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| LETTER TO EDITOR |
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| Year : 2021 | Volume
: 12
| Issue : 2 | Page : 237-238 |
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Do we require better classification of diabetes in pregnancy?
Jethwani Pratap1, Lata Jethwani1, Shalini Jaggi2, Banshi Saboo3
1 Jethwani Hospital, Rajkot, Gujarat, India
2 Lifecare Diabetes Centre, New Delhi, India
3 Diabetes Care & Hormone Clinic, Ahmedabad, Gujarat, India
| Date of Submission | 07-Oct-2020 |
| Date of Decision | 05-Nov-2020 |
| Date of Acceptance | 11-Dec-2020 |
| Date of Web Publication | 31-Mar-2021 |
Correspondence Address:
Dr. Jethwani Pratap
Fellow-RSSDI, Fellow- DiabetesIndia, Ex Tutor- Leicester University (UK), Consultant Diabetes specialist, Jethwani Hospital, 5-Junction Plot, Rajkot-1, Gujarat.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_90_20
How to cite this article:
Pratap J, Jethwani L, Jaggi S, Saboo B. Do we require better classification of diabetes in pregnancy?. J Diabetol 2021;12:237-8 |
Dear Editor,
The International Diabetes Federation (IDF) defines hyperglycemia in pregnancy (HIP) as an elevated blood glucose level detected during pregnancy.[1] According to the World Health Organization (WHO) and the International Federation of Gynaecology and Obstetrics (FIGO), HIP can be classified as either gestational diabetes mellitus (GDM) or diabetes in pregnancy (DIP). DIP can be further classified into preexisting known diabetes before conception or diabetes (either type 1 diabetes or type 2 diabetes) that is detected first time in pregnancy.[2] These different terminologies become really confusing for clinicians and researchers, because DIP-type 2 then encompasses both preexisting type 2 diabetes before pregnancy and newly diagnosed type 2 diabetes in pregnancy. There is enough evidence of increased risk of complications in preexisting DIP, particularly if glycemic control remains poor during pregnancy.[3] A recent Japanese study demonstrated a higher risk of maternal complications in overt diabetes in pregnancy (newly diagnosed type 2 diabetes in pregnancy) as compared with GDM.[4],[5] DIP existing before pregnancy has a higher risk of congenital malformations and maternal microvascular complications as compared with DIP detected first time during pregnancy, thereby underlining a need for different terminologies for these two categories. An old quote by William Shakespeare “What’s in a name?” may not always hold true in this situation.
To resolve the confusion created by this common terminology for two separate conditions, we hereby propose a simpler three-category nomenclature system—preexisting diabetes, pregestational diabetes, and gestational diabetes —as explained later. In medical literature, “preexisting diabetes” and “pregestational diabetes” are the terms often used to describe diabetes present before pregnancy. But here we have used them separately to differentiate between (1) diabetes existing before pregnancy, where the entire health-care team, including the woman herself, is aware of its diagnosis and (2) diabetes being diagnosed first time during early pregnancy but which is likely to be present before conception.
Preexisting Diabetes: Diabetes present before pregnancy should be termed “preexisting diabetes.” The entire health-care team, including the patient herself, is aware of diabetes and most of these women are already on treatment for the same. Prepregnancy counseling is very much important, as poor glycemic control in the periconceptional period is associated with an increased risk of congenital malformations and spontaneous abortions in these women.[3] This can be further classified into type 1 diabetes, type 2 diabetes, maturity onset diabetes of the young (MODY), or other types.
Pregestational Diabetes: Diabetes being diagnosed the first time in early pregnancy that may actually have been present before conception should be termed “pregestational diabetes.” This was termed as “overt diabetes” by the IADPSG group.[4] The woman and her health-care team are not aware of the presence of diabetes before pregnancy and, hence, she is obviously not on any treatment for the same. Here, the detection of high fasting plasma glucose and/ or high glycated hemoglobin A1c (HbA1c) in the diabetic range (≥6.5%) in the first trimester or early pregnancy suggests the presence of diabetes before conception. This can be further confirmed by the persistence of diabetes even after delivery. This may mostly be type 2 diabetes or MODY (mostly glucokinase) or rarely even type 1 diabetes.
Gestational Diabetes: Diabetes that appears for the first time in the second or third trimester in a woman without a history of diabetes with HbA1c still remaining lower than 6.5% should be termed as “gestational diabetes.” In GDM, dysglycemia remains only during gestation and often reverts to normoglycemia after the delivery of the baby. There is mainly postprandial hyperglycemia in GDM that can be very well managed with medical nutrition therapy in most cases.[6]
This simple classification will help clinicians know about the type of diabetes and its presence in relation to pregnancy to anticipate likely complications and determine the level of care as well as monitoring required during pregnancy. Currently, studies comparing preexisting diabetes with pregestational diabetes and pregestational diabetes with gestational diabetes are lacking. Therefore, there is a strong need for further research/studies based on our suggested terminologies to generate a simple and practical classification system of these clearly distinct categories of hyperglycemia in pregnancy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | International Diabetes Federation Atlas. 8th ed. Available at www.idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html [Last accessed on 2019 June 20].  |
| 2. | Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: A World Health Organization Guideline. Diabetes Res Clin Pract2014;103:341-63. |
| 3. | Guerin A, Nisenbaum R, Ray JG Use of maternal ghb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes. Diabetes Care 2007;30:1920-5. |
| 4. | Metzger BE, Gabbe SG, Persson B, et al; on behalf of International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676-82. |
| 5. | Sugiyama T, Saito M, Nishigori H, Nagase S, Yaegashi N, Sagawa N, et al.; Japan Diabetes and Pregnancy Study Group. Comparison of pregnancy outcomes between women with gestational diabetes and overt diabetes first diagnosed in pregnancy: A retrospective multi-institutional study in Japan. Diabetes Res Clin Pract 2014;103:20-5. |
| 6. | Seshiah V, Banerjee S, Balaji V, Muruganathan A, Das AK; Diabetes Consensus Group. Consensus evidence-based guidelines for management of gestational diabetes mellitus in India. J Assoc Physicians India 2014;62:55-62. |
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