Gestational diabetes: universal or selective screening?

OBJECTIVE: To evaluate the incidence of gestational diabetes in our population and verify costs of universal screening. To assess neonatal and obstetrical outcomes with respect to maternal epidemiological characteristics. METHODS: Eight hundred and fifty-six pregnant women between 24th and 28th weeks of gestation were examined in this observational study. Universal screening with glucose challenge test was used to screen the group for gestational diabetes. History, obstetrical and neonatal outcomes were collected and then analyzed. RESULTS: Gestational diabetes was diagnosed in 6.6% of cases. Patients with at least one risk factor had a cesarean section in 50% of cases and a spontaneous vaginal delivery in 23.59% of cases (p < 0.001). The absence of any risk factor was found in 73.7% of positive glucose tolerance test and in 62.5% of affected patients. The cost of universal screening in our study, was 57,60 Euros per case identified. CONCLUSIONS: Given the high prevalence of diabetes, the high proportion of patients potentially not identified with a selective screening in this study and the relatively low cost, universal screening for gestational diabetes seems the best way to identify patients and prevent adverse obstetrical and neonatal outcomes.     

Gestational diabetes screening in subsequent pregnancies of previously healthy patients

OBJECTIVE: Our purpose was to evaluate women without gestational diabetes mellitus in an index pregnancy for the likelihood that gestational diabetes would develop and for risk factors for carbohydrate intolerance in a subsequent pregnancy.Study Design: A retrospective review of medical records at a teaching hospital universally screening for gestational diabetes identified multiparous women who had been delivered twice between 1994 and 1997 and who, in the first (index) pregnancy, had had a normal result on a screening test with 50 g of glucose used in a "glucola" beverage (< or =140 mg/dL). RESULTS: In this population with normal glucose screening values in the index pregnancy, 352 (92.4%) of 381 women had at least one risk factor for gestational diabetes. However, none of the 381 women had gestational diabetes in the subsequent pregnancy (0/381, 95% confidence interval < or =1%), including 45 (12. 4%) who had an abnormal result on the 50-g glucose screening test. Regression analysis showed this test result in the index pregnancy (P =.001) to be the only studied variable significantly associated with the 50-g glucose value in the subsequent pregnancy. CONCLUSION: Despite a high rate of risk factors for gestational diabetes, women in our population with a normal glucose value in an index pregnancy have a minimal risk (<1%) that gestational diabetes will develop in a subsequent singleton pregnancy within 4 years. This factor may be included in determining whether women should undergo screening for gestational diabetes.     

Screening for gestational diabetes mellitus by a model based on risk indicators: a prospective study

OBJECTIVE: This study was performed to prospectively evaluate a screening model for gestational diabetes mellitus on the basis of clinical risk indicators. STUDY DESIGN: In a prospective multicenter study with 5235 consecutive pregnant women, diagnostic testing with a 2-hour 75-g oral glucose tolerance test was routinely performed in women with risk indicators and offered to women without risk indicators as part of the study. RESULTS: Forty-four percent of the women underwent testing, 43% declined participation, 6% did not speak Danish, and 7% could not be contacted. By extrapolation of the results from tested women to the whole group in question, a 2.4% prevalence of gestational diabetes mellitus was calculated. Sensitivity and specificity of the model was 80.6 (73.7-87.6) and 64.8 (63.5-66.1), respectively (95% CIs). CONCLUSION: Under ideal conditions, sensitivity of the model was comparable with universal screening by fasting glucose or a 1-hour 50-g glucose challenge test. Both screening and diagnostic testing could be avoided in two thirds of all pregnant women.     

Early-pregnancy glucose screening for gestational diabetes mellitus

OBJECTIVE: To determine the accuracy of the 50-g, one-hour glucose screening test administered at 16 weeks of pregnancy for identifying women with gestational diabetes mellitus. STUDY DESIGN: Two hundred fifty-five women underwent 50-g, one-hour glucose screening tests at 16 weeks of pregnancy. Those with results > or = 135 mg/dL underwent 100-g, three-hour glucose tolerance tests. All patients without diagnoses of gestational diabetes during the second trimester of pregnancy underwent standard third-trimester glucose testing. RESULTS: Gestational diabetes mellitus was diagnosed in 25 patients. Glucose screening tests administered at 16 weeks of pregnancy identified 96% (24) of these patients. Patients with 16-week glucose screening test results > or = 135 mg/dL had a 55% risk of developing diabetes during pregnancy, while the risk was 0.6% for patients with 16-week test results < or = 110 mg/dL. Patients with 16-week glucose screening test results in the intermediate range, 111-134 mg/dL, had a 4.8% risk of developing diabetes during pregnancy. CONCLUSION: Glucose screening at 16 weeks of pregnancy is a useful alternative to third-trimester screening for gestational diabetes. The negative predictive value of screening test results < or = 110 mg/dL is 99.4%. The positive predictive value for screening test results > or = 135 mg/dL is 55%. This latter finding is superior to the 8.6-22% found during the third-trimester.     

Efficacy of screening for gestational diabetes

A cost analysis of glucose screening was studied prospectively in 434 patients. All patients underwent a 50-gm oral glucose load followed by a 1-hour plasma glucose screen test at 28 weeks (+/- 2 weeks). Patients with a screen test greater than or equal to 130 mg/dl plasma glucose were further tested with an oral glucose tolerance test. Also, previously described clinical risk factors for diabetes were documented on all patients. A 3.3% prevalence of gestational diabetes was found in 178 patients with risk factors, compared with 2.4% of 256 patients without risk factors, not a significant difference. Ten of the 12 gestational diabetics were at least 24 years old, so that screening only this subgroup would still retain a good sensitivity (83%) but at half the cost of universal screening. Screening on the basis of risk factors other than age is inefficient. Though testing only patients who are 24 years of age or older is more cost effective than universal screening, an individual decision must be made regarding its reduced sensitivity.     

Screening for gestational diabetes mellitus in adolescent Hispanics

Objective: To determine the incidence of gestational diabetes mellitus in an adolescent Hispanic population and calculate the cost of screening.Methods: A retrospective chart review of deliveries to adolescent (<20 years old) Hispanic women from January 1991 through May 1996 was performed. The incidence of gestational diabetes mellitus (GDM) was determined and the cost of screening calculated.Results: Three hundred twenty-six adolescent Hispanic women were screened for GDM with a 1-hour 50-g oral glucose tolerance test at an average gestational age of 26 weeks (range 11–39 weeks), at a cost of $26 per test. Thirty (9.2%) had positive screens defined as a plasma glucose level of ≥140 mg%. Three-hour 100-g oral glucose tolerance tests were performed on those with positive screens, at a cost of $124 per test. Five women were diagnosed with GDM, an incidence of 1.5%. The cost to diagnose each case of GDM was $2,569.Conclusion: The incidence of GDM in this population is low, and therefore universal screening of Hispanic adolescents may be unwarranted and cost prohibitive. Large prospective trials evaluating maternal and neonatal outcomes would provide the best means to assess the value of screening.     

Clinical predictors for a high risk for the development of diabetes mellitus in the early puerperium in women with recent gestational diabetes mellitus

OBJECTIVE: The purpose of this study was to identify which maternal, antepartum, or neonatal clinical parameters were predictive for a high risk of diabetes mellitus in the puerperium in women with recent gestational diabetes mellitus and to calculate the associated diabetes mellitus rates and odds ratios. STUDY DESIGN: One thousand six hundred thirty-six women underwent an oral glucose tolerance test within 1 to 4 months of delivery. Demographic, historic, and antenatal glycemic parameters and neonatal outcome parameters were tested by univariate and multivariate logistic regression for risk of postpartum diabetes mellitus. Continuous variables were divided into quartiles that compared the upper to lower quartile adjusted odds ratio and prevalence of diabetes mellitus. RESULTS: Postpartum diabetes mellitus was diagnosed in 230 women (14.1%) according to the American Diabetes Association criteria (1997). No maternal demographic or neonatal parameters were significantly associated with diabetes mellitus. The final model of independent predictors in decreasing significance included the highest fasting plasma glucose level during pregnancy, any fasting plasma glucose level of > or = 105 mg/dL (class A(2)), the area under the curve of pregnancy oral glucose tolerance test, gestational age at diagnosis, previous gestational diabetes mellitus history, and 50-g glucose challenge test results. The fasting plasma glucose level was the best discriminator, with a 21-fold (95% CI, 4.6-96.3) increased odds ratio comparing the 4th quartile (fasting plasma glucose level, >121 mg/dL; diabetes mellitus rate, 36.7%) to 1st quartile (fasting plasma glucose level, < 95 mg/dL; diabetes mellitus rate, 0.5%). The presence of previous gestational diabetes mellitus or current class A(2) gestational diabetes mellitus approximately doubled the odds ratio for diabetes mellitus. The odds ratio increased 3- to 4-fold when the area under the curve was > or = 33.36 min small middle dot g/dL (4th quartile) or the glucose challenge test was > or = 155 mg/dL (2nd-4th quartiles) and decreased > 50% if gestational diabetes mellitus was diagnosed at > 27 weeks (3rd-4th quartile). CONCLUSION: During pregnancy, the highest fasting glucose level, followed by the severity of glucose intolerance, and earlier gestational diabetes mellitus diagnosis were the best predictors for postpartum diabetes mellitus. Diabetic education should begin during pregnancy, especially for women who are identified to be at a high risk when they are highly motivated and under medical care.     

Maternal age and screening for gestational diabetes: a population-based study

The American College of Obstetricians and Gynecologists (ACOG) has recommended screening for gestational diabetes, using a 50-g, 1-hour glucose challenge (threshold for further testing 140 mg/dL or higher), for all pregnant women aged 30 or older and for younger women with risk factors. In order to assess these recommendations, we collected demographic and historic data on 6214 pregnant women representing a population of universally screened individuals. Of 125 cases of gestational diabetes diagnosed (ACOG criteria), 70 patients (56%) were under the age of 30. In addition, 44% of gestational diabetics had no risk factors. The cost per case diagnosed would be $190 with the ACOG recommendations, $192 if the age for routine screening were lowered to 25 years or more, and $222 if universal screening were practiced. Using the ACOG recommendations, 35% of gestational diabetes would go undiagnosed, with little cost savings.     

Screening for gestational diabetes mellitus in adolescent pregnancies

Objective: Our purpose was to determine the incidence of gestational diabetes mellitus in an adolescent population and to determine the cost of screening. Study Design: A retrospective review of 509 adolescent pregnancies was performed. The incidence of gestational diabetes mellitus was determined and the cost of screening analyzed. Results: Five hundred nine adolescent pregnancies were screened for gestational diabetes mellitus with a 1-hour, 50 gm oral glucose challenge test. Twenty-three of the screens (4.5%) had positive results at a plasma glucose level of ≥140 mg/dl. Three-hour 100 gm oral glucose tolerance tests were performed on screen-positive women, six of whom were diagnosed with gestational diabetes mellitus, for an incidence of 1.18%. The cost per case diagnosed was $2733. Conclusions: The incidence of gestational diabetes mellitus in an adolescent population is low. The cost of universal screening may be prohibitive in this population. Large prospective studies are needed to better analyze outcome data and efficacy of screening in adolescent pregnancies. (Am J Obstet Gynecol 1998;178:1251-6.)     

Results of screening tests for gestational diabetes mellitus at Medical University in Warsaw

Our purpose was to determine the incidence of screening for gestational diabetes among the population of women delivering at I and II Departments of the First Faculty of Medical University in Warsaw. A retrospective review of 647 pregnancies was performed. The incidence of gestational diabetes mellitus screening was determined and the rate of occurrence of GDM analyzed. 310 (48%) pregnancies were screened for gestational diabetes mellitus with a 1-hour, 50 gm oral glucose challenge test. 49 (16.07%) of the screens had positive results at a plasma glucose level of > 139 mg/dl. Two-hour 75 gm oral glucose tolerance tests (according to the 1994 World Health Organization panel recommendations) were performed on screen-positive women, eleven of whom (22.45%) were diagnosed with gestational diabetes mellitus. Despite of positive oral 50 gm glucose test, (plasma glucose level 140-179 mg/l) 15 women (30%) haven't had the 75 gm oral glucose test. The incidence of GDM among analyzed population is 4% and when GDM screening is carried out, exceeds 7%. Early gestational glucose screening, if performed, may be beneficial in detecting gestational diabetes. Consideration should be given to fulfill it more frequently and for sure, repeat glucose testing in patients with positive one-hour screening tests.     

Predictive factors of developing diabetes mellitus in women with gestational diabetes

BACKGROUND: To investigate which factors during gestational diabetes pregnancies correlate with the risk of developing impaired glucose tolerance or diabetes 1 year postpartum and to compare this risk in women with gestational diabetes and women with a normal oral glucose tolerance test during pregnancy. METHODS: Of 315 women with gestational diabetes, defined as a 2-hr blood glucose value of at least 9.0 mmol/l at a 75-g oral glucose tolerance test, who delivered in Lund 1991-99, 229 (73%) performed a new test 1 year postpartum. We compared maternal and fetal factors during pregnancy with the test value at follow up. A control group of 153 women with a 2-hr test value below 7.8 mmol/l during pregnancy were invited to a new test 1 year postpartum and 60 (39%) accepted. RESULTS: At 1 year follow up, 31% of the women with gestational diabetes but only one of the 60 controls showed pathologic glucose tolerance and one had developed diabetes. The following factors in women with gestational diabetes were identified as predicting impaired glucose tolerance or diabetes at 1 year follow up: maternal age over 40 and--in a multiple regression analysis, independent of each other--a high 2-hr value at oral glucose tolerance test during pregnancy and insulin treatment during pregnancy. CONCLUSION: The risk of developing manifest diabetes after gestational diabetes may be high enough to justify a general screening or diagnostic procedure in all pregnant women to identify women with gestational diabetes and a postpartum follow up program for them. This study did not identify any particular factor during pregnancy with enough precision to predict a later progression to diabetes.     

Diabetic family history is an isolated risk factor for gestational diabetes after 30 years of age

BACKGROUND: Family history of diabetes is regarded as a risk factor for gestational glucose intolerance. Most selective screening policy includes family history as an indication of oral glucose tolerance test. However, few studies had evaluated the actual incidence of glucose intolerance in this group of women. METHODS: Pregnant women with oral glucose tolerance test performed for family history of diabetes over two consecutive years were identified. Receiver operating curve was used to identify the age cut-off that give the highest sensitivity and specificity. The incidence of glucose intolerance was compared between women with age above and below this cut-off. RESULTS: One hundred and eighty-seven women were identified. The age cut-off selected was 30.5 years. In young women (age 相似文献   

Universal versus selective gestational diabetes screening: application of 1997 American Diabetes Association recommendations.

OBJECTIVE: We sought to evaluate the impact of the 1997 American Diabetes Association gestational diabetes mellitus screening guidelines applied to a universally screened population. STUDY DESIGN: A retrospective analysis of 18,504 women universally screened for gestational diabetes mellitus at Mayo Clinic, Rochester, between January 1, 1986, and December 31, 1997, was performed. Diabetic screening consisted of plasma glucose determination 1 hour after a 50-g oral glucose challenge. Diagnosis of gestational diabetes mellitus was based on National Diabetes Data Group criteria. RESULTS: Of 564 cases of gestational diabetes mellitus diagnosed during the study period, 17 (3.0%) would have been missed under the 1997 American Diabetes Association selective screening guidelines while exempting only 10% of this predominantly white population from screening. Screening only women >/=25 years old would have detected 90.4% of gestational diabetes mellitus cases, whereas the addition of the remaining 3 screening criteria combined would have detected only an additional 6.6% of cases. CONCLUSIONS: The proportion of patients with gestational diabetes mellitus that would remain undiagnosed under the 1997 American Diabetes Association screening guidelines would be relatively small in our population. However, implementation of these guidelines would decrease the number of screens by only 10% while adding significant complexity to the screening process. Youth appears to be the most significant protective factor for gestational diabetes mellitus in our population.     

Predictive factors for the development of diabetes in women with previous gestational diabetes mellitus.

OBJECTIVES: The purpose of this study was to determine the incidence of diabetes in women with previous dietary-treated gestational diabetes mellitus and to identify predictive factors for development of diabetes. STUDY DESIGN: Two to 11 years post partum, glucose tolerance was investigated in 241 women with previous dietary-treated gestational diabetes mellitus and 57 women without previous gestational diabetes mellitus (control group). RESULTS: Diabetes developed in 42 (17.4%) women with previous gestational diabetes mellitus (3.7% insulin-dependent diabetes mellitus and 13.7% non-insulin-dependent diabetes mellitus). Diabetes did not develop in any of the controls. Predictive factors for diabetes development were fasting glucose level at diagnosis (high glucose, high risk), preterm delivery, and an oral glucose tolerance test result that showed diabetes 2 months post partum. In a subgroup of previous patients with gestational diabetes mellitus in whom plasma insulin was measured during an oral glucose tolerance test in late pregnancy a low insulin response at diagnosis was found to be an independent predictive factor for diabetes development. CONCLUSIONS: Women with previous dietary-treated gestational diabetes mellitus have a considerably increased risk of later having diabetes. Follow-up investigations are therefore important, especially in those women with previous gestational diabetes mellitus in whom the identified predictive factors are present.     

Risk factor screening for abnormal glucose tolerance in pregnancy.

OBJECTIVES: To assess the prevalence and association of frequently used screening risk factors for gestational diabetes mellitus (GDM) and to compare the validity and cost of universal screening with risk factor screening. METHOD: A cross-sectional survey of 768 pregnant women at > or = 24 weeks' gestation who were attending the antenatal clinic at the Hospital Universiti Kebangsaan Malaysia (HUKM) was made. Risk factors were determined using a questionnaire. An abnormal oral glucose tolerance test was defined as a 2-h post-prandial blood sugar level of > or = 7.8 mmol/l. RESULTS: A total of 191 pregnant mothers (24.9%) had GDM. The most commonly identified screening factors were positive family history of diabetes mellitus (31.4%), history of spontaneous abortion (17.8%), vaginal discharge and pruritis vulvae in current pregnancy (16.0%), and maternal age greater than 35 years (14.7%). Five hundred and thirteen mothers (66.8%) had at least one risk factor. All screening risk factors, except past history of diabetes mellitus in previous pregnancy and maternal age, were not significantly associated with abnormal glucose tolerance (GT). Risk factor screening gave a sensitivity of 72.2% and a specificity of 35.0%. Universal screening would cost RM 12.06 while traditional risk factor screening would cost RM 11.15 per identified case and will have missed 53 of the 191 cases. CONCLUSIONS: Risk factor screening scored poorly in predicting GDM. Cost analysis of universal compared with traditional risk factor screening showed a negligible difference. Thus universal screening appears to be the most reliable method of diagnosing GDM.     

Cost-effective criteria for glucose screening

To study cost-effective screening criteria for gestational diabetes, a prospective study of 1012 patients was completed. All patients underwent a glucose screen between 26 and 30 weeks of gestation, consisting of a 50-g oral glucose load followed by a one-hour plasma glucose determination. Patients with a glucose screen greater than or equal to 130 mg/dL were studied with a standard three-hour oral glucose tolerance test. The incidence of gestational diabetes was 2.4% (24 of 1012). Only one gestational diabetic was identified with a glucose screen below 150 mg/dL. Twenty-two of the 24 cases were at least 24 years old. Twenty-one of the 24 (88%) gestational diabetes had a glucose screen greater than or equal to 150 mg/dL and were 24 years old or greater. The cost of the diagnosis in these latter patients was 40% of the cost of diagnosis of universal screening with a threshold of 130 mg/dL. It is concluded that screening with a threshold of 150 mg/dL only patients who are at least 24 years old should be considered an alternative to universal screening.     

Comparison of two routine screening strategies for gestational diabetes mellitus: the experience of Jean-Verdier Hospital

OBJECTIVE: Screening strategies for gestational diabetes mellitus are controversial. Thus, we sought to determine the benefits of universal screening. PATIENTS AND METHODS: Prospective study with 2121 women involved but 1610 really screened (75.9%). According to WHO's recommendations, the strategy implemented was one-step, universal screening with a 75g oral glucose tolerance test. Screening was performed between 24 and 28 weeks of gestation or earlier if risk factors were identified. Results were compared to previous year (2001) then only a selective screening was done. RESULTS: Application of universal screening increased the prevalence of gestational diabetes mellitus (8.39% to 15.65%). Out of the 252 patients with gestational diabetes, 66 did not display any identified risk factor (26.19%). Some new risk factors have been identified: age>30, Asian, Indian or Pakistan ethnies. If these new risk factors were applied, this super selective screening would have a sensibility of 96%. DISCUSSION AND CONCLUSION: Universal screening seems to be the most appropriate routine screening strategy because it is difficult to know exactly the specific risk factors of a population to do a super selective screening.     

Risk factors for pre-eclampsia in pregnant Chinese women with abnormal glucose metabolism.

OBJECTIVES: To investigate the incidence and risk factors for pre-eclampsia in pregnant Chinese women with abnormal glucose metabolism. METHODS: A retrospective cohort study was performed on 1499 pregnant women with abnormal glucose metabolism at Peking University First Hospital from January 1995 to December 2004. RESULTS: The overall prevalence of pre-eclampsia in women with abnormal glucose metabolism was 9.4% (141/1499). The prevalence of pre-eclampsia in women diagnosed with diabetes mellitus prior to pregnancy was higher than that of gestational diabetes mellitus and gestational impaired glucose tolerance patients (29.1% vs 8.7% and 7.8%, P<0.01). Pre-pregnancy body mass index was significantly higher in women with pre-eclampsia than in those without. A higher rate of pre-eclampsia was found in women with chronic hypertension and those with poor glucose control. The independent risk factors for pre-eclampsia were chronic hypertension and elevated pre-pregnancy body mass index. CONCLUSIONS: The type of diabetes, chronic hypertension, and elevated pre-pregnancy body mass index are high risk factors for pre-eclampsia in pregnant women with abnormal glucose metabolism.     

Postpartum diabetes screening in women with a history of gestational diabetes

OBJECTIVE: Women with a history of gestational diabetes mellitus (GDM) are at high risk for developing type 2 diabetes (diabetes mellitus, DM). The American Diabetes Association recommends regular postpartum diabetes screening for women with a history of GDM, but the American College of Obstetricians and Gynecologists (ACOG) is not as directive. We sought to examine postpartum glycemic testing in women diagnosed with GDM. METHODS: We conducted an observational cohort study of women diagnosed with GDM at one of two large academic medical centers between 2000 and 2001. Kaplan-Meier estimates of the time from delivery to the first postpartum DM screening tests were determined, and predictors of postpartum DM screening were examined using Cox proportional hazards testing. RESULTS: Only 37% of eligible women underwent the postpartum diabetes screening tests recommended by the American Diabetes Association (fasting glucose or oral glucose tolerance test [OGTT]), with a median time from delivery to the first such testing of 428 days. By comparison, 94% of women underwent postpartum cervical cancer screening using a Papanicolaou (Pap) test, with a median time from delivery to Pap testing of 49 days. Even when random glucose testing was included in a broad definition of postpartum DM screening (random or fasting glucose, glycosylated hemoglobin, or OGTT), only two thirds of women (67%) received a postpartum glycemic assessment. CONCLUSION: In the population studied, only 37% of women with a history of GDM were screened for postpartum DM according to guidelines published by the American Diabetes Association. Efforts to improve postpartum DM screening in this high-risk group are warranted.     

Can increased nuchal translucency in the first trimester of pregnancy predict gestational diabetes mellitus.

The current study was designed to evaluate whether increased nuchal translucency can predict gestational diabetes mellitus. This was a prospective observational study. Among the pregnant women at 11-14 weeks of pregnancy who came to our prenatal unit for a first trimester screening test, 389 pregnant women whose nuchal translucency above 95th centile were selected as the study group and 386 age-matched pregnant women whose nuchal translucency were within the normal range were enrolled as a control group. First, subjects underwent a 50 g glucose screening test; if it was positive then a 100 g oral glucose tolerance test was performed. The main outcome measures were the prevalence of gestational diabetes mellitus and impaired glucose tolerance and the number of macrosomic infants. Impaired glucose tolerance was more common in pregnant women whose nuchal translucency was above the 95th centile (p = 0.048). In addition, macrosomic infants were also more common in pregnant women with a fetal nuchal translucency above the 95th centile (p = 0.045). Macrosomia was more common in the study group with gestational diabetes mellitus (p = 0.046). In conclusion, increased nuchal translucency seems to be predictive for impaired glucose tolerance and macrosomia, which are associated with gestational diabetes mellitus.