One-step or 2-step testing for gestational diabetes: which is better?

In the United States, the common approach to detecting gestational diabetes mellitus is the 2-step protocol recommended by the American College of Obstetricians and Gynecologists. A 50 g, 1-hour glucose challenge at 24 to 28 weeks' gestation is followed by a 100 g, 3-hour oral glucose tolerance test when a screening test threshold is exceeded. Notably, 2 or more elevated values diagnose gestational diabetes mellitus.

Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop.

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated.

Stillbirth, Inflammatory Markers, and Obesity: Results from the Stillbirth Collaborative Research Network.

Background: Obesity is associated with increased risk of stillbirth, although the mechanisms are unknown. Obesity is also associated with inflammation. Serum ferritin, C-reactive protein, white blood cell count, and histologic chorioamnionitis are all markers of inflammation.

Insulin Delivery Method and Admission for Glycemic Control in Pregnant Women with Type 1 Diabetes Mellitus.

Objective:  To determine if there was a difference in glycemic control admissions or perinatal outcomes in women with type 1 diabetes mellitus (DM) treated with multiple daily injections (MDIs) versus continuous subcutaneous insulin infusion (CSII).

Materials And Methods:  This was a retrospective cohort study of women with type 1 DM with a singleton gestation who delivered between 2006 and 2014 at a tertiary hospital and received care at a dedicated DM clinic. Women who used MDI were compared with those who used CSII.

Prenatal Care Adherence and Neonatal Intensive Care Unit Admission or Stillbirth among Women with Gestational and Preexisting Diabetes Mellitus.

Objective:  To determine if there was an association between prenatal care adherence and neonatal intensive care unit (NICU) admission or stillbirth, and adverse perinatal outcomes in women with preexisting diabetes mellitus (DM) and gestational DM (GDM).

Materials And Methods:  This is a retrospective cohort study among women with DM and GDM at a Diabetes in Pregnancy Program at an academic institution between 2006 and 2014. Adherence with prenatal care was the percentage of prenatal appointments attended divided by those scheduled.

The association of stillbirth with depressive symptoms 6-36 months post-delivery.

Background: Stillbirths (≥ 20 weeks' gestation), which account for about 1 in 200 US pregnancies, may grieve parents deeply. Unresolved grief may lead to persistent depression.

Methods: We compared depressive symptoms in 2009 (6-36 months after index delivery) among consenting women in the Stillbirth Collaborative Research Network's population-based case-control study conducted 2006-08 (n = 275 who delivered a stillbirth and n = 522 who delivered a healthy livebirth (excluding livebirths < 37 weeks, infants who had been admitted to a neonatal intensive care unit or who died).

Prediction of abnormal postpartum glucose tolerance testing in mild gestational diabetes mellitus.

Objective: To describe the liikelihood of women with gestational diabetes mellitus (GDM)--who are at increased risk for developing overt diabetes--undergoing postpartum testing, and the patient characteristics associated with abnormal postpartum glucose tolerance testing (GTT) in mild GDM.

Study Design: This was a retrospective chart review that included mild GDM patients, defined as those with fasting plasma glucose levels < 95 mg/dL on a 3-hour 100-g oral glucose tolerance test (OGTT). Patients who underwent postpartum testing were assessed and predictive factors for abnormal results evaluated.

Diagnosis of gestational diabetes.

Abstract Previous approaches to diagnosing gestational diabetes mellitus (GDM) have included 50 g, 75 g and 100 g glucose challenges, lasting 1-3 hours, with 1 or 2 elevations required. Thresholds were validated by their predictive value for subsequent diabetes, or were the same thresholds used in non-pregnant individuals. None were based on their prediction of adverse pregnancy outcomes.

Counterpoint: Establishing consensus in the diagnosis of GDM following the HAPO study.

The International Association of Diabetes in Pregnancy Study Groups (IADPSG) recommended a new protocol of 1-step testing with a 75 g oral glucose tolerance test for gestational diabetes in 2010. Since that time, these recommendations have been carefully scrutinized and accepted by a variety of organizations, but challenged or rejected by others. In the current review, we present more details regarding the background to the development of the IADPSG recommendations and seek to place them in context with the available epidemiologic and randomized controlled trial data.

Impact of an intensive follow-up program on the postpartum glucose tolerance testing rate.

Objective: Gestational diabetes mellitus (GDM) is a strong risk factor for the development of diabetes. We assessed the impact of a 1-year intensive follow-up demonstration program, using direct nurse and outreach worker case management, aimed at increasing compliance with postpartum oral glucose tolerance testing (OGTT).

Study Design: During the year of implementation, a nurse or bilingual outreach worker contacted patients to encourage attendance at their scheduled postpartum 2-h 75-g OGTT and assisted in overcoming obstacles to testing.

Placental findings in singleton stillbirths.

Objective: To compare placental lesions for stillbirth cases and live birth controls in a population-based study.

Methods: Pathologic examinations were performed on placentas from singleton pregnancies using a standard protocol. Data were analyzed overall and within gestational age groups at delivery.

Can hemoglobin A1c in early pregnancy predict adverse pregnancy outcomes in diabetic patients?

Objective: To examine the association of elevated early pregnancy hemoglobin A1c (HbA1c) levels with adverse pregnancy outcomes in women with preexisting diabetes mellitus.

Study Design: Retrospective cohort study of 330 women with preexisting diabetes enrolled in a Diabetes in Pregnancy Program at an academic institution between 2003 and 2011 who had an early HbA1c determination. The frequencies of composite maternal adverse pregnancy outcomes (birth at<37 weeks, preeclampsia, and medically indicated birth <39 weeks), and composite fetal adverse pregnancy outcomes [shoulder dystocia, Apgar scores<7 at 5 minutes, small for gestational age (SGA), large for gestational age (LGA), and stillbirth] were compared between HbA1c categories (<6.

Treatment of severe insulin resistance in pregnancy with 500 units per milliliter of concentrated insulin.

Objective: To evaluate glycemic control and pregnancy outcomes among pregnant women with severe insulin resistance treated with 500 units/mL concentrated insulin.

Methods: Retrospective analysis of gravid women with severe insulin resistance (need for greater than 100 units of insulin per injection or greater than 200 units/d) treated with either 500 units/mL concentrated insulin or conventional insulin therapy. We performed a two-part analysis: 1) between gravid women treated with and without 500 units/mL concentrated insulin; and 2) among gravid women treated with 500 units/mL concentrated insulin, comparing glycemic control before and after its initiation.

Gestational diabetes mellitus.

Background: Gestational diabetes mellitus, defined as diabetes diagnosed during pregnancy that is not clearly overt diabetes, is becoming more common as the epidemic of obesity and type 2 diabetes continues. Newly proposed diagnostic criteria will, if adopted universally, further increase the prevalence of this condition. Much controversy surrounds the diagnosis and management of gestational diabetes.

A population-based case-control study of stillbirth: the relationship of significant life events to the racial disparity for African Americans.

Stillbirths (fetal deaths occurring at ≥20 weeks' gestation) are approximately equal in number to infant deaths in the United States and are twice as likely among non-Hispanic black births as among non-Hispanic white births. The causes of racial disparity in stillbirth remain poorly understood. A population-based case-control study conducted by the Stillbirth Collaborative Research Network in 5 US catchment areas from March 2006 to September 2008 identified characteristics associated with racial/ethnic disparity and interpersonal and environmental stressors, including a list of 13 significant life events (SLEs).

Predicting the need for medical therapy in patients with mild gestational diabetes.

Objective: The enforcement of a one-step gestational diabetes mellitus (GDM) diagnosis would capture more patients with milder forms of glucose intolerance thereby increasing the incidence. We propose to identify characteristics predicting the need for medical therapy in such patients.

Study Design: Retrospective chart review of patients with mild GDM, defined as a fasting plasma glucose (FPG) < 95 mg/dL on the 3-hour 100-g oral glucose tolerance test (OGTT).