NICE targeted screening to identify gestational diabetes: who are we missing?
DOI:
https://doi.org/10.15277/bjd.2019.211Keywords:
gestational diabetes, screening, diagnosis, diabetes, glucose, hyperglycaemiaAbstract
Background: Women with gestational diabetes (GDM) are at increased risk of perinatal complications. NICE currently recommends targeted screening of high-risk pregnant women. Our hospital’s diagnostic pathway for GDM has changed from universal screening (glucose challenge test followed by oral glucose tolerance test) to NICE-recommended targeted screening.
Aims: We investigated whether women who would be missed by a targeted screening protocol had adverse clinical outcomes.
Methods: We reviewed the electronic records of all women with GDM who delivered between April and October 2016, during a period of universal screening. Treatment and birth outcomes were compared between those with NICE risk factors (RF) and those with no risk factors (NoRF). Differences were assessed using χ2 tests.
Results: 92 women with GDM gave birth during the six months studied. 32 (35%) had no risk factors and would not currently be diagnosed with GDM. There was a significant difference in treatment between the NoRF and RF groups (p=0.003). More women in the NoRF group were managed on diet and exercise alone (53% vs. 40%) and fewer NoRF women required insulin therapy (19% vs. 45%). Delivery events were similar in the two groups (p=0.23). Fewer women in the NoRF group had macrosomia (birth weight >4000 g) (NoRF n=1 (3.1%) vs. RF n=5 (8.3%)). Admissions to the special care baby unit, predominantly for neonatal hypoglycaemia (capillary blood glucose <2.2 mmol/L), were greater in the NoRF group (NoRF n=7 (21.9%) vs. RF n=5 (8.3%)). No stillbirths or shoulder dystocia occurred in either group.
Conclusions: Targeted screening for GDM using NICE guidelines would have missed over a third of women with GDM. Although women in the NoRF group required less pharmacological treatment, they had adverse maternal and fetal outcomes equivalent to those of women with RF. Our results support universal screening of GDM.
References
Barbour L, McCurdy C, Hernandez T, Kirwan J, Catalano P, Friedman J. Cellular mechanisms for insulin resistance in normal pregnancy and gestational diabetes. Diabetes Care 2007;30(Suppl 2):S112–S119. https://doi.org/10.2337/dc07-s202
Buckley B, Harreiter J, Damm P, et al. Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review. Diabet Med 2012;29:844–54. https://doi.org/10.1111/j.1464-5491. 2011.03541.x
Immanuel J, Simmons D. Screening and treatment for early-onset gestational diabetes mellitus: a systematic review and meta-analysis. Current Diabetes Rep 2017;17. https://doi.org/10.1007/s11892-017-0943-7
Venkataraman H, Sattar N, Saravanan P. Postnatal testing following gestational diabetes: time to replace the oral glucose tolerance test? Lancet Diabetes Endocrinol 2015;3:754–6. https://doi.org/10.1016/S2213-8587(15)00232-6
National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy: management from preconception to the postnatal period. NICE guideline [NG3]. 2017. https://www.nice.org.uk/Guidance/NG3
National Institute for Health and Care Excellence (NICE). Costing statement: Diabetes in pregnancy. Implementing the NICE guideline on diabetes in pregnancy [NG3]. 2017. https://www.nice.org.uk/guidance/ng3/resources/costing-statement-3782989
Lowe L, Metzger B, Dyer A, et al. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: associations of maternal A1C and glucose with pregnancy outcomes. Diabetes Care 2012;35:574–80. https://doi.org/10.2337/dc11-1687
Agarwal M. Gestational diabetes mellitus: an update on the current international diagnostic criteria. World J Diabetes 2015;6:782–91. https://doi.org/10.4239/wjd.v6.i6.782
Meek C. Natural selection? The evolution of diagnostic criteria for gestational diabetes. Ann Clin Biochem 2016;54:33–42. https://doi.org/10.1177/0004563216674743
Meek C, Lewis H, Patient C, Murphy H, Simmons D. Diagnosis of gestational diabetes mellitus: falling through the net. Diabetologia 2015;58:2003–12. https://doi.org/10.1007/s00125-015-3647-z
Griffin M, Coffey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabet Med 2000;17:26–32. https://doi.org/10.1046/j.1464-5491.2000.00214.x
Jacklin P, Maresh M, Patterson C, et al. A cost-effectiveness comparison of the NICE 2015 and WHO 2013 diagnostic criteria for women with gestational diabetes with and without risk factors. BMJ Open 2017;7(8): e016621. https://doi.org/10.1136/bmjopen-2017-01662
Tieu J, McPhee A, Crowther C, Middleton P, Shepherd E. Screening for gestational diabetes mellitus based on different risk profiles and settings for improving maternal and infant health. Cochrane Database of Systematic Reviews [online]. August 2017. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007222.pub4/full
National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy. Management of diabetes and its complications from preconception to the postnatal period. NICE Guideline 3. Methods, evidence and recommendations. 2015. https://www.nice.org.uk/guidance/ng3/evidence/full-guideline-3784285
Crowe C, Noctor E, Carmody LA, et al. ATLANTIC DIP: The prevalence of pre-diabetes/type 2 diabetes in an Irish population with gestational diabetes mellitus 1–5 years post index pregnancy. BMC Proc 2012;6(Suppl 4):O35. https://doi.org/10.1186/1753-6561-6-S4-O35
Published
Issue
Section
License
Publish & Transfer of Copyright Agreement
For the mutual benefit and protection of the Author and the Journal Owner/Publisher it is necessary that the Author provides formal written Consent to Publish and Transfer of Copyright before publication of the Work.
