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The urgent need for universally applicable simple screening procedures and diagnostic criteria for gestational diabetes mellitus – lessons from projects funded by the World Diabetes Foundation  [cached]
Karoline Kragelund Nielsen,Maximilian de Courten,Anil Kapur
Global Health Action , 2012, DOI: 10.3402/gha.v5i0.17277
Abstract: Background: To address the risks of adverse pregnancy outcomes and future type 2 diabetes associated with gestational diabetes mellitus (GDM), its early detection and timely treatment is essential. In the absence of an international consensus, multiple different guidelines on screening and diagnosis of GDM have existed for a long time. This may be changing with the publication of the recommendations by the International Association of Diabetes and Pregnancy Study Groups. However, none of these guidelines take into account evidence from or ground realities of resource-poor settings. Objective: This study aimed to investigate whether GDM projects supported by the World Diabetes Foundation in developing countries utilize any of the internationally recommended guidelines for screening and diagnosis of GDM, explore experiences on applicability and usefulness of the guidelines and barriers if any, in implementing the guidelines. These projects have reached out to thousands of pregnant women through capacity building and improvement of access to GDM screening and diagnosis in the developing world and therefore provide a rich field experience on the applicability of the guidelines in resource-poor settings. Design: A mixed methods approach using questionnaires and interviews was utilised to review 11 GDM projects. Two projects were conducted by the same partner; interviews were conducted in person or via phone by the first author with nine project partners and one responded via email. The interviews were analysed using content analysis. Results: The projects use seven different screening procedures and diagnostic criteria and many do not completely adhere to one guideline alone. Various challenges in adhering to the recommendations emerged in the interviews, including problems with screening women during the recommended time period, applicability of some of the listed risk factors used for (pre-)screening, difficulties with reaching women for testing in the fasting state, time consuming nature of the tests, intolerance to high glucose load due to nausea, need for repeat tests, issues with scarcity of test consumables and lack of equipment making some procedures impossible to follow. Conclusion: Though an international consensus on screening and diagnosis for GDM is welcome, it should ensure that the recommendations take into account feasibility and applicability in low resource settings to ensure wider usage. We need to move away from purely academic discussions focusing on sensitivity and specificity to also include what can actually be done at the basic care
Gestational diabetes and pregnancy outcomes - a systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria
Eliana M Wendland, Maria Torloni, Maicon Falavigna, Janet Trujillo, Maria Dode, Maria Campos, Bruce B Duncan, Maria Schmidt
BMC Pregnancy and Childbirth , 2012, DOI: 10.1186/1471-2393-12-23
Abstract: We searched relevant studies in MEDLINE, EMBASE, LILACS, the Cochrane Library, CINHAL, WHO-Afro library, IMSEAR, EMCAT, IMEMR and WPRIM. We included cohort studies permitting the evaluation of GDM diagnosed by WHO and or IADPSG criteria against adverse maternal and perinatal outcomes in untreated women. Only studies with universal application of a 75 g OGTT were included. Relative risks (RRs) and their 95% confidence intervals (CI) were obtained for each study. We combined study results using a random-effects model. Inconsistency across studies was defined by an inconsistency index (I2) > 50%.Data were extracted from eight studies, totaling 44,829 women. Greater risk of adverse outcomes was observed for both diagnostic criteria. When using the WHO criteria, consistent associations were seen for macrosomia (RR = 1.81; 95%CI 1.47-2.22; p < 0.001); large for gestational age (RR = 1.53; 95%CI 1.39-1.69; p < 0.001); perinatal mortality (RR = 1.55; 95% CI 0.88-2.73; p = 0.13); preeclampsia (RR = 1.69; 95%CI 1.31-2.18; p < 0.001); and cesarean delivery (RR = 1.37;95%CI 1.24-1.51; p < 0.001). Less data were available for the IADPSG criteria, and associations were inconsistent across studies (I2 ≥ 73%). Magnitudes of RRs and their 95%CIs were 1.73 (1.28-2.35; p = 0.001) for large for gestational age; 1.71 (1.38-2.13; p < 0.001) for preeclampsia; and 1.23 (1.01-1.51; p = 0.04) for cesarean delivery. Excluding either the HAPO or the EBDG studies minimally altered these associations, but the RRs seen for the IADPSG criteria were reduced after excluding HAPO.The WHO and the IADPSG criteria for GDM identified women at a small increased risk for adverse pregnancy outcomes. Associations were of similar magnitude for both criteria. However, high inconsistency was seen for those with the IADPSG criteria. Full evaluation of the latter in settings other than HAPO requires additional studies.The definition of gestational diabetes mellitus (GDM) as any degree of glucose intolerance with
Nueva clasificación y criterios diagnósticos de la diabetes mellitus New classification and diagnostic criteria for diabetes mellitus  [cached]
Gloria López Stewart
Revista médica de Chile , 1998,
Abstract: The new Classification and Diagnostic Criteria for Diabetes Mellitus (DM), prepared by a group of experts from the American Diabetes Association is presented and analyzed. On an etiopathogenic basis, it designates Insulin Dependent and Non Insulin Dependent as Type 1 and Type 2 respectively. It specifies DM having specific known causes. It maintains Gestational Diabetes and Glucose Intolerance and adds the Impaired Fasting Glucose Condition. It recommends fasting plasma glucose for search and diagnosis, and lowers the level to 3126 mg/dl instead of 3140 mg/dl, due to its association with chronical complications of DM. It mantains the diagnostic criteria of random and post charge glycemia 3200 mg/dl. It does not alter the glucose intolerance figure (140ó200 mg/dl in OGTT) and introduces fasting abnormality 3110 and <126 mg/dl. It encourages the search with fasting glucose every 3 years in individuals aged over 45, and at more frequent intervals in younger individuals with high risk factors. Analysis of the report allows to conclude that, although the classification does not introduce any significant change in daily clinical use, its pathogenic orientation makes future innovations possible. The preferential use of fasting glucose 3126 mg/dl for diagnosis of DM has theoretical basis and practical advantages. Identification of individuals with impaired fasting glucose allows to detect, in a simple manner, a high risk group in which to start preventive measures. However, there is a percentage of cases which are not diagnosed by fasting glycemia, but are diagnosed by OGTT, therefore the latter should not be discarded.
Risk factors for coronary heart disease and actual diagnostic criteria for diabetes mellitus
Mitrovi?-Peri?i? Nata?a,Anti? Slobodan
Vojnosanitetski Pregled , 2009, DOI: 10.2298/vsp0912973m
Abstract: Background/Aim. Recent studies indicate that the prevalence of diabetes mellitus (DM) type 2 is increasing in the world. Chronic hyperglycemia in DM is associated with a long term damage, dysfunction and failure of various organs, especially retina, kidney, nerves and, in addition, with an increased risk of cardiovasclar disease. For a long time the illness has been unknown. Early diagnosis of diabetes could suspend the development of diabetic complications. The aim of the study was to establish risk for the development of coronary disease in the patients evaluated by the use of new diagnostic criteria for DM. Methods. The study included 930 participants without diagnosis of DM, hypertension, dyslipidemia, nor coronary heart disease two years before the study. The patients went through measuring of fasting plasma glycemia, erythrocytes, hematocrit, cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, aspartate aminotransferase and alanine aminotransferase. In the group with hyperglycemia the 2-hour oral glucose tolerance test was performed. We analyzed ECG and made blood pressure monitoring, and also measured body mass, height, waist and hip circumference. We analyzed life style, especially smoking, and exercise and family history. Results. Diabetes prevalence was 2.68%, and prevalences of impaired fasting glucose, impaired glucose tolerance and DM were 12.15%. Average age of males and females was 38 and 45 years, respectively. In the healthy population there was higher frequency of smokers (55% vs 42%), but in the population with hyperglycemia there were more obesity (23% vs 10.5%), hypertension (39% vs 9%), hypercholesterolemia (76% vs 44.1%), lower HDL-C (52.2% vs 25.7%). Cummulative risk factor in healthy subjects, and those with hyperglycemia were 5.6% and 14%, respectively. Conclusion. Subjects with hyperglicemia without diagnosis of DM have higher risk factors for coronary heart disease.
Hemoglobin A1c for Diagnosis of Postpartum Abnormal Glucose Tolerance among Women with Gestational Diabetes Mellitus: Diagnostic Meta-Analysis  [PDF]
Xudong Su, Zhaoyan Zhang, Xinye Qu, Yaqiang Tian, Guangzhen Zhang
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0102144
Abstract: Objective To evaluate the accuracy of glycosylated hemoglobin A1c (HbA1c) for the diagnosis of postpartum abnormal glucose tolerance among women with gestational diabetes mellitus (GDM). Methods After a systematic review of related studies, the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and other measures about the accuracy of HbA1c in the diagnosis of postpartum abnormal glucose tolerance were pooled using random-effects models. The summary receiver operating characteristic (SROC) curve was used to summarize the overall test performance. Results Six studies met our inclusion criteria. The pooled results on SEN, SPE, PLR, NLR, and DOR were 0.36 (95% CI 0.23–0.52), 0.85 (95% CI 0.73–0.92), 2.4 (95% CI 1.6–3.6), 0.75 (95% CI 0.63–0.88) and 3 (95% CI 2–5). The area under the summary receiver operating characteristic (SROC) curve was 0.67 with a Q value of 0.63. Conclusions Measurement of HbA1c alone is not a sensitive test to detect abnormal glucose tolerance in women with prior GDM.
Inherited destiny? Genetics and gestational diabetes mellitus
Richard M Watanabe
Genome Medicine , 2011, DOI: 10.1186/gm232
Abstract: Gestational diabetes mellitus (GDM) refers to hyperglycemia that first presents during pregnancy and typically resolves itself post-partum. There are inadequate data on the prevalence of GDM; however, in 1988 it was estimated that about 4% of pregnancies in the United States were complicated by diabetes, with 88% of these accounted for by GDM [1]. More recent data suggest that, as with the overall increased prevalence of diabetes, rates of GDM are significantly increasing [2]. For example, Dabelea and colleagues [3] examined trends in singleton pregnancies from the Kaiser Permanente health maintenance organization of Colorado between 1994 and 2002 and noted that rates of GDM increased two-fold in all ethnic groups. Accurate data on the prevalence and incidence of GDM are likely to become available given that screening during pregnancy is almost routine and consistent diagnostic criteria are now being implemented [4].Hyperglycemia during pregnancy, whether due to GDM or other forms of diabetes, has implications for mother, developing fetus, and child. Women diagnosed with GDM have a higher risk for future type 2 diabetes mellitus (T2DM) [5]. Kjos et al. [6] were the first to demonstrate that this risk was even higher in Hispanic women with previous GDM by showing that 45% of a cohort followed for 5 years post-partum developed T2DM despite plasma glucose returning to non-diabetic levels. The observation that previous GDM increases risk for future T2DM was subsequently confirmed in other ethnic groups [7]. Women with GDM have a higher rate of caesarean section, gestational hypertension, and large for gestational age deliveries [8]. Maternal diabetes has been shown to be associated with increased risk for macrosomia [8,9], and GDM-associated macrosomia is associated with increased rates of a variety of complications, including hypoglycemia and respiratory distress syndrome [10].Pettitt et al. [11] were among the first to show the association between maternal hyperglycem
Gestational Diabetes Mellitus: Screening and Outcomes in Southern Italian Pregnant Women  [PDF]
Carmelo Capula,Eusebio Chiefari,Anna Vero,Biagio Arcidiacono,Stefania Iiritano,Luigi Puccio,Vittorio Pullano,Daniela P. Foti,Antonio Brunetti,Raffaella Vero
ISRN Endocrinology , 2013, DOI: 10.1155/2013/387495
Abstract: Recent Italian guidelines exclude women <35 years old, without risk factors for gestational diabetes mellitus (GDM), from screening for GDM. To determine the effectiveness of these measures with respect to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria, we evaluated 2,448 pregnant women retrospectively enrolled in Calabria, southern Italy. GDM was diagnosed following the IADPSG 2010 criteria. Among 538 women <35 years old, without risk factors, who would have not been tested according to the Italian guidelines, we diagnosed GDM in 171 (31.8%) pregnants (7.0% of total pregnants). Diagnosis was made at baseline (55.6%), 1 hour (39.8%), or 2 hours (4.7%) during OGTT. Despite of appropriate treatment, GDM represented a risk factor for cesarean section, polyhydramnios, increased birth weight, admission to neonatal intensive care units, and large for gestational age. These outcomes were similar to those observed in GDM women at high risk for GDM. In conclusion, Italian recommendations failed to identify 7.0% of women with GDM, when compared to IADPSG criteria. The risk for adverse hyperglycaemic-related outcomes is similar in low-risk and high-risk pregnants with GDM. To limit costs of GDM screening, our data suggest to restrict OGTT to two steps (baseline and 1 hour). 1. Introduction Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy [1]. Incidence of GDM is increasing worldwide for recent trends in obesity and advancing maternal age, with huge healthcare and economic costs [2, 3]. Women exposed to GDM are at high risk for pregnancy complications [4–6], future type 2 diabetes mellitus (DM), and cardiovascular disease [7–9]. In particular, several lines of evidence indicate a continuum of risk for adverse pregnancy outcomes for mothers and their offsprings related to increasing maternal glucose levels [10, 11], whereas treatment to reduce maternal glucose levels reduces this risk [12–14]. Based on these evidences, to identify women at risk for adverse pregnancy outcomes and improve prognosis through evidence-based interventions, recent tight diagnostic criteria for GDM have been introduced by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) [15]. Diagnosis requires a 75?g oral glucose tolerance test (OGTT) carried out between 24 and 28 weeks of gestation in all women not previously found to have overt diabetes or GDM, considering glycaemia of 92?mg/dL at baseline, 180?mg/dL at 1?h, and 153?mg/dL at 2?h
The Use Of Receiver Operating Characteristic (Roc) Analysis In The Evaluation Of The Performance Of Two Binary Diagnostic Tests Of Gestational Diabetes Mellitus.  [cached]
Okeh UM,Ogah IE,Okeh US,Agwu A
International Journal of Asian Social Science , 2012,
Abstract: Objective: To compare the accuracy measures of the random glucose test and the 50-g glucose challenge test as screening tests for gestational diabetes mellitus (GDM). Research Design And Methods: In this prospective cohort study, pregnant women without preexisting diabetes in two perinatal centers in the Ebonyi State underwent a random glucose test and a 50-g glucose challenge test between 24 and 28 weeks of gestation. If one of the screening tests exceeded predefined threshold values, the 75-g oral glucose tolerance test (OGTT) was performed within 1 week. Furthermore, the OGTT was performed in a random sample of women in whom both screening tests were normal. GDM was considered present when the OGTT (reference test) exceeded predefined threshold values. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the two screening tests. The results were corrected for verification bias. Results: We included 1,301 women. The OGTT was performed in 322 women. After correction for verification bias, the random glucose test showed an area under the ROC curve of 0.69 (95% CI 0.61– 0.78), whereas the glucose challenge test had an area under the curve of 0.88 (0.83– 0.93). There was a significant difference in area under the curve of the two tests of 0.19 (0.11– 0.27) in favor of the 50-g glucose challenge test. Conclusions: In screening for GDM, the 50-g glucose challenge test is more useful than the random glucose test.
Predictors of Postpartum Glucose Tolerance Testing in Italian Women with Gestational Diabetes Mellitus  [PDF]
Carmelo Capula,Eusebio Chiefari,Anna Vero,Stefania Iiritano,Biagio Arcidiacono,Luigi Puccio,Vittorio Pullano,Daniela Foti,Antonio Brunetti,Raffaella Vero
ISRN Endocrinology , 2013, DOI: 10.1155/2013/182505
Abstract: Postpartum screening is critical for early identification of type 2 diabetes in women previously diagnosed with gestational diabetes mellitus (GDM). Nevertheless, its rate remains disappointingly low. Thus, we plan to examine the rate of postpartum glucose tolerance test (ppOGTT) for Italian women with GDM, before and after counseling, and identify demographic, clinical, and/or biochemical predictors of adherence. With these aims, we retrospectively enrolled 1159 women with GDM, in Calabria, Southern Italy, between 2004 and 2011. During the last year, verbal and written counseling on the importance of followup was introduced. Data were analyzed by multiple regression analysis. A significant increase of the return rate was observed following introduction of the counseling [adjusted odds ratio (AOR) 5.17 (95% CI, 3.83–6.97), ]. Interestingly, previous diagnosis of polycystic ovary syndrome (PCOS) emerged as the major predictor of postpartum followup [AOR 5.27 (95% CI, 3.51–8.70), ], even after stratification for the absence of counseling. Previous diagnosis of GDM, higher educational status, and insulin treatment were also relevant predictors. Overall, our data indicate that counseling intervention is effective, even if many women fail to return, whereas PCOS represents a new strong predictor of adherence to postpartum testing. 1. Introduction Gestational diabetes mellitus (GDM) is historically defined as “any degree of glucose intolerance with onset or first recognition during pregnancy” [1]. Incidence of GDM is increasing worldwide for recent trends in obesity and advancing maternal age, significantly contributing to increased overall health-care and economic costs [2, 3]. Approximately 7% of all pregnancies are complicated by GDM, resulting in more than 200,000 cases annually [4–7]. Women with GDM are at high risk for short pregnancy complications, such as gestational hypertensive disorders, fetal macrosomia, shoulder dystocia, and cesarean delivery [8–10]. In addition, GDM constitutes a high risk for future type 2 diabetes mellitus (DM) and cardiovascular disease [11–13]. In particular, women with GDM, even with mild glucose intolerance, have up to seven times more risk of developing type 2 DM compared to women with normoglycemic pregnancies [13–15], thus justifying recently recommended tighter diagnostic criteria for GDM [16]. Based on the compelling evidence that lifestyle intervention can effectively prevent or delay the development of type 2 DM [17–19], early identification of women at high risk of diabetes is very important. In this regard,
Gestational Diabetes Mellitus in Africa: A Systematic Review  [PDF]
Shelley Macaulay, David B. Dunger, Shane A. Norris
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0097871
Abstract: Background Gestational diabetes mellitus (GDM) is any degree of impaired glucose tolerance first recognised during pregnancy. Most women with GDM revert to normal glucose metabolism after delivery of their babies; however, they are at risk of developing type 2 diabetes later in life as are their offspring. Determining a country’s GDM prevalence can assist with policy guidelines regarding GDM screening and management, and can highlight areas requiring research. This systematic review assesses GDM prevalence in Africa. Methods and Findings Three electronic databases were searched without language restrictions; PubMed, Scopus and the Cochrane Library. Thirty-one search terms were searched. Eligible articles defined GDM, stated what GDM screening approaches were employed and reported GDM prevalence. The reporting quality and risk of bias within each study was assessed. The PRISMA guidelines for systematic reviews were followed. The literature search identified 466 unique records. Sixty full text articles were reviewed of which 14 were included in the systematic review. One abstract, for which the full text article could not be obtained, was also included. Information regarding GDM classification, screening methods and prevalence was obtained for six African countries; Ethiopia (n = 1), Morocco (n = 1), Mozambique (n = 1), Nigeria (n = 6), South Africa (n = 4) and Tanzania (n = 1). Prevalence figures ranged from 0% (Tanzania) to 13.9% (Nigeria) with some studies focussing on women with GDM risk factors. Most studies utilised the two hour 75 g oral glucose tolerance test and applied the World Health Organization’s diagnostic criteria. Conclusions Six countries, equating to 11% of the African continent, were represented in this systematic review. This indicates how little is known about GDM in Africa and highlights the need for further research. Considering the increasing public health burden of obesity and type 2 diabetes, it is essential that the extent of GDM is understood in Africa to allow for effective intervention programmes.
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