Screening and subsequent management for gestational diabetes for improving maternal and infant health

ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 1st floor, Queen Victoria Building, 72 King William Road, Adelaide, South Australia, Australia, 5006.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 07/2010; 7(7):CD007222. DOI: 10.1002/14651858.CD007222.pub2
Source: PubMed


Gestational diabetes mellitus (GDM) is a form of diabetes that can develop during pregnancy, usually toward the end of the second trimester. Having GDM increases the risk of complications during the rest of the pregnancy. Women with GDM are more likely to develop pre-eclampsia (a combination of high blood pressure and protein in the urine) and require a caesarean section. For the baby, potential problems include the baby growing larger than it normally would, causing difficulties with birth. The baby can also have low blood sugar levels after birth. Although GDM usually resolves following birth, both mother and child are at risk of developing type 2 diabetes in the future. There is strong evidence that treatment of GDM is beneficial and improves health outcomes. It may therefore help if pregnant women are screened to identify as many as possible of those who do have GDM before they have symptoms, such as excessive thirst, frequent urination or fatigue. The two main approaches to screening approaches are 'universal' where all women undergo a screening test for GDM; and a selective approach where only those women at high risk are screened. The main risk factors are maternal age, high body mass index, family history and cigarette smoking. The different screening strategies used around the world to identify women with GDM include identifying women based on their risk factors, a blood sugar test one hour after a 50 g glucose drink, and random blood sugar measurements. It is however unclear whether screening for GDM leads to better health outcomes and if so, which screening strategy is the most appropriate. This review of four trials involving 3972 women found that there is little high-quality evidence on the effects of screening for GDM on health outcomes for mothers and their babies. Further research is required to see which recommendations for screening practices for gestational diabetes are most appropriate.

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Available from: Andrew J Mcphee, Nov 18, 2015
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    • "As an unintended result of this overview, during the literature selection process we discovered 28 Cochrane reviews which intended to report on PTB < 37, but were not able to find any RCTs reporting PTB < 37 data. These reviews addressed highly relevant and sometimes routinely used interventions like cervical pessary for prevention [64] or risk scoring systems for predicting PTB [65], routine ultrasound in early pregnancy [66], or dietary advice for the prevention of [67] and screening for [68] gestational diabetes. In order to provide some information about potential effects on secondary outcomes considered in this overview, we prepared Table S4 as an additional file ([see Additional file 5]). "
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    ABSTRACT: Several factors are associated with an increased risk of preterm birth (PTB); therefore, various interventions might have the potential to influence it. Due to the large number of interventions that address PTB, the objective of this overview is to summarise evidence from Cochrane reviews regarding the effects and safety of these different interventions. We conducted a systematic literature search in the Cochrane Database of Systematic Reviews. Included reviews should be based on randomised controlled trials comparing antenatal non-pharmacological and pharmacological interventions that directly or indirectly address PTB with placebo / no treatment or routine care in pregnant women at less than 37 completed weeks of gestation without signs of threatened preterm labour. We considered PTB at less than 37 completed weeks of gestation as the primary outcome. We included 56 Cochrane systematic reviews. Three interventions increased PTB risk significantly. Twelve interventions led to a statistically significant lower incidence of PTBs. However, this reduction was mostly observed in defined at-risk subgroups of pregnant women. The remaining antenatal interventions failed to prove a significant effect on PTB < 37 weeks, but some of them at least showed a positive effect in secondary outcomes (e.g., reduction in early PTBs). As an unintended result of this review, we identified 28 additional Cochrane reviews which intended to report on PTB < 37 weeks, but were not able to find any RCTs reporting appropriate data. The possible effects of a diverse range of interventions on PTB have been evaluated in Cochrane systematic reviews. Few interventions have been demonstrated to be effective and a small number have been found to be harmful. For around half of the interventions evaluated, the Cochrane review concluded that there was insufficient evidence to provide sound recommendations for clinical practice. No RCT evidence is available for a number of potentially relevant interventions.
    Full-text · Article · Apr 2014 · BMC Research Notes
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    • "For example, a review of four trials comparing universal and selective screening, found that there is little high-quality evidence on the effects of screening for GDM on health outcomes for mothers and their babies. The paper concluded that further research is required to see which recommendations for screening practices for GDM are most appropriate [22]. "
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    ABSTRACT: The risks associated with gestational diabetes mellitus (GDM) are well recognized, and there is increasing evidence to support treatment of the condition. However, clear guidance on the ideal approach to screening for GDM is lacking. Professional groups continue to debate whether selective screening (based on risk factors) or universal screening is the most appropriate approach. Additionally, there is ongoing debate about what levels of glucose abnormalities during pregnancy respond best to treatment and which maternal and neonatal outcomes benefit most from treatment. Furthermore, the implications of possible screening options on health care costs are not well established. In response to this uncertainty there have been repeated calls for well-designed, randomised trials to determine the efficacy of screening, diagnosis, and management plans for GDM. We describe a randomised controlled trial to investigate screening uptake rates and the clinical and cost effectiveness of screening in primary versus secondary care settings. The objective of this study is to assess screening uptake rates, and the clinical and cost effectiveness of screening for GDM in primary versus secondary care. This is will be an unblinded, two-group, parallel randomised controlled trial (RCT). The target population includes 784 women presenting for their first antenatal visit at 12 to 18 weeks gestation at two hospitals in the west of Ireland: Galway University Hospital and Mayo General Hospital. Participants will be offered universal screening for GDM at 24 to 28 weeks gestation in either primary care (n = 392) or secondary care (n = 392) locations. The primary outcome variable is the uptake rate of screening. Secondary outcomes include indicators of clinical effectiveness of screening at each screening site (primary and secondary) including gestational week at time of screening, time to access antenatal diabetes services for women diagnosed with GDM, and pregnancy and neonatal outcomes for women with GDM. In addition, parallel economic and qualitative evaluations will be conducted. The trial will cover the period from the woman's first hospital antenatal visit at 12 to 18 weeks gestation, until the completion of the pregnancy.Trial registration: Current Controlled Trials: ISRCTN02232125.
    Full-text · Article · Jan 2014 · Trials
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    • "Our finding that there is the limited evidence for GDM screening among indigenous women is similar to a review examining the evidence-base among non-indigenous women 26, although our analysis has shown that the quality and quantity of evidence for indigenous women is significantly more limited. This review makes similar conclusions to other major studies among non-indigenous women with regard to the risks of DIP 12, low rates of screening during and after pregnancy205,206, and the challenges with nutritional and exercise interventions to prevent or reduce GDM207–209. A review of research gaps for the general community also identified a need for more research into effective treatment and management strategies for women with DIP and for improved post-pregnancy follow-up210. "
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    ABSTRACT: BACKGROUND: Recently proposed international guidelines for screening for Gestational Diabetes Mellitus (GDM) recommend additional screening in early pregnancy for sub-populations at a high risk of Type 2 Diabetes Mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population-based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. METHODS: Any publications were included that referred to diabetes in pregnancy (DIP) among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. RESULTS: There is sufficient evidence describing the epidemiology of DIP, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre-existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow-up after pregnancy (n = 5). CONCLUSIONS: Given the impact of DIP, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy-makers and clinicians must work together with communities to develop effective strategies for implementation and minimising the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow-up after pregnancy are urgently needed. Copyright © 2013 John Wiley & Sons, Ltd.
    Full-text · Article · May 2013 · Diabetes/Metabolism Research and Reviews
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