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The Impact of Risk Factors and More Stringent Diagnostic Criteria of Gestational Diabetes on Outcomes in Central European Women

Departments of Endocrinology and Metabolism (A.K.-W., T.P.), Obstetrics and Gynecology (D.B.-T.), Neonatology (R.B.), and Statistics (B.S.), Medical University of Vienna, Vienna, Austria; First Department of Medicine (R.W.) and Department of Obstetrics and Gynecology (H.S.), Paracelsus Private Medical University Salzburg, Salzburg, Austria; Department of Internal Medicine I (N.S., G.S.), Rudolfstiftung Vienna, Vienna, Austria; First Department of Medicine (M.R.), Hanusch-Krankenhaus, Vienna, Austria; and Department of Internal Medicine (C.M., M.L.), University of Innsbruck, Innsbruck, Austria, for The Austrian Gestational Diabetes Study Group

Address all correspondence and requests for reprints to: Alexandra Kautzky-Willer, M.D., Associate Professor of Medicine, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna; Austria. E-mail: alexandra.kautzky-willer{at}meduniwien.ac.at.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Objectives: In the face of the ongoing discussion on the criteria for the diagnosis of gestational diabetes (GDM), we aimed to examine whether the criteria of the Fourth International Workshop Conference of GDM (WC) select women and children at risk better than the World Health Organization (WHO) criteria.

Design and Setting: This was a prospective longitudinal open study in five tertiary care centers in Austria.

Patients and Outcome Measures: The impact of risk factors, different thresholds (WC vs. WHO), and numbers of abnormal glucose values (WC) during the 2-h, 75-g oral glucose tolerance test on fetal/neonatal complications and maternal postpartum glucose tolerance was studied in 1466 pregnant women. Women were treated if at least one value according to the WC (GDM-WC1) was met or exceeded.

Results: Forty-six percent of all women had GDM-WC1, whereas 29% had GDM-WHO, and 21% of all women had two or three abnormal values according to WC criteria (GDM-WC2). Eighty-five percent of the GDM-WHO were also identified by GDM-WC1. Previous GDM [odds ratio (OR) 2.9], glucosuria (OR 2.4), preconceptual overweight/obesity (OR 2.3), age 30 yr or older (OR 1.9), and large-for-gestational age (LGA) fetus (OR 1.8) were the best independent predictors of the occurrence of GDM. Previous GDM (OR 4.4) and overweight/obesity (OR 4.0) also independently predicted diabetes postpartum. GDM-WC1 had a higher rate of obstetrical complications (LGA neonates, neonatal hypoglycemia, cesarean sections; P < 0.001) and impaired postpartum glucose tolerance (P < 0.0001) than GDM-WHO.

Conclusion: These results suggest the use of more stringent WC criteria for the diagnosis of GDM with the initiation of therapy in case of one fasting or stimulated abnormal glucose value because these criteria detected more LGA neonates with hypoglycemia and mothers with impaired postpartum glucose metabolism than the WHO criteria.

	Introduction

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Considerable controversy exists regarding the thresholds and the numbers of the plasma glucose values considered for diagnosis of gestational diabetes (GDM) during oral glucose tolerance testing (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11). In addition, it is not known whether general screening for GDM in all pregnancies is preferable to selective screening of groups at increased risk for glucose intolerance. GDM is the most frequent single complication of pregnancy, causing increased fetal mortality and perinatal morbidity (12, 13, 14), leaving both mother and child at an increased risk to develop diabetes mellitus and/or obesity in later life (15, 16, 17, 18). On the other hand, recent studies showed that strict metabolic control is able to reduce perinatal complications (19, 20).

The 75-g, 2-h oral glucose tolerance test (oGTT) is widely accepted for the diagnosis of large for gestational age (LGA) in Central Europe, and the diagnostic criteria are either recommended by the World Health Organization (WHO) (2 h > 140 mg/dl) or following the Fourth International Workshop Conference on Gestational Diabetes (WC) (modified Carpenter/Coustan criteria). The latter are also supported by the American Diabetes Association as an alternative to the 100-g oGTT (8, 10) if at least two values meet or exceed the glucose thresholds (GDM-WC2: fasting 95 or greater; 1 h, 180 or greater; 2 h, 155 mg/dl or greater). The general use of 75-g oGTTs in pregnant and nonpregnant women seems to be preferable for simplicity and better comparison in the pre- and/or postpregnant state. However, because maternal and fetal morbidity is even increased in women with borderline GDM (21, 22, 23, 24), the diagnostic criteria during pregnancy need to be lowered, compared with those for impaired glucose tolerance in the nonpregnant state. To aim at an ideal test for identification of both children at risk for macrosomia and mothers at risk for diabetes at follow-up, the German and Austrian Diabetes Association adopted the criteria of the WC for the 75-g, 2-h oGTT (fasting 95 or greater; 1 h, 180 or greater; 2 h, 155 mg/dl or greater) with the exception that one abnormal plasma glucose value would be sufficient for diagnosis of GDM impaired glucose tolerance (IGT) (GDM-WC1) and subsequent treatment (25).

Thus, the primary objectives of our observational prospective multicenter national study were to evaluate the diagnostic efficacy of the different criteria (WC vs. WHO) to detect: 1) LGA and neonatal hypoglycemia; 2) impaired maternal glucose metabolism early after delivery; and 3) to compare the relationship of the three glucose values (oGTT) with fetal and maternal outcome. The secondary objective was to evaluate the predictive value of risk factors for fetal growth as well as the occurrence of GDM, the need of subsequent insulin therapy, and postpartum glucose tolerance in these women.

We hypothesized that the GDM-WC1 criteria would detect more LGA newborns and better identify women with impaired glucose metabolism early postpartum. In addition, we hypothesized that each glucose value (oGTT) independently relates to maternal and fetal/neonatal complications.

	Subjects and Methods

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This prospective open multicenter study was conducted in five hospitals with suitable infrastructure including an intensive care unit for neonates in different parts of Austria (Vienna, Salzburg, Steyr, and Innsbruck) from 2001 until 2004. All women gave informed consent before participation in this study. The study was performed according to the most recent version of the Helsinki declaration.

Risk assessment

At an initial contact, which occurred between 11 and 13 wk gestation, a broad risk assessment of conventional and nonconventional risk factors for GDM was carried out, and each subject at risk was scheduled for a full diagnostic oGTT (75 g, 2 h) between 24 and 28 gestational weeks. Conventional risk factors were history of GDM or history of prediabetes (26) [IGT or impaired fasting glucose (IFG)]; intrauterine fetal death, birth weight of previous child greater than 4000 g, malformation, or previous recurrent abortion (>3 in previous pregnancies); ethnic group at high risk for type 2 diabetes (Hispanics, African, Asian, or Indian origin); moderate overweight or obesity before [body mass index (BMI) 27 kg/m²] or during pregnancy (weight gain 10 kg in first trimester); age 30 yr or older; history of first- and second-degree relative with type 2 diabetes; clinical markers: glucosuria and LGA fetus (ultrasound: abdominal circumference > 90th percentile of reference group) (27); other risk factors: hypertension (140/90 mm Hg), preconceptual dyslipidemia (triglycerides > 150 mg/dl or cholesterol > 200 mg/dl); and previous preterm delivery (<37 gestational wk). Another group of women without any of these risk factors, but referred to the hospitals for booking, were also tested between 24 and 28 gestational weeks by oGTT to serve as reference group (n = 171). Women presenting with type 1 diabetes, women screened positive for GAD autoantibodies, and women with known pregestational type 1 or type 2 diabetes were excluded from this study.

Children with a birth weight greater than the 90th percentile on the basis of actual local growth standard curves were defined as LGA newborns [analysis of the newborns from 1999 to 2004 in Austria (2007); http://dx.doi.org/10.1007/s00112–007-1545–2].

Diagnostic criteria and oGTT

All women were on an isocaloric diet containing 200 g of carbohydrates per day at least 3 d before the oGTT. oGTTs were performed after a 10- to 12-h overnight fasting period. All women ingested 75 g of glucose solution within 2 min, and venous plasma samples were collected for glucose measurements at fasting and 1 and 2 h after glucose loading. Glucose measurements were done on a Hitachi modular system (Hitachi Ltd., Tokyo, Japan) by a hexokinase method (Roche Diagnostics, Basel, Switzerland). Gestational diabetes was diagnosed according to the criteria of the WC adapted by the German and Austrian Diabetes Association, which suggest treatment in women in case of at least one (GDM-WC1) abnormal value (oGTT, 75 g; plasma glucose fasting 95, 1 h 180, 2 h 155 mg/dl) (25). The subgroup of women with two or more abnormal values are defined as GDM-WC2, whereas women with diagnosis of GDM according to WHO criteria are called GDM-WHO. GDM-WC1 were referred to dietary counseling (three main meals and three snacks corresponding to 25–30 kcal/kg per day; in case of BMI greater than 30 kg/m² 30% caloric restriction was recommended) and advised to measure blood glucose levels four times daily until delivery. If self-measured blood glucose levels exceeded the treatment targets (5.0 mmol/liter at fasting and 7.2 mmol/liter 1 h postprandially), insulin therapy was started and the insulin dose was adjusted accordingly (see Table 4). In GDM women mean fasting and postprandial glucose concentrations were within the target range (data not shown). All GDM-WC1 were examined every 2–3 wk and, if necessary, in weekly intervals.

Statistical analysis

All data are expressed as means ± SEM. Comparisons between groups were performed using ANOVA for parameters with means following normal distribution. Nonparametric Kruskal Wallis test was carried out if appropriate. For multiple group comparison, the Tukey post hoc test was applied. Predictors for the occurrence of gestational diabetes were obtained by stepwise logistic regression analysis. Odds ratios are reported including 95% confidence intervals (CIs). To compare the different oGTT criteria the McNemar test was applied. For all analyses the SAS Package 9.1.3 (Cary, NC) was used.

	Results

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Diagnostic criteria and oGTT

Twenty-one percent of the 1466 pregnant women had GDM-WC2, whereas 46% had GDM-WC1. Twenty-nine percent would have been diagnosed by WHO criteria and 85% of these GDM-WHO women were also identified as GDM-WC1.

Of note, 31% of all women had an elevated 1-h value, 26% had an increased fasting value, and only 18% a 2-h glucose value above normal range.

There was no significant difference in the relative proportion of women with impaired glucose tolerance within the various centers. In the reference group with no apparent risk factors, 9% had GDM-WC2, 25% GDM-WC1, and 15% would have been diagnosed as GDM-WHO.

Studying the relationship between fasting, the 1- and the 2-h glucose value during the oGTT as well as fetal and maternal outcome, it turned out that the fasting glucose was the best predictor for birth weight [P < 0.003, odds ratio (OR) 1.01 (1.004–1.018)], LGA newborns [P < 0.002, OR 1.023 (1.01–1.04)] as well as impaired glucose metabolism [P < 0.0001; OR 1.3 (1.2–1.4)] or overt diabetes [P < 0.0001; OR 1.16 (1.1–1.2)] early after delivery. On the other hand, 1 h glucose best predicted neonatal hypoglycemia [P < 0.003, OR 1.009 (1.003–1.014)] and 2 h glucose the rate of cesarean sections [P < 0.0001, OR 1.007 (1.004–1.01)] and neonates with a birth weight of more than 4500 g [P < 0.0001, OR 1.018 (1.009–1.27)].

Risk factors

Characteristics (Table 1) GDM-WC1 women featured the phenotype of the metabolic syndrome. Ninety-two percent of the women were Caucasians and 8% were of Asian origin.

Logistic regression analysis revealed that maternal type 2 diabetes was the best independent predictor [OR 1.78 (1.26–2.51), P < 0.0005]. Family history in total explained only 2.5% of the occurrence of GDM-WC1.

Distribution and predictive value of risk factors (Table 2) Twenty-four percent of the pregnant women had only one risk factor; the most common risk factor was age above 30 yr.

Logistic regression analysis revealed that the risk factors previous GDM [2.32 (1.8–3.0), P < 0.0001], glucosuria [2.42 (1.8–3.2), P < 0.0001], overweight/obesity [2.92 (1.8–4.7), P < 0.0001], age 30 yr or older [1.85 (1.4–2.3), P < 0.0001], LGA fetus [1.8 (1.1–2.9), P < 0.01], and ethnicity [1.6 (1.2–2.2), P < 0.005] independently predicted the occurrence of GDM-WC1.

The best independent predictors for subsequent need of insulin therapy were the risk factors previous GDM (OR 4.1; CI 2.6–6.5), previous IGT/IFG (OR 6.0; CI 2.5–14.6), glucosuria (OR 2.7; CI 2.0–3.7), ethnicity (OR 2.4; CI 1.7–3.5), preconceptional overweight/obesity (OR 1.9; CI 1.4–2.6), and age (OR 1.7; CI 1.3–2.3) (all P < 0.0001).

Obstetric characteristics (Table 3)

In GDM patients with three abnormal glucose values, the highest rate of obstetric complications was observed, but even the group with one abnormal glucose value had a higher rate of neonatal hypoglycemia than women with NGT. The rate of small-for-gestational age neonates did not differ between groups (12.3 vs. 11.3%, GDM-WC1 vs. NGT, respectively). Induction of labor was more frequent in GDM, compared with NGT (22 vs. 15%, P < 0.01).

Postpartum glucose tolerance (Table 5)

Mean hemoglobin a1c values were 5.4 ± 0.03% and mean triglycerides were 122.7 ± 4.7 mg/dl in GDM women 3 months after delivery. A quarter of GDM-WC1 with persistent impairment of glucose metabolism early postpartum had only one abnormal glucose value (oGTT) during pregnancy. Twenty percent of the women with persistent type 2 diabetes would have been missed by the WHO criteria and 10% if two or more glucose values (oGTT) were required.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This study detected a high rate of pregnant women with at least one abnormal glucose value (GDM-WC1) and with two or more abnormal glucose values (GDM-WC2), which may be attributed to the fact that only tertiary care centers with mostly preselected women participated in this study. Interestingly, the rates found in our study were similar to those recently reported in Italian women using the 3-h, 100-g oGTTs after an abnormal prescreening test (28).

Our study tried to evaluate the criteria proposed by the Fourth International Workshop Conference on Gestational Diabetes for the 75-g, 2-h oGTT, but treatment was already initiated in case of one single abnormal value according to the recommendations of the German and the Austrian Diabetes Association (25). Previous studies showed that one value in the oGTT is already associated with impaired insulin secretion and sensitivity (28), increased perinatal complications, such as LGA neonates or cesarean delivery (22), as well as fetal hyperinsulinemia, neonatal obesity and placental immaturity (24). In our study, women with one abnormal value did not differ from those with two abnormal values in their obstetric outcome, which supports the arguments for a strict surveillance of such women. However, the risk of earlier delivery and LGA infants including those with a birth weight greater than 4.5 kg was highest in GDM women with three abnormal values as was the rate of previous obstetric complications in general. Therefore, three abnormal values seem to hint at preexisting disturbances of maternal glucose metabolism, which is also supported by the observation that these women had the highest rate of overt diabetes postpartum.

We also found that, although fasting glucose was the strongest predictor of birth weight and glucose tolerance postpartum, each of the three glucose values measured during the oGTT independently related to and predicted maternal or fetal/neonatal complications, which is a new finding of the study. This further argues for the consideration of each glucose value for diagnosis and subsequent therapy. The final proof of the concept that there is a linear relationship between all glucose values across a broad range during the 75-g, 2-h oGTT and perinatal outcome independently of ethnicity can be expected from the Hyperglycemia and Adverse Pregnancy Outcome study (29).

In our observational study, all GDM-WC1 patients were treated to target with dietary modification and if necessary insulin therapy. Two recent studies with similar targets for glycemic control during pregnancy as in our study, one prospective, randomized, controlled study conducted in women diagnosed by the WHO criteria (20) and one study using the WC criteria (two or more abnormal values) (19) proved the efficacy of strict therapy in GDM on perinatal outcome. In the present study, we found similar rates of complications in the GDM-WC1 or GDM-WC2 women as in the treated women of these studies. Interestingly, although all women were closely monitored and on strict metabolic control, even the group with one single increased glucose value still had higher rates of complications. Therefore, it is questionable whether strict metabolic control alone is able to normalize perinatal complications. One might hypothesize that additional unmodified factors will contribute to the increased risk. These factors could be variations in circulating adipocytokines like decreased adiponectin levels (30, 31) or alterations of lipid metabolism and body fat content like increased intramyocellular lipids as previously shown in women with GDM (32).

Of note, Asian origin and family history of type 2 but not type 1 diabetes were associated with an increased risk of GDM-WC1, confirming the assumption that GDM-WC1 and type 2 share the same genetic background. Maternal type 2 diabetes was the most important independent risk factor regarding first-degree relatives, but family history in total explained only a very low number of cases. This finding further outlines the influence of the maternal intrauterine environment for the risk of diabetes in the offspring and the importance of acquired risk factors.

The 3.5-fold increased risk for recurrence of GDM-WC1 and the high rate of women with impaired glucose metabolism at the postpartum oGTT outlines the need for an oGTT early after delivery and regular follow-up, even in women with subclinical GDM.

The risk factors, previous gestational diabetes, pregestational overweight/obesity, and glucosuria, increased age and LGA independently predicted occurrence of GDM-WC1 with subsequent need of insulin therapy and fetal and maternal complications supporting a risk assessment in pregnancy independently of their glucose tolerance.

The results of our study propose that diagnosis of GDM-WC1 leads to an additional dietary treatment necessity for 20% of all women and could identify another 10% requiring insulin therapy during pregnancy to maintain normoglycemia, compared with GDM-WC2 or GDM-WHO.

In summary, each of three glucose values measured during the oGTT is independently associated with perinatal complications and should be considered for diagnosis of impaired glucose tolerance during pregnancy. Initiation of therapy, even in case of one abnormal glucose value according to WC criteria (GDM-WC1), detected a higher rate of LGA newborns with neonatal hypoglycemia, and in addition, more women with impaired glucose metabolism early after delivery than the WHO criteria. Pregnancy is a good opportunity to change lifestyle and many women will continue a healthy diet after delivery, which is important for public health facing the epidemic of obesity. The higher costs of insulin therapy and dietary counseling during pregnancy should be justified by the better detection of newborns at risk and potentially fewer long-term complications of mothers and children.

	Acknowledgments

 
We are indebted to our coworkers M. Politor, M. Hofmann, B. Gappmayer, C. Garstenauer, G. Hasenöhrl, T. Kann, and M. Olechowsky.

	Footnotes

 
This work was supported by a clinical research project award of the Austrian Diabetes Association (to A.K.-W.).

Disclosure Statement: The authors have nothing to disclose.

First Published Online February 19, 2008

Abbreviations: BMI, Body mass index; CI, confidence interval; GDM, gestational diabetes; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; LGA, large for gestational age; NGT, normal glucose tolerance; oGTT, oral glucose tolerance test; OR, odds ratio; WC, Fourth International Workshop Conference of GDM.

Received October 15, 2007.

Accepted February 8, 2008.

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Top Abstract Introduction Subjects and Methods Results Discussion References

 

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This Article Abstract Full Text (PDF) Submit a related Letter to the Editor Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Copyright Permission Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kautzky-Willer, A. Articles by Lechleitner, M. Search for Related Content PubMed PubMed Citation Articles by Kautzky-Willer, A. Articles by Lechleitner, M. Related Collections Pediatric Endocrinology Diabetes and Insulin Female Endocrinology