The International Federation of Gynecology and Obstetrics (FIGO) Initiative on …

Hod M, Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. Int J Gynaecol Obstet. 2015;131 Suppl 3:S173-S211. doi:10.1016/S0020-7292(15)30033-3

Hyperglycemia is one of the most common medical conditions women encounter during pregnancy. The International Diabetes Federation (IDF) estimates that one in six live births (16.8%) are to women with some form of hyperglycemia in pregnancy. While 16% of these cases may be due to diabetes in pregnancy (either preexisting diabetes—type 1 or type 2—which antedates pregnancy or is first identified during testing in the index pregnancy), the majority (84%) is due to gestational diabetes mellitus (GDM).

The occurrence of GDM parallels the prevalence of impaired glucose tolerance (IGT), obesity, and type 2 diabetes mellitus (T2DM) in a given population. These conditions are on the rise globally. Moreover, the age of onset of diabetes and pre-diabetes is declining while the age of childbearing is increasing. There is also an increase in the rate of overweight and obese women of reproductive age; thus, more women entering pregnancy have risk factors that make them vulnerable to hyperglycemia during pregnancy.

GDM is associated with a higher incidence of maternal morbidity including cesarean deliveries, shoulder dystocia, birth trauma, hypertensive disorders of pregnancy (including preeclampsia), and subsequent development of T2DM. Perinatal and neonatal morbidities also increase; the latter include macrosomia, birth injury, hypoglycemia, polycythemia, and hyperbilirubinemia. Long-term sequelae in offspring with in utero exposure to maternal hyperglycemia may include higher risks for obesity and diabetes later in life.

In most parts of low-, lower middle-, and upper middleincome countries (which contribute to over 85% of the annual global deliveries), the majority of women are either not screened or improperly screened for diabetes during pregnancy—even though these countries account for 80% of the global diabetes burden as well as 90% of all cases of maternal and perinatal deaths and poor pregnancy outcomes.

Given the interaction between hyperglycemia and poor pregnancy outcomes, the role of in utero imprinting in increasing the risk of diabetes and cardiometabolic disorders in the offspring of mothers with hyperglycemia in pregnancy, as well as increasing maternal vulnerability to future diabetes and cardiovascular disorders, there needs to be a greater global focus on preventing, screening, diagnosing, and managing hyperglycemia in pregnancy. The relevance of GDM as a priority for maternal health and its impact on the future burden of noncommunicable diseases is no longer in doubt, but how best to deal with the issue remains contentious as there are many gaps in knowledge on how to prevent, diagnose, and manage GDM to optimize care and outcomes. These must be addressed through future research.

The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to develop a document to frame the issues and suggest key actions to address the health burden posed by GDM. FIGO’s objective, as outlined in this document, is: (1) to raise awareness of the links between hyperglycemia and poor maternal and fetal outcomes as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) to create a consensus document that provides guidance for testing, management, and care of women with GDM regardless of resource setting and to disseminate and encourage its use.

Despite the challenge of limited high-quality evidence, the document outlines current global standards for the testing, management, and care of women with GDM and provides pragmatic recommendations, which because of their level of acceptability, feasibility, and ease of implementation, have the potential to produce significant impact. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap.

To address the issue of GDM, FIGO recommends the following:

Public health focus: There should be greater international attention paid to GDM and to the links between maternal health and noncommunicable diseases on the sustainable developmental goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age must be prioritized.

Universal testing: All pregnant women should be tested for hyperglycemia during pregnancy using a one-step procedure and FIGO encourages all countries and its member associations to adapt and promote strategies to ensure this.

Criteria for diagnosis: The WHO criteria for diagnosis of diabetes mellitus in pregnancy [1] and the WHO and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for diagnosis of GDM [1,2] should be used when possible. Keeping in mind the resource constraints in many low-resource countries, alternate strategies described in the document should also be considered equally acceptable.

Diagnosis of GDM: Diagnosis should ideally be based on laboratory results of venous serum or plasma samples that are properly collected, transported, and tested. Though plasmacalibrated handheld glucometers offer results that are less accurate and precise than those from quality-controlled laboratories, it is acceptable to use such devices for the diagnosis of glucose intolerance in pregnancy in locations where laboratory support is either unavailable or at a site remote to the point of care.

Management of GDM: Management should be in accordance with available national resources and infrastructure even if the specific diagnostic and treatment protocols are not supported by high-quality evidence, as this is preferable to no care at all.

Lifestyle management: Nutrition counselling and physical activity should be the primary tools in the management of GDM. Women with GDM must receive practical nutritional education and counselling that will empower them to choose the right quantity and quality of food and level of physical activity. They should be advised repeatedly during pregnancy to continue the same healthy lifestyle after delivery to reduce the risk of future obesity, T2DM, and cardiovascular diseases.

Pharmacological management: If lifestyle modification alone fails to achieve glucose control, metformin, glyburide, or insulin should be considered as safe and effective treatment options for GDM.

Postpartum follow-up and linkage to care: Following a pregnancy complicated by GDM, the postpartum period provides an important platform to initiate beneficial health practices for both mother and child to reduce the future burden of several noncommunicable diseases. Obstetricians should establish links with family physicians, internists, pediatricians, and other healthcare providers to support postpartum follow-up of GDM mothers and their children. A follow-up program linked to the child’s vaccination and regular health check-up visits provides an opportunity for continued engagement with the high risk mother−child pair.

Future research: There should be greater international research collaboration to address the knowledge gaps to better understand the links between maternal health and noncommunicable diseases. Evidence-based findings are urgently needed to provide best practice standards for testing, management, and care of women with GDM. Cost-effectiveness models must be used for countries to make the best choices for testing and management of GDM given their specific burden of disease and resources.

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