Diagnostic Criteria For Gestational Diabetes Mellitus Research Articles

Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period (NG3)

In February 2015 the National Institute for Health and Care Excellence (NICE) published new guidance (NG3) on the management of diabetes in pregnancy. Care teams need to be aware of this guidance and implement its recommendations. These include preconception care with target HbA1c 48 mmol/mol. Women at risk of gestational diabetes mellitus (GDM) should have a 75 g oral glucose tolerance test (OGTT). Diagnostic criteria for GDM have changed to fasting glucose of 5.6 mmol/L or above or 2 hour glucose of 7.8 mmol/L or above. Glycaemic targets in all diabetic pregnancies have changed to fasting glucose below 5.3 mmol/L (4–5.2 mmol/L if on insulin) and 1 hour postprandial glucose below 7.8 mmol/L if these can be achieved safely. Continuous glucose monitoring and insulin pump therapy should not be used routinely but can be used if glycaemic control is problematic. Capillary ketone testing should be routine for women with type 1 diabetes when hyperglycaemic and for all women with diabetes including, GDM when acutely unwell. More flexibility is offered around recommended delivery timing: 37+0 weeks to 38+6 weeks for women with types 1 and 2 diabetes; prior to 40+6 in GDM (and earlier if complications arise). Postnatal testing following GSM should be by fasting glucose (not OGTT) at 6–13 weeks post partum. Testing later than this can use HbA1c. Introducing these changes will have resource implications, including a likely increase in the number of women diagnosed with GDM.

AB031. Standardizing Gestational Diabetes Mellitus diagnostic criteria and systematic management in China

ObjectiveType 2 diabetes has been dramatically increasing and becoming a major public issue in China. Gestational diabetes mellitus (GDM) is one of the most common complications during pregnancy causing severe complications both for the gravida and offspring without systematic management. Furthermore, GDM can also increase the risk of developing metabolic syndrome for the mother and offspring in the long-term. However, several issues regarding GDM are still controversial such as systematical screening, diagnosis strategy and management as well as postpartum follow up issues. Our study aimed to standardize GDM diagnostic criteria and systematic management in China.MethodsWe have conducted multiple studies to verify the adverse outcome of GDM and establish suitable screening and diagnostic criteria for GDM of our country. Such as Prospective case control study and large clinical researches, large clinical multicenter study and randomized controlled trial.ResultsThrough a prospective case control study and large clinical researches, we confirmed it is beneficial to monitor and control blood glucose level during pregnancy. As early as 1993 we have reported blood glucose management playing important role in reducing adverse outcome, also proposed full term GDM patients can not routinely to promote fetal lung maturity before termination of pregnancy. After standardized management of GDM, the perinatal mortality and incidence of macrosomia had been significantly decreased. Through the research of threshold on 50 g Glucose Challenge Test (GCT) and the 75 g oral glucose tolerance test (OGTT), we gradually established suitable screening and diagnostic criteria for GDM of our country. We proposed to cancel 75 g OGTT 3 h value based on 535 GDM cases before the international new recommendation in 2010. According to the research of more than 16,000 cases of GDM multicenter study, principal investigator composed the national GDM clinical recommendations and published it in 2007. Ministry of health in China finally approved the new GDM diagnostic guideline we drafted. We initially cooperated with endocrinologists and pediatricians and opened the GDM postpartum follow up clinic as well as did early interventions to the offspring in order to decrease the Type 2 diabetes incidence later in their life. Furthermore, we opened GDM one-day clinic in 2011 and ultimately achieved national extension.ConclusionsIt is important to standardize GDM diagnostic criteria and systematic management in China. Controlled the incidence of GDM could reduce the prevalence of type 2 diabetes in China and decrease the adverse effects on the offspring. It is instant for the obstetrician, nutrition doctor, endocrinologist, and pediatrician making joint efforts to systematically manage GDM in China.

NICE's latest guidelines on diabetes in pregnancy: getting the balance right

<scp>NICE</scp>'s latest guidelines on diabetes in pregnancy: getting the balance right

Possibility to predict early postpartum glucose abnormality following gestational diabetes mellitus based on the results of routine mid-gestational screening.

IntroductionWomen with previous gestational diabetes mellitus (GDM) have increased risk of developing glucose abnormality, but current diagnostic criteria are evidence-based for adverse pregnancy outcome. The aims of our study were: (i) to ascertain a frequency of early conversion of GDM into permanent glucose abnormality, (ii) to determine predictive potential of current GDM diagnostic criteria for prediction of postpartum glucose abnormality and (iii) to find optimal cut-off values of oral glucose tolerance test (oGTT) to stratify GDM population according to postpartum risk.Materials and methodsElectronic medical records of an ethnically homogenous cohort of women diagnosed and treated for GDM in a single medical centre during the period 2005–2011 who completed postpartum oGTT up to 1 year after the index delivery were retrospectively analysed (N = 305).ResultsPostpartum glucose abnormality was detected in 16.7% subjects. Mid-trimester oGTT values, respective area under the curve and HbA1c were significantly associated with early postpartum glucose abnormality (P < 0.05, Mann-Whitney) and exhibited significant predictive potential for postpartum glucose abnormality risk assessment. Optimal cut-off values for discrimination of at-risk sub-population were identified using ROC analysis and their comparison with WHO and IADPSG criteria exhibited superiority of IADPSG for risk-stratification of GDM population.ConclusionRisk-based stratification at the time of GDM diagnosis could improve efficiency of the post-gestational screening for diabetes. IADPSG criteria seem to optimally capture both perinatal and maternal metabolic risks and are therefore medically and economically justified.

“Sugamama” – Gestational Diabetes Mobile ‘app’ innovation in integrated care Proof Of Concept

This proof of concept (POC) involves the user-centred design of a mobile application (app) and web-based system to promote self-management of women with gestational diabetes mellitus (GDM). During the brief period between diagnosis and birth we seek to maximise tight blood glucose control, known to impact on maternal and fetal outcomes. This is timely due to clinician burdens anticipated to increase by up to 30% with the adoption of new GDM diagnostic criteria. Incidence of GDM is on the rise due to the increasing percentage of overweight or obese pregnant women and the advancing age of first time mothers. The system has been designed from the ground up by clinicians, patients and subject matter experts and is grounded in theory. It offers the opportunity for remote management of patients; individualised patient care plans; automatic upload of blood glucose measurements via Bluetooth; triage of patients based on pre-determined parameters; flagging of those at high risk; consultations and referral; tracking of diet, exercise, weight, fetal movements, appointments and medications; appropriate and accessible education and support to patients, including those with low health literacy; and recording of occasions of clinical service for billing purposes. Care across acute and primary services and partnership with patients are supported. The system will integrate with secure messaging due to be introduced into the district. Patient’s own mobile devices will be utilised. The app is expected to significantly reduce the number of clinic visits required by stable well-managed gestational diabetics. These cost saving can be fed back into the system. Clinicians will be freed from non-core activities such as administrative tasks and data entry, enabling them to work to their full scope of practice, creating efficiencies and greater job satisfaction. Local needs will specifically be addressed and local policies, procedures and guidelines embodied in the app. Through app use, patient and clinician behaviours will be aligned thereby minimising clinical variation and adverse outcomes. The target population for the POC is English speaking women over the age of 18, diagnosed with GDM at RHW. A subsequent iteration of the app is planned to offer resources in additional languages. Primary stakeholders are: patient consumers; the RHW executive and diabetes service; Eastern Sydney and South Eastern Sydney Medicare Locals (representing communitybased primary services); Information Management Services Directorate, South Eastern Sydney Local Health District (SESLHD); Clinical Efficiency & Evaluation Unit, SESLHD; and New South Wales (NSW) Health. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116666– http://www.ijic.org/ The POC will evaluate clinician and patient adoption of a novel model of care. Theories and methods stem from diverse areas of inquiry including: healthcare delivery; diabetes selfmanagement; health informatics; patient educational technology; transformational learning; social cognition; health literacy; implementation science; social marketing; and commerce. This is the first digital solution of its kind in Australia that we are aware of. Once the POC is successfully completed we aim to roll-out to other sites. There has been interest across our health district in adapting the model to diabetes and chronic disease in general. The system is due to go live in October 2014.

Vitamin D and gestational diabetes: an update.

Vitamin D status (which is involved in glucose homeostasis) is related to gestational diabetes mellitus (GDM). GDM is characterized by increased resistance to and impaired secretion of insulin and results in higher risk of adverse pregnancy outcomes including operative delivery, macrosomia, shoulder dystocia and neonatal hypoglycemia. Women with GDM and their babies are at increased risk for developing type II diabetes. International definitions of vitamin D deficiency and normality are inconsistent. Vitamin D deficiency is common in pregnant women particularly those with poor diets and who have dark skins living in temperate climes with lack of exposure to sunlight. Few interventional studies indicate that supplementation optimizes maternal vitamin D status or improves maternal glucose metabolism. Observational studies about maternal vitamin D status and risk of GDM are conflicting. This could be because of measurement of vitamin D or differences in population characteristics such as ethnicity, geographic location, gestational age at sampling and diagnostic criteria for GDM. Good-quality randomized controlled trials are required to determine whether vitamin D supplementation decreases the risk of GDM or improves glucose tolerance in diabetic women.

Effect of new criteria on the diagnosis of gestational diabetes in women submitted to gastric bypass

BackgroundBariatric surgery has been shown to improve many obesity related co-morbidities, including gestational diabetes mellitus (GDM). Recently, new diagnostic criteria for GDM following the International Association of Diabetes and Pregnancy Study Group recommendations were implemented. The objective of this study was to compare the use of 2 different GDM criteria in diagnostic and pregnancy outcome after Roux-en-Y gastric bypass (RYGB). MethodsPregnant women who had previously undergone RYGB (n = 30) were screened for GDM with Carpenter and Coustan (C&C) criteria (n = 18) or the new diagnostic criteria (n = 12). ResultsNone of the patients screened using C&C criteria where diagnosed with GDM, while 50% of the patients screened with the new criteria had GDM. Among women that underwent oral glucose tolerance tests (OGTT) (n = 19) as required for the new diagnostic criteria, 57.9% developed reactive hypoglycemia. All women diagnosed with GDM had excellent metabolic control during pregnancy and comparing the outcome of these pregnancies and those of women without GDM, there were no significant differences regarding the age at time of surgery or at pregnancy, body mass index before surgery and pregnancy, parity, previous history of GDM, time from surgery to conception, weight lost until pregnancy, weight gain during pregnancy, gestational age at delivery, and birth weight adjusted for gestational age. ConclusionNew GDM diagnostic criteria in post-RYGB pregnant women increased the prevalence of GDM diagnostic without changing pregnancy outcomes. In addition, OGTTs were associated with a high rate of reactive hypoglycemia. These data suggest that alternative GDM diagnostic criteria are needed for these postbariatric patients.

Correlations between fasting plasma glucose level in the first trimester and gestational diabetes mellitus

Objective To investigate the relationships between fasting plasma glucose (FPG) level in early pregnancy and gestational diabetes mellitus (GDM).Methods Data of 11 477 pregnant women who accepted prenatal care in Beijing Obstetrics and Gynecology Hospital from October 2011 to September 2012 were collected.FPG was tested during 8 to 12 weeks of pregnancy in all women and those with FPG＜7.00 mmol/L were recruited.Women accepted 75 g oral glucose tolerance test (OGTT) during 24 to 28 weeks of pregnancy.The GDM diagnostic criteria was with reference to the criteria of International Association of Diabetes and Pregnancy Study Group.Mann-Whitney U test was used to analyze the difference of early pregnancy FPG between normal pregnant women and GDM women.Receiver operating characteristic (ROC) curve was used to analyze the validity and applicability of using early pregnancy FPG in GDM diagnosis.Chi-square test was used to analyze the relationship between the FPG levels and GDM diagnosis.Results There were 1 535 (13.4％) women diagnosed as GDM in 24 to 28 weeks of pregnancy (the rest 9 942 normal cases were taken as the controls).The median FPG level of the GDM group was 4.89 mmol/L (4.62-5.15 mmol/L),which was higher than that of the controls [4.75 mmol/L(4.53-4.98 mmol/L)] (Z=-13.994,P=0.000).The maximum area under curve (AUC),which was used to predict GDM with early pregnancy FPG,was 0.599 (95％ CI:0.582-0.617).Taking FPG 4.88 mmol/L as the cutoff value,the sensitivity was 0.523 and the specificity was 0.645.While taking FPG 5.10 and 5.60 mmol/L as the cutoff value,the sensitivity was 0.334 and 0.068,and the specificity was 0.811 and 0.983,respectively.When the FPG level ≤ 4.09,-4.60,-5.10,-5.60,-6.10 and ≥ 6.10 mmol/L,the GDM diagnostic rate gradually increased [8.5％(23/212),9.9％(335/3 379),12.3％(719/5 858),20.7％(359/1 734),40.2％ (78/194) and 52.5％ (21/40)] (x2=300.523,P=0.000).GDM diagnostic rate in FPG ≤ 4.09,-4.60,-5.10 and-5.60 mmol/L group were lower than that in FPG ≥ 5.60 but ＜6.10 mmol/L group and ≥ 6.10 mmol/L group (x2 were 67.242,164.680,128.125,37.860,55.843,76.856,58.589 and 23.484,all P=0.000) ; GDM diagnostic rate in FPG ≤ 4.09,-4.60,-5.10 mmol/L group were lower than that in FPG ≥ 5.10 but ＜5.60 mmol/L group (x2 were 22.877,113.717 and 78.040,all P=0.000); GDM diagnostic rate in FPG ≥ 4.09 but ＜4.60 mmol/L group was lower than that in FPG ≥ 4.60 but ＜5.10 mmol/L group (x2=11.803,P=0.001).When using abnormal fasting and postprandial OGTT level as GDM diagnostic criteria,the ratio of GDM in early pregnancy FPG level ≥ 5.60 but ＜6.10 mmol/L group and FPG ≥ 6.10 mmol/L group were higher than that of the FPG level ＜5.60 mmol/L group [50.0％ (39/78) and 71.4％ (15/21) vs24.1％ (346/1 436),x2 were 12.456 and 21.443,all P＜0.003].Conclusions Early pregnancy FPG level is not proper to be used as an early diagnostic tool of GDM.However,when early pregnancy FPG level is equal to or greater than 5.60 mmol/L,the incidence of GDM in late pregnancy will increase significantly. Key words: Blood glucose; Pregnancy trimester, first; Diabetes, gestational

Suggested consensus for the diagnosis of gestational diabetes

SUMMARY Recent proposals for the revision of diagnostic criteria for gestational diabetes mellitus (GDM) have engendered worldwide debate. Within and between countries there is disagreement between obstetric, medical and endocrine groups regarding the diagnosis and management of GDM. There have been many articles written recently on this topic in an attempt to clarify opinions and, in some cases, promote a more unified approach. This review aims to discuss the criteria currently in use for the diagnosis of GDM and proposes the universal acceptance of the International Association for Diabetes in Pregnancy Study Group (IADPSG) GDM diagnostic criteria. It also aims to put into perspective the importance of GDM and its increasing prevalence, irrespective of the criteria used for diagnosis. Other factors associated with GDM diagnosis are also covered, including the epidemiology of testing for GDM around the world, the suggested elimination of a two-step diagnostic approach, the cost–effectiveness of testing a...

Translating the HAPO Study into New Diagnostic Criteria for GDM? From HAPO to IADPSG and Back to O’Sullivan

The various strategies to diagnose gestational diabetes mellitus (GDM), starting from O'sullivan, followed by numerous opinions and recommendations and up to the recently published International association of diabetes and pregnancy study groups criteria, have been and still are the subject of extensive and ongoing debate, since the 1960s, and holding, fiercely than ever, nowadays. In this review we shall provide an overlook on the history of GDM diagnosis, concentrating on the interpretation of the hyperglycemia and adverse pregnancy outcome results into clinical guidelines, and the pros and cons for changing the criteria for GDM diagnosis.

Feto-maternal outcomes in women with and without gestational diabetes mellitus according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria

Gestational diabetes mellitus (GDM) is responsible for majority of pregnancies complicated with diabetes mellitus. Both the screening (universal vs. selective) and the diagnostic criteria of GDM has been the subject of considerable controversy. This prospective cohort study was undertaken at Pondicherry Institute of Medical Sciences, Puducherry from August 2011 to July 2012. All the patients attending antenatal clinic underwent oral glucose tolerance test (OGTT) with 75g of anhydrous glucose between 24 and 32 weeks of gestation. Those patients diagnosed as GDM according to IADPSG diagnostic criteria were treated with diet and physical activity with or without insulin. All the antenatal and perinatal outcomes were noted. The prevalence of GDM in our study was 27% (83/304). Out of all the GDM patients, 87% (72/83) cases were diagnosed by raised FBS alone or with other two values. A significant family history of diabetes mellitus was found among GDM mothers compared to non-GDM group (10.8% vs. 3.6%, p=0.01). Insulin was required only in 8 patients for glycemic control. The GDM patients delivered at significantly lower gestational age (p=0.02) with more antenatal complications (25% vs. 12%, p=0.02). Among neonatal outcomes, there was a significant difference only in the need for NICU admission>24h between GDM and non-GDM groups (p=0.02). The prevalence of GDM increases with universal screening using IADPSG diagnostic criteria in India. The antenatal complications are present in up to one fourth of these patients.

Gestational diabetes mellitus: to screen or not to screen?: Is this really still a question?

Discussion about gestational diabetes mellitus (GDM) is slowly creating traction on the best way forward. Recent evidence has confirmed that there is a continuum of risk for adverse maternal and fetal outcomes as the maternal glucose level rises (1,2). There is an increasing number of studies supporting the importance of fuel-mediated teratogenesis, including epigenetic influences, that are leading to intergenerational transmission of type 2 diabetes, features of the metabolic syndrome, and overall amplification of the current diabetes pandemic (3,4). Treatment of women with GDM, variously defined, improves outcomes (5,6). New consensus guidelines for the diagnosis of GDM have been recommended by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) (7) based on the risk of adverse pregnancy outcomes, rather than the long-term maternal diabetes risk, alignment with diabetes complication risks outside of pregnancy, workload, or local consensus (8). Although there has been a vigorous debate about the validity of the IADPSG diagnostic criteria, less attention has been paid to the other recommendations of universal testing and using a one-stage diagnostic glucose tolerance test (GTT) without preliminary risk factor screening and/or a glucose challenge test (GCT). The National Institutes of Health has recently highlighted the need for action toward standardization of GDM diagnostic criteria, but has not advocated adopting any of the IADPSG recommendations. Thus, there remains a recommendation to continue with risk factor screening and the use of a GCT (9). In this issue of Diabetes Care , Avalos …

Gestational diabetes and pregnancy outcome – do we have right diagnostic criteria?

Objective: To determine thresholds of maternal glycemia at which specific adverse pregnancy outcomes occur in high-risk population.Methods: A total of 1002 pregnant women with risk factors for gestational diabetes mellitus (GDM) underwent an originally modified glucose tolerance test (OGTT) with 75 g of glucose. Information on OGTT results and pregnancy outcomes were collected from database and medical records.Results: Large for gestational age (LGA) newborn, infant’s stay in the neonatal intensive care unit (NICU) >24 h, neonatal hyperbilirubinemia and cesarean section due to cephalopelvic disproportion were identified as specific GDM adverse outcomes. In the study group of participants with one or more specific GDM adverse outcomes, mean glycemic values during the modified OGTT (4.2 ± 1.0 mmol/L at 0 min, 6.8 ± 1.7 mmol/L at 30 min, 7.9 ± 2.1 mmol/L at 60 min, 7.7 ± 2.3 mmol/L at 90 min and 7.5 ± 2.3 mmol/L at 120 min) according to Student’s t-test for independent samples were significantly higher than mean glycemic values in the control group of participants without specific adverse outcomes (p < 0.001, p = 0.02, p < 0.001, p < 0.001, p < 0.001).Conclusion: This study provides additional data that support the acceptance of the newly recommended outcome-based GDM diagnostic criteria.

Perspectives on the Proposed Gestational Diabetes Mellitus Diagnostic Criteria

To date, The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria for the diagnosis of gestational diabetes mellitus (GDM) have not been analyzed systematically for medical, social, and economic ramifications if used in substitution for the current GDM diagnostic criteria. The IADPSG dependence on expert opinion and consensus rather than on rigorously obtained outcome measures is concerning given the dramatic changes in clinical intervention and medical-resource reallocation that would follow their wide adoption. This commentary attempts to highlight needed research as well as the key knowledge gaps that should prevent adoption of the revised criteria until their effect on perinatal outcomes and health care costs is determined. In light of the overall, ethnic, and regional variation in GDM prevalence and the demands of increased GDM diagnosis on clinical resources, it may not be realistic and practical to impose universal strategies and standards for diagnosis. The newly proposed criteria may affect medical care negatively, unnecessarily stigmatize patients with a "sick label," and adversely affect health care costs without ensuring the desired improvements in maternal and neonatal outcomes. This commentary serves as a caution to not promote a new endeavor until it has been compared rigorously with current practice and its implications are understood fully.

Better understanding and new insight of genetic risk loci for gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy, and women with GDM are at increased risk for type 2 diabetes mellitus1. Uncomplicated pregnancy is characterized by insulin resistance and enhanced insulin secretion as a compensatory mechanism to maintain normal glucose tolerance (NGT). However, previous studies showed that in women with GDM during pregnancy, the decreased sensitivity of insulin is at a similar level to NGT, but with more pronounced insulin resistance than NGT. These phenomena might contribute to hyperglycemia in addition to defective insulin release2. Furthermore, women with a history of GDM have been considered a high‐risk group for diabetes mellitus. A study reported from Korea showed that Korean women with a history of GDM have a four‐ to fivefold greater risk of developing postpartum diabetes than the general population (Figure 1). The incidence of type 2 diabetes mellitus within 30 years), prepregnant body mass index (>23 kg/m2), family history of type 2 diabetes mellitus, fasting glucose level at the time of GDM diagnosis (>5.8 mmol/L) and early diagnosis of GDM during pregnancy (<26 weeks)3. In contrast, the putative risk factors for type 2 diabetes mellitus in the Korean population include (but are not limited to) old age, urban living, female sex, obesity, smoking, family history of diabetes, impaired liver function, metabolic syndrome, elevated blood pressure and increased triglycerides4. Although all the risk factors have yet to be identified, the aforementioned variables are the key risk factors for diabetes mellitus in Koreans. Most of these risk factors have also been identified as key risk factors in other places including Europe, South America, North America and Africa. As previously mentioned, some of the risk factors, such as family history of diabetes, lipid profile, high blood pressure and obesity, are common risk factors of both type 2 diabetes mellitus and GDM. Thus, one could question whether GDM is another type of diabetes mellitus or a simple identification of existing type 2 diabetes mellitus during pregnancy when physical, metabolic and psychological changes occur dramatically. It was very difficult to answer the question until the advancement of the Genome‐Wide Association Study (GWAS), which enabled the investigation of genetic background. The genome‐wide association (GWA) approach is an emerging methodology that allows us to identify genetic variants with specific loci that predispose individuals to complex traits and/or diseases.

Exercise for pregnant women for preventing gestational diabetes mellitus

Gestational diabetes mellitus (GDM) affects a significant number of women each year. GDM is associated with a wide range of adverse outcomes for women and their babies. Recent observational studies have found physical activity during normal pregnancy decreases insulin resistance and therefore might help to decrease the risk of developing GDM. To assess the effects of physical exercise for pregnant women for preventing glucose intolerance or GDM. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 April 2012), ClinicalTrials.gov (2 April 2012) and the WOMBAT Perinatal Trials Registry (2 April 2012). Randomised and cluster-randomised trials assessing the effects of exercise for preventing pregnancy glucose intolerance or GDM. Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. We included five trials with a total of 1115 women and their babies (922 women and their babies contributed outcome data). Four of the five included trials had small sample sizes with one large trial that recruited 855 women and babies. All five included trials had a moderate risk of bias. When comparing women receiving additional exercise interventions with those having routine antenatal care, there was no significant difference in GDM incidence (three trials, 826 women, risk ratio (RR) 1.10, 95% confidence interval (CI) 0.66 to 1.84), caesarean section (two trials, 934 women, RR 1.33, 95% CI 0.97 to 1.84) or operative vaginal birth (two trials, 934 women, RR 0.83, 95% CI 0.58 to 1.17). No trial reported the infant primary outcomes prespecified in the review.None of the five included trials found significant differences in insulin sensitivity. Evidence from one single large trial suggested no significant difference in the incidence of developing pregnancy hyperglycaemia not meeting GDM diagnostic criteria, pre-eclampsia or admission to neonatal ward between the two study groups. Babies born to women receiving exercise interventions had a non-significant trend to a lower ponderal index (mean difference (MD) -0.08 gram x 100 m(3), 95% CI -0.18 to 0.02, one trial, 84 infants). No significant differences were seen between the two study groups for the outcomes of birthweight (two trials, 167 infants, MD -102.87 grams, 95% CI -235.34 to 29.60), macrosomia (two trials, 934 infants, RR 0.91, 95% CI 0.68 to 1.22), or small-for-gestational age (one trial, 84 infants, RR 1.05, 95% CI 0.25 to 4.40) or gestational age at birth (two trials, 167 infants, MD -0.04 weeks, 95% CI -0.37 to 0.29) or Apgar score less than seven at five minutes (two trials, 919 infants, RR 1.00, 95% CI 0.27 to 3.65). None of the trials reported long-term outcomes for women and their babies. No information was available on health services costs. There is limited randomised controlled trial evidence available on the effect of exercise during pregnancy for preventing pregnancy glucose intolerance or GDM. Results from three randomised trials with moderate risk of bias suggested no significant difference in GDM incidence between women receiving an additional exercise intervention and routine care.Based on the limited data currently available, conclusive evidence is not available to guide practice. Larger, well-designed randomised trials, with standardised behavioural interventions are needed to assess the effects of exercise on preventing GDM and other adverse pregnancy outcomes including large-for-gestational age and perinatal mortality. Longer-term health outcomes for both women and their babies and health service costs should be included. Several such trials are in progress. We identified another seven trials which are ongoing and we will consider these for inclusion in the next update of this review.

Point: The American Diabetes Association and the International Association of Diabetes and Pregnancy Study Groups Recommendations for Diagnosing Gestational Diabetes Should Be Used Worldwide

Various challenge tests have been used around the world for the diagnosis of gestational diabetes mellitus (GDM)2, and substantial variation among these methods has been noted, not only in the amount of glucose for the challenge and the testing intervals but also in the concentration thresholds used for interpretation. The interpretive criteria for these testing approaches have variably been based on the value for predicting future maternal diabetes or been adopted from standards developed with nonpregnant individuals, despite the changes in glucose metabolism known to occur during pregnancy. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study was an observational study of values obtained in blinded 75-g, 2-h oral glucose tolerance tests (OGTTs) for >23 000 pregnancies from 9 different countries around the world (1). The adverse pregnancy outcomes evaluated included birth weight >90th percentile (large for gestational age), fetal hyperinsulinemia, primary cesarean section, neonatal hypoglycemia, neonatal adiposity, shoulder dystocia, and preeclampsia. All adverse outcomes were related directly and significantly to the glucose concentration at each OGTT time point, but there was no obvious inflection point in any of the curves. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) undertook a process to reach consensus on the diagnostic criteria for GDM with respect to their value for predicting adverse pregnancy outcomes and recommended that GDM be diagnosed when one or more of the following plasma glucose values in the 75-g, 2-h OGTT was met or exceeded: fasting, 92 mg/dL (5.1 mmol/L); 1 h, 180 mg/dL (10 mmol/L); 2 h, 153 mg/dL (8.5 mmol/L) (2). According to the HAPO Study data, patients with GDM have an approximate doubling of the likelihood of a baby with a birth weight above the 90th percentile, 2.6 times the likelihood of fetal hyperinsulinemia, twice the likelihood of preeclampsia, and a 40% increase …

Interventions for pregnant women with hyperglycaemia not meeting gestational diabetes and type 2 diabetes diagnostic criteria

Pregnancy hyperglycaemia without meeting gestational diabetes mellitus (GDM) diagnostic criteria affects a significant proportion of pregnant women each year. It is associated with a range of adverse pregnancy outcomes. Although intensive management for women with GDM has been proven beneficial for women and their babies, there is little known about the effects of treating women with hyperglycaemia who do not meet diagnostic criteria for GDM and type 2 diabetes (T2DM). To assess the effects of different types of management strategies for pregnant women with hyperglycaemia not meeting diagnostic criteria for GDM and T2DM (referred as borderline GDM in this review). We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011). Randomised and cluster-randomised trials comparing alternative management strategies for women with borderline GDM. Two review authors independently assessed study eligibility, extracted data and assessed risk of bias of included studies. Data were checked for accuracy. We included four trials involving 543 women and their babies (but only data from 521 women and their babies is included in our analyses). Three of the four included studies had moderate to high risk of bias and one study was at low to moderate risk of bias. Babies born to women receiving management for borderline GDM (generally dietary counselling and metabolic monitoring) were less likely to be macrosomic (birthweight greater than 4000 g) (three trials, 438 infants, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.19 to 0.74) or large-for-gestational (LGA) age (three trials, 438 infants, RR 0.37, 95% CI 0.20 to 0.66) when compared with those born to women in the routine care group. There were no significant differences in rates of caesarean section (three trials, 509 women, RR 0.93, 95% CI 0.68 to 1.27) and operative vaginal birth (one trial, 83 women, RR 1.37, 95% CI 0.20 to 9.27) between the two groups. This review found interventions including providing dietary advice and blood glucose level monitoring for women with pregnancy hyperglycaemia not meeting GDM and T2DM diagnostic criteria helped reduce the number of macrosomic and LGA babies without increasing caesarean section and operative vaginal birth rates. It is important to notice that the results of this review were based on four small randomised trials with moderate to high risk of bias without follow-up outcomes for both women and their babies.

Promoting Health After Gestational Diabetes

The National Diabetes Education Program joins the American College of Obstetricians and Gynecologists (the College) to promote opportunities for obstetrician-gynecologists (ob-gyns) and other primary care providers to better meet the long-term health needs of women with prior gestational diabetes mellitus (GDM) and their children. Up to one third of GDM women may have diabetes or prediabetes postpartum, yet only about half of these women are tested postpartum, and about a quarter are tested 6-12 weeks postpartum. Women with GDM face a lifelong increased risk for subsequent diabetes, primarily type 2 diabetes mellitus. Timely testing for prediabetes may provide an opportunity for ob-gyns to prevent or delay the onset of type 2 diabetes mellitus through diet, physical activity, weight management, and pharmacologic intervention. The College and the American Diabetes Association recommend testing women with a history of GDM at 6-12 weeks postpartum. If the postpartum test is normal, retest every 3 years and at the first prenatal visit in a subsequent pregnancy. If prediabetes is diagnosed, test annually. Because children of GDM pregnancies face an increased risk for obesity and type 2 diabetes mellitus, families need support to develop healthy eating and physical activity behaviors. Current criteria indicate that GDM occurs in 2% to 10% of all pregnancies. If new GDM diagnostic criteria are used, the frequency of GDM may increase to about 18% of pregnancies annually. The projected increase in the number of women with GDM and the potential subsequent associated risks underscore the need for proactive long-term primary care treatment of the mother and her children.

A comparative study of the different diagnostic criteria of gestational diabetes mellitus and its incidence

BackgroundHigh prevalence of diabetes and genetic predisposition to metabolic syndrome among Indians places Indian women at risk to develop gestational diabetes mellitus (GDM) and its complications. Literature defines multiple criteria for GDM. This prospective study compares available diagnostic criteria for GDM in Indian women and their correlation with perinatal morbidity. MethodNine hundred and forty-eight consecutive voluntary nondiabetic pregnant women were recruited for the study. Seven hundred and twenty-three of these (mean age 23.45 years; 75.7% < 25 years) who reported for the follow-up were screened for GDM at 24–28 weeks gestation by American College of Obstetrics and Gynaecology (ACOG) guidelines and World Health Organization (WHO) criteria. Glycated haemoglobin (HbA1c) and fasting and two-hours postglucose plasma insulin levels were also analysed. Pregnancy outcome was known for 291 of these. Concordance of risk factors and perinatal complications was analysed with respect to GDM. ResultsPrevalence of GDM at 24–28 weeks gestation was found to be 4.8% by WHO criteria, 6.36% by Carpenter and Coustan's criteria, and 3.5% by O'Sullivan's criteria. Prevalence was marginally higher in women of higher age, having past history of abortion or family history of diabetes mellitus (DM) (P > 0.05). None of these women had HbA1c > 6%. Relative risk of abnormal delivery (pregnancy outcome) was 1.93, 1.39, and 1.17 in women with GDM by O'Sullivan's, WHO, and Carpenter's criteria, respectively (P > 0.05). Abnormal deliveries were marginally higher in women with high postglucose load insulin levels. Mean weight of the newborns was essentially the same in GDM and nonGDM women by any of the criteria. One-hour and two-hours postglucose values were more sensitive in diagnosing GDM by O'Sullivan's criteria while fasting plasma glucose value had the poorest specificity with 2.5% of nonGDM women having values above the cut-off. Modifications of these criteria did not im-prove their predictive value for abnormal delivery over that of O'Sullivan's criteria. ConclusionPrevalence of GDM and abnormal delivery in women < 35 years of age is low. Therefore, global screening for GDM may not be very useful in women < 25 years of age unless family history of DM or past history of abortion is present. Existing evidence is inadequate to justify the switchover from O'Sullivan's criteria for diagnosis of GDM.