- freely available
J. Clin. Med. 2018, 7(6), 123; https://doi.org/10.3390/jcm7060123
“So, oft in theologic warsThe disputants, I ween,Rail on in utter ignoranceOf what each other mean,And prate about an ElephantNot one of them has seen”—John Godfrey Saxe
2. Problems Caused by a Lack of Consensus
- It is difficult to compare prevalence in different countries. In one study, due to variation in criteria and practices, the prevalence of GDM in 173 countries varied from <1–28% : the different criteria used were a major contributor to the heterogeneity. Another study showed that, applying the diagnostic thresholds of eight major expert guidelines to the same glucose values of the diagnostic oral tolerance test (OGTT), the GDM prevalence varied from 9.2% to 45.3% depending on which criteria was used .
- The GDM risk of progress to diabetes mellitus, type 2 (DM2) after delivery is difficult to estimate since different standards are used by various studies.
- The variation in diverse ethnic groups is important since high-risk immigrants can be targeted. However, if the criteria for diagnosis vary, it is hard to estimate risk.
- Published studies cannot be compared as the gold-standard for diagnoses vary. The 2008 effort by the United States Preventive Services Task Force (USPSTF) for screening of GDM acknowledged that the literature was limited by the lack of consistent standards for screening and diagnosis of GDM .
- The association of perinatal and maternal complications in index pregnancy complicated GDM is difficult to determine objectively.
- Since different criteria for diagnosing GDM exist, the effectiveness of different treatments cannot be compared.
3. Consensus on What Constitutes GDM
4. Consensus on Screening of GDM
5. Consensus on Diagnosis of GDM
- Since the 1980s, both ACOG and the ADA recommendations were similar with some minor differences. However, their disparities were most evident in 2011 when the ADA endorsed universal screening with the 75-g OGTT (IADPSG criteria) while the ACOG did not. However, after the NIH sponsored conference , they accepted each other’s points of view, which is shown by their latest individual guidelines.
- In Europe, the WHO, which is another mover and shaker with global reach, decided in 1980 that it was easier to use the 75-g OGTT for both pregnant and non-pregnant women and adult males. This approach is convenient but inaccurate . However, subsequently, multiple studies also showed that the subsequent WHO-1999 criteria for GDM diagnosis predicted complications in index pregnancy as well as DM2 after delivery. Due to its global acceptance, major local diabetes organizations across the world use 75-g OGGT as advocated by the WHO. However, despite great progress, there is still much heterogeneity in Europe, which is shown by a study from 28 European countries .
- In Australia, the Australasian Diabetes in Pregnancy Society (ADIPS) modified the WHO criteria and issued its own criteria (1991) based on expert opinion. These criteria were subsequently modified (1996). However, since 2013, the ADIPS issued new guidelines after considering the available evidence like HAPO accepted the WHO 2013 . In New Zealand, guidelines of the ADIPS-1991 were accepted but the criteria for GDM diagnosis were made more restrictive. The reason was that less women would be diagnosed with GDM, which conserves New Zealand’s overextended funds. Even in 2018, despite all the newer data, the NZ guidelines have not been modified since 2014. Unlike ADIPS, they do not accept the IADPSG.
- The United Kingdom had three organizations with their own guidelines including NICE, SIGN, and Clinical Resource Efficiency Support Team (CREST). These organizations had a varying approach for the diagnosis and screening of GDM. NICE and SIGN have newer guidelines incorporating the new data. However, the CREST does not.
- The Canadian Diabetes Association (CDA) in their 2013 guidelines  suggest a modified approach to the IADPSG with minor differences. However, they still endorse the 50-g GCT, which the IADPSG does not. The Society of the Obstetricians and Gynecologists of Canada (SOGC)  differed from the CDA. However, in their 2016 guidelines, the SOGC has endorsed the CDA 2013 approach. Therefore, some of the disparities that are present between the obstetric and endocrine organizations in Canada over the last three decades do not exist anymore.
- Countries such as Japan, Brazil, and France followed their own recommendations or hybrid recommendations of the international organizations. However, many have accepted the IADPSG guidelines .
6. Consensus on GDM Diagnosis in Early Pregnancy
7. Consensus about OGTT as a Gold Standard for Diagnosis of GDM
8. Consensus on Management of GDM
9. Consensus on Follow-Up of GDM
10. Efforts at Consensus
- HAPO trial: Since the later part of the last decade, almost all the preeminent organizations and experts have been looking to the HAPO study —a massive and expensive global effort—to be the panacea . More than 23,000 pregnant women were enrolled in 15 field centers located in nine different countries between 2000–2006. However, even though it did resolve many issues, major differences and concerns still remain.
- IADPSG criteria were the collective wisdom of experts from 40 different countries to achieve consensus after the HAPO study. Therefore, the IADPSG criteria had the possibility to be accepted by the preeminent medical, endocrine, and health organizations worldwide. The IADPSG guideline is currently the most popular guideline for GDM. It has been accepted by many major world organizations like WHO, ADIPS, IDF, and FIGO . CDA has not argued against it but would rather avoid them. However, the ACOG and the NIH consensus panel have reservations about the IADPSG recommendations .
- NIH conference: In 2013, the United States National Institutes of Health convened a Consensus Conference to consider all aspects of screening and diagnosis of gestational diabetes . Again, the differences could not be resolved.
- FIGO: A major effort was undertaken by the International Federation of Gynecology and Obstetrics (FIGO), which has members from about 125 gynecology and obstetrics organizations worldwide to achieve consensus on GDM . Their guidelines were widely endorsed by major international groups like EBCOG, the Society of Obstetricians and Gynecologists of Canada (SOGC), African Federation of Obstetrics and Gynecology (SAFOG), ADIPS, European Association of Perinatal Medicine, and Diabetes in Pregnancy Study Group of Latin America . These guidelines acknowledge the difficulty in achieving a universal approach for GDM. This is because, among different countries, resources available are different, maternal and fetal complications during delivery vary in different locations, local findings are diverse, and the experts differ in using the resources. FIGO offers a practical solution by dividing the approach based on resources, i.e., countries with fully resourced settings, countries with fully resourced settings serving populations with high risk for GDM, and countries with medium resourced to low resourced settings. Therefore, every country can be on a trajectory toward improvement depending on its circumstances and yet be able to offer optimal care to its pregnant patients with hyperglycemia.
Conflicts of Interest
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|Organization||Glucose Load, Grams||Glucose Thresholds (mmol/L)||Number of OGTT Values for Diagnosis ≥|
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