Laboratory diagnosis of gestational diabetes mellitus (original) (raw)
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The post-HAPO situation with gestational diabetes: the bright and dark sides
Acta Diabetologica, 2018
Aim In 2010, in light of the data coming from the HAPO study, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed a new detection strategy and diagnostic criteria for gestational diabetes based on a onestep approach with a 75 g OGTT. This review analyzes and discusses the bright and dark sides of their application. Methods The assessment of these recommendations by the international organizations involved in the care of gestational diabetes and a series of observational, retrospective and prospective studies that have been published since 2010 regarding the use of the IADPSG recommendations have been evaluated. Results The different international associations involved in the care of pregnancy and of pregnancy complicated by diabetes have not taken an univocal position some of which have accepted them, while others have criticized them. Then, the actual application of the approach recommended by the IADPSG for detecting and diagnosing GDM varies, even at centers that reportedly accept the new diagnostic criteria. Conclusion So the challenge lies in making every effort to achieve a global standardization of the strategies for detecting, diagnosing and treating GDM.
Changing the Diagnostic Criteria for Gestational Diabetes Mellitus
D iabetes mellitus is the most common medical complication of pregnancy , with approximately 85% of such cases representing gesta-tional diabetes mellitus (GDM). These women demonstrate impaired glucose tolerance first discovered during pregnancy, which occurs primarily as a result of a state of increased insulin resistance. O'Sullivan originally projected that 50% of women with GDM would develop diabetes in a follow-up study of 22–28 years. 1 Subsequent studies have documented an overall sevenfold increased risk for developing type 2 diabetes after pregnancy complicated by GDM. O'Sullivan's original work of nearly 60 years ago provided the basis for the widely used diagnostic criteria for GDM. Currently in the United States, screening and diagnosis for GDM typically involves a two-step approach based on O'Sullivan's work, which employs an initial 50-g glucose screen followed by a 3-hour diagnostic oral glucose tolerance test (OGTT) using either the Carpenter-Coustan or National Diabetes Data Group criteria. In much of the world, a 2-hour 75-g OGTT is employed to diagnose GDM with varying diagnostic criteria recommended by professional organizations. The lack of an international standard for the diagnosis of GDM has been viewed by some as an obstacle to both collaborative research as well as meaningful interpretation of published clinical studies. Thus, standardization of the diagnostic criteria for GDM might improve the care of affected patients. Importantly, the original diagnostic values after a 100-g OGTT as proposed by O'Sullivan were based on the likelihood of subsequent diabetes and not any specific perinatal or pregnancy-related outcome. This simple fact led many for decades to challenge the overall clinical significance of GDM. In doing so, those who doubted the clinical significance of GDM typically asserted that perinatal outcomes commonly associated with GDM such as macrosomia were simply a function of the high disproportionate obesity rate present in reported GDM cohorts. Thus, over time, these brewing controversies set the stage for conducting a study that would both determine the association between maternal glycemia and perinatal outcomes as well as lay the groundwork for developing universally accepted diagnostic thresholds for GDM. With this in mind, the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study was conceived to aid in the development of internationally agreed-on diagnostic criteria for GDM based on the predictive value for adverse pregnancy outcomes. 2 This multicenter international study provided analysis of blinded 75-g 2-hour OGTT data in 23,316 nondiabetic pregnancies. Increases in each of the three values on the 75-g 2-hour OGTT were associated with graded increases in the likelihood of the following outcomes, among others: large for gestational age (LGA), primary cesarean delivery, fetal insulin levels, and neonatal adi-posity. Importantly, the results were significant after adjustment for several variables, including maternal body mass index and specific study site.
Implementation of new recommendations for the diagnosis of gestational diabetes: a 5-month audit
Clinical Chemistry and Laboratory Medicine, 2000
Background: Recent international recommendations for the diagnosis of gestational diabetes (GD) were implemented in a university hospital. The aim was to audit the appropriateness of use of the new diagnostic approach. Methods: The same 5-month period, one before [2009, traditional two-step oral glucose tolerance test (OGTT) approach, S1] and one after the implementation of new criteria (2010, S2) were compared. Results: In the two periods, 256 (S1) and 245 (S2) pregnant women were examined and 298 (50 g, n = 195; 100 g, n = 103) and 252 (75 g) OGTTs were, respectively, executed. In S1, 54 (27.7 % ) 50 g OGTTs resulted positive and 36 (66.7 % ) of those performed the 100 g OGTT. In addition, three (1.5 % of total) 50 g OGTT negative women were submitted to 100 g OGTT. Sixty-three women did 100 g OGTT only. In total, 14 (13.6 % ) 100 g OGTTs were positive. In S2, 38 (15.1 % ) 75 g OGTTs were positive. In women who did the complete protocol in the hospital, 98.3 % in S1 and 77.0 % in S2 performed the correct protocol (p < 0.0001). Conclusions: In this hospital new recommendations for GD diagnosis are not correctly applied in 23 % of cases. The main issue seems to be the lack of consideration of the new threshold for fasting glycemia (5.1 mmol/L) as a main decisional driver for performing OGTT.
Journal of Maternal-Fetal and Neonatal Medicine, 2014
Objective: The goal of this study is to compare the prevalence and clinical outcomes of a onestep with a two-step screening method, both of which are commonly used for the diagnosis of gestational diabetes mellitus (GDM). Methods: Women who presented for GDM screening and who consented to participate in this study were randomized into two groups. The women in Group 1 (n ¼ 386) were screened using a one-step method (2-h, 75 g oral glucose tolerance test (OGTT)) and in Group 2 (n ¼ 400) by a two-step method (the 50 g glucose challenge test (GCT) followed by the 100 g OGTT). The pregnancies were then classified into three subgroups as follows: women who had negative 2-h 75 g OGTT results according to IADPSG criteria (IADPSG-negative), women with negative 50 g GCT results (GCT-negative) and women with positive 50 g GCT results but negative 3-h 100 g OGTT results according to C&C criteria (C&C-negative). Results: The prevalence of GDM using the one-step and two-step methods was 14.5% and 6%, respectively. In adjusted multivariable regression models, women in the GCT-negative and the C&C-negative groups had greater risk of polyhydramnios than women in the IADPSG-negative group [adjusted prevalence risk ratios (aPR), 1.40; 95% confidence intervals (CI), 1.03-1.91; aPR, 2.76; 95% CI, 1.27-6.02, respectively]. Women in the C&C-negative group had greater risk of pre-eclampsia than women in the IADPSG-negative group (aPR, 3.30; 95% CI, 1.57-6.91). Conclusions: Women who were defined as having normal glucose tolerance by IADPSG had better perinatal outcomes than women who were defined as having normal glucose tolerance by GCT and women who were GCT-positive with a negative OGTT.
Performance of Variables in Screening for Gestational Diabetes
European Endocrinology
Gestational diabetes mellitus (GDM) has traditionally been defined as carbohydrate intolerance, with its onset or first recognition in pregnancy. 1,2 The definition, screening and diagnosis of GDM continue to be subjects of controversy. 3 Recent guidelines have emphasised the importance of the definition of GDM and its distinction from overt diabetes mellitus in pregnancy, because this definition affects the management of the condition during and after pregnancy. 4 Even a mild degree of hyperglycaemia is associated with a linearly increasing rate of adverse pregnancy outcomes, with no inflection point for risk. 5,6 Therefore, a diagnostic cutoff value can be considered arbitrary, and this has created confusion about how best to screen for and diagnose GDM. 3,7 Based on the Hyperglycemia and Adverse Pregnancy Outcomes study, the International Association of Diabetes and Pregnancy Study Group has suggested screening all pregnant women without known pre-existing diabetes or GDM at 24-28 weeks of gestation. The recommended test for screening and diagnosis is the 2-hour 75 g oral glucose tolerance test (OGTT). 8 These recommendations have also been adopted by the World Health Organization (WHO). 4 In contrast, the American College of Obstetricians and Gynecologists (ACOG) suggests that screening should be based on a 50 g OGTT, followed by a 3-hour 100 g OGTT, for the diagnosis. 9 According to the European Association for the Study of Diabetes, the diagnosis of GDM should be based on a 75 g OGTT. 10,11 In the UK, the National Institute for Health and Care Excellence (NICE) guideline suggests that previously healthy pregnant women should be screened only if certain risk factors are present. 12 This approach differs critically from the other well-established guidelines discussed above. In Sweden, the National Board of Health (Socialstyrelsen) adopted the new WHO and International Association of Diabetes and Pregnancy Study Groups thresholds for the diagnosis of GDM in 2015, but leaves it up to local health authorities to specify the strategy for screening. 8,11 However, these guidelines do not provide a national recommendation for screening for GDM because the evidence for different screening strategies was found to be inadequate. 11 The main screening strategy used in Sweden is based on repeated measurements of capillary random plasma glucose (RPG) and the assessment of risk factors for the development of GDM. 13,14 When RPG ≥9.0 mmol/l and/or risk factors for GDM are present, the one-step, 2-hour 75 g OGTT is recommended in gestational weeks 28-32. 15,16 There are several predisposing factors for GDM, including maternal body mass index (BMI) and maternal age. 17,18 Selective screening may be cost-effective, but risk-factor-based screening has been shown to miss a substantial number of women with GDM. 19,20 The use of other strategies,
Variability in diagnostic evaluation and criteria for gestational diabetes
Diabetes Care, 1996
OBJECTIVE -To determine the frequency of screening for gestational diabetes mellitus (GDM) among a population receiving regular prenatal care and to assess the extent to which National Diabetes Data Group (NDDG) criteria for the diagnosis of GDM are used by practicing obstetricians.
2017
BackgroundIn August 2011, the Specialized Center for Diabetes and Pregnancy of the Botucatu Medical School/Unesp adopted a new diagnostic protocol for gestational diabetes mellitus, recommended by the American Diabetes Association and the International Association of the Diabetes and Pregnancy Study Group. The glycemic profile was evaluated using the 75-g oral glucose tolerance test (OGTT) used to diagnose mild gestational hyperglycemia, recognized and treated in our department as gestational diabetes mellitus. The cost-effectiveness of the new guidelines and the continued need for the evaluation of the glycemic profile, as part of our Service protocol, are controversial and require further investigation. We aimed to assess the impact of the new guidelines on the evaluation of mild gestational hyperglycemia and gestational diabetes mellitus, the incidence of adverse perinatal outcomes, and the association between the 75-g OGTT and the glycemic profile for the diagnosis of mild gesta...