Diabetes gestacional

Screening for Gestational Diabetes Mellitus [Internet].

Hillier TA, Vesco KK, Whitlock EP, Pettitt DJ, Pedula KL, Beil TL.

Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. Report No.: 08-05115-EF-1.
U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews.
Excerpt

BACKGROUND: In a 2003 evidence report, the United StatesPreventive Services Task Force (USPSTF) concluded that the scientific evidence was insufficient to advise for or against routine screening for gestational diabetes mellitus (GDM) in all pregnant women. The 2003 review did not include evidence pertaining to GDM screening prior to 24 weeks gestation. As the prevalence of women at high risk for type 2 diabetes and GDM has continued to increase dramaticallyover the intervening years, the issue of early screening has taken on greater importance.

PURPOSE: This review identifies and evaluates new evidence since the prior review on the risks and benefits of GDM screening at 24 weeks or later; it also newly reviews all of the available evidence pertaining to GDM screening prior to 24 weeks.

DATA SOURCES: We conducted five database searches ofMEDLINE®, Cochrane Central Registry of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment, and National Institute for Health and Clinical Excellence from 2000 to September 2006, supplemented by a search for screening prior to 24 weeks gestation from 1966-99. Searches were also supplemented with recommendations fromoutside experts and reviews of bibliographies of other relevant articles and systematic reviews. We dual-reviewed all citations in the 2003 Evidence Synthesis for inclusion in this review.

STUDY SELECTION: In conjunction with USPSTF members and with Agency for Healthcare Research and Quality staff, we developed and refined an analytic framework and five key questions (KQ). For assessing potentialbenefit of GDM screening and treatment, we included only randomized trials that used the standard, currently accepted one-step and two-step diagnostic criteria to evaluate screening and treatment of GDM. Study design and criteria were less stringent for considering potential harms. Using inclusion/exclusion criteria for each question, two investigators dual-reviewed 1403 abstracts and 277 potentiallyincluded articles. Of the potentially included articles, 90 were excluded for study design and 12 for poor quality, and the remainder for other reasons.

DATA EXTRACTION: We abstracted, critically appraised, and synthesized 13 total articles meeting criteria for the five KQs. Abstracted elements were arrayed in evidence tables, using criteria specific to each KQ. DATA SYNTHESIS AND

RESULTS:The best new evidence is a good-quality randomized controlled trial (RCT) that evaluated the maternal and neonatal outcomes for 1,000 pregnancies in which mild GDM was diagnosed between 24–34 weeks gestation and treated, compared to outcomes for pregnancies in which mild GDM was diagnosed but not treated. With treatment, there was a statistically significant reduction in the composite neonataloutcome of any serious perinatal complication (Adjusted RR 0.33 [95 percent CI 0.14–0.75]). Serious perinatal complications was defined as any of the following: death, shoulder dystocia, bone fracture, and nerve palsy. The absolute rates of these individual perinatal outcomes were also reported in the paper, but could not be compared between groups due to no events for death, bone fracture, or nervepalsy in the treatment group. Overall, there were seven infants with serious perinatal complications in the treatment group (all shoulder dystocia), compared to 23 infants with 25 serious perinatal complications in the non-treated group (five deaths, one fractured humerus, three nerve palsies, and 16 shoulder dystocia). Shoulder dystocia was not a specified health outcome for this evidence...