Gestational Diabetes: Screening

Patient Population Under Consideration

This recommendation applies to pregnant persons who have not been previously diagnosed with type 1 or type 2 diabetes.

Definitions of Gestational Diabetes

During pregnancy, insulin resistance increases, leading to higher glucose intolerance and development of gestational diabetes in some pregnant persons. In the past, gestational diabetes was defined as glucose intolerance discovered during pregnancy; however, this definition does not distinguish between persons with glucose intolerance related to pregnancy and those with preexisting, overt diabetes that was previously undiagnosed.18 Because of this, several organizations, such as the American Diabetes Association, have updated the definition to specify gestational diabetes as diabetes that develops during pregnancy that is not clearly overt diabetes that developed prior to pregnancy.2,3 Screening for and treatment of undiagnosed type 2 diabetes in pregnant persons is not part of this recommendation.

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Assessment of Risk

Several factors increase a person’s risk for developing gestational diabetes, including obesity, increased maternal age, history of gestational diabetes, family history of diabetes, and belonging to a racial/ethnic group that is at increased risk for developing type 2 diabetes (Hispanic, Native American, South or East Asian, or Pacific Island descent).4,19,20 Factors associated with a lower risk for developing gestational diabetes include age younger than 25 to 30 years, White race, a body mass index (BMI) of 25 or less (calculated as weight in kilograms divided by height in meters squared), no family history (in a first-degree relative) of diabetes, and no history of glucose intolerance or adverse pregnancy outcomes related to gestational diabetes.21-23 The risk in different racial/ethnic groups may be due in part to social risk factors such as low socioeconomic status or structural racism, although these associations are not examined in the current evidence. Although a higher BMI increases the risk of gestational diabetes across racial/ethnic groups, the association varies. In Asian American persons, the prevalence of gestational diabetes at a BMI of 22 to less than 25 is similar to the prevalence in Hispanic persons, non-Hispanic White persons, and Black persons with a higher (>28) BMI.24,25

Screening Tests

Screening for gestational diabetes in asymptomatic persons involves either a 2-step (screening test followed by a diagnostic test) or 1-step (diagnostic test used for all patients) approach. In the US, a 2-step approach is commonly used.8,26 A 50-g oral glucose challenge test (OGCT) is performed between 24 and 28 weeks of gestation in a nonfasting state. If the screening threshold is met or exceeded, patients receive the oral glucose tolerance test (OGTT). During the OGTT, a fasting glucose level is obtained, followed by administration of a 75-g or 100-g glucose load, then evaluation of glucose levels after 1, 2, and often 3 hours. A diagnosis of gestational diabetes is made when 2 or more glucose values fall at or above the specified glucose thresholds.27

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In the 1-step approach, a 75-g glucose load is administered after a fasting glucose level is obtained, and plasma glucose levels are evaluated after 1 and 2 hours. A diagnosis of gestational diabetes is made when 1 or more glucose values fall at or above the specified glucose thresholds.28

Screening Intervals

There are limited data on the benefits and harms of screening before 24 weeks of gestation. The American College of Obstetricians and Gynecologists recommends testing between 24 and 28 weeks of gestation.1 Pregnant persons whose first prenatal visit happens after 28 weeks of gestation (ie, late entry into prenatal care) should be screened as soon as possible.

Treatment and Interventions

Initial treatment generally includes moderate physical activity, dietary changes, support from diabetes educators and nutritionists, and glucose monitoring. If the patient’s glucose is not controlled after these initial interventions, clinicians often prescribe medications (either insulin or oral hypoglycemic agents), perform increased surveillance in prenatal care, adopt changes in delivery management, or some combination thereof.1

Suggestions for Practice Regarding the I Statement

In deciding whether to screen for gestational diabetes before 24 weeks of gestation, primary care clinicians may consider the following.

Potential Preventable Burden

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Between 2006 and 2016, there was an absolute increase of 3.6% in the prevalence of gestational diabetes.7 Pregnant persons with gestational diabetes are at increased risk for maternal and fetal complications and may benefit from early identification and treatment. They are also at increased risk for developing type 2 diabetes after pregnancy.29 Pregnant persons who are diagnosed with gestational diabetes before 24 weeks of gestation may be at even greater risk for maternal and fetal complications.29

Potential Harms

Potential harms of screening for gestational diabetes include psychological harms (anxiety, depression), intensive medical interventions (induction of labor, cesarean delivery, or admission to the neonatal intensive care unit [NICU]), and negative hospital experiences related to labeling (reduction in breastfeeding and fewer newborns staying in the mother’s room) that may be associated with a diagnosis of gestational diabetes. Possible adverse effects of treatment include neonatal or maternal hypoglycemia, increased risk of small for gestational age infants, and maternal stress.

Current Practice

Although current data are limited, a 2014-2015 survey found that universal screening is the most common practice in the US, with 90% of obstetricians reporting routinely screening for gestational diabetes using a 2-step approach.26 Other potential (although not widely used) approaches to screening include fasting plasma glucose level, glycosylated hemoglobin (HbA1c) concentration, and risk-based screening tools. Some pregnant persons are screened earlier than 24 weeks of gestation because they have risk factors for type 2 diabetes, such as obesity, family history of type 2 diabetes, or fetal macrosomia during a previous pregnancy. If a pregnant person presents in the first trimester or in early pregnancy with risk factors for type 2 diabetes, clinicians should use their clinical judgment to determine what is appropriate screening for that individual patient, given the patient’s health needs.

Other Related USPSTF Recommendations

The USPSTF has several recommendations related to pregnancy and the prevention of gestational diabetes. This includes recommendations on screening for abnormal blood glucose levels and type 2 diabetes (B recommendation),30 behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults (B recommendation),31 and behavioral counseling interventions for healthy weight and weight gain during pregnancy (B recommendation).32

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