WHO recommendations on antenatal care for a positive pregnancy experience
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B.1.4: Gestati<strong>on</strong>al diabetes mellitus (GDM)<br />
RECOMMENDATION B1.4: Hyperglycaemia first detected at any time during <strong>pregnancy</strong> should<br />
be classified as either gestati<strong>on</strong>al diabetes mellitus (GDM) or diabetes mellitus in <strong>pregnancy</strong>,<br />
according to <str<strong>on</strong>g>WHO</str<strong>on</strong>g> criteria. a (Recommended)<br />
<str<strong>on</strong>g>WHO</str<strong>on</strong>g> <str<strong>on</strong>g>recommendati<strong>on</strong>s</str<strong>on</strong>g> <strong>on</strong> <strong>antenatal</strong> <strong>care</strong> <strong>for</strong> a <strong>positive</strong> <strong>pregnancy</strong> <strong>experience</strong><br />
Remarks<br />
• This recommendati<strong>on</strong> has been integrated from the 2013 <str<strong>on</strong>g>WHO</str<strong>on</strong>g> publicati<strong>on</strong> Diagnostic criteria and<br />
classificati<strong>on</strong> of hyperglycaemia first detected in <strong>pregnancy</strong> (the strength of the recommendati<strong>on</strong> and the<br />
quality of the evidence were not stated) (94).<br />
• <str<strong>on</strong>g>WHO</str<strong>on</strong>g> currently does not have a recommendati<strong>on</strong> <strong>on</strong> whether or how to screen <strong>for</strong> GDM, and screening<br />
strategies <strong>for</strong> GDM are c<strong>on</strong>sidered a priority area <strong>for</strong> research, particularly in LMICs.<br />
• Diabetes mellitus in <strong>pregnancy</strong> differs from GDM in that the hyperglycaemia is more severe and does not<br />
resolve after <strong>pregnancy</strong> as it does with GDM.<br />
• A systematic review of cohort studies shows that women with hyperglycaemia (diabetes mellitus<br />
and GDM) detected during <strong>pregnancy</strong> are at greater risk of adverse <strong>pregnancy</strong> outcomes, including<br />
macrosomia, pre-eclampsia/hypertensive disorders in <strong>pregnancy</strong>, and shoulder dystocia. Treatment<br />
of GDM, which usually involves a stepped approach of lifestyle changes (nutriti<strong>on</strong>al counselling and<br />
exercise) followed by oral blood-glucose-lowering agents or insulin if necessary, is effective in reducing<br />
these poor outcomes (94).<br />
• There are many uncertainties about the cost–effectiveness of different screening strategies, the<br />
prevalence of GDM and diabetes mellitus according to the 2013 criteria in diverse populati<strong>on</strong>s, and the<br />
impact of earlier diagnosis <strong>on</strong> <strong>pregnancy</strong> outcomes (see Chapter 5: Research implicati<strong>on</strong>s) (94).<br />
• The usual window <strong>for</strong> diagnosing GDM is between 24 and 28 weeks of gestati<strong>on</strong>. Risk factor screening<br />
is used in some settings as a strategy to determine the need <strong>for</strong> a 2-hour 75 g oral glucose tolerance test<br />
(OGTT). These include a BMI of greater than 30 kg/m 2 , previous GDM, previous macrosomia, family<br />
history of diabetes mellitus, and ethnicity with a high prevalence of diabetes mellitus (95). In additi<strong>on</strong>,<br />
glycosuria <strong>on</strong> dipstick testing (2+ or above <strong>on</strong> <strong>on</strong>e occasi<strong>on</strong>, or 1+ <strong>on</strong> two or more occasi<strong>on</strong>s) may indicate<br />
undiagnosed GDM and, if this is observed, per<strong>for</strong>ming an OGTT could be c<strong>on</strong>sidered (95).<br />
• The management approach <strong>for</strong> women classified with diabetes mellitus in <strong>pregnancy</strong> (i.e. severe<br />
hyperglycaemia first detected in <strong>pregnancy</strong>) usually differs from the approach <strong>for</strong> women with GDM,<br />
particularly when diagnosed early in <strong>pregnancy</strong>; however, the principles of management are similar and<br />
both require referral and increased m<strong>on</strong>itoring.<br />
• Further in<strong>for</strong>mati<strong>on</strong> and c<strong>on</strong>siderati<strong>on</strong>s related to this recommendati<strong>on</strong> can be found in the 2013 <str<strong>on</strong>g>WHO</str<strong>on</strong>g><br />
guideline (94), available at: http://www.who.int/diabetes/publicati<strong>on</strong>s/Hyperglycaemia_In_Pregnancy/<br />
en/<br />
a This is not a recommendati<strong>on</strong> <strong>on</strong> routine screening <strong>for</strong> hyperglycaemia in <strong>pregnancy</strong>. It has been adapted and integrated from the 2013 <str<strong>on</strong>g>WHO</str<strong>on</strong>g> publicati<strong>on</strong> (94),<br />
which states that GDM should be diagnosed at any time in <strong>pregnancy</strong> if <strong>on</strong>e or more of the following criteria are met:<br />
• fasting plasma glucose 5.1–6.9 mmol/L (92–125 mg/dL)<br />
• 1-hour plasma glucose 10.0 mmol/L (180 mg/dL) following a 75 g oral glucose load<br />
• 2-hour plasma glucose 8.5–11.0 mmol/L (153–199 mg/dL) following a 75 g oral glucose load<br />
Diabetes mellitus in <strong>pregnancy</strong> should be diagnosed if <strong>on</strong>e or more of the following criteria are met:<br />
• fasting plasma glucose 7.0 mmol/L (126 mg/dL)<br />
• 2-hour plasma glucose 11.1 mmol/L (200 mg/dL) following a 75 g oral glucose load<br />
• random plasma glucose 11.1 mmol/L (200 mg/dL) in the presence of diabetes symptoms..<br />
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