WHO recommendations on antenatal care for a positive pregnancy experience

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B.1.4: Gestational diabetes mellitus (GDM) RECOMMENDATION B1.4: Hyperglycaemia first detected at any time during pregnancy should be classified as either gestational diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to <strong>WHO</strong> criteria. a (Recommended) <strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience Remarks • This recommendation has been integrated from the 2013 <strong>WHO</strong> publication Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy (the strength of the recommendation and the quality of the evidence were not stated) (94). • <strong>WHO</strong> currently does not have a recommendation on whether or how to screen for GDM, and screening strategies for GDM are considered a priority area for research, particularly in LMICs. • Diabetes mellitus in pregnancy differs from GDM in that the hyperglycaemia is more severe and does not resolve after pregnancy as it does with GDM. • A systematic review of cohort studies shows that women with hyperglycaemia (diabetes mellitus and GDM) detected during pregnancy are at greater risk of adverse pregnancy outcomes, including macrosomia, pre-eclampsia/hypertensive disorders in pregnancy, and shoulder dystocia. Treatment of GDM, which usually involves a stepped approach of lifestyle changes (nutritional counselling and exercise) followed by oral blood-glucose-lowering agents or insulin if necessary, is effective in reducing these poor outcomes (94). • There are many uncertainties about the cost–effectiveness of different screening strategies, the prevalence of GDM and diabetes mellitus according to the 2013 criteria in diverse populations, and the impact of earlier diagnosis on pregnancy outcomes (see Chapter 5: Research implications) (94). • The usual window for diagnosing GDM is between 24 and 28 weeks of gestation. Risk factor screening is used in some settings as a strategy to determine the need for a 2-hour 75 g oral glucose tolerance test (OGTT). These include a BMI of greater than 30 kg/m 2 , previous GDM, previous macrosomia, family history of diabetes mellitus, and ethnicity with a high prevalence of diabetes mellitus (95). In addition, glycosuria on dipstick testing (2+ or above on one occasion, or 1+ on two or more occasions) may indicate undiagnosed GDM and, if this is observed, performing an OGTT could be considered (95). • The management approach for women classified with diabetes mellitus in pregnancy (i.e. severe hyperglycaemia first detected in pregnancy) usually differs from the approach for women with GDM, particularly when diagnosed early in pregnancy; however, the principles of management are similar and both require referral and increased monitoring. • Further information and considerations related to this recommendation can be found in the 2013 <strong>WHO</strong> guideline (94), available at: http://www.who.int/diabetes/publications/Hyperglycaemia_In_Pregnancy/ en/ a This is not a recommendation on routine screening for hyperglycaemia in pregnancy. It has been adapted and integrated from the 2013 <strong>WHO</strong> publication (94), which states that GDM should be diagnosed at any time in pregnancy if one or more of the following criteria are met: • fasting plasma glucose 5.1–6.9 mmol/L (92–125 mg/dL) • 1-hour plasma glucose 10.0 mmol/L (180 mg/dL) following a 75 g oral glucose load • 2-hour plasma glucose 8.5–11.0 mmol/L (153–199 mg/dL) following a 75 g oral glucose load Diabetes mellitus in pregnancy should be diagnosed if one or more of the following criteria are met: • fasting plasma glucose 7.0 mmol/L (126 mg/dL) • 2-hour plasma glucose 11.1 mmol/L (200 mg/dL) following a 75 g oral glucose load • random plasma glucose 11.1 mmol/L (200 mg/dL) in the presence of diabetes symptoms.. 48
B.1.5: Tobacco use RECOMMENDATION B.1.5: Health-care providers should ask all pregnant women about their tobacco use (past and present) and exposure to second-hand smoke as early as possible in pregnancy and at every antenatal care visit. (Recommended) Remarks • This strong recommendation based on low-quality evidence has been integrated from the 2013 <strong>WHO</strong> <strong>recommendations</strong> for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy (96). Related <strong>recommendations</strong> from this guideline include the following: –– Health-care providers should routinely offer advice and psychosocial interventions for tobacco cessation to all pregnant women who are either current tobacco users or recent tobacco quitters (strong recommendation based on moderate quality evidence). –– All health-care facilities should be smoke-free to protect the health of all staff, patients and visitors, including pregnant women (strong recommendation based on low-quality evidence). –– Health-care providers should provide pregnant women, their partners and other household members with advice and information about the risks of second-hand smoke (SHS) exposure from all forms of smoked tobacco, as well as strategies to reduce SHS in the home (strong recommendation based on lowquality evidence). –– Health-care providers should, wherever possible, engage directly with partners and other household members to inform them of all the risks of SHS exposure to pregnant women from all forms of tobacco, and to promote reduction of exposure and offer smoking cessation support (strong recommendation based on low-quality evidence). • Further guidance on strategies to prevent and manage tobacco use and SHS exposure can be found in the 2013 <strong>WHO</strong> <strong>recommendations</strong> (96), available at: http://www.who.int/tobacco/publications/pregnancy/ guidelinestobaccosmokeexposure/en/ Chapter 3. Evidence and <strong>recommendations</strong> 49
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WHO recommendations on antenatal care for a positive pregnancy experience

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