Original Investigation

25

Gestational diabetes mellitus screening and outcomes

Hale Lebriz Aktn, Derya Uyan, Betl Yorgunlar, Mustafa Acet
Department of Obstetrics and Gynecology, stanbul Medipol University Hospital, stanbul, Turkey

Abstract
Objective: To verify the usefulness of the World Health Organization criteria for the diagnosis of gestational diabetes mellitus in pregnant
women and its effectiveness in the prevention of maternal and neonatal adverse results in women younger than 35 years without apparent risk
factors for gestational diabetes mellitus.
Material and Methods: This is a retrospective study based on population involving 1360 pregnant women who delivered and who were
followed-up in a university hospital in Istanbul. All women underwent the 75-g oral glucose tolerance test screening, usually in between the 24th28th weeks of pregnancy. In all cases, the identification of gestational diabetes mellitus was determined in accordance with the World Health
Organization criteria.
Results: Approximately 28% of the pregnant women aged younger than 35 years with no risk factors for gestational diabetes mellitus were
diagnosed with the oral glucose tolerance test in this study. In the gestational diabetes mellitus group, the primary cesarean section rate was
importantly higher than that in the non-gestational diabetes mellitus group. Preterm delivery was also associated with gestational diabetes
mellitus. The diagnosis of gestational diabetes mellitus was strongly associated with admittance to the neonatal intensive care unit. Neonatal
respiratory problems didnt showed any significant deviation between the groups. There was a moderate association between gestational diabetes mellitus and metabolic complications.
Conclusion: Pregnant women with no obvious risk factors were diagnosed with gestational diabetes mellitus using the World Health Organization criteria. The treatment of these women potentially reduced their risk of adverse maternal and neonatal hyperglycemia-related events, such
as cesarean section, polyhydramnios, preterm delivery, admission to neonatal intensive care unit, large for gestational age, and higher neonatal
weight. (J Turk Ger Gynecol Assoc 2015; 16: 25-9)
Keywords: Gestation, diabetes mellitus, pregnancy, oral glucose tolerance test, neonatal outcomes

Received: 25 July, 2014

Accepted: 10 January, 2015

Introduction

Material and Methods

Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance with onset or first recognition during pregnancy (1). GDM is currently the most frequently diagnosed
metabolic disorder in pregnant women (2), and its incidence
is growing (3).
GDM is associated with several adverse pregnancy outcomes
with macrosomia, shoulder dystocia, and neonatal hypoglycemia being the most common serious complications.
Currently, there is no consensus on the screening criteria for
GDM, and no specific universally accepted protocol exists
with respect to the selective or global screening of pregnant women. Consequently, it is difficult to compare the
prevalence of GDM among various populations. In particular,
ethnicity has been proven to be an independent risk factor
for GDM (4, 5). The goals of this study were to verify the usefulness of the World Health Organization (WHO) criteria for
the diagnosis of GDM in a fragment of local population and
the effectiveness of these criteria in preventing maternal and
neonatal adverse outcomes in women younger than 35 years
old without obvious risk factors for GDM.

This was a retrospective population-based study involving

1360 pregnant women who delivered and who were observed
in a university hospital in Istanbul from September 2012 to
October 2013. Ethics Committee approval and informed consent has been taken.
All the subjects were younger than 35 years and had no
known risk factors for GDM. Women having chronic systemic
illnesses, preexisting diabetes (type 1 or type 2), or multifetal gestations were excluded. All the women underwent
oral glucose tolerance test (OGTT) screening between 24
and 28 weeks of pregnancy, and ultrasound examination
was made to determine gestational age. In all cases, GDM
was diagnosed according to the WHO criteria (4, 5). After a
minimum of 8 h of overnight fasting, blood for glucose level
determination was collected, after which the patient received
75 g glucose orally. An additional blood sample was collected
for glucose level determination 2 h later. The WHO criteria
define GDM as a fasting blood glucose >126 mg/dL, with a 2
h post dosing value >140 mg/dL. In case of GDM diagnosis,
the patients underwent individualized diet and/or insulin

Address for Correspondence: Hale Lebriz Aktn, Department of Obstetrics and Gynecology, stanbul Medipol University Hospital, stanbul, Turkey.
Phone: +90 532 291 91 96 e.mail: [email protected]
Copyright 2015 by the Turkish-German Gynecological Education and Research Foundation - Available online at www.jtgga.org
DOI:10.5152/jtgga.2015.15081

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Lebriz Aktn et al.

Gestational diabetes mellitus screening and outcomes

J Turk Ger Gynecol Assoc 2015; 16: 25-9

Table 1. Anthropometric, clinical, and biochemical features of all pregnant women in the study

GDM (n=380)

No GDM (n=980)

p value

Age (year)

29.33.4

30.83.2

<0.001

BMI (kg/m2)

22.91.9

21.41.9

<0.001

Gravida, n

2.50.7

2.50.6

0.934

Week at OGTT

27.11.2

27.10.8

0.230

Fasting glucose (mg/dL)

91.48.97

79.45.7

<0.001

2-h postprandial glucose (mg/dL)

140.521.8

111.618.9

<0.001

Weight gain at OGTT (kg)

9.83.4

7.02.7

<0.001

Weight gain at delivery (kg)

14.33.3

12.02.7

<0.001

Values are meanSD.

GDM: gestational diabetes mellitus; BMI: body mass index; OGTT: oral glucose tolerance test

treatment with self-observing of blood glucose levels (fasting

and 1 h after each meal) daily with a glucometer. Subsequent
follow-ups were conducted for all patients biweekly or more
frequently as indicated. Treatment outcomes were evaluated
according to the American Diabetes Association recommendations (6).
All demographic characteristics (age, parity, family history
of diabetes, and self-reported prepregnancy weight) of the
patients were obtained from their existing records. Birth mode
(cesarean or vaginal delivery) and labor induction, preterm
delivery (delivery before 37 weeks of gestation), gestational
hypertension, preeclampsia, polyhydramnios, and oligohydramnios were also documented from these records.
The recorded adverse fetal outcomes were infant death, stillbirth, dystocia, bone fracture, nerve palsy, admission to the
neonatal intensive care unit (NICU), respiratory complications
[including respiratory distress syndrome (RDS) and transient
tachypnea of newborn (TTN)] that increased birth weight,
macrosomy (birth weight of >4000 g), large for gestational age
(LGA, defined as birth weight> the 90th percentile on standard
charts), small for gestational age (SGA, defined as birth weight
< the 10th percentile on standard charts), and metabolic complications including hypocalcemia, hemoglobin level 20 g/dL,
hypoglycemia (blood glucose level 35 mg/dL), and hyperbilirubinemia requiring phototherapy.

Results
The present study included 1360 pregnant women who underwent screening for GDM. Out of the 1360 women screened
between September 2012 and October 2013, 380 (28%) women
were diagnosed with GDM, whereas the remaining 980 (72%)
had no GDM. Anthropometric, clinical, and biochemical features of all pregnant women having no GDM risk factors are
shown in Table 1.
Maternal age, body mass index (BMI), and weight gain at the
time of 75-g OGTT and at delivery were remarkably different
between the groups. Glycemic levels in both fasting samples
and following the glucose load were also remarkably higher in
the GDM group. Out of the 380 women with GDM, 102 (27%)
received insulin, whereas the remaining 278 (73%) were treat-

ed with dietary modifications. The only adverse event in 18 of

the 380 women was polyhydramnios.
Logistic regression analysis was performed to test whether the
diagnosis of GDM in women younger than 35 years without
risk factors influenced maternal and neonatal adverse events
despite achieving adequate glycemic control. GDM was the
dependent variable in this analysis. Maternal outcomes in
women included in the study are shown in Table 2a.
In the GDM group, the rate of primary cesarean section (CS)
was significantly higher than that in the non-GDM group [29.6%
vs 15.3%; odds ratio (OR)=2.35, 95% confidence interval (CI)
1.53-3.64; p<0.001]; furthermore, the difference remained significant after correcting for age, prepregnancy BMI, and parity
(Table 2a). The rate of CS after vaginal labor induction was alike
in both groups. Secondary CS in women who had previously
delivered via CS was strongly associated with GDM [adjusted
odds ratio (AOR)=5.05, 95% CI 2.11-12.08, p<0.001]. In unadjusted analyses, the combination of gestational hypertension
and preeclampsia was associated with GDM (OR=2.44, 95%
CI 1.05-5.65, p=0.037), as was preterm delivery (OR=2.43, 95%
CI 1.11-5.29, p=0.025); however, these associations were insignificant subsequent to adjusting for age, prepregnancy BMI,
and parity (for the combination of gestational hypertension and
preeclampsia AOR=2.03, 95% CI 0.83-4.97, p=0.120, for preterm
delivery AOR=1.65, 95% CI 0.32-8.51, p=0.549). The diagnosis
of GDM was associated with polyhydramnios even after correcting for age, prepregnancy BMI, and parity (AOR=4.48, 95%
CI 1.20-16.73, p=0.025). No association was observed between
fetal distress and oligohydramnios (Table 2a). Fetal/neonatal
outcomes in the women included in the study are shown in
Table 2b.
No stillbirth, neonatal deaths, or nerve palsy occurred among
the infants in either group. The newborns of women with GDM
showed a significantly higher weight (p<0.001) after correcting
for maternal age, prepregnancy BMI, and gestational age at birth.
Additionally, the diagnosis of GDM was strongly associated with
admission to NICU following adjustment for age, BMI, parity,
and neonatal weight (AOR=4.39, 95% CI 1.44-13.37, p=0.009).
Nevertheless, no significant association was observed between
the groups regarding other important perinatal outcomes such
as shoulder dystocia and bone fracture (AOR=1.47, 95% CI 0.81-

Lebriz Aktn et al.

Gestational diabetes mellitus screening and outcomes

J Turk Ger Gynecol Assoc 2015; 16: 25-9

27

Table 2a. Maternal outcomes in women with and without GDM

Outcome

GDM
(n=380)

No GDM
(n=980)

OR
(95% CI)

p
value

OR
p
(95% CI)a valuea

Power
(%)

Primary cesarean section, n (%)

112 (30)

147 (15)

2.4 (1.5-3.6)

<0.001

1.9 (1.2-3.1)

0.006

>95

Secondary cesarean section, n (%)

42 (11)

37 (4)

3.9 (1.8-8.8)

0.001

5.1 (2.1-12.1)

<0.001

85.2

Cesarean section after labor, n (%)

7 (2)

27 (3)

0.6 (0.2-2.4)

0.498

0.6 (0.1-2.2)

0.401

9.7

Labor induction, n (%)

5 (1)

4 (1)

4.3 (0.4-48.1)

0.233

3.8 (0.3-53.3)

0.314

13.5

Gestational hypertension, n (%)

15 (4)

15 (2)

2.6 (0.9-7.8)

0.095

1.7 (0.7-7.2)

0.173

33.4

Preeclampsia, n (%)

10 (3)

12 (1)

2.2 (0.6-77.6)

0.223

1.7 (0.4-6.7)

0.443

18.1

Fetal distress, n (%)

11(3)

26 (3)

1.1 (0.4-3.2)

0.896

0.9 (0.3-3.0)

0.879

Polyhydramnios, n (%)

18 (5)

11 (1)

4.5 (1.3-14.1)

0.016

4.5 (1.2-16.7)

0.025

58.7

Oligohydramnios, n (%)

9 (2)

7 (1)

2.9 (0.6-13.1)

0.166

1.7 (0.3-8.5)

0.549

28.5

Preterm delivery, n (%)

31 (8)

33 (3)

2.4 (1.1-5.3)

0.025

1.9 (0.8-4.5)

0.116

52.3

Breech presentation, n (%)

39 (10)

81 (8)

1.2 (0.7-2.3)

0.502

1.2 (0.7-2.2)

0.563

9.9

Values were adjusted for maternal age, prepregnancy BMI and parity.

Power was calculated post hoc with G*Power 3.1, entering R-squared multiple correlation coefficient obtained with regression for each trait.
OR: odds ratio; CI: confidence interval; GDM: gestational diabetes mellitus

Table 2b. Fetal/neonatal outcomes in women with and without GDM

Outcome

GDM
(n=380)

No GDM
(n=980)

OR
(95% CI)

p
value

OR
p
Power
(95% CI)a valuea (%)

Birth weight (kg)

3.20.4

3.090.3

0.002a

Serious perinatal complications, n (%)

44 (12)

84 (9)

1.5 (0.8-2.6)

0.199

Dystocia, n (%)

0 (0.0)

0 (0.0)

Bone fracture, n (%)

4 (1.1)

0 (0.0)

Admission to NICU, n (%)

24 (6)

14 (2)

4.1 (1.5-11.4)

0.006

4.4 (1.4-13.4)

0.009

68.5

RDS, n (%)

6 (2)

4 (1)

3.3 (0.5-19.7)

0.197

2.7 (0.4-17.4)e

0.306e

26.3

TTN, n (%)

9 (3)

8 (1)

2.9 (0.7-13.1)

0.167

1.9 (0.3-10.7)e

0.472e

27.8

Macrosomia (4 kg), n (%)

5 (1)

16 (2)

1.5 (0.2-8.7)

0.694

0.5(0.9-2.7)

0.482c

28.7

LGA, n (%)

33 (9)

18 (2)

4.9 (1.9-12.4)

<0.001

3.5 (1.3-9.3)

0.011

85.6

SGA, n (%)

10 (3)

14 (2)

1.8 (0.5-6.0)

0.331

1.9 (0.5-7.4)c

0.311c

16.5

Metabolic complications, n (%)

20 (5)

18 (2)

2.9 (1.0-7.8)

0.040

2.3 (0.8-7.1)

0.137

46.6

Hypoglycaemia, n (%)

3 (1)

0 (0.0)

Hyperbilirubinemia, n (%)

8 (2)

6 (1)

2.9 (0.6-13.1)

0.164

1.2 (0.2-5.8)

0.824

27.5

Hypocalcemia, n (%)

5 (1)

5 (1)

2.2 (0.3-15.5)

0.443

5.3 (0.7-41.4)

0.113

15.4

Polycythemia, n (%)

4 (1)

5 (1)

2.2 (0.3-15.5)

0.443

2.2 (0.3-18.7)c

0.474c

15.4

<0.001b

>95

1.2 (0.7-2.3)

0.497

17.2

-
d

Calculated by Mann-Whitney U test.

Calculated by linear regression analysis after adjustment for maternal age, prepregnancy BMI, and gestational age at birth.
c
Values were obtained by logistic regression analysis after adjustment for maternal age, prepregnancy BMI, parity, and gestational age at birth.
d
Values were obtained by logistic regression analysis after adjustment for maternal age, prepregnancy BMI, parity, and neonatal weight.
e
Values were obtained with logistic regression after adjustment for maternal age, prepregnancy BMI, parity, and delivery mode.
NICU: neonatal intensive care unit; RDS: respiratory distress syndrome; TTN: transient tachypnea of newborn; LGA: large for gestational age;
SGA: small for gestational age
Power was calculated post hoc with G*Power 3.1, entering R-squared multiple correlation coefficient obtained with regression for each trait
OR: Odd ratio; GDM: Gestational diabetes mellitus
a

2.63, p=0.202). There was no remarkable difference between

the groups regarding SGA or macrosomia, yet significantly
more infants in the GDM group were LGA (AOR=3.53, 95% CI

1.34-9.34, p=0.011). Neonatal respiratory problems at delivery, including RDS and TTN, were not significantly different
between the two groups. GDM appeared to be associated with

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Lebriz Aktn et al.

Gestational diabetes mellitus screening and outcomes

metabolic complications (OR=2.86, 95% CI 1.05-7.80, p=0.040),

although this association was not observed after correcting
for age, BMI, parity, and gestational age at birth. All significant
associations were independent of BMI; however, prepregnancy
BMI was correlated with primary CS (r=0.103, p=0.017), neonatal weight (r=0.122, p=0.005), and LGA (r=0.113, p=0.009)
independently from GDM via Pearsons test.

Discussion
GDM is a type of diabetes and is the most common metabolic disorder seen during gestation occurring in 1%-14% of pregnancies
(1). The prevalence of GDM continues to increase globally (7).
GDM may cause serious morbidities both for mother and infant
(8). Women with GDM have been reported to have increased
rates of stillbirth, polyhydramnios, gestational hypertension,
macrosomia, and cesarean delivery (9). GDM usually resolves
after delivery, but it appears that the risk of recurring GDM and
type 2 diabetes mellitus are increased in subsequent pregnancies, along with cardiovascular risk later in life (10, 11). Although
the precise role of the risk factors related to GDM (multiparity,
obesity,) has not yet been entirely defined, they may be included
in the classification of pregnancy-related or maternal factors (12).
Early diagnosis of metabolic disorder is highly critical for the
prevention of fetal and maternal complications (5, 13).
Since the adoption of the 2 h 75-g OGTT in pregnancy, the
WHO recommended the same diagnostic limit values accepted
for the identification of impaired glucose tolerance in nonpregnant women (14, 15). The WHO stated in 1999 that GDM
encompasses both impaired glucose tolerance and diabetes
(fasting plasma glucose 7 mmol/dL or 126 mg/dL; 2 h plasma glucose 7.8 mmol/dL or 140 mg/dL, respectively) (16) and
has maintained their recommendations to date.
With early diagnosis and good medical and obstetric care, the
risks of higher perinatal mortality and infant morbidity rates
associated with GDM should be minimized (17, 18). In patients
with persistent maternal hyperglycemia, the use of additional
oral medications, insulin treatment, and lifestyle changes has
shown improved perinatal outcomes. Medical nutrition counseling and diet therapy to achieve an overall healthy lifestyle are
valuable in the management of GDM (19-21) and can optimize
maternal and fetal outcomes (22, 23).
In this study, our aims were to verify the effectiveness of the
WHO GDM diagnostic criteria in preventing adverse maternal
and neonatal outcomes in women younger than 35 years with
no apparent risk factors for GDM and to verify the effectiveness of dietary modifications in those outcomes. With no prior
knowledge of any risk factors, 1360 pregnant women underwent OGTT at the 24th-28th gestational weeks. Approximately
28% of them were diagnosed with GDM and subsequently treated, thus reducing the risk of adverse maternal and neonatal
hyperglycemia-related events, including high rates of primary
CS, polyhydramnios, preterm delivery, admission to NICU, LGA,
and higher neonatal weight.
The rate of adverse events in this group was similar to all the
other women with GDM. Similar findings have been recently
reported (24, 25).

J Turk Ger Gynecol Assoc 2015; 16: 25-9

While women with GDM were significantly older and had a

significantly higher BMI compared with their non-GDM counterparts, all observed associations remained significant after
correcting for age and prepregnancy BMI, indicating that GDM
was an independent risk factor. Our findings confirm and
extend previous observations that GDM and increased BMI are
independently associated with adverse maternal and neonatal
outcomes, with their combination having a greater impact.
Some adverse pregnancy outcomes in our study were correlated with prepregnancy BMI even within the normal range
(<25 kg/m2) and independently from GDM. Our results show
that most cases of GDM were diagnosed at baseline and at 2 h
of the OGTT timeframe.
The interpretation of the results of this study is limited by the
small sample size. Higher rates of preterm delivery observed
among the GDM cases together with the increase in both CS
and NICU admission rates may be considered to be the result
of excessive medical interventions. However, the higher rate of
polyhydramnios and LGA in women with GDM accounted for
the higher number of CS in this group, whereas overtreatment
would not help explain the neonatal primary outcomes, such
as LGA, and higher neonatal weight. All outcomes in our GDM
group are remarkably lower with respect to those observed in
other studies of GDM in the general population (25).
There are only a few studies on GDM prevalence reported from
Turkey. In the study by Akbay et al. (26), a prevalence of 8.9%
was reported, whereas K et al. (27) reported a prevalence
of 8.6%. In both these studies, GDM was diagnosed after a
50-g glucose screening test followed by a 100-g glucose OGTT
in two steps. While only a few studies using the 75-g OGTT
according to the WHO criteria have been reported in literature,
this method has the advantage of being both a screening and
diagnostic test and being performed in a single step. Additional,
larger studies are needed to confirm our findings.
Ethics Committee Approval: Ethics committee approval was received
for this study from the ethics committee of stanbul Medipol University.
Informed Consent: Written informed consent was obtained from
patients who participated in this study.
Peer-review: Externally peer-reviewed.
Author contributions: Concept - L.H.A.; Design - L.H.A.; Supervision L.H.A.; Resource - L.H.A., B.Y.; Materials - L.H.A., B.Y., M.A., D.U.; Data
Collection&/or Processing - L.H.A., B.Y.; Analysis&/or Interpretation L.H.A., B.Y.; Literature Search - L.H.A., B.Y., M.A.; Writing - L.H.A.; Critical
Reviews - D.U., B.Y.
Conflict of Interest: No conflict of interest was declared by the authors.

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