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Gestational Diabetes Testing Protocol

  • Author: Sonal J Patel, MD; Chief Editor: George T Griffing, MD  more...
 
Updated: Nov 03, 2014
 

Background

Gestational diabetes mellitus (GDM), defined as any degree of glucose intolerance with onset or first recognition during pregnancy, affects 2-10% pregnancies in the United States.[1, 2] Women with gestational diabetes have a 35-60% chance of developing diabetes mellitus over 10-20 years after pregnancy.[1]

See Clinical Findings in Diabetes Mellitus, a Critical Images slideshow, to help identify various cutaneous, ophthalmologic, vascular, and neurologic manifestations of DM.

Hyperglycemia in pregnancy results in both maternal and fetal complications. Maternal complications consist of hypertension, preeclampsia, increased risk of cesarean delivery, and development of diabetes mellitus after pregnancy. Fetal complications include macrosomia, neonatal hypoglycemia, polycythemia, increased perinatal mortality, congenital malformation, hyperbilirubinemia, respiratory distress syndrome, and hypocalcaemia. Long-term consequences of macrosomia include increased risk of glucose intolerance, diabetes, and obesity in childhood.[3]

The Western diet of high fat, high carbohydrate, and high sodium foods is a significant contributor to excessive weight gain during pregnancy and, thus, a risk factor for developing diabetes. Other risk factors, which should be assessed at the first prenatal visit, include obesity, age greater than 25 years, prior history of gestational diabetes, first-degree relative with diabetes, history of poor obstetrical outcome, and certain ethnic groups.[4]

Women with underlying insulin resistance are at risk for developing GDM. This progression to GDM is thought to be due to physiologic changes of late pregnancy. In pregnancy, human placental lactogen, which is structurally similar to growth hormone, and tumor-necrosis factor-alpha induce changes in the insulin receptor and in post-receptor signaling. Changes in the beta-subunit of the insulin receptor, decreased phosphorylation of tyrosine kinase on the insulin receptor, and alterations in insulin receptor substrate-1 (IRS-1) and the intracytoplasmic phosphatidylinositol 3-kinase (PI3K) appear to be involved in reducing glucose uptake in skeletal muscle tissue.[5]

The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) was a large randomized control trial that investigated the role of screening and treatment of gestational diabetes in reducing perinatal complications, improving maternal outcomes, and affecting quality of life.[6] This trial of 1000 participants showed a composite reduction in serious perinatal morbidity and mortality (death, shoulder dystocia, bone fracture, and nerve palsy) in the intervention group compared to the conventional group. Also, a decrease in prevalence in macrosomia in the intervention group infants and reduced rate of gestational hypertension in the intervention group was found.[6]

Another large, multicenter randomized controlled trial conducted in the United States recruited women with mild gestational diabetes mellitus. One group received treatment consisting of dietary changes, self-monitoring of blood glucose and insulin if needed and the other received the usual prenatal care. Outcomes with respect to perinatal and obstetrical outcomes were compared.[7] This trial of 19,665 participants used slightly different parameters to diagnose gestational diabetes mellitus but had similar outcomes. There was a significant reduction in macrosomia with the treatment group as well as reduction in rates of Cesarean delivery, shoulder dystocia, preeclampsia or gestational hypertension and weight gain.

Finally, the HAPO trial (Hyperglycemia and Adverse Pregnancy Outcomes), which included over 23,000 pregnant women, sought to clarify risks of adverse outcomes associated with various degrees of maternal glucose intolerance less severe than overt diabetes mellitus.[8] The study results showed positive linear correlations between increasing levels of fasting, 1-hour and 2-hour plasma glucose after oral glucose tolerance testing (OGTT), and macrosomia and cord-blood C-peptide levels above the 90th percentile. Weaker associations were noted between glucose levels and cesarean delivery and neonatal hypoglycemia. The secondary outcomes of premature delivery, shoulder dystocia, hyperbilirubinemia, and preeclampsia were also noted to increase in incidence with higher levels of post OGTT glucose levels.[8]

The HAPO trial showed that maternal, fetal, and neonatal outcomes increased significantly with maternal hyperglycemia even at lower threshold ranges than prior diagnostic criteria for GDM. This prompted the International Association of Diabetes and Pregnancy study groups (IADPSG), whose committee consists of members from US and International diabetes organizations, including American Diabetes Association (ADA), and obstetrical organizations, to revise recommendations for diagnosing GDM. Whereas previously in the 2005 Fifth International Workshop-Conference on Gestational Diabetes Mellitus screening was based on risk stratification, now the IADPSG along with the ADA recommend that all women with no prior history of diabetes undergo 75-g Glucola oral glucose tolerance test (OGTT) at 24-28 weeks gestation.[9, 10]

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Indications

All pregnant women need to be screened for gestational diabetes. The timing of the screening depends on risk factor assessment. Pregnant women with no known history of diabetes are screened at 24-28 weeks gestation. Women at high risk for GDM are screened at the first prenatal visit. A 75-g 2-hour OGTT is the test of choice in both groups.[9]

The risk factors for GDM are as follows:

  • Increased weight (ie, BMI greater than or equal to 25)
  • Decreased physical activity
  • First degree relative with diabetes
  • Member of ethnic group with high prevalence of diabetes (African American, Latino, Native American, Asian American, Pacific Islander)
  • Prior history of GDM or delivery of a baby greater than 9 pounds
  • Metabolic abnormalities - Hypertension, HDL less than 35 mg/dL, triglyceride level greater than 250 mg/dL
  • HbA1C 5.7% or higher
  • Impaired glucose tolerance or impaired fasting glucose testing in the past
  • Evidence of insulin resistance (acanthosis nigricans or severe obesity)
  • History of cardiovascular disease

The 75-g Glucola OGTT is best performed after an overnight fast; the diagnosis is made if fasting plasma glucose is documented at 92mg/dL or higher, a 1-hr plasma glucose of 180 mg/dL or higher, or a 2-hr plasma glucose of 153 mg/dL or higher. The diagnosis of gestational diabetes is confirmed with a minimum of one abnormal value. The cut-offs were based on the prior HAPO study outcomes.[11]

The standard criteria for the diagnosis of diabetes is as follows:

  • HbA1c of 6.5% or higher
  • Fasting plasma glucose of 126 mg/dL or higher or
  • 2-h plasma glucose of 200 mg/dL or higher during an 75-g OGTT or
  • A symptomatic patient with random plasma glucose of 200 or higher (all plasma glucose values are recorded as mg/dL).

The pregnant women who meet the above criteria are considered to have overt type 2 diabetes mellitus.[9]

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Contraindications

No known contraindications to gestational diabetes testing protocol, although some patients may experience nausea, gastric irritation, and delayed emptying from the Glucola.

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Technical Considerations

Two major changes from the previous diagnostic guidelines are lower diagnostic cut points for the fasting, 1-hour and 2-hour plasma glucose measurements and needing only one abnormal value to make the diagnosis versus 2 abnormal values in the previous guidelines. The implications of increased health care costs and a predictable increase in the diagnosis of GDM, possibly up to 18% of all pregnancies, have not been studied yet.[11] Also, the intensity of monitoring and treating these women is not yet known in terms of maternal and neonatal outcomes.[9, 11]

Comparatively, the American College of Obstetricians and Gynecologists (ACOG) has not adopted the IADPSG and ADA guidelines in gestational diabetes testing protocol.[12] In the most recent committee opinion, September 2011, ACOG recommends screening for GDM at initial prenatal visit by history, risk factors or 50 gram/1-hour OGTT. The diagnosis of GDM continues to be based on the 100 gram/3-hour tolerance test using the Carpenter and Coustan cutoffs of fasting less than 95mg/dL, 1-hr less than 180 mg/dl, 2-hr less than 155 mg/dL, and 3-hr less than 140 mg/dL, with 2 or more abnormal values to confirm diagnosis.

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Outcomes

As stated above, diagnosis of GDM is made if any of the following plasma glucose values are exceeded after 75 grams Glucola is given:

  • Fasting of 92 mg/dL or higher (5.1 mmol/L)
  • 1 hour of 180 mg/dL or higher (10 mmol/L)
  • 2 hour of 153 mg/dL or higher (8.5 mmol/L)
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Contributor Information and Disclosures
Author

Sonal J Patel, MD Fellow, Department of Endocrinology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine

Sonal J Patel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Medical Association, American Thyroid Association, Endocrine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Deepika Reddy, MD Assistant Professor of Medicine, Texas A&M Health Science Center College of Medicine; Attending Physician, Department of Endocrinology and Metabolism, Scott and White Clinic

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

References
  1. National Diabetes Information. Clearinghouse (NDIC). http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#Gestational. 2011.

  2. Metzger BE, Coustan DR. Proceedings of the Fourth International Work-shop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 1998. 21 (Suppl. 2):B1–B167.

  3. Setji TL, Brown AJ, Feinglos MN. Gestational Diabetes Mellitus. Clinical Diabetes. 2005. 23:17-24.

  4. Jovanovic L, Pettitt DJ. Gestational diabetes mellitus. JAMA. 2001 Nov 28. 286(20):2516-8. [Medline].

  5. Metzger BE, Buchanan TA. Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 2005. 30 (Suppl. 2):S251-260.

  6. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005 Jun 16. 352(24):2477-86. [Medline].

  7. Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med. 2009 Oct 1. 361(14):1339-48. [Medline].

  8. Lowe LP, Metzger BE, Dyer AR, Lowe J, McCance DR, Lappin TR, et al. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associations of maternal A1C and glucose with pregnancy outcomes. Diabetes Care. 2012 Mar. 35(3):574-80. [Medline]. [Full Text].

  9. American Diabetes Association. Standards of Medical Care in Diabetes-2011. Diabetes Care. 2011. 34 (Suppl. 1):S11-61.

  10. McIntyre HD, Metzger BE, Coustan DR, Dyer AR, Hadden DR, Hod M, et al. Counterpoint: establishing consensus in the diagnosis of GDM following the HAPO study. Curr Diab Rep. 2014 Jun. 14(6):497. [Medline]. [Full Text].

  11. Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010 Mar. 33(3):676-82. [Medline].

  12. American College of Obstetricians and Gynecologists. Screening and diagnosis of gestational diabetes mellitus. Committee Opinion No. 504. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2011. 118:751-3.

  13. Tieu J, McPhee AJ, Crowther CA, Middleton P. Screening and subsequent management for gestational diabetes for improving maternal and infant health. Cochrane Database Syst Rev. 2014 Feb 11. 2:CD007222. [Medline].

  14. Carson MP, Morgan B, Gussman D, Brown M, Rothenberg K, Wisner TA. SUGAR: Spotting Undiagnosed Glucose Abnormal Results-A New Protocol To Increase Postpartum Testing Among Women With Gestational Diabetes Mellitus. Am J Perinatol. 2014 Aug 5. [Medline].

 
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