The urgent need for universally applicable simple screening procedures and diagnostic criteria for gestational diabetes mellitus – lessons from projects funded by the World Diabetes Foundation

Figures & data

Table 1. Overview of recommendations for screening procedures and diagnostic criteria for GDM

Organisation	Type of test	Glucose load (g)	Cut-off points	Who should be screened?
WHO 1999 (40)*	One-step	75	FPG ≥ 126 mg/dl (7.0 mmol/l)	Not mentioned
			2 h ≥ 140 mg/dl (7.8 mmol/l)
ADA 2003 (36)	Fasting or random non-challenge test in general. The OGTT recognised as a valid test.	NA	Random > 200 mg/dl (11.1 mmol/l)	Selective
ADA 2010 (37)**	Two- or one-step	50 (GCT) and 100 (OGTT)	GCT: ≥140 mg/dl (7.8 mmol/l) OR ≥130 mg/dl (7.2 mmol/l)	Selective
			OGTT:
			FPG ≥95 mg/dl (5.3 mmol/l)
			1 h ≥180 mg/dl (10.0 mmol/l)
			2 h ≥155 mg/dl (8.6 mmol/l)
			3 h ≥140 mg/dl (7.8 mmol/l)
ADA 201151*	One-step	75	FPG ≥92 mg/dl (5.1 mmol/l)	Universal
			1 h ≥180 mg/dl (10.0 mmol/l)
			2 h ≥153 mg/dl (8.5 mmol/l)
IADPSG 2010 35*	One-step	75	FPG ≥92 mg/dl (5.1 mmol/l)	Universal
			1 h ≥180 mg/dl (10.0 mmol/l)
			2 h ≥153 mg/dl (8.5 mmol/l)
Fifth International Workshop Conference on GDM 2007 38**	Two- or one-step	50 (GCT) and 75 OR 100 (OGTT)	GCT: ≥140 mg/dl (7.8 mmol/l) or ≥130 mg/dl (7.2 mmol/l)	Selective
			OGTT:
			FPG ≥95 mg/dl (5.3 mmol/l)
			1 h ≥180 mg/dl (10.0 mmol/l)
			2 h ≥155 mg/dl (8.6 mmol/l)
			3 h ≥140 mg/dl (7.8 mmol/l)–3 h only measured for 100 g OGTT
NICE 2008 39*	One-step	75	FPG ≥126 mg/dl (7.0 mmol/l) 2 h ≥140 mg/dl (7.8 mmol/l)	Selective

*One or more of the listed values for the OGTT must be found to make a diagnosis of GDM. ** Two or more of the listed values for the OGTT must be found to make a diagnosis of GDM.

Table 2. Overview of projects included in review¹

WDF project number	Country	Project title	Implementing partner	Collaborating partners	Project period
04-067	India, Tamil Nadu	Gestational diabetes mellitus – awareness creation, prevention and control in the community	Dr V. Seshiah Diabetes Care and Research Institute	Department of Public Health and Preventive Medicine, Tamil Nadu; The Municipal Corporation of Chennai; Local NGOs and women's self help groups	August 2004–January 2010
06-196	Cuba	Completion of the diabetes and pregnancy services network in all the provincial capitals in Cuba	Instituto Nacional de Endocrinología; Hospital Ginecobstétrico ‘Ramón Glez. Coro’	The Maternity and Infant Program; the National Group of Obstetrics and Gynaecology; the National Group of Endocrinology; the National Committee on Diabetes and Pregnancy	August 2007–October 2012
06-207	Sudan	Gestational diabetes mellitus control project	Sudan Fertility Care Association	UNFPA Sudan Country Office; Federal Ministry of Health	June 2007–August 2012
07-278	Cameroon	Improving screening, management, and outcome of gestational diabetes in urban and rural Sub Saharan Africa	Institute of Health and Society, University of Newcastle	Cameroon Burden of Diabetes Project; Ministry of Health	October 2008–August 2012
08-312	India, Tamil Nadu	Extension of project on gestational diabetes mellitus – awareness creation, prevention and control in the community	Dr V. Seshiah Diabetes Care and Research Institute	Centre for Health Education and Development; Department of Public Health and Preventive Medicine, Government of Tamil Nadu	August 2008–July 2012
08-381	India, Karnataka	Addressing gestational diabetes mellitus in a rural and tribal population of Mysore District, India	Swami Vivekananda Youth Movement	Prashasa Health Consultants Pvt Ltd	March 2009–March 2012
09-436	Kenya	Mainstreaming Comprehensive Diabetes Care in Kenya	Ministry of Public Health and Sanitation; The Kenya Diabetes Management and Information Centre	The Kenya Diabetes Association; the Kenya Diabetes Study Group; Kenya Diabetes Educators; the World Health Organization	August 2009–March 2015
10-517	China	China GDM centres – establishment and training dissemination	Peking University First Hospital	Ministry of Health of China; Novo Nordisk (China)	November 2010–August 2013
10-551	India, Punjab	Gestational diabetes in Punjab	Deep Hospital	Jagran Pehel; Sri Rama Charitable Hospital; Iqbal Hospital; Novo Nordisk; Steno Diabetes Cebter; Health Strategies International; Government Medical Colleges in Patiala, Amritsar and Faridkot; Municipal Corporation in Ludhiana; Department of Health and Familly Welfare in Ludhiana; Copenhagen University; University of California, San Francisco	January 2011–April 2013

¹For more information on the projects please see www.worlddiabetesfoundation.org

Table 3. Screening procedure and diagnostic criteria used in the projects

WDF project number	Country	Test used	Cut-off values	Universal or selective	Approximate number of pregnant women screened for GDM
04-067	India, Tamil Nadu	75 g OGTT	Plasma glucose	Universal	12,056
			2 h OGTT ≥ 140 mg/dl (7.8 mmol/l)
06-196	Cuba	Fasting non-challenge test confirmed by a 75 g OGTT	Plasma glucose Fasting ≥ 100 mg/dl (5.6 mmol/l) 2h OGTT ≥ 140 mg/dl (7.8 mmol/l)	Universal	25,066
06-207	Sudan	Random non-challenge test	Blood glucose ≥ 120 mg/dl (6.7 mmol/l)	Selective	7,551
07-278	Cameroon	Fasting non-challenge test with borderline cases confirmed by 75 g OGTT	Blood glucose Fasting > 92 mg/dl (5.1 mmol/l) Fasting: 80–92 mg/dl (4.4–5.1 mmol/l) → OGTT Plasma glucose 1-h OGTT ≥ 180 mg/dl (10.0 mmol/l) 2-h OGTT ≥ 153 mg/dl (8.5 mmol/l)	Universal	12,000
08-312	India, Tamil Nadu	75 g OGTT (irrespective of fasting or non fasting)	Plasma glucose 2 h ≥ 140 mg/dl (7.8 mmol/l)	Universal	12,500
08-381	India, Karnataka	50 g GCT confirmed by 75 g OGTT	Plasma glucose GCT ≥ 130mg/dl (7.2 mmol/l)→OGTT Fasting ≥ 92 mg/dl (5.1 mmol/l) 1 h OGTT ≥ 180mg (10.0 mmol/l) 2 h OGTT ≥ 153 mg/dl (8.5 mmol/l)	Universal	2,054
09-436	Kenya	75 g OGTT	Plasma glucose Fasting ≥ 126 mg/dl (7.0 mmol/l) 2 h OGTT ≥ 140 mg/dl (7.8 mmol/l)	Selective	NA
10-517	China	75 g OGTT OR Fasting non-challenge test confirmed by 75 g OGTT	Plasma glucose Fasting ≥ 92 mg/dl (5.1 mmol/l) → OGTT 1-h OGTT ≥ 180 mg/dl (10.0 mmol/l) 2-h OGTT ≥ 153 mg/dl (8.5 mmol/l)	Universal	26,459
10-551	India, Punjab	75 g OGTT	Plasma glucose 2-h OGTT ≥ 140 mg/dl (7.8 mmol/l)	Universal	1,150

Table 4. Overview of risk factors used for selective screening

	Risk factors which should be determined
WDF project number
06-207 Sudan	Overweight, obesity, pre-gestational diabetes, family history of diabetes, history of GDM, diagnosis of PCOS, previous baby weighing > 4 kg, history of unexplained stillbirth, history of baby with birth defect, glucosuria, high blood pressure, history of repeated, unexplained abortions.
09-436 Kenya	Age > 25 years, BMI > 25 kg/m^2, history of GDM, history of glucosuria, previous baby weighing > 4 kg, history of poor obstetric outcome, family history of diabetes, known impaired glucose tolerance, known diabetic fasting glucose, grand multipara.
Organisation
American Diabetes Association 2003 (36)	Obesity, age > 25 years, member of ethnic group with average or high prevalence of GDM, family history of diabetes, history of abnormal glucose tolerance, history of poor obstetrical outcome.
American Diabetes Association 2010 (37)	Obesity, history of GDM, previous baby that was large-for-gestational age, presence of glucosuria, diagnosis of PCOS, family history of type 2 diabetes, age > 25 years, member of ethnic group with average or high prevalence of GDM, history of abnormal glucose tolerance, history of poor obstetrical outcome.
Fifth International Workshop Conference on GDM 2007 (38)	Obesity, family history of type 2 diabetes, history of GDM, previous history of impaired glucose metabolism, previous history of glucosuria, age > 25 years, low or high birth weight, history of poor obstetric outcome, member of ethnic group with average or high prevalence of GDM.
NICE 2008 (39)	BMI > 30kg/m^2, previous baby weighing ≥ 4.5 kg, history of GDM, family history of diabetes, member of ethnic group with high prevalence of diabetes (South Asian, Black Caribbean or Middle Eastern).

Table 5. Overview of themes that address problems encountered with using recommended screening procedures and diagnostic criteria in low resource settings

Themes	Respondents mentioning/total number of respondents
Pregnant women do not necessarily attend antenatal care in the 24th to 28th weeks of gestation	4/8
GDM risk factor assessments may not be useful or valid	5/8
Women are not always fasting when they come to the health facility	4/8
Tests are time consuming and may need to be repeated	4/8
Nausea associated with concentrated glucose solution	2/8
Scarcity of test consumables and lack of equipment	4/8

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