Karcaaltincaba Et Al-2017-International Journal of Gynecology %26amp%3B Obstetrics

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  148   |   wileyonlinelibrary.com/journal/ijgo Int J Gynecol Obstet 2017; 138: 148–151 © 2017 Internaonal Federaon of Gynecology and Obstetrics Received: 21 December 2016 |  Revised: 14 March 2017 |  Accepted: 8 May 2017 |  First published online: 13 June 2017 DOI: 10.1002/ijgo.12205 CLINICAL ARTICLE Obstetrics Prevalence of gestaonal diabetes mellitus evaluated by universal screening with a 75- g, 2- hour oral glucose tolerance test and IADPSG criteria Deniz Karcaalncaba 1   |  Pinar Calis 1, * |  Nagehan Ocal 2   |  Aykut Ozek 1   |  Melis Altug Inan 1   |  Merih Bayram 1 1 Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Ankara, Turkey 2 Gazi University Faculty of Medicine, Ankara, Turkey * Correspondence Pinar Calis, Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Besevler, Ankara, Turkey.Email: ptokdemir86@gmail.com  Abstract Objecve: To determine the prevalence of gestaonal diabetes mellitus (GDM) and its associaon with maternal age among Turkish women diagnosed by Internaonal Associaon of Diabetes and Pregnancy Study Group (IADPSG) criteria. Methods: A cross- seconal study was conducted in 2013–2015 among non- diabec preg-nant women aged 18–49 years who were universally screened for GDM by IADPSG crite-ria. The percentage of women meeng each diagnosc threshold and the prevalence of GDM by age group were calculated. Linear trends were evaluated by logisc regression. Results: Among 1434 women screened, 159 (11.1%, 95% condence interval 9.5%–12.7%) were diagnosed with GDM; eleven of these women had been diagnosed accord-ing to a fasng glucose level in the rst trimester. The prevalence of GDM was 6.6% (10/151), 7.3% (37/507), 8.8% (42/479), 16.7% (45/270), and 35.2% (25/71) among women aged younger than 25, 25–29, 30–34, 35–39, and 40 years or older, respecvely. GDM prevalence increased with age ( P <0.001). The numbers of women diagnosed with GDM in the second trimester who exceeded one, two, and three thresholds of the 2- hour oral glucose tolerance test were 66 (44.6%), 52 (35.1%), and 30 (20.3%), respecvely. Conclusion: Prevalence of GDM was correlated with maternal age. Most women diag-nosed in the second trimester exceeded the threshold at only one of the three mepoints. KEYWORDS Gestaonal diabetes mellitus; IADPSG criteria; Internaonal Associaon of Diabetes and Pregnancy Study Group; Maternal age; Pregnancy 1 |  INTRODUCTION Gestaonal diabetes mellitus (GDM) is carbohydrate intolerance of vari-able severity that has its onset or is recognized during pregnancy. 1  It is one of the most common medical disorders of pregnancy. 1  Women with GDM are at high risk for future type 2 diabetes, with 50% of women with GDM subsequently developing type 2 diabetes within 25 years. 2,3   Addionally, maternal diabetes during pregnancy exposes the fetus to hyperglycemia and high insulin levels, which might be related to increased risk of childhood and adult obesity, and of GDM and type 2 diabetes at childbearing ages. 4  Therefore, diagnosis of GDM is crucial.GDM remains one of the most controversial syndromes in obstet-rics because of the dierent screening protocols, diagnosc tests, and diagnosc criteria applied worldwide. At present, the American College of Obstetricians and Gynecologists (ACOG) recommends selecve screening with a two- step approach between weeks 24 and    |  149 K ARCAALTINCABA  ETAL. 28 of pregnancy. 1  The rst step involves the determinaon of venous glucose levels 1 hour aer oral ingeson of 50 g of glucose soluon. Individuals exceeding the threshold (7.77 mmol/L [140 mg/dL]) undergo a 100- g, 3- hour diagnosc oral glucose tolerance test (OGTT). In 1979, the Naonal Diabetes Data Group (NDDG) recommended threshold values for 100- g OGTT, 5  and these were accepted as diagnosc cuto points unl 1999. In 2000, Carpenter and Coustan (CC) threshold val-ues 6  were adopted worldwide.In 2010, however, the Internaonal Associaon of Diabetes and Pregnancy Study Group (IADPSG) recommended screening all women using a one- step, 75- g, 2- h diagnosc OGTT and new diagnosc cri- teria based on data from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. 7–9  The same approach has also been adopted by the American Diabetes Associaon. It has been predicted that, in the US populaon, the mean prevalence of GDM diagnosed by the proposed IADPSG criteria will be approximately 18%, which is at least twofold higher than the prevalence determined by ACOG recommendaons. 1 The aim of the present study was to determine the prevalence of GDM and its associaon with maternal age in a Turkish populaon, as determined by universal screening using the IADPDG criteria. This will demonstrate how these criteria aect both the prevalence of GDM and the proporon of pregnant women needing treatment due to glu-cose intolerance. 2 |  MATERIALS AND METHODS The present cross- seconal study was undertaken at the Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine, Ankara, Turkey. Consecuve non- diabec pregnant women aged 18–49 years were enrolled prospecvely between January 1, 2013, and December 31, 2015. Pregnant women with known type 1 or type 2 diabetes were excluded. Approval for the study was obtained from the Instuonal Review Board in Clinical Studies (Approval No. 14.12.2015- 130). All parcipants gave informed consent.Since 2011, the study clinic has followed the recommendaons of the American Diabetes Associaon and IADPSG for GDM screen-ing, including both the rst- trimester fasng glucose level and the one- step approach using the 75- g, 2- hour diagnosc OGTT at weeks 24–28. Universal screening for GDM was performed at the rst prena-tal visit via a fasng glucose test. Women whose fasng glucose levels were met or exceeded 5.11 mmol/L (92 mg/dL) were considered to have GDM. The remaining women received an appointment for the 75- g, 2- hour OGTT at 24–28 weeks of pregnancy.To determine fasng glucose levels in the OGTT, venous plasma samples were collected from the women aer a 12- hour overnight fast. The women were then given 75 g of anhydrous glucose orally, and 1- hour and 2- hour venous plasma samples were collected. Blood samples were collected in uoride- oxalate vials. GDM was diagnosed if at least one of the threshold values was met or exceeded as per the IADPSG criteria (fasng value 5.11 mmol/L [92 mg/dL]; 1- hour value 9.99 mmol/L [180 mg/dL]; 2- hour value 8.49 mmol/L [153 mg/dL]).The mean prevalence of GDM and the percentage of women that met or exceeded each of the 75- g OGTT thresholds were calculated. Addionally, the percentages of women meeng one, two, or all three thresholds were compared.The study women were divided into ve subgroups by maternal age (<25, 25–29, 30–34, 35–39, and ≥40 years), and the prevalence of GDM in each subgroup was calculated separately. The linear trend in the prevalence of GDM with age was evaluated by logisc regres-sion. Stascal analysis was performed using SPSS version 21.0 (IBM, Armonk, NY, USA). P <0.05 was considered stascally signicant. 3 |  RESULTS During the study period, 1478 consecuve pregnant women were enrolled in the study. Eleven of them had a fasng glucose level of 5.11 mmol/L (92 mg/dL) or higher at the rst prenatal visit and were diagnosed with GDM. The remaining 1467 paents were scheduled to undergo the 75- g 2- hour OGTT at 24–28 weeks. Of the 1423 women who completed the 75- g OGTT test, 148 were diagnosed with GDM. Thus, the overall mean prevalence of GDM was 11.1% (159/1434) (Fig. 1).Overall, OGTT thresholds were exceeded 260 mes (fasng, 1- hour, and 2- hour values considered separately). The most common point at which glucose values were elevated was at 1 hour (108/260 [41.5%]) (Fig. 2). The percentage of women who met the GDM diag-nosis with only one threshold value (fasng, 1- hour, or 2- hour) was 44.6% (66/148), the percentage with two threshold values (fasng and 1- hour, fasng and 2- hour, or 1- hour and 2- hour) was 35.1% (52/148), and the percentage with all three threshold values was 20.3% (30/148) (Table 1). FIGURE 1 Flow chart showing recruitment of the study women and prevalence of GDM by IADPSG criteria. Abbreviations: GDM, gestational diabetes; IADPSG, International Association of Diabetes and Pregnancy Study Group. Pregnant women screened for GDM (n=1478)First prenatal visitFasting plasma glucose≥5.11 mmol/L but nodiagnosisof overt diabetes(n=11)75-g OGTT at 24-28 wk (n=1423)GDM diagnosed (n=148) GDM by IADPSG criteria(n=159, 11.1%)Fasting plasma glucose <5.11 mmol/L(n=1467)Excluded (n=44)Refused testing (n=23)Vomiting (n=21)  150 |   K ARCAALTINCABA  ETAL. The prevalence of GDM was correlated with maternal age ( P< 0.001), with the highest prevalence among women aged 40 years or older (Table 2). 4 |  DISCUSSION Among the study women, the mean prevalence of GDM diagnosed by IADPSG criteria was 11.1%. GDM prevalence increased with age: the lowest frequency was observed among women younger than 25 years (6.6%) and the highest among those aged 40 years or older (35.2%). Of the three threshold values in the 75- g 2- hour diagnosc OGTT, the elevated 1- hour value was found to be the most prevalent (40.1%).In a previous study using NDDG and CC criteria, 10  the mean prevalence of GDM in the Turkish populaon was reported as 3.17% and 4.48%, and the mean prevalence of gestaonal impaired glucose tolerance (GIGT) as 1.97% and 2.46%, respecvely. The prevalence of both GDM and GIGT was correlated with maternal age. 9  In the present study, on the basis of the one- step screening approach, the mean prevalence of GDM was 11.1% (95% condence interval 9.5%–12.7%), showing an approximately 3.5- fold increase as compared with the NDDG criteria, and a 2.5- fold increase as compared with the CC criteria.Studies have been done in several countries to determine the prev-alence of GDM in accordance with the new IADPSG criteria. The preva-lence of GDM diagnosed by IADPSG criteria has been reported as 17.6%, 4.2%, 11.8%, 9.5%, 23.3%, 8.6%, and 45% in Singapore, 11  Greenland, 12   Switzerland, 13  South Korea, 14  Sri Lanka, 15  Sub- Saharan Africa, 16  and the United Arab Emirates, 17  respecvely. By contrast, a two- step approach for diagnosis determined a GDM prevalence of 3.3% in Switzerland 13   and 12% in the United Arab Emirates. 17  This approximately fourfold increase in prevalence of GDM determined by the IADPSG criteria is similar to the present ndings. The main cricism of ACOG regarding the IADDPG criteria, as compared with the convenonal two- step screen-ing approach, has been the increased cost of health care owing to the higher numbers of women diagnosed with GDM. 1 GIGT is diagnosed on the basis of one posive value in a 100- g OGTT. Although not accepted to have GDM, women with GIGT have an increased likelihood of developing abnormal glucose tolerance later in life, similar to the increased risk for women with GDM. 18  Addionally, GIGT is associated with increased risk of adverse perinatal outcomes; thus, dietary counseling and glucose monitoring are recommended to reduce perinatal morbidity. 19  Given the increased number of women needing treatment during pregnancy for GDM idened by the IADPSG criteria, cases of GIGT should also be evaluated by these criteria.In a previous study, 10  the percentage of pregnant women needing treatment due to glucose intolerance (GDM+GIGT) was 5.14% and 6.94%, respecvely. Although the IADPSG criteria led to a 2.5- fold and 3.5- fold increase in GDM prevalence relave to the NDDG and CC criteria, respecvely, it caused only a 1.6- fold and 2.1- fold increase in the respecve frequency of pregnant women needing treatment due to glucose intolerance. Although the dierence in prevalence of GDM diagnosed by the IADPDG criteria was 7.93% and 6.62% (vs NDDG and CC criteria, respecvely), the dierence in pregnant women need-ing treatment due to glucose intolerance was only 5.96% and 4.16% (vs NDDG and CC criteria, respecvely).The increase in prevalence of GDM with age observed in the pres-ent study is similar to previous reports using dierent screening crite- ria. 14,20  In a comparison of the prevalence of GDM or GDM plus GIGT across dierent age groups using the present ndings and data obtained by NDDG and CC criteria, 10  the highest frequencies were observed FIGURE 2 Percentage of positive results occurring at each of the OGTT timepoints. Abbreviation: OGTT, oral glucose tolerance test. TABLE 1 Women with gestaonal diabetes meeng or exceeding each IADPSG threshold (n=148). a Glucose testNo. (%) of women meeng threshold Fasng20 (13.5)Only 1- h33 (22.3)Only 2- h13 (8.8)Fasng, 1- h13 (8.8)Fasng, 2- h7 (4.7)1- h, 2- h32 (21.6)Fasng, 1- h, 2- h30 (20.3)Abbreviaon: IADPSG, Internaonal Associaon of Diabetes and Pregnancy Study Group. a Fasng threshold 5.11 mmol/L (92 mg/dL); 1- h value 9.99 mmol/L (180 mg/dL); 2- h value 8.49 mmol/L (153 mg/dL). TABLE 2 Prevalence of GDM diagnosed by IADPSG criteria straed by maternal age.  Age, yTotal no. of womenNo. of women with GDM% of women with GDM (95% CI) <2515110 6.6 (2.6–10.7)25–29 50737 7.3 (5.1–9.7) 30–34 479 42 8.8 (6.2–11.3)35–39 27045 16.7 (12.2–21.2)≥40 7125 35.2 (24.2–47.3)Total 1478 15911.1 (9.5–12.7)Abbreviaons: GDM, gestaonal diabetes; IADPSG, Internaonal Associaon of Diabetes and Pregnancy Study Group; CI, condence interval.    |  151 K ARCAALTINCABA  ETAL. for women younger than 25 years of age (6.6%, 0.95%, and 1.44% by IADPSG, NDDG, and CC criteria, respecvely). In a previous comparison of CC criteria and NDDG criteria, 10  the largest dierence in prevalence was also found for women younger than 25 years 9 ; this discrepancy was aributed to the increased sensivity of the test using CC criteria due to its lower threshold and a markedly lower incidence of GDM at young ages. These observaons infer that the IADPSG criteria might have even higher sensivity than the CC criteria in diagnosing GDM.In the present study, GDM was diagnosed when one glucose value met or exceeded the criteria dened for a posive test during the 75- g OGTT, as compared with two or more glucose posive values during the 100- g OGTT in previous screens. The frequency of women who were diagnosed with GDM by one elevated threshold value, two elevated threshold values, and three elevated threshold values was 44.6%, 35.1%, and 20.3%, respecvely. Thus, almost half the women who were diagnosed with GDM had only one elevated threshold value.The present results provide a good esmate of the higher prev-alence of GDM dened by the IADPSG criteria in Turkey, and the increased number of paents needing treatment to according to age. The study focused on determining the prevalence of GDM and did not analyze its consequences, which represents a limitaon. In the HAPO study, the threshold levels were derived from an odds rao of 1.75 for a macrosomic fetus and clinical hyperinsulinemia. 9  As stated in the HAPO study, 9  use of the IADPSG diagnosc criteria coupled with proper treatment might lead to a lower incidence of macrosomia, primary cesarean delivery, clinically diagnosed neonatal hypoglycemia, delivery before 37 weeks, pre- eclampsia, shoulder dystocia or birth injury, hyperbilirubinemia, and need for intensive neonatal care.In conclusion, the prevalence of GDM was found to be higher when assessed by a one- step screening approach with the IADPSG criteria than with the two- step approach, and was found to be correlated with maternal age. The proporon of women needing treatment owing to glucose intolerance was also higher, but the increase was less marked as compared with the increase in GDM prevalence.  AUTHOR CONTRIBUTIONS DK designed and planned the study, and wrote the manuscript. PC planned the study, analyzed the data, and wrote the manuscript. NO conducted the study and wrote the manuscript. AO planned and con-ducted the study, and revised the manuscript. MAI conducted the study and wrote the manuscript. MB designed and planned the study, and revised the manuscript. CONFLICTS OF INTEREST The authors have no conicts of interest. REFERENCES  1. American College of Obstetrics and Gynecology. Pracce Bullen No. 137: Gestaonal diabetes mellitus. Obstet Gynecol . 2013;122(2 Pt 1):406–416. 2. England LJ, Dietz PM, Njoroge T, et al. Prevenng type 2 diabetes: Public health implicaons for women with a history of gestaonal dia-betes mellitus.  Am J Obstet Gynecol . 2009;200:365.e361–365.e368. 3. O’Sullivan JB. Body weight and subsequent diabetes mellitus.  JAMA . 1982;248:949–952. 4. Dabelea D, Hanson RL, Lindsay RS, et al. Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: A study of discordant sibships. 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