Title:
Early gestational diabetes screening in class III obesity (BMI³40kg/m2)
Authors:
Macie L. Champion, Victoria C. Jauk, Joseph R. Biggio, Jeff M. Szychowski, Alan T. Tita, Lorie M. Harper
Background:
- Early screening for GDM is recommended by ACOG for women with BMI³40kg/m2.
- These recommendations have not been evaluated.
Objective:
- Evaluate whether early screening for GDM improves pregnancy outcomes in patients with BMI³40kg/m2.
Methods:
- Secondary analysis of randomized controlled trial comparing early GDM screening (14-20wga) to routine (24-28wga)
- Inclusion Criteria: BMI³40kg/m2
- Exclusion Criteria: pregestational diabetes, major medical comorbidities, bariatric surgery, prior cesarean
- Primary Outcome: primary cesarean, macrosomia (³4000g), pregnancy induced hypertension, neonatal hypoglycemia (<40mg/dL), neonatal hyperbilirubinemia
- Secondary Outcome: composite in patients diagnosed with GDM
- Intention to treat analysis
- Chi squared test for categorical measures
- Student T-test and Wilcoxon rank sum for continuous variables
Results:
- 218 (23%) of 954 women in original study included in analysis
- 111 randomized to early screening
- 107 randomized to routine screening
- Similar baseline characteristics
- Early screening did not reduce the incidence of the primary outcome.
- Of women diagnosed with GDM, there was no change in the primary composite.
Conclusion:
- In women with BMI³40kg/m2, early GDM screening is not beneficial.
Table 1: Baseline Characteristics
|
Characteristic |
Early Screening N = 426 |
Routine Screening N = 442 |
p-value |
|
Age |
27.4 ± 5.9 |
26.9 ± 5.9 |
0.16 |
|
Race/Ethnicity |
|
|
0.85 |
|
African American |
278 (65.3%) |
296 (67.0%) |
|
|
White |
21 (4.9%) |
17 (3.9%) |
|
|
Hispanic |
122 (28.6%) |
123 (27.8%) |
|
|
Other |
5 (1.2%) |
6 (1.4%) |
|
|
BMI |
37.4 ± 6.8 |
37.1 ± 6.6 |
0.58 |
|
Insurance |
|
|
0.77 |
|
Medicaid |
285 (67.9%) |
295 (67.7%) |
|
|
Private |
16 (3.8%) |
13 (3.0%) |
|
|
No Insurance |
119 (28.3%) |
128 (29.4%) |
|
|
Parity |
|
|
0.92 |
|
Nulliparous |
115 (27%) |
118 (26.7%) |
|
|
Multiparous |
311 (73%) |
324 (73.3%) |
|
|
Gestational Age at Randomization |
13.8 ± 3.8 |
13.6 ± 3.7 |
0.51 |
|
Gestational Age at Delivery |
38.1 ± 3.7 |
38.4 ± 3.4 |
0.16 |
|
HbA1c |
5.3 (5-5.6) |
5.3 (5-5.6) |
0.52 |
|
Prior Infant >4000g |
28 (6.6%) |
23 (5.2%) |
0.39 |
|
History of GDM |
10 (2.4%) |
6 (1.4%) |
0.28 |
|
Chronic HTN |
60 (14.1%) |
50 (11.3%) |
0.22 |
|
A1c ≥5.7% |
78 (18.3%) |
70 (15.8%) |
0.33 |
|
BMI > 40 |
111 (26.1%) |
107 (24.2%) |
0.53 |
Table 2: Outcomes in Early GDM Screening (BMI≥40kg/m2)
|
|
Early (n=111) |
Routine (n=107) |
p-value |
Relative Risk (95%CI) |
|
Primary Composite Outcome |
71 (64.0%) |
63 (58.9%) |
0.44 |
1.09 (0.88-1.34) |
|
Macrosomia |
4 (3.7%) |
6 (5.6%) |
0.54 |
0.65 (0.19-2.25) |
|
Primary Cesarean |
28 (25.2%) |
28 (26.2%) |
0.87 |
0.96 (0.61-1.5) |
|
Gestational HTN |
28 (25.5%) |
17 (16.0%) |
0.09 |
1.59 (0.92-2.72) |
|
Preeclampsia |
5 (4.6%) |
4 (3.8%) |
>0.99 |
1.20 (0.33-4.36) |
|
Neonatal Hyperbilirubinemia |
26 (23.4%) |
18 (16.8%) |
0.22 |
1.39 (0.81-2.39) |
|
Neonatal Hypoglycemia |
6 (5.4%) |
6 (5.6%) |
0.95 |
0.96 (0.32-2.90) |
|
GDM |
20 (18.0%) |
12 (11.2%) |
0.16 |
1.61 (0.83-3.12) |
|
Any Diabetic Medication |
10 (9.0%) |
6 (5.6%) |
0.34 |
1.61 (0.61-4.27) |
|
Insulin |
5 (4.5%) |
2 (1.9%) |
0.45 |
2.41 (0.48-12.16) |
|
Induction of Labor |
63 (56.8%) |
59 (55.1%) |
0.81 |
1.03 (0.81-1.30) |
Table 3: Outcomes in GDM only with early vs. routine screening (BMI≥40kg/m2)
|
|
Early (n=20) |
Routine (n=12) |
p-value |
Relative Risk (95%CI) |
|
Primary Composite Outcome |
15 (75%) |
10 (83.3%) |
0.68 |
0.9 (0.63-1.29) |
|
Macrosomia |
0 |
2 (16.7%) |
0.15 |
- |
|
Primary Cesarean |
9 (45%) |
5 (41.7%) |
0.85 |
1.1 (0.47-2.47) |
|
Gestational HTN |
7 (35%) |
6 (50%) |
0.47 |
0.7 (0.31-1.59) |
|
Preeclampsia |
1 (5%) |
0 |
>0.99 |
- |
|
Neonatal Hyperbilirubinemia |
5 (25%) |
3 (25%) |
>0.99 |
- |
|
Neonatal Hypoglycemia |
4 (20%) |
4 (33.3%) |
0.43 |
0.6 (0.18-1.97) |
|
Any Diabetic Medication |
10 (50%) |
5 (41.7%) |
0.65 |
1.2 (0.54-2.67) |
|
Insulin |
5 (25%) |
2 (16.7%) |
0.68 |
1.5 (0.34-6.56) |
|
Induction of Labor |
12 (60%) |
10 (83.3%) |
0.25 |
0.72 (0.45-1.12) |