancy, but it is useful to have published data backing us up. We should consider whether to incorporate this information into our guidelines. It looks like we are going to be a very busy society over the next year!

The next Newsletter will be very full, but I thought I should get this slimmer version out so people can plan to go to relevant meetings over the next couple of months if they wish. It will be a very important year to attend our ADIPS meeting in Adelaide. I have had a glimpse at the preliminary programme that Bill Jeffries had been working on with others. There will be plenty of topical issues for us to think about and discuss….and write about for the next Newsletter, of course.

Janet rowan

email: [email protected]

Editor’s Comment Hi everyone,

Should energy-dense, nutrient-

poor food have warnings on it “Not

recommended for women planning

pregnancy or during pregnancy?”


A D I P S A P R I l 2 0 0 8

Ruth Hughes, with colleagues, has started the STEP study outlined below. At the bottom of the information sheet, there is a bit more detail about the study design for the Newsletter, so we can see the initial HbA1c and glucose levels she is looking at with respect to screening, recognising that these numbers may be modified after planned interim analyses are undertaken.

steP screening for type 2 diabetes in early pregnancy February 2008 until 2011

What is this study for?It is designed to assess whether random glucose, glycosylated haemoglobin (HbA1c) or a combination of both are useful screening tests for undiagnosed Type 2 diabetes in early pregnancy.

Why do this study?Type 2 diabetes is reaching epidemic proportions and untreated diabetes in pregnancy plays a role. Up to 50% of people with Type 2 diabetes are undiagnosed as it is initially asymptomatic; the number undiagnosed in New Zealand is estimated to be 100,000 people. Pregnant women with diabetes produce offspring with an increased risk of diabetes themselves and so the vicious cycle starts. Early detection and treatment of diabetes in pregnancy may break this cycle of events.

What will the study involve?We want to assess the validity of using early pregnancy HbA1c and random blood glucose as screening tests for undiagnosed Type 2 diabetes. We have ethical approval to add HbA1c and random blood glucose to all first antenatal bloods in the Christchurch area for 3 years. Women with a high test will be eligible for entry into the study and will be approached for consent. They will then be offered a diagnostic oral glucose tolerance test at 12 weeks gestation. If a woman is diagnosed with diabetes she will attend the high-risk obstetric clinic at Christchurch Women’s Hospital in addition to the care provided by her lMC.

But we screen for diabetes in pregnancy already don’t we?In Australia and New Zealand screening for gestational diabetes (GDM) occurs at 24-28 weeks gestation. However, for women who may have undiagnosed Type 2 diabetes it is preferable for them to be recognised as early as possible to avoid adverse pregnancy outcomes such as pre-eclampsia, placental abruption and pre-term labour. Other adverse outcomes that can be prevented by early treatment include fetal macrosomia, delayed lung maturation, and perinatal death.

Screening for diabetes with the first antenatal bloods


A D I P S A P R I l 2 0 0 8

What happens at the completion of this study?The results will be analysed and, if appropriate, recommendations will be made on screening for Type 2 diabetes with the 1st antenatal bloods.

Who are the study investigators?Dr Ruth Hughes Obstetric Physician, Gill Halksworth-Smith Research Midwife, Dr Peter Moore Obstetric Physician, and Dr Rosemary Reid Obstetrician. They are all based at Christchurch Women’s Hospital.

How do I find out more?If you have further questions about the study please don’t hesitate to contact Dr Ruth Hughes or Gill Smith by email:

[email protected]; [email protected]

STEP: Details for ADIPS membersAn HbA1c and random blood glucose will be added to the current antenatal booking bloods. Women with an HbA1c <5.3% and a random blood glucose ≤5.5 mmol/l will have no further testing until the standard polycose test, followed by a 2 hour oral glucose tolerance test (OGTT) if positive, at 26-28 weeks gestation; women with an HbA1c 5.3 to 6% or a random blood glucose >5.5 mmol/l will have an OGTT to detect diabetes or impaired glucose tolerance. If this is normal a 2 hour OGTT will be repeated at 26-28 weeks gestation, if abnormal they will commence glucose monitoring and treatment as necessary; women with an HbA1c >6% or a random blood glucose >11 mmol/l will commence glucose monitoring without further investigation and further treatment instigated as necessary. The specificity of each test will be calculated from the number of women who have a positive 2 hour OGTT in early pregnancy; the sensitivity from the number who have a normal early pregnancy screening test but are later diagnosed with gestational diabetes from a 2 hour OGTT at 26-28 weeks gestation and confirmed to have impaired glucose tolerance or Type 2 diabetes on the standard follow-up 2 hour OGTT at six weeks postpartum. Demographic data relating to risk factors for diabetes will be collected from all women with an HbA1c or 5.3% or more, or a random blood glucose >5.5mmol/l including: age, body mass index, ethnicity, family history of diabetes, history of polycystic ovarian syndrome, previous GDM, macrosomic baby, shoulder dystocia or unexplained stillbirth.

Main Outcome measures• Sensitivity and specificity of a random blood glucose, HbA1c, and a combination of both tests, in identifying women

with diabetes or impaired glucose tolerance in early pregnancy.

• Sensitivity and specificity of each test, and a combination of both tests, in women with at least one risk factor for diabetes.

Ruth Hughes

Women with a HbA1c 5.3 to 6% or a random blood glucose >5.5 mmol/L will have a 2 hour oral glucose tolerance test (OGTT) to detect diabetes or impaired glucose tolerance.


A D I P S A P R I l 2 0 0 8

There are three articles and an editorial that provide useful data and interpretations about maternal weight gain during pregnancy across different BMI categories.

The references are: 1. DeVader S, Neeley H, Myles T, Leet T. Evaluation

of gestational weight gain guidelines for women with normal prepregnancy body mass index. Obstet Gynecol 2007;110:745-51

2. Kiel D, Dodson E, Artal R, Boehmer T, Leet T. Gestational weight gain and pregnancy outcomes in obese women: How much is enough? Obstet Gynecol 2007;110:752-8

3. Cedergren M. Optimal weight gain for body mass index categories. Obstet Gynecol 2007;110:759-64

And the accompanying editorial Catalano P. Increasing maternal obesity and weight gain during pregnancy. Obstet Gynecol 2007;110:743-4

The studies are large population cohort-studies looking at approximately 18,000 (De Vader) 120,000 (Kiel) and 300,000 (Cedergren) births in Missouri (first two papers) and Sweden (third paper). The first article focuses on the adherence to current weight gain guidelines from the Institute of Medicine (IOM) that were written in 1990. The other two articles focus on pregnancy outcomes and maternal weight gain in different BMI categories.

The main points that Pat Catalano discussed in his editorial were: • Almost half of pregnant women gain more

weight than recommended by IOM guidelines. Recommended weight gain for women with a normal BMI is 11.4-15.9 kg. Women with a normal BMI who gain more than 16 kg have increased rates of preeclampsia, failed induction and large for gestational age infants (lGA) compared with women in the same BMI category that gain less weight. We need to provide better education and diet advice to all pregnant women, not just overweight and obese women. This is a public health issue.

• Current recommendations for overweight and obese women are to gain “at least” 6.8 kg, but

those who gain less than 6.8 kg have a reduction in pregnancy complications compared with those in the same BMI same BMI category that gained more weight.

Cedergren calculated optimal weight gain as:

o BMI 20-24.9 kg/m2; optimal weight gain 2-10 kg

o BMI 25-29.9 kg/m2; optimal weight gain < 9.0 kg

o BMI ≥ 30 kg/m2; optimal weight gain <6.0 kg

o Weight loss was not looked at in this study

In Kiel’s study, weight loss was also looked at. In general, pregnancy complications continued to improve or plateau with maternal weight loss. However, rates of small for gestational age (SGA) started to rise above 10% with different levels of weight loss in the different BMI categories. I think that population birth weight centiles were used rather than customised centiles. Findings were as follows:

• BMI category 30-34.9 kg/m2, SGA rates:

o 10% if weight gain of 1-4kg.

o 14% if no weight gain

o 15% if weight loss 1-4kg

o 20% if weight loss >4.5 kg.

• BMI category 35-39.9 kg/m2, SGA rates:

o 10% if no weight gain

o 11% if loss of 1-4kg

o 15% if loss of >4.5 kg

• BMI category ≥ 40 kg/m2, SGA rates:

o 7% if no weight change

o 7% if weight loss 1-4kg

o 10% if weight loss >4.5 kg

Kiel made optimal weight gain recommendations in obese women

• BMI category 30-34.9 kg/m2, 4.5- 11 kg

• BMI category 35-39.9 kg/m2, 0- 4 kg

• BMI category ≥ 40 kg/m2, no weight gain or loss of 4.5 kg or more.

So, until current guidelines are formally reviewed, I think it is reasonable to use these data in our clinical practice.

Janet Rowan

Journal ClubWeight gain during pregnancy


A D I P S A P R I l 2 0 0 8

At first glance, I might have been inclined to think that, despite its very evident breadth and depth, the IDF congress programme did not include enough pregnancy-specific papers to justify my attendance. Fortunately, I was undeterred, and can confidently say that the congress constituted the most worthwhile time I’ve spent in “professional development” in recent years.

I attended a variety of presentations across different streams; all were informative and thought-provoking, and will enhance my practice as diabetes midwife not just by adding to my clinical knowledge, but also by expanding my awareness of the impact of social, economic and political environments on the increasingly apparent epidemic of obesity and Type 2 diabetes.

Epidemiologist Shiriki Kumanyika’s opening plenary session identified a need for a political and philosophical approach to the global problems of obesity and diabetes, asserting that solutions cannot be confined to health initiatives. In a later session, Shiriki discussed her own work promoting lifestyle change among African Americans and suggested strategies likely to be useful when working with any ethnic minority group. Shiriki is a charismatic speaker and her presentations encompassed the “big picture” while demonstrating her personal commitment to supporting individual change.

English epidemiologist Nick Wareham (“Causes and prevention of Type 2 diabetes”) challenged the assumption that IGT and IFG equate to pre-diabetes, and considers that there is no current evidence that early pharmacological treatment of those with IGT of IFG is beneficial. What he sees as not controversial, are the public health benefits of increased physical activity, referring to a range of research findings including those of the Finnish Diabetes Prevention Study.

In their presentations, Boyd Swinburn, Robert Scragg and Robyn Toomath all emphasised the need for change in the food environment, seeing this as essential to addressing the obesity and diabetes epidemics. They share the view that this can only be achieved by government regulation, and point out that such regulation will not come easily, as it is opposed by very powerful sectors of the food industry which have much to lose through restrictions on the promotion and sale of high-energy/low-nutrient food and drink.

Jim Mann discussed continuing nutrition controversies, pointing out that there is still uncertainty over what is the optimal macronutrient distribution, and that this may vary between certain groups. Those with metabolic syndrome, for example, may benefit from a low carbohydrate diet unless they are able to adhere strictly to a regime of high-fibre carbohydrates. Also controversial is an assumption that glycaemic index (GI) is an absolute indicator of preferable/less preferable foods. Food may have low GI, but still be comparatively high in sugars, and GI can be variable, that is, the same food may have a different GI when eaten by the an individual on different days.

David Dunstan, from the International Diabetes Institute in Melbourne, presented research into the impact of physical activity on the prevention and treatment of Type 2 diabetes. Of particular interest was his discussion of the benefits of resistance training, which (demonstrated in a RCT) not only enhances blood sugar control, but also has good compliance rates, perhaps in part due to those with obesity, peripheral neuropathy and other complications finding it a more manageable way to exercise than walking. I was intrigued by David’s finding that one can be defined as active (exercise purposefully for 150 minutes or more per week) but also sedentary (spend extended periods sitting). °∞Sedentariness°± (even in an active person) is positively associated with abnormal glucose metabolism; conversely, breaks in sedentary time (“pottering around”) appear to have beneficial effects not only blood sugar levels, but also waist circumference, BMI and triglyceride levels.

Western Pacific region Meeting

International Diabetes Federation-

EpidEmiologist shiriki kumanyika s opEning plEnary sEssion idEntifiEd a nEEd for a political and philosophical

approach to thE global problEms of obEsity and diabEtEs, assErting that

solutions cannot bE confinEd to hEalth initiativEs.

’


A D I P S A P R I l 2 0 0 8

English researcher Susan Ozanne and Auckland neonatologist Jane Harding both looked at the profound and long-reaching metabolic effects of the in utero environment and postnatal nutrition. I found the possibility that these effects may extend beyond the third generation particularly sobering, as was the likelihood that preterm birth alone may adversely affect glucose tolerance in adulthood.

I attended other sessions, all of which gave me new perspectives, and would have attended more, could I have been in two places at once! I left the congress feeling very grateful to have been able to attend, and keen to share new insights with colleagues who hadn’t had my good fortune.

I returned to work with an increased sense of the importance of the work we do, and its potential for positive intergenerational impact by promoting women’s wellbeing and facilitating lifestyle changes. Additionally, I feel responsible to become more politically engaged; high-quality clinical care of the individual is vital, but unless it is supported by the wider socio-political environment, we will be swamped by the needs of an increasingly unhealthy population.

Andrea Dawe Diabetes Midwife, Auckland

of particular intErEst was his discussion of thE bEnEfits of rEsistancE training, which (dEmonstratEd in a rct) not only EnhancEs blood sugar control, but also has good compliancE ratEs, pErhaps in part duE to thosE with

obEsity, pEriphEral nEuropathy and othEr complications

finding it a morE managEablE way to ExErcisE than walking.

The Australasian Diabetes in Pregnancy Society 32 St. Georges Road, Toorak Vic 3142, Australia Phone/Fax: +61 3 9827 8263 E-mail: [email protected] ABN: 79 371 815 899

APPLICATION FOR NEW MEMBERSHIP AUSTRALASIAN DIABETES IN PREGNANCY SOCIETY

Name of Applicant: ___________________________________________________

Address: ___________________________________________________

___________________________________________________

State ____________________ Post Code ____________

ProfessionalQualifications: ___________________________________________________

Phone No: Bus: _____________________ Fax: ________________

E-mail: ___________________________________________________ (please print clearly)

Nominated: ____________________ Seconded: _________________

Please Note: Nominators and Seconders must be financial Members of ADIPS. If you have no contact with financial members, please notify Secretary Dr Aidan McElduff, Royal North Shore Hospital Pacific Highway, St. Leonards, N.S.W. 2065 Tel: (02) 9926 8388, Fax (02) 9906 7525, E-mail: [email protected]

For Australian Members: Membership fee is AU$66:00 (includes GST) For New Zealand Members: Membership fee is AU$60:00 (excludes GST)

Membership is based on a calendar year

Application form together with Membership fee should be forwarded toMrs. Trish Cohen ADIPS Secretariat 32 St. Georges Road Toorak, VIC 3142, Australia Fax: +61 3 9827 8263

Cheque: Please make payable to “ADIPS” Credit Card: MasterCard Visa

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The Australasian Diabetes in Pregnancy Society 32 St. Georges Road, Toorak Vic 3142 Phone/Fax: (03) 9827 8263 E-mail: [email protected] ABN: 79 371 815 899

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The Australasian Diabetes in Pregnancy Society 32 St. Georges Road, Toorak Vic 3142, Australia Phone/Fax: +61 3 9827 8263 E-mail: [email protected] ABN: 79 371 815 899

APPLICATION FOR NEW MEMBERSHIP AUSTRALASIAN DIABETES IN PREGNANCY SOCIETY

Name of Applicant: ___________________________________________________

Address: ___________________________________________________

___________________________________________________

State ____________________ Post Code ____________

ProfessionalQualifications: ___________________________________________________

Phone No: Bus: _____________________ Fax: ________________

E-mail: ___________________________________________________ (please print clearly)

Nominated: ____________________ Seconded: _________________

Please Note: Nominators and Seconders must be financial Members of ADIPS. If you have no contact with financial members, please notify Secretary Dr Aidan McElduff, Royal North Shore Hospital Pacific Highway, St. Leonards, N.S.W. 2065 Tel: (02) 9926 8388, Fax (02) 9906 7525, E-mail: [email protected]

For Australian Members: Membership fee is AU$66:00 (includes GST) For New Zealand Members: Membership fee is AU$60:00 (excludes GST)

Membership is based on a calendar year

Application form together with Membership fee should be forwarded toMrs. Trish Cohen ADIPS Secretariat 32 St. Georges Road Toorak, VIC 3142, Australia Fax: +61 3 9827 8263



Card Number: ______________________ Expiry Date: _____________________



australasian diabetes in pregnancy society april2008.pdf · women with a high test will be eligible...

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