A number of important questions and issues should be addressed before changes are made to the guidelines for the diagnosis of gestational diabetes, according to a new article by University of Maryland School of Medicine Dean E. Albert Reece, M.D., Ph.D., M.B.A., published online in the American Journal of Obstetrics and Gynecology on Oct. 31. The article publishes in advance of a new National Institutes of Health (NIH) initiative to reconsider diagnostic guidelines for the condition.
The NIH Office of Disease Prevention has called a Consensus Development Conference in early 2013 to assess available scientific evidence. At the end of the conference, an independent panel will publicly disclose its findings, assessing and analyzing evidence including a literature review and expert presentations. In advance of the event and possible recommendations for changing diagnostic criteria, Dean Reece and co-author Thomas Moore, M.D., professor and chairman of the Department of Reproductive Medicine at the University of California, San Diego, urge caution in their article.
"Some in obstetrics and gynecology and maternal-fetal medicine have advocated for change to the diagnostic criteria for gestational diabetes for some time now," says Dean Reece, who is also vice president for medical affairs at the University of Maryland and John Z. and Akiko K. Bowers Distinguished Professor at the University of Maryland School of Medicine. "Others, including the American College of Obstetricians and Gynecologists, say it is not clear that change is needed. Dr. Moore and I have considered the arguments and evidence on both sides. We have concluded that before change is made, there needs to be careful analysis of the possible risk, cost and benefit involved in any revisions. If the data aren't available to answer these questions, it would seem prudent and advisable to delay change at this time."
Two additional articles, both asserting concerns about revisions to the diagnostic criteria, have been published electronically in other journals in advance of the conference. Both articles were co-authored by Oded Langer, M.D., Ph.D., maternal-fetal medicine expert at Cookeville Medical Regional Center in Tennessee; Jason G. Umans, M.D., Ph.D., F.A.C.P., scientific director of the MedStar Health Research Institute in Maryland and associate professor of medicine at Georgetown University; and Menachem Miodovnik, M.D., chairman of women's services at MedStar Washington Hospital Center. "Perspectives on the Proposed Gestational Diabetes Mellitus Diagnostic Criteria" appeared in the journal, Obstetrics & Gynecology, and "The proposed GDM diagnostic criteria: A difference, to be a difference, must make a difference" appeared in the Journal of Maternal-Fetal Neonatal Medicine.
The authors advised that "such a change would dramatically increase the number of women identified as having this disease and place a significantly greater burden on an already overburdened primary health care system."
Gestational diabetes is a condition that can be potentially devastating to pregnancies. Even mild forms of hyperglycemia could potentially pose significant adverse health consequences for pregnant women and their children. Advocates for changing diagnostic criteria - increasing the number of women diagnosed with and thus treated for the condition - could reduce morbidity and health care costs. Those cost reductions, however, could be offset by an increase in patients diagnosed and treated, according to Dean Reece.
Some studies have shown that such a change could potentially improve health outcomes for mothers and their babies, but at least one prominent study showed that the potential public health benefits will only occur if a higher level of care is given to newly diagnosed patients. Changing the criteria also could increase cesarean delivery rates, which could increase health care costs and offset any public health gains involved with diagnosing and treating more patients.
"The scientific dilemma to change or not to change, thus, requires a rigorous analysis of the scientific, economic, practice, and legal ramifications as well as the pros and cons to achieve a satisfactory answer," the article by Dean Reece and Dr. Moore concludes.