Dr.

Biman Mondal, CCGDM 2013 Participant

Faculty:

Dr. Debasis Basu

Dr. Suranjan Chakraborty

Assignment 1 ( submitted during Module III)

Compare and contrast the various criteria for the diagnosis of GDM. Which of these do you think is
the most ideal one for your practice?

Ans.:

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance that either has its
onset or first becomes apparent during pregnancy. Disappearance of GDM postpartum is critical, as
previously undiagnosed type 2 diabetes can be mistaken for GDM. Current (2002) prevalence
estimates for GDM is approximately 16.5 percent of pregnancies in India, depending on population
characteristics, such as ethnicity and clinical status. GDM incidence has increased over the past
decades, alongside the increase in rates of obesity and type 2 diabetes, and these trends are expected
to continue to rise.

GDM is an important public health concern, as impaired glucose tolerance may affect maternal and
fetal health outcomes. Mothers may face an increased risk of labor and birth complications,
psychological issues, and an increased likelihood of developing diabetes later in life.6 Risks for the
fetus include macrosomia (excessive birth weight) and birth injuries, such as shoulder dystocia, nerve
palsies, and fractures. In addition, risk of glucose intolerance and obesity in childhood is associated
with GDM.

Diagnostic oral glucose tolerance test

Overview

There has been longstanding controversy about the optimal diagnostic test and criteria for
interpretation of glucose tolerance tests in pregnancy. A brief overview may help to put some of the
issues into perspective. In the original epidemiological study of OGTT in pregnancy by O’Sullivan and
Mahan, the objective was to devise a scheme that identified women at risk for diabetes mellitus outside
of pregnancy sometime in the future. That objective was fulfilled in O’Sullivan’s group’s long-term
follow-up of the original cohort of women and it has been validated extensively in other populations.
Evidence that GDM may be associated with adverse perinatal events was found later. O’Sullivan and
Mahan’s criteria for the interpretation of OGTTs in pregnancy were based on measurements of glucose
concentration in whole blood.Extrapolation of these values to approximate plasma glucose equivalent
values has limitations and the need to do so has generated some of the controversy regarding diagnostic
criteria for GDM.
Diagnosis of GDM: 100-g oral glucose tolerance test*

Concentration†

Specimen mg/dL mmol/L

Fasting 95 5.3

One hour 180 10.0

Two hour 155 8.6

Three hour 140 7.8

*The test should be performed in the morning after an overnight fast of at least 8 h but not more than
14 h and after at least 3 days of unrestricted diet (≥ 150 g carbohydrate per day) and physical activity.
The subject should remain seated and should not smoke throughout the test.

†The cutoff values are those proposed by Carpenter and Coustan for extrapolation of the whole blood
glucose values found by O’Sullivan and Mahan to plasma or serum glucose concentrations. Two or more
of the venous plasma concentrations must be met or exceeded for a positive diagnosis.

Diagnosis of GDM: 75-g oral glucose tolerance test*

Concentration†

Specimen mg/dL mmol/L

Fasting 95 5.3

One hour 180 10.0

Two hour 155 8.6

*The test should be performed in the morning after an overnight fast of at least 8 h but not more than
14 h and after at least 3 days of unrestricted diet (≥150 gm carbohydrate per day) and physical activity.
The subject should remain seated and should not smoke throughout the test.

†Cutoff values for the 75-g, 2-h oral glucose tolerance test in pregnancy are, of necessity, arbitrary. The
lack of definitive data relating such test results to perinatal outcome made it difficult for the panel and
the Organizing Committee of the Fourth International Workshop Conference on GDM to arrive at a
consensus.
World Health Organization Criterion

To standardize the diagnosis of GDM, the World Health Organization (WHO) recommends using a 2-hour
75 g oral glucose tolerance test (OGTT) with a threshold plasma glucose concentration of greater than
140 mg/dL at 2 hours, similar to that of IGT (> 140 mg/dL and < 199 mg/dL), outside pregnancy.

American Diabetes Association Criterion

American Diabetes Association (ADA) procedure has become obsolete.

The International Association of the Diabetes and Pregnancy Study Groups

Based on the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, International Association
of the Diabetes and Pregnancy Study Groups (IADPSG) suggested the guidelines. In this HAPO study,
population from India, China, South Asian countries (except city of Bangkok, Hong Kong), Middle East
and Sub Saharan countries were not included. Thus, essentially HAPO study was performed in Caucasian
population.

• The IADPSG recommends that diagnosis of GDM is made when any of the following plasma glucose
values meet or exceed: Fasting: ≥ 5.1 mmol/L (92 mg/dL), 1-hour: ≥ 10.0 mmol/L (180 mg/dL), 2-hour: ≥
8.5 mmol/L (153 mg/dL) with 75 g OGTT.

• The IADPSG also suggests: Fasting plasma glucose (FPG) > 7.0 mmol/L (126 mg/dL)/A1C > 6.5% in the
early weeks of pregnancy is diagnostic of overt diabetes. Fasting > 5.1 mmol/L and < 7.0 mmol/L is
diagnosed as GDM.

Disadvantages of the IADPSG suggestions are:

• Most of the time pregnant women do not come in the fasting state because of commutation and
belief not to fast for long hours. The dropout rate is very high when a pregnant woman is asked to come
again for the glucose tolerance test. Attending the first prenatal visit in the fasting state is impractical in
many settings.

• In all GDM, FPG values do not reflect the 2-hour post glucose with 75 g oral glucose [2-hour plasma
glucose (PG)], which is the hallmark of GDM. Ethnically Asian Indians have high insulin resistance and as
a consequence, their 2-hour PG is higher compared to Caucasians. The insulin resistance during
pregnancy escalates further and hence FPG is not an appropriate option to diagnose GDM in Asian
Indian women. In this population by following FPG > 5.1 mmol/L as cut-off value, 76% of pregnant
women would have missed the diagnosis of GDM.
THE DIPSI CRITERION

The Diabetes In Pregnancy Study Group in India, has recommended a 2-hr post-OGTT (75 GM ) plasma-
glucose value between 140-199 mg/dl is diagnostic of GDM. A value above 200 mg/dl is diagnostic of
pre-existing Diabetes Mellitus. This closely resembles the WHO criterion. Very recently though DIPSI has
suggested OGTT in non-fasting state. But this suggestion is pending further validation. Some recent
studies do suggest a 100-gm OGTT to be more effective for diagnosing GDM but in Indian scenario, The
DIPSI GUIDELINE is appropriate for several reasons. It is cost-effective, easy to implement, can be done
in mass-scale even at primary health care level. Therefore, I being a primary care physian will stick to
DIPSI criterion.

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