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Cochrane Database of Systematic Reviews

Different strategies for diagnosing gestational diabetes to improve maternal and infant health

Information

DOI:
https://doi.org/10.1002/14651858.CD007122.pub4Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 23 August 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Pregnancy and Childbirth Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Diane Farrar

    Correspondence to: Maternal and Child Health, Bradford Institute for Health Research, Bradford, UK

    [email protected]

  • Lelia Duley

    Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK

  • Therese Dowswell

    Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK

  • Debbie A Lawlor

    MRC Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, University of Bristol, Bristol, UK

Contributions of authors

Three review authors were involved in planning and development of the review (Diane Farrar, Leila Duley and Debbie Lawlor). Diane Farrar and Lelia Duley analysed the studies and extracted data for the original review. All review authors analysed the studies included in the updates. Diane Farrar and Therese Dowswell extracted data. Therese Dowswell generated the 'Summary of findings' table with comments from all remaining review authors. Diane Farrar drafted the review, incorporating comments from Lelia Duley, Therese Dowswell and Debbie Lawlor.

Sources of support

Internal sources

  • Medical Research Council Integrative Epidemiology Unit, The University of Bristol, UK.

External sources

  • National Institute for Health Research Post‐doctoral Fellowship Award, UK.

  • National Institute for Health Research (NIHR), UKNIHR Cochrane Programme Grant Project: 13/89/05 – Pregnancy and childbirth systematic reviews to support clinical guidelines, UK.

Declarations of interest

Diane Farrar: none known.

Lelia Duley: I hold an NIHR Programme Grant for Applied Research addressing care at preterm birth.

Therese Dowswell: I am paid via my institution by the UK NHS to work on a range of Cochrane Reviews. In the last 36 months I have received funding from the WHO to work on other Cochrane Reviews. The Funders have no influence on the content or conclusions of the reviews I work on.

Debbie Lawlor: none known.

Acknowledgements

Thank you to Sabina Abbas for transcribing Weiss (Austria 1994) from German to English, and thank you to Ana Duarte for translating Dueñas (Mexico 2011) from Portuguese to English.

Nancy Medley was an author on the previous 2015 update. Her work was financially supported by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization. The named review authors alone are responsible for the views expressed in this publication.

This project was supported by the National Institute for Health Research, via Cochrane Programme Grant funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Therese Dowswell is supported by the NIHR Cochrane Programme Grant Project: 13/89/05 – Pregnancy and childbirth systematic reviews to support clinical guidelines.

Version history

Published

Title

Stage

Authors

Version

2017 Aug 23

Different strategies for diagnosing gestational diabetes to improve maternal and infant health

Review

Diane Farrar, Lelia Duley, Therese Dowswell, Debbie A Lawlor

https://doi.org/10.1002/14651858.CD007122.pub4

2015 Jan 21

Different strategies for diagnosing gestational diabetes to improve maternal and infant health

Review

Diane Farrar, Lelia Duley, Nancy Medley, Debbie A Lawlor

https://doi.org/10.1002/14651858.CD007122.pub3

2011 Oct 05

Different strategies for diagnosing gestational diabetes to improve maternal and infant health

Review

Diane Farrar, Lelia Duley, Debbie A Lawlor

https://doi.org/10.1002/14651858.CD007122.pub2

2008 Apr 23

Alternative strategies for diagnosing gestational diabetes mellitus to improve maternal and infant health

Protocol

Diane Farrar, Lelia Duley, Debbie A Lawlor

https://doi.org/10.1002/14651858.CD007122

Differences between protocol and review

*A number of the primary and secondary maternal and infant outcome measures are based on the core outcomes for Cochrane gestational diabetes reviews reached by consensus between the review authors of reviews for treatment of GDM. A number of these were added as secondary outcomes for this update and are labelled as non‐prespecified in the following list.

Maternal

  1. Perineal trauma (non‐prespecified outcome).*

  2. Placental abruption (non‐prespecified outcome).*

  3. Weight gain during pregnancy (non‐prespecified outcome).*

  4. Breastfeeding (e.g. at discharge, six weeks postpartum) (non‐prespecified outcome).*

Neonatal

  1. Apgar score (less than seven at five minutes) (non‐prespecified outcome).*

  2. Birthweight and z‐score (non‐prespecified outcome).*

  3. Ponderal index (non‐prespecified outcome).*

  4. Measures of adiposity (non‐prespecified outcome).*

  5. Shoulder dystocia (non‐prespecified outcome).*

  6. Bone fracture (non‐prespecified outcome).*

  7. Nerve palsy (non‐prespecified outcome).*

  8. Relavent biomarkers, e.g. cord C‐peptide, cord insulin (non‐prespecified outcome).*

The outcome plasma glucose was not originally specified in the protocol but was added in the first version of this review.

Methods have been updated to current Cochrane Pregnancy and Childbirth Group standard text, and a 'Summary of findings' table has been incorporated.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 75 g OGTT versus 100 g OGTT, Outcome 1 Diagnosis of gestational diabetes.
Figures and Tables -
Analysis 1.1

Comparison 1 75 g OGTT versus 100 g OGTT, Outcome 1 Diagnosis of gestational diabetes.

Comparison 1 75 g OGTT versus 100 g OGTT, Outcome 2 Plasma glucose (mmol/L).
Figures and Tables -
Analysis 1.2

Comparison 1 75 g OGTT versus 100 g OGTT, Outcome 2 Plasma glucose (mmol/L).

Comparison 2 50 g glucose polymer drink versus 50 g glucose monomer drink, Outcome 1 Maternal side effects.
Figures and Tables -
Analysis 2.1

Comparison 2 50 g glucose polymer drink versus 50 g glucose monomer drink, Outcome 1 Maternal side effects.

Comparison 2 50 g glucose polymer drink versus 50 g glucose monomer drink, Outcome 2 Plasma glucose (mmol/L).
Figures and Tables -
Analysis 2.2

Comparison 2 50 g glucose polymer drink versus 50 g glucose monomer drink, Outcome 2 Plasma glucose (mmol/L).

Comparison 2 50 g glucose polymer drink versus 50 g glucose monomer drink, Outcome 3 Gestational age at birth (weeks).
Figures and Tables -
Analysis 2.3

Comparison 2 50 g glucose polymer drink versus 50 g glucose monomer drink, Outcome 3 Gestational age at birth (weeks).

Comparison 3 Candy bar versus 50 g glucose monomer drink, Outcome 1 Maternal side effects.
Figures and Tables -
Analysis 3.1

Comparison 3 Candy bar versus 50 g glucose monomer drink, Outcome 1 Maternal side effects.

Comparison 3 Candy bar versus 50 g glucose monomer drink, Outcome 2 1‐hour serum glucose level (mmol/L).
Figures and Tables -
Analysis 3.2

Comparison 3 Candy bar versus 50 g glucose monomer drink, Outcome 2 1‐hour serum glucose level (mmol/L).

Comparison 4 50 g glucose in food versus 50 g glucose drink, Outcome 1 Maternal side effects.
Figures and Tables -
Analysis 4.1

Comparison 4 50 g glucose in food versus 50 g glucose drink, Outcome 1 Maternal side effects.

Comparison 4 50 g glucose in food versus 50 g glucose drink, Outcome 2 Need for repeat testing by same or alternative method.
Figures and Tables -
Analysis 4.2

Comparison 4 50 g glucose in food versus 50 g glucose drink, Outcome 2 Need for repeat testing by same or alternative method.

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 1 Caesarean section.
Figures and Tables -
Analysis 5.1

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 1 Caesarean section.

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 2 Instrumental delivery.
Figures and Tables -
Analysis 5.2

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 2 Instrumental delivery.

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 3 Diagnosis of gestational diabetes.
Figures and Tables -
Analysis 5.3

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 3 Diagnosis of gestational diabetes.

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 4 Macrosomia.
Figures and Tables -
Analysis 5.4

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 4 Macrosomia.

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 5 Stillbirth.
Figures and Tables -
Analysis 5.5

Comparison 5 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria), Outcome 5 Stillbirth.

Comparison 6 Two‐step (50 g OGCT and 100 g OGTT) versus one‐step (75 g OGTT) approach, Outcome 1 Diagnosis of gestational diabetes.
Figures and Tables -
Analysis 6.1

Comparison 6 Two‐step (50 g OGCT and 100 g OGTT) versus one‐step (75 g OGTT) approach, Outcome 1 Diagnosis of gestational diabetes.

Summary of findings for the main comparison. 75 g OGTT versus 100 g OGTT for diagnosing GDM to improve maternal and infant health

75 g oral glucose tolerance test (OGTT) versus 100 g OGTT for diagnosing gestational diabetes mellitus (GDM) to improve maternal and infant health

Patient or population: pregnant women at low or high risk of gestational diabetes
Settings: 1 study, Nigeria
Intervention: 75 g OGTT

Comparison: 100 g OGTT

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

100 g OGTT

75 g OGTT

Diagnosis of gestational diabetes

Study population

RR 2.55
(0.96 to 6.75)

248
(1 study)

⊕⊝⊝⊝
Very lowa,b

Women who received the 75 g OGTT test were 2.55 times more likely to test positive for gestational diabetes.

45 per 1000

116 per 1000
(44 to 307)

Caesarean section

See comment

See comment

Not estimable

0
(0)

See comment

None of the included studies reported this outcome.

Macrosomia > 4.5 kg or as defined in trial

See comment

See comment

Not estimable

0
(0)

See comment

None of the included studies reported this outcome.

Long‐term type 2 diabetes maternal

See comment

See comment

Not estimable

0
(0)

See comment

None of the included studies reported this outcome.

Long‐term type 2 diabetes infant

See comment

See comment

Not estimable

0
(0)

See comment

None of the included studies reported this outcome.

Economic costs

See comment

See comment

Not estimable

0
(0)

See comment

None of the included studies reported this outcome.

*The basis for the assumed risk (e.g. median control group risk across studies) is the risk. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aOne study with design limitations (‐1).
bWide confidence intervals crossing the line of no effect, few events and small sample size.

Figures and Tables -
Summary of findings for the main comparison. 75 g OGTT versus 100 g OGTT for diagnosing GDM to improve maternal and infant health
Table 1. International Association of Diabetes and Pregnancy Study Groups (IADPSG)

Time

Plasma

Fasting glucose (≥)

5.1 mmol/L

1‐hour glucose (≥)

10.0 mmol/L

2‐hour glucose (≥)

8.5 mmol/L

IADPSG cutoff levels for diagnosis of gestational diabetes for plasma glucose; gestational diabetes is diagnosed if any one value equals or exceeds any other value (Metzger 2010). World Health Organization (WHO) published revised guidance in 2013 recommended IADPSG cutoff levels for the diagnosis of gestational diabetes (WHO 2013).

Figures and Tables -
Table 1. International Association of Diabetes and Pregnancy Study Groups (IADPSG)
Table 2. World Health Organization criteria for 75 g OGTT

Time

Whole blood venous

Whole blood capillary

Plasma venous

Plasma capillary

Fasting glucose (≥)

6.1 mmol/L

6.1 mmol/L

7.0 mmol/L

7.0 mmol/L

2‐hour glucose

6.7 mmol/L

7.8 mmol/L

7.8 mmol/L

8.9 mmol/L

Cutoff levels for diagnosis of gestational diabetes for whole blood and plasma glucose. Diabetes is diagnosed if fasting plasma glucose level is > 7.0 mmol/L, or if 2‐hour level is > 11.1 mmol/L (WHO 1999).

Figures and Tables -
Table 2. World Health Organization criteria for 75 g OGTT
Table 3. Alternative criteria for the 100 g oral GTT

Time

O'Sullivan 1964a

NDDG 1997b

Carpenter 1982c

Fasting glucose (≥)

5.0 mmol/L

5.8 mmol/L

5.3 mmol/L

1‐hour glucose (≥)

9.1 mmol/L

10.0 mmol/L

10.0 mmol/L

2‐hour glucose (≥)

8.0 mmol/L

9.1 mmol/L

8.6 mmol/L

3‐hour glucose (≥)

6.9 mmol/L

8.0 mmol/L

7.8 mmol/L

Gestational diabetes is diagnosed when two or more measurements in a single column exceed stated cutoff levels.

aO'Sullivan 1964: cutoff levels for diagnosis of gestational diabetes for whole blood.

bNDDG 1997: cutoff for diagnosis of gestational diabetes for plasma glucose.

cCarpenter 1982: cutoff for diagnosis of gestational diabetes for plasma glucose.

Figures and Tables -
Table 3. Alternative criteria for the 100 g oral GTT
Comparison 1. 75 g OGTT versus 100 g OGTT

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Diagnosis of gestational diabetes Show forest plot

1

248

Risk Ratio (M‐H, Fixed, 95% CI)

2.55 [0.96, 6.75]

2 Plasma glucose (mmol/L) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 At 1 hour

1

248

Mean Difference (IV, Fixed, 95% CI)

‐0.11 [‐0.44, 0.22]

2.2 At 2 hours

1

248

Mean Difference (IV, Fixed, 95% CI)

‐0.31 [‐0.64, 0.02]

2.3 At 3 hours

1

248

Mean Difference (IV, Fixed, 95% CI)

‐1.08 [‐1.47, ‐0.69]

Figures and Tables -
Comparison 1. 75 g OGTT versus 100 g OGTT
Comparison 2. 50 g glucose polymer drink versus 50 g glucose monomer drink

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Maternal side effects Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 Nausea

1

66

Risk Ratio (M‐H, Random, 95% CI)

0.29 [0.11, 0.78]

1.2 Headache

1

66

Risk Ratio (M‐H, Random, 95% CI)

0.2 [0.02, 1.62]

1.3 Bloatedness

2

131

Risk Ratio (M‐H, Random, 95% CI)

0.33 [0.04, 2.60]

1.4 Dizziness

1

66

Risk Ratio (M‐H, Random, 95% CI)

0.4 [0.08, 1.92]

1.5 Tiredness

1

66

Risk Ratio (M‐H, Random, 95% CI)

1.33 [0.32, 5.50]

1.6 Vomiting

1

66

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

1.7 Pain

2

129

Risk Ratio (M‐H, Random, 95% CI)

0.14 [0.02, 1.15]

1.8 Total number of side effects

1

63

Risk Ratio (M‐H, Random, 95% CI)

0.21 [0.07, 0.59]

1.9 Taste

1

63

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.76, 1.29]

2 Plasma glucose (mmol/L) Show forest plot

3

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 At 1, 2 and 3 hours

3

239

Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.71, 0.32]

2.2 At 2 hours

1

100

Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.85, 0.05]

2.3 At 3 hours

1

100

Mean Difference (IV, Random, 95% CI)

0.0 [‐0.45, 0.45]

3 Gestational age at birth (weeks) Show forest plot

1

100

Mean Difference (IV, Fixed, 95% CI)

‐0.80 [‐1.69, 0.09]

Figures and Tables -
Comparison 2. 50 g glucose polymer drink versus 50 g glucose monomer drink
Comparison 3. Candy bar versus 50 g glucose monomer drink

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Maternal side effects Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Pain

1

58

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 3.91]

1.2 Bloatedness

1

60

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.21, 5.40]

1.3 Total side effects

1

58

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.58, 1.82]

1.4 Taste

1

59

Risk Ratio (M‐H, Fixed, 95% CI)

0.60 [0.42, 0.86]

2 1‐hour serum glucose level (mmol/L) Show forest plot

1

59

Mean Difference (IV, Fixed, 95% CI)

‐1.0 [‐1.13, ‐0.87]

Figures and Tables -
Comparison 3. Candy bar versus 50 g glucose monomer drink
Comparison 4. 50 g glucose in food versus 50 g glucose drink

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Maternal side effects Show forest plot

1

30

Risk Ratio (M‐H, Fixed, 95% CI)

0.08 [0.01, 0.56]

2 Need for repeat testing by same or alternative method Show forest plot

1

30

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.55]

Figures and Tables -
Comparison 4. 50 g glucose in food versus 50 g glucose drink
Comparison 5. 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Caesarean section Show forest plot

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

1.07 [0.85, 1.35]

2 Instrumental delivery Show forest plot

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

0.21 [0.01, 3.94]

3 Diagnosis of gestational diabetes Show forest plot

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [0.66, 3.25]

4 Macrosomia Show forest plot

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.19, 2.79]

5 Stillbirth Show forest plot

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

0.49 [0.02, 11.68]

Figures and Tables -
Comparison 5. 75 g OGTT (WHO criteria) versus 75 g OGTT (ADA criteria)
Comparison 6. Two‐step (50 g OGCT and 100 g OGTT) versus one‐step (75 g OGTT) approach

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Diagnosis of gestational diabetes Show forest plot

1

726

Risk Ratio (M‐H, Random, 95% CI)

0.51 [0.28, 0.95]

Figures and Tables -
Comparison 6. Two‐step (50 g OGCT and 100 g OGTT) versus one‐step (75 g OGTT) approach