Poor performance of American Diabetes Association criteria in women with gestational diabetes

Performance characteristics of postpartum screening tests for type 2 diabetes mellitus in women with a history of gestational diabetes mellitus: a systematic review

BACKGROUND

Women with a history of gestational diabetes mellitus are at high risk for type 2 diabetes mellitus. We systematically reviewed and synthesized the literature on the sensitivity, specificity, and reproducibility of postpartum screening tests for type 2 diabetes in women with prior gestational diabetes to inform screening guidelines.

METHODS

We searched electronic databases through October 1, 2008. Two investigators independently reviewed titles, abstracts, and articles, performed serial data abstraction, and independently assessed quality. We calculated standard errors and confidence intervals for sensitivity and specificity using the exact binomial formula.

RESULTS

Eleven studies contained 13 evaluations of a comparison screening test with the 2-h 75-g oral glucose tolerance test (OGTT) reference. All studies used a cross-sectional study design. There were ten comparisons of a single fasting blood glucose (FBG) >=7.0 mmol/L (>=126 mg/dL) with the OGTT. The sensitivity ranged from 14%-100% in five studies using the 1985 World Health Organization's (WHO) criteria as the reference and from 16%-89% in five studies using the 1999 WHO criteria as the reference. Variation in the sensitivities may be due to the limited number of comparisons, differences in populations, and timing of screening. There were high losses to follow-up, limiting generalizability.

CONCLUSIONS

When compared with the OGTT, the single FBG alone was not consistently reported to be a sensitive screening test for type 2 diabetes in women with a history of gestational diabetes. Longitudinal studies are needed to address the natural history of glucose metabolism in women with a history of gestational diabetes, the optimal approach to diagnostic testing for type 2 diabetes in this population, and the short-term and long-term outcomes of testing.

Diagnostic controversy: gestational diabetes and the meaning of risk for pima Indian women

Gestational diabetes is the one form of this well known, chronic disease of development that disappears. After the birth of the child, the mother's glucose levels typically return to normal. As a harbinger of things to come, gestational diabetes conveys greater risk for later type 2 (previously "non-insulin dependent") diabetes in both the mother and child. Thus, pregnant women have become a central target for prevention of this disease in the entire Pima population. Based on ethnographic interviews conducted between 1999 and 2000, I discuss the negotiated meanings of risk, "borderline" diabetes, and women's personal knowledge and experiences of diabetes, particularly during the highly surveilled period of pregnancy. I also highlight the heterogeneity of professional discourse pertaining to gestational diabetes, most notably the debate surrounding its diagnosis. Significantly, women's narratives reveal the same set of questions as is raised in the professional debate. Implications for diabetes prevention and for balancing the increased surveillance of pregnant women with clinical strategies that privilege their experience and perspectives are also discussed.