Comparison of different criteria for diagnosis of gestational diabetes mellitus

Screening for gestational diabetes, Ahmedabad, India

Objective

To implement a community-based screening and awareness-raising project for gestational diabetes in Ahmedabad, India.

Methods

The project took place between April 2016 and August 2019 in Ahmedabad. Medical college faculty members and medical officers trained 3582 paramedical staff on screening for gestational diabetes. These paramedical staff tested all pregnant women 24–28 weeks gestation, who were attending village health and nutrition days – also called mamta days – in urban and rural health centres for routine antenatal care, for gestational diabetes. An oral glucose tolerance test was used and blood sugar ≥ 7.8 mmol/L was the cut-off for gestational diabetes. Women with gestational diabetes were referred for counselling and treatment and all women were followed until 6 weeks after delivery.

Findings

Of 53 522 pregnant women screened, 6786 (12.7%) had gestational diabetes and were referred for nutritional therapy or medication; 836 (12.3%) of these women started medication. There was no significant difference in the prevalence of stillbirths between women with gestational diabetes (0.8%; 54/6786) and women without (0.7%; 338/46 736; P-value: 0.51). Of the women on treatment, 38 had abnormal blood glucose after delivery and continued with the medication. Two women with gestational diabetes died; they had other associated co-morbidities – pre-eclampsia and anaemia.

Conclusion

We found a high prevalence of gestational diabetes, indicating the need for gestational diabetes screening and implementation of this project on a larger scale. Gestational diabetes screening at the community level is operationally feasible using the existing human resources and infrastructure of the reproductive health programmes.

Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis

OBJECTIVE

To investigate the association between gestational diabetes mellitus and adverse outcomes of pregnancy after adjustment for at least minimal confounding factors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Web of Science, PubMed, Medline, and Cochrane Database of Systematic Reviews, from 1 January 1990 to 1 November 2021.

REVIEW METHODS

Cohort studies and control arms of trials reporting complications of pregnancy in women with gestational diabetes mellitus were eligible for inclusion. Based on the use of insulin, studies were divided into three subgroups: no insulin use (patients never used insulin during the course of the disease), insulin use (different proportions of patients were treated with insulin), and insulin use not reported. Subgroup analyses were performed based on the status of the country (developed or developing), quality of the study, diagnostic criteria, and screening method. Meta-regression models were applied based on the proportion of patients who had received insulin.

RESULTS

156 studies with 7 506 061 pregnancies were included, and 50 (32.1%) showed a low or medium risk of bias. In studies with no insulin use, when adjusted for confounders, women with gestational diabetes mellitus had increased odds of caesarean section (odds ratio 1.16, 95% confidence interval 1.03 to 1.32), preterm delivery (1.51, 1.26 to 1.80), low one minute Apgar score (1.43, 1.01 to 2.03), macrosomia (1.70, 1.23 to 2.36), and infant born large for gestational age (1.57, 1.25 to 1.97). In studies with insulin use, when adjusted for confounders, the odds of having an infant large for gestational age (odds ratio 1.61, 1.09 to 2.37), or with respiratory distress syndrome (1.57, 1.19 to 2.08) or neonatal jaundice (1.28, 1.02 to 1.62), or requiring admission to the neonatal intensive care unit (2.29, 1.59 to 3.31), were higher in women with gestational diabetes mellitus than in those without diabetes. No clear evidence was found for differences in the odds of instrumental delivery, shoulder dystocia, postpartum haemorrhage, stillbirth, neonatal death, low five minute Apgar score, low birth weight, and small for gestational age between women with and without gestational diabetes mellitus after adjusting for confounders. Country status, adjustment for body mass index, and screening methods significantly contributed to heterogeneity between studies for several adverse outcomes of pregnancy.

CONCLUSIONS

When adjusted for confounders, gestational diabetes mellitus was significantly associated with pregnancy complications. The findings contribute to a more comprehensive understanding of the adverse outcomes of pregnancy related to gestational diabetes mellitus. Future primary studies should routinely consider adjusting for a more complete set of prognostic factors.

REVIEW REGISTRATION

PROSPERO CRD42021265837.

Fibroblast growth factor-21 is a potential diagnostic factor for patients with gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a metabolic disease with symptoms of hyperglycemia, insulin resistance and fetal maldevelopment. Evidence has indicated that fibroblast growth factor (FGF)-21 is a multifunctional protein and exhibits potential therapeutic value for metabolic diseases. The present study investigated the diagnostic value of FGF-21 serum levels in patients with GDM (n=50) and age-matched healthy individuals (n=50). It was demonstrated that the gene and protein expression levels of FGF-21 were downregulated in adipose cells in patients with GDM compared with those in healthy individuals. The results also indicated that the serum levels of FGF-21 were downregulated in patients with GDM compared with those in healthy individuals. In addition, it was demonstrated that blood glucose and blood pressure were higher in patients with GDM compared with those in healthy individuals. GDM patients had a markedly higher insulin resistance and glucose tolerance than healthy individuals. However, GDM patients had significantly lower serum levels of insulin than healthy individuals. It was observed that the serum levels of FGF-21 were positively correlated with those of glucose in GDM patients. In conclusion, these results indicate that decreased FGF-21 levels are associated with the risk of GDM, suggesting that FGF-21 may be a potential diagnostic factor for GDM.

Screening and diagnosis of gestational diabetes in India: a systematic review and meta-analysis

AIMS

Although diabetes is rapidly increasing in India, there is no national consensus on best practices for screening, diagnosis, and management of gestational diabetes mellitus (GDM). The goal of this study was to systematically review the literature for studies reporting the prevalence and screening and diagnostic methods for gestational diabetes in India.

METHODS

We searched MEDLINE, Embase, and POPLINE for studies on screening for GDM in India. We included English-language full reports and conference abstracts of cross-sectional studies, prospective, and retrospective cohorts that reported the screening method and prevalence of GDM. We performed descriptive analysis on all studies and meta-analysis, meta-regression, and subgroup meta-analysis on studies with medium or low risk of bias.

RESULTS

We included 64 studies reporting 90 prevalence estimates. Prevalence estimates ranged from 0 to 41.9%. Subset meta-analyses showed that the IADPSG diagnostic criteria found significantly more GDM cases (prevalence = 19.19% [15.5, 23.6], p < 0.05) than the WHO 1999 criteria (10.13% [8.17, 12.50]) and DIPSI criteria (7.37% [5.2, 10.16]). Studies that compared the IADPSG and WHO 1999 criteria showed poor positive agreement (33-79%). Studies specifying time of GDM diagnosis showed that patients (11-60%) develop GDM as early as the first trimester, but many GDM cases (16-40%) are missed if screened only at first visit.

CONCLUSIONS

In India, prevalence estimates of GDM vary substantially by diagnostic criteria. When evaluating screening and diagnostic criteria for GDM, providers should consider their patients' needs and correlate screening criteria with pregnancy outcomes.

Impact of adopting the 2013 World Health Organization criteria for diagnosis of gestational diabetes in a multi-ethnic Asian cohort: a prospective study

BACKGROUND

We assessed the impact of adopting the 2013 World Health Organization (WHO) diagnostic criteria on the rates of gestational diabetes (GDM), pregnancy outcomes and identification of women at future risk of type 2 diabetes.

METHODS

During a period when the 1999 WHO GDM criteria were in effect, pregnant women were universally screened using a one-step 75 g 2-h oral glucose tolerance test at 26-28 weeks' gestation. Women were retrospectively reclassified according to the 2013 criteria, but without the 1-h glycaemia measurement. Pregnancy outcomes and glucose tolerance at 4-5 years post-delivery were compared for women with GDM classified by the 1999 criteria alone, GDM by the 2013 criteria alone, GDM by both criteria and without GDM by both sets of criteria.

RESULTS

Of 1092 women, 204 (18.7%) and 142 (13.0%) were diagnosed with GDM by the 1999 and 2013 WHO criteria, respectively, with 27 (2.5%) reclassified to GDM and 89 (8.2%) reclassified to non-GDM when shifting from the 1999 to 2013 criteria. Compared to women without GDM by both criteria, cases reclassified to GDM by the 2013 criteria had an increased risk of neonatal jaundice requiring phototherapy (relative risk (RR) = 2.78, 95% confidence interval (CI) 1.32, 5.86); despite receiving treatment for GDM, cases reclassified to non-GDM by the 2013 criteria had higher risks of prematurity (RR = 2.17, 95% CI 1.12, 4.24), neonatal hypoglycaemia (RR = 3.42, 95% CI 1.04, 11.29), jaundice requiring phototherapy (RR = 1.71, 95% CI 1.04, 2.82), and a higher rate of abnormal glucose tolerance at 4-5 years post-delivery (RR = 3.39, 95% CI 2.30, 5.00).

CONCLUSIONS

Adoption of the 2013 WHO criteria, without the 1-h glycaemia measurement, reduced the GDM rate. Lowering the fasting glucose threshold identified women who might benefit from treatment, but raising the 2-h threshold may fail to identify women at increased risk of adverse pregnancy and future metabolic outcomes.

TRIAL REGISTRATION

NCT01174875 . Registered 1 July 2010 (retrospectively registered).

Neonatal hyperglycemia induces cell death in the rat brain

Several studies have examined neonatal diabetes, a rare disease characterized by hyperglycemia and low insulin levels that is usually diagnosed in the first 6 month of life. Recently, the effects of diabetes on the brain have received considerable attention. In addition, hyperglycemia may perturb brain function and might be associated with neuronal death in adult rats. However, few studies have investigated the damaging effects of neonatal hyperglycemia on the rat brain during central nervous system (CNS) development, particularly the mechanisms involved in the disease. Thus, in the present work, we investigated whether neonatal hyperglycemia induced by streptozotocin (STZ) promoted cell death and altered the levels of proteins involved in survival/death pathways in the rat brain. Cell death was assessed using FluoroJade C (FJC) staining and the expression of the p38 mitogen-activated protein kinase (p38), phosphorylated-c-Jun amino-terminal kinase (p-JNK), c-Jun amino-terminal kinase (JNK), protein kinase B (Akt), phosphorylated-protein kinase B (p-Akt), glycogen synthase kinase-3β (Gsk3β), B-cell lymphoma 2 (Bcl2) and Bcl2-associated X protein (Bax) protein were measured by Western blotting. The main results of this study showed that the metabolic alterations observed in diabetic rats (hyperglycemia and hypoinsulinemia) increased p38 expression and decreased p-Akt expression, suggesting that cell survival was altered and cell death was induced, which was confirmed by FJC staining. Therefore, the metabolic conditions observed during neonatal hyperglycemia may contribute to the harmful effect of diabetes on the CNS in a crucial phase of postnatal neuronal development.

Clinical characteristics of women with gestational diabetes - comparison of two cohorts enrolled 20 years apart in southern Brazil

CONTEXT AND OBJECTIVE:

The prevalence and characteristics of gestational diabetes mellitus (GDM) have changed over time, reflecting the nutritional transition and changes in diagnostic criteria. We aimed to evaluate characteristics of women with GDM over a 20-year interval.

DESIGN AND SETTING:

Comparison of two pregnancy cohorts enrolled in different periods, in university hospitals in Porto Alegre, Brazil: 1991 to 1993 (n = 216); and 2009 to 2013 (n = 375).

METHODS:

We applied two diagnostic criteria to the cohorts: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/World Health Organization (WHO); and National Institute for Health and Care Excellence (NICE). We compared maternal-fetal characteristics and outcomes between the cohorts and within each cohort.

RESULTS:

The women in the 2010s cohort were older (31 ± 7 versus 30 ± 6 years), more frequently obese (29.4% versus 15.2%), with more hypertensive disorders (14.1% versus 5.6%) and at increased risk of cesarean section (adjusted relative risk 1.8; 95% confidence interval: 1.4 - 2.3), compared with those in the 1990s cohort. Neonatal outcomes such as birth weight category and hypoglycemia were similar. In the 1990s cohort, women only fulfilling IADPSG/WHO or only fulfilling NICE criteria had similar characteristics and outcomes; in the 2010s cohort, women only diagnosed through IADPSG/WHO were more frequently obese than those diagnosed only through NICE (33 ± 8 kg/m2 versus 28 ± 6 kg/m2; P < 0.001).

CONCLUSION:

The epidemic of obesity seems to have modified the profile of women with GDM. Despite similar neonatal outcomes, there were differences in the intensity of treatment over time. The IADPSG/WHO criteria seemed to identify a profile more associated with obesity.

Comparison of Diagnostic Accuracy of Non-fasting DIPSI and HbA1c with Fasting WHO Criteria for Diagnosis of Gestational Diabetes Mellitus

BACKGROUND

To compare diagnostic accuracy of non-fasting DIPSI and HbA1c with fasting WHO 1999 as gold standard for diagnosis of gestational diabetes mellitus (GDM).

METHODS

Pregnant women attending antenatal clinic underwent a 2-h 75-gm GCT in non-fasting state (DIPSI). HbA1c was also determined at the same sitting. A 2-h 75-gm GCT was repeated for all women after 72 h in a fasting state (WHO criteria). GDM was diagnosed if plasma glucose was ≥140 mg/dl by either test or if HbA1C ≥6%.

RESULTS

Of the 800 women evaluated, 51 were diagnosed as GDM by WHO criteria, 63 by DIPSI, and 40 by HbA1c. The sensitivity of DIPSI test with respect to WHO 1999 was 98.04% and specificity 98.26%. The diagnostic accuracy was 98.25%. The area under the ROC curve for DIPSI was 0.988 (p < 0.001) (95% confidence interval: 0.960-1.000). The sensitivity of HbA1c with respect to WHO GTT was 47.06%, specificity 97.86%, and diagnostic accuracy 94.63%. The ROC curve between WHO GTT and HbA1c covered an area of 0.805 (p < 0.01) (95% confidence interval: 0.731-0.879).

CONCLUSIONS

Non-fasting DIPSI criteria had high diagnostic accuracy compared to gold-standard WHO GTT and can be an effective and practical alternative to the latter. HbA1c had a low sensitivity although the specificity was good and therefore is not a suitable test for screening GDM.