2011 GESTATIONAL DIABETES UPDATE
compiled by Kristin Effland, LM, CPM
In 2011 the International Association of Diabetes and Pregnancy Study Group Consensus Panel (IADPSGP) released Guidelines for the Diagnosis of Hyperglycemia in Pregnancy. These Guidelines differ significantly from previous obstetrical guidelines followed by many providers in the US.
- Click here to see an algorithm of the new guidelines (PDF)
- For more information about what the American Diabetes Association and the International Association of Diabetes and Pregnancy Study Groups have to say about Gestational Diabetes and the hemoglobin A1c lab test, click here.
In response to the 2011 IADPSGP Guidelines, ACOG (the American College of Obstetricians and Gynecologists) released "Screening and Diagnosis of Gestational Diabetes Mellitus: ACOG Committee Opinion Number 504" published in September 2011. Vol. 118(3), pp. 751-753.
At this time, the ACOG Committee on Obstetric Practice continues to recommend the following:
- All pregnant women should be screened for GDM, whether by patient history, clinical risk factors, or a 50-g, 1-hour loading test to determine blood glucose levels.
- The diagnosis of GDM can be made based on the result of the 100-g, 3-hour oral glucose tolerance test, for which there is evidence that treatment improves outcome. Either the plasma or serum glucose level established by Carpenter and Coustan or the plasma level designated by the National Diabetes Data Group are appropriate to use (see Table 1). A positive diagnosis requires that two or more thresholds be met or exceeded.
- Diagnosis of GDM based on the one-step screening and diagnosis test outlined in the International Association of Diabetes in Pregnancy Study Group guidelines is not recommended at this time because there is no evidence that diagnosis using these criteria leads to clinically significant improvements in maternal or newborn outcomes and it would lead to a significant increase in health care costs.
ACOG also notes that "The National Institutes of Health is planning a Consensus Development Conference to determine the optimal approach to screening and diagnosis in the United States. Consensus regarding optimal diagnostic criteria among the many groups and professional organizations will further much needed research regarding the benefits and harms of screening and diagnosis of GDM."
Best practices regarding Gestational Diabetes are being reconsidered because of the many varied perspectives on the evidence. Below is an outline of the most recent published information regarding Gestational Diabetes.
In May 2008, the US Preventative Services Task Force (USPSTF) concluded that:
- The current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes mellitus (GDM), either before or after 24 weeks gestation.
- Nearly all women should be encouraged to achieve moderate weight gain based on their BMI & to participate in physical activity.
- Although screening and early treatment of GDM reduces macrosomia, and although 1 trial suggests the possibility of other health benefits, the overall evidence is poor to determine whether maternal or fetal complications are reduced by screening.
- SOURCE: US Preventative Services Task Force Recommendations on GDM Screening
The American Diabetes Association (ADA) & European Association for the Study of DM (EASD) Guidelines conclude that the specific components of Medical Nutritional Therapy should include:
- Management of energy balance, overweight, and obesity with diet, physical activity, and behavior modification (B);
- Primary prevention of diabetes among individuals at high risk of developing type 2 diabetes (A);
- Promoting fiber and whole-grain intake meeting US Department of Agriculture recommendations (B);
- Controlling dietary fat intake by limiting saturated fat intake to less than 7% of total calories (A)
- Minimizing trans fat intake (E); and managing carbohydrate intake.
- SOURCE: ADA Guidelines
- "Nutrition Recommendations and Interventions for Diabetes: A position statement of the American Diabetes Association."
The American Academy of Family Physicians (AAFP) on Diagnosis & Management of GDM (July 2009) finds that:
- “Although earlier delivery reduced the risk of macrosomia, it did not reduce rates of brachial plexus injuries, hypoglycemia, or clavicle fractures.” (61)
- “A financial-based decision analysis argues against facilitated delivery; an estimated 443 elective cesarean deliveries need to be performed to prevent one case of brachial plexus injury, at a cost of $930,000 (in 1996).” (61)
- “Based on the limited data, as well as the medicolegal climate, many physicians still opt to facilitate delivery before 39 weeks' gestation. If this option is chosen in the absence of maternal or fetal compromise, amniocentesis should be strongly considered to assess for fetal lung maturity.” (61)
- SOURCE: Serlin DC, and Lash RW. "Diagnosis and management of gestational diabetes mellitus.” American Family Physician. Vol. 80, No. 1, July 1, 2009
The New Zealand College of Midwives Consensus Statement on GDM concludes:
- All women should be offered screening between 24-28 weeks gestation for GDM but it is the woman’s decision whether she wishes to be screened following this discussion.
- Full Statement (PDF)
The recent study (Oct 2009) on the treatment of Mild GDM published in the NEJM found:
- Significant reductions in Mean birth weight (3302 vs. 3408 g), Neonatal fat mass (427 vs. 464 g), Frequency of large-for-gestational-age (LGA) infants (7.1% vs. 14.5%), Birth weight greater than 4000 g (5.9% vs. 14.3%), Shoulder dystocia (1.5% vs. 4.0%), Cesarean delivery (26.9% vs. 33.8%) and Rates of preeclampsia and gestational hypertension (combined rates for the two conditions, 8.6% vs. 13.6%; P=0.01)
- Scrutinizing the study results reveals that the Mean Birth Weight Difference was only 3.7 ounces, and the Neonatal Fat Mass Avg. Difference was only 1.3 ounces
- For comparison, consider that the percentage of LGA Babies in the CPM 2000 study 24.3% and yet the C/S rate was 3.7%!
- Importantly, this and other related studies have begun to conclude that “Increased birth weight and neonatal fat mass may have long-term health implications for the offspring of mothers with gestational diabetes mellitus, including an increased risk of impaired glucose tolerance and childhood obesity.” (Landon, 1346)
- SOURCE: Landon et al. "A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes." New England Journal of Medicine. Vol: 361:1339-1348, No:14, October 1, 2009.
The Hyperglycemia & Adverse Pregnancy Outcomes (HAPO) study in 2008 found:
- Strong, continuous associations of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels (a marker for increased adiposity).
- An important consideration with the HAPO study is that the effects are determined by odds ratios. Odds tend to inflate the effect size of an analysis (esp. if the events being studied are relatively common). Whereas probabilities/Relative Risks are relatively easy to interpret, odds can be tricky. In fact, odds ratios can illegitimately inflate the effect size substantially.
- SOURCE:"Hyperglycemia and Adverse Pregnancy Outcomes." New England Journal of Medicine 2008; 358:1991-2002. May 8, 2008.
The Australian Carbohydrate Intolerance Study (ACHOIS) in 2005 found that:
- The rate of serious perinatal complications was significantly lower among the infants of mothers in the intervention group (1% vs. 4%, adjusted RR 0.33; CI, 0.14 to 0.75; P=0.01)
- Serious perinatal complications were 67% less likely in the treated group
- Thus, the Number of women who needed to be treated for GDM to prevent a serious outcome in an infant was 34
- However, more infants of women in the intervention group were admitted to the neonatal nursery (71% vs. 61%; adjusted RR, 1.13; CI, 1.03 to 1.23; P=0.01).
- The number who needed to be treated for GDM to cause this harm was 11 (CI, 7-29)
- Treated women were more likely to be induced (39% vs. 29%; RR, 1.36; CI, 1.15 to 1.62; P<0.001)
- Despite a higher rate of induction, the rates of C/S were similar (31% and 32%; RR, 0.97; CI, 0.81 to 1.16; P=0.73).
- For comparison, the C/S rate in the CPM 2000 study was 3.7%.
- The increased NICU admissions and increased rates of induction may both be related to the knowledge of the diagnosis by the attending physician.
- “The earlier gestational age at birth as a consequence of the induction of labor may have contributed to the reduction in serious perinatal outcomes.” (2483)
- Or to Iatrogenic prematurity necessitating NICU admission!!! (This is not concluded by study authors, but seems like a major oversight in my opinion)
- “Long-term follow-up is needed to assess whether the lower birth weights among the infants in the intervention group will translate into reduced rates of [impaired glucose tolerance, diabetes, & GDM].” (2484)
- At three months postpartum, data on the women's mood and quality of life, available for 573 women, revealed lower rates of depression and higher scores, consistent with improved health status, in the intervention group.
- SOURCE: Crowther, et al.
A study published in August 2010, found a reduced incidence of gestational diabetes with bariatric surgery:
- Obese women who have weight loss surgery before they get pregnant are three times less likely to develop gestational diabetes and are also less likely to require a cesarean section.
- Most of the women in the study had a gastric bypass operation, with some opting for an adjustable band procedure.
- Like all operations, however, bariatric surgery is not without risk.
- There were 346 women who had a delivery before bariatric surgery, and 354 had a delivery after bariatric surgery. Women with delivery after bariatric surgery had lower incidences of GDM (8% vs 27%, odds ratio (OR) 0.23, (95% CI 0.15 to 0.36) and cesarean section (28% vs 43%, OR0.53, 95% CI 0.39 to 0.72) than those with delivery before bariatric surgery.
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