Clinical Diagnosis of Gestational Diabetes

The Perinatal Biopsychosocial Consequences of Various Levels of Gestational Hyperglycemia

This study was to compare biopsychosocial consequences among three groups of women with gestational hyperglycemia. We conducted a repeated-measures study at five time points among 132 women with gestational hyperglycemia. Women's physiological indicators and their psychosocial indicators were measured. There were 22.7% of participants had gestational diabetes mellitus (GDM), 11.4% had gestational impaired glucose tolerance (G-IGT), and 65.9% had mild gestational hyperglycemia (MGH). Women with GDM had higher fasting blood glucose and systolic/diastolic blood pressure than women with MGH. Women with GDM had higher diastolic blood pressure compared to women with G-IGT. Significant differences were found between the five time points regarding women's fasting blood glucose, diastolic blood pressure, depression, and health status. Health care providers should conduct early screening for predictors of metabolic syndrome in women with any degree of gestational hyperglycemia. Nursing interventions could be offered as early as the perinatal period to promote women's health.

Population-Level Outcomes with a 2-Step Approach for Gestational Diabetes Screening and Diagnosis

OBJECTIVES

To examine outcomes associated with alternative glucose thresholds in a 2-step approach for screening and diagnosing gestational diabetes mellitus (GDM).

METHODS

We studied 178,527 pregnancies between 2008 and 2012 in Alberta, Canada. They were categorized retrospectively as normal 50 g screen (n=144,191); normal 75 g oral glucose tolerance test (OGTT) (n=21,248); abnormal at glucose thresholds suggested by the International Association of Diabetes and Pregnancy Group (IADPSG) (HAPO 1.75, n=4308); abnormal at glucose thresholds associated with an odds ratio of 2.0 for adverse events in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. This latter group, which would have been treated for GDM based on customary care, was further divided into those with 1 (HAPO 2-1 n=5528) or 2 or more abnormal glucose values (HAPO 2-2 n=3252). Main outcomes were large for gestational age (LGA), induced labour and Cesarean-section rates.

RESULTS

LGA rates were 8.2%, 10.5%, 14.2%, 11.8% and 16.5% among normal 50 g, normal 75 g OGTT, HAPO 1.75, HAPO 2-1, and HAPO 2-2 groups, respectively. Labour induction and caesarean-section rates were 29.6% and 36.2% in the IADPSG, 38.2% and 36.8% in the HAPO 2-1 group, and 42.3% and 41.1% in the HAPO 2-2 groups, respectively. Excessive maternal weight (≥91 kg) was associated with a higher risk for all adverse outcomes.

CONCLUSIONS

The 2-step approach effectively identifies pregnancies at low risk for adverse outcomes. Labelling influences induction practice. Any glucose intolerance increases risk for adverse outcomes, and pregnancies with highest (2 or higher) abnormal glucose values remain at greatest risk. Further research is needed to determine whether glycemic thresholds for GDM diagnosis should incorporate information about maternal weight.

Association between Maternal Serum Concentrations of Angiopoietin-like Protein 2 in Early Pregnancy and Subsequent Risk of Gestational Diabetes Mellitus

Background:

A recent study reported a positive association between elevated serum levels of angiopoietin-like protein 2 (ANGPTL2) and the development of type 2 diabetes in a general population. However, the relationship of serum ANGPTL2 levels with the risk of developing gestational diabetes mellitus (GDM) has not been reported to date. The aim of this study was to investigate the change of maternal serum ANGPTL2 concentrations in the first trimester of pregnancy and to determine whether ANGPTL2 is a biomarker for subsequent GDM development.

Methods:

We conducted a prospective, nested case-control study in a pregnancy cohort. First-trimester ANGPTL2 levels were measured using a high-resolution assay in 89 women who subsequently developed GDM and in a random sample of 177 women who remained euglycemic throughout the pregnancy. Median ANGPTL2 levels were compared using Mann-Whitney U-test. Logistic regression was used to compute unadjusted and multivariable-adjusted odds ratios for developing GDM among ANGPTL2 quartiles.

Results:

The serum levels of ANGPTL2 was higher in women with GDM than that in women without GDM (3.06 [2.59, 3.65] ng/ml vs. 2.46 [2.05, 2.96] ng/ml, P = 0.003). Fasting blood glucose was higher in women with GDM than that in women without GDM (5.0 ± 0.9 mmol/L vs. 4.4 ± 0.6 mmol/L, P < 0.001). Glucose challenge test showed that the blood glucose was higher in women with GDM than that in women without GDM (9.1 ± 3.5 mmol/L vs. 6.2 ± 1.2 mmol/L, P < 0.001). A multivariate model adjusted for baseline characteristics, medical complications, and gestational characteristics revealed that the risk of developing GDM among women in Q4 compared with Q1 was 2.90-fold more likely to develop GDM later in pregnancy.

Conclusions:

At 11–13 weeks in pregnancies that develop GDM, the serum concentration of ANGPTL2 is increased, and it can be combined with maternal factors to provide effective early screening for GDM.

[Clinical audit of screening for gestational diabetes among 848 pregnant women in 23 maternity units of the Pays de la Loire, 2014]

INTRODUCTION

Guidelines for screening for gestational diabetes mellitus (GDM) were published in 2010. An audit of the maternity units of the Pays de la Loire network sought to determine the adherence rate and to study the factors affecting it in order to propose corrective measures to improve it.

METHODS

The perinatal network in Pays de la Loire provided obstetricians of the 23 participating maternity units with a set of criteria to be collected from the files of women giving birth. The methodology of the audit was designed to enable calculation of the adherence rate overall and according to indications (risk factors, hyperglycemia, and macrosomia): adherence, non-adherence, and over-adherence (screening in the absence of an indication). To obtain around 900 pregnancies, the audit was planned to cover a week of deliveries in June 2014.

RESULTS

The analysis included 848 pregnancies and 872 newborns. Risk factors were found for 46.6% of the women (43.2 to 49.9): 13.2% for maternal age≥35years and 30.8% for BMI≥25kg/m². GDM was diagnosed for 14.6% (12.4 to 17.2). The adherence rate for screening was 45.5% (42.2 to 49.9), the non-adherence rate 27.6% (24.7 to 30.7), and the over-adherence rate 26.9% (24.0 to 30.0). Among the factors potentially associated with adherence, we observed only the second-trimester factor (macrosomia); there was no "professional" effect on adherence criteria. No evidence of overmanagement was observed for the pregnancies/deliveries/newborns with overdiagnosis. Oral glucose tolerance tests were performed in accordance with the guidelines (95.9%). Follow-up of women with GDM by specialists was satisfactory (84.6%).

DISCUSSION

This audit showed that adherence to the guidelines was insufficient in the Pays de la Loire network. The reasons for this are numerous: ignorance of the guidelines, in part due to their relative recency, the change in the blood sugar levels defining GDM (perceived as too low), and the absence of strong evidence about these thresholds from publications and practices in other countries, the need to select women for risk factors, and sometimes the late onset of prenatal care at the maternity unit.

CONCLUSION

In view of this audit, the Perinatal Network of Pays de la Loire must work to improve the knowledge and screening practices for GDM among its professionals, by the repeated dissemination of these guidelines and chart review sessions.

The risk factors for gestational diabetes mellitus: A retrospective study

OBJECTIVE

To investigate the risk factors for developing GDM among Taiwanese pregnant women.

DESIGN

A retrospective cohort and case-control study.

SETTING

At a medical centre in Southern Taiwan.

PARTICIPANTS

The hospitalised pregnant women who were diagnosed with either GDM or normal glucose tolerance (NGT) between 1997 and 2011. The glucose tolerance test results were interpreted according to criteria established by the National Diabetes Data Group for GDM. Participants were divided into either a GDM group (case group) or a normal glucose tolerance (NGT) group (control group) in order to determine the risk factors for GDM.

MEASUREMENTS

With a retrospective chart review, data regarding demographics, a family history of diabetes, history of gestation, and physiological index for pre- and postpregnancy periods were collected. χ² tests and independent t tests were used to examine the correlations between demographic characteristics and GDM. Stepwise multivariate logistic regression was used to determine the factors associated with GDM.

FINDINGS

The results of the comparison between the GDM group (n=106) and the NGT group (n=406) showed that the risk factors for GDM were maternal age, education, a family history of diabetes, and prepregnancy body mass index (BMI).

KEY CONCLUSION AND IMPLICATION FOR PRACTICE

Older age, lower levels of education, a family history of diabetes, and higher prepregnancy BMI were significant risk factors for GDM. In addition to performing risk factor assessment, health care providers should proactively promote the importance of GDM screening to pregnant women at their first antenatal visit.