ORIGINAL ARTICLE

Early random capillary glucose level screening and multidisciplinaryantenatal teamwork to improve outcome in gestational diabetesmellitus

MARIE BERG1,2, ANNIKA ADLERBERTH3, BO SULTAN2,

MARGARETA WENNERGREN2 & GUNNAR WALLIN2

1The Institute of Health and Care Sciences, Sahlgrenska Academy, Goteborg University, Goteborg, Sweden, 2Department

of Obstetrics and Gynaecology, The Institute of Clinical Sciences, Sahlgrenska University Hospital, Goteborg, Sweden, and3The Institute of Medicine, Sahlgrenska University Hospital, Goteborg, Sweden

AbstractBackground . This study describes maternal and neonatal characteristics and delivery outcome in women with gestationaldiabetes mellitus [GDM], compared to a control group. Methods. A retrospective observational studyof 719 women with GDMwas undertaken in a Swedish urban district. All other parturients at the same hospital served as the control group. GDM wasdiagnosed using random capillary glucose levels at fixed intervals, beginning early in pregnancy. An oral glucose tolerance testwas performed at glucose levels ]/7.0 mmol/l (127.8 mg/dl). Data was analysed according to glucose levels at diagnosis, ie, mildor severe GDM. Results. GDM was diagnosed in 2.28% of the women who were older and had higher Body Mass Index [BMI].A high proportion was of non-Nordic origin (44.5%); they had severe GDM more often (49.1%) than the Nordic group(33.1%). The GDM-mild group had less complications and abnormalities, compared to the GDM-severe group, althoughboth groups differed from the control group in this respect. Delivery was spontaneous in 70.2% of GDM-mild, 65.7% of GDM-severe and 81.0% of the control group. LGA (�/2 SD) was found in 4.8, 10.5 and 3.2%, respectively. Conclusion. Early non-fasting random universal screening and multidisciplinary antenatal teamwork intervention seems to be favourable, with lowrates of excessive fetal growth, instrumental vaginal delivery and caesarean section.

Key words: Gestational diabetes mellitus, maternal-fetal outcome, random blood glucose, oral glucose tolerance test

Abbreviations: AGA: average for gestational age, BMI: body mass index, GDM: gestational diabetes mellitus, LGA: large

for gestational age, MBR: the Medical Birth Register, NS: not significant, NA: not applicable, OGTT: oral glucose tolerance

test, OOOW: obstetrical outpatient observation ward, OR: odds ratio, RCG: random capillary whole blood glucose, SD:

standard deviation, SGA: small for gestational age, SUH: Sahlgrenska University Hospital, WHO: World Health

Organisation, 2-h OGTT: two-hour capillary blood glucose OGTT

Introduction

Gestational diabetes mellitus [GDM] is defined as

any abnormal glucose tolerance first diagnosed

during pregnancy and caused by insulin resistance

connected with pregnancy-related defects in insulin

secretion. Occurrence of GDM during early preg-

nancy may indicate abnormal metabolism preceding

pregnancy. GDM is associated with adverse preg-

nancy outcome, such as pre-eclampsia, macrosomia,

brachial plexus palsy, neonatal hypoglycaemia and

jaundice (1�5). There is also an increased risk of

developing diabetes mellitus, mainly type 2, later in

life (6). No definite knowledge exists about at what

level the impairment in glucose metabolism will

affect obstetric outcome (7).

Globally, a multitude of diagnostic criteria and

treatments are available. The 75-g oral glucose

tolerance test [OGTT], proposed by the World

Correspondence: M Berg, Institute of Health and Caring Sciences, Sahlgrenska Academy, Goteborg University, Box 457, SE 405 30, Goteborg, Sweden.

E-mail: marie.berg@fhs.gu.se

Acta Obstetricia et Gynecologica. 2007; 86: 283�290

(Received 3 March 2006; accepted 4 November 2006)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2007 Taylor & Francis

DOI: 10.1080/00016340601110747

Health Organization [WHO] (8), is utilised for

diagnosis in many centres. OGTT may be adminis-

tered to all pregnant women at a certain gestational

age or only to those with risk factors for gestational

diabetes. Another option is non-fasting random

blood glucose sampling only once or at regular

intervals during pregnancy to select women for

OGTT (9,10).

The aim of this study was to examine maternal

and neonatal characteristics and delivery outcomes

associated with a new antenatal care regimen for

GDM, including early non-fasting random capillary

whole blood glucose [RCG] level screening and

multidisciplinary antenatal teamwork.

Material and methods

In connection with an organisational change in

maternity care in the western part of Sweden,

including concentration of maternity care to Sahl-

grenska University Hospital [SUH], the routines for

detecting and treating GDM were changed. The

WHO recommendation (11), suggesting early inter-

vention, was followed. All pregnant non-diabetic

women attending the antenatal clinics were offered

non-fasting RCG tests, at fixed gestational ages, but

at random times during the day. Tests were taken at

the first visit, at gestational week 8�12, and every

4�6 weeks, beginning from gestational week 24, a

total of 5�6 tests during pregnancy. Women with

RCG ]/11.1 mmol/l (203 mg/dl), or with a fasting

glucose level ]/6.1 mmol/l (111 mg/dl) preceding

OGTT, were diagnosed as GDM. If RCG was ]/7.0

mmol/l (128 mg/dl) and B/11.1 mmol/l (203 mg/dl),

OGTT, with 75 g anhydrous glucose dissolved in

300 ml of water, was performed after an overnight

fast. Both RCG and blood tests for the OGTT

were analysed in a Hemocue† using 5 ml capillary

whole blood (Hemocue AB, Angelholm, Sweden).

A 2-h capillary blood glucose level (2-h OGTT)

]/7.8 mmol/l (142 mg/dl) during the OGTT led to a

diagnosis of GDM. This is in agreement with the

1998 WHO classification criteria (11).

After diagnosis, the woman attended the hospital’s

obstetrical outpatient observation ward [OOOW]

and met a specially trained ‘diabetes midwife’. The

model of care stressed the importance of the

woman’s participation in and responsibility for her

treatment, aimed at normalising blood glucose

levels, and consisted of individual adjusted diet and

physical activities. She received a blood glucose

monitor and was instructed to test glucose levels at

least three times pre-prandially and 1 h postpran-

dially daily. Dietary advice included a balanced diet

with slow carbohydrates without caloric restriction

and regular food intake, including three meals and

two or three snacks. To avoid hyperglycemia before

noon, breakfast was commonly divided into smaller

portions. The ‘slow carbohydrate diet’ included

dietary fibres, eg, whole-grain sourdough bread

instead of white, sweetened bread, fruit instead of

juice, no milk in liquid form, fibre rich legumes as

carrots and not only lettuce, tomatoes or cucumbers.

Information was given on the positive effects of

physical activity to lower blood glucose level and

daily walks were proposed as exercise. The target

glucose level was 4�6 mmol/l (73�109 mg/l) pre-

prandially, and B/8 mmol/l (146 mg/dl) postpran-

dially. Follow-up was scheduled at the OOOW some

days later, including a visit to an obstetrician who

also performed an ultrasound in cases �/28 gesta-

tional weeks. The blood glucose levels, changed diet

regimen and physical activities were followed up and

revised in dialogue between the woman and the

‘diabetes midwife’. When lifestyle changes were

sufficient to normalise blood glucose levels, the

woman continued her visits to the primary antenatal

clinic. Twice a week, she monitored blood glucose

levels six times daily as prescribed above, and had

telephone contact with the diabetes midwife at the

OOOW every other week in order to follow up

glucose levels, be given additional advice on diet and

physical activities and engage in dialogue according

to her needs. Ultrasound, including estimation of

weight and amniotic fluid index, was performed

every 4 weeks, beginning from 28 gestational weeks.

If treatment with diet and physical activities was

insufficient, insulin treatment was added and the

woman terminated her contact with the primary

antenatal clinic. Her antenatal care, including the

GDM treatment, was taken over by a multidisci-

plinary team consisting of a diabetes midwife, a

diabetologist, and an obstetrician specially trained in

diabetology, at the hospital’s antenatal specialist out-

patient department. Mealtime insulin (human in-

sulin or analogue) was initiated at postprandial

glycemic increases of �/2 mmol/l (target value

B/8 mmol/l), and bedtime insulin (Neutral Prota-

mine Hagedon; NPH) was prescribed if fasting

glucose levels were �/6 mmol/l. If there were

problems normalising preprandial blood glucose

levels, treatment with NPH insulin was also given

in the morning.

At term, the woman saw the obstetrician in order

to review the pregnancy and plan for delivery. The

first choice was spontaneous vaginal delivery at a

special high-risk delivery ward. After birth, rooming-

in was the norm and early breastfeeding/supplemen-

tary formula, and strict blood glucose monitoring of

the neonate were routine. The woman returned to

284 M. Berg et al.

her ordinary diet and checked blood glucose levels

after at least 24 h to ensure a normal range.

The study population consisted of all women with

GDM identified and treated according to the rou-

tines described above during the period July 1 1998

to June 30 2002, who gave birth at SUH. Among the

included women, 15 gave birth twice during the

study period.

Analysis

Maternal, delivery and neonatal outcomes in the

study group were compared with a control group

consisting of all other women (without signs of

GDM) giving birth during the same period at the

same hospital (SUH controls). Data was available

from hospital records and the Swedish Medical Birth

Register [MBR] (12).

The European Pregnancy Study Group (10) has

suggested a 2-h OGTT ]/9.0 mmol/l (165 mg/dl) as

the diagnostic criterion for GDM. We, therefore,

stratified the GDM subjects into two subgroups for

analysis, according to the blood glucose level at

diagnosis, ie, (1) GDM-mild: fasting glucose B/6.1

mmol/l (111 mg/dl) and 2-h OGTT 7.8�8.9 mmol/

L (142�163 mg/dl), and (2) GDM-severe: RCG ]/

11.1 mmol/l (203 mg/dl), or fasting glucose �/

¯6.1

mmol/l (111 mg/dl) preceding OGTT, or 2-h

OGTT ]/9 mmol/l (165 mg/dl). For the sake of

completeness, we also present the GDM-composite

group.

Statistical analyses were performed using the

statistical software package (SPSS). Descriptive

statistics were performed for all variables. The x2-

test (Pearson x2), odds ratio with 95% confidence

interval were applied for analyse categorical vari-

ables. Analysis of variance [ANOVA] was used for

continuous variables, as well as the t-test when

assumptions of normality were met. Otherwise, the

Wilcoxon test was performed. The Bonferroni ad-

justment procedure was used to control for multiple

testing. p-Values B/0.05 were regarded as signifi-

cant. Body mass index [BMI] was calculated from

height and weight at the first visit to the antenatal

clinic.

Results

Prevalence and week for diagnosis

During the observational period, 31,542 deliveries,

resulting in 32,176 children, took place at SUH.

GDM was diagnosed in 719 women (699 singleton

mothers) resulting in 741 children, corresponding to

2.28% of the whole population. Of these, 84.4%

(n�/ 607) were treated with diet only and 15.6%

(n�/ 112) were also treated with insulin. The mean

gestational age at GDM diagnosis was 27 weeks and

5 days, 59.8% (n�/ 430) were diagnosed as GDM-

mild and 40.2% (n�/ 289) as GDM-severe. Signifi-

cantly more women, 26.0% (n�/ 75), with GDM-

severe needed insulin treatment compared to 8.6%

(n�/ 37) in the GDM-mild group (pB/ 0.001).

Maternal characteristics and delivery outcome

Maternal characteristics and delivery outcomes are

presented in Tables I �IV. Many of the women with

GDM were of non-Nordic origin (44.5%, n�/ 320),

and significantly more women in this group had

GDM-severe, 49.1% (n�/157) compared to 33.1%

(n�/ 132) (pB/ 0.001) among the Nordic women. No

information concerning ethnic origin in the SUH

control group was available, but 25.3% of women of

fertile age (age 15�45) were of non-Nordic origin in

the city of Goteborg (the main geographic area of the

study) at the time (Personal communication, Mar-

ianne Tedeholm, Goteborg Statistics).

Women with GDM were older and of higher parity

than those in the SUH-control group. Obesity was

more frequent in the GDM-mild and GDM-severe

groups than in the control group (18.5 and 29.6%

versus 8.3%). The need for insulin treatment in-

creased with increasing BMI. Among women with

normal weight (BMI B/25 kg/m2), 9.6% (n�/ 33)

required insulin, compared to 31.9% (n�/ 52) in the

obese group (pB/0.001). Pre-eclampsia, induction

of labour and elective caesarean section in both

groups was more frequent than in the control group.

Neonatal characteristics

Neonatal characteristics are presented in Tables V

and VI. There was a significant difference in mean

birth weight when dividing in weight classes based

on growth standards for a Swedish population (13),

including ‘small for gestational age’ [SGA] defined

as B/�2 SD and ‘large for gestational age’ [LGA]

defined as �/2 SD. Both GDM groups had lower

frequency of average weight for gestational age

[AGA]. The LGA frequency was 10.5% in the

GDM-severe group, and 7.1% in the GDM-compo-

site group, compared to 3.2% in the control group.

There were significantly more infants with Apgar

scores B/7 at 5 min in the GDM-severe group than

in the control group (2.7 versus 0.8%, OR: 3.25)

and well as in the GDM-composite group (1.8

versus 0.8%, OR: 2.10). There were two stillbirths

in the GDM-mild group (chromosome fault and

abruption of placenta), and none in the GDM-severe

Gestational diabetes; antenatal teamwork 285

group, compared to 157 among the controls. Un-

fortunately, data on neonatal complications such as

jaundice and hypoglycemia, was not available due to

insufficient hospital records.

Discussion

In this observational retrospective study, it was

concluded that the pregnancy outcome of women

with GDM differs from that of a control group of

women from the same unit. This is in agreement

with other studies in which GDM women, despite

various treatments, are more likely to suffer maternal

and fetal complications (3,14,15).

Our choosing to analyse the results in two

subgroups, GDM-mild and GDM-severe, seems

appropriate as earlier studies (14,16) suggest that

women with 2-h OGTT ]/7.8�9. 0 mmol/l (142�165 mg/dl) (GDM-mild) should not be the objects

of intervention. More knowledge is needed concern-

ing the glucose level at which metabolic disorders

affect mother and child, knowledge which will

hopefully evolve from the Hyperglycemia and Ad-

verse Pregnancy Outcome study (17).

One of the most important outcomes in our study

is the low frequency of LGA and macrosomia. It is

considerable lower compared to data 10 years ago,

when we used another model of treatment (unpub-

lished data). First, we compare our result with

studies on untreated GDM. In Swedish studies by

Nord et al. (16) and Ostlund et al. (18), using the

same criterion for LGA (�/2 SD), the frequency of

LGA infants was 10.8% in a group with 2-h OGTT

]/8.0�8.9 (147�163 mg/dl) (16), and 25% in a

group with 2-h OGTT ]/9.0�11.0 (165�201 mg/

dl) (18). In our study, the frequency of LGA

neonates was 4.8 and 10.5% in the group with 2-h

OGTT ]/7.8�8.9 mmol/l (GDM-mild), and ]/9.0

(GDM-severe), respectively. In the composite

GDM-group, the frequency was 7.1%. As the

definition of LGA varies globally, frequency of

macrosomia may be a useful variable when compar-

ing different studies. In a large Danish cohort study

by Jensen et al. (14), 33.9% of the infants born to

the group of women with 2-h OGTT ]/7.8�8.9

(142�163 mg/dl) and with no intervention had birth

weights over 4000 g. This can be compared to

14.3% for the corresponding group of women who

were the objects of active intervention in our study

(GDM-mild). In the Swedish study by Ostlund et al.

(18), 33% had macrosomia compared to 21.8% in

our corresponding group (GDM-severe).

Table I. Maternal characteristics according to glucose level at diagnosis.

GDM-mild

(n�/ 430)

GDM-severe

(n�/ 289)

SUH-control

group

(n�/ 30823)$ p -value

OR (95% CI)

GDM-mild/SUH-

control group

OR (95% CI)

GDM-severe/SUH-

control group

Maternal age (years) 31.89/4.9 32.09/5.0 30.19/5.0

(n�/ 30793)$$B/0.001 NA NA

BMI* (kg/m2) 26.79/8.8 27.89/9.5 24.19/4.0

(n�/ 19758)$$B/0.001 NA NA

BMI B/25 kg/m2 51.5 (217) 43.6 (125) 67.7 (13384)

(n�/ 19758)

B/0.001 0.49

(0.40, 0.59)

0.36

(0.29, 0.46)

255/BMIB/30 kg/m2 29.9 (126) 26.8 (77) 24.0 (4742)

(n�/ 19758)

0.0241 1.31

(1.1, 1.62)

1.15

(0.89, 1.50)

BMI �/

¯30 kg/m2 18.5 (78) 29.6 (85) 8.3 (1632)

(n�/ 19758)

B/0.0001 2.46

(1.92, 3.16)

4.63

(3.58, 6.00)

Parity** (No.) 2.09/1.3 2.29/1.4 1.79/0.9

(n�/ 31291)$$B/0.0001 NA NA

Smoking* 3.8 (16)

(n�/ 419)

8.2 (23)

(n�/ 281)

10.6 (3104)

(n�/ 29159)$$B/0.0001 0.33

(0.20, 0.55)

0.75

(0.49, 1.15)

Pre-pregnancy

hypertension

0.5 (2) 0.7 (2) 0.3 (99)

(n�/ 31514)$$NS 1.48

(0.37, 6.03)

2.21

(0.54, 9.01)

Pregnancy-induced

hypertension

1.9 (8) 1.4 (4) 0.5 (169)

(n�/ 31514)$$0.0002 3.52

(1.72, 7.19)

2.60

(0.96, 7.06)

Pre-eclampsia 5.1 (22) 6.6 (19) 2.9 (920)

(n�/ 31514)$$B/0.0001 1.79

(1.16, 2.77)

2.34

(1.46, 3.74)

$The GDM group is excluded except for parity, pre-pregnancy hypertension, pre-pregnancy hypertension and pre-eclampsia.$$From the MBR. Personal communication, Frida Lundblad, MBR, September 2005.

*BMI and smoking at first visit at the antenatal clinic. BMI B/25 kg/m2�/normal weight, 255/BMIB/30 kg/m2�/overweight, BMI ]/30 kg/

m2�/obesity.

**Parity: after the present delivery.

Data are given as mean9/SD, or rate% (n ). Significance test p�/ B/0.05 (x2 or variance test) for all three groups.

286 M. Berg et al.

This comparison indicates that treatment of GDM

reduces macrosomia/LGA, as has been shown in

other studies. Furthermore, we have compared our

results with studies on treated GDM. In a large case-

control study (19), the frequency of LGA and

macrosomia and composite neonatal outcome in

treated cases of GDM approached that in the group

of non-diabetic subjects, in contrast to untreated

cases. The frequency of macrosomia was 7% in the

treated group, compared to 17% in the untreated

group (19). It is difficult to compare this with the

results of our study, as the study groups differ. The

criteria for diagnosis of GDM differ and there are

considerable differences in ethnicity; 86% of the

subjects in the above-mentioned study were Hispa-

nic. A randomised, multi-centre, study with similar

inclusion criteria as in our GDM-composite group

(2-h OGTT 7.8�11.0 mmol; 142�200 mg/dl) has

recently been presented (20). The frequency of

macrosomia in the treatment group was 10%,

compared with 17.3% in our GDM-composite

group. The difference may be due to diverse study

populations, eg, 19% of Asian origin compared to

44.5% of non-Nordic origin in our study. Moreover,

Table III. Maternal characteristics in GDM-composite group versus SUH-control group.

GDM-composite

group (n�/ 719)

(98�02)

SUH-control

group

(n�/ 30,823)$ p -Value

OR (95% CI)

GDM-composite

group/SUH-control

group

Maternal age (years) 31.99/5.0 30.19/5.0 (n�/ 30,793)$$ 0.0000 NA

BMI* (kg/m2) 27.19/9.1 24.19/4.0 (n�/ 19,758)$$ 0.0000 NA

BMI B/25 kg/m2 48.3 (342) 67.7 (13,384) (n�/ 19,758) 0.0000 0.43 (0.37, 0.50)

255/BMIB/30 kg/m2 28.7 (203) 24.0 (4742) (n�/ 19,758) 0.0092 1.25 (1.06, 1.47)

BMI ]/30 kg/m2 23 (163) 8.3 (1632) (n�/ 19,758) 0.0000 3.26 (2.72, 3.91)

Parity** (No.) 2.19/1.3 1.79/0.9 (n�/ 31,291)$$ 0.0000 NA

Smoking* 5.6 (39) (n�/ 700) 10.6 (3104) (n�/ 29,159)$$ 0.0000 0.48 (0.35, 0.67)

Pre-pregnancy hypertension 0.6 (4) 0.3 (99) (n�/ 31,514)$$ NS 1.78 (0.65, 4.84)

Pregnancy-induced hypertension 1.7 (12) 0.5 (169) (n�/ 31,514)$$ 0.0001 3.15 (1.75, 5.68)

Pre-eclampsia 5.7 (41) 2.9 (920) (n�/ 31,514)$$ 0.0000 2.01 (1.46, 2.78)

$The GDM group is excluded except for parity, pre-pregnancy hypertension, pre-pregnancy hypertension and pre-eclampsia.

*BMI and smoking at first visit at the antenatal clinic. BMI B/25 kg/m2�/normal weight, 255/BMIB/30 kg/m2�/overweight, BMI ]/30 kg/

m2�/obesity.

**Parity: after the present delivery.$$From the MBR. Personal communication, Frida Lundblad, MBR, September 2005.

Data are given as mean9/SD or rate% (n ). Significance test p�/ B/0.05 (x2 or t -test).

Table II. Delivery outcomes according to glucose level at diagnosis.

GDM-mild

(n�/ 430)

GDM-severe

(n�/ 289)

SUH-control

group

(n�/ 30,823) p -Value

OR (95% CI)

GDM-mild/

SUH-control group

OR (95% CI)

GDM-severe/

SUH-control group

Delivery gestational

age (weeks)

39.49/1.9 39.29/1.6 39.19/2.2

(n�/ 28,849)

B/0.0001 NA NA

Premature delivery

B/37 week

8.4 (36) 6.9 (20) 8.0 (2315)

(n�/ 28,847)

NS 1.05

(0.74, 1.48)

0.85

(0.54, 1.35)

Induction of labour 16.7 (72) 17.0 (49) 10.7 (3297)

(n�/ 30,820)

B/0.0001 1.68

(1.30, 2.17)

1.70

(1.25, 2.32)

Spontaneous delivery 70.2 (302) 65.7 (190) 81.0 (24,963)

(n�/ 30,820)

B/0.0001 0.55

(0.45, 0.68)

0.45

(0.35, 0.58)

Vaginal delivery,

non-instrumental

77.7 (334) 73.7 (213) 79.2 (24,418)

(n�/ 30, 820)

0.0529 0.91

(0.73, 1.15)

0.73

(0.57, 0.96)

Instrumental vaginal

delivery

6.5 (28) 5.9 (17) 5.5 (1681)

(n�/ 30,820)

NS 1.21

(0.82, 1.78)

1.08

(0.66, 1.77)

Emergency caesarean

section

7.0 (30) 8.3 (24) 8.6 (2664)

(n�/ 30,820)

NS 0.79

(0.55, 1.15)

0.96

(0.63, 1.46)

Elective caesarean

section

8.8 (38) 12.1 (35) 6.5 (1993)

(n�/ 30,820)

B/0.0001 1.40

(1.00, 1.96)

1.99

(1.40, 2.85)

Data are given as mean9/SD, or rate% (n ). Significance test p�/ B/0.05 (x2 or variance test) for all three groups.

Gestational diabetes; antenatal teamwork 287

different frequencies of insulin treatment (20 versus

15.6%) cannot be ruled out as an explanation for the

lower macrosomia frequency in their study.

We found a significantly increased rate of induc-

tion of labour in the GDM-mild and -severe groups

compared to the controls (16.7 and 17.0%, respec-

tively, versus 10.7%) (Table II). The rates of elective

caesarean section were also increased in both groups

(8.8 and 12.1%, respectively, versus 6.5%). One

may speculate that the obstetrician’s knowledge of

GDM diagnosis makes him/her more inclined to

intervene. However, the total caesarean rate, includ-

ing emergency and elective procedures, of 17.6% for

the composite GDM group and 15.1% for the SUH

control group is much lower than that generally

described (18,20), and points to the fact that

Sweden, in an international perspective, still has a

comparably low caesarean section rate.

Different models of treatment of GDM are

proposed in the literature. Bonomo et al. (21) has

shown, in a randomised trial study, that flexible

ultrasound-based approach to the treatment of

GDM is more effective than conventional manage-

ment focusing glycemia. They used fetal abdominal

circumference, showing indirect evidence of fetal

hyperinsulinisation, as an indication for the use of

insulin treatment. However, Schaeffer et al. (22), in

their randomised trial study, has found that GDM

management, based on strict maternal glycemia

criteria alone, provides outcomes equivalent to

Table IV. Delivery outcomes in GDM-composite group versus SUH-control group.

GDM composite group

(n�/ 719)

SUH-control

group (n�/ 30,823) p -Value

OR (95% CI) GDM

composite group/

SUH-control group

Delivery gestational age (weeks) 39.39/1.8 39.19/2.2 (n�/ 28,849) 0.0029 NA

Premature delivery B/37 week 7.8 (56) 8.0 (2315) (n�/ 28,847) NS 0.97 (0.74, 1.28)

Induction of labour 16.8 (121) 10.7 (3297) (n�/ 30,820) 0.0000 1.69 (1.39, 2.06)

Spontaneous delivery 68.4 (492) 81.0 (24,963) (n�/ 30,820) 0.0000 0.51 (0.43, 0.60)

Vaginal delivery, non-instrumental 76.1 (547) 79.2 (24,418) (n�/ 30,820) 0.0398 0.83 (0.70, 0.99)

Instrumental vaginal delivery 6.3 (45) 5.5 (1681) (n�/ 30,820) NS 1.16 (0.85, 1.57)

Emergency caesarean section 7.5 (54) 8.6 (2664) (n�/ 30,820) NS 0.86 (0.65, 1.14)

Elective caesarean section 10.2 (73) 6.5 (1993) (n�/ 30,820) 0.0001 1.63 (1.28, 2.09)

Data are given as mean9/SD or rate% (n ). Significance test p�/ B/0.05 (x 2 or t -test).

Table V. Neonatal characteristics, according to glucose level at diagnosis.

Mode of delivery

GDM-mild

(n�/ 443)

GDM-severe

(n�/ 298)

SUH-control

group

(n�/ 31,435) p -Value

OR (95% CI)

GDM-mild/

SUH-control

group

OR (95% CI) GDM-

severe/SUH-control

group

Birth weight (g) 3422.99/588.7 3515.59/620.6 3472.69/619.7

(n�/ 28,959)

0.0139$ NA NA

Birth weight ]/4000 g 14.3 (62) 21.8 (64)* 16.9 (4812)

(n�/ 28,958)

0.0264 0.82

(0.62, 1.07)

1.37

(1.04, 1.81)

Birth weight ]/4500 g 2.7 (12) 6.4 (19)* 3.2 (922)

(n�/ 28,958)

0.0066 0.85

(0.48, 1.51)

2.07

(1.30, 3.31)

Birth weight ]/5000 g 0.5 (2) 0.3 (1) 0.4 (121)

(n�/ 28,958)

NS 1.08

(0.27, 4.39)

0.80

(0.11, 5.76)

LGA �/�/2 SD 4.8 (21) 10.5 (31)* 3.2 (900)

(n�/ 28,535)

B/0.0001 1.53

(0.98, 2.38)

3.57

(2.44, 5.20)

SGA B/�2 SD 5.3 (23) 3.7 (11) 3.5 (1008)

(n�/ 28,535)

NS 1.50

(0,98, 2,29)

1,05

(0,57, 1,92)

AGA ]/�2SD, 5/�/2 SD 89.9 (391)* 85.7 (252)* 93.3 (26627)

(n�/ 28,535)

B/0.0001 0.54

(0.40, 0.72)

0.39

(0.29, 0.54)

Apgar score B/4 at 5 min 0.9 (4)* 0.7 (2) 0.3 (93)

(n�/ 31,435)

0.0376 3.08

(1.13, 8.40)

2.28

(0.56, 9.30)

Apgar score B/7 at 5 min 1.1 (5) 2.7 (8)* 0.8 (265)

(n�/ 31,435)

0.0024 1.35

(0.55, 3.27)

3.25

(1.59, 6.63)

$The adjusted Bonferroni p -value is not significant.

*Statistical significant difference comparing sub-group versus SUH-control group.

Data are given as mean9/SD, or rate% (n ). Significance test p�/ B/0.05 (x2 or variance test) for all three groups.

288 M. Berg et al.

management based on fetal growth combined with

high glycemic criteria. The treatment in our study

was based on strict maternal glycemic criteria, but

also included a high degree of women’s participation

in and responsibility for their own treatment. This

increased their consciousness of relationship be-

tween lifestyle (diet and physical activities) and

blood glucose level. They were also informed about

the increased risk for future type 2 diabetes and were

encouraged to continue the ‘healthy lifestyle’ and

strive for normal weight as a tool to prevent type 2

diabetes.

Our study included early universal screening for

GDM, which is found beneficial as it is associated

with a decrease in adverse fetal outcomes (23,24). As

a consequence of early screening and diagnosis, a

larger proportion of pregnant women in our study

started their treatment early compared with other

studies. This provided more time for intervention

before term, in contrast to a screening procedure and

intervention late in pregnancy. It has been shown

that early diagnosis of GDM is a predictor of adverse

maternal and neonatal outcome (23,25), and that

early intervention to improve glucose homeostasis

may prevent some complications commonly related

to pregestational diabetes (23).

It is well-known that GDM covaries with higher

BMI. The rising incidence of obesity in society is

apparent and frequently discussed and, furthermore,

one would expect a rising incidence of GDM in the

population. Moreover, the need for insulin treatment

was found to be much higher in obese patients in our

study. It has been suggested that intense insulin

treatment improves outcome in this group (26,27).

Our impression is that early screening, early

intervention and out-patient treatment by a multi-

disciplinary team, including specially trained dia-

betes midwives and a participative woman, is highly

beneficial. This model of care yields low rates of

excessive fetal growth, instrumental vaginal delivery

and caesarean section, comparable to those found in

other studies.

Acknowledgements

The study was supported by grants from Swedish

Diabetes Association.

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