UNSW Medicine MFAC 2514-6

Beginnings, Growth and Development – Women’s Health

Gestational Diabetes Mellitus and the Oral Glucose Tolerance

Test

List B: Social and Cultural Aspects of Health

Screening programs for disease and/or how the problem can be prevented or
identified early in the community
~
Student Number: z5168965
Consent obtained: 01/03/2019
Presentation Conducted: 08/03/2019
Due date: 15/03/2019
Word count: 1265 (excluding cover page, case history and rationale, reference
list)
The patient consented to the use of their case. For confidentiality, a pseudonym
was used.

1
Contents
Case History ............................................................................................................................................ 3
Rationale ................................................................................................................................................. 3
Introduction to GDM .............................................................................................................................. 4
Screening ................................................................................................................................................ 4
Important Health Problem................................................................................................................... 5
Suitable test ......................................................................................................................................... 6
Conclusion .............................................................................................................................................. 7
Reflection ................................................................................................................................................ 8
References ............................................................................................................................................... 9

2
Case History
Priya is a 34 year-old Indian assistant in nursing of G1P0 who presented to the Coffs Harbour
Health Campus maternity ward on 1/03/19 for a planned caesarean section this day, on the
background of a failed labour induction one week prior. The gestational age of her child was
39+6 weeks. Throughout the pregnancy Priya’s only symptom was nausea which was
controlled by metoclopramide. Priya has a strong family history of type 2 diabetes. At 28
weeks, she was diagnosed with gestational diabetes (GDM) by an oral glucose tolerance test
(OGTT). Following this, she was administered insulin with dosage eventually increasing to 40
units by 37 weeks. Her blood glucose levels were self-monitored and reported to her general
physician weekly. Additionally, she was advised to regulate carbohydrate consumption and
space meals evenly. Her daughter was born with a birth weight of 3470 grams (and at 28 weeks
was 1080 grams).

Rationale
Gestational diabetes mellitus (GDM) is an international growing concern. Its increasing
incidence is attributable to factors pertinent to Australia such as a rise in average BMI and
maternal age (Ferrara, 2007). In Australia, approximately 10% of women develop GDM
(Nankervis, Price & Conn, 2018). I chose this perspective because I wanted to develop an
educated appreciation of the link between screening and patient outcomes, and more broadly
the role of secondary intervention in maternal health. As part of the capability, the utility and
limitation of GDM screening will be evaluated.

3
Introduction to GDM
GDM is defined by the World Health Organisation as glucose intolerance resulting in
hyperglycaemia with onset or first recognition during pregnancy (Farrar, 2016).

Pregnancy induces a natural predisposition toward diabetes, due to altered secretions of

hormones. These include growth hormone, cortisol, human placental lactogen, and insulinase.
Estrogen and progesterone also disrupt the glucose/insulin balance. Additionally, maternal
adipose deposition and increased net caloric intake contribute to this state of relative glucose
intolerance (Gilmartin, Ural & Repke, 2008). Ultimately, cells are less sensitive to insulin and
glucose uptake is impaired. If the patient’s pancreatic beta cells are unable to produce more
insulin to compensate for the resistance (see figure 1), GDM develops.

Screening
The current guidelines recommended by the International Association of the Diabetes and
Pregnancy Study Groups (IADPSG), The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists (RANZCOG) and the Australasian Diabetes in Pregnancy
Society (ADIPS) outline a single-step screening process using oral glucose tolerance testing
(OGTT) for every woman at 24-28 weeks gestation. The woman fasts for 8-12 hours, then a

4
venous blood sample is taken. She then drinks 75g of glucose, with blood samples taken one
and two hours later. One positive value is sufficient for diagnosis.

Table 1: Current criteria for diagnosis of GDM (RANZCOG, 2014)

Fasting One hour Two hour
≥5.1mmol glucose/L ≥10 mmol/L ≥8.5 mmol/L

A selection of the criteria developed by Wilson and Jungner in 1968 (which is still considered
gold standard by WHO) will be used to guide discussion of antenatal GDM screening, as
highlighted below (Andermann, Blancquaert, Beauchamp & Dery, 2008).

Figure 2: Wilson and Jungner Classic Screening Criteria (Ross, Saal, David et al., 2013)

Important Health Problem

When poorly controlled, GDM is associated with poorer maternal and fetal outcomes (see table
below) that can involve both short-term and long-term effects. Risks of adverse perinatal
outcomes increase linearly with rising maternal glucose levels (Buchanan, Xiang & Page,
2012).

Table 2: Adverse outcomes of uncontrolled GDM (Hopkins & Artal, 2013)

Pregnancy Labour & short- Long- term
term postnatal
Mother Pre-eclampsia c-section T2DM
Maternal induction Recurrent GDM
hypertensive labour complications
disorders

Baby Perinatal death Stillbirth T2DM, T1DM

Stillbirth Pre-term labour Obesity
Macrosomia Shoulder dystocia

5
 Nerve palsy Increased
Hypoglycaemia cardiovascular and
Respiratory distress atherosclerosis risk
Jaundice
Polycythemia
Perinatal asphyxia

These outcomes are related to increased morbidity and mortality for mothers with GDM and
their babies. Thus, there is a need for GDM screening that facilitates early detection and
management.

Half of the GDM cases resolve after birth, however the other fifty percent of patients develop
Type 2 diabetes mellitus (T2DM) within 20 years, a condition associated with significant
complications such as kidney damage and cardiovascular disease (Nankervis & Conn, 2013).
Therefore, the significance of GDM screening reaches beyond the postnatal period.

Women diagnosed with GDM will have an OGTT at 6-12 weeks postpartum, and if negative,
one every 3 years after. Pregnancy screening is especially important considering there are no
diabetic screening programs for women before they fall pregnant, and thus undiagnosed T2DM
will be picked up in antenatal screening.

Suitable test
As aforementioned, screening, diagnosis and subsequent management of GDM is a significant
aspect of decreasing adverse maternal and foetal outcomes. The criteria for diagnosis is
reiterated, with Priya’s results in red:

Table 3: GDM diagnosis criteria & Priya’s results

Fasting One hour Two hour
≥5.1mmol glucose/L ≥10 mmol/L ≥8.5 mmol/L
6.1 mmol/L 11.6 mmol/L 9.6 mmol/L

This process differs from the preceding guidelines from 1998 which recommended a two-step
process including a screening oral glucose challenge test. A positive result was followed by a
diagnostic OGTT with slightly higher threshold values compared to the newer guidelines
(RANZCOG, 2014). One argued advantage of the two-step process is that it is more specific
in diagnosing someone with significant glucose intolerance. The current test may unnecessarily
cause healthy women to take glucose-lowering therapy. This would increase the risk of
maternal hypoglycemia and poor fetal growth, which in turn will contribute to metabolic
disorders in adulthood (Gupta, Kalra, Baruah et al., 2015). A recent meta-analysis concluded
that the only pregnancy outcomes affected by lowering the threshold for detection and

6
treatment of GDM are a reduction in macrosomia, low gestational age infants, and the
incidence of shoulder dystocia. Ultimately, the risk–benefit ratio for treatment of patients with
mild hyperglycaemia, which the current criteria encourages, is debatable (Long & Cundy,
2013).

According to RANZCOG, the two-step process however misses approximately a quarter of

women with GDM and is responsible for significant delay in starting treatment. For this reason,
it is generally agreed upon that the new recommended guidelines are relatively suitable.

As well as being safe and accurate, an acceptable screening test should be cheap. The current
recommended criteria is predicted to increase the diagnosis of GDM to around 12-14% of
pregnant women, which will affect resource allocation and budgeting, and potentially
contribute to overmedicalisation of mild GDM cases (Cade, Polyakov & Brennecke, 2019).

Finally, it is recommended that patients with risk factors for GDM be screened earlier. Priya
was not screened early despite her numerous risk factors (bolded):

• Previous GDM
• Advanced maternal age (>30years)
• Family history
• Overweight/obesity
• Aboriginal & Torres Strait Islander background
• Ethnicity
• History of macrosomia or obstetrics complications
• Previous unexplained stillbirth/perinatal death
• Corticosteroids, antipsychotics
• Polyhydramnios
• Polycystic ovarian syndrome
The benefit of screening is limited if the patient does not access healthcare, or if the physician
doesn’t elicit a full history. Rurality and lack of fluency in English may have been a factor for
Priya not receiving early screening.

Conclusion
Although the benefits of screening for GDM are indisputable, our methods of universally
screening GDM require research and evolution. Perhaps primary intervention for GDM can be
enhanced to cover the shortfalls of screening.

There are some limitations of the data used to guide discussion in this report. Trials often
include few women, are poorly reported with unclear risk of bias and report few outcomes.

7
There is an issue with compliance - the one-step screening is less convenient because patients
must be fasting. Large, well-designed and well-conducted trials are urgently needed (Farrar,
Simmonds, Bryant et al., 2017).

Reflection
It was rewarding to speak to Priya antenatally, watch her caesarean section and follow up
afterwards. In undiagnosed GDM all these time periods can involve complications. Watching
her uncomplicated progress (barring the failed induction) reaffirmed the benefits of screening
discussed in this assignment.

Compared to Phase One, the assignment criteria are less didactic, and have a restricted word
count. These aspects forced me to judiciously deduce which aspects of screening I consider
most important to discuss. Initially I was going to discuss “there should be an accepted
treatment” (the 2nd Wilson and Jungner criteria for good screening), but concluded that
discussing management was outside the assignment’s scope. I am still unsure about this
decision and should have sought advice from mentors via the Moodle board.

One weakness identified in the presentation was our discussion of the old and new screening
criteria caused by an overwhelming use of tables and numbers. Therefore, instead of
elaborating on the old criteria I just explained the differences to the new criteria. I think in the
future I will benefit from giving dense sections to a peer to proof-read and ensure the writing
is not congested.

This assignment made me aware that the decisions I make as a future practitioner, about who
to screen and what tests to order, will have a direct impact on patient outcomes. I am also
reminded of the cost of each decision regarding assessment and management, and my
responsibility to the healthcare system. I hope my ability to weigh these responsibilities will
evolve throughout this degree.

8
 References
Andermann, A., Blancquaert, I., Beauchamp, S., & Déry, V. (2008). Revisiting Wilson and
Jungner in the genomic age: a review of screening criteria over the past 40 years.
Bulletin of the World Health Organization, 86, 317-319.
Buchanan, T. A., Xiang, A. H., & Page, K. A. (2012). Gestational diabetes mellitus: risks and
management during and after pregnancy. Nature reviews. Endocrinology, 8(11), 639-
49.
Cade, T. J., Polyakov, A., & Brennecke, S. P. (2019). Implications of the introduction of new
criteria for the diagnosis of gestational diabetes: a health outcome and cost of care
analysis. BMJ open, 9(1), e023293.
Farrar D. (2016). Hyperglycemia in pregnancy: prevalence, impact, and management
challenges. International journal of women's health, 8, 519-527.
doi:10.2147/IJWH.S102117
Farrar, D., Simmonds, M., Bryant, M., Sheldon, T. A., Tuffnell, D., Golder, S., & Lawlor, D.
A. (2017). Treatments for gestational diabetes: a systematic review and meta-analysis.
BMJ open, 7(6), e015557.
Ferrara, A. (2007). Increasing prevalence of gestational diabetes mellitus: A public health
perspective. Diabetes Care, 30(2), 141–146.
Gilmartin, A. B., Ural, S. H., & Repke, J. T. (2008). Gestational diabetes mellitus. Reviews in
obstetrics & gynecology, 1(3), 129-34.
Gupta, Y., Kalra, B., Baruah, M. P., Singla, R., & Kalra, S. (2015). Updated guidelines on
screening for gestational diabetes. International journal of women's health, 7, 539-50.
doi:10.2147/IJWH.S82046
Hopkins, S. A., & Artal, R. (2013). The role of exercise in reducing the risks of gestational
diabetes mellitus. Women’s Health, 9(6), 569-581.
Long H, Cundy T. Establishing consensus in the diagnosis of gestational diabetes following
HAPO: where do we stand? Curr Diab Rep. 2013;13(1):43–50.
Nankervis, A. & Conn, J. (2013). Gestational diabetes mellitus. Negotiating the confusion.
Australian Family Physician, 42(8) 528-531
Nankervis, A., Price, S., & Conn, J. (2018). Gestational diabetes mellitus: A pragmatic
approach to diagnosis and management. Australian journal of general practice, 47(7),
445.
NDSS (2013). Gestational Diabetes. Caring for yourself and your baby. Diabetes Australia,
Australian Government.
RANZCOG (2014). Diagnosis of Gestational Diabetes Mellitus (GDM) and Diabetes Mellitus
in Pregnancy.
Ross, L. F., Saal, H. M., David, K. L., & Anderson, R. R. (2013). Technical report: ethical and
policy issues in genetic testing and screening of children Genetics in Medicine, 15(3),
234-245. Shravage