31/5/2016 Diabetesmellitusinpregnancy:Screeninganddiagnosis

OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Diabetesmellitusinpregnancy:Screeninganddiagnosis

Author SectionEditors DeputyEditor

DonaldRCoustan,MD DavidMNathan,MD VanessaABarss,MD,FACOG
MichaelFGreene,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Apr2016.|Thistopiclastupdated:May20,2016.
INTRODUCTIONPregnancyisaccompaniedbyinsulinresistance,mediatedprimarilybyplacental
secretionofdiabetogenichormonesincludinggrowthhormone,corticotropinreleasinghormone,placental
lactogen,andprogesterone.Theseandothermetabolicchangesensurethatthefetushasanamplesupplyof
nutrients.(See"Maternalendocrineandmetabolicadaptationtopregnancy".)

Gestationaldiabetesdevelopsduringpregnancyinwomenwhosepancreaticfunctionisinsufficientto
overcometheinsulinresistanceassociatedwiththepregnantstate.Amongthemainconsequencesare
increasedrisksofpreeclampsia,macrosomia,andcesareandelivery,andtheirassociatedmorbidities.

Theapproachtoscreeningforanddiagnosisofdiabetesinpregnantwomenwillbereviewedhere.
Managementandprognosisarediscussedseparately:

(See"Gestationaldiabetesmellitus:Glycemiccontrolandmaternalprognosis".)
(See"Gestationaldiabetesmellitus:Obstetricalissuesandmanagement".)

TERMINOLOGYTheterminologyfordescribingdiabetesfirstdiagnosedduringpregnancyvariesamong
nationalorganizations.Historically,theterm"gestationaldiabetes"hasbeendefinedasonsetorfirst
recognitionofabnormalglucosetoleranceduringpregnancy[1].TheAmericanCollegeofObstetriciansand
Gynecologists(ACOG)continuestousethisterminology[2].

Inrecentyears,theInternationalAssociationofDiabetesandPregnancyStudyGroups(IADPSG),the
AmericanDiabetesAssociation(ADA),theWorldHealthOrganization(WHO),theInternationalFederationof
GynecologyandObstetrics(FIGO),andothershaveattemptedtodistinguishwomenwithprobablepreexisting
diabetesthatisfirstrecognizedduringpregnancyfromthosewhosediseaseisatransientmanifestationof
pregnancyrelatedinsulinresistance[36].Thischangeacknowledgestheincreasingprevalenceof
undiagnosedtype2diabetesinnonpregnantwomenofchildbearingage[7].Theseorganizationstypicallyuse
theterm"gestationaldiabetes"todescribediabetesdiagnosedduringthesecondhalfofpregnancy,andterms
suchas"overtdiabetes"or"diabetesmellitusinpregnancy"todescribediabetesdiagnosedbystandard
nonpregnantcriteriaearlyinpregnancy,whentheeffectsofinsulinresistancearelessprominent.Theterm
"gestationaldiabetes"hasalsobeenusedtodescribeglucoselevelsinearlypregnancythatdonotmeet
standardnonpregnantcriteriaforovertdiabetesbutarediagnosticforgestationaldiabetes.Oneshortcomingof
thisapproachisthatthediagnosticcriteriaforgestationaldiabeteshavenotbeenvalidatedforearlypregnancy,
andwerebasedondatafromthelatesecondandearlythirdtrimester.

BACKGROUND

PrevalenceTheprevalenceofgestationaldiabetesastraditionallydefinedisabout6to7percentinthe
UnitedStates(range1to25percent[8])[9].Theprevalencevariesworldwideandamongracialandethnic
groups,generallyinparallelwiththeprevalenceoftype2diabetes.IntheUnitedStates,prevalenceratesare
higherinAfricanAmerican,HispanicAmerican,NativeAmerican,PacificIslander,andSouthorEastAsian
womenthaninwhitewomen[10].Prevalencealsovariesbecauseofdifferencesinscreeningpractices,
populationcharacteristics(eg,averageageandbodymassindex[BMI]ofpregnantwomen),testingmethod,
anddiagnosticcriteria.Prevalencehasbeenincreasingovertime,possiblyduetoincreasesinmeanmaternal
ageandweight[1117].

In2010,theInternationalAssociationofDiabetesandPregnancyStudyGroups(IADPSG)proposednew
screeninganddiagnosticcriteriafordiabetesinpregnancy[4].Usingthesecriteria,theglobalprevalenceof

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hyperglycemiainpregnancyhasbeenestimatedat17percent,withregionalestimatesvaryingbetween10
percentinNorthAmericaand25percentinSoutheastAsia[18].

SignificanceSeveraladverseoutcomeshavebeenassociatedwithdiabetesduringpregnancy[1928]:

Preeclampsia
Hydramnios
Macrosomiaandlargeforgestationalageinfant
Fetalorganomegaly(hepatomegaly,cardiomegaly)
Maternalandinfantbirthtrauma
Operativedelivery
Perinatalmortality
Neonatalrespiratoryproblemsandmetaboliccomplications(hypoglycemia,hyperbilirubinemia,
hypocalcemia,erythremia)

Importantly,therisksoftheseoutcomesincreaseasmaternalfastingplasmaglucoselevelsincreaseabove75
mg/dL(4.2mmol/L)andastheonehourandtwohouroralglucosetolerancetest(GTT)valuesincrease.This
isacontinuouseffectthereisnoclearthresholdthatdefinespatientsatincreasedriskofadverseoutcome
[20,29].

Inaddition,ifthemotherishyperglycemicduringorganogenesis,suchaswomenwithknownorunknownovert
diabetes,therisksofmiscarriageandcongenitalanomaliesareincreased.(See"Pregestationaldiabetes:
Preconceptioncounseling,evaluation,andmanagement".)

Longterm,womenwithgestationaldiabetesareatincreasedriskofdevelopingtype2diabetes,aswellas
type1diabetesandcardiovasculardisease(see"Gestationaldiabetesmellitus:Glycemiccontrolandmaternal
prognosis",sectionon'Longtermrisk').Theiroffspringarealsoatriskoflongtermsequelae,suchasobesity
andmetabolicsyndrome[28](see"Infantofadiabeticmother").Gestationaldiabetes[30]andthecombination
ofobesityanddiabetes(gestationalorpregestational)[31]havebeenassociatedwithanincreasedriskof
autisminoffspring.

Treatmentofgestationaldiabetescanreducetheriskofsomepregnancycomplications(eg,preeclampsia)and
adverseneonataloutcomes(eg,macrosomia)[32,33].Inonestudy,theriskofchildhoodobesityinoffspringof
motherstreatedforgestationaldiabeteswasattenuatedcomparedwithoffspringofwomenwithlesserdegrees
ofhyperglycemiawhodidnotmeetcriteriaforgestationaldiabetes[28].Inanotherstudy,longtermfollowupof
offspringofmotherswithmildgestationaldiabeteswhoparticipatedinaclinicaltrialdidnotrevealaconsistent
benefitofgestationaldiabetestreatmentonglycemiaorbodymassindexinoffspring,althoughfemale
offspringhadlowerfastingglucoselevels[34].

RiskfactorsPregnantwomenwithanyofthefollowingcharacteristicsappeartobeatincreasedriskof
developinggestationaldiabetestheriskincreaseswhenmultipleriskfactorsarepresent[35]:

Personalhistoryofimpairedglucosetoleranceorgestationaldiabetesinapreviouspregnancy

Memberofoneofthefollowingethnicgroups,whichhaveahighprevalenceoftype2diabetes:Hispanic
American,AfricanAmerican,NativeAmerican,SouthorEastAsian,PacificIslander

Familyhistoryofdiabetes,especiallyinfirstdegreerelatives[36]

Prepregnancyweight110percentofidealbodyweightorBMI>30kg/m2,significantweightgaininearly
adulthoodandbetweenpregnancies[37],orexcessivegestationalweightgain[3840]

Maternalage>25yearsofage

Previousdeliveryofababy>9pounds(4.1kg)

Previousunexplainedperinatallossorbirthofamalformedinfant

Maternalbirthweight>9pounds(4.1kg)or<6pounds(2.7kg)

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Glycosuriaatthefirstprenatalvisit

Medicalcondition/settingassociatedwithdevelopmentofdiabetes,suchasmetabolicsyndrome,
polycysticovarysyndrome(PCOS),currentuseofglucocorticoids,hypertension

Womenatlowriskofgestationaldiabetesareyounger(<25yearsofage),nonHispanicwhite,withnormal
BMI(<25kg/m2),nohistoryofpreviousglucoseintoleranceoradversepregnancyoutcomesassociatedwith
gestationaldiabetes,andnofirstdegreerelativewithdiabetes[8].Only10percentofthegeneralobstetric
populationintheUnitedStatesmeetsallofthesecriteriaforlowriskofdevelopinggestationaldiabetes,which
isthebasisforuniversalratherthanselectivescreening(see'Candidatesforscreening/testing'below)[41].

ApproachesforriskreductionInoverweightandobesewomen,weightlossbeforepregnancycan
reducetheriskofdevelopinggestationaldiabetes.However,theefficacyofanexerciseprogramofbrisk
walking,stairclimbing,orothervigorousactivitybeforepregnancyandinearlypregnancyforreducingdiabetes
riskinallwomenhasnotbeenproven.

PrepregnancyweightlossThepossiblebenefitofprepregnancyweightlossisillustratedbythe
followingtwoexamplesofobservationalstudies:

Inapopulationbasedcohortstudy,obesewomenwholostatleast10pounds(4.5kg)between
pregnanciestrendedtowarddecreasedriskofgestationaldiabetesrelativetowomenwhoseweight
changedbylessthan10pounds(relativerisk0.6395%CI0.381.02,adjustedforageandweight
gainduringeachpregnancy).Womenwhogained10pounds(4.5kg)ormorebetweenpregnancies
significantlyincreasedtheirriskofgestationaldiabetes(relativerisk1.4795%CI1.052.04)[42].

Inastudythatcomparedtheincidenceofgestationaldiabetesin346womenwhodeliveredbefore
bariatricsurgerywiththeincidencein354womenwhodeliveredafterbariatricsurgery,theincidence
ofgestationaldiabeteswaslowerafterbariatricsurgery(8versus27percent,OR0.23,95%CI
0.150.36)[43].Bariatricsurgeryalsoinduceshormonalchangesthatmaylowertheriskof
gestationaldiabetesindependentofweightloss.

PrepregnancyandearlypregnancyexerciseInnonpregnantwomen,regularmoderateexercise
lowerstheriskofdevelopingtype2diabetescomparedwithbeingsedentary(see"Preventionoftype2
diabetesmellitus",sectionon'Exercise').Whetherexercisealoneorincombinationwithdietlowersthe
riskofdevelopinggestationaldiabetesisunclear,asmetaanalysesofrandomizedtrialshavereported
conflictingfindings[4447].Thetypesanddurationsoftheexerciseprogramsinthesetrialshavevaried
andmayaccountforthesediscordancies.Inparticular,beginninganexerciseprograminpregnancymay
betoolatetoimpactriskofgestationaldiabetes[4446,48].

Typeofdiet,smokingInadditiontoexercise,ahealthydietandsmokingcessationbeforepregnancy
arehealthybehaviorsthatmaybeassociatedwithreducedriskofdevelopinggestationaldiabetes[49].
Fewstudiesontheroleofdietaryfactorsinthedevelopmentofgestationaldiabeteshavebeen
performed.Thereislimitedevidence(nonefromrandomizedtrials)thatadietfavoringfruit,vegetables,
wholegrains,andfishandlowinredandprocessedmeat,refinedgrains,andhighfatdairyreducesthe
riskofdevelopinggestationaldiabetes[50,51].However,ahealthydietcanpromoteweightlossbefore
pregnancyandreduceexcessiveweightgainduringpregnancy,whichisbeneficialinoverweightand
obesewomen.Smokingcessationshouldbeencouragedinallpatients,andmayreducediabetesrisk.
(See"Preventionoftype2diabetesmellitus".)

SupplementsMyoinositolisanaturallyoccurringsugarinfruits,beans,grains,andnutsthatcan
improveinsulinresistance.Metaanalysesofrandomizedtrialsofantenatalmyoinositolsupplementation
duringpregnancysuggestareductionintheincidenceofgestationaldiabetes,butthetrialswereoflow
quality[52,53].Beforethisinterventioncanberecommended,largemulticenter,blinded,randomizedtrials
areneededtoconfirmsafetyanddemonstrateimprovementinclinicallyimportantmaternaland/or
neonataloutcomes.

BENEFITSANDHARMSOFSCREENINGScreeninganddiagnostictestingfordiabetesareperformed
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becauseidentifyingpregnantwomenwithdiabetesfollowedbyappropriatetherapycandecreasefetaland
maternalmorbidity,particularlymacrosomia,shoulderdystocia,andpreeclampsia.(See"Gestationaldiabetes
mellitus:Glycemiccontrolandmaternalprognosis",sectionon'Rationalefortreatment'.)

Mostofthecommonlyusedscreeninganddiagnostictestsinvolvedrinkingaglucosecontainingbeverage
followedbybloodglucosemeasurementnoneofthesetestsareassociatedwithseriousharmfulmaternalor
fetaleffects.However,somewomenfindthehyperosmolardrinksdifficulttotolerate.Ifgestationaldiabetesis
diagnosed,managementinvolveschangesindiet,anincreasedfrequencyofprenatalvisits,bloodglucose
monitoring,possiblepharmacologictherapy,andadditionalmaternalandfetalmonitoring.

Thecostimplicationsofscreeningversusnotscreeninghavebeenmodeled,andscreeningappearstobecost
effectiveforpreventionoftype2diabetesinpopulationswithahighprevalenceofgestationaldiabetesand
type2diabetes,providedthatlifestyleinterventionsareappliedsubsequenttopregnancy[54].

SCREENINGANDDIAGNOSTICTESTINGThepurposeofscreeningistoidentifyasymptomatic
individualswithahighprobabilityofhavingordevelopingaspecificdisease.Screeningisusuallyperformedas
atwostepprocesswheresteponeidentifiesindividualsatincreasedriskforthediseasesothatsteptwo,
diagnostictesting,whichisdefinitivebutusuallymorecomplicatedorcostlythanthescreeningtest,canbe
limitedtotheseindividualsandavoidedinlowriskindividuals.Alternatively,adiagnostictestcanbe
administeredtoallindividuals,whichisaonestepprocess.

Onestepandtwostepapproaches

TwostepapproachThetwostepapproachisthemostwidelyusedapproachforidentifyingpregnant
womenwithgestationaldiabetesintheUnitedStates.Thefirststepisaglucosechallengetest.Screen
positivepatientsgoontothesecondstep,a100gram,threehouroralglucosetolerancetest(GTT),
whichisthediagnostictestforgestationaldiabetes.

OnestepapproachTheonestepapproachomitsthescreeningtestandsimplifiesdiagnostictesting
byperformingonlya75gram,twohouroralGTT.

Candidatesforscreening/testingIntheUnitedStates,universalscreeningortestingappearstobethe
mostpracticalapproachbecause90percentofpregnantwomenhaveatleastoneriskfactorforglucose
impairmentduringpregnancy(see'Riskfactors'above)[41].Furthermore,2.7to20percentofwomen
diagnosedwithgestationaldiabeteshavenoriskfactors[55,56].

Timingofscreening/testingWhiletherearenoprovenbenefitstoscreening/testingfordiabetesinearly
pregnancy,screening/testingcanbeperformedasearlyasthefirstprenatalvisitifthereisahighdegreeof
suspicionthatthepregnantwomanhasundiagnosedtype2diabetes(eg,bodymassindex[BMI]>30kg/m2,
priorhistoryofgestationaldiabetesorknownimpairedglucosemetabolism,polycysticovarysyndrome
[PCOS][57])[2].Inparticular,womenwithapriorhistoryofgestationaldiabeteshavea48percentriskof
recurrence(95%CI4154percent)[58],andsomeoftheserecurrencesmayrepresentunrecognizedinter
gestationaltype2diabetes.Therearenovalidatedcriteriaforselectinghighriskpregnantwomenforearly
screening/testing.Riskassessmenttoolsforestimatingpersonaldiabetesriskinnonpregnantadultsare
available[59],butrarelyused.(See"Screeningfortype2diabetesmellitus",sectionon'Calculatingarisk
score'.)

Intheabsenceofearlyscreening/testingorifearlyscreening/testingisnegative,universalscreeningis
performedat24to28weeksofgestation[2,6,9].

AsystematicreviewbytheUnitedStatesPreventiveServicesTaskForce(USPSTF)ontheaccuracyof
screeningtestsforgestationaldiabetes,thebenefitsandharmsofscreeningbeforeandafter24weeksof
gestation,andthebenefitsandharmsoftreatment,foundgoodevidencetosupportuniversalscreeningafter
24weeks,butnotforuniversalscreeningearlierinpregnancy[9].Asecondaryanalysisofdatafroma
randomizedtrial[33]foundthatoutcomesofpregnancieswithearlydiagnosisandtreatment(between24and
306/7thsweeksofgestation)ofmildGDM(fastingvalue<95mg/dLandtwoelevatedpostchallengevalues)
werenotsignificantlydifferentbasedonwhenGDMwasidentifiedandtreatmentinitiated[60].Pregnancy
outcomesweresimilarwhentreatmentwasinitiatedat24to26,27,28,or29weekscomparedwith30

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weeksofgestation.

ScreeningmethodsLaboratoryscreeningisgenerallyperformedwithaglucosechallengetest.

50gramonehourglucosescreenA50gramoralglucoseloadisgivenwithoutregardtothetime
elapsedsincethelastmealandplasmaglucoseismeasuredonehourlater(sometimescalledaglucose
challengetest[GCT]orglucoseloadingtest[GLT]).Glucoseconcentrationshouldbemeasuredinvenous
plasmausinganaccurateandpreciseenzymaticmethod.Thefollowingthresholdshavebeenproposedto
defineapositivescreen:130mg/dL,135mg/dL,or140mg/dL(7.2mmol/L,7.5mmol/L,or7.8mmol/L).

Theoriginalthresholdforanelevatedtest(equivalentto143mg/dL[7.9mmol/L]withcurrentmethodology)was
arbitrary,usedwholebloodandanonspecificglucoseassay,andwasvalidatedbyitsabilitytopredicta
positivethreehouroralGTT[61].Useofalowerthreshold(130mg/dL[7.2mmol/L]withcurrentmethodology)
providesgreatersensitivity,butresultsinmorefalsepositivesandwouldrequireadministeringanoralGTTto
morepatients[62,63].Inasystematicreviewofcohortstudiesofscreeningtestsforgestationaldiabetesby
theUSPSTF,atthe130mg/dL(7.2mmol/L)threshold,sensitivityandspecificitywere88to99percentand66
to77percent,respectively[64].Atthe140mg/dL(7.8mmol/L)threshold,sensitivitywaslower(70to88
percent),butspecificitywashigher(69to89percent).

MarkedlyelevatedonehourglucoselevelThelikelihoodofanabnormalGTTishigherinwomen
whohaveahighglucoselevelontheir50gramonehourglucosescreen.Thepositivepredictivevalue(PPV)
ofthistestvariesdependingontheprevalenceofGDMinthepopulationtestedandtheGTTcriteriausedfor
diagnosisofGDM(NationalDiabetesDataGroup[NDDG],CarpenterCoustan).Forexample,Carpenterand
Coustanfoundthata50gramonehourplasmaglucose>182mg/dL(10.1mmol/L)had>95percentprobability
ofdiabetes[62].Atglucoselevels200mg/dL(11.1mmol/L),othershavereportedPPVsof47to54percent
[65],79percent[66],and69to80percent[67]foranabnormalGTT.

Forwomenwith50gramonehourglucoseresults200mg/dL(11.1mmol/L),theauthormakesapresumptive
diagnosisofgestationaldiabetes,unlessthepatientpreferstoundergoaGTTfordefinitivediagnosis.TheGTT
canbeperformedsafelyasthe100gramglucoseloadwouldnotleadtodiabeticketoacidosisinwomenwith
gestationaldiabetesorunrecognizedtype2diabetes.Ithasbeenperformedinthousandsofpatientswithno
reportsofseriousadverseevents.

OthertestsIntheUSPSTFsystematicreviewdescribedabove[64]:

Fastingplasmaglucoselevelatathresholdof85mg/dL(4.7mmol/L)didnotperformaswellasthe50
gramglucosechallengetestforidentifyingwomenwhowereultimatelydiagnosedwithgestational
diabetes.

Nothresholdforglycatedhemoglobin(A1C)inthesecondandthirdtrimestershadbothgoodsensitivity
andspecificityasascreeningtestforgestationaldiabetes.Infourstudies,A1Cthresholdsof5.0,5.3,
5.5,and7.5wereevaluatedusingdifferentdiagnosticcriteriaforgestationaldiabetes[6871]therewas
noclearpatternbetweenA1Clevelandprobabilityofgestationaldiabetesacrossthefourstudies.

However,inlowresourcesettingswhereuniversalscreeningwithaglucosechallengeordiagnostictesting
withanoralGTTisnotfeasible,useoffastingplasmaglucoseat24to28weekstoscreenwomenmaybea
practicalapproach.Inastudyfrom15Chinesehospitals,ifperformanceoftheGTTwasrestrictedtowomen
withfastingglucosefrom79mg/dL(4.4mmol/L)to90mg/dL(5.0mmol/L),then50percentofpregnantwomen
couldavoidaGTTsince38percentofthispopulationhadfastingglucose<79mg/dL(4.4mmol/L)and12
percenthadfastingglucose>90mg/dL(5.0mmol/L)diagnosticofgestationaldiabetesinthissystem12
percentofpatientswithgestationaldiabetesweremissed[72].Thesefindingsmaynotbegeneralizableto
otherpopulationssinceAsianshaveahigherincidenceoftype2diabetesandgestationaldiabetesthan
Caucasians,anddifferentdiagnosticthresholdsareusedinChina.

DiagnostictestingmethodsThediagnosisofgestationaldiabetesisbasedonresultsofanoralGTT.
However,itshouldbenotedthat,althoughitisalsouniversallyusedtodiagnosediabetesoutsideof
pregnancy,thisisanimprecisetestwithpoorreproducibility[73].Astudythatperformedtwooralthreehour
GTTsonetotwoweeksapartin64pregnantwomenwhose50gramglucosechallengewas135mg/dLfound

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48hadnormal/normal,11hadnormal/abnormal,3hadabnormal/normal,and2hadabnormal/abnormalresults
[74].Thus,only50of64(78percent)hadreproducibletestresults.Nevertheless,itisapracticalandwidely
utilizedmeansofdiagnosingbothgestationaldiabetesanddiabetesinnonpregnantindividuals.

TheGTTcanbeperformedasa75gramtwohourtestora100gramthreehourtestthereisnoconsensus
regardingtheoptimumthresholdsforapositivetest(table1).Althoughthe100gramthreehourGTTistypically
performedasthesecondstepofthetwostepapproachwhilethe75gramtwohourtestisperformedasthe
onlytestintheonestepapproach,thisisarbitrary.Infact,theCanadianDiabetesAssociation(CDA)clinical
guidelinessuggestthe75gramtwohourGTTasthesecondstepofthetwostepapproach[75].Carbohydrate
loadingforthreedaysbeforethetesthasbeenrecommended,butisprobablynotnecessaryifthepatientis
notonalowcarbohydratediet[7679].

SomecliniciansobtainafastingglucoselevelbeforeadministeringtheGTT.Ifa75gramtwohourGTTis
plannedandthefastingglucoselevelis92mg/dL(5.1mmol/L),thenthediagnosisofgestationaldiabetesis
madeandtheGTTiscancelled.Ifa100gramthreehourGTTisplanned,nodatatosupportaparticularcutoff
fordiagnosinggestationaldiabetesandanabnormalfastingglucoselevelaloneisnotdiagnosticofgestational
diabetes.However,aglucoselevel126mg/dL(7.0mmol/L)isareasonablethresholdforcancellingtheGTT
asitisdiagnosticofdiabetesinthegeneralpopulation.Thisapproachrequiresaskingthepatienttohaveblood
drawnforherfastingglucoselevelandthenwaitfortheresultsbeforeproceedingwiththeGTTlateronthe
sameday(andremainfasting)oronanotherday(andfastagain),whichiscumbersome.

Asdiscussedabove,itisnotnecessarytoexcludefastinghyperglycemiatosafelyperformthetest.(See
'Markedlyelevatedonehourglucoselevel'above.)

100gramthreehouroralglucosetolerancetestThe100gramthreehouroralGTTisdiagnosticof
gestationaldiabeteswhentwoglucosevaluesareelevated.Themostcommonlyusedthresholdsfordefining
elevatedvalueshavebeenproposedbyCarpenterandCoustanandbytheNDDG(table2)[2,4,62,80,81].
BotharemodificationsofthresholdsproposedbyOSullivanandMahan[82],originallybasedonvenouswhole
bloodsamplesnowconvertedtoplasmasamples.TheCarpenterandCoustanvaluesarelowerbecausethe
thresholdsderivedfromtheolderSomogyiNelsonmethodofglucoseanalysiswerealsocorrectedtoaccount
fortheenzymaticassayscurrentlyisuse.

Treatmentofwomenwhomeeteithercriteriaforgestationaldiabetesappearstoimprovesomepregnancy
outcomes(eg,pregnancyinducedhypertension,macrosomia,shoulderdystocia)comparedwithnotreatment.
Asecondaryanalysisofdatafromarandomizedtrialfoundthattreatingpatientsmeetingthelessstringent
CarpenterandCoustancriteriawasaseffectiveastreatingthosemeetingthemorestringentNDDGcriteria
[83].

75gramtwohouroralglucosetolerancetestThe75gramtwohouroralGTTisdiagnosticof
gestationaldiabeteswhenoneglucosevalueiselevated.Themostcommonlyusedthresholdsfordefining
elevatedvalueshavebeenproposedbytheInternationalAssociationofDiabetesandPregnancyStudyGroups
(IADPSG)(table3).The75gramtwohouroralGTTismoreconvenient,bettertolerated,andmoresensitivefor
identifyingthepregnancyatriskforadverseoutcomethanthe100gramthreehouroralGTT.Increased
sensitivityisprimarilyrelatedtothefactthatonlyoneelevatedglucosevalueisneededforapositivetest[84]
althoughthecutoffsarealsoslightlylower.

TheIADPSGdefinedthresholdsforthe75gramtwohouroralGTTprimarilybasedonoutcomedatareportedin
theHyperglycemiaandAdversePregnancyOutcome(HAPO)study,aprospectiveobservationalstudyofmore
than23,000pregnanciesevaluatedwitha75gramtwohouroralGTTat24to32weeksgestation[4,20].
Thesethresholdsrepresenttheglucosevaluesatwhichtheoddsofinfantbirthweight,cordCpeptide(proxy
forfetalinsulinlevel),andneonatalpercentbodyfat>90percentilewere1.75timestheestimatedoddsof
theseoutcomesatmeanglucoselevels,basedonfullyadjustedlogisticregressionmodels.Comparedto
womenintheHAPOstudywithallglucosevaluesbelowthethresholds,womenwhoexceededoneormoreof
thesethresholdshadatwofoldhigherfrequencyoflargeforgestationalageinfantsandpreeclampsia,and>45
percentincreaseinpretermdeliveryandprimarycesareandelivery.Usinganoddsratioof2forthethresholds
definedapopulationwithahigherfrequencyoftheseoutcomes,butthedifferencewasmodestandresultedin
failuretoidentifymanywomenwhowereatalmostcomparablerisk.Norandomizedtrialdataareavailableon

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theeffectoftreatingwomendiagnosedwithgestationaldiabetesbyIADPSGcriteriaonpregnancyoutcomes.

IADPSGdefinedthresholdsarealsopredictiveofanincreasedlongtermriskofmaternaldiabetesand
metabolicsyndrome.Astudythatcomparedtherateoftheseoutcomesin265womenwhoseoralGTTsmet
IADPSGthresholdsforGDMwiththerateincontrolswithnormalGTTsinpregnanciesduringthesameperiod
reportedthestudygrouphadhigherratesofmetabolicsyndrome(25versus7percent)andinsulinresistance
(34versus9percent)thancontrolsapproximatelythreeyearspostpartum[85].

PatientsunabletotolerateoralhyperosmolarglucosePeriodicglucoseassessmentisapragmatic
approachforexcludinghyperglycemiainwomenunabletocompleteastandardoralglucosetolerancetest.

SerialglucosemonitoringPeriodicrandomfastingandtwohourpostprandialbloodglucosetestingis
amonitoringoptionforwomenathighriskforgestationaldiabeteswhoareunabletotolerateanoral
glucoseload.ThisapproachisalsousefulforwomenwhohavedumpingsyndromeafterarouxenY
gastricbypassprocedurethesewomenareunlikelytotolerateahyperosmolarglucosesolution[86].
(See"Fertilityandpregnancyafterbariatricsurgery".)

FastingplasmaglucoseInasystematicreviewofcohortstudiesofscreeningtestsforgestational
diabetesperformedfortheUSPSTF,afastingplasmaglucoselevellessthan85mg/dL(4.7mmol/L)by
24weeksofgestationperformedwellforidentifyingwomenwhodidnothavegestationaldiabetes[64].
However,avalueover85mg/dL(4.7mmol/L)performedlesswellthantheoralglucosechallengetestfor
identifyingwomenwithgestationaldiabetes.

TestalternativestotheglucosechallengetestandGTTThehighlyconcentratedhyperosmolar
glucosesolutionusedfortheglucosechallengetestandGTTcancausegastricirritation,delayed
emptying,andgastrointestinalosmoticimbalance,leadingtonauseaand,inasmallpercentageof
women,vomiting[8789].Servingthehyperosmolarglucosedrinkonicemayreducenauseaand
vomiting,AlternativestotheoralscreeningandGTTshavebeenproposedandarebettertolerated,but
appeartobelesssensitiveandhavenotbeenvalidatedinlargestudies.Theseapproachestypicallyuse
candy,apredefinedmeal,orcommercialsoftdrinksinsteadofastandardglucosemonomerorpolymer
solution[9095].NonehavebeenendorsedbytheAmericanDiabetesAssociation(ADA)orAmerican
CollegeofObstetriciansandGynecologists(ACOG).

IntravenousGTTTheintravenousGTTmaybeanalternativeforpatientswhocannottolerateanoral
glucoseload[96,97].ThisapproachisrarelyusedandhasnotbeenwellvalidatedagainstoralGTT
resultsoragainstpregnancyoutcomehowever,oneauthor(DC)hasfoundittobeusefulinthese
patients.

IDENTIFICATIONOFOVERTDIABETESINEARLYPREGNANCYAsdiscussedabove(see
'Terminology'above),anincreasingproportionofwomenhaveasyetunrecognizedtype2diabetesduetothe
increasingprevalenceofobesityandlackofroutineglucosescreening/testinginthisagegroup.Identifying
thesewomenearlyinpregnancymaybeimportantbecausetheyareatincreasedriskofhavingachildwitha
congenitalanomalyandmaybeatincreasedriskoflongtermcomplicationsfromdiabetes(nephropathy,
retinopathy)[98100].Furthermore,earlyidentificationandtreatmentofhyperglycemiamayreducetheriskof
congenitalanomalies.A2014UnitedStatesPreventiveServicesTaskForce(USPSTF)guidelineconcluded
availableevidencewasinsufficienttoassessthebalanceofbenefitsandharmsofscreeningfordiabetesin
asymptomaticpregnantwomenbefore24weeksofgestation[9],whiletheInternationalAssociationof
DiabetesandPregnancyStudyGroups(IADPSG)suggestedthatthedecisiontotestfordiabetesatthefirst
prenatalvisitshouldbebaseduponthebackgroundfrequencyofabnormalglucosemetabolisminthe
populationandonlocalcircumstances[4].InagreementwiththeAmericanDiabetesAssociation(ADA)[6],
theAmericanCollegeofObstetriciansandGynecologists(ACOG)suggestsearlypregnancyscreeningfor
undiagnosedtype2diabetesinwomenwithriskfactors(eg,previousgestationaldiabetesorknownimpaired
glucosemetabolism,obesity)[2].

Severalorganizations(eg,WorldHealthOrganization,IADPSG,ADA,InternationalFederationofGynecology
andObstetrics,butnotACOG)allowforadiagnosisofovertdiabetesinwomenwhomeetcriteriafordiabetes
attheirinitialprenatalvisit.Thegestationalageatwhichadiagnosisofovertversusgestationaldiabetesis
lesslikelytobeaccurateisunclear.Statedinanotherway,ifapatientinearlypregnancy(beforesignificant
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insulinresistance)meetscriteriafordiabetes,sheisassumedtohavehaddiabetespriortothepregnancy,but
thereisnowaytodetermineatwhatgestationalagethiswouldnolongerbetrue.

ADAcriteriafordiagnosisofdiabetesinnonpregnantadultsmaybeusedtodiagnoseovertdiabetesinearly
pregnancy(table4).Thesethresholdswerechosenbecausetheycorrelatewithdevelopmentofadverse
vasculareventsinnonpregnantindividuals,suchasretinopathyandcoronaryarterydiseaseovertime.(See
"Clinicalpresentationanddiagnosisofdiabetesmellitusinadults".)

RECOMMENDATIONSOFNATIONALANDINTERNATIONALORGANIZATIONSTheoptimum
strategyfordiagnosisofgestationaldiabetesmellitustoimprovematernalandinfanthealthisunclear[101].
Manyorganizationshavepublishedrecommendationsforscreeninganddiagnosisofdiabetesinpregnancy,
including:

AmericanCollegeofObstetriciansandGynecologists(ACOG,twostepapproach(table5andtable2))
[2]

InternationalAssociationofDiabetesandPregnancyStudyGroups(IADPSG,onestepapproach(table
3))[4]

AmericanDiabetesAssociation(ADA,onesteportwostepapproach)[6]

WorldHealthOrganization(WHO,onestepapproach(table6))[5]

CanadianDiabetesAssociation(CDA,twostep[preferred]oronestepapproach)[75]

TheEndocrineSociety(onestepapproach)[102]

AustralasianDiabetesinPregnancySociety(WHOapproach)[103]

NationalInstituteforHealthandCareExcellence(NICE,UnitedKingdom)

InternationalFederationofGynecologyandObstetrics(FIGO),IADPSG(onestepapproach,with
possiblevariationineconomicallychallengedregions)[3]

OURAPPROACH

InitialprenatalvisitTheauthorsperformuniversaltestingforovertdiabetesattheinitialprenatalvisitby
checkingA1CadiagnosisofovertdiabetesismadewhenA1Cis6.5percent(48mmol/mol)(table4).
Giventheincreasingfrequencyoftype2diabetesinresourcerichcountries,webelieveuniversalearlytesting
whenroutineinitialprenatallaboratorytestsaredrawnisbothdesirableandconvenient,althoughimprovement
inpregnancyoutcomehasnotbeenestablishedconclusivelybyrandomizedtrials.CheckingA1Cratherthan
fastingglucoseconcentrationisapracticalapproachbecausemostpatientsarenotfastingwhentheirinitial
prenatallaboratorytestsaredrawn.However,afastingglucose126mg/dL(7.0mmol/L),ifavailable,is
diagnosticofovertdiabetes(table4).(See'Identificationofovertdiabetesinearlypregnancy'above.)

WeacknowledgethatA1Cisnotasuitabletesttodetectmildlyimpairedglucosetolerance.Toidentify
pregnantwomenwithmildlyimpairedglucosetolerance,theauthorsperformaglucosetolerancetest(GTT)
whenA1Cis5.7to6.4percent(39to46mmol/mol)atthefirstprenatalvisit.Thisapproachisbasedonthe
followingrationale.ThenormalA1Creferencerangeestablishedinhealthynondiabetic,nonpregnantadults
aged13to39yearsis5.0+/0.5percent(26to37mmol/mol).Inmenandnonpregnantwomen,anA1C6.5
percent(48mmol/mol)isoneofthecriteriausedtodiagnosediabetes(table4).Therefore,anA1C6.5
percentearlyinpregnancy,whenA1Clevelsaregenerallyslightlylowerthaninthenonpregnantstate[104],
suggestspreviouslyundiagnosedtype2diabetes.However,anA1Cbelow6.5percentcannotbetakenas
strongevidenceagainstthediagnosisofdiabetes,especiallyinpregnantwomenwithA1Cabovetheupper
limitofthenormalrange.WebelieveexclusionofdiabetesinwomenwithA1Csintherangeassociatedwith
anincreasedriskfordiabetes(A1C5.7to6.4percent[39to46mmol/mol])isbestachievedwithanoralGTT
[105].

Earlyinpregnancy,werecommenda75gram,twohouroralGTTandAmericanDiabetesAssociationcriteria
fordiagnosisofovertdiabetes(table4).InternationalAssociationofDiabetesandPregnancyStudyGroups
criteriafordiagnosisofgestationaldiabeteshavenotbeenvalidatedinthefirsttrimester.Aboutonequarterof
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womenwithA1C5.7to6.4percent(39to46mmol/mol)inearlypregnancydevelopgestationaldiabeteswhen
screenedandtestedlaterinpregnancycomparedwith<10percentofthosewithA1C<5.7percent(39
mmol/mol)[106].(See"Clinicalpresentationanddiagnosisofdiabetesmellitusinadults",sectionon
'Diagnosticcriteria'.)

At24to28weeksForwomenwhohavenotbeenpreviouslydiagnosedwithdiabetes,at24to28weeksof
gestation,wepreferaonesteptestingapproachusingthe75gramtwohouroralGTTandInternational
AssociationofDiabetesandPregnancyStudyGroups(IADPSG)thresholdsbecauseofitshighsensitivity
(table3).However,mostobstetriciansintheUnitedStatesfollowAmericanCollegeofObstetriciansand
Gynecologists(ACOG)guidelines,whichsuggestatwostepapproach(50gramoralglucosechallenge
followedby100gramthreehouroralGTTinscreenpositivewomen)[2].Screeningwithaglucosechallenge
hasthepracticaladvantagethatitcanbeperformedatanytimeofday,withoutdietarypreparation,whilethe
onestepapproachrequiresthatallpatientsundergoanovernightfastpriortolaboratorytestingandmustbe
doneinthemorning.Ontheotherhand,twosteptestinginvolvesanadditionallaboratoryvisitandcollectionof
fouradditionalblooddrawsformanywomen[107].

BytheIADPSGestimate,18percentofallpregnantwomenwouldbediagnosedwithgestationaldiabetes
usingtheonestepapproachsinceitomitsthescreening50gramglucosechallenge,requiresonlyasingle
elevatedvalue,andhasslightlylowerthresholdsforapositivetestthanthe100gramthreehouroralGTT
(table3andtable2).ACOGandothersrecommendagainstadoptionoftheonestepapproachandcriteria
becauseitwouldincreasetheprevalenceofgestationaldiabetes,leadingtomorefrequentprenatalvisits,more
fetalandmaternalsurveillance,andmoreinterventions,includinginductionoflabor,withoutclear
demonstrationofimprovementsinthemostclinicallyimportanthealthandpatientcenteredoutcomes
[107,108].Webelievetheincreaseindiagnosisofgestationaldiabeteswouldprovideanopportunitytoprevent
macrosomia,preeclampsia,andshoulderdystociaastworandomizedtrialshavedemonstratedthat
identificationandtreatmentofevenmildgestationaldiabetesbyvariouscriteriacanimproveoutcomes[32,33].
Althoughtheincreaseddiagnosisofgestationaldiabeteswouldofferchallengesinuseofresourcesand
improvingtheefficiencyofhealthcaredeliveryforthiscondition,itisnotclearthatincreasedidentificationof
patientswithmildgestationaldiabeteswouldrequirethesameintensityofglucosemonitoring,fetaltestingand
interventionasthosewithgestationaldiabetesdiagnosedbymorestringentcriteria[109].Inaddition,the
increasedrateofgestationaldiabeteswouldparalleltheincreaseindiabetesandprediabetesintheoverall
population,posingsimilarchallenges.

Whilemoreresearchisnecessary,severalretrospectivestudiesthatcomparedpregnancyoutcomewithone
stepversustwosteptestingfoundthattheonestepapproachidentifiedmorewomenatincreasedriskof
adverseoutcomesassociatedwithdiabetes[110115].Forexample,inaprospectivestudyinwhichthetwo
stepapproachwasreplacedbytheonestepapproach,theprevalenceofgestationaldiabetesincreased3.5
fold,pregnancyoutcomesimprovedsignificantly,andthechangewascosteffective[114].Another"beforeand
after"studyreporteda2.25foldincreaseinprevalenceofgestationaldiabetes,withaconcomitantfallinrates
ofcesareandelivery,fetalmacrosomia,andneonatalhypoglycemiaintheoverallpopulation[115].Available
dataarenotallconsistent,asonestudyreportedthatuseoftheonestepapproachincreasedboththe
diagnosisofgestationaldiabetes(1.6foldinaveryhighprevalencepopulation)andthecesareandeliveryrate,
butdidnotdecreasetherateoflargeforgestationalageormacrosomicneonatesorimprovematernalor
neonatalmorbidity[116].Anothersmallerstudyreportedafourfoldincreaseingestationaldiabeteswithnon
statisticaldecreasesincesareandeliveryandlargeforgestationalagenewborns[117].

InaCanadiantrial,thecostofthetestalonewaslowerwiththetwostepapproach(CAN$89.03foraone
hour50gglucosescreenplusthreehour100gramGTTwhenindicatedversusCAN$108.38whenonlyatwo
hour75gramGTTwasperformed)thisstudywasunusualbecausetheprevalenceofdiabeteswaslowand
similarinbothgroups(3.7and3.6percent)[118].Amodelingstudyoftheonestepparadigmfordiagnosing
gestationaldiabetesfoundittobecosteffectiveintheUnitedStateswhenpostpartuminterventionstoprevent
type2diabetesareinitiated[119].Thereisalsosomeevidencethatitiscosteffectiveinimprovingmaternal
andneonataloutcomes,evenwhenpostpartuminterventionstopreventtype2diabetesarenotincludedin
costeffectivenessanalyses[120].

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
th th
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and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)

Basicstopics(see"Patientinformation:Gestationaldiabetes(diabetesthatstartsduringpregnancy)(The
Basics)")

BeyondtheBasicstopics(see"Patientinformation:Gestationaldiabetesmellitus(BeyondtheBasics)")

SUMMARYANDRECOMMENDATIONSTheterminologyfordiabetesdiagnosedinpregnancyisinflux.
Theterms"overt"and"gestationaldiabetes"arebasedprimarilyongestationalageatdiagnosis.Diagnosisof
diabetesat24to28weeksofgestationisconsistentwithgestationaldiabetes,whilediagnosisatthefirst
prenatalvisit(inearlypregnancy)ismoreconsistentwithovertdiabetes.(See'Terminology'above.)

OvertdiabetesTheauthorsobtainanA1Clevelattheinitialprenatalvisittoidentifywomenwithovert
diabetesavalue6.5percent(<48mmol/mol)isdiagnostic.Afastingglucose126mg/dL(7.0mmol/L),if
available,isalsodiagnosticofdiabetes.IftheA1Cis5.7to6.4percent(39to46mmol/mol),theauthors
performatwohour75gramoralglucosetolerancetest(GTT)(table4).(See'Ourapproach'above.)However,
thereisnoconsensusregardingwhetherorhowtotestfordiabetesatthefirstprenatalvisit.(See
'Identificationofovertdiabetesinearlypregnancy'above.)

Gestationaldiabetes

Identifyingpregnantwomenwithgestationaldiabetesfollowedbyappropriatetherapycandecreasefetal
andmaternalmorbidity,particularlymacrosomia,shoulderdystocia,andpreeclampsia.(See'Significance'
aboveand'Benefitsandharmsofscreening'above.)

Weagreewithrecommendationsofmajorsocietiestoscreen/testforgestationaldiabetes(Grade2B).
(See'Recommendationsofnationalandinternationalorganizations'above.)

IntheUnitedStates,universalscreeningappearstobethemostpracticalapproachbecause90percent
ofpregnantwomenhaveatleastoneriskfactorforglucoseimpairmentduringpregnancy.(See
'Candidatesforscreening/testing'above.)

Inwomenwhohavenotbeenpreviouslydiagnosedwithdiabetes,screening/testingforgestational
diabetesisperformedat24to28weeksofgestationusingaonesteportwostepapproach.(See'One
stepandtwostepapproaches'above.)

Theauthorsrecommendaonesteptestingapproachusingthe75gramtwohouroralGTTand
InternationalAssociationofDiabetesandPregnancyStudyGroups(IADPSG)thresholds(table3).(See
'Ourapproach'above.)

TheAmericanCollegeofObstetriciansandGynecologists(ACOG)recommendsatwostepapproach
(50gramglucosechallengescreenfollowedbya100gramthreehouroralGTT)inscreenpositive
patients(twostepapproach(table5andtable2)).TheAmericanDiabetesAssociation(ADA)supports
useofeitheraonesteportwostepapproach.(See'Recommendationsofnationalandinternational
organizations'aboveand'Screeningmethods'aboveand'Diagnostictestingmethods'above.)

ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeLoisJovanovic,MD,
whocontributedtoanearlierversionofthistopicreview.

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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Topic6797Version60.0

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GRAPHICS

Rangeofdiagnosticcriteriaforgestationaldiabetes

Two Three
Fasting Onehour
Approach Criteria* hour hour
mg/dL mg/dL
mg/dL mg/dL
Twostep(100 Carpenter 95(5.3 180(10.0 155(8.6 140(7.8
gramload) andCoustan mmol/L) mmol/L) mmol/L) mmol/L)

NDDG 105(5.8 190(10.6 165(9.2 145(8.0

mmol/L) mmol/L) mmol/L) mmol/L)

Twostep(75 CDA 95(5.3 191(10.6 160(8.9

gramload) mmol/L) mmol/L) mmol/L)

Onestep(75 WHO 92to125 180(10.0 153to199

gramload) (5.1to6.9 mmol/L) (8.5to11
mmol/L) mmol/L)

IADPSG 92to125 180(10.0 153(8.5

(5.1 mmol/L) mmol/L)
mmol/L)

Thesethresholdsarefordiagnosisofgestationaldiabetes.Diagnosisofovertdiabetesand
diabetesinpregnancyarebasedondifferentcriteria(eg,IADPSG:fastingbloodglucose
126mg/dL[7.0mmol/L]isconsistentwithovertdiabetesWHO:twohourglucose200
mg/dL[11.1mmol/L]followinga75gramoralglucoseloadisconsistentwithdiabetesin
pregnancy).

NDDG:NationalDiabetesDataGroupCDA:CanadianDiabetesAssociationWHO:WorldHealth
OrganizationIADPSG:InternationalAssociationofDiabetesandPregnancyStudyGroups.

Datafrom:VandorstenJP,DodsonWC,EspelandMA,etal.NationalInstitutesofHealthconsensus
developmentconference:diagnosinggestationaldiabetesmellitus.NIHConsensStateSciStatements
201329:1.

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Diagnosticcriteriaforthe100gramthreehourGTTtodiagnose
gestationaldiabetesmellitus

Plasmaorserumglucose Plasmalevel
level NationalDiabetesData

Carpenter/Coustan Group
mg/dL mmol/L mg/dL mmol/L

Fasting 95 5.3 105 5.8

Onehour 180 10.0 190 10.6

Twohours 155 8.6 165 9.2

Threehours 140 7.8 145 8.0

100gramoralglucoseloadisgiveninthemorningtoapatientwhohasfasted
overnightforatleast8hours.Glucoseconcentrationgreaterthanorequaltothesevalues
atTWOormoretimepointsisapositivetest.
TwodifferentclassificationschemesofGDMbaseduponresultsofthethreehourGTT
resultshavebeenproposed.TheFourthInternationalWorkshopConferenceonGestational
DiabetesGTTvaluescitedabovearebasedupontheCarpenterandCoustanmodification
ofearliervalues.TheyarelowerthanthoseproposedbytheExpertCommitteeonthe
DiagnosisandClassificationofDiabetesMellitusandtheNationalDiabetesDataGroup
(NDDG),whichusedcutoffvaluesof105,190,165,and145mg/dL(5.8,10.6,9.2,and
8.0mmol/L),respectively.Thevaluesarelowerbecausethethresholdsderivedfromthe
olderSomogyiNelsonmethodofglucoseanalysiswerecorrectedtoaccountforthe
enzymaticassayscurrentlyinuse.

GTT:glucosetolerancetest.

Datafrom:VanDorstenJP,DodsonWC,EspelandMA,etal.NationalInstitutesofHealthConsensus
DevelopmentConferenceStatement:DiagnosingGestationalDiabetesMellitus.NIHConsensStateSci
Statements201329:1.

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IADPSGandADAcriteriaforapositivetwohour75gramoral
glucosetolerancetestforthediagnosisofgestationaldiabetes

Twohour75gramoralglucosetolerancetest
Fasting 92mg/dL(5.1mmol/L)

OR

Onehour 180mg/dL(10.0mmol/L)

OR

Twohour 153mg/dL(8.5mmol/L)

Thediagnosisofgestationaldiabetesismadeat24to28weeksofgestationwhenoneor
moreplasmaglucosevaluesmeetsorexceedstheabovevalues.

ADA:AmericanDiabetesAssociationIADPSG:InternationalAssociationoftheDiabetesand
PregnancyStudyGroups.

Graphic61208Version15.0

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ADAcriteriaforthediagnosisofdiabetes

1.A1C6.5percent.ThetestshouldbeperformedinalaboratoryusingamethodthatisNGSP
certifiedandstandardizedtotheDCCTassay.*
OR

2.FPG126mg/dL(7.0mmol/L).Fastingisdefinedasnocaloricintakeforatleasteight
hours.*
OR

3.Twohourplasmaglucose200mg/dL(11.1mmol/L)duringanOGTT.Thetestshouldbe
performedasdescribedbytheWorldHealthOrganization,usingaglucoseloadcontainingthe
equivalentof75gramanhydrousglucosedissolvedinwater.*
OR

4.Inapatientwithclassicsymptomsofhyperglycemiaorhyperglycemiccrisis,arandom
plasmaglucose200mg/dL(11.1mmol/L).

A1C:glycatedhemoglobinDCCT:diabetescontrolandcomplicationstrialFPG:fastingplasma
glucoseNGSP:nationalglycohemoglobinstandardizationprogramOGTT:oralglucosetolerancetest.
*Intheabsenceofunequivocalhyperglycemia,criteria1to3shouldbeconfirmedbyrepeattesting.

Reprintedwithpermissionfrom:AmericanDiabetesAssociation.StandardsofMedicalCareinDiabetes
2011.DiabetesCare201134:S11.Copyright2011AmericanDiabetesAssociation.

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ACOGtwostepapproachforscreeninganddiagnosisof
gestationaldiabetes

Stepone
1.Give50gramoralglucoseloadwithoutregardtotimeofday

2.Measureplasmaorserumglucose

3.Glucose135mg/dL(7.5mmol/L)or140mg/dL(7.8mmol/L)iselevatedandrequires
administrationofa100gramoralglucosetolerancetest*.Thelowerthresholdprovides
greatersensitivity,butwouldresultinmorefalsepositivesandwouldrequireadministering
thefullglucosetolerancetesttomorepatientsthanthe140mg/dLthreshold.Thelower
thresholdshouldbeconsideredinpopulationswithhigherprevalenceofgestationaldiabetes.

Steptwo
1.Measurefastingserumorplasmaglucoseconcentration

2.Give100gramoralglucoseload

3.Measureplasmaorserumglucoseatone,two,andthreehoursafterglucoseload

4.Apositivetestisdefinedbyelevatedglucoseconcentrationsattwoormoretimepoints
(eitherCarpenterandCoustanthresholdsorNationalDiabetesDataGroupthresholdscanbe
used)

*Someexpertsuseathresholdof130mg/dL(7.2mmol/L)

Datafrom:AmericanCollegeofObstetriciansandGynecologists.PracticeBulletinnumber137:
Gestationaldiabetes.ObstetGynecol2013122:406.

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WorldHealthOrganization(WHO)thresholdsforpositivetwo
hour75gramoralGTT(2013).Adiagnosisof"gestational
diabetesmellitus"ismadewhenoneormoreofthefollowing
glucosethresholdsismetanytimeduringpregnancy.

Fasting 92to125mg/dL(5.1to6.9mmol/L)

OR

Onehour 180mg/dL(10.0mmol/L)

OR

Twohour 153to199mg/dL(8.5to11.0mmol/L)

Bycomparison,adiagnosisof"diabetesmellitusinpregnancy"ismadeifoneormoreof
thefollowingcriteriaaremet:fastingplasmaglucose126mg/dL(7.0mmol/L),twohour
plasmaglucose200mg/dL(11.1mmol/L)followinga75gramoralglucoseload,random
bloodglucose200mg/dL(11.1mmol/L)inthepresenceofdiabetessymptoms.Thereare
noestablishedcriteriaforthediagnosisof"diabetesmellitusinpregnancy"basedonthe
1hourpostloadvalue.

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