SCREENING AND DIAGNOSIS

Objectives
At the end of this session you will be
able to:
Define GDM
Identify the risks for development of GDM.
State the prevalence of GDM locally
Explain the reason for identifying and treating
GDM
Identify appropriate screening measures
Identify who should be screened
Identify diagnostic criteria
Definition

Glucose intolerance with onset or first

recognition during pregnancy

Characterized by -cell function that is

unable to meet the bodys insulin needs

Buchanan, Wiang, Kjos, Watanabe 2007

 Glucose regulation during pregnancy

Insulin resistance begins in mid pregnancy and

progresses through the third trimester
A result of maternal adiposity and effects of placental
hormones

-cells usually make more insulin to compensate

for resistance when they cannot meet the
needs hyperglycemia occurs
 GDM represents a state of chronic -cell
dysfunction in the face of insulin
resistance
Insulin resistance and insulin levels are different
prior to pregnancy in women who develop GDM
and those who do not
Changes in insulin sensitivity are similar in both
groups during pregnancy
However in GDM women, insulin secretion does
not increase adequately

Buchanan, Wiang, Kjos, Watanabe 2007

Prevalence
The prevalence of GDM is estimated to be 10-
16.9% in pregnant women depending on the
diagnostic criteria used.

Prevalence also varies by region and ethnicity.

Highest prevalence is in South East Asia
Lowest in North America and the Caribbean

Prevalence higher
in less physically active women.
In older women
In women with higher BMI
In those with a strong family history of diabetes

WHO, 2013
IDF, 2013
Discussion

What are the risk factors for gestational

diabetes?

What risk factors do you see most often

in your setting?
Risk factors for GDM
High risk Low risk
Obesity Age less than 25 years
Diabetes in 1st degree relative
No previous poor
Previous pregnancy outcomes
history of GDM or glucose
intolerance No diabetes in 1st degree
complicated pregnancy
relatives
infant with macrosomia > Normal prepregnancy
3.5 kg weight and weight gain
Older age during pregnancy
High risk ethnic group; South No history of abnormal
Asian, East Asian, Indigenous glucose tolerance
American or Australian,
Hispanic
PCOS
Perkins, Dunn, Jagastia, 2007
Is Hypertension a risk factor?

Hypertension prior to pregnancy or during

1st trimester doubled the risk of GDM
independent of maternal weight

Hence all women with hypertension should

be screened for GDM

Hedderson, Ferrara, 2008

Why diagnose and treat GDM?

Short term risks for the mother

Development of gestational hypertension, worsening essential
hypertension or development of preeclampsia
Operative delivery - related to macrosomia
Polyhydramnios
Premature labour

Long term risks for the mother

Development of type 2 diabetes in next ~10 years (30-60%
depending on population)
Development of cardiovascular disease

CDA, 2013
Metzger, Buchanan, et al. 2007
Why diagnose and treat GDM?

Short term risks for the baby

Macrosomia
Neonatal hypoglycemia
Jaundice
Preterm birth
Birth injury
Hypocalcemia/ hypomagnesimia
Respiratory distress syndrome

Long term risks for the baby

Obesity
Type 2 diabetes
Importance of follow up

Long term follow up studies have shown

that most women with GDM will develop
diabetes within the first decade after the
pregnancy

Testing after pregnancy is important - more

about this later

Kim, Newton, Knopp 2002

Screening
- Whom to screen
- When to screen
- How to screen
Who to screen

Some guidelines recommend screening all

women at the first visit to rule out pre-
existing type 2 diabetes

Most guidelines recommend screening all

women for GDM at 24-28 weeks gestation.

ADA, 2015
CDA , 2013
When to screen?
First trimester
Screening in 1st trimester
- to rule out unidentified pre-existing diabetes

Fasting plasma glucose >126 mg/dl (7 mmol/L)

or
HbA1c >6.5%
or
Random >200mg/dl (11.1 mmol/L)
or
2hr value in OGTT >200mg/dl (11.1 mmol/L)

If overt diabetes is detected, it must be treated appropriately.

ADA, 2015
When to screen
Screening for GDM
Screening should be done at 24-28 weeks

Diagnosis based on a 75 gm glucose load given in fasting

state

GDM diagnosed when one or more of the following is

present

Fasting 92 - 125 mg/dl (5.0 6.9 mmol/L)

1 hour post 75 gm load >180 mg/dl (10 mmol/L)
2 hour post 75 gm load >153mg/dl (8.5 mmol/L)

If woman tests negative, screening at 32 weeks also may

be necessary in presence of high risks
World Health Organization, 2013
Diagnostic criteria
WHO (2013) IADPSG ADA ADA
1 or more 1 or more one step two step

Fasting 5.1-6.9 >5.1 mmol/L >5.1 mmol/L 50-g glucose

plasma mmol/L (92 mg/dl) (92 mg/dl) load
glucose (92-125 (nonfasting)
mg/dl) If 1 hour >
7.8mmol/L
(140mg/dl)
1 hour PG >10.0mmol/L >10.0mmol/L >10.0mmol/L
after 75gm (180mg/dl) (180mg/dl) (180mg/dl)
Do 100 g
load
OGTT
2 hour PG 8.5-11.0 >8.5 mmol/L >8.5 mmol/L
after 75gm mmol/L (153- (153 mg/dl) (153 mg/dl) GDM If 2 of 4
load 199 mg/dl) results high

Diabetes Care 2015, WHO 2013

How to screen
Key considerations for screening in low resource
countries
Low cost
No requirement for elaborate preparation
High sensitivity and specificity
Short turn-around time
Be administered by health workers with minimal training
Need little maintenance, calibration, or refrigeration

Agarwal et al, 2007

Venous or capillary
The venous plasma is the gold standard

Where laboratory facilities or technicians are not

available, capillary glucose estimations may be done
using a hand held glucose meter.

The glucose meter must be standardized with a lab and

calibrated against the lab on a regular basis.
Which of these women has GDM?
All have had 75g glucose load at about 25 weeks
Rupinder, overweight, 35 years old,
fasting 90 mg/dl (5.0 mmol/L),
1 hr 170mg/d (9.4 mmol/L),
2hr 135mg/dl (7.5 mmol/L)
Joanne, 3rd pregnancy, history of big babies,
fasting 130 mg/dl (7.2 mmol/L),
1 hr 190mg/dl (10.5 mmol/L)
2 hr 220mg/dl (12.2 mmol/L)
Maria, 1st pregnancy, 25 years old, obese,
fasting 90mg/dl (5 mmol/L),
1 hr 168mg/dl (9.3mmol/L)
2 hr 160 mg/dl (8.8mmol/L)
Giving the diagnosis
Will my baby be ok? 1st question often asked
Is this temporary? 2nd question
Questions provide an opportunity for teaching
Must answer truthfully
Must convey importance of management during
pregnancy for healthy outcome but also for
future health of baby and mother
Risk of type 2 diabetes
Risk of obesity
References
American Diabetes Association. Clinical Practice Recommendations 2015. Diabetes Care. 2015;38(1)
Agarwal et al - Fasting plasma glucose as a screening test for gestational diabetes mellitus, Archives of Gynecology
and Obstetrics 2007
Buchanan T, Xiang A, Kjos S, Watanabe R. What is gestational Diabetes? Diabetes Care 2007;30(2):S105-111.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013
Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy.
Can J of Diabetes. 2013;37(suppl 1):S168-183.
Hedderson MM, Ferrara A. High blood pressure before and during early pregnancy is associated with an increased risk
of gestational diabetes mellitus. Diabetes Care. 2008;31(12):2362-2367.
IDF Diabetes Atlas 6th Ed, 2013
Kim C. Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care
2002;25:1862-1868
Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth
international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007;30(suppl 2):S251-260.
Perkins JM, Dunn JP, Jagastia SM. Perspectives in gestational diabetes mellitus: A review of screening, diagnosis and
treatment. Clinical Diabetes. 2007;25(2):57-62
WHO. Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy , 2013