Testing for gestational diabetes during the COVID-19 pandemic. An evaluation of proposed protocols for the United Kingdom, Canada and Australia

The Impact of Telemedicine during the COVID-19 Pandemic on Diabetes Management and Pregnancy Outcomes in Women with Gestational Diabetes Mellitus (GDM)

Background/Objectives: Gestational diabetes mellitus (GDM) can lead to various complications for both the mother and the child. Many factors influence the onset of the disease including GDM in a previous pregnancy, overweight and obesity, as well as the increasing age of women who become pregnant. The aim of this study was to assess the impact of telemedicine during the COVID-19 pandemic on diabetes management and pregnancy outcomes in women with gestational diabetes mellitus (GDM). Methods: A retrospective analysis was conducted. We compared two groups of GDM women from the pandemic and pre-pandemic periods in terms of pregnancy course and obstetric outcomes. Results: It was observed that women with GDM in the pandemic group were significantly more often overweight and significantly less often obese before pregnancy than women in the pre-pandemic group. GDM was diagnosed significantly earlier but in later pregnancies in the pandemic group than in the pre-pandemic group. The course of pregnancy in both groups was similar and the percentage of pregnancies with the delivery of neonates > 4000 g did not differ significantly. The number of caesarean sections and spontaneous deliveries was also similar in both periods. No differences were found in anthropometric parameters in newborns and neonatal and maternal complications. Conclusions: The occurrence of the COVID-19 pandemic and the necessity of employing telemedicine tools in the medical care of women with GDM did not significantly impact diabetes management and the pregnancy outcomes achieved.

Changes in screening, diagnosis, management, and outcomes of gestational diabetes during the COVID-19 pandemic: A systematic review

Background

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy, and it can lead to complications for the mother and the infant/fetus. This was especially evident during the COVID-19 pandemic. Therefore, the present systematic review aimed to describe the changes in screening, diagnosis, management, and outcomes of gestational diabetes during the COVID-19 pandemic.

Methods

The systematic review was conducted from December 2019 until January 1, 2022. To find articles related to the purpose of the study, PubMed, Scopus, Web of Science, and WHO were searched using relevant and validated keywords using MeSH/Emtree.

Results

In total, 675 entries were ascertained from the database inquiry, and 17 scholarly works were deemed suitable for inclusion in the final review. The salient conclusions derived from this review were as follows: (a) During the COVID-19 pandemic, there was a significant decrease in the use of OGTTs and a rise in the use of HbA1c assays for both GDM screening and diagnosing. (b) A predominant number of physicians incorporated some variation of telemedicine to remotely supervise and conduct follow-up evaluations of patients with GDM. Various strategies are presented for the provision of prenatal care to women afflicted with GDM, such as concentrating on high-risk demographics, the initiation of lifestyle modifications at early stages, and the implementation of remote patient monitoring techniques. The 'single test procedure' is identified as the most suitable for the preliminary screening of GDM. The OGTT should be assigned clinical precedence in patients at high risk during the ongoing COVID-19 pandemic. Additionally, Medical Nutrition Therapy (MNT) was established as the primary management strategy, and the most influential determinant of the transition from dietary adjustments to pharmacotherapy was the Fasting Blood Glucose (FBG) levels during the second trimester.

Conclusion

Suggested strategies for GDM screening and management during the pandemic integrated into routine antenatal care, emphasized the importance of remote diabetes education and technology utilization during health emergencies.

Use of the Japanese gestational diabetes mellitus diagnostic strategy during the COVID-19 pandemic in Japan: A questionnaire survey

AIM

Some concerns exist that diagnosis of gestational diabetes mellitus (GDM) may be missed when the simplified diagnostic criteria of the Japanese Society of Diabetes and Pregnancy (JSDP) for GDM (published during the COVID-19 pandemic) are used. Moreover, limited data is available regarding how widespread these diagnostic criteria are used when managing GDM during the COVID-19 pandemic. Therefore, this study aimed to determine how GDM diagnosis has changed during the COVID-19 pandemic in Japan.

METHODS

The changes in GDM diagnosis during the COVID-19 pandemic were investigated using an online questionnaire to 2159 obstetric facilities in Japan. The questionnaire collected data on facility type, awareness of Japanese GDM diagnostic strategies, modifications to diagnostic methods for early and late GDM, and opinions on GDM management, with the pandemic divided into seven periods.

RESULTS

We received responses from 593 facilities (27%). Approximately 90% of the facilities did not change their diagnostic process for early GDM or late GDM (occurring after 24 weeks gestation). However, during the COVID-19 pandemic, 19 facilities discontinued the use of 75-g oral glucose tolerance tests before 24 weeks of gestation, and 17 facilities discontinued it after 24 weeks of gestation, instead using the aforementioned Japanese GDM diagnostic strategy.

CONCLUSIONS

Although a limited number of facilities modified their diagnostic method in response to the COVID-19 pandemic, this study demonstrated that those that adjusted their diagnostic method primarily used the Japanese COVID-19 GDM strategy by the JSDP.

Impact of COVID-19 on gestational diabetes pregnancy outcomes in the UK: A multicentre retrospective cohort study

OBJECTIVE

To determine the impact of implementing emergency care pathway(s) for screening, diagnosing and managing women with gestational diabetes (GDM) during COVID-19.

DESIGN

Retrospective multicentre cohort.

SETTING

Nine National Health Service (NHS) Hospital Trusts/Health boards in England and Scotland.

POPULATION

4915 women with GDM pre-pandemic (1 April 2018 to 31 March 2020), and 3467 women with GDM during the pandemic (1 May 2020 to 31 March 2021).

METHODS

We examined clinical outcomes for women with GDM prior to and during the pandemic following changes in screening methods, diagnostic testing, glucose thresholds and introduction of virtual care for monitoring of antenatal glycaemia.

MAIN OUTCOME MEASURES

Intervention at birth, perinatal mortality, large-for-gestational-age infants and neonatal unit admission.

RESULTS

The new diagnostic criteria more often identified GDM women who were multiparous, had higher body mass index (BMI) and greater deprivation, and less frequently had previous GDM (all p < 0.05). During COVID, these women had no differences in the key outcome measures. Of the women, 3% were identified with pre-existing diabetes at antenatal booking. Where OGTT continued during COVID, but virtual care was introduced, outcomes were also similar pre- and during the pandemic.

CONCLUSIONS

Using HbA1c and fasting glucose identified a higher risk GDM population during the pandemic but this had minimal impact on pregnancy outcomes. The high prevalence of undiagnosed pre-existing diabetes suggests that women with GDM risk factors should be offered HbA1c screening in early pregnancy.

Comparing the screening methods for gestational diabetes mellitus before and during the COVID-19 pandemic: A systematic review

BACKGROUND

The oral glucose tolerance test (OGTT) is the gold standard for detecting gestational diabetes mellitus (GDM). However, during the COVID-19 pandemic, screening practices were reevaluated due to the risk of infection associated with the prolonged hospital visit required for the OGTT. Some countries have published novel screening protocols for GDM, suggesting the utilization of hemoglobin A1c (HbA1c), random plasma glucose (RPG), or fasting plasma glucose (FPG) in favor of OGTTs during the pandemic. Therefore, differences in screening methods before and after the epidemic need to be examined.

METHODS

A systematic search was carried out across five electronic databases (Cinahl, Medline, Embase, Pubmed, and Web of Science) between 2016 and 2023. The Critical Appraisal Skills Programme (CASP) checklist for cohort studies was used to evaluate the quality of included papers.

RESULTS

A total of 13 eligible studies were included. Prior to the COVID-19 pandemic, the OGTT was the recommended measure to screen GDM, internationally based on various official guidelines. During the pandemic, it was recommended that HbA1c or FPG, or RPG be used as a substitute for OGTTs. However, the new methods have low sensitivity, may not reflect accurately the prevalence of GDM, and may lead to many false-negative results in women and to adverse pregnancy and neonatal outcomes.

CONCLUSION

The new screening methods for GDM have poor accuracy and a high risk of adverse pregnancy outcomes. Comparatively, targeted screening tests to detect GDM according to the risk level are more effective in an emergency. In the future, the alternatives to OGTTs still need to be further explored in more depth.

COVID-19, Pregnancy, and Diabetes Mellitus

During the severe acute respiratory distress virus coronavirus type 2 (SARS-CoV-2) pandemic, many women were infected during their pregnancies. The SARS-CoV-2-induced coronavirus disease 19 (COVID-19) has an impact on maternal health and pregnancy outcomes; peripartum and perinatal morbidity and mortality are increased. Pregnancy is considered a risk factor for severe COVID-19 course. Additional risk factors during pregnancy are diabetes mellitus, gestational diabetes mellitus (GDM), and obesity. Systemic inflammation can lead to severe metabolic dysregulation with ketoacidosis. The endocrine pancreas is a target organ for SARS-CoV-2 and the fetal risk depends on inflammation of the placenta. Up to now there is no evidence that SARS-CoV-2 infection during pregnancy leads to permanent diabetes in mothers or their offspring via triggering autoimmunity or beta cell destruction. The frequently observed increased prevalence of GDM compared to the years before the pandemic is most likely due to changed lifestyle during lockdown. Furthermore, severe COVID-19 may be associated with the development of GDM due to worsening of glucose tolerance. Vaccination with a mRNA vaccine is safe and highly effective to prevent infection and to reduce hospitalization. Registries support offering evidence-based recommendations on vaccination for pregnant women. Even with the current omicron virus variant, there are increased risks for symptomatic and unvaccinated pregnant women.

Impact of a modified screening approach during the COVID-19 pandemic on the diagnosis and outcomes of gestational diabetes mellitus: A population-level analysis of 90,518 pregnant women

AIMS

To provide real-world evidence on the uptake of and outcomes associated with the modified gestational diabetes mellitus (GDM) screening approach offered during the COVID-19 pandemic compared with the standard screening approach.

METHODS

All pregnancies between 01 January 2020 and 31 December 2021, in Alberta, Canada, were included in the study. We examined GDM screening and diagnosis rates, and large-for-gestational-age (LGA) outcomes.

RESULTS

Annual GDM screening rates were > 95% during the study time period. Overall, 84.7%, and 11.6% of the 92,505 pregnancies underwent standard and modified screening for GDM, respectively. The use of modified screening was the highest among deliveries in August 2020 (49.8%) which corresponded to the early first wave of the pandemic. GDM diagnosis rate was lower in the modified screening (7.4%) than in the standard screening (12.3%, p < 0.001) group. The LGA rates in the modified screening with GDM and the standard screening with GDM groups were 24.8% and 12.6%, respectively (p < 0.001). Women in the modified screening with GDM group were at a higher risk of having an LGA infant (adjusted odds ratio: 3.46; 95% confidence interval: 2.93, 4.08) compared to the standard screening with no GDM group.

CONCLUSIONS

The COVID-19 epidemic had no impact on screening for GDM. Women who underwent modified screening, based on HbA1c/random plasma glucose, had lower rates of GDM cases.

Employing fasting plasma glucose to safely limit the use of oral glucose tolerance tests in pregnancy: a pooled analysis of four Norwegian studies

Background/objective

There is no international consensus about the optimal approach to screening and diagnosis of gestational diabetes mellitus (GDM). Fasting plasma glucose (FPG) has been proposed as an alternative universal screening test to simplify the diagnosis of GDM. We investigate the ability of the FPG to predict a 2-hour glucose value below the cut-off for GDM, thereby "ruling out" the necessity of a full OGTT and assess the proportion of GDM-related complications associated with the identified FPG level.

Materials and methods

This study included secondary data from four Norwegian pregnancy cohorts (2002-2013), encompassing 2960 women universally screened with late mid-pregnancy 75g OGTT measuring FPG and 2-hour glucose. For a range of FPG thresholds, we calculated sensitivity to predict elevated 2-hour glucose, number of OGTTs needed and percentage of GDM cases missed, applying modified World Health Organization (WHO) 2013 criteria (2013WHO) and 2017 Norwegian criteria (2017Norwegian). We analyzed pregnancy outcomes for women above and below our selected threshold.

Results

The prevalence of GDM was 16.6% (2013WHO) and 10.1% (2017Norwegian). A FPG threshold of 4.7 mmol/L had a sensitivity of 76% (2013WHO) and 80% (2017Norwegian) for detecting elevated 2-hour glucose, with few missed GDM cases (2.0% of those ruled out and 7.5% of all GDM cases for 2013WHO, and 1.1% of those ruled out and 7% of all GDM cases for 2017Norwegian). When excluding women with FPG <4.7mmol/l and those with GDM based on FPG, only 24% (2013WHO) and 29% (2017Norwegian) would require OGTT. Women with FPG <4.7mmol/l, including missed GDM cases, had low risk of large-for-gestational-age newborns, cesarean section and operative vaginal delivery.

Conclusion

A FPG threshold of 4.7mmol/l as a first step when screening for GDM could potentially eliminate the need for OGTT in 70-77% of pregnancies. Women with FPG below this threshold appear to carry low risk of GDM-associated adverse pregnancy outcomes.

Gestational diabetes mellitus screening and diagnosis criteria before and during the COVID-19 pandemic: a retrospective pre-post study

OBJECTIVE

To determine whether perinatal outcomes after excluding gestational diabetes mellitus (GDM) on the basis of fasting venous plasma glucose (FVPG) assessment during the coronavirus disease 2019 (COVID-19) pandemic in 2020 were similar to those during the preceding year after excluding GDM using the standard oral glucose tolerance test (OGTT) procedure.

DESIGN

Retrospective pre-post study.

SETTING, PARTICIPANTS

All women who gave birth in Queensland during 1 July - 31 December 2019 and 1 July - 31 December 2020.

MAIN OUTCOME MEASURES

Perinatal (maternal and neonatal) outcomes for pregnant women assessed for GDM, by assessment method (2019: OGTT/glycated haemoglobin [HbA1c ] assessment; 2020: GDM could be excluded by an FVPG value below 4.7 mmol/L).

RESULTS

3968 of 29 113 pregnant women in Queensland during 1 July - 31 December 2019 (13.6%) were diagnosed with GDM, and 4029 of 28 778 during 1 July - 31 December 2020 (14.0%). In 2020, FVPG assessments established GDM in 216 women (1.1%) and excluded it in 1660 (5.8%). The frequencies of most perinatal outcomes were similar for women without GDM in 2019 and those for whom it was excluded in 2020 on the basis of FVPG values; the exception was caesarean delivery, for which the estimated probability increase in 2020 was 3.9 percentage points (95% credibility interval, 2.2-5.6 percentage points), corresponding to an extra 6.5 caesarean deliveries per 1000 births. The probabilities of several outcomes - respiratory distress, neonatal intensive care or special nursery admission, large for gestational age babies - were about one percentage point higher for women without GDM in 2020 (excluding those diagnosed on the basis of FVPG assessment alone) than for women without GDM in 2019.

CONCLUSIONS

Identifying women at low absolute risk of gestational diabetes-related pregnancy complications on the basis of FVPG assessment as an initial step in GDM screening could reduce the burden for pregnant women and save the health system substantial costs.

Performance of glycated hemoglobin A1c for the diagnosis of gestational diabetes mellitus during the SARS-CoV-2 pandemic in Belgium (2020-2021)

OBJECTIVES

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, health care access was restricted. To reduce the risk of maternal SARS-CoV-2 infection, simplified screening recommendations for gestational diabetes mellitus (GDM) have been suggested, leading to glycated hemoglobin A1c (HbA1c) being proposed as an alternative to the oral glucose tolerance test (OGTT). This study aimed to assess the optimal HbA1c cutoff to confirm GDM diagnosis according to IADPSG/WHO2013 guidelines.

METHODS

In this retrospective study, 3361 pregnancies were followed at the hospital of Mouscron and the Cliniques Universitaires St Luc in Brussels (2020-2021). GDM was universally screened in the third trimester of gestation. The ROC curve was used to evaluate the diagnostic performance of HbA1c with OGTT as the reference. Sensitivity, specificity and likelihood ratios for different HbA1c thresholds were calculated.

RESULTS

In total, 312 women were selected due to HbA1c analysis in addition to OGTT, and 149 had GDM. The area under the ROC curve for GDM detection by HbA1c was 0.73 (95% CI 0.68-0.79, p < 0.0001). The cutoff value chosen as a possible threshold was HbA1c 5.5% (37 mmol/mol). The sensitivity, specificity, positive and negative likelihood ratios for this cutoff were 12.0%, 99.4%, 20 and 0.88, respectively. The Fagan nomogram test showed a posttest GDM probability of approximately 70%, corresponding to a 10-fold higher pretest probability. An HbA1c ≥ 5.5% (37 mmol/mol) would have avoided OGTT in 18% of women with GDM. These women with an HbA1c ≥ 5.5% had significantly higher rates of family history of diabetes, older age, higher BMI and higher blood glucose levels (fasting, 1 h and 2 h) at OGTT.

CONCLUSION

Our results are consistent with the literature concerning the diagnostic ability of GDM through HbA1c ≥ 5.5%.

Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

BACKGROUND

Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association.

CONTENT

Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed.

SUMMARY

The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.

Gestational diabetes mellitus and COVID-19: The epidemic during the pandemic

During the global coronavirus disease 2019 (COVID-19) pandemic, people worldwide have experienced an unprecedented rise in psychological distress and anxiety. In addition to this challenging situation, the prevalence of diabetes mellitus (DM), a hidden epidemic, has been steadily increasing in recent years. Lower-middle-income countries have faced significant barriers in providing accessible prenatal care and promoting a healthy diet for pregnant women, and the pandemic has made these challenges even more difficult to overcome. Pregnant women are at a higher risk of developing complications such as hyper-tension, preeclampsia, and gestational diabetes, all of which can have adverse implications for both maternal and fetal health. The occurrence of gestational diabetes has been on the rise, and it is possible that the pandemic has worsened its prevalence. Although data is limited, studies conducted in Italy and Canada suggest that the pandemic has had an impact on gestational diabetes rates, especially among women in their first trimester of pregnancy. The significant disruptions to daily routines caused by the pandemic, such as limited exercise options, indicate a possible link between COVID-19 and an increased likelihood of experiencing higher levels of weight gain during pregnancy. Notably, individuals in the United States with singleton pregnancies are at a significantly higher risk of excessive gestational weight gain, making this association particularly important to consider. Although comprehensive data is currently lacking, it is important for clinical researchers to explore the possibility of establishing correlations between the stress experienced during the pandemic, its consequences such as gestational gain weight, and the increasing incidence of gestational DM. This knowledge would contribute to better preventive measures and support for pregnant individuals during challenging times.

Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

BACKGROUND

Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association of Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association.

CONTENT

Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (Hb A1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of Hb A1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed.

SUMMARY

The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.

MIDO GDM: an innovative artificial intelligence-based prediction model for the development of gestational diabetes in Mexican women

Given the barriers to early detection of gestational diabetes mellitus (GDM), this study aimed to develop an artificial intelligence (AI)-based prediction model for GDM in pregnant Mexican women. Data were retrieved from 1709 pregnant women who participated in the multicenter prospective cohort study 'Cuido mi embarazo'. A machine-learning-driven method was used to select the best predictive variables for GDM risk: age, family history of type 2 diabetes, previous diagnosis of hypertension, pregestational body mass index, gestational week, parity, birth weight of last child, and random capillary glucose. An artificial neural network approach was then used to build the model, which achieved a high level of accuracy (70.3%) and sensitivity (83.3%) for identifying women at high risk of developing GDM. This AI-based model will be applied throughout Mexico to improve the timing and quality of GDM interventions. Given the ease of obtaining the model variables, this model is expected to be clinically strategic, allowing prioritization of preventative treatment and promising a paradigm shift in prevention and primary healthcare during pregnancy. This AI model uses variables that are easily collected to identify pregnant women at risk of developing GDM with a high level of accuracy and precision.

Clinicians' perspectives on gestational diabetes screening during the global COVID-19 pandemic in Australia

AIM

There is no international consensus for the screening and diagnosis of gestational diabetes mellitus (GDM). In March 2020, modified screening and diagnostic recommendations were rapidly implemented in Queensland, Australia, in response to the COVID-19 pandemic. How clinicians perceived and used these changes can provide insights to support high-quality clinical practice and provide lessons for future policy changes. The aim of this study was to understand clinicians' perceptions and use of COVID-19 changes to GDM screening and diagnostic recommendations.

METHODS

Queensland healthcare professionals responsible for diagnosing or caring for women with GDM were recruited for semi-structured telephone interviews. Data analysis of transcribed interviews used inductive reflexive thematic analysis.

RESULTS

Seventeen interviews were conducted with the following participants: six midwives/nurses, three endocrinologists, two general practitioners, two general practitioners/obstetricians, two diabetes educators, one dietitian and one obstetrician. Three themes emerged: communication and implementation, perceptions and value of evidence and diversity in perceptions of GDM screening. Overall, clinicians welcomed the rapid changes during the initial uncertainty of the pandemic, but as COVID-19 became less of a threat to the Queensland healthcare system, some questioned the underlying evidence base. In areas where GDM was more prevalent, clinicians more frequently worried about missed diagnoses, whereas others who felt that overdiagnosis had occurred in the past continued to support the changes.

CONCLUSIONS

These findings highlight the challenges to changing policy when clinicians have diverse (and often strongly held) views.

Gestational diabetes screening from the perspective of consumers: Insights from early in the COVID-19 pandemic and opportunities to optimise experiences

BACKGROUND

Consumer perspectives are a cornerstone of value-based healthcare. Screening and diagnosis of gestational diabetes mellitus (GDM) were among many of the rapid changes to health care recommended during the COVID-19 pandemic. The changes provided a unique opportunity to add information about women's perspectives on the debate on GDM screening.

AIMS

The aim of this qualitative study was to explore women's perspectives and understanding of GDM screening and diagnosis comparing the modified COVID-19 recommendations to standard GDM screening and diagnostic practices.

METHODS

Women who had experienced both the standard and modified GDM screening and diagnostic processes were recruited for telephone interviews. Data analysis used inductive reflexive thematic analysis. Online surveys were disseminated to any registrant not included in interviews to provide an opportunity for all interested participants to provide their perspective.

RESULTS

Twenty-nine telephone interviews were conducted and 19 survey responses were received. Seven themes were determined: (1) information provision from clinicians; (2) acceptability of GDM screening; (3) individualisation of GDM screening methods; (4) safety nets to avoid a missed diagnosis; (5) informed decision making; (6) women want information and evidence; and (7) preferred GDM screening methods for the future.

CONCLUSIONS

Overall, women preferred the modified GDM screening recommendations put in place due to the COVID-19 pandemic. However, their preference was influenced by their prior screening experience and perception of personal risk profile. Women expressed a strong need for clear communication from health professionals and the opportunity to be active participants in decision making.

Impact of Covid-19 on rates of gestational diabetes in a North American pandemic epicenter

AIMS

We assessed the impact of Covid-19 on gestational diabetes rates in Quebec, the pandemic epicenter of Canada.

METHODS

We conducted a population-based study of 569,686 deliveries in Quebec between 2014 and 2021. We measured gestational diabetes rates in wave 1 (March 1, 2020-August 22, 2020) and wave 2 (August 23, 2020-March 31, 2021), compared with the prepandemic period. We used interrupted time series regression to assess changes in gestational diabetes rates during each wave, and log-binomial regression models to estimate adjusted risk ratios (RR) and 95% confidence intervals (CI) for the association of the pandemic with gestational diabetes. We identified the types of patients that contributed to the change in gestational diabetes rates using Kitagawa's decomposition.

RESULTS

Gestational diabetes rates were higher during the first (13.2 per 100 deliveries) and second waves (14.3 per 100 deliveries) than during the prepandemic period (12.4 per 100 deliveries). Risk of gestational diabetes increased both in wave 1 (RR 1.05, 95% CI 1.02-1.09) and wave 2 (RR 1.14, 95% CI 1.10-1.18), compared with the prepandemic period. However, most of the increase in gestational diabetes rates was driven by low-risk women without Covid-19 infections who were socioeconomically advantaged, had no comorbidity, and were 25-34 years of age.

CONCLUSIONS

Gestational diabetes rates increased during the pandemic, mainly among women traditionally at low risk of hyperglycemia who did not have Covid-19 infections. Sudden widespread changes in screening or lifestyle can have a large impact on gestational diabetes rates in a population.

First-trimester glycaemic markers as predictors of gestational diabetes and its associated adverse outcomes: A prospective cohort study

OBJECTIVE

Gestational diabetes mellitus (GDM) is associated with excessive fetal growth in later gestation. Recent data suggest accelerated growth may begin before 28 weeks' gestation when GDM is typically diagnosed. The identification of pregnancies at risk of early fetal growth would enable early intervention. We assessed the use of early pregnancy HbA1c in predicting excessive fetal growth.

RESEARCH DESIGN AND METHODS

Women were recruited at antenatal booking from a major maternity unit in the UK. HbA1c was measured at <14 weeks gestation in 1243 women at risk of GDM as defined by UK NICE risk factors of whom 1115 underwent OGTT. Women with previous GDM were excluded. Comprehensive fetal ultrasound was performed at 28 weeks' gestation alongside 75 g OGTT in 976 of these women. GDM was defined using WHO criteria. Pregnancy outcomes were extracted from the regional maternity care database.

RESULTS

Two hundred and thirty-six women screened positive for GDM. At diagnosis, GDM pregnancies demonstrated higher adjusted fetal weight percentile than non-GDM pregnancies: (51.8 vs. 46.3, p = 0.008). This was driven by increases in the fetal abdominal circumference percentile in GDM compared with non-GDM pregnancies (55.3 vs. 46.2, p = <0.001). Early pregnancy HbA1c was higher in the GDM versus non-GDM group: (35.7 mmol/mol vs. 32.9 mmol/mol p = <0.01). A threshold for predicting excessive fetal growth was not identified in this cohort.

CONCLUSIONS

Accelerated fetal growth is evident prior to the diagnosis of GDM. There remains a need for suitable methods of early identification of pregnancies at high risk for early accelerated fetal growth due to GDM. First-trimester HbA1c was not useful in identifying these pregnancies.

NOVELTY STATEMENT

WHAT IS ALREADY KNOWN?: Recent research suggests excessive growth associated with GDM may begin prior to 28 weeks' gestation, when GDM is typically tested for WHAT THIS STUDY HAS FOUND?: Pregnancies affected by GDM are already subject to accelerated fetal growth in comparison to non-GDM pregnancies by way of higher estimated fetal weight and fetal abdominal circumference Neither first-trimester HbA1c nor plasma glucose was useful predictors of these outcomes WHAT ARE THE IMPLICATIONS OF THIS STUDY?: Highlights the emergence of excessive growth prior to detection of GDM Reinforces need for suitable methods of identifying such pregnancies in earlier gestation.

The Role of Adiponectin during Pregnancy and Gestational Diabetes

Pregnancy involves a range of metabolic adaptations to supply adequate energy for fetal growth and development. Gestational diabetes (GDM) is defined as hyperglycemia with first onset during pregnancy. GDM is a recognized risk factor for both pregnancy complications and long-term maternal and offspring risk of cardiometabolic disease development. While pregnancy changes maternal metabolism, GDM can be viewed as a maladaptation by maternal systems to pregnancy, which may include mechanisms such as insufficient insulin secretion, dysregulated hepatic glucose output, mitochondrial dysfunction and lipotoxicity. Adiponectin is an adipose-tissue-derived adipokine that circulates in the body and regulates a diverse range of physiologic mechanisms including energy metabolism and insulin sensitivity. In pregnant women, circulating adiponectin levels decrease correspondingly with insulin sensitivity, and adiponectin levels are low in GDM. In this review, we summarize the current state of knowledge about metabolic adaptations to pregnancy and the role of adiponectin in these processes, with a focus on GDM. Recent studies from rodent model systems have clarified that adiponectin deficiency during pregnancy contributes to GDM development. The upregulation of adiponectin alleviates hyperglycemia in pregnant mice, although much remains to be understood for adiponectin to be utilized clinically for GDM.

Maternal and Perinatal Outcomes During the COVID-19 Epidemic in Pregnancies Complicated by Gestational Diabetes

Introduction

Gestational diabetes (GDM) is one of the most common complications in pregnancy, with a prevalence that continues to rise. At the time of the COVID-19 epidemic, immediate reorganisation and adjustment of the system was needed. Telemedicine support was offered in order to provide high-quality treatment to pregnant women. However, the success of the treatment is unknown. We therefore aimed to evaluate COVID-19 epidemic effects on pregnancy outcomes in GDM.

Methods

The maternal outcomes (insulin treatment, gestational weight gain, caesarean section, hypertensive disorders) and perinatal outcomes (rates of large and small for gestational age, preterm birth and a composite child outcome) of women visiting a university hospital diabetes clinic from March to December 2020 were compared with those treated in the same period in 2019.

Results

Women diagnosed with GDM during the COVID-19 epidemic (n=417), were diagnosed earlier (23.9 [11.7-26.0] vs. 25.1 [21.8-26.7] gestational week), had higher fasting glucose (5.2 [5.0-5.4] vs. 5.1 [4.8-5.3] mmol/l) and earlier pharmacological therapy initiation, and had achieved lower HbA1c by the end of followup (5.1% (32.2 mmol/mol) [4.9% (30.1 mmol/mol)-5.4% (35.0 mmol/mol)] vs. 5.2% (33.3 mmol/mol) [5.0% (31.1 mmol/mol) - 5.4%·(35.5 mmol/mol)], p<0.001) compared to a year before (n=430). No significant differences in perinatal outcomes were found.

Conclusions

Although GDM was diagnosed at an earlier gestational age and higher fasting glucose concentration was present at the time of diagnosis, the COVID-19 epidemic did not result in worse glucose control during pregnancy or worse pregnancy outcomes in Slovenia.

Gestational Diabetes Mellitus—Recent Literature Review

Gestational diabetes mellitus (GDM), which is defined as a state of hyperglycemia that is first recognized during pregnancy, is currently the most common medical complication in pregnancy. GDM affects approximately 15% of pregnancies worldwide, accounting for approximately 18 million births annually. Mothers with GDM are at risk of developing gestational hypertension, pre-eclampsia and termination of pregnancy via Caesarean section. In addition, GDM increases the risk of complications, including cardiovascular disease, obesity and impaired carbohydrate metabolism, leading to the development of type 2 diabetes (T2DM) in both the mother and infant. The increase in the incidence of GDM also leads to a significant economic burden and deserves greater attention and awareness. A deeper understanding of the risk factors and pathogenesis becomes a necessity, with particular emphasis on the influence of SARS-CoV-2 and diagnostics, as well as an effective treatment, which may reduce perinatal and metabolic complications. The primary treatments for GDM are diet and increased exercise. Insulin, glibenclamide and metformin can be used to intensify the treatment. This paper provides an overview of the latest reports on the epidemiology, pathogenesis, diagnosis and treatment of GDM based on the literature.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Fasting Glucose for the Diagnosis of Gestational Diabetes Mellitus (GDM) during the COVID-19 Pandemic

Background: During the COVID-19 pandemic, different non-validated tests were proposed to simplify the diagnosis of gestational diabetes (GDM). Aim: To analyse the effects of replacing the two-step approach for Early-GDM and GDM diagnosis, with a fasting plasma glucose test. Material and Methods: This is a cohort study consisting of 3200 pregnant women: 400 with Early-GDM, 800 with GDM and 2000 with Non-GDM diagnosed using the two-step approach. Using fasting plasma glucose for Early-GDM and GDM diagnosis, according to the recommendations of Spain, Australia, Italy and the UK during the pandemic, the rates of missed and new Early-GDM and GDM were calculated and perinatal outcomes were analysed. Results: Using fasting plasma glucose in the first trimester >100 mg/dL for Early-GDM diagnosis, the rates of post-COVID missed and new Early-GDM were 79.5% and 3.2%, respectively. Using fasting plasma glucose at 24−28 weeks <84 or >92, 95 or 100 mg/dL for GDM diagnosis, the rates of missed GDM were 50.4%, 78%, 82.6% and 92.4%, respectively, and 8.6%, 5.6% and 2.3% women with Non-GDM were diagnosed with new GDM. Conclusion: Fasting plasma glucose is not a good test for the diagnosis of GDM either in the first trimester or at 24−28 weeks.

Hyperglycemia First Detected in Pregnancy in South Africa: Facts, Gaps, and Opportunities

This review contextualizes hyperglycemia in pregnancy from a South-African perspective. It aims to create awareness of the importance of hyperglycemia in pregnancy in low-middle-income countries. We address unanswered questions to guide future research on sub-Saharan African women with hyperglycemia first detected in pregnancy (HFDP). South African women of childbearing age have the highest prevalence of obesity in sub-Saharan Africa. They are predisposed to Type 2 diabetes (T2DM), the leading cause of death in South African women. T2DM remains undiagnosed in many African countries, with two-thirds of people living with diabetes unaware. With the South African health policy's increased focus on improving antenatal care, women often gain access to screening for non-communicable diseases for the first time in pregnancy. While screening practices and diagnostic criteria for gestational diabetes mellitus (GDM) differ amongst geographical areas in South Africa (SA), hyperglycemia of varying degrees is often first detected in pregnancy. This is often erroneously ascribed to GDM, irrespective of the degree of hyperglycemia and not overt diabetes. T2DM and GDM convey a graded increased risk for the mother and fetus during and after pregnancy, with cardiometabolic risk accumulating across the lifespan. Resource limitations and high patient burden have hampered the opportunity to implement accessible preventative care in young women at increased risk of developing T2DM in the broader public health system in SA. All women with HFDP, including those with true GDM, should be followed and undergo glucose assessment postpartum. In SA, studies conducted early postpartum have noted persistent hyperglycemia in a third of women after GDM. Interpregnancy care is advantageous and may attain a favourable metabolic legacy in these young women, but the yield of return following delivery is suboptimal. We review the current best evidence regarding HFDP and contextualize the applicability in SA and other African or low-middle-income countries. The review identifies gaps and shares pragmatic solutions regarding clinical factors that may improve awareness, identification, diagnosis, and management of women with HFDP.

Development and evaluation of an online questionnaire to identify women at high and low risk of developing gestational diabetes mellitus

BACKGROUND

Established risk factors for Gestational Diabetes Mellitus (GDM) include age, ethnicity, family history of diabetes and previous GDM. Additional significant influences have recently been demonstrated in the literature. The oral glucose tolerance test (OGTT) used for GDM diagnosis has sub-optimal sensitivity and specificity, thus often results in GDM misdiagnoses. Comprehensive screening of risk factors may allow more targeted monitoring and more accurate diagnoses, preventing the devastating consequences of untreated or misdiagnosed GDM. We aimed to develop a comprehensive online questionnaire of GDM risk factors and triangulate it with the OGTT and continuous glucose monitoring (CGM) parameters to better evaluate GDM risk and diagnosis.

METHODS

Pregnant women participating in two studies on the use of CGM for GDM were invited to complete the online questionnaire. A risk score, based on published literature, was calculated for each participant response and compared with the OGTT result. A total risk score (TRS) was then calculated as a normalised sum of all risk factors. Triangulation of OGTT, TRS and CGM score of variability (CGMSV) was analysed to expand evaluation of OGTT results.

RESULTS

Fifty one women completed the questionnaire; 29 were identified as 'high-risk' for GDM. High-risk ethnic background (p < 0.01), advanced age, a family diabetic history (p < 0.05) were associated with a positive OGTT result. The triangulation analysis (n = 45) revealed six (13%) probable misdiagnoses (both TRS and CGMSV discordant with OGTT), consisting of one probable false positive and five probable false negative by OGTT results.

CONCLUSIONS

This study identified pregnant women at high risk of developing GDM based on an extended evaluation of risk factors. Triangulation of TRS, OGTT and CGMSV suggested potential misdiagnoses of the OGTT. Future studies to explore the correlation between TRS, CGMSV and pregnancy outcomes as well as additional GDM pregnancy biomarkers and outcomes to efficiently evaluate OGTT results are needed.

Fasting plasma glucose level to guide the need for an OGTT to screen for gestational diabetes mellitus

AIMS

To determine the fasting plasma glucose (FPG) level at which an oral glucose tolerance test (OGTT) could be avoided to screen for gestational diabetes (GDM) and to evaluate the characteristics of women across this FPG threshold.

METHODS

A multi-centric prospective cohort study with 1843 women receiving universal screening for GDM with a 75 g OGTT.

RESULTS

In the total population, GDM prevalence was 12.5% (231). A FPG < 78 mg/dL was the cut-off with best trade-off to limit the number of missed GDM cases [44 (19.0%)] with a negative predictive value of 97.3% (95% CI 96.5-98.0) for GDM, while avoiding 52.2% OGTTs. Compared to GDM with FPG ≥ 78 mg/dL [187 (81.0%)], GDM women with FPG < 78 mg/dL had a significantly lower BMI (27.1 ± 4.5 vs. 29.6 ± 5.2 kg/m², p = 0.003), less insulin resistance [Matsuda: 0.4 (0.4-0.7) vs. 0.3 (0.2-0.5), p < 0.001] and better β-cell function [ISSI-2: 0.13 (0.08-0.25) vs. 0.09 (0.04-0.15), p = 0.004]. Compared to NGT women (1612) with FPG ≥ 78 mg/dL [846 (52.5%)], NGT with FPG < 78 mg/dL [766 (47.5%)] had a significantly lower BMI (26.0 ± 3.9 vs. 27.8 ± 4.7 kg/m², p < 0.001), less insulin resistance [Matsuda: 0.7 (0.5-0.9) vs. 0.5 (0.4-0.7), p < 0.001], better β-cell function [ISSI-2: 0.17 (0.10-0.30) vs. 0.12 (0.07-0.21), p < 0.001], and less often large-for-gestational age infants [9.2 (70) vs. 16.2% (136), p < 0.001].

CONCLUSIONS

FPG < 78 mg/dL can be used to limit the number of OGTTs when screening for GDM. Women with FPG < 78 mg/dL had a better metabolic profile and in NGT women also less fetal overgrowth.

Cardiometabolic and Mental Health in Women With Early Gestational Diabetes Mellitus: A Prospective Cohort Study

CONTEXT

Early diagnosis and treatment of gestational diabetes (GDM) may reduce adverse obstetric and neonatal outcomes, especially in high-risk women. However, there is a lack of data for other outcomes.

OBJECTIVE

We compared cardiometabolic and mental health outcomes in women with early (eGDM) and classical (cGDM) GDM.

METHODS

This prospective cohort included 1185 All women with cGDM and 76 women with eGDM. The eGDM group had GDM risk factors (BMI >30 kg/m2, family history of diabetes, history of GDM, ethnicity), were tested at <20 weeks gestational age, and diagnosed using American Diabetes Association prediabetes criteria. All women underwent lifestyle adaptations. Obstetric, neonatal, mental, and cardiometabolic outcomes were assessed during pregnancy and postpartum.

RESULTS

The eGDM group had lower gestational weight gain than cGDM (10.7 ± 6.2 vs 12.6 ± 6.4; P = 0.03) but needed more medical treatment (66% vs 42%; P < 0.001). They had similar rates of adverse maternal and neonatal outcomes, except for increased large-for-gestational-age infants (25% vs 15%; P = 0.02). Mental health during pregnancy and postpartum did not differ between groups. eGDM had more atherogenic postpartum lipid profile than cGDM (P ≤ 0.001). In eGDM, the postpartum prevalence of the metabolic syndrome (MetS) was 1.8-fold, prediabetes was 3.1-fold, and diabetes was 7.4-fold higher than cGDM (waist circumference-based MetS: 62% vs 34%/BMI-based MetS: 46% vs 24%; prediabetes: 47.5% vs 15.3%; diabetes: 11.9% vs 1.6%, all P < 0.001). These differences remained unchanged after adjusting for GDM risk factors.

CONCLUSION

Compared with cGDM, eGDM was not associated with differences in mental health, but with increased adverse cardiometabolic outcomes, independent of GDM risk factors and gestational weight gain. This hints to a preexisting risk profile in eGDM.

Clinical Outcomes Following a Change in Gestational Diabetes Mellitus Diagnostic Criteria Due to the COVID-19 Pandemic: A Case-Control Study

Background: Due to COVID-19, many centres adopted a change to the diagnosis of GDM. Methods: A case-control study of antenatal patients between 1 April and 30 June in 2019 and 2020 looking at detection rates of GDM, use of medication, obstetric, and fetal outcomes. Results: During COVID-19, the rate of positive GDM tests approximately halved (20% (42/210) in 2020 vs. 42.2% (92/218) in 2019, (p < 0.01)) with higher rates of requirement for insulin at diagnosis (21.4% (2020) vs. 2.2% (2019); p < 0.01), and at term (31% (2020) vs. 5.4% (2019); p < 0.01). and metformin at diagnosis (4.8% (2020) vs. 1.1% (2019); p < 0.01), and at term (14.3% (2020) vs. 7.6% (2019) p < 0.01), with no differences in birth outcomes. Conclusions: There was likely an underdiagnosis of GDM while women at a higher risk of hyperglycaemia were correctly identified. The GTT should be maintained as the gold-standard test where possible, with provisions made for social distancing during testing if required.

Impact of the Gestational Diabetes Diagnostic Criteria during the Pandemic: An Observational Study

OBJECTIVE

To analyze the effect of applying alternative diagnostic criteria for gestational diabetes mellitus (GDM) during the COVID-19 pandemic on GDM prevalence and obstetrical and perinatal outcomes, in comparison to usual diagnostic approaches.

METHODS

Data from women referred to GDM diagnosis from 1 September to 30 November 2019 were retrospectively collected (2019-group). The same data from the same period in 2020 were prospectively collected (2020-group). In both cases, a two-step diagnostic approach was used, the first step being a screening test (1 h 50 goral glucose tolerance test, OGTT). In 2019 it was followed by a 100 gr OGTT for diagnosis. In 2020, this was replaced by a blood test for the measurement of plasma glucose and HbA1c, according to alternative GDM diagnostic criteria during the COVID-19 pandemic.

RESULTS

From 237 women in the 2019 group, 40 (16.9%) were diagnosed with GDM, while from 255 women in the 2020 group, 37 (14.5%) had GDM (p = 0.470). More women in the 2020 group, in comparison to the 2019 group, were nulligravid (41.9% vs. 47.2%, p = 0.013), had a personal history of GDM (11.4% vs. 4.6%, p = 0.013) and had macrosomia in previous pregnancies (10.2% vs. 2.1%, p = 0.001). Obstetrical and perinatal outcomes were similar when comparing women with GDM to non-GDM women in the 2019 and 2020 groups and between GDM women and non-GDM women.

CONCLUSION

In a Spanish population, GDM prevalence during the COVID-19 pandemic using the alternative diagnostic criteria was similar to that found in 2019 using the usual diagnostic criteria. Despite women referred for GDM diagnosis during the pandemic having more GDM risk factors, obstetrical and perinatal outcomes were comparable to those observed before the pandemic.

Polish Women Have Moderate Knowledge of Gestational Diabetes Mellitus and Breastfeeding Benefits

Gestational diabetes mellitus (GDM) is a multifaceted disease and is associated with complications for newborns and mothers. The aim of the study was to assess Polish women’s knowledge concerning GDM and their attitude to breastfeeding. As a research tool, an anonymous online survey that included 33 questions, grouped into three main sections—sociodemographic and obstetric variables, risk factors for GDM and neonatal adverse outcomes, and knowledge about breastfeeding—was used and administered online. A total of 410 women aged from 18 to 45 participated in this study. Based on the survey, it was demonstrated that the women had moderate knowledge concerning the maternal risk factors and adverse neonatal outcomes associated with GDM and, additionally, the short- and long-term effects of breastfeeding. Significantly deeper knowledge about GDM, including breastfeeding by GDM mothers, was observed among hyperglycemic mothers in comparison to normoglycemic mothers. However, knowledge concerning the health benefits of breastfeeding was not related to the mothers’ glycemic status. In conclusion, educational programs must include pre-pregnancy education of women and place emphasis on explaining the mechanism of development of GDM and the transformation of GDM to type 2 diabetes. This is crucial for changing the public’s perception of GDM as a temporary, reversible clinical entity.

Negotiating Gestational Diabetes Mellitus in India: A National Approach

The worldwide epidemic of diabetes mellitus and hyperglycemia in pregnancy (HIP) presents many challenges, some of which are country-specific. To address these specific problems, parochial resolutions are essential. In India, the government, by working in tandem with (a) national groups such as the Diabetes in Pregnancy Study Group of India, and (b) global organizations such as the International Diabetes Federation, has empowered the medical and paramedical staff throughout the country to manage HIP. Additionally, despite their academic university backgrounds, Indian health planners have provided practical guidelines for caregivers at the ground level, who look up to these experts for guidance. This multipronged process has helped to negotiate some of the multiple problems that are indigenous and exclusive to India. This review traces the Indian journey to manage and prevent HIP with simple, constructive, and pragmatic solutions.

An Update on Screening Strategies for Gestational Diabetes Mellitus: A Narrative Review

Gestational diabetes mellitus (GDM) is a frequent medical complication during pregnancy. Screening and diagnostic practices for GDM are inconsistent across the world. This narrative review includes data from 87 observational studies and randomized controlled trials (RCTs), and aims to give an overview of the current evidence on screening strategies and diagnostic criteria for GDM. Screening in early pregnancy remains controversial and studies show conflicting results on the benefit of screening and treatment of GDM in early pregnancy. Implementing the one-step "International Association of Diabetes and Pregnancy Study Groups" (IADPSG) screening strategy at 24-28 weeks often leads to a substantial increase in the prevalence of GDM, without conclusive evidence regarding the benefits on pregnancy outcomes compared to a two-step screening strategy with a glucose challenge test (GCT). In addition, RCTs are needed to investigate the impact of treatment of GDM diagnosed with IADPSG criteria on long-term maternal and childhood outcomes. Selective screening using a risk-factor-based approach could be helpful in simplifying the screening algorithm but carries the risk of missing significant proportions of GDM cases. A two-step screening method with a 50g GCT and subsequently a 75g oral glucose tolerance test (OGTT) with IADPSG could be an alternative to reduce the need for an OGTT. However, to have an acceptable sensitivity to screen for GDM with the IADPSG criteria, the threshold of the GCT should be lowered from 7.8 to 7.2 mmol/L. A pragmatic approach to screen for GDM can be implemented during the COVID-19 pandemic, using fasting plasma glucose (FPG), HbA1c or even random plasma glucose (RPG) to reduce the number of OGTTs needed. However, usual guidelines and care should be resumed as soon as the COVID pandemic is controlled.

Performance of guidelines for the screening and diagnosis of gestational diabetes mellitus during the COVID-19 pandemic: A scoping review of the guidelines and diagnostic studies evaluating the recommended testing strategies

Aim

The COVID-19 pandemic has necessitated less resource-intensive testing guidelines to identify gestational diabetes mellitus (GDM). We performed a scoping review of the international evidence reporting the ability of diagnostic tests recommended during the pandemic to accurately identify patients with GDM, compared to pre-pandemic reference standards, and associated test and clinical outcomes.

Methods

A comprehensive search of the literature was carried out in Embase, LitCovid, Cochrane Covid-19 study register, and medRxiv on 14^th June 2021.

Results

145 unique citations were returned; after screening according to pre-specified inclusion criteria by title and abstract and then full text, 13 studies involving 40,836 pregnant people and an additional 52,884 instances of OGTT were included. Thresholds defined in the Australian pandemic guideline appear adequate to identify most GDM cases; false negative cases appeared at lower risk of hyperglycaemia-in-pregnancy(HIP)-related events. For UK and Canadian guidelines, a larger proportion would be misdiagnosed as non-GDM; these false negative cases had broadly equivalent HIP-related event rates as true positives.

Conclusions

The OGTT remains the most effective test to identify abnormal glucose processing in pregnancy, supporting the prompt return to standard guidelines post-pandemic. Cohort studies investigating the impact of the change in guidelines on GDM pregnancies and associated outcomes are needed.

Exercise and the Prevention of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is associated with pregnancy complications and fetal complications, as well as long-term health consequences for women and their offspring. Pregnancy is a pseudodiabetogenic state of increasing insulin resistance and decreasing insulin sensitivity, which places a woman at increased risk for GDM. Exercise facilitates the uptake of blood glucose into cells to be used for energy, making exercise a potential strategy in preventing GDM. Extensive evidence has found an association between consistent moderate to vigorous exercise in pregnancy and the prevention of GDM. With close attention to risk factors, maternity care nurses and other health care providers can play an important role in educating pregnant women on exercise recommendations to help them achieve optimal health and wellness.

Screening for Gestational Diabetes during the COVID-19 Pandemic-Current Recommendations and Their Consequences

Gestational diabetes mellitus (GDM) is recognized as one of the most common medical complications of pregnancy that can lead to significant short-term and long-term risks for the mother and the fetus if not detected early and treated appropriately. Current evidence suggests that, with the use of appropriate screening programs for GDM, those women diagnosed and treated have reduced perinatal morbidity. It has been implied that, when screening for GDM, there should be uniformity in the testing used and in further management. This paper summarizes and compares current screening strategies proposed by international bodies and discusses application in the context of the COVID-19 pandemic.

RESUMING ADEQUATE SCREENING FOR GESTATIONAL DIABETES MELLITUS DURING THE ONGOING COVID-19 PANDEMIC

The novel coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on antenatal care, forcing authorities to consider some medical services unessential in the pursuit of avoiding the valid risk of patient contamination. The oral glucose tolerance test (OGTT) has been in some cases overlooked for screening in pregnancy, with potential detrimental consequences in terms of not diagnosing and treating gestational diabetes mellitus (GDM). The number of tests has dropped by 35% in 2020 in our hospital. We make a plea for resuming OGTT at 24-28 weeks gestation at least for women considered at high risk.

Screening for Gestational Diabetes Mellitus in Early Pregnancy: What Is the Evidence?

The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. This has a significant effect on the health of the mother and offspring. There is no doubt that screening for GDM between 24 and 28 weeks is important to reduce the risk of adverse pregnancy outcomes. However, there is no consensus about diagnosis and treatment of GDM in early pregnancy. In this narrative review on the current evidence on screening for GDM in early pregnancy, we included 37 cohort studies and eight randomized controlled trials (RCTs). Observational studies have shown that a high proportion (15–70%) of women with GDM can be detected early in pregnancy depending on the setting, criteria used and screening strategy. Data from observational studies on the potential benefit of screening and treatment of GDM in early pregnancy show conflicting results. In addition, there is substantial heterogeneity in age and BMI across the different study populations. Smaller RCTs could not show benefit but several large RCTs are ongoing. RCTs are also necessary to determine the appropriate cut-off for HbA1c in pregnancy as there is limited evidence showing that an HbA1c ≥6.5% has a low sensitivity to detect overt diabetes in early pregnancy.

Maternal medicine in the COVID era

The coronavirus disease-19 (COVID-19) pandemic has directly and indirectly impacted pregnant women with co-morbidities or antenatal medical complications, through vulnerability to the severe effects of COVID-19 and service reconfiguration. Women with diabetes or hypertension in pregnancy are at higher risk of admission to intensive care, need for invasive ventilation and death from COVID-19. Suggested service modifications specific to maternal medicine services include home measurement of blood glucose or blood pressure, the use of risk calculators, adaptations to screening criteria for gestational diabetes and monitoring of obstetric cholestasis. Neither the added risk of COVID-19 on pregnant women with medical comorbidities nor the impact of maternal medicine service modifications has yet been established.

Improved gestational diabetes screening protocol

Objectives

This work aimed to assess the diagnostic validity of two approaches for the screening of gestational diabetes mellitus (GDM) with less discomfort for pregnant women.

Methods

A prospective diagnostic validation study was conducted with 2007 pregnant women. According to risk factors for GDM, women were classified into high-risk and low-risk groups. The current diagnostic procedure, based on oral glucose overload, was followed; simultaneously HbA_1c was tested and an algorithm combining both biomarkers was applied.

Results

In the low-risk group, the Glucose challenge test (GCT) showed a higher area under the curve (AUC 0.953; 95% CI 0.915-0.992) than the HbA_1c test (0.688; 95% CI 0.541-0.834). The best GCT cut-off, 153.5 mg/dL (8.52 mmol/L), showed higher diagnostic validity than that for HbA_1c, 28 mmol/mol (4.75%), and that the algorithm using both tests. In the high-risk group, the GCT showed better diagnostic performance than the HbA_1c and the algorithm; the optimal GCT cut-offs were higher than those recommended in current protocols. 13th week: GCT AUC 0.882 (95% CI 0.843-0.921), HbA_1c AUC 0.624 (95% CI 0.562-0.686), GCT cut-off 140.5 mg/dL (7.8 mmol/L), HbA_1c cut-off 33 mmol/mol (5.15%). 24th week: GCT AUC 0.944 (95% CI 0.925-0.962), HbA_1c AUC 0.642 (95% CI 0.575-0.709), GCT cut-off, 145.5 mg/dL (8.08 mmol/L), HbA_1c cut-off 29 mmol/mol (4.85%).

Conclusions

The GDM diagnostic approach using as the first step the GCT with higher cut-offs showed the best diagnostic validity. Applying these thresholds, 55.6 and 13.7% of 100 g. Oral glucose overloads would have been avoided in low-risk and high-risk pregnant women.

Utility of Screening Fasting Plasma Glucose and Glycated Hemoglobin to Circumvent the Need for Oral Glucose Tolerance Test in Women with Prior Gestational Diabetes

INTRODUCTION

Our aim is to propose an evidence-based strategy for screening postpartum dysglycemia.

METHODS

This study included adult non-pregnant women who were diagnosed with gestational diabetes (GDM) using International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria during their index pregnancy (2012-2019). Eligible participants underwent a concurrent oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) test. A detailed questionnaire documenting relevant personal and medical history was filled, and the relevant anthropometric parameters were recorded.

RESULTS

We evaluated data from 377 women at a mean (± SD) age of 32.1 ± 4.6 years and at a median duration of 15 (10-33) months following childbirth. Diabetes was diagnosed in 42 (11.1%) women. Use of a combination cutoff [fasting plasma glucose (FPG) ≥ 6.1 mmol/L or glycated hemoglobin (HbA1c) ≥ 6.0% (42 mmol/mol)] avoided OGTT in 80.9% of the study cohort, without missing the diagnosis of diabetes in any study subject. The diagnosis was missed in 2.4% of women with diabetes (and 0.3% of whole cohort) using only the FPG criterion (≥ 5.6 mmol/L) or HbA1c criterion [HbA1c ≥ 5.7% (39 mmol/mol)] alone. These tests avoided the need for an OGTT in 75.3% and 65.5% of women, respectively.

CONCLUSIONS

The proposed strategies are likely to be both patient- and physician-friendly and have the potential to address several barriers for postpartum screening among women with prior GDM.

COVID-19 pandemic: Can fasting plasma glucose and HbA1c replace the oral glucose tolerance test to screen for hyperglycaemia in pregnancy?

AIMS

To evaluate proposals considering HbA1c and fasting plasma glucose (FPG) measurement as a substitute for oral glucose tolerance test (OGTT) to diagnose hyperglycaemia in pregnancy (HIP) during COVID-19 pandemic.

METHODS

Of the 7,334 women who underwent the OGTT between 22 and 30 weeks gestation, 966 had HIP (WHO diagnostic criteria, reference standard). The 467 women who had an available HbA1c were used for analysis. French-speaking Society of Diabetes (SFD) proposal to diagnose HIP during COVID-19 pandemic was retrospectively applied: HbA1c ≥5.7% (39 mmol/mol) and/or FPG level ≥5.1 mmol/l. SFD proposal sensitivity for HIP diagnosis and the occurrence of HIP-related events (preeclampsia, large for gestational age infant, shoulder dystocia or neonatal hypoglycaemia) in women with false negative (FN) and true positive (TP) HIP-diagnoses were evaluated.

RESULTS

The sensitivity was 57% [95% confidence interval 52-62]. FN women had globally lower plasma glucose levels during OGTT, lower HbA1c and body mass index than those TP. The percentage of HIP-related events was similar in FN (who were cared) and TP cases, respectively 19.5 and 16.9% (p = 0.48). We observed similar results when women at high risk for HIP only were considered.

CONCLUSION

The SFD proposal has a poor sensitivity to detect HIP. Furthermore, it fails to have any advantages in predicting adverse outcomes.

Limiting the Use of Oral Glucose Tolerance Tests to Screen for Hyperglycemia in Pregnancy during Pandemics

We aimed to evaluate each proposal of Australian–New Zealand Societies to limit the number of oral glucose tolerance tests (OGTTs) to diagnose hyperglycemia in pregnancy (HIP) during the coronavirus disease 2019 (COVID-19) pandemic. At our university hospital (2012–2016), we retrospectively applied in 4245 women who had OGTT between 22 and 30 weeks of gestation (reference standard: WHO criteria) the proposals in which OGTT is performed only in high-risk women; in all (Option 1) or high-risk (Option 1-Sel) women with fasting plasma glucose (FPG) 4.7–5.0 mmol/L; in all (Option 2) or high-risk (Option 2-Sel) women without history of HIP and with FPG 4.7–5.0 mmol/L. We also tested FPG measurement alone in all high-risk women. Measuring FPG alone had a sensitivity of 49% (95% confidence interval 45–54) applying universal screening. Option 2 appeared to have the best balance considering the needed OGTT (17.3%), sensitivity (72% (67–76)) and rates of a composite outcome (true negative cases: 10.6%, false positive cases: 24.4%; true positive cases: 19.5%; false negative cases: 10.2%). Consideration of a history of HIP and measuring first FPG can avoid more than 80% of OGTTs and identify women with the highest risk of adverse HIP-related events.

Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic

The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1^st March 2020 and 15^th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24–28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.

A Review of the Current Status of Gestational Diabetes Mellitus in Australia-The Clinical Impact of Changing Population Demographics and Diagnostic Criteria on Prevalence

The current status of gestational diabetes mellitus in Australia reveals an almost quadrupling prevalence over the last decade. A narrative review of the current Australian literature reveals unique challenges faced by Australian maternity clinicians when addressing this substantial disease burden in our diverse population. Rising rates of maternal overweight and obesity, increasing maternal age and the diversity of ethnicity are key epidemiological impactors, overlaid by the 2015 changes in screening and diagnostic parameters. Our vast land mass and the remote location of many at risk women requires innovative and novel ideas for pathways to diagnose and effectively manage women with gestational diabetes mellitus. By modifying and modernizing models of care for women with gestational diabetes mellitus, we have the ability to address accessibility, resource management and our acute response to global events such as the COVID 19 pandemic. With continuing research, education and robust discourse, Australia is well placed to meet current and future challenges in the management of gestational diabetes mellitus.