In addition to concerns regarding the dramatic increase in the number of women diagnosed with GDM that would occur with adoption of the IADPSG criteria – ACOG estimates the proportion would be 18% of all pregnant women – the ACOG committee opinion also cited the lack of evidence regarding impact on outcomes.
“There is no evidence that the identification and treatment of women based on the new [IADPSG] recommendations will lead to clinically significant improvements in maternal and neonatal outcomes and it would lead to a significant increase in health care costs,” the ACOG authors noted, adding “Significant questions remain regarding the implications on health care costs, the effect of GDM diagnosis on the pregnant woman and her family, the effect of diagnosis on obstetric interventions in pregnancy, and whether the identification and treatment of GDM will improve meaningful perinatal, neonatal, and maternal outcomes.”
ACOG and other organizations are looking ahead to the National Institutes of Health's Consensus Development Conference on Diagnosing Gestational Diabetes Mellitus scheduled for October 29-31, 2012, to develop a uniform diagnostic standard. “Consensus regarding optimal diagnostic criteria among the many groups and professional organizations will further much needed research regarding the benefits and harms of screening and diagnosis of GDM,” the ACOG opinion statement said.
The Norwegian study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, and the Norwegian Directorate of Health. Dr. Morkrid had no financial disclosures.
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Changing Criteria Is Tough
The diagnostic criteria for gestational diabetes have been disputed for decades. We are forced to think more of those now that women from certain countries are more obese and are having their first children later in life. With diagnostic criteria, you first have to think about what you “win” by designating over 200% more women as having diabetes, investing in seeing them on a regular basis, deciding whether to treat this marginally increased glycemia, and determining what will be the outcome for these women and for their children, as well as the perinatal consequences, including delivery complications. I think you need to study all of this before you can decide to change the criteria.
It's similar to the recent decision to use hemoglobin A1c criteria to diagnose diabetes, another controversial area. It's one thing to look simply at the increased risk with elevated HbA1c. But from a political standpoint, HbA1c tests are best done in the West, and are more expensive. Would we have two standards, one for the West and one for Africa? That's very difficult to sell. Also, does it apply to all forms of diabetes? No. And also, how do you convince the politicians that it's a big epidemic, when they could respond that the reason the numbers are so large is that the diagnostic criteria were changed?
Changing criteria is tough, and it has to be done based on evidence.
MICHAELA DIAMANT, M.D., is associate professor of endocrinology and scientific director of the diabetes center at Free University Medical Center, Amsterdam. She had no relevant financial disclosures.
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