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Philippine CPG on diagnosis and screening of gestational diabetes presented for comments at the 3rd Unite for Diabetes Annual Convention this September.
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UNITE FOR DIABETES CPG
Screening and Diagnosis of Diabetes in
Pregnant Women
Iris Thiele Isip Tan MD, FPCP, FPSEMClinical Associate Professor
UP College of MedicineSection of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital
Should universal screening for diabetes be done among pregnant women?
Recommendation:
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
6.1
Should universal screening for diabetes be done among pregnant women?
6.1
ADAVery low risk* women need
not be screened
DIPSIUniversal screeninghigh GDM prevalence
in India
National GDM Technical Working
Party of N. Zealand Universal screening
NICEWomen with
any risk factor should be screened
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
Filipino women are at increased risk for diabetes in pregnancy.
ASGODIP Data n/N
Low risk 35/853
High risk 136/350
Overall171/1203
14.2%
Litonjua AD et al. AFES Study Group on Diabetes in Pregnancy: Preliminary Data on Prevalence. PJIM 1996:34:67-68.
6.1
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
RR for developing gestational diabetes by ethnicity (adjusted for age, BMI and parity; white as reference)
UK Data (1992) RR (95%CI)
Black 3.1 (1.8 to 5.5)
South East Asian 7.6 (4.1 to 14.1)
Indian 11.3 (6.8 to 18.8)
6.1
Dornhorst A, Paterson CM, Nicholls JSD, et al. High prevalence of gestational diabetes in women from ethnic minority groups. Diabetic Medicine 1992; 9:820–5.
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
6.1
http://www.flickr.com/photos/mikewade/3267336862/
Macrosomia
Birth injuries
http://www.flickr.com/photos/clairity/1385780317/
Shoulder Dystocia
Increased risk of
perinatal morbidity
http://www.flickr.com/photos/jessicafm/280232106/
Hypoglycemia
http://www.flickr.com/photos/tessawatson/379265818/
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
6.1
Treatment reduces perinatal morbidityACHOIS
Crowther et al. NEJM 2005; 352:2477-86.
Landon et al NEJM 2009; 361:1339-48.
ACHOISCrowther et al. NEJM 2005; 352:2477-86.
Crowther CA et al. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. NEJM 2005; 352:2477-86.
PI
MO
GDM24-28 wks AOG
Intervention (n=490)
diet CBG insulin vs
routine care (n=510)
Serious perinatal
complications
deathshoulder dystocia
bone fracturenerve palsy
Randomized controlled
trial
ACHOISCrowther et al. NEJM 2005; 352:2477-86.
Crowther CA et al. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. NEJM 2005; 352:2477-86.
PI
MO
GDM24-28 wks AOG
Intervention (n=490)
diet CBG insulin vs
routine care (n=510)
Serious perinatal
complications
deathshoulder dystocia
bone fracturenerve palsy
Randomized controlled
trial
Any serious perinatal complication Adj RR 0.33 (95% CI 0.14-0.75), p=0.01
Landon et al NEJM 2009; 361:1339-48.
PI
MO
Intervention (n=485)
diet CBG insulin vs
routine care (n=473)
Composite of stillbirth/perinatal
death and neonatal
complications
Randomized controlled
trial
“mild” GDM24-31 wks AOG
Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.
hyperbilirubinemia hypoglycemia
hyperinsulinemia birth trauma
Landon et al NEJM 2009; 361:1339-48.
PI
MO
Intervention (n=485)
diet CBG insulin vs
routine care (n=473)
Composite of stillbirth/perinatal
death and neonatal
complications
Randomized controlled
trial
“mild” GDM24-31 wks AOG
Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.
hyperbilirubinemia hypoglycemia
hyperinsulinemia birth trauma
Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14
Landon et al NEJM 2009; 361:1339-48.
PI
MO
Intervention (n=485)
diet CBG insulin vs
routine care (n=473)
Randomized controlled
trial
“mild” GDM24-31 wks AOG
Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.
Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14
Landon et al NEJM 2009; 361:1339-48.
PI
MO
Intervention (n=485)
diet CBG insulin vs
routine care (n=473)
Randomized controlled
trial
“mild” GDM24-31 wks AOG
Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.
Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14
LGA infants RR 0.49
(95%CI 0.32-0.76) p<0.001
BW >4000 g RR 0.41
(95%CI 0.26-0.66) p<0.001
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
6.1
Cesearean Section
Pregnancy-induced hypertension
Preeclampsia
Increased risk of
maternal morbidity
Type 2 diabetes mellitushttp://www.flickr.com/photos/j2dread/4501366303/ http://www.flickr.com/photos/ulybug/512369383/
http://www.flickr.com/photos/78428166@N00/4921825364/
All pregnant women should be screened for gestational diabetes (Level 2, Grade B).
6.1
Treatment reduces maternal morbidity
Ratner et al JCEM 2008; 93:4774-9
Landon et al NEJM 2009; 361:1339-48
Landon et al NEJM 2009; 361:1339-48.
PI
MO
Intervention (n=485)
diet CBG insulin vs
routine care (n=473)
Composite of stillbirth/perinatal
death and neonatal
complications
Randomized controlled
trial
“mild” GDM24-31 wks AOG
Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.
hyperbilirubinemia hypoglycemia
hyperinsulinemia birth trauma
Landon et al NEJM 2009; 361:1339-48.
Cesarean delivery
RR 0.79 (0.64-0.99)
p=0.02
Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.
Preeclampsia
RR 0.46 (0.22-0.97)
p=0.02
Preeclampsia or gestational hypertension
RR 0.63 (0.42-0.96)
p=0.01
PI
MO
Women in DPP350 with previous GDM
1416 without
DPP arms placebo
metformin intensive lifestyle
Time to development of diabetes
semiannual FPG annual OGTT
Randomized controlled
trial
Ratner RE et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. JCEM 2008;93: 4774-9
Ratner et al JCEM 2008; 93:4774-9
Ratner RE et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. JCEM 2008;93: 4774-9We estimate that metformin therapy, on the other hand,
may be as much as 3 times more effective in reducing theincidence of diabetes in those with a history of GDM com-pared with those without. This may in part be explained by theyounger age (mean of 43 yr) of the GDM group becausewomen between 25 and 44 yr of age within DPP as a whole hada similar risk reduction with either metformin or ILS, butmetformin was no more effective than placebo in women overage 60 yr (5).
The Troglitazone in Prevention of Diabetes (TRIPOD)study data provide the closest comparison to the DPP results(15). TRIPOD enrolled an exclusively Latina population,
whereas DPP was ethnically mixed with 54% Caucasian. Inthe DPP, the GDM population was older (43 vs. 34 yr) andconsiderably more distant from their index pregnancies (12vs. ! 4 yr). As a result, we lost those individuals converting todiabetes in the early postpartum years before entering DPP.Nevertheless, parous female DPP participants, both with andwithout history of GDM, had a marked risk of progressing todiabetes (15.2 and 8.9 cases per 100 person-years, respec-tively) over the subsequent 3–5 yr. TRIPOD demonstrated a55% risk reduction with troglitazone treatment, comparablewith our observed reductions of 50.4% for metformin and53.4% for ILS among women with history of GDM.
0
5
10
15
20
25
30
35
40
45
0 0.5 1 1.5 2 2.5 3
Metformin (n=464)
Placebo (n=487)
ILS(n=465)
Cum
ulat
ive
inci
denc
e (%
)
Years from randomization
0
5
10
15
20
25
30
35
40
45
0 0.5 1 1.5 2 2.5 3Years from randomization
Cum
ulat
ive
inci
denc
e (%
)
Metformin (n=111)
Placebo (n=122)
ILS(n=117)
A
B
FIG. 4. Cumulative incidence of diabetes in DPP by randomized treatment group. Panel A, Women without a history of GDM; Panel B, women with a history of GDM.
4778 Ratner et al. Diabetes in Women with a History of GDM J Clin Endocrinol Metab, December 2008, 93(12):4774–4779
Cum
ulat
ive
inci
den
ce o
f dia
bet
es in
DP
P (%
)Without a history of GDM
With a history of GDM
Placebo
MetforminILS
Placebo
Metformin
ILS
} ~50% reduction
For pregnant women, when should screening be done?
Recommendations:
1. All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Level 4, Grade C).
6.2
6.2
USPSTFNo RCTs on screening before 24
weeks AOG
National GDM Technical Working
Party of N. Zealand Screen high risk
women at booking
NICEDetermine risk
factors for GDM at booking
appointment
http://www.flickr.com/photos/fdecomite/406635986/
ADAScreen high
risk women at first prenatal
visit
All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes (Level 4, Grade C).
Bartha et al. Am J Obstet
Gynecol 2000; 182:346-50.
Bartha JL et al. Gestational Diabetes Mellitus Diagnosed During Early Pregnancy. Am J Obstet Gynecol 2000; 182:346-50.
PI
MO
Pregnant at first prenatal visit
50-g GCT 1st visit then 24-28 weeks if initial result
normal (n=3986)
Early- (n=65) vs late-onset
(n=170) GDM
pregnancy complications, obstetric and
perinatal outcomes
Cross-sectional
comparative
Bartha et al. Am J Obstet
Gynecol 2000; 182:346-50.
Bartha JL et al. Gestational Diabetes Mellitus Diagnosed During Early Pregnancy. Am J Obstet Gynecol 2000; 182:346-50.
PI
MO
Pregnant at first prenatal visit
50-g GCT 1st visit then 24-28 weeks if initial result
normal (n=3986)
Early- (n=65) vs late-onset
(n=170) GDM
pregnancy complications, obstetric and
perinatal outcomes
Cross-sectional
comparative
Women with an early diagnosis of GDM represent a high-risk subgroup
Bartha et al. Am J Obstet
Gynecol 2000; 182:346-50.
Bartha JL et al. Gestational Diabetes Mellitus Diagnosed During Early Pregnancy. Am J Obstet Gynecol 2000; 182:346-50.
PI
MO
Pregnant at first prenatal visit
50-g GCT 1st visit then 24-28 weeks if initial result
normal (n=3986)
Early- vs late-onset GDM
Cross-sectional
comparative
Women with an early diagnosis of GDM represent a high-risk subgroup
Bartha et al. Am J Obstet
Gynecol 2000; 182:346-50.
Bartha JL et al. Gestational Diabetes Mellitus Diagnosed During Early Pregnancy. Am J Obstet Gynecol 2000; 182:346-50.
PI
MO
Pregnant at first prenatal visit
50-g GCT 1st visit then 24-28 weeks if initial result
normal (n=3986)
Early- vs late-onset GDM
Cross-sectional
comparative
Women with an early diagnosis of GDM represent a high-risk subgroup
Likely hypertensive
(18.46% vs 5.88%,
p=0.006)
Higher need for insulin (33.85% vs
7.06%, p=0.0000)
Risk Factors for Gestational Diabetes
Prior history of GDM (OR 23.6 [95%CI 11.6, 48.0])3
Glucosuria (OR 9.04 [95%CI 2.6, 63.7]2; PPV 50% 4)
Family history of diabetes (OR 7.1 [95%CI 5.6, 8.9]1; OR 2.74 [95%CI 1.47, 5.11]3)
First-degree relative with type 2 diabetes (PPV 6.7%)4 First-degree relative with type 1 diabetes (PPV 15%)4Prior macrosomic baby (OR 5.59 [95%CI 2.68, 11.7])3
Age >25 years old (OR 1.9 [95%CI 1.3, 2.7]1; OR 3.37 [95%CI 1.45, 7.85]3)
1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus:
an evaluation of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21.
2 Schytte T, Jorgensen LG, Brandslund I, et al. The clinical impact of screening for gestational diabetes. Clinical Chemistry and Laboratory Medicine 2004;42(9):1036–42.
3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8.
4 Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32.
Risk Factors for Gestational Diabetes
Diagnosis of polycystic ovary syndrome (OR 2.89 [95%CI 1.68, 4.98])5
Overweight or obese before pregnancy
(BMI >27 kg/m2 OR 2.3 [95%CI 1.6, 3.3]1; BMI>30 kg/m2 OR 2.65 [95%CI 1.36, 5.14]3
Macrosomia in current pregnancy (PPV 40% 4)Polyhydramnios in current pregancy (PPV 40% 4)Intake of drugs affecting carbohydrate metabolism
3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8.
1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21.
4 Griffin ME, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32.
5 Toulis KA, Goulis DG, Kolibiankis EM, Venetis CA, et al. Risk of gestational diabetes mellitus in women with polycystic ovary syndrome: a systematic review and a meta-analysis. Fertil Steril 2009;92(2):667–77.
For pregnant women, when should screening be done?
Recommendations:
2. High-risk women should be tested at the soonest possible time (Level 3, Grade B).
6.2
6.2
DIPSIScreen early
“... fetal beta cell recognizes and
responds... as early as 16th week of
gestation.”
ADA Screen very
high risk women at first prenatal
visit
NICE Offer SMBG or OGTT at 16-18
wks AOG to women with
previous GDM
High-risk women should be tested at the soonest possible time (Level 3, Grade B).
For pregnant women, when should screening be done?
Recommendations:
3. Routine testing for gestational diabetes is recommended at 24-28 weeks age of gestation for women with no risk factors (Level 3, Grade B).
6.2
6.2
USPSTFNo evidence
that screening after the 24th week
leads to reduction in morbidity &
mortality
ACHOISTreatment of
GDM after 24 wks AOG reduces complications
ADA Test “greater than low risk women” for GDM at 24-28
wks AOG
Routine testing for gestational diabetes is recommended at 24-28 weeks age of gestation (Level 3, Grade B).
NICE Offer OGTT at 24 to 28 wks AOG to women with other
risk factors
For pregnant women, when should screening be done?
Recommendations:
4. Testing for gestational diabetes should still be carried out in women at risk, even beyond 24 to 28 weeks age of gestation (Level 3, Grade C).
6.2
Testing for gestational diabetes should still be carried out in women at risk, even beyond 24 to 28 weeks age of gestation (Level 3, Grade C).
6.2
Positive OGTT <26 weeks AOG >26 weeks AOG
Low risk15/2955.1%
20/5583.6%
High risk43/12035.8%
93/23040.4%
Litonjua AD et al. AFES Study Group on Diabetes in Pregnancy: Preliminary Data on Prevalence. PJIM 1996:34:67-68.
Testing for gestational diabetes should still be carried out in women at risk, even beyond 24 to 28 weeks age of gestation (Level 3, Grade C).
6.2
Sy RAG et al. Viewpoints on Gestational Diabetes: Report from ASGODIP Participating Hospital: Cardinal Santos Medical Center. PJIM 1996;34:45-48
>75% diagnosed GDM from 26 to 38 wks AOG
Higher morbidity rate (33%) in those
evaluated after 26th wk AOG
3 macrosomic babies
1 infant with multiple
congenital anomalies
and Down’s syndrome
ASGODIP Cardinal Santos Medical Center
Testing for gestational diabetes should still be carried out in women at risk, even beyond 24 to 28 weeks age of gestation (Level 3, Grade C).
6.2
Bihasa MTG et al. Screening for gestational diabetes: Report from ASGODIP participating hospital: Veterans Memorial Medical Center. PJIM 1996:34:57-61.
%AOG tested
<20 weeksn=19
21-30 weeksn = 74
31-40 weeksn = 60
Negative for GDM
95 92 85
Positive for GDM
5 8 15
ASGODIP (Veterans Memorial Medical Center)
Which tests should be used to screen pregnant women for gestational diabetes?
Recommendation:
An oral glucose tolerance test (OGTT), preferably the 75-g OGTT, should be used to screen for gestational diabetes (Level 3, Grade B).
6.3
6.3
IASDPGInitial visit
FPG, A1c or RPG 75-g OGTT at
24-28 wks ADA
One-step OGTT or two-step with GCT
ASGODIP 50-g GCT if low-risk
75-g OGTT if high-risk
An oral glucose tolerance test (OGTT), preferably the 75-g OGTT, should be used to screen for gestational diabetes (Level 3, Grade B).
DIPSI 75-g OGTT
NICE 75-g OGTT
Qualitative Strength
LR (+) LR (-)
Excellent 10 0.1
Very Good 6 0.2
Fair 2 0.5
Useless 1 1
Should we still do the 50-g glucose challenge test (GCT)?
NICE does not
recommend 50-g GCT
4 studies n=2437
LR(+) 4.34 95%CI(1.53,12.26)
LR(-) 0.42 95%CI(0.33,0.55)
Positive likelihood ratio: The increase in the odds of having the
disease after a positive test resultfair
National Institute for Health and Clinical Excellence. Diabetes in pregnancy: management of diabetes & its complications from pre-conception to the postnatal period. March 2008 (reissued July 2008)
Should we still do the 50-g glucose challenge test (GCT)?
Positive Predictive value The probability that a patient with a
positive test result will have the disease fair(+) OGTT (-) OGTT Total
(+) GCT 91 113 204
(-) GCT Not done 477
Total 681Positive
Predictive Value (PPV)
44.6%
Carlos-Raboca J et al. JAFES 2002;20:19-24
Should we still do the 50-g glucose challenge test (GCT)?
Only
moderately reproducible
More likely to be positive if conducted in the afternoon
Significantly affected by the time of the last
meal
http://www.flickr.com/photos/neeta_lind/3572379176/
Should we still do the 50-g glucose challenge test (GCT)?
10 to 23% of women fail to
return for OGTT after an initial
GCT
PGH (unpublished)
36% after (+) GCT
ASGODIPVeterans Memorial
17.8%1
FEU-NRMFH 48%2
after (+) GCT
http://www.flickr.com/photos/daquellamanera/4552683663/
1 De Asis TP et al. Incidence of gestational diabetes mellitus at Veterans Memorial Medical Center PJIM 1996; 34:63-66
2 Chua-Ho C et al. Screening for gestational diabetes mellitus: Report from ASGODIP Participating Hospital FEU-NRMFH PJIM 1996; 34:43-44
75-g or 100-g OGTT?
100-g more cumbersome;
4 blood samples
100-g OGTT duration 3 hours
100-g OGTT high glucose
load often unpalatable
75-g OGTT international standard in
non-pregnant
Head-to-head
studiesDeerochanawong
et al Diabetologia 1996;39:1070-3
Pettitt et al Diabetes Care 1994; 17(11):
1264-8
75-g or 100-g OGTT?
PI
MO
Pregnant Pima Indian women (n=127)
WHO 75-g OGTT
vs
NDDG 100-g OGTT
Macrosomia
Cesarean section
Cross-sectional
comparative
Pettitt DJ et al. Comparison of WHO and NDDG procedures to detect abnormalities of glucose tolerance during pregnancy. Diabetes Care 1994;17(11): 1264-8
Pettitt et al Diabetes Care 1994; 17(11):
1264-8
PI
MO
Pregnant Pima Indian women (n=127)
WHO 75-g OGTT
vs
NDDG 100-g OGTT
Cross-sectional
comparative
Pettitt DJ et al. Comparison of WHO and NDDG procedures to detect abnormalities of glucose tolerance during pregnancy. Diabetes Care 1994;17(11): 1264-8
Pettitt et al Diabetes Care 1994; 17(11):
1264-8
PI
MO
Pregnant Pima Indian women (n=127)
WHO 75-g OGTT
vs
NDDG 100-g OGTT
Macrosomia
6/16 (38%) had (+) 75g
OGTT
1/16 (6%) had (+) 100 g
OGTT
Cross-sectional
comparative
Pettitt DJ et al. Comparison of WHO and NDDG procedures to detect abnormalities of glucose tolerance during pregnancy. Diabetes Care 1994;17(11): 1264-8
Pettitt et al Diabetes Care 1994; 17(11):
1264-8
Cesarean section
4/7 (57%) had (+) 75g
OGTTNo one had (+)
100g OGTT
PI
MO
Pregnant 24-28 wks AOG (n=709)
WHO 75-g OGTT
vs
NDDG 100-g OGTT
Diagnosed GDM
Macrosomia
Cross-sectional
comparative
Deerochanawong et al. Comparison of NDDG and WHO criteria for detecting gestational diabetes. Diabetologia 1996;39: 1070-3
Deerochanawong et al Diabetologia 1996;39:1070-3
PI
MO
Pregnant 24-28 wks AOG (n=709)
WHO 75-g OGTT
vs
NDDG 100-g OGTT
Diagnosed GDM
75-g OGTT 15.7%
(111/709)
100-g OGTT 1.4%
(10/709)
Cross-sectional
comparative
Deerochanawong et al. Comparison of NDDG and WHO criteria for detecting gestational diabetes. Diabetologia 1996;39: 1070-3
Deerochanawong et al Diabetologia 1996;39:1070-3
PI
MO
Pregnant 24-28 wks AOG (n=709)
WHO 75-g OGTT
vs
NDDG 100-g OGTT
Diagnosed GDM
75-g OGTT 15.7%
(111/709)
100-g OGTT 1.4%
(10/709)
Cross-sectional
comparative
Deerochanawong et al. Comparison of NDDG and WHO criteria for detecting gestational diabetes. Diabetologia 1996;39: 1070-3
Deerochanawong et al Diabetologia 1996;39:1070-3
Macrosomia
6/14 (43%) (+)75g OGTT
3/14 (21%) (+)100 g OGTT
What criteria will be used to interpret the 75-g OGTT?
Recommendation:
The criteria put forth by the International Association of Diabetes & Pregnancy Study Groups (IADPSG) will be used to interpret the 75-g OGTT (Level 3, Grade B).
6.4
International Association of Diabetes and Pregnancy Study Groups Consensus Panel. IADPSG Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care 2010; 33(3):676-82.
Interpreting the 75-g OGTT
75-g OGTTThreshold(s) for diagnosing gestational
diabetes (mg/dL)
IADPSG* ADA**ASGODIP & DIPSI
FBS 92 95 -1-hour 180 180 -2-hour 153 155 140
*Any one value meeting threshold is considered gestational diabetes.** Two values must meet thresholds to be considered gestational diabetes
What other tests can be used to screen pregnant women for diabetes?
Recommendation:The following tests should not be used for the diagnosis of diabetes in pregnancy (Level 5, Grade D):
Capillary blood glucose FBS*
RBS* HbA1c
Fructosamine Urine glucose
Do an OGTT for those with glucosuria, elevated CBG or HbA1c.
6.5
* If available at consultation, use same diagnostic threshold for diabetes as in non-pregnant
6.5 CBG should not be used for the diagnosis of diabetes in pregnancy (Level 5,Grade D).
Different glucometers
used in studies
Validity of CBG vs OGTT
unproven
PostprandialCBG higher than venous
blood
Sensitivity 47-87%
Specificity 51-100%
6.5 FBS should not be used for the diagnosis of diabetes in pregnancy (Level 5,Grade D).
FBS varies with
advancing gestation
Paucity of data regarding reproducibility
Agardh C- D . Åberg A , Nordén N . Glucose levels and insulin secretion during a 75 g glucose challenge test in normal pregnancy. J Intern Med 1996 ; 240 : 303–9.
Lind T , Billewicz WZ , Brown G . A serial study of changes occurring in the oral glucose tolerance test in pregnancy J Obstet Gynaecol Br Com 1973 ; 80 : 1033–9 .
Kühl C . Glucose metabolism during and after pregnancy in normal and
gestational diabetic women . Acta Endocrinol 1975 ; 79 : 709–19.
Only 2 studies:
RBS vs OGTT
No optimal threshold for
RBS indicating an OGTT
RBS 6.5 mmol/L (117 mg/dL)
Sensitivity 75%Specificity 78%
6.5 RBS should not be used for the diagnosis of diabetes in pregnancy (Level 5,Grade D).
Jowett NI , Samanta AK , Burden AC . Screening for diabetes in pregnancy: Is a random blood glucose enough? Diabet Med 1987;4:160–3
Östlund I , Hanson U . Repeated random blood glucose measurements as universal screening test for gestational diabetes mellitus . Acta Obstet Gynecol Scand 2004;83:46–51
6.5 A1c should not be used for the diagnosis of diabetes in pregnancy (Level 5,Grade D).
HbA1c in normal women
varies with ethnicity and
gestation
HbA1c values did not differ
between normal women and those with
GDM
Loke DFM . Glycosylated haemoglobins in women with low risk for diabetes in pregnancy . Singapore Med J 1998;36:501–4
Agarwal M , Dhatt GS , Punnose J , Koster G . Gestational diabetes:a reappraisal of HBA1c as a screening test . Acta Obstet Gynecol Scand 2005;84:1159–63
6.5 Fructosamine should not be used for the diagnosis of diabetes in pregnancy (Level 5,Grade D).
Fructosamine varies with
ethnicity and albumin levels
Fructosamine did not differ
between normal women and those with
GDM
Bor MV , Bor P , Cevik C . Serum fructosamine and fructosamine - albumen ratio as screening tests for gestational diabetes mellitus . Gynecol Obstet 1999; 262:105–11
Huter O , Heinz D , Brezinka C , Soelder E , Koelle D , Patsch JR . Low sensitivity of serum fructosamine as a screening parameter for gestational diabetes mellitus . Gynecol Obstet Invest 1992;34:20–3
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Glucosuriatrace glucose
75 to >250 mg/dL
High ascorbic acid intake can
cause glucosuria
6.5 Urine glucose should not be used for the diagnosis of diabetes in pregnancy (Level 5,Grade D).
Sensitivity7-36%
Specificity83-98%
False-positive glucosuria
with high levels of urinary ketones
(starvation ketosis)
Comments/suggestions welcome
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