To screen or not to screen for gestational diabetes mellitus. The clinical quagmire

Diabetes in low-resourced countries

Maternal and newborn health poses one of the greatest health challenges in the developing world. Many low-income countries are now experiencing a demographic and epidemiological transition and changing of lifestyles. Thus, apparent "Western" diseases such as diabetes and obesity have been reaching the Third World countries. There is a paucity of reliable data on diabetes in pregnancy in many low-income countries. Adequate information about maternal and perinatal mortality and morbidity as a consequence of diabetes in pregnancy is scarce. This chapter presents evidence of the magnitude and impact of diabetes in pregnancy. Additionally, we discuss interventions in screening and managing diabetes in pregnancy in these specific patient populations.

Gestational diabetes: diagnosis and management

PURPOSE

To review the diagnosis and management of gestational diabetes.

EPIDEMIOLOGY

In the United States, approximately 2 to 5% of all pregnant women have gestational diabetes. Those women with a family history of type 2 diabetes mellitus, Asian or native American race, Latina ethnicity or obesity are at higher risk for developing gestational diabetes.

CONCLUSION

Women with gestational diabetes who are treated appropriately can achieve good outcomes in the majority of pregnancies. Frequent blood glucose monitoring, nutrition counseling and frequent physician contact allow for individualized care to achieve optimal outcomes. Such treatment includes diet, exercise and insulin. The use of oral hypoglycemic agents is controversial and there is some concern about worse maternal and neonatal outcomes as compared to treatment with insulin. Evolving technologies promise to provide more therapeutic options.

Gestational diabetes in rural East Africa: a call to action

The number of cases of diabetes worldwide has increased significantly in the last decade. Characteristically, the incidence of gestational diabetes (GDM) reflects the incidence of type 2 diabetes mellitus (T2DM) in the background population, which is a warning that a rapid increase in the incidence is to be expected concomitant with the already observed increase in the incidence of T2DM. Although the majority of all deliveries worldwide take place in the so-called developing world, little is known about the prevalence of diabetes in pregnancy in rural areas of East Africa. Diabetes in pregnancy has effects on prospects for marriage, motherhood, and the role of women in East African society. Furthermore, intrauterine exposure to the metabolic environment of maternal diabetes, or GDM, is associated with increased risk of altered glucose homeostasis in the offspring, beginning in childhood and producing a higher prevalence of GDM in the next generation with all burdens and complications being associated with this disease. It is reasonable to conclude that more newborn infants each year are being exposed to the metabolic environment of diabetes during intrauterine development as a result of changing incidence and demographics of diabetes and pregnancy. We believe that programs and policies have to be established, including organization of the health system to provide care, medicines, and other tools necessary for diabetes in pregnancy management, consideration of accessibility and affordability of care, education for healthcare workers, and education of pregnant and nonpregnant women of reproductive age.

Management of diabetes in pregnancy: comparison of guidelines with current practice at Austrian and Australian obstetric center

AIM

To compare Austrian and Australian national guidelines for gestational and pre-gestational diabetes and estimate the level to which physicians comply with their country's guidelines.

METHODS

Austrian (ODG, Austrian Diabetes Society) and Australian guidelines (ADIPS, Australasian Diabetes in Pregnancy Society) for the treatment of gestational diabetes and pre-gestational diabetes were systematically reviewed. Current practices in two obstetric centers in Austria and Australia were assessed by interviewing key stakeholders through questionnaires assessing different components of diabetes care. For gestational diabetes, these components were screening, abnormal oral glucose tolerance test values (mmol/L), abnormal values for diagnosis, further management when abnormal values are detected, monitoring/glucose targets (mmol/L), further management and indications for insulin therapy, route and timing of delivery, and postpartum management and counseling. For pre-gestational diabetes, the components were management during the preconceptional period, glucose target values, medical surveillance, obstetric surveillance, medication used, route and timing of delivery, and postpartum management and counseling.

RESULTS

More variation was found in the management of gestational than pre-gestational diabetes. There were differences in oral glucose tolerance test and cut-off levels for diagnosing gestational diabetes in both centers and guidelines. Australian guidelines recommended two-stage screening for gestational diabetes, while Austrian guidelines recommended one-stage screening. At the Austrian obstetric center, amniocentesis was recommended for determining the start of insulin treatment in pregnant women with gestational diabetes. This approach was neither used at the Australian obstetric center nor recommended by any of the two guidelines.

CONCLUSION

Our study showed that it was difficult to standardize screening criteria and diagnostic methods for gestational and pre-gestational diabetes. National and international consensus has yet to be achieved in the management of diabetes in pregnancy.

Elevated zinc protoporphyrin/heme ratios in umbilical cord blood after diabetic pregnancy

OBJECTIVE

Offspring of diabetes patients may suffer from tissue iron deficiency. Erythrocyte zinc protoporphyrin/heme (ZnPP/H) ratios measure impaired iron status. The aim of the study was to examine whether cord ZnPP/H ratios were associated with pregnancy glycemic control.

METHODS

ZnPP/H was measured in cord blood from 31 pregnancies with insulin-treated diabetes (diabetes group) and compared to population normal values. Maternal glycemic control was assessed by daily glucose log, glycosylated hemoglobin and birth weight.

RESULTS

Median cord ZnPP/H was higher in the diabetes group than the population normal values (106 (65.2 to 146.8) microM/M vs 68.2 (37.6 to 98.8) micro/M, P < 0.0001). Ratios were directly correlated to surrogates of control (glycosylated hemoglobin, P = 0.05, and birth weight, P < 0.04). Cord ZnPP/H ratios from pregnancies with pre-existing and gestational diabetes were similar.

CONCLUSION

Because cord ZnPP/H was higher in large offspring of diabetic pregnancy, it might identify greater iron utilization for fetal erythropoiesis.