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OB
CMECNE

Screening for Gestational Diabetes: The ‘2 Step’ Approach

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Explain why screening all women for GDM rather than only those with risk factors is appropriate
2. Assess a patient for risk factors for gestational diabetes that should prompt and early screening in pregnancy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Professional organizations agree that all pregnant women should be screening for Gestational Diabetes Mellitus (GDM).  While there are varying approaches, ACOG and a consensus panel convened by the NIH have endorsed the following ‘2 step’ approach to screening for GDM:

STEP 1: All women should be screened for GDM between 24 and 28 weeks gestation with a 50g oral glucose solution followed by a 1 hour venous glucose measurement. Healthcare providers have the option of using the following values:

  • 130 or 135 mg/dL – lower cut-off threshold – which may identify women who may have GDM but also increase false positive rates
  • 140 mg/dL – higher cut-off threshold – which may limit the number of screen positive women, but may miss those with GDM

Screen earlier in pregnancy if high risk factors for GDM are identified:

Patient is overweight with BMI of 25 (23 in Asian Americans) and one of the following:

  • Physical inactivity
  • Known impaired glucose metabolism
  • Previous pregnancy history of:
    • GDM
    • Macrosomia (≥ 4000 g)
    • Stillbirth
  • Hypertension (140/90 mm Hg or being treated for hypertension)
  • HDL cholesterol < 35 mg/dl (0.90 mmol/L)
  • Triglyceride > 250 mg/dL (2.82 mmol/L)
  • PCOS
  • Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose
  • Cardiovascular disease
  • Signs/symptoms suggesting increased risk for diabetes such as acanthosis nigricans or morbid obesity)
  • Family history of diabetes – 1st degree relative
  • Ethnicity of African American, American Indian, Asian American, Hispanic, Latina, or Pacific Islander

If a patient with risk factors is tested earlier and is screen negative, the patient should still be screened again between 24-28 weeks using the 50g oral glucose load.

STEP 2: If screen positive following STEP 1,  a diagnostic test, the 100g 3 hour oral glucose tolerance test (OGTT), is recommended. A diagnosis is made if at least two values are exceeded using one of two methods:

Note: ACOG recommends that currently there is insufficient evidence to diagnose GDM based on only one abnormal value | Patients with only one elevated value may require additional surveillance

National Diabetes Data Group

  • Fasting ≥ 105 mg/dL  (5.8 mmol/l)
  • 1-hour ≥ 190 mg/dL   (10.6 mmol/l)
  • 2-hour ≥ 165 mg/dL   (9.2 mmol/l)
  • 3-hour ≥ 145 mg/dL   (8.0 mmol/l)

Carpenter and Coustan

  • Fasting ≥ 95 mg/dL (5.3 mmol/l)
  • 1-hour ≥ 180 mg/dL (10.0 mmol/l)
  • 2-hour ≥ 155 mg/dL (8.6 mmol/l)
  • 3-hour ≥ 140 mg/dL (7.8 mmol/l)

SYNOPSIS:

GDM is a common complication of pregnancy. Aside from well-known complications associated with birth trauma and increased risk of operative delivery and preeclampsia, there may be long term complications including increased risk of obesity and diabetes later in life, although maternal obesity and excessive weight gain may be independent risk factors for macrosomia and childhood obesity. Treatment for GDM does appear to improve outcomes.  Screening all women is necessary as traditional risk factors may only detect 50% of GDM.

KEY POINTS:

  • ACOG and consensus panel convened by the NIH do not recommend the ‘one step’ approach, but rather the ‘two step’ approach
  • The ‘one-step’ screening approach will result is increased diagnosis of GDM
  • Targeting obesity and improved nutrition can also address macrosomia risks

Learn More – Primary Sources:

ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus

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GDM and Postpartum Followup – The ‘When and How’ of Screening
Practical info on evidence based medicine for your women's healthcare practice
Addition of glyburide in mild GDM-is there benefit?
Practical obstetrics info for your women's healthcare practice
What Is The ‘One-Step’ GDM Screening Approach?
Practical obstetrics info for your women's healthcare practice
Gestational Diabetes Mellitus – Definitions, Risk Factors and Complications
Practical obstetrics info for your women's healthcare practice

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Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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