Randomization of Early Diabetes Screening Among Obese Pregnant Women.
Randomization of Early Diabetes Screening Among Obese Pregnant Women.
This will be a randomization of two groups of obese pregnant women into early screening for
 diabetes mellitus at the time of their first or subsequent prenatal visits before 20 weeks of
 gestation versus standard time of screening for diabetes at 24 - 28 weeks as it is done for
 all pregnant women. The perinatal outcomes between the two groups will be compared to
 determine whether early screening for diabetes in all obese pregnant women has a clinical
 merit or significant.
As part of normal physiological changes of pregnancy, there is increased insulin resistance,
 which causes dysregulation of maternal glucose homeostasis. Obesity, which is body mass index
 greater or equal to 30 kg/m2, is also associated with impaired glucose metabolism. Women with
 higher body mass index (BMI) usually have higher risk of developing gestational diabetes
 mellitus (GDM) than normal BMI women. The American Congress of Obstetricians and
 Gynecologists (ACOG) recommends early screening for gestational diabetes mellitus in certain
 categories of patients with higher risk factors which includes previous medical history of
 gestational diabetes mellitus, known impaired glucose metabolism and obesity.

 However, there is poor compliance by many clinicians of this ACOG recommendation.. One of the
 reasons for the poor compliance is that it was based on expert opinion and consensus which is
 level III evidence. There has not been any robust study to determine the clinical importance
 of screening obese women early versus screening them at the same time like every pregnant
 women at 24 - 28 weeks.

 The justifications for recommendation for early diabetes screening are:

 1. It will help diagnose pre-existing type 2 DM unrecognized prior to pregnancy.
 Uncontrolled pre-gestational type 2 DM in the first trimester has been shown to have the
 same maternal and perinatal adverse effects as type 1 DM.

 2. It will help detect women with impaired glucose metabolism, in which early interventions
 may prevent the development of GDM later on in pregnancy and its associated
 complications.

 3. Treatment of type 2 diabetes in the first trimester will minimize adverse maternal and
 perinatal outcomes such as congenital malformation, hypertension or preeclampsia often
 associated with poorly controlled diabetes.

 However, there is currently no strong evidence to support that early GDM screening in obese
 pregnant women is cost effective or is beneficial in reducing maternal and perinatal adverse
 outcomes despites its recommendation by many professional societies.

 Objectives of this study:

 1. Primary objectives:

 1. To compare the rate of neonatal large for gestational age (> 90 percentile) or
 macrosomia (> 4000gm birth weight) between the two groups: The study group and the
 control group.

 2. To compare the rate of neonatal large for gestational age (> 90 percentile) or
 macrosomia (> 4000gm) between participants with diabetes diagnosed at early
 screening and those with true gestational diabetes diagnosed at 24 - 28 weeks.
 Those with true GDM are those who test negative during early screening but become
 positive at 24 - 28 weeks of gestation.

 2. Secondary objectives:

 1. To compare pregnancy outcomes between the early screening group and the control
 group. Maternal outcomes will include the development of pre-eclampsia, pregnancy
 induced hypertension, maternal weight gain during pregnancy, and 3rd or 4th degree
 perineal lacerations. Perinatal outcomes will include rate of miscarriage, preterm
 delivery, intra-uterine growth restriction, intra-uterine fetal death and neonatal
 metabolic complications (hypoglycemia, hypocalcaemia or hyperbilirubinemia).

 2. To compare pregnancy outcomes between diabetes diagnosed at early screening and
 true gestational diabetes diagnosed at 24 - 28 weeks.

 3. To describe characteristics of participants in each group including medical
 co-morbidities and obstetric complications.

 4. To determine glycemic control by measurement of HbA1C at the time of diagnosis of
 diabetes and at term, prior to delivery.

 5. To compare composite neonatal complications between the two groups such as NICU
 admission, duration of NICU stay, respiratory distress syndrome, neonatal sepsis,
 necrotizing enterocolitis, intra-ventricular hemorrhage and neonatal death.

 6. To determine sensitivity and specificity of early diabetes screening across the
 obesity classes according to the world health organization (WHO) classification.

 7. Cost analysis of early diabetes screening among obese pregnant women. The duration
 of this study will be approximately 2 years; obese pregnant women will be enrolled
 September 2016 to August 2017, and they will be followed to the end of their
 pregnancy.

 -  This will be a randomized controlled trial of two groups of obese pregnant
 women. The study group will receive early diabetes screening (a GCT) during
 their first prenatal clinic visit or a subsequent visit at less than 20 weeks
 of gestation. The control group will be screened at 24 - 28 weeks of
 gestation, which is the time all low risk pregnant women are screened.

 -  The study will be performed in the Center for Women's Health and Mile Square
 health center of the University of Illinois Hospital and Health Science System
 (UI Health). The providing physician, midwife or trained recruiters will
 recruit participants from these two sites if they meet eligibility criteria.

 -  Eligible participants will be approached and counseled about the nature of the
 study. If they are willing to participate, informed consent would be obtained
 from them and a questionnaire to obtain vital clinical information would be
 administered. Thereafter, they would be instructed to go to the laboratory to
 perform 1 hour 50 g glucose challenge test (GCT) with HbA1C (study group) or
 HbA1C only (control group). The 1-hour GCT involves administration of 50g of
 glucose solution by mouth. Participants do not need to be fasting. After 1
 hour, venous blood will be drawn along with other prenatal labs, and glucose
 level and HbA1C would be analyzed. The control group will not be given the
 1-hour GCT but only perform HbA1C level during their routine prenatal lab
 tests. Practitioners at UIC routinely request the HbA1C test as standard of
 care for obese pregnant women at early gestation based on ACOG recommendation.

 -  As part of standard clinical care, if a pregnant patient has a positive 1-hour
 GCT at any point in her pregnancy (defined by plasma glucose level of 140
 mg/dl or greater) they are to receive a 3-hour 100g oral glucose tolerance
 test (OGTT) at a later date. In this test, the patients are advised to avoid
 smoking or alcohol for 3 days preceding the test date, although they may
 continue with their regular diet during this period. The patient is instructed
 to fast over-night for 8 -10 hours prior to the test. A 2.5 ml blood sample is
 drawn for the fasting plasma glucose level, then a 100 g glucose solution is
 given to the patient orally. A 2.5 ml blood sample is then drawn each at 1, 2
 and 3 hours. A diagnosis of diabetes mellitus is made if there are two or more
 abnormal plasma glucose values using the Carpenter and Coustan criteria
 (Fasting plasma glucose > 90 mg/dl, 1 hour > 180 mg/dl, 2 hours > 155 mg/dl
 and 3 hours > 140 mg/dl) 21. A random plasma glucose or 1-hour 50 g GCT> 200
 mg/dl will also be considered as diagnostic of diabetes mellitus and will no
 require the 3-hours OGTT.

 -  As part of standard clinical care, those diagnosed with DM would receive
 diabetic teaching and would be referred to a dietitian for nutritional
 counseling. Patients would be taught on how to monitor daily blood glucose at
 home and come back 1 - 2 weeks later for evaluation where they would be
 evaluated for glycemic control. If the blood glucose values are within normal
 range, patient would continue with dietary intervention only. However, if the
 blood glucose values are abnormal, they would be given oral hypoglycemic drugs
 (Metformin or Glyburide), or insulin according to the discretion of the
 provider. All pregnant diabetic patients on medications are usually managed in
 the high risk OB clinic at UIC.

 -  Those in the study group that test negative to the 1-hour GCT and 3-hour OGTT,
 and the participants in the control group will be followed routinely according
 to their medical and / or other obstetric conditions. At 24 - 28 weeks, they
 will undergo a 1-hour GCT and those that test positive will be also have the
 3-hour OGTT based on current ACOG recommendation. If they are diagnosed with
 diabetes, they would receive the same standard-of-care interventions or
 treatments as necessary.

 Note: those patients in the early screening group who have a negative GCT or OGTT at the <
 20week prenatal visit will not be charged for the GCT at the 24-28week visit.

 -  As part of standard clinical care, participants will be followed until delivery in a
 manner appropriate to their clinical or other medical and obstetric conditions. Data
 would be collected via the administered questionnaire and also from the participants'
 electronic medical records. Additionally, the records of the participant's newborns will
 be reviewed in order to collect neonate outcomes.

 -  The questionnaire will be used to collect baseline data such as medical record number,
 maternal age, race / ethnicity, educational level, employment status, nature of job,
 BMI, gravidity, parity, social and family history, obstetric history, medical and
 surgical history, and medications.
Inclusion Criteria:

 1. Obese pregnant women with BMI > 30 kg/m2

 2. First prenatal visit or subsequent visit prior to 20 weeks of gestation

 3. Maternal age > 18 years

 4. Willingness to participate in the study and give informed consent

 Exclusion Criteria:

 1. Pre-existing DM or pre-gestational diabetes mellitus,

 2. Gestational age more than 20 weeks at time of enrollment

 3. Unknown or inability to determine gestational age even with last menstrual period

 4. Previous medical history of gestational diabetes mellitus.

 5. Known impaired glucose metabolism

 6. HbA1C > 6.5 %