Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Simon Weitzman, MD, MPH

Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Diagnostic methods and criteria Screening strategies Maternal and offspring outcomes

Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Diagnostic methods and criteria Screening strategies Maternal and offspring outcomes

Diagnostic Methods for GDM

1-hr.

Oral Glucose Challenge Test (GCT) Oral Glucose Tolerance Test (OGTT)
World Health Organization (WHO) National Diabetes Data Group (NDDG) Coustan odi!ication

Diagnostic criteria for GDM

ethod Criteria ("g#dl)
$%G 1 hr. & hr. ' hr.
WHO (() gr) 1*+ NDDG (1++ gr) 1+) Coustan (1++ gr) ,)
$%G/ $asting plas"a glucose

1,+ 1.+

&++ 1-) 1*) 1)) 1*+

Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Diagnostic methods and criteria Screening strategies Maternal and offspring outcomes

Screening strategies for GDM

The

approach
One-step approach

Two-step approach

The 50 gr. GCT (Cutoff >1 ! "g#dl)

Sensitivity:

38.2% Specificity: 93.3%

Positive Predictive Value: 78.6 % Negative Predictive Value : 7 . %

The 50 gr. GCT (Cutoff >1 !"g#dl)

Sensitivity: 38.2% Specificity: 93.3%

Positive Predictive Value:!9."% Negative Predictive Value: 97.2%

Screening strategies for GDM

The
Uni

population

ersal screening ris! groups screening

High

$niversal versus high ris% strateg&

Uni ersal screening
0 )(.*1 agreed to screening 0 &(.( 1 GCT positi2e ha2e abnor"al OGTT 0 Non-participants ha2e "ore ris3 !actors High "is! #roup Screening 0Would "iss 4 *+1 o! GD

$niversal screening in the 'egev

7

% of #e$is% and "7% of &edouins agreed to screening '() only in *9% of $o+en ,')) only in ! % ,verall non- participation: * %

Critical evaluation of the diagnosis of Gestational Diabetes Mellitus (GDM)

Diagnostic methods and criteria Screening strategies Maternal and offspring outcomes

(nfluence of GDM on the later develo)"ent of diabetes in the child

H5pergl5ce"ia a!!ects !etal beta-cell !unction in ani"als nutritional depri2ation and "aternal h5pergl5ce"ia increase the ris3 o! diabetes in later li!e

6ntrauterine

Maternal and offs)ring outco"es

Characteristic
7G8 (1) Gestational age (9) Hospital da5s '.(

Nor"al OGTT
'* ',

GD
'. ',.& '.,

*erinatal characteristics of +o"en +ith GDM, according to ris% factors

$haracteristic "is! %actors O"&'()$*+
,es
$esarean section &)+ Macrosomia &)+ Shoulder D7stocia &)+ *nsulin therap7 &)+ ./ .. 4 .3

-o
.( 04 0. 5/ 012 &314-.14+ 516 &31'-214+ 31( &310-510+ 010 &316-514+

*las"a glucose levels in non obese, and obese +o"en +ith )revious GDM, after 5-10 &ears of follo+-u)
Plasma glu ose (mmol!l)

15 10 5 0

Controls NOpGDM OpGDM

30

60

90

120

150

Time (min)

*las"a insulin levels in non obese and obese +o"en +ith )revious GDM, after 5-10 &ears of follo+-u)
Plasma insulin (pmol!l)

#00 600 "00 200 0 0 30 60 90 120 150

Controls NOpGDM OpGDM

Time (min)

.ogistic regression anal&sis of factors related to the develo)"ent of diabetes in +o"en +ith )revious GDM
'a tor O&&s ratio
6(9" 3(15 5(26

95$ C%

'asting glu ose at &iagnosis 0)120 min glu ose *+C at postpartum OGTT 0)60 min insulin *+C at &iagnosti OGTT

1(#3)26(2" 1(0#)9(23 1(13)22(50

Glucose tolerance at follo+-u) in +o"en +ith )revious GDM and health& controls
.tatus at /ollo0)up
Normal OGTT %GT T1pe 2 DM T1pe 1 DM

GDM (n,139)
6"(- (90) 20(1 (2#) 10(# (15) "(3 (6)

Controls (n,2-)
##(9 (2") 11(1 (3) )))))))) ))))))))

Conclusions
#.

Nerup said t%at )ype ! dia.etes is t%e nig%t+are of geneticists. Parap%rasing %is state+ent/ $e can say t%at '01 is t%e nig%t+are of epide+iologists. )%ere is controversy a.out its definition/ t%e .est diagnostic +et%od/ diagnostic criteria/ and t%e population to .e screened.

Conclusions (2)
0espite

t%is confusion/ t%e +anage+ent of t%e condition %as greatly i+proved/ and t%e perinatal outco+es of offspring2s of '01 +ot%ers are co+para.le to t%ose of non-dia.etic $o+en/ e3cept for +acroso+ia.

Conclusions(3)
)%ere

is an increasing .ody of evidence supporting t%e ris4 of developing dia.etes +ellitus 5and particularly type 2 dia.etes6 a+ong $o+en $it% previous '01 7+ong o.ese '01 $o+en/ even years after delivery/ features of insulin resistance can .e found