Updated ACOG Guidance on Gestational Diabetes

SUMMARY:

ACOG released updated guidance on gestational diabetes (GDM), which has become increasingly prevalent worldwide.  Class A1GDM refers to diet-controlled GDM. Class A2GDM refers to the clinical scenario where medications are required. Highlights and changes from the previous practice bulletin include the following:

• Screening for GDM – One or Two Step?
• Who Should be Screened Early?
• Screening for Diabetes and Pre-Diabetes in The Postpartum Period
• What Are Glucose Target Levels?
• Diet and Exercise
• Pharmacologic Treatment
• Fetal Monitoring
• When to Deliver?

Screening for GDM – One or Two Step?

• ACOG (based on NIH consensus panel findings) supports the ‘2 step’ approach (24 to 28 week 1 hour venous glucose measurement following 50g oral glucose solution), followed by a 100g 3 hour oral glucose tolerance test (OGTT) if positive
  • Note: Diagnosis of GDM is based on 2 abnormal values on the 3 hour OGTT
    • 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
• 1 step approach (75 g OGTT) on all women will increase the diagnosis of GDM but sufficient prospective studies demonstrating improved outcomes still lacking
• The USPSTF
  • Recommends screening for gestational diabetes in asymptomatic pregnant persons at ≥24 weeks of gestation or after (B recommendation)
  • Current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes in asymptomatic pregnant persons <24 weeks of gestation (I statement)

Who Should be Screened Early?

Consider early screening in pregnancy if patient is overweight with BMI of 25 (23 in Asian Americans), and one or more of the following

• Physical inactivity
• Family history of diabetes – 1st degree relative (parent or sibling)
• African American, Native American, Asian American, Latino, or Pacific Islander
• Previous pregnancy history of
  • GDM
  • Macrosomia (≥ 4000 g)
• Hypertension (140/90 mm Hg or being treated for hypertension) | ADA now uses 130/80 cut-off for prediabetes screening
• HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L)
• Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L)
• PCOS
• Conditions associated with insulin resistance (e.g., acanthosis nigricans, morbid obesity)
• Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose | If A1C>6.5%, diagnosis of pregestational diabetes is met and GCT/GTT not needed
• Cardiovascular disease

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