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One-Step Compared With Two-Step Gestational Diabetes Screening and Pregnancy Outcomes: A Systematic Review and Meta-analysis. Obstet Gynecol 2022; 140:712-723. [PMID: 36201772 DOI: 10.1097/aog.0000000000004943] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/14/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate short-term maternal and neonatal outcomes with one-compared with two-step testing for gestational diabetes mellitus (GDM). DATA SOURCES A systematic review of randomized controlled trials (RCTs) and observational studies comparing one-step and two-step GDM testing strategies before September 2021 was conducted. We searched Ovid Medline (1946-), EMBASE (1947-), Scopus (1960-), Cochrane Central, and ClinicalTrials.gov . The primary outcome was rate of large-for-gestational age (LGA) neonates. Secondary outcomes were clinically relevant outcomes for GDM that were selected a priori. METHODS OF STUDY SELECTION Titles, abstracts, and manuscripts were screened, selected, and reviewed by the first two authors. Four RCTs (24,966 patients) and 13 observational studies (710,677 patients) were analyzed. TABULATION, INTEGRATION, AND RESULTS Pooled relative risks (RRs) were calculated with 95% CIs using random-effects models and were plotted graphically with forest plots. Study heterogeneity was evaluated using Cochran Q and Higgins I 2 tests. The quality of studies that met the inclusion criteria was evaluated with the Downs and Black checklist. Publication bias was assessed by using asymmetry of funnel plots and Harbord's test. There was no difference in the rate of LGA neonates (pooled RR 0.95; 95% CI 0.88-1.04) by testing strategy among RCTs, but patients who underwent one-step testing were more likely to be diagnosed with GDM (pooled RR 2.13; 95% CI 1.61-2.82) and treated with diabetes medications (pooled RR 2.24; 95% CI 1.21-4.15). One-step testing was associated with higher rates of neonatal intensive care unit (NICU) admission (pooled RR 1.12; 95% CI 1.00-1.26) and neonatal hypoglycemia (pooled RR 1.23; 95% CI 1.13-1.34). In analysis of high-quality RCTs and observational studies, one-step testing was associated with a lower rate of LGA neonates (pooled RR 0.97; 95% CI 0.95-0.98), but higher rates of GDM diagnosis, treatment, NICU admission, and neonatal hypoglycemia. CONCLUSION Despite a significant increase in GDM diagnosis and treatment with one-step testing, there is no difference in rate of LGA neonates compared with two-step testing among RCTs. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021252703.
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Bastidas K, Romero XC, Uriel M, De la Hoz JA. Perinatal outcomes associated with the diagnosis of gestational diabetes: Systematic review and meta-analysis. Diabetes Metab Syndr 2021; 15:102262. [PMID: 34509793 DOI: 10.1016/j.dsx.2021.102262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare perinatal outcomes in pregnant women diagnosed with gestational diabetes using the one-step and the two-step test. METHODS Meta-analysis of observational studies pregnancies women with gestational diabetes from January 2014 to February 2019. The outcomes studied were induction of labor and delivery, preterm delivery, fetal macrosomia, neonatal hypoglycemia, hyperbilirubinemia, low birth weight, and admission to the neonatal intensive care unit. RESULTS Eight studies were included with a population of 108,609 pregnancies. Statistical differences were obtained for fetal macrosomia RR0.9 (95%CI0.85-0.97; I20%) and neonatal hypoglycemia RR1.1 (95%CI1.01-1.40; I248.5%). CONCLUSION Neonatal macrosomia appears to be less present when the one-step diagnostic test is used and neonatal hypoglycemia was lower with the two-step test. Register PROSPERO CRD42020215062.
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Affiliation(s)
- Karina Bastidas
- Maternal Fetal Medicine Fellowship. El Bosque University. El Bosque Research Group of Maternal Fetal Medicine and Gynecology, Bogotá, Colombia
| | - Ximena C Romero
- El Bosque Research Group of Maternal Fetal Medicine and Gynecology. El Bosque University, Bogotá, Colombia; Ecodiagnóstico El Bosque S.A.S. Maternal Fetal Medicine Unit, Bogotá, Colombia.
| | - Montserrat Uriel
- El Bosque Research Group of Maternal Fetal Medicine and Gynecology. El Bosque University, Bogotá, Colombia; Ecodiagnóstico El Bosque S.A.S. Maternal Fetal Medicine Unit, Bogotá, Colombia
| | - José A De la Hoz
- Master's Degree in Epidemiology El Bosque University, Bogotá, Colombia
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Nakanishi S, Aoki S, Kasai J, Shindo R, Saigusa Y, Miyagi E. Have pregnancy outcomes improved with the introduction of the International Association of Diabetes and Pregnancy Study Groups criteria in Japan? J Diabetes Investig 2020; 11:994-1001. [PMID: 32012487 PMCID: PMC7378452 DOI: 10.1111/jdi.13223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/11/2019] [Accepted: 01/29/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS/INTRODUCTION This study aimed to investigate the effects of the introduction of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosing gestational diabetes mellitus (GDM) on maternal and neonatal outcomes in Japan. MATERIALS AND METHODS This was a retrospective study carried out at a tertiary center in Japan. Previously in Japan, GDM was diagnosed if two or more of the following Japan Society of Obstetrics and Gynecology (JSOG) criteria were met: fasting plasma glucose ≥100 mg/dL, 1-h value ≥180 mg/dL or 2-h value ≥150 mg/dL on the 75-g oral glucose tolerance. Since 2010, GDM has been diagnosed if one or more of the following IADPSG criteria are met: fasting plasma glucose ≥92 mg/dL, 1-h value ≥180 mg/dL or 2-h value ≥153 mg/dL on the 75-g oral glucose tolerance. We compared the pregnancy outcomes of all pregnant women with singleton pregnancies after 22 weeks' gestation at our hospital before (JSOG period) and after (IADPSG period) the IADPSG criteria were adopted. RESULTS There were 3,912 women in the JSOG period and 4,772 in the IADPSG period. GDM prevalence increased from 2.9% in the JSOG period to 13% in the IADPSG period (P < 0.001). No significant differences between the groups were found in rates of macrosomia, or large for gestational age, and no significant differences were found in birthweight. The neonatal hypoglycemia rate and neonatal intensive care unit admission rate were significantly lower in the IADPSG period (adjusted odds ratio 0.51 and 0.78, respectively). CONCLUSIONS Introduction of the IADPSG criteria for diagnosing GDM increased GDM diagnosis frequency fourfold, but reduced neonatal intensive care unit admission and neonatal hypoglycemia rates significantly.
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Affiliation(s)
- Sayuri Nakanishi
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Shigeru Aoki
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Junko Kasai
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Ryosuke Shindo
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Yusuke Saigusa
- Department of BiostatisticsYokohama City University Graduate School of MedicineYokohamaJapan
| | - Etsuko Miyagi
- Department of Obstetrics and GynecologyYokohama City University School of MedicineYokohamaJapan
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Ji J, He Z, Yang Z, Mi Y, Guo N, Zhao H, Gao J, Ma Z, Luo X, Han Z. Comparing the efficacy and safety of insulin detemir versus neutral protamine hagedorn insulin in treatment of diabetes during pregnancy: a randomized, controlled study. BMJ Open Diabetes Res Care 2020; 8:8/1/e001155. [PMID: 32265255 PMCID: PMC7254127 DOI: 10.1136/bmjdrc-2019-001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/01/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To compare the efficacy and safety of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) insulin used in pregnant women with diabetes. RESEARCH DESIGN AND METHODS A randomized study was conducted in diabetic pregnant women (n=240) (including 132 with pregestational diabetes and 108 with gestational diabetes). All patients were randomly divided into two groups: IDet group (n=120) treated with IDet plus short acting insulin Novolin-R before three meals (RRR-IDet plan), and NPH group treated with NPH plus Novolin-R before three meals (RRR-NPH plan). Patients were enrolled during 12-28 gestation weeks and followed up until delivery. RESULTS Basal characteristics, such as age, enrollment gestational weeks, average HbA1c, fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) were similar between two groups. After 1 week of treatment, the FPG of IDet group were significantly lower than NPH group (p<0.05) and the time required to reach the targeted blood glucose level was significantly shorter (p<0.001). After 3 months of treatment, the HbA1c level in the two groups was normalized but there was no significant difference in HbA1c level. Maternal and neonatal outcomes were comparable between the two therapeutic approaches; however, the incidence of hypoglycemia in IDet group was remarkably lower than that of NPH group (p<0.05). The adverse drug reactions were rare and similar between the two groups. CONCLUSIONS For the treatment of gestational diabetes, both RRR-IDet plan and RRR-NPH plan were reported to control blood glucose effectively. Compared with NPH, IDet could control blood glucose and reached the targets faster and more effectively, thus reducing the number of insulin injections and the incidence of hypoglycemia in pregnant women without increasing adverse birth outcomes. Therefore, for pregnant women with gestational diabetes, who require insulin therapy, IDet would be an ideal basal insulin being worthy of promotion in clinical settings.
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Affiliation(s)
- Jing Ji
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Zhangya He
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Zhao Yang
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yang Mi
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Na Guo
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Hong Zhao
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Jiayi Gao
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Zhengfeei Ma
- Department of Health and Environmental Sciences, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Xiaoqin Luo
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Zhen Han
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Cade TJ, Polyakov A, Brennecke SP. Implications of the introduction of new criteria for the diagnosis of gestational diabetes: a health outcome and cost of care analysis. BMJ Open 2019; 9:e023293. [PMID: 30612109 PMCID: PMC6326329 DOI: 10.1136/bmjopen-2018-023293] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To identify effects on health outcomes from implementing new criteria diagnosing gestational diabetes mellitus(GDM) and to analyse costs-of-care associated with this change. DESIGN Quasi-experimental study comparing data from the calendar year before (2014) and after (2016) the change. SETTING Single, tertiary-level, university-affiliated, maternity hospital. PARTICIPANTS All women giving birth in the hospital, excluding those with pre-existing diabetes or multiple pregnancy. MAIN OUTCOME MEASURES Primary outcomes were caesarean section, birth weight >90th percentile for gestation, hypertensive disorder of pregnancy and preterm birth less than 37 weeks. A number of secondary outcomes reported to be associated with GDM were also analysed.Care packages were derived for those without GDM, diet-controlled GDM and GDM requiring insulin. The institutional Business Reporting Unit data for average occasions of service, pharmacy schedule for the costs of consumables and medications, and Medicare Benefits Schedule ultrasound services were used for costing each package. All costs were estimated in figures from the end of 2016 negating the need to adjust for Consumer Price Index increases. RESULTS There was an increase in annual incidence of GDM of 74% without overall improvements in primary health outcomes. This incurred a net cost increase of AUD$560 093. Babies of women with GDM had lower rates of neonatal hypoglycaemia and special care nursery admissions after the change, suggesting a milder spectrum of disease. CONCLUSION New criteria for the diagnosis of GDM have increased the incidence of GDM and the overall cost of GDM care. Without obvious changes in short-term outcomes, validation over other systems of diagnosis may require longer term studies in cohorts using universal screening and treatment under these criteria.
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Affiliation(s)
- Thomas J Cade
- Diabetes Service, Royal Women's Hospital, Parkville, Victoria, Australia
- Pregnancy Research Service, Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
| | - Alexander Polyakov
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Department of Reproductive Biology, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Shaun P Brennecke
- Pregnancy Research Service, Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
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Hagen G, Brown C, Dietrich J, Gibbs C, Lee GT. The Utility of Lower Glycemic Targets for Treating Gestational Diabetes: A Retrospective Study. J Diabetes Res 2019; 2019:6372474. [PMID: 31886283 PMCID: PMC6915122 DOI: 10.1155/2019/6372474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/16/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE In vivo study of glucose homeostasis in pregnancy suggests normal glucose levels are lower than current glycemic targets used in gestational diabetes. After the HAPO study results, our institution began using glycemic targets of fasting 85 mg/dL and 2-hour postprandial of 110 mg/dL. We reviewed our results. METHODS A retrospective cohort of GDM patients that delivered at KUMC from January 2007 to May 2017 was reviewed. All patients were diagnosed with the 2-step Carpenter-Coustan thresholds. High targets were compared with low targets. The primary outcome investigated was birthweight > 90% (large for gestational age, LGA). RESULTS 604 patients were studied, and 34% were treated with low glycemic targets. Our unadjusted results showed that the low-target group had a lower incidence of LGA infants (24.0 vs. 31.8%), higher incidence of neonatal hypoglycemia (20.7 vs. 11.6%), and inductions (39.4 vs. 20.5%). After adjustment for demographic variables, only a higher risk of inductions remained (aOR 2.54 (1.44, 4.49)). CONCLUSION Lower glycemic targets did not produce large reductions in fetal overgrowth, but they were associated with a higher rate of inductions. As there were no observed differences in maternal or neonatal outcomes otherwise, aiming for lower glycemic targets in GDM is likely not cost-effective.
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Affiliation(s)
- Grace Hagen
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Crystal Brown
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jordan Dietrich
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Charles Gibbs
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gene T. Lee
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
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Yeh T, Yeung M, Mendelsohn Curanaj FA. Inpatient Glycemic Management of the Pregnant Patient. Curr Diab Rep 2018; 18:73. [PMID: 30112679 DOI: 10.1007/s11892-018-1045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW There is a rising prevalence of type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM) in pregnancy. Reaching and maintaining glycemic targets during and after this time are important for both the health of the mother and her baby. RECENT FINDINGS Based on recently published guidelines from various societies, we review the diagnosis of diabetes in pregnancy, types of therapies available to maintain euglycemia, important keys to management of T1DM, T2DM, and GDM, and strategies for reaching inpatient glycemic targets during the peripartum period. Care for pregnant patients with T1DM is especially challenging, and providers should be aware of the varying insulin requirements at different stages of pregnancy and how to reduce hypoglycemia and avoid diabetic ketoacidosis. Insulin sensitivity fluctuates throughout pregnancy due to physiologic changes, especially during labor and delivery and immediately post-partum. We review recommendations regarding how to manage this dynamic time and present our own institution's inpatient management protocol. Finally, we review management of diabetes post-partum, including medications, breast-feeding, and continued monitoring and screening. With the collaborative efforts of the patient and an interdisciplinary team and in-depth knowledge of the most up-to-date management principles, it is possible to achieve euglycemia during this critical time of a mother and baby's life.
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Affiliation(s)
- Tiffany Yeh
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine/New York-Presbyterian Hospital, 525 East 68th St, Baker 2023, New York, NY, 10065, USA
| | - Michele Yeung
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine/New York-Presbyterian Hospital, 525 East 68th St, Baker 2023, New York, NY, 10065, USA
| | - Felicia A Mendelsohn Curanaj
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine/New York-Presbyterian Hospital, 525 East 68th St, Baker 2023, New York, NY, 10065, USA.
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