Gestational Diabetes: An Update

GESTATIONAL DIABETES:AN UPDATE

Iris Thiele Isip Tan MD, MSc, FPCP, FPSEMClinical Associate Professor, UP College of Medicine

Section of Endocrinology, Diabetes & MetabolismDepartment of Medicine, Philippine General Hospital

Friday, November 18, 11

http://www.flickr.com/photos/yogma/3961135108/

1st birthday

MD

Here I am!http://www.sxc.hu/photo/533027

Son #1 Son #2

19641972

19821996 2003 2006

2008 2010 2011






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1st birthday

MD


Son #1 Son #2

19641972

19821996 2003 2006

2008 2010 2011

“For at least a generation there has been a divergence of opinions about GDM.”

Robert G. Moses, MDNew Consensus Criteria for GDM: Problem Solved or a Pandora’s Box

Diabetes Care 2010;33(3):690-1









1st birthday

MD


Son #1 Son #2

19641972

19821996 2003 2006

2008 2010 2011

O’Sullivan & Mahan criteria

Carpenter & Coustan

HAPO

IADPSGConsensus

“For at least a generation there has been a divergence of opinions about GDM.”

Robert G. Moses, MDNew Consensus Criteria for GDM: Problem Solved or a Pandora’s Box

Diabetes Care 2010;33(3):690-1








Hyperglycemia Adverse Pregnancy Outcomes (HAPO)

International Association of Diabetes

in Pregnancy Study Groups (IADPSG)

Implications on screening and

diagnosis of GDM


Hyperglycemia Adverse Pregnancy Outcomes

HAPO25,505 pregnant

15 centers9 countries

Thailand, Hong Kong, Singapore

NEJM 2008; 358:1991-2002

largediverse

populationsingle protocol


75-g OGTT24-32 weeks

Results unblinded ifFPG >105 mg/dL2h PG >200 mg/dLRPG >160 mg/dLany PG <45 mg/dL

HAPO NEJM 2008; 358:1991-2002


HAPO

http://www.flickr.com/photos/mikewade/3267336862/

BW>90th %ile

Primary CS

Cord blood serum C-peptide >90 %ile

Neonatal hypoglycemia

http://www.flickr.com/photos/tessawatson/379265818/

PrimaryOUTCOMES

http://www.flickr.com/photos/clairity/1385780317/http://www.flickr.com/photos/j2dread/4501366303/

NEJM 2008; 358:1991-2002






http://www.flickr.com/photos/clairity/1385780317/


http://www.flickr.com/photos/j2dread/4501366303/


OR for adverse pregnancy outcomes

1 level SD increase

FPG 6.9 mg/dL (0.4 mmol/L)

HAPO NEJM 2008; 358:1991-2002

1 h PG 30.9 mg/dL (1.7 mmol/L)2 h PG 23.5 mg/dL (1.3 mmol/L)


HAPO


BW>90th %ile Fasting 1.38 (95%CI

1.32,1.44) OR

NEJM 2008; 358:1991-2002 1h PG 1.46 (95%CI

1.39,1.53)2h PG 1.38 (95%CI

1.32,1.44)

Fasting 1.55(95%CI

1.47,1.64)1h PG 1.46 (95%CI

1.38,1.54) 2h PG 1.37(95%CI

1.30,1.44)Cord blood serum

C-peptide >90 %ilehttp://www.flickr.com/photos/clairity/1385780317/






HAPO

OR

NEJM 2008; 358:1991-2002

Primary CS Fasting 1.11 (95%CI

1.06,1.15)

1h PG 1.10 (95%CI

1.06,1.15) 2h PG 1.08 (95%CI

1.03,1.12)


Fasting 1.08(95%CI

0.98,1.19)1h PG 1.13 (95%CI

1.03,1.26) 2h PG 1.10(95%CI

1.00,1.12)

Neonatal hypoglycemia







HAPO NEJM 2008; 358:1991-2002

No obvious threshold at which risks increased


HAPO NEJM 2008; 358:1991-2002

FPG mg/dLCategory 1 <752 75-793 80-844 85-89 5 90-946 95-997 >100

FPG mg/dLCategory 1 <752 75-793 80-844 85-89 5 90-946 95-997 >100



HAPO NEJM 2008; 358:1991-2002

1h PG mg/dLCategory 1 <1052 106-1323 133-1554 156-171 5 172-1936 194-2117 >212

1h PG mg/dLCategory 1 <1052 106-1323 133-1554 156-171 5 172-1936 194-2117 >212



HAPO NEJM 2008; 358:1991-2002

2h PG mg/dLCategory1 <902 91-1083 109-1254 126-1395 140-1576 158-1777 >178

2h PG mg/dLCategory1 <902 91-1083 109-1254 126-1395 140-1576 158-1777 >178



HAPO NEJM 2008; 358:1991-2002

LGA

Hypoglycemia

C-section

C-peptide


HAPO NEJM 2008; 358:1991-2002

“Lack of clear thresholds and the fact that the four primary outcomes are not necessarily of equal clinical importance make direct translation of our results into clinical practice challenging.”


Coustan et al. AJOG 2010; 202(6):654.e1-654.e6

“... the relationship between maternal glucose levels and fetal growth and outcome appear to be a basic biologic phenomenon, and not a clearly demarcated disease state ...”


“What is a challenge is to decide how much increase in risk is the point at which treatment should be initiated and what is the hope and expectation for the treatment to reduce those risks ...”

Metzger B. Endocrine Today 2008


“Secondly, should the associations of glucose be weighted equally with the primary outcomes or are some more important than others?

The third issue is whether all of the glucose measures are needed to identify increased risk.”

Metzger B. Endocrine Today 2008



IADPSGencourage and facilitate research and advance education

facilitate an international approach to enhancing the quality of care for women with diabetes in pregnancy






workshop/conference June 2008 (220 delegates approx 40 countries)

consensus development session (50 delegates)

IADPSG


OR for increased neonatal body fat, LGA and cord serum C-peptide

Mean glucose as reference


OR%

Subjects > Threshold

Positive Predictive Valuefor >90th %ile

Positive Predictive Valuefor >90th %ile

Positive Predictive Valuefor >90th %ileOR

% Subjects > Threshold Birth

weight C-peptide % Body fat

1.75 16.1 16.2 17.5 16.62.0 8.8 17.6 19.7 18.8



IADPSG recommendation for diagnosis of GDM

FBS 92 mg/dL

1h 180 mg/dL

2h 153 mg/dL

Diagnosis requires only one threshold value exceeded




FBS 92 mg/dL

1h 180 mg/dL

2h 153 mg/dL

ADA FBS 95 mg/dL1h 180 mg/dL2h 155 mg/dL

Diagnosis requires only one threshold value exceeded


First prenatal visit Measure FPG, A1c or random plasma glucose in all or only in high-risk

IADPSG Consensus Panel. Diabetes Care Mar 2010;33(3):676-82

Overt Diabetes in Pregnancy

FPG > 7 mmol/L A1c > 6.5%Random PG > 11.1 mmol/L

Gestational Diabetes

FPG 5.1-6.9 mmol/L (92-125 mg/dL)

Order a 75-g OGTT at 24-28 wks AOG

FPG <5.1 mmol/L




FBS 92 mg/dL

1h 180 mg/dL

2h 153 mg/dLDiagnosis requires only one

threshold value exceeded

Overt diabetesFPG >7.0 mmol/L (126 mg/dL)

24-28 wks AOG


Implications on screening and diagnosis of GDM


http://www.flickr.com/photos/kkoshy/4334413228/

More women will be diagnosed with GDM17.8% of pregnant women in HAPO

Use of IADPSG criteria

Ryan EA. Diabetologia 2011; 54:480-6

+ 1,702 women with GDMfrom 2,448 to 4,150 of 23,316 pregnancies in HAPO




n = 1038

50-g GCT

Morikawa M. Diab Res Clin Pract 2010; 90:339-42.


n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228



n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810



n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810

75-g OGTTJapan SOG criteriaFPG>100 mg/dL1h PG >180 mg/dL2h PG >150 mg/dL



n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810



>7.8 mmol/L+

n = 25

OGTT


n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810



>7.8 mmol/L+

n = 25

OGTT

n = 203

>7.8 mmol/L- OGTT


n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810


+IADPSG criteria

5 overt DM20 GDM

43 GDM


>7.8 mmol/L+

n = 25

OGTT

n = 203

>7.8 mmol/L- OGTT


n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810


+IADPSG criteria

5 overt DM20 GDM

43 GDM

Total 68 GDM172% increase


>7.8 mmol/L+

n = 25

OGTT

n = 203

>7.8 mmol/L- OGTT


Flack JR et al. Aus NZ J Obstet Gynecol 2010; 50:439-43.

29% increase in workload

extra 366 women diagnosed

Impact on workload of changing GDM diagnostic criteria by lowering fBGL alone and with increasing 2h BGL (IADPSG)

ADIPS criteriafBGL >5.5 mmol/L2h BGL >8.0 mmol/L



“One approach will be to argue that we cannot cope with the change in numbers and that these new criteria should be ignored.”

will leave a significant number at risk untreated...



Adjust thresholds for fasting, 1h & 2h BG levels “to keep the number of women diagnosed with GDM stable ... an example of explicit rationing of medical care.”


Stratify risk.

“Those women diagnosed at the lower end of the ‘new’ diagnostic range may be expected to be at ‘lower risk’ and if so, their management ‘may’ be ...‘less stringent’.”




IADPSG criteria43 GDM

of which 5 needed insulin

20 GDM 5 overt DM

needed insulin


>7.8 mmol/L+ n = 25OGTT

n = 203

>7.8 mmol/L- OGTT

n = 228

IADPSG “overt diabetes” diagnosis may help differentiate women who need insulin from women who do not need insulin.



X 140 cases of LGAX 21 cases of shoulder dystocia

X 16 cases of birth injury


IADPSG criteria

of 23,316 pregnancies in HAPO cohort





X 140 cases of LGAX 21 cases of shoulder dystocia

X 16 cases of birth injury


Modest outcomes?

IADPSG criteria

of 23,316 pregnancies in HAPO cohort




n = 1038

50-g GCT

>7.8 mmol/L+ GCT

n = 228

<7.8 mmol/L- GCT

n = 810


+IADPSG criteria

5 overt DM20 GDM

43 GDM

Total 68 GDM172% increase

Morikawa M. Diab Res Clin Pract 2010;90: 339-42.

>7.8 mmol/L+

n = 25

OGTT

n = 203

>7.8 mmol/L- OGTT




5 overt DM20 GDM

Morikawa M. Diab Res Clin Pract 2010;90 339-42.


n = 203

>7.8 mmol/L- OGTT

n = 228

no specific treatment for GDM

+ GCT




5 overt DM20 GDM

Morikawa M. Diab Res Clin Pract 2010;90 339-42.


n = 203

>7.8 mmol/L- OGTT

n = 228

no specific treatment for GDM

6 infants >3600 g (14%)p=0.021 vs non-GDM 3.8% (n=160)

Number Needed to Treat (NNT)1/(0.14-0.038) = 9.8

+ GCT


Nurses, dietitians & physicians

Glucose monitoringTherapy of diabetes



Nurses, dietitians & physicians

Glucose monitoringTherapy of diabetes


Cost-effective strategy based on riskGDM risk <1%: no screening/treatment strategy1-4.2%: FPG followed by OGTT>4.2%: OGTT alone

Round JA et al. Diabetologia 2011; 54:256-63


RR for developing gestational diabetes by ethnicity (adjusted for age, BMI and parity; white as reference)

UK Data (1992) RR (95%CI)Black 3.1 (1.8 to 5.5)

South East Asian 7.6 (4.1 to 14.1)

Indian 11.3 (6.8 to 18.8)

Dornhorst A, Paterson CM, Nicholls JSD, et al. High prevalence of gestational diabetes in women from ethnic minority groups. Diabetic Medicine 1992; 9:820–5.


Prevalence (%)Indonesia 16Malaysia 13Philippines 14Singapore 10Thailand 13ASEAN 13

AFES Study Group on Diabetes in Pregnancy (ASGODIP)

Litonjua AD et al. AFES Study Group on Diabetes in Pregnancy: Preliminary Data on Prevalence. PJIM 1996:34:67-68.

Philippines n/NLow risk 35/853High risk 136/350

Overall 171/120314.2%

ASGODIP protocol 1-step (high-risk)75-g OGTT2h cut-off 140 mg/dL


Holt RIG et al. Diabete Med 2011; 28:382-5.

Increased prevalence of GDM using the IADPSG criteria “can only be justified if it is shown convincingly that pregnancy outcomes are improved.”


Landon et al NEJM 2009; 361:1339-48.

PI

MO

Intervention (n=485)

diet CBG insulin vs

routine care (n=473)

Composite of stillbirth/perinatal

death and neonatal

complications

Randomized controlled

trial

“mild” GDM24-31 wks AOG

Landon MB et al. A multicenter, randomized trial of treatment for mild gestational diabetes. NEJM 2009; 361:1339-48.

hyperbilirubinemia hypoglycemia

hyperinsulinemia birth trauma


Landon et al NEJM 2009; 361:1339-48.

PI

MO


diet CBG insulin vs


Composite of stillbirth/perinatal

death and neonatal

complications


trial



hyperbilirubinemia hypoglycemia

hyperinsulinemia birth trauma

Composite endpoint RR 0.87 (95% CI 0.72-1.07), p=0.14


Landon et al NEJM 2009; 361:1339-48.

PI

MO


diet CBG insulin vs



trial





Landon et al NEJM 2009; 361:1339-48.

PI

MO


diet CBG insulin vs



trial




LGA infants RR 0.49

(95%CI 0.32-0.76) p<0.001

BW >4000 g RR 0.41

(95%CI 0.26-0.66) p<0.001


ACHOISCrowther et al. NEJM 2005; 352:2477-86.

Crowther CA et al. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. NEJM 2005; 352:2477-86.

PI

MO

GDM24-28 wks AOG


diet CBG insulin vs


Serious perinatal

complications death

shoulder dystociabone fracturenerve palsy


trial


ACHOISCrowther et al. NEJM 2005; 352:2477-86.

Crowther CA et al. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. NEJM 2005; 352:2477-86.

PI

MO

GDM24-28 wks AOG


diet CBG insulin vs


Serious perinatal

complications death

shoulder dystociabone fracturenerve palsy


trial

Any serious perinatal complication Adj RR 0.33 (95% CI 0.14-0.75), p=0.01


http://www.flickr.com/photos/craigoneal/4084388198/

OGTT is poorly reproducibleDiagnosis based on a single test, on a single abnormal value





Gestational diabetes would be diagnosed if one or morevalues met or exceeded the following levels of glucose:fasting 5.1 mmol/l, 1 h post glucose 10.0 mmol/l and 2 hpost glucose 8.5 mmol/l. Use of these criteria will result in17.8% of the pregnant population being diagnosed withgestational diabetes. A detailed analysis of the same HAPOstudy information and other recent related publicationsraises issues that are worthy of further debate in the widerdiabetes community.

Observational data

HAPO was an international prospective observational studyof 23,316 pregnant women directed to answer the question:‘Is hyperglycaemia during pregnancy, at a level below thatfor overt diabetes, associated with increased risk ofmaternal or fetal complications?’ [2]. The participatingwomen had an OGTT and were divided into seven glucosecategories. The category 3 group encompassed the meanglucose values, i.e. fasting 4.5 mmol/l, 1 h post OGTT7.4 mmol/l and 2 h post OGTT 6.2 mmol/l, while the newproposed cut-offs from IADPSG fall in category 5. Theprimary endpoints were large-for-gestational age infants(LGA), primary Caesarean section rate, neonatal hypogly-caemia and cord C-peptide. The study demonstrated acontinuous relationship between glycaemia (fasting, and 1or 2 h post glucose load) and each of the primary outcomes,having adjusted for field centre and ethnicity. Whilesupporting the Pedersen hypothesis [3], the results did notshow any inflection point indicating clearly increased riskof any of these outcomes with a particular glucose category;rather, risk increased gradually over the glucose range.

A further publication from the group examined the roleof maternal BMI with the same primary outcomes [4]. Thisreport used an adjustment (Model 1) for many of theexpected confounders (age, alcohol, smoking, sex etc.), andalso a model (Model 2) that adjusted for fasting plasma

glucose and mean arterial pressure. The OR for LGA,primary Caesarean section and cord C-peptide increasedsignificantly for increasing categories of BMI, this differ-ence being maintained when adjusted for glucose and meanarterial pressure (reference group BMI <22.6 kg/m2;Fig. 1a). When the plot for LGA vs glucose is added(reference group category 1 glucose as used in the HAPOreport; Fig. 1a), it is apparent that maternal BMI has agreater impact on OR than maternal glucose in all exceptthe highest glucose category. This is also true for theprimary Caesarean section rate (Electronic supplementarymaterial [ESM] Fig. 1a), whereas the glucose level hadmore influence on the OR for cord C-peptide in glucosecategories 5–7 (ESM Fig. 1b). Thus, maternal BMI andglucose both contribute to risk of LGA, but the role of BMIwas more pronounced than that of glucose in determiningLGA incidence, until the highest glucose category wasreached. Using the category BMI 22.6–28.4 kg/m2 (whichincludes overweight women) and category 3 for glucose asthe reference groups (i.e. using reference groups thatinclude the means) shows that BMI and glucose have asimilar impact on the OR (ESM Fig. 2a–c).

The majority of women from the HAPO data hadglucose levels !category 3, i.e. the category encompassingthe mean glucose level (Fig. 1b). Moreover, the number ofLGA increased proportionately with higher glucose levels(Fig. 1b), but when the numbers of mothers with LGA ingiven glucose categories are classed separately (Fig. 1c),the majority (63%) of women with LGA are seen to haveglucose levels from the OGTT at or lower than category 3,the category incorporating the mean glucose level. This isalso true for the 1 and 2 h post-load challenge (ESMFig. 3). It is also noteworthy that at category 5 (equivalentto the IADPSG cut-off criteria, accepting that some cases incategory 5 will lie above these cut-offs within category 5)women below these cut-offs who had LGA represented78% of all women giving birth to LGA.

BMI category (Kg/m2)

Glucose category

Wom

en (

n)

Wom

en (

n)

8,000 700

600

500

400

300

200

100

0

6,000

4,000

2,000

0

<22.6 22.6!28.4

28.5!32.9

33.0!37.4

37.5! 42.041.9

1 2 3 4 5 6 7

Glucose category1 2 3 4 5 6 7

a b c

OR

0

1

2

3

4

5

1 3 52 4 6 7Glucose category

Fig. 1 a Relationship of the OR for an infant of birthweight >90thpercentile vs the BMI in categories (reference group BMI <22.6 kg/m2

[4]) or maternal fasting glucose in categories from HAPO (diamonds;reference group category 1 lowest glucose [2]). a The BMIrelationship is adjusted for model 1 (circles) or model 2 (triangles)

(see text for details). The relationship for maternal fasting glucosecategories is also shown (black diamonds). b Number of participantsin each category of glucose in HAPO (white bars), with number ofmothers with LGA infants (black bars). c Number of participants ineach category of glucose who had LGA infants

Diabetologia (2011) 54:480–486 481


Greater impact of maternal BMI on OR for LGA than maternal glucose except highest glucose category

HAPO

● BMI Model 1▲ BMI Model 2

◆ Maternal FG

Model 1: Adjusted for age, alcohol, smoking, sex, etc.Model 2: Adjusted for mean FG and MAP


Gestational diabetes would be diagnosed if one or morevalues met or exceeded the following levels of glucose:fasting 5.1 mmol/l, 1 h post glucose 10.0 mmol/l and 2 hpost glucose 8.5 mmol/l. Use of these criteria will result in17.8% of the pregnant population being diagnosed withgestational diabetes. A detailed analysis of the same HAPOstudy information and other recent related publicationsraises issues that are worthy of further debate in the widerdiabetes community.

Observational data

HAPO was an international prospective observational studyof 23,316 pregnant women directed to answer the question:‘Is hyperglycaemia during pregnancy, at a level below thatfor overt diabetes, associated with increased risk ofmaternal or fetal complications?’ [2]. The participatingwomen had an OGTT and were divided into seven glucosecategories. The category 3 group encompassed the meanglucose values, i.e. fasting 4.5 mmol/l, 1 h post OGTT7.4 mmol/l and 2 h post OGTT 6.2 mmol/l, while the newproposed cut-offs from IADPSG fall in category 5. Theprimary endpoints were large-for-gestational age infants(LGA), primary Caesarean section rate, neonatal hypogly-caemia and cord C-peptide. The study demonstrated acontinuous relationship between glycaemia (fasting, and 1or 2 h post glucose load) and each of the primary outcomes,having adjusted for field centre and ethnicity. Whilesupporting the Pedersen hypothesis [3], the results did notshow any inflection point indicating clearly increased riskof any of these outcomes with a particular glucose category;rather, risk increased gradually over the glucose range.

A further publication from the group examined the roleof maternal BMI with the same primary outcomes [4]. Thisreport used an adjustment (Model 1) for many of theexpected confounders (age, alcohol, smoking, sex etc.), andalso a model (Model 2) that adjusted for fasting plasma

glucose and mean arterial pressure. The OR for LGA,primary Caesarean section and cord C-peptide increasedsignificantly for increasing categories of BMI, this differ-ence being maintained when adjusted for glucose and meanarterial pressure (reference group BMI <22.6 kg/m2;Fig. 1a). When the plot for LGA vs glucose is added(reference group category 1 glucose as used in the HAPOreport; Fig. 1a), it is apparent that maternal BMI has agreater impact on OR than maternal glucose in all exceptthe highest glucose category. This is also true for theprimary Caesarean section rate (Electronic supplementarymaterial [ESM] Fig. 1a), whereas the glucose level hadmore influence on the OR for cord C-peptide in glucosecategories 5–7 (ESM Fig. 1b). Thus, maternal BMI andglucose both contribute to risk of LGA, but the role of BMIwas more pronounced than that of glucose in determiningLGA incidence, until the highest glucose category wasreached. Using the category BMI 22.6–28.4 kg/m2 (whichincludes overweight women) and category 3 for glucose asthe reference groups (i.e. using reference groups thatinclude the means) shows that BMI and glucose have asimilar impact on the OR (ESM Fig. 2a–c).

The majority of women from the HAPO data hadglucose levels !category 3, i.e. the category encompassingthe mean glucose level (Fig. 1b). Moreover, the number ofLGA increased proportionately with higher glucose levels(Fig. 1b), but when the numbers of mothers with LGA ingiven glucose categories are classed separately (Fig. 1c),the majority (63%) of women with LGA are seen to haveglucose levels from the OGTT at or lower than category 3,the category incorporating the mean glucose level. This isalso true for the 1 and 2 h post-load challenge (ESMFig. 3). It is also noteworthy that at category 5 (equivalentto the IADPSG cut-off criteria, accepting that some cases incategory 5 will lie above these cut-offs within category 5)women below these cut-offs who had LGA represented78% of all women giving birth to LGA.

BMI category (Kg/m2)

Glucose category

Wom

en (

n)

Wom

en (

n)

8,000 700

600

500

400

300

200

100

0

6,000

4,000

2,000

0

<22.6 22.6!28.4

28.5!32.9

33.0!37.4

37.5! 42.041.9

1 2 3 4 5 6 7

Glucose category1 2 3 4 5 6 7

a b c

OR

0

1

2

3

4

5

1 3 52 4 6 7Glucose category

Fig. 1 a Relationship of the OR for an infant of birthweight >90thpercentile vs the BMI in categories (reference group BMI <22.6 kg/m2

[4]) or maternal fasting glucose in categories from HAPO (diamonds;reference group category 1 lowest glucose [2]). a The BMIrelationship is adjusted for model 1 (circles) or model 2 (triangles)

(see text for details). The relationship for maternal fasting glucosecategories is also shown (black diamonds). b Number of participantsin each category of glucose in HAPO (white bars), with number ofmothers with LGA infants (black bars). c Number of participants ineach category of glucose who had LGA infants

Diabetologia (2011) 54:480–486 481


HAPO☐ Participants■ Participants with LGA infants

Majority of women had glucose levels < Cat. 3 (mean glucose level)

Most cases of LGA occur in normal maternal glycemia

78% of LGA born to women not fulfilling IADPSG criteria


Diagnosis of GDM identifies women at risk of type 2 diabetes

GDM independent risk

factor for diabetes in Filipino-Americans

RR 21.65 (95%CI 6.73-69.67)

Cuasay et al. Diabetes Care 2001;24(12):2054-8

IADPSG criteria may overestimate

risk of diabetes


Approved by ADAACOG did not approve

IADPSG Consensus

ACOG Committee on Obstetric Practice. Screening & Diagnosis of Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3


Philippine Diabetes CPG has partially adopted the IADPSG consensus by endorsing the HAPO-derived thresholds for the 75-g OGTT.





Implications on screening and

diagnosis of GDM


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Gestational Diabetes: An Update

Health & Medicine

Transcript of Gestational Diabetes: An Update