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

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

doi:10.1002/14651858.CD007122.pub4

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 2.3

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

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Analysis 3.1

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

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Analysis 3.2

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

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Analysis 4.1

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

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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.

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Analysis 5.1

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

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Analysis 5.2

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

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Analysis 5.3

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

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Analysis 5.4

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

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Analysis 5.5

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

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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.

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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 low^a,b	Women who received the 75 g OGTT test were 2.55 times more likely to test positive for gestational diabetes.
Diagnosis of gestational diabetes	45 per 1000	116 per 1000 (44 to 307)	RR 2.55 (0.96 to 6.75)	248 (1 study)	⊕⊝⊝⊝ Very low^a,b
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.

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

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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).

Table 1. International Association of Diabetes and Pregnancy Study Groups (IADPSG)

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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).

Table 2. World Health Organization criteria for 75 g OGTT

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Table 3. Alternative criteria for the 100 g oral GTT

Time	O'Sullivan 1964^a	NDDG 1997^b	Carpenter 1982^c
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.

Table 3. Alternative criteria for the 100 g oral GTT

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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]

Comparison 1. 75 g OGTT versus 100 g OGTT

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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]

Comparison 2. 50 g glucose polymer drink versus 50 g glucose monomer drink

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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]

Comparison 3. Candy bar versus 50 g glucose monomer drink

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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]

Comparison 4. 50 g glucose in food versus 50 g glucose drink

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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]

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

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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]

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

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