Lower versus Higher Glycemic Criteria for Diagnosis of Gestational Diabetes
Open accessAbstract
BACKGROUND: Treatment of gestational diabetes improves maternal and infant health, although diagnostic criteria remain unclear. METHODS: We randomly assigned women at 24 to 32 weeks' gestation in a 1:1 ratio to be evaluated for gestational diabetes with the use of lower or higher glycemic criteria for diagnosis. The lower glycemic criterion was a fasting plasma glucose level of at least 92 mg per deciliter (≥5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥8.5 mmol per liter). The higher glycemic criterion was a fasting plasma glucose level of at least 99 mg per deciliter (≥5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥9.0 mmol per liter). The primary outcome was the birth of an infant who was large for gestational age (defined as a birth weight above the 90th percentile according to Fenton-World Health Organization standards). Secondary outcomes were maternal and infant health. RESULTS: A total of 4061 women underwent randomization. Gestational diabetes was diagnosed in 310 of 2022 women (15.3%) in the lower-glycemic-criteria group and in 124 of 2039 women (6.1%) in the higher-glycemic-criteria group. Among 2019 infants born to women in the lower-glycemic-criteria group, 178 (8.8%) were large for gestational age, and among 2031 infants born to women in the higher-glycemic-criteria group, 181 (8.9%) were large for gestational age (adjusted relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P = 0.82). Induction of labor, use of health services, use of pharmacologic agents, and neonatal hypoglycemia were more common in the lower-glycemic-criteria group than in the higher-glycemic-criteria group. The results for the other secondary outcomes were similar in the two trial groups, and there were no substantial between-group differences in adverse events. Among the women in both groups who had glucose test results that fell between the lower and higher glycemic criteria, those who were treated for gestational diabetes (195 women), as compared with those who were not (178 women), had maternal and infant health benefits, including fewer large-for-gestational-age infants. CONCLUSIONS: The use of lower glycemic criteria for the diagnosis of gestational diabetes did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria. (Funded by the Health Research Council of New Zealand and others; GEMS Australian New Zealand Clinical Trials Registry number, ACTRN12615000290594.).
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The GEMS Trial showed that lower glycemic criteria for GDM diagnosis did not result in a lower risk of a large-for-gestational-age infant than higher glycemic criteria.
“The recently published results of the GEMS Trial showed that lower glycemic criteria (fasting plasma glucose level of at least 92 mg/dL, a 1 h level of at least 180 mg/dL or a 2 h level of at least 153 mg/dL) for the diagnosis of GDM did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria (fasting plasma glucose level of at least 99 mg/dL or a”
From Gestational Diabetes Mellitus—Recent Literature Review (2022) · cites this paper as [33]
Treatment at lower glycaemic thresholds was associated with greater health service use and an increased risk of small for gestational age offspring, as well as lower lean mass and increased risk of early term birth, compared with women who were not treated.
“However, treatment at these lower glycaemic thresholds was also associated with greater health service use and an increased risk of small for gestational age offspring, 27 as well as lower lean mass and increased risk of early term birth, 28 compared with women who were not treated.”
In the subgroup with OGTT results between lower and higher glycaemic criteria, treatment for gestational diabetes mellitus was associated with reduced risk of large for gestational age babies (aRR, 0.49; 95% CI, 0.29-0.83) and pre-eclampsia (aRR, 0.08; 95% CI, 0.002-0.60).
“In this subgroup, treatment for gestational diabetes mellitus was associated with reduced risk of large for gestational age babies (adjusted relative risk [aRR], 0.49; 95% CI, 0.29–0.83) and pre‐eclampsia (aRR, 0.08; 95% CI, 0.002–0.60).”
In the overall population, the IADPSG criteria more than doubled the prevalence of gestational diabetes mellitus compared with the New Zealand guidelines (15.3% v 6.1%), with no difference in the primary outcome of large for gestational age offspring.
“In the overall population, the IADPSG criteria more than doubled the prevalence of gestational diabetes mellitus compared with the New Zealand guidelines (15.3% v 6.1%), with no difference in the primary outcome of large for gestational age offspring.”
GEMS suggested that women diagnosed with gestational diabetes mellitus via the lower POGTT thresholds had some maternal and infant health benefits compared with women with the same mild degree of hyperglycaemia who were not diagnosed with (or treated for) gestational diabetes mellitus.
“GEMS suggested that women diagnosed with gestational diabetes mellitus via the lower POGTT thresholds had some maternal and infant health benefits compared with women with the same mild degree of hyperglycaemia who were not diagnosed with (or treated for) gestational diabetes mellitus. 27”
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Epidemiology and management of gestational diabetes
Sweeting, A., Hannah, W., Backman, H., Catalano, P., Feghali, M., Herman, W. H., Hivert, M.-F., Immanuel, J., Meek, C., Oppermann, M. L., et al. (2024) · The Lancet · doi:10.1016/s0140-6736(24)00825-0 · Cited by 431 · see citing works
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Modzelewski, R., Stefanowicz-Rutkowska, M. M., Matuszewski, W., & Bandurska-Stankiewicz, E. M. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11195736 · Cited by 223 · see citing works
Pathophysiology from preconception, during pregnancy, and beyond.
Hivert, M.-F., Backman, H., Benhalima, K., Catalano, P., Desoye, G., Immanuel, J., McKinlay, C. J. D., Meek, C. L., Nolan, C. J., Ram, U., et al. (2024) · The Lancet · doi:10.1016/s0140-6736(24)00827-4 · Cited by 186 · see citing works
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Bastian, B., Smithers, L. G., Pape, A., Davis, W., Fu, K., & Francois, M. (2024) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2024.111890 · Cited by 18 · see citing works
Diagnosis of gestational diabetes: Evidence and pitfalls
Wong, T., Immanuel, J., Wong, V. W., Barnes, R., & Simmons, D. (2025) · Best Practice & Research Clinical Endocrinology & Metabolism · doi:10.1016/j.beem.2025.102069 · Cited by 4 · see citing works
- Authors
- Crowther, C. A., Samuel, D., McCowan, L. M. E., Edlin, R., Tran, T., & McKinlay, C. J.
- Affiliations
- Garvan Institute of Medical Research (AU)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2022-08-18
- Volume
- 387
- Issue
- 7
- Pages
- 587-598
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W4292148160
- Cited by
- 120
- References
- 10
- Citations by year
- 2026: 12 · 2025: 29 · 2024: 23 · 2023: 44 · 2022: 11
- FWCI
- 26.92
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Health and Research Council of New Zealand (14/104)
- Liggins Institute Philanthropic Fund
- New Zealand Society for the Study of Diabetes
- Tupu Fund, Counties Manukau Health
- Topics
- Health Sciences › Medicine › Obstetrics and Gynecology › Gestational Diabetes Research and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- gestational diabetes mellitus, diagnostic criteria, glycemic thresholds, fasting blood glucose, 2-hour oral glucose tolerance test, large for gestational age, neonatal hypoglycemia, labor induction, maternal health, infant health, second-trimester screening, gestational diabetes screening, health care utilization, adverse events, cost-effectiveness, quality of life
- MeSH terms
- Australia, Blood Glucose, Female, Glucose Tolerance Test, Humans, Hyperglycemia, Infant, Newborn, Pregnancy, Diabetes, Gestational
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