International Workshop-Conference Research Articles

APPROXIMATION OF DIFFERENTIATION OPERATORS BY BOUNDED LINEAR OPERATORS IN LEBESGUE SPACES ON THE AXIS AND RELATED PROBLEMS IN THE SPACES OF \((p,q)\)-MULTIPLIERS AND THEIR PREDUAL SPACES

We consider a variant \(E_{n,k}(N;r,r;p,p)\) of the four-parameter Stechkin problem \(E_{n,k}(N;r,s;p,q)\) on the best approximation of differentiation operators of order \(k\) on the class of \(n\) times differentiable functions \((0<k<n)\) in Lebesgue spaces on the real axis. We discuss the state of research in this problem and related problems in the spaces of multipliers of Lebesgue spaces and their predual spaces. We give two-sided estimates for \(E_{n,k}(N;r,r;p,p)\). The paper is based on the author's talk at the S.B. Stechkin's International Workshop-Conference on Function Theory (Kyshtym, Chelyabinsk region, August 1–10, 2023).

Prevalence, risk factors and perinatal outcomes of gestational diabetes in Mexican adolescents when applying diagnostic criteria from three different international guidelines

To compare the prevalence, risk factors and perinatal outcomes of gestational diabetes mellitus (GDM) for Mexican adolescent population when applying different diagnostic criteria based on the 2-h 75-g oral glucose tolerance test, as established by three international guidelines. Comparative, observational, and retrospective study, which included pregnant women under 19 years, who underwent screening for GDM in our center. Data were obtained from the hospital’s electronic records and were analyzed using descriptive statistics. The X2 test was used to compare group proportions. Statistical significance was set at p ≤ 0.05. A total of 999 adolescents were screened for GDM. The observed prevalence was 3%, 14.4%, and 29.3% when using the Fifth International Workshop-Conference on Gestational Diabetes Mellitus (FIWC), National Institute for Health and Care Excellence (NICE-2015), and International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, respectively. Of our sample, 42.5% presented at least one risk factor. An association was observed regarding the need for cesarean section in patients with GDM diagnosed through IADPSG criteria (OR = 1.35, p = 0.04). On the other hand, the use of the FIWC and NICE standards showed an association between GDM and obstetric hemorrhage (OR = 17.8, p = 0.000, and OR = 4.8, p = 0.01, respectively) and preeclampsia with severity criteria (OR = 5.1, p = 0.001, and OR = 2.4, P = 0.025, respectively). The prevalence of GDM in adolescents is high, and we can conclude that the prevalence varies based on which international diagnostic guideline is applied. While there is an association with adverse pregnancy outcomes such as hypertensive disorders of pregnancy, obstetric hemorrhage, and the need for cesarean section, this requires further evaluation.

HbA1c levels in patients with gestational diabetes mellitus: Relationship with pre-pregnancy BMI and pregnancy outcome.

The use of glycated hemoglobin (HbA1c) measurement in gestational diabetes mellitus (GDM) is controversial. Aim of the present study was to determine HbA1c levels in a series of GDM patients, in order to verify the possible contribution of HbA1c to GDM management. The study included 148 caucasian GDM patients. GDM screening was performed between the 24th and the 28th week of gestation by a two-step procedure, according to the 4th and 5th International Workshop Conference on Gestational Diabetes Mellitus recommendations. Exclusion criteria were: preexisting diabetes, corticosteroid therapy, history of asthma or hypertension, known fetal anomaly, history of previous stillbirth, preterm delivery considered to be likely for either maternal disease or fetal conditions. HBA1c was determined by a standard HPLC technique. At GDM diagnosis, all HbA1c levels were ≤ 6% and the greatest frequency (71/148; 48.0%) of HbA1c values resulted in the range 5.0-5.3%. This frequency increased to 54% before delivery. A significant correlation between HbA1c values at GDM diagnosis and individual BMI prior to conception was observed. The proportion of pregnancies presenting negative outcomes increased progressively with increasing HbA1c levels, from 6.2% (1/16) for HbA1c levels <5% to 18.3% (13/71) for HbA1c 5.0-5.3%, to 37.8% (17/45) in patients with HBA1c levels 5.4-5.6%, to 56.2% (9/16) for HbA1c levels >5.6%. ROC analysis showed that HbA1c at diagnosis and before delivery resulted a good predictor of adverse pregnancy outcome. The present results indicate that HbA1c levels could be of help in predicting adverse pregnancy events.

New International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosing gestational diabetes compared with former criteria: a retrospective study on pregnancy outcome

The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) Consensus Panel recommends new criteria for diagnosing gestational diabetes. We evaluated the clinical and metabolic characteristics, and pregnancy outcome, in women previously classifiable as 'normal' according to the 4th International Workshop Conference on gestational diabetes criteria, but reclassified as 'abnormal' according to the new recommendations. Using the new IADPSG criteria, 3953 pregnancies were retrospectively reclassified as 1815 women with normal glucose tolerance and 2138 with gestational diabetes, 112 (2.8%) of whom would have been classified as normal according to the older criteria. Of the 2138 women classified as abnormal by the new criteria, the 112 women now reclassified as abnormal were younger and had a lower pre-pregnancy BMI than the 2026 women who had also been classified as abnormal by the previous criteria. The 100-g oral glucose tolerance test showed significantly higher glucose levels in these 112 women than in the 1815 women reclassified as normal (P < 0.0001). Caesarean section was significantly more frequent (P < 0.01) and the ponderal index for the newborn significantly higher in these reclassified women than in those classified as normal (P < 0.0001), and their basal glucose levels correlated significantly with the ponderal index (P < 0.05). The new criteria for diagnosing gestational diabetes identified a group of women previously classifiable as normal according to the 4th International Workshop Conference criteria, but revealing metabolic characteristics and pregnancy outcomes resembling those of women who would have been considered to have gestational diabetes by the previous criteria.

News and Notes

News and Notes

Management of gestational diabetes by physicians in Turkey

Aims We sought to investigate the practice patterns of clinicians (family physicians, internists and obstetricians) in Turkey in screening for gestational diabetes mellitus (GDM), management and monitoring of hyperglycaemia in pregnant women with GDM, and assessment of glucose tolerance in the postpartum state. Methods Between January and December 2007, current practices of Turkish physicians ( n = 434) were assessed by a questionnaire which was concerned with physician demographics and clinical practice including screening and diagnostic methods for GDM, management of GDM during pregnancy and postpartum assessment of glucose tolerance. The questionnaire was developed in respect to the recommendation of the Fifth International Workshop-Conference on GDM and the standards of the American Diabetes Association (ADA). Results Although most of the physicians stated that they performed screening for GDM and postpartum screening for glucose intolerance in women with GDM, their screening practices vary. The proportion of women who were provided with a nutrition counselling by a registered dietician and a patient education by a trained nurse was low, especially in women treated by the family physicians. Home glucose monitoring was widely used in the management of GDM, however, postprandial glucose assays were used occasionally. Regular and NPH insulin preparations were the most preferred drugs to treat GDM. Internists were more likely to use insulin analogues. On the other hand, a significant number of physicians stated that they used oral antidiabetics (OADs). A considerable number of family physicians used OADs which have not been proved to be safe in pregnancy. Conclusions Our results suggest that there is considerable variation in the clinical practice patterns of physicians. An education program to enhance the clinical aptitude of physicians, particularly family physicians, in the medical management of GDM should be designed throughout the country.

News and Notes

News and Notes

Neue Erkenntnisse zur Diagnostik und Management des Gestationsdiabetes

Physiology and current knowledge about gestational diabetes which led to the adoption of new diagnostic criterias and blood glucose target levels during pregnancy by the Swiss Society for Endocrinology and Diabetes are reviewed. The 6th International Workshop Conference on Gestational Diabetes mellitus in Pasedena (2008) defined new diagnostic criteria based on the results of the HAPO-Trial. These criteria were during the ADA congress in New Orleans in 2009 presented. According to the new criteria there is no need for screening, but all pregnant women have to be tested with a 75 g oral glucose tolerance test between the 24th and 28th week of pregnancy. The new diagnostic values are very similar to the ones previously adopted by the ADA with the exception that only one out of three values has to be elevated in order to make the diagnosis of gestational diabetes. Due to this important difference it is very likely that gestational diabetes will be diagnosed more frequently in the future. The diagnostic criteria are: Fasting plasma glucose > or = 5.1 mmol/l, 1-hour value > or = 10.0 mmol/l or 2-hour value > or = 8.5 mmol/l. Based on current knowledge and randomized trials it is much more difficult to define glucose target levels during pregnancy. This difficulty has led to many different recommendations issued by diabetes societies. The Swiss Society of Endocrinology and Diabetes follows the arguments of the International Diabetes Federation (IDF) that self-blood glucose monitoring itself lacks precision and that there are very few randomized trials. Therefore, the target levels have to be easy to remember and might be slightly different in mmol/l or mg/dl. The Swiss Society for Endocrinology and Diabetes adopts the tentative target values of the IDF with fasting plasma glucose values < 5.3 mM and 1- and 2-hour postprandial (after the end of the meal) values of < 8.0 and 7.0 mmol/l, respectively. The last part of these recommendations deals with the therapeutic options during pregnancy (nutrition, physical exercise and pharmaceutical treatment). If despite lifestyle changes the target values are not met, approximately 25 % of patients have to be treated pharmaceutically. Insulin therapy is still the preferred treatment option, but metformin (and as an exception glibenclamide) can be used, if there are major hurdles for the initiation of insulin therapy.

The Impact of Risk Factors and More Stringent Diagnostic Criteria of Gestational Diabetes on Outcomes in Central European Women

In the face of the ongoing discussion on the criteria for the diagnosis of gestational diabetes (GDM), we aimed to examine whether the criteria of the Fourth International Workshop Conference of GDM (WC) select women and children at risk better than the World Health Organization (WHO) criteria. This was a prospective longitudinal open study in five tertiary care centers in Austria. The impact of risk factors, different thresholds (WC vs. WHO), and numbers of abnormal glucose values (WC) during the 2-h, 75-g oral glucose tolerance test on fetal/neonatal complications and maternal postpartum glucose tolerance was studied in 1466 pregnant women. Women were treated if at least one value according to the WC (GDM-WC1) was met or exceeded. Forty-six percent of all women had GDM-WC1, whereas 29% had GDM-WHO, and 21% of all women had two or three abnormal values according to WC criteria (GDM-WC2). Eighty-five percent of the GDM-WHO were also identified by GDM-WC1. Previous GDM [odds ratio (OR) 2.9], glucosuria (OR 2.4), preconceptual overweight/obesity (OR 2.3), age 30 yr or older (OR 1.9), and large-for-gestational age (LGA) fetus (OR 1.8) were the best independent predictors of the occurrence of GDM. Previous GDM (OR 4.4) and overweight/obesity (OR 4.0) also independently predicted diabetes postpartum. GDM-WC1 had a higher rate of obstetrical complications (LGA neonates, neonatal hypoglycemia, cesarean sections; P < 0.001) and impaired postpartum glucose tolerance (P < 0.0001) than GDM-WHO. These results suggest the use of more stringent WC criteria for the diagnosis of GDM with the initiation of therapy in case of one fasting or stimulated abnormal glucose value because these criteria detected more LGA neonates with hypoglycemia and mothers with impaired postpartum glucose metabolism than the WHO criteria.

Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus

The Fifth International Workshop-Conference on Gestational Diabetes Mellitus (GDM) was held in Chicago, IL, 11–13 November 2005 under the sponsorship of the American Diabetes Association. The meeting provided a forum for review of new information concerning GDM in the areas of pathophysiology, epidemiology, perinatal outcome, long-range implications for mother and her offspring, and management strategies. New information and recommendations related to each of these major topics are summarized in the report that follows. The issues regarding strategies and criteria for the detection and diagnosis of GDM were not reviewed or discussed in detail, since it is anticipated that the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study will provide data in mid-2007 that will foster the development of criteria for the diagnosis of GDM that are based on perinatal outcomes. Thus, for the interim, the participants of the Fifth International Workshop-Conference on GDM endorsed a motion to continue use of the definition, classification criteria, and strategies for detection and diagnosis of GDM that were recommended at the Fourth Workshop-Conference. Those guidelines are reproduced (with minor modifications) in this article in appendix Tables 1 and 2. The invited lectures, topical discussions, and posters presented at the conference and the invited manuscripts that appear in this issue of Diabetes Care served as the basis for the following summary and recommendations. ### Pathophysiology #### General considerations. Current diagnostic criteria assign the diagnosis of GDM to women with glucose levels in the upper ∼5–10% of the population distribution. The hyperglycemia varies in severity from glucose concentrations that would be diagnostic of diabetes outside of pregnancy to concentrations that are asymptomatic and only slightly above normal, but associated with some increased risk of fetal morbidity. Like all forms of hyperglycemia, GDM is characterized by insulin levels that are insufficient to meet insulin demands. The causes of pancreatic β-cell dysfunction that …

Low Birth Weight as a Risk Factor for Gestational Diabetes, Diabetes, and Impaired Glucose Tolerance During Pregnancy

Small size at birth as a risk factor for the development of diabetes or other metabolic disorders has been described in numerous populations over the past 2 decades (1–12). Most studies dealing with children or nonpregnant adults have reported an inverse linear relationship between birth size and the prevalence of disease (1–4,6–10), but the relationship among the Pima Indians from Arizona has been described as “U-shaped” because the high risk is seen in individuals with high birth weight as well as low birth weight (5). Several reasons for this relationship have been proposed (13) and a similar finding was subsequently reported among schoolchildren in Taiwan (11). Since the 4th International Workshop-Conference on Gestational Diabetes Mellitus, where the association between a woman's birth weight and gestational diabetes mellitus (GDM) or pregestational diabetes was first presented (14), there have been several similar reports in the literature. The purpose of this article is to review some of the recently published data on this relationship, which is well described in the general population but still less studied among pregnant women. Table 1 presents results of studies presenting data on a woman's birth weight as a risk factor for GDM (14– …

Contraception After Gestational Diabetes

Women with prior gestational diabetes mellitus (GDM) are at risk of developing overt diabetes, predominantly type 2 diabetes, after pregnancy, often during their reproductive years (1–4). Type 2 diabetes will often be present without symptoms years before the clinical diagnosis is made. Women with type 2 diabetes often do not plan their pregnancy (5) or enter pregnancy with unrecognized diabetes. In both cases, an increased risk of congenital malformations in the offspring has been found (5–7). Similar to type 1 diabetes, this risk has been shown to increase with increasing maternal hyperglycemia (8). Although intervention trials are lacking in type 2 diabetic women, studies in type 1 diabetic women have shown that the proportion of congenital malformations can be reduced to a background population value by prepregnancy planning, including optimization of metabolic control (8). Contraception is an essential component to be able to plan pregnancy when glucose status is normalized and may also confer protection from developing diabetes by preventing a subsequent pregnancy (9). Recent studies show that women with previous GDM exhibit a markedly increased prevalence of the metabolic syndrome, even when glucose tolerance is normal (10,11). Metabolic syndrome is associated with an increased risk of cardiovascular disease and mortality (12). For both maternal and future offspring, women with prior GDM need safe, efficient, and acceptable choices for contraceptive methods that do not enhance their already substantial risk to develop either overt diabetes or metabolic syndrome and associated sequelae. Studies on contraception in women with prior GDM are limited, especially new studies published since the Fourth International Workshop-Conference on GDM (13). The present article provides a condensed review of contraceptive methods available for women with prior GDM, focusing on recent studies. When data in women with prior GDM are unavailable, extrapolations will …

Obstetric Management in Gestational Diabetes

Reviewing the areas of controversy related to the obstetric management of women with GDM, we are unfortunately unable to provide significant refinement of the recommendations agreed upon after the Fourth International Workshop-Conference due to the lack of properly controlled and powered clinical studies in this area since 1997. In the area of the need for antenatal fetal surveillance in women with milder degrees of GDM, we may be able to draw indirect conclusions from ongoing cohort studies that will include large numbers of women. In the area of optimal timing and mode of delivery to avoid fetal injury, large well-controlled prospective studies do not currently exist and are urgently needed. In addition, refinement of fetal and pelvic imaging techniques to more accurately identify the maternal-fetal pairs most likely to benefit from avoiding vaginal delivery, and the more widespread availability of these technologies, may also prove to be of benefit in the obstetric management of women with GDM.

Incidencia de la diabetes mellitus gestacional según distintos criterios diagnósticos en la zona suroeste de Madrid. Influencia del diagnóstico sobre los parámetros maternofetales

BACKGROUND. In 1997, The Fourth International Workshop-Conference on Gestational Diabetes Mellitus (GDM) recommended the use of Carpenter and Coustan diagnostic criteria instead of those of Sullivan and Mahan used until then. The objective of this work was to study the incidence of GDM in the southeast Madrid area by applying both the classical and new criteria, as well as to determine whether patients diagnosed of GDM by the new criteria present a higher materno-fetal morbidity than treated GDM patients or non diabetic pregnant patients.Methods. Review of a cohort of 1,293 pregnant women from September 1998 to August 1999 who were screened for GDM. The annual cumulated incidence of GDM was estudied by using both diagnostic criteria and materno-fetal evolution of four groups of patients classified according to glucose intolerance degree. RESULTS. The annual cumulated incidence of GDM was 4.8% and 7.3% using the classical criteria and the new criteria, respectively. GDM patients fulfilling only the new criteria and not treated as such had children with a significantly higher birth-weight than the other groups, and a trend towards a higher percentage of macrosomies, instrumental deliveries and cesarean sections in such group was observed, although they were not statistically significant. CONCLUSIONS. The incidence of GDM in the southeast Madrid area was similar to that among other Caucasian populations and increased by 52% when the new diagnostic criteria were used. It is our opinion that a study with a larger number of patients should be conducted before the new diagnostic criteria are applied in our country.

The impact of lower threshold values for the detection of gestational diabetes mellitus

Objective: To compare the 4th International Workshop-Conference on Gestational Diabetes Mellitus (GDM) 100-g OGTT (NEW) criteria to the current ACOG criteria.Methods: An analysis of a comprehensive perinatal database (1991–1998) identified women with singletons who underwent a 100-g OGTT after an abnormal 50-g GCT performed at 24 weeks or more. Women were classified into three groups for comparison: those who met the ACOG criteria and received diet or insulin therapy or both; those who did not meet ACOG criteria, but did meet the NEW criteria; and those who met neither criteria (non-GDM).Results: Of 3,253 women, 478 women met ACOG criteria, 319 women would have been reclassified as GDM by the NEW criteria, and 2,456 women met neither criteria. The selected characteristics and outcomes (%) for the three groups are as follows: legendlegendCesareanLGABWT ≥4,000 gShoulder dystociaNon-GDM17.518.49.75.5NEW21.828.117.07.3ACOG26.529.016.58.7P value<0.0001<0.0001<0.0001NSlegendLGA indicates large for gestational age; BWT, birth weight.After controlling for confounders (including maternal weight, age, race, parity, and smoking status), the adjusted odds ratios and 95% CI, compared with non-GDM women are as follows: CesareanLGABWT ≥4,000 gShoulder dystociaNEW1.4 (1.0, 1.9)1.3 (0.98, 1.8)1.6 (1.1, 2.3)1.7 (0.6, 4.6)ACOG1.5 (1.1, 1.9)1.5 (1.2, 2.0)1.4 (1.0, 2.0)2.5 (1.1, 5.5)Conclusions: At our institution, utilization of the NEW criteria would increase the diagnosis of GDM by 40% and identify gravidas with similar risks of cesarean delivery and macrosomia as those with GDM diagnosed by ACOG criteria. Whether or not standard GDM therapy in women with the disease diagnosed by the NEW criteria can reduce the incidence of cesarean delivery and macrosomia to rates comparable with non-GDM women remains to be verified by well-designed randomized controlled studies.

Evaluation des 50 g-Glukose-Screeningtests an 1416 Schwangeren

Einleitung: Glukosetoleranzstörungen gehören zu den häufigsten Erkrankungen in der Schwangerschaft. Die mit ihnen verbundenen Risiken betreffen Mutter und Kind. Die Diagnosestellung erfolgt anhand biochemischer Parameter, z.B. dem oralen Glukosetoleranztest (oGTT). Allerdings herrscht über die zu verwendenden Kohlenhydratdonatoren und die jeweiligen Grenzwerte Uneinigkeit, die u.a. für die weltweit unterschiedlichen Angaben über die Häufigkeit dieser Erkrankung von 1-12% verantwortlich ist. Um Gestationsdia-betikerinnen möglichst frühzeitig zu entdecken und zu therapieren, wurde in vielen Ländern ein 50g-Screeningtest eingeführt. Bei diesem Test bekommt jede Schwangere zwischen der 24. und 28. Schwangerschaftswoche ohne Berücksichtigung der letzten Mahlzeit und der Tageszeit 50 g Oligosaccharid, gelöst in 200 ml Flüssigkeit. Nach einer Stunde wlrd die Blutglukosekonzentration gemessen, bei Überschreiten von 140mg/dl soil nach den Empfehlungen der Deutschen Diabetes Gesellschaft ein oGTT durchgeführt werden. Material und Methoden: In einer prospektiven Studie solite an einer unselektierten Patient^nnengruppe von 1416 Patientinnen die Häufigkeit dieser Erkrankurrg geprüft werden. Folgende Fragen sollten beantwortet werden: 1. Rechtfertigt die Häufigkeit des Gestationsdiabetes die Einführung eines generellen Screenings in Deutschland? 2,Sind klinisch relevante Auswirkungen einer ausbleibenden Behandlung nachweisbar? 3. Ist die Komplikationsrate bei Patientinnen mit einer „Impaired glucose tolerance“ (IGT) gegenüber dem Normalkollektiv erhöht? Hierzu wurden alle Schwangerenakten postpartal durchgesehen, um auch die nachfolgend erkrankten Patientinnen aufzudecken. Ergebnisse: 26.3% (372/1416) der Patientinnen wiesen einen erhöhten Screeningwert auf. Von diesen ließen 264 einen oGTT durchführen, 108 erschienen aus verschiedenen Gründen nicht zur weiteren Diagnostik. Bei 38% (100/264) wurde durch den nachfolgend durchgeführten oGTT ein Gestationsdiabetes diagnostiziert, 27% (71/264) hatten zumindest einen erhöhten Wert (IGT). Von 50 Patientinnen mit normalem Screeningergebnis wurde aufgrund einer klinischen Diagnose ein oGTT durchgeführt. dieser bewies bei 7 (14%) Patientinnen ebenfalls einen Gestationsdiabetes. Die Gesamthäufigkeit des Gestationsdiabetes in dem untersuchten Kollektiv betrug demnacti 8.2% (107/1308). Dabei ließen sich nationalitätsspezifische Unterschiede nachweisen. Aus den untersuchten Patientinnen ließen sich sechs Gruppen bilden (Kontrollgruppe, IGT, GDM, Gruppe mit ausschließlich erhöhtem Screening bzw. ausschließlich erhöhtem oGTT, Gruppe ohne Therapie), an denen sich Unterschiede hinsichtlich anthropometrischer Daten sowie im outcome, gemessen an der Rate vaginal-operativer Entbindungen sowie Schnittentbindungen, dem Kindsgewicht und der Anzahl von Neugeborenenverlegungen und der Entwicklung einer schwa ngerschaftsinduzierten Hypertonie, nachweisen ließen. Ferner wird gezeigt. daß auch die Patientinnen mit nur einem erhöhten Wert (IGT) einer strafferen Stoffwechsel-führung bedürfen. Schlußfolgerung: Anhand der Auswertung klinischer Parameter in den sechs Gruppen verdeutlicht die vorliegende Studie die Notwendigkeit der Einführung des 50g-Screeningtests in Deutschland und damit seine Aufnahme in die Mutterschaftsrichtlinien. Es gibt keinen Grund, den in Deutschland lebenden Patientinnen diesen Test weiterhin vorzuenthalten.

Screening for gestational diabetes mellitus in Korea

Objectives: To examine the effect of clinical characteristics on the prevalence of gestational diabetes mellitus (GDM) and to find the most effective screening program for GDM in Korea. Methods: Universal screening with a 50-g glucose load at 24–28 weeks' gestation, as recommended by the Third International Workshop-Conference on Gestational Diabetes Mellitus, was carried out among 3581 consecutive Korean women. Women with a 1-h plasma glucose ≥ 130 mg/dl underwent a 3-h 100-g oral glucose tolerance test. The women's clinical characteristics and risk factors for GDM were recorded at the time of the screening test. Results: The overall prevalence of GDM in Korean women was 2.2 cases/100. Although only 1.3% of this population was obese, the prevalence of GDM was found to be significantly increased with increasing body mass index. When 135 mg/dl is used as a threshold, the number of women requiring a diagnostic test decreases to 19.5%, enabling identification of 98.8% of women with GDM. Conclusion: Universal screening using 135 mg/dl as a threshold and early screening of those with two or more risk factors represent the most effective paradigm for Korea.

Summary and Recommendations of the Third International Workshop-Conference on Gestational Diabetes Mellitus

The Third International Workshop-Conference on Gestational Diabetes Mellitus (GDM) was convened in Chicago, Illinois, on 8 November 1990 as an invitational meeting sponsored by the American Diabetes Association with the cooperation of the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the National Diabetes Advisory Board, the Centers for Disease Control, and the Diabetic Pregnancy Study Group of the European Association for the Study of Diabetes. The meeting provided a forum for the review of new information concerning GDM in the areas of diagnosis and prevalence, perinatal and long-range implications, and management strategies.

1990 Overview of GDM: Accomplishments of the Last Decade—Challenges for the Future

The First International Workshop-Conference on Gestational Diabetes Mellitus (GDM) was held in the fall of 1979 on the campus of Northwestern University Medical School. The purpose of that event was to examine the impact of mild disturbances of maternal metabolism on fetal development. The conference sought to “establish how such disturbances can be detected most effectively; whether all pregnant subjects should be examined for them; and whether positive identification justifies therapeutic attempts at rectification” (1). In his opening remarks, Norbert Freinkel (1) anticipated some of the issues that are of greatest importance more than a decade later. In particular, he stressed the public-health implications that would follow national and worldwide detection of GDM. Five years later, the Second International Workshop-Conference on GDM provided an opportunity for reappraisal of many of the same issues. The proceedings of each conference concluded with summary statements drafted by the participants (2,3). Both included the recommendation that all women (not known to have diabetes) should be screened for glucose intolerance during pregnancy by measurement of plasma glucose after an oral glucose challenge. The recommendations from the second conference formed the basis of a position statement on GDM that was adopted by the board of directors of the American Diabetes Association (4).

Gestational Diabetes Mellitus: Levels of Glycemia as Management Goals

In the United States, glucose tolerance test criteria for the diagnosis of gestational diabetes mellitus are, in plasma glucose after a 100-g challenge, as follows: fasting, greater than 5.8 mM; 1 h, greater than 10.6 mM; 2 h, greater than 9.2 mM; and 3 h, greater than 8.1 mM; any two values must be elevated. The Second International Workshop-Conference on Gestational Diabetes Mellitus recommended in 1985 that, once diagnosed, women should receive dietary therapy. If fasting or 2-h postprandial hyperglycemia later occurs (fasting, greater than 5.8 mM; 2-h, greater than 6.7 mM), insulin therapy should begin. Data from others have suggested both that the criteria for diagnosis may be too liberal and that the thresholds for instituting insulin therapy may be too high. We address these two issues by reviewing several papers with conflicting conclusions. There is controversy over whether women with gestational diabetes diagnosed by glucose tolerance testing, but who have fasting plasma glucose levels less than 5.8 mM and 2-h postprandial values less than 6.7 mM, should also be insulin treated. Finally, the usual clinical criteria for making therapeutic decisions all rely on glycemia. Other fuels (amino acids, lipids, and ketones) are regulated by circulating insulin and have deleterious effects on fetal development. Further study is required to make more sound clinical decisions based not just on glycemia but on the entire metabolic milieu.