Background  
The countries and associations introduced several guidelines to diagnose gestational diabetes mellitus (GDM). After many years, the International Association of Diabetes in Pregnancy Study Group (IADPSG) is the latest guideline. This study group suggests that anyone value of OGTT with 75 g glucose may be diagnosed as GDM based on Odd Ratio (OR) 1.75, but it does not happen on the ground. Center-to-center differences occur in GDM frequency and relative diagnostic importance of fasting, 1-hour and 2-hour glucose levels, which may impact different strategies for diagnosing GDM.%26nbsp; In the IADPSG consensus panel, a few countries suggested OR 1.5 for diagnosing GDM. The outcome of a study found the prevalence of GDM was almost the same by following OR 1.5 whether it is in the fasting, 1 hour or 2 hours, which is the idea of suggesting anyone value to diagnose GDM.

Aim  
  
The outcome of a study found the prevalence of GDM was almost the same by following OR 1.5 whether it is in the fasting, 1 hour or 2 hours, which is the idea of suggesting anyone value to diagnose GDM.

Method  
Where is the problem, and What is the problem for not universally accepting IADPSG guidelines? We analyzed our data of n = 1463 antenatal women who underwent OGTT with 75g oral glucose. In this cohort, the cumulative prevalence of GDM was 14.60% based on the IADPSG methodology.

TABLE -1:

[ Table Removed ]

Results  
  


TABLE – 2:

[ Table Removed ]

 The methodology of working out the prevalence of GDM by applying OR 1.5, which few countries suggested during consensus meeting at Pasadena, USA:

TABLE 3: If IADPSG had accepted OR 1.5, the prevalence would be the same for FPG, 1 hr, and 2 hr.

 

[ Table Removed ]

Discussion  
All the diagnostic criteria require women to be in fasting, but most of the time, pregnant women do not come in the fasting state because of commutation(18). Many health services, especially in low-resource settings, cannot routinely perform an OGTT in pregnant women. The guidelines and diagnostic criteria which are feasible and straightforward on the ground are essential. as the procedure of following OR 1.5 is cost-effective and suitable for the population belonging to any economic status.

References  
1. International Diabetes Federation (IDF), Atlas Ninth edition2019. The online version of IDF Diabetes Atlas. www.diabetesatlas.org  
  
2. International Association of Diabetes &amp; Pregnancy Study Groups (IADPSG) Recommendations on diagnosing and classifying hyperglycemia in pregnancy. IADPSG Consensus panel, Diabetes Care 33 (3), 2010.  
  
3. Annunziata Lapolla, Boyd E. Metzger. The post-HAPO situation with gestational diabetes: the bright and dark sides- Acta Diabetologica (2018) 55:885-892. September 2018, Volume 55.  
  
4. Samantha F. Ehrlich, Assiamira Ferrara, Monique M. Hedderson, Juanran Feng and Romain Neugebauer. Exercise During the First Trimester of Pregnancy and the Risks of Abnormal Screening and Gestational Diabetes Mellitus https://doi.org/10.2337/dc20-1475.  
  
5. Gestational Diabetes Mellitus American Diabetes Association. Diabetes Care 2002 Jan; 25(suppl 1): s94-s96.https://doi.org/10.2337/diacare.25.2007.S94.  
  
6. Dornhost, M. Rossi Rossi and prevention of type 2 diabetes in women with gestational diabetes. Diabetes Care 21 (Supppl.2) (1998) B43-B49.  
  
7. Asslamira Ferrara. Increasing prevalence of GDM Diabetes Care 30 (2): 2007.S141- 146.  
  
8. Kristina Fiore. The United States Preventive Service Taskforce (USPSTF) backs Universal diabetes Screening. Jan 13, 2014.  
  
9. Sacks DA, Hadden DR, Maresh M, et al. Frequency of Gestational Diabetes Mellitus at collaboration centers based on IADPSG consensus panel-recommended criteria: the hyperglycemia and adverse pregnancy outcome (HAPO) study. Diabetes Care 2012; 35:526-8.  
  
10. Elliot Marseille 1, Nicolai Lohse 2, Aliya Jiwani1, Moshe Hod3, V Seshiah4, Chittaranjan S. Yajnik5, Geeti Puri Arora6, V Balaji4, Ole Henriksen7, Nicky Lieberman8, Rony Chen3, Peter Damm9, Boyd E. Metzger10, and James G. Kahn11 – The Cost-effectiveness of gestational diabetes screening including prevention of type 2 diabetes: application of a new model in India and Israel J Matern Fetal Neonatal Med 2013;26(8):802-10.  
  
11. Anjalakshi C, Balaji V, Balaji MS, et al. A single test procedure to diagnose gestational diabetes mellitus. Acta Diabetol. 2009;46(1):51-4.   
  
12. Paul W. Franks, Helen C. Looker, Sayuko Kobes, Leslie Touger, P. Antonio Tataranni, Robert L. Hanson, and William C. Knowler. Gestational Glucose Tolerance and Risk of Type 2 Diabetes in Young Pima Indian Offspring. Diabetes 2006 55: 460 -465.   
  
13. Petit et al. (12) used the non-fasting 2hour 75 g OGTT Long term effects on offspring, Diabetes 1991;40(suppl 2):126-30.   
  
14. Karolin Karglund Nelson, Anil Kapur, V. Seshiah et al. Factors influencing timely initiation and completion of Gestational Diabetes mellitus screening and diagnosis. BMC Pregnancy and childbirth Aug 1, 2017.   
  
15. Wahi P, Dogra V, Jandial K, Bhagat R, Gupta R, Gupta S, Wakhloo A, Singh J. Prevalence of gestational diabetes mellitus (GDM) and its outcomes in Jammu region. J AssocPhysicians India 2011; 59:227-30.   
  
16. National Institute for Health and Care Excellence. Diabetes in pregnancy: management from preconception to the postnatal period NICE guideline Published: Feb 25, 2015, nice.org.uk/guidance/ng3.   
  
17. Maternal Health Division Ministry of Health &amp; Family Welfare Government of India, www.mohfw.gov.in &amp; www.nhm.gov.in. February 2018.   
  
18. Strategies for Implementing the WHO Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy. Stephen Colagiuri, Maicon Falavigna, Mukesh M. Agarwal, Michel Boulvain, Edward Coetzee, Moshe Hod, Sara Meltzer, Boyd Metzger, Yasue Omori, Ingvars Rasa, Maria Inês, Veerasamy Seshiah, David Simmons, Eugene Sobngwi, Maria Regina Torloni, Hui-Xia Yang. DRCP. 103 (2014) 364-372.   
  
19. Moshe HOD, Anil Kapur, David A. Sacks, Eran Hadar, Mukesh Agarwal, Gian Carlo Di Renzo, Luis Cabero Ruaro, Harold David McIntyre, Jessica L. Morris, Hema Divakar: 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 Oct;131 Supply 3: S173-211. DOI: 10.1016/S0020-7292(15)30033-3.   
  
20. Chittaranjan N Purandare (FIGO), Shaukat Sadikot (IDF), Nam Cho Han (IDF), Moshe Hod (FIGO). FIGO-IDF Joint Statement and Declaration on Hyperglycemia in Pregnancy. IDF Congress. Abu Dhabi, Dec 6, 2017. www.diabetesatlas.org / atlas@idf.org .   
  
21. Gestational Diabetes Mellitus- Indian Guidelines. Journal of Indian Medical Association (JIMA) November 2009, 107 (11); 799- 806.



**Background**
The countries and associations introduced several guidelines to diagnose gestational diabetes mellitus (GDM). After many years, the International Association of Diabetes in Pregnancy Study Group (IADPSG) is the latest guideline. This study group suggests that anyone value of OGTT with 75 g glucose may be diagnosed as GDM based on Odd Ratio (OR) 1.75, but it does not happen on the ground. Center-to-center differences occur in GDM frequency and relative diagnostic importance of fasting, 1-hour and 2-hour glucose levels, which may impact different strategies for diagnosing GDM.  In the IADPSG consensus panel, a few countries suggested OR 1.5 for diagnosing GDM. The outcome of a study found the prevalence of GDM was almost the same by following OR 1.5 whether it is in the fasting, 1 hour or 2 hours, which is the idea of suggesting anyone value to diagnose GDM.
**Aim**
The outcome of a study found the prevalence of GDM was almost the same by following OR 1.5 whether it is in the fasting, 1 hour or 2 hours, which is the idea of suggesting anyone value to diagnose GDM.
**Method:**
Where is the problem, and What is the problem for not universally accepting IADPSG guidelines?
We analyzed our data of n = 1463 antenatal women who underwent OGTT with 75g oral glucose. In this cohort, the cumulative prevalence of GDM was 14.60% based on the IADPSG methodology( Table 1).
IADPSG recommends that GDM be diagnosed if any one value is abnormal in OGTT. In this procedure, as depicted in Table 2, the prevalence is different in the fasting, 1 hour and 2-hour. Unless the value is closer to each other this recommendation is not conducive.  Suggesting any one value to diagnose GDM is applicable only when fasting 1 hour and 2-hour is closer. This is possible only if OR 1.5 is implemented to diagnose GDM, that is, FPG ≥ 90 mg/dl (5 mmol/l), 1-hour: ≥ 160 mg/dl (8.8 mmol/l), 2-hour: ≥ 140 mg/dl (7.8 mmol/l) with 75g OGTT. (Table 3)

**Table 1: Steps    Working methodology No of GDM**
**STEP 1    FPG > 92 mg/dl is 136 (9.30%)   9.30%**
**STEP 2    Detect 136 form 1463 and the balance is 1327. Out of 1327 1hr PG > 180 mg/dl is 36 (2.46%). 2.46%**
**STEP 3    Detect 36 from 1327 and the balance is 1291. Out of 1291 2hr PG > 153 mg/dl is 42 (2.87%).  2.87%**
** Total cumulative prevalence = 14.60%**

**Table 2:S.no  Working methodology N =1463 No of antenatal women   (Percentage)**
**1 Only FPG ≥ 92 mg/dl 136                        (9.30%)**
**2 Only 1hr PG ≥ 180 mg/dl 65                  (4.40%)**
**3 Only 2hr PG ≥ 153 mg/dl 98                  (6.70%)**
** Total cumulative prevalence 299     (20.40%)**

**TABLE 3: If IADPSG had accepted OR 1.5, the prevalence would be the same for FPG, 1 hr, and 2 hr.**
**S.no  Working methodology n =1463 No of antenatal women   (Percentage)**
**1 Only FPG ≥ 90 mg/dl        183                 (12.50%)**
**2 Only 1hr PG ≥ 160 mg/dl 190                (12.90%)**
**3 Only 2hr PG ≥ 140 mg/dl 196                 (13.40%)**




**Conclusion:**
All the diagnostic criteria require women to be in fasting, but most of the time, pregnant women do not come in the fasting state because of commutation18. Oral glucose tolerance test (OGTT) with 75 g glucose is resource-intensive. Many health services, especially in low-resource settings, cannot routinely perform an OGTT in pregnant women. In these circumstances, many health services do not test for hyperglycemia in pregnancy18. Therefore, options that do not involve an OGTT are required. The guidelines and diagnostic criteria which are feasible and straightforward on the ground are essential. Since anyone value of FPG 1 hr PG or 2 hr PG picks up the exact prevalence of GDM, there is no necessity for performing an OGTT, as the procedure of following OR 1.5 is cost-effective (Table 3) and suitable for the population belonging to any economic status. “A single-test procedure with a single glucose value,” which is a walk-in test to diagnose abnormal glucose tolerance in pregnancy, is rational, evidence-based, and causes negligible inconvenience to the expectant mother21.
**References**
1. International Diabetes Federation (IDF), Atlas Ninth edition2019. The online version of IDF Diabetes Atlas. www.diabetesatlas.org
2. International Association of Diabetes & Pregnancy Study Groups (IADPSG) Recommendations on diagnosing and classifying hyperglycemia in pregnancy. IADPSG Consensus panel, Diabetes Care 33 (3), 2010.
3. Annunziata Lapolla, Boyd E. Metzger. The post-HAPO situation with gestational diabetes: the bright and dark sides- Acta Diabetologica (2018) 55:885-892. September 2018, Volume 55.
4. Samantha F. Ehrlich, Assiamira Ferrara, Monique M. Hedderson, Juanran Feng and Romain Neugebauer. Exercise During the First Trimester of Pregnancy and the Risks of Abnormal Screening and Gestational Diabetes Mellitus https://doi.org/10.2337/dc20-1475.
5. Gestational Diabetes Mellitus American Diabetes Association. Diabetes Care 2002 Jan; 25(suppl 1): s94-s96.https://doi.org/10.2337/diacare.25.2007.S94.
6. Dornhost, M. Rossi Rossi and prevention of type 2 diabetes in women with gestational diabetes. Diabetes Care 21 (Supppl.2) (1998) B43-B49.
7. Asslamira Ferrara. Increasing prevalence of GDM Diabetes Care 30 (2): 2007.S141- 146.
8. Kristina Fiore. The United States Preventive Service Taskforce (USPSTF) backs Universal diabetes Screening. Jan 13, 2014.
9. Sacks DA, Hadden DR, Maresh M, et al. Frequency of Gestational Diabetes Mellitus at collaboration centers based on IADPSG consensus panel-recommended criteria: the hyperglycemia and adverse pregnancy outcome (HAPO) study. Diabetes Care 2012; 35:526-8.
10. Elliot Marseille 1, Nicolai Lohse 2, Aliya Jiwani1, Moshe Hod3, V Seshiah4, Chittaranjan S. Yajnik5, Geeti Puri Arora6, V Balaji4, Ole Henriksen7, Nicky Lieberman8, Rony Chen3, Peter Damm9, Boyd E. Metzger10, and James G. Kahn11 – The Cost-effectiveness of gestational diabetes screening including prevention of type 2 diabetes: application of a new model in India and Israel J Matern Fetal Neonatal Med 2013;26(8):802-10.
11. Anjalakshi C, Balaji V, Balaji MS, et al. A single test procedure to diagnose gestational diabetes mellitus. Acta Diabetol. 2009;46(1):51-4.
12. Paul W. Franks, Helen C. Looker, Sayuko Kobes, Leslie Touger, P. Antonio Tataranni, Robert L. Hanson, and William C. Knowler. Gestational Glucose Tolerance and Risk of Type 2 Diabetes in Young Pima Indian Offspring. Diabetes 2006 55: 460 -465.
13. Petit et al. (12) used the non-fasting 2hour 75 g OGTT Long term effects on offspring, Diabetes 1991;40(suppl 2):126-30.
14. Karolin Karglund Nelson, Anil Kapur, V. Seshiah et al. Factors influencing timely initiation and completion of Gestational Diabetes mellitus screening and diagnosis. BMC Pregnancy and childbirth Aug 1, 2017.
15. Wahi P, Dogra V, Jandial K, Bhagat R, Gupta R, Gupta S, Wakhloo A, Singh J. Prevalence of gestational diabetes mellitus (GDM) and its outcomes in Jammu region. J AssocPhysicians India 2011; 59:227-30.
16. National Institute for Health and Care Excellence. Diabetes in pregnancy: management from preconception to the postnatal period NICE guideline Published: Feb 25, 2015, nice.org.uk/guidance/ng3.
17. Maternal Health Division Ministry of Health & Family Welfare Government of India, www.mohfw.gov.in & www.nhm.gov.in. February 2018.
18. Strategies for Implementing the WHO Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy. Stephen Colagiuri, Maicon Falavigna, Mukesh M. Agarwal, Michel Boulvain, Edward Coetzee, Moshe Hod, Sara Meltzer, Boyd Metzger, Yasue Omori, Ingvars Rasa, Maria Inês, Veerasamy Seshiah, David Simmons, Eugene Sobngwi, Maria Regina Torloni, Hui-Xia Yang. DRCP. 103 (2014) 364-372.
19. Moshe HOD, Anil Kapur, David A. Sacks, Eran Hadar, Mukesh Agarwal, Gian Carlo Di Renzo, Luis Cabero Ruaro, Harold David McIntyre, Jessica L. Morris, Hema Divakar: 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 Oct;131 Supply 3: S173-211. DOI: 10.1016/S0020-7292(15)30033-3.
20. Chittaranjan N Purandare (FIGO), Shaukat Sadikot (IDF), Nam Cho Han (IDF), Moshe Hod (FIGO). FIGO-IDF Joint Statement and Declaration on Hyperglycemia in Pregnancy. IDF Congress. Abu Dhabi, Dec 6, 2017. www.diabetesatlas.org / atlas@idf.org .
21. Gestational Diabetes Mellitus- Indian Guidelines. Journal of Indian Medical Association (JIMA) November 2009, 107 (11); 799- 806.

Puzzle and Muddle in the Guidelines for Diagnosing Gestational Diabetes Mellitus-Efforts to Solve