Corresponding author. Based on their diagnostic criteria, there are different glucose cut-offs and strategies to diagnose GDM [ 2 ]. As a consequence, more women who had mild hyperglycemia were diagnosed with GDM. However, those studies were retrospective, and the comparison groups were women with normal glucose tolerance or GDM determined through different glucose cut-off values or diagnostic methods, such as g OGTT [ 8 , 9 , 10 ]. A recent study reported that no differences were noted between untreated and treated patients diagnosed by the IADPSG criteria [ 11 ].
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ORs are for the difference in glucose between the mean glucose value and the recommended threshold. In addition to the outcomes used to determine the thresholds, there were strong associations between maternal glucose and preeclampsia ORs 1.
The frequencies of HAPO study outcomes when all three glucose measures were below threshold values and when any one or more values were greater than or equal to threshold concentration were compared supplemental Table B.
Other considerations Measurement of glucose. The frequencies and ORs for outcomes on which the recommended diagnostic thresholds are based increase substantially over relatively small changes in glucose concentration supplemental Fig.
Therefore, to achieve reliable diagnosis and classification of hyperglycemia in pregnancy, clinical laboratories must measure venous plasma or serum glucose using an enzymatic method with high accuracy and precision. This includes proper sample collection and processing to minimize pre-analytic glycolysis and proper laboratory analysis 34 , Capillary and venous plasma glucose concentrations differ and are not interchangeable, and conversion factors do not accurately estimate equivalent values Consideration was given to glucose values and outcome frequencies for adjusted ORs of 1.
The threshold OR of 1. At ORs of 2. Rounding threshold values to easy-to-remember numbers. Values such as 5. However, this strategy is not feasible. First, as indicated above, arbitrarily choosing an FPG threshold of 5. Second, both Si and standard units are widely used, and the numbers are not equally easy or difficult to remember for both units of measure. The values in Table 1 represent the best choice from a clinical perspective, and they meet the predefined strength of association from an epidemiological perspective.
Randomized treatment trials and choice of threshold values. Two randomized controlled trials comparing active treatment versus standard obstetric care for mild GDM have been conducted during the years in which the HAPO study was carried out 47 , Recruitment processes and glycemic values of participants were not identical in the randomized controlled trials and the HAPO observational study. However, there was substantial overlap between glucose values used for inclusion in the randomized controlled trials and those recommended in this report as new threshold values.
Although not directly comparable, it was concluded that results of the two randomized controlled trials 47 , 48 and HAPO 25 , 26 are highly complementary. The definition has applied whether or not insulin is used for treatment or hyperglycemia persists after pregnancy.
The possibility that unrecognized glucose intolerance antedated the pregnancy is not excluded. This facilitates a uniform strategy for detection and classification of GDM but has limitations. As ongoing epidemics of obesity and diabetes result in more type 2 diabetes in young women, the number who are undiagnosed before pregnancy is increasing 49 , The need to identify these women and address perinatal risks that may be particular to their greater degree of hyperglycemia is becoming more important.
Several arguments were made for identifying as a distinct group women with overt diabetes: Increased risk of congenital anomalies in offspring Risk of diabetes complications nephropathy and retinopathy requiring treatment during pregnancy Need for rapid treatment and close follow-up during pregnancy to ensure prompt restoration of normal glycemia 53 , Need to ensure confirmation and appropriate treatment of diabetes after pregnancy.
Identification of overt diabetes When and how to identify women with overt diabetes during pregnancy not previously diagnosed and how to define overt diabetes were considered during the IADPSG Pasadena meeting and subsequently. There was uniform agreement that this assessment should be made during the initial visit for prenatal care.
There was debate about performing universal early testing or limiting testing to those women classified as high risk according to locally defined criteria. It was acknowledged that background population prevalence of diabetes in young women and extent of previous testing for metabolic disturbances vary greatly in different regions.
Furthermore, it has not been determined whether universal testing early in pregnancy to detect overt diabetes is either of clinical value or cost-effective.
Cost and standardization of A1C testing are issues for consideration, and hemoglobin variants are prevalent in some populations. Attending the first prenatal visit in the fasting state is impractical in many settings. Consensus thresholds recommended for the individual glycemia measures are indicated in Table 1. Other considerations Timing of the initial test.
It is desirable to detect overt diabetes in pregnancy as early as possible to provide an opportunity to optimize pregnancy outcome. However, there is variability in time of enrollment for prenatal care beyond the control of health care providers.
Accordingly, no limit is placed on the timing of initial assessment for detection of overt diabetes in pregnancy. Indeterminate results of initial testing. It was recognized that any assessment of glycemia in early pregnancy would also result in detection of milder degrees of hyperglycemia short of overt diabetes.
Recently, it was reported that higher first-trimester FPG levels lower than those diagnostic of diabetes are associated with increased risks of later diagnosis of GDM and adverse pregnancy outcomes Two discrete phases are included. The first is detection of women with overt diabetes not previously diagnosed or treated outside of pregnancy.
Universal early testing in populations with a high prevalence of type 2 diabetes is recommended, especially if metabolic testing in this age-group is not commonly performed outside of pregnancy. Well-designed studies should be conducted to determine whether it is beneficial and cost-effective to perform an OGTT in women who do not have overt diabetes at early testing but have indeterminate nondiagnostic results.
Postpartum glucose testing should be performed for all women diagnosed with overt diabetes during pregnancy or GDM. The strategy outlined in Table 2 will finally lead to using a g glucose dose for an OGTT in all clinical settings in or outside of pregnancy. In most areas, using the outcome-linked diagnostic criteria in Table 1 and the detection strategy in Table 2 will substantially increase the frequency of hyperglycemic disorders in pregnancy.
However, this is consistent with the high prevalence of obesity and disorders of glucose metabolism in the general population of young adults 21 , 22 and with recent reports of a rising prevalence of GDM and preexisting overt diabetes in pregnant women Future considerations In future clinical practice, simpler and more cost-effective strategies that do not require performing an OGTT on most pregnant women may be developed.
However, it was thought that using FPG to potentially identify pregnancies at very low risk for GDM and for adverse outcomes requires further evaluation.
Similarly, further evaluation of A1C results from the HAPO study, results from other populations, or new integrated tests of glycemia with a shorter timeframe than A1C might serve this purpose.
The HAPO study was a basic epidemiological investigation that for the first time conclusively identified strong continuous associations of maternal glucose levels below those diagnostic of diabetes with several perinatal outcomes.
It was not a clinical trial, but two randomized controlled trials of treatment of mild GDM have been carried out successfully in participants with glucose values that overlap with the thresholds recommended in this report.
However, it is likely that additional well-designed randomized controlled trials and other clinical studies will be needed to determine 1 cost-effective therapeutic strategies for treatment of GDM diagnosed by the IADPSG Consensus Panel—recommended criteria; 2 optimal glycemic treatment targets; 3 appropriate follow-up of mothers to determine risks for later development of diabetes, other metabolic disorders, or CVD risk factors; and 4 follow-up of children to assess potential associations of maternal glycemia with long-term risks of obesity, altered glucose metabolism, and CVD risk factors.
Supplementary Material Click here to view. No other potential conflicts of interest relevant to this article were reported. Footnotes The costs of publication of this article were defrayed in part by the payment of page charges.
Section solely to indicate this fact. See accompanying editorial, p. References 1. Diabetes Care ;32 Suppl. Diabetes Care ; 21 Suppl. Diabetes ;— [ PubMed ] [ Google Scholar ] 4. Diabetes Care ;30 Suppl. Jarrett RJ: Reflections on gestational diabetes. Lancet ;— [ PubMed ] [ Google Scholar ] 8. New York, Oxford University Press, , p. Coustan DR: Management of gestational diabetes: a self-fulfilling prophecy?
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Treatment of gestational diabetes diagnosed by the IADPSG criteria decreases excessive fetal growth
Adverse pregnancy outcomes APOs , including preterm birth, required Cesarean section, preeclampsia, macrosomia and low birth weight, were recorded and analyzed. Download PDF Introduction Gestational diabetes mellitus GDM is one of the most common medical complications during pregnancy and its prevalence appears to be increasing around the world, probably because of the increase in the number of women of child-bearing age who are overweight, of older age, and have sedentary lifestyles. There is mounting evidence that treatment of even mild GDM reduces morbidity for both the mother and baby. However, the diagnostic criteria for GDM vary greatly worldwide among different countries or even different regions in the same country, although great effort has been invested to reach a consensus over the past half century. In , the Hyperglycemia and Adverse Pregnancy Outcomes HAPO study 3 reported that the increase in glucose levels close to but lower than that traditionally required for the diagnosis of GDM were significantly associated with subsequent adverse pregnancy outcomes.