Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
J Matern Fetal Neonatal Med. 2022 Dec;35(25):6430-6436. doi: 10.1080/14767058.2021.1914578. Epub 2021 May 27.
Screening strategies for gestational diabetes mellitus (GDM), particularly early GDM, have traditionally relied upon the use of clinical risk factors (CRFs). Although commonly used in nonpregnant patients, HbA1c screening is not widely used despite reports of abnormal HbA1c values being predictive of GDM development. The aims of this study are to assess the utility of universal HbA1c screening in predicting GDM and to compare universal screening to targeted CRF-based screening for the diagnosis of GDM.
This is a retrospective cohort study of patients undergoing universal HbA1c screening at ≤16 completed weeks gestation with a singleton pregnancy between December 2016 and April 2018 at a single urban tertiary care center. Patients with preexisting diabetes (HbA1c ≥6.5%) or patients who did not have glucose tolerance testing were excluded. Patients with HbA1c 5.7-6.4% underwent early two-step GDM screening. Positive screens were diagnosed with early GDM. Normal early screeners underwent repeat 3rd trimester screening. Clinical risk factors for early GDM screening at our institution prior to universal screening were history of GDM, body mass index (BMI) ≥40 kg/m, prior macrosomia (birth weight ≥4000 g) or stillbirth, and polycystic ovary syndrome. Multivariable regression was performed to assess the relationship between HbA1c and GDM. The predictive ability of universal HbA1c screening compared to that of CRFs was evaluated by testing for differences in the area under the curve (AUC) of receiver operating curves (ROCs).
One thousand nine hundred and fifteen patients met inclusion criteria. Two hundred and thirty-one (12.1%) patients had an elevated HbA1c ≥5.7%. Patients with elevated HbA1c were more likely to be older, Black, or obese compared with patients with normal HbA1c values. After adjusting for Black race, BMI, age, and public insurance, the odds of GDM development are 3.50 (95%CI 2.26-5.39) times higher among patients with HbA1c ≥5.7% compared to those with a normal HbA1c. Clinical risk factors for early glucose screening were present in 33% of patients with an elevated HbA1c. The AUC of CRF screening and HbA1c ≥5.7% was 0.72 and 0.75, respectively (= .07), after controlling for Black race, BMI, maternal age, and insurance.
An elevated HbA1c is associated with an increased risk of GDM. Universal HbA1c screening performs as favorably as CRF based screening for the prediction of GDM.
妊娠期糖尿病（GDM）的筛查策略，尤其是早期 GDM，传统上依赖于临床危险因素（CRF）的使用。尽管糖化血红蛋白（HbA1c）筛查在非妊娠患者中常被使用，但尽管有报道称异常的 HbA1c 值可预测 GDM 的发生，但其并未被广泛应用。本研究的目的是评估在预测 GDM 方面，普遍进行 HbA1c 筛查的效用，并将普遍筛查与针对 GDM 的基于目标 CRF 的筛查进行比较。
这是一项回顾性队列研究，纳入了 2016 年 12 月至 2018 年 4 月期间在一家城市三级保健中心进行普遍 HbA1c 筛查且单胎妊娠、≤16 周完成妊娠的患者。排除患有糖尿病（HbA1c≥6.5%）或未行葡萄糖耐量试验的患者。HbA1c 在 5.7-6.4%的患者进行早期两步 GDM 筛查。阳性筛查者诊断为早期 GDM。正常早期筛查者进行重复的 3 期筛查。本机构进行早期 GDM 筛查的 CRF 包括既往 GDM 史、体重指数（BMI）≥40kg/m2、既往巨大儿（出生体重≥4000g）或死胎，以及多囊卵巢综合征。采用多变量回归分析评估 HbA1c 与 GDM 之间的关系。通过检验受试者工作特征曲线（ROC）下面积（AUC）的差异，评估普遍进行 HbA1c 筛查与 CRF 筛查的预测能力。
符合纳入标准的患者共 1915 名。231 名（12.1%）患者的 HbA1c 升高≥5.7%。与 HbA1c 值正常的患者相比，HbA1c 升高的患者更年长、为黑人或肥胖。在调整了黑人种族、BMI、年龄和公共保险因素后，HbA1c≥5.7%的患者发生 GDM 的几率是 HbA1c 值正常患者的 3.50 倍（95%CI 2.26-5.39）。HbA1c 升高的患者中，有 33%存在早期葡萄糖筛查的 CRF。在控制了黑人种族、BMI、产妇年龄和保险因素后，CRF 筛查和 HbA1c≥5.7%的 AUC 分别为 0.72 和 0.75（=0.07）。
HbA1c 升高与 GDM 风险增加相关。普遍进行 HbA1c 筛查与基于 CRF 的筛查在预测 GDM 方面同样有效。
