table 1 compares the ada , acog , and nice guidelines for diabetes in pregnancy ( 68 ) .
comparison of nice , ada , and acog guidelines for gdm fbg , fasting blood glucose ; gtt , glucose tolerance testing ; ifg , impaired fasting glucose . unlike nice
nice used a single cost - effectiveness model addressing screening , diagnosis , and treatment , and the model was used to direct the guideline recommendations . using the data from the australian carbohydrate intolerance study in pregnant women ( achois ) ( 2 ) , nice
demonstrated that the screening , diagnosis , and treatment of gdm are cost - effective .
this comparison of nice , ada , and acog guidelines has identified a number of key areas where the recommendations are markedly divergent . of particular importance
are : the recent point - counterpoint ( 4,5 ) comprehensively debated is in regards to whether screening for gdm should be selective ( i.e. , using risk factors ) or universal ( i.e. , using blood tests ) .
there was general agreement on the risk factors of importance , while the latter addressed the broader issues of complexity and long - term benefits .
nice recommendations exclude several risk factors , including some shown to be cost - effective .
nice cost - effectiveness analysis substantially understated the benefits of screening because the basic decision tree structure omitted many avoidable downstream costs including some maternal morbidity ( e.g. , preeclampsia ) , neonatal morbidity ( e.g. , hypoglycemia ) , long - term maternal morbidity ( e.g. , preventable complications by earlier diabetes diagnosis and intervention ) , and long - term offspring risk ( e.g. , fetal morbidity if undiagnosed diabetes in a subsequent pregnancy ; possibly future obesity and diabetes ) ( 10 ) .
nice cost - effectiveness analysis acknowledged that a large number of assumptions were made  owing to data limitations and methodological complexity  and that there was potential for underestimating the true costs and effects ( by using a cohort excluding those with worse glucose control ) ( 2 ) .
the published modeling showed that universal screening becomes more cost - effective as the disease prevalence increases and used a sensitivity analysis with prevalence estimates of gdm ranging from 25% ; actual gdm prevalence is now running at least 58% ( 1 ) .
women with undiagnosed type 2 diabetes are significantly more prone to have babies with malformations and may have established diabetic complications ( e.g. , nephropathy and retinopathy ) requiring close follow - up to ensure prompt restoration of normoglycemia .
nice recommendations delay the time to testing and ignore important criteria ( e.g. , strong family history ) . given the often asymptomatic nature of type 2 diabetes and its potential to cause severe pregnancy complications , we consider that testing should be undertaken early in those at high risk , ideally as part of the first antenatal contact .
nice dependence on fasting plasma glucose screening without performing an oral glucose tolerance test ( ogtt ) has been shown to reduce the sensitivity of identifying postpartum diabetes and impaired glucose tolerance ( igt ) by 3860% ( 1112 ) . in another study , 83% of those with igt and
the follow - up of women with a history of gdm is becoming increasingly important because of their increased risk of progression to type 2 diabetes ( 1 ) and the secular trend for a shortening of time between gdm and the development of diabetes ( 14 ) .
many of these women would have been diagnosed at ogtt on the 2-h glucose alone , avoiding the risk of undiagnosed diabetes at the next pregnancy ( should one occur ) . moreover , without an ogtt , igt can not be identified .
this is particularly important given the clear evidence that progression to subsequent diabetes can be reduced by over 50% ( 3 ) . among increasingly empowered , knowledgeable , and
 patients , clinicians run the risk of having their management undermined by conflicting guidelines , making the implementation of clinical care substantially harder and more time - consuming .
nice guidelines are a relatively new addition to the scene but appear to be the most minimalist in relation to screening and postnatal follow - up ( 1 ) .
fortunately , the completion of the hyperglycemia and adverse pregnancy outcomes ( hapo ) study ( 15 ) now provides a large observational cohort that is being used to redefine diagnostic criteria for gdm in relation to adverse outcomes . in conclusion
, the comparison between nice , ada , and acog guidelines has demonstrated significant differences in recommendations for the screening , diagnosis , and management of gdm .
cost - effective management is a major issue in the debate on health care reform in the u.s . ,
and current nice recommendations appear to reduce access to proven , cost - effective gdm management .
the recent point - counterpoint ( 4,5 ) comprehensively debated is in regards to whether screening for gdm should be selective ( i.e. , using risk factors ) or universal ( i.e. , using blood tests ) .
there was general agreement on the risk factors of importance , while the latter addressed the broader issues of complexity and long - term benefits .
nice recommendations exclude several risk factors , including some shown to be cost - effective .
nice cost - effectiveness analysis substantially understated the benefits of screening because the basic decision tree structure omitted many avoidable downstream costs including some maternal morbidity ( e.g. , preeclampsia ) , neonatal morbidity ( e.g. , hypoglycemia ) , long - term maternal morbidity ( e.g. , preventable complications by earlier diabetes diagnosis and intervention ) , and long - term offspring risk ( e.g. , fetal morbidity if undiagnosed diabetes in a subsequent pregnancy ; possibly future obesity and diabetes ) ( 10 ) .
nice cost - effectiveness analysis acknowledged that a large number of assumptions were made  owing to data limitations and methodological complexity  and that there was potential for underestimating the true costs and effects ( by using a cohort excluding those with worse glucose control ) ( 2 ) .
the published modeling showed that universal screening becomes more cost - effective as the disease prevalence increases and used a sensitivity analysis with prevalence estimates of gdm ranging from 25% ; actual gdm prevalence is now running at least 58% ( 1 ) .
women with undiagnosed type 2 diabetes are significantly more prone to have babies with malformations and may have established diabetic complications ( e.g. , nephropathy and retinopathy ) requiring close follow - up to ensure prompt restoration of normoglycemia .
nice recommendations delay the time to testing and ignore important criteria ( e.g. , strong family history ) . given the often asymptomatic nature of type 2 diabetes and its potential to cause severe pregnancy complications , we consider that testing should be undertaken early in those at high risk , ideally as part of the first antenatal contact .
nice dependence on fasting plasma glucose screening without performing an oral glucose tolerance test ( ogtt ) has been shown to reduce the sensitivity of identifying postpartum diabetes and impaired glucose tolerance ( igt ) by 3860% ( 1112 ) . in another study ,
83% of those with igt and 56% of those with diabetes would have been missed ( 13 ) .
the follow - up of women with a history of gdm is becoming increasingly important because of their increased risk of progression to type 2 diabetes ( 1 ) and the secular trend for a shortening of time between gdm and the development of diabetes ( 14 ) .
many of these women would have been diagnosed at ogtt on the 2-h glucose alone , avoiding the risk of undiagnosed diabetes at the next pregnancy ( should one occur ) . moreover , without an ogtt , igt can not be identified .
this is particularly important given the clear evidence that progression to subsequent diabetes can be reduced by over 50% ( 3 ) . among increasingly empowered , knowledgeable , and
 internet savvy  patients , clinicians run the risk of having their management undermined by conflicting guidelines , making the implementation of clinical care substantially harder and more time - consuming .
nice guidelines are a relatively new addition to the scene but appear to be the most minimalist in relation to screening and postnatal follow - up ( 1 ) .
fortunately , the completion of the hyperglycemia and adverse pregnancy outcomes ( hapo ) study ( 15 ) now provides a large observational cohort that is being used to redefine diagnostic criteria for gdm in relation to adverse outcomes . in conclusion
, the comparison between nice , ada , and acog guidelines has demonstrated significant differences in recommendations for the screening , diagnosis , and management of gdm .
cost - effective management is a major issue in the debate on health care reform in the u.s . ,
and current nice recommendations appear to reduce access to proven , cost - effective gdm management .
 objectiveto compare recent u.s . and 
 u.k . guidelines on gestational diabetes mellitus ( gdm).research design and methodsthe guidelines from the american diabetes association , the american college of obstetricians and gynecologists , and the national institute for health and clinical excellence ( nice ) in the u.k . were collated and compared using a general inductive approach.resultsthere are substantial differences in the recommendations between the u.k . and 
 the u.s . guidelines . of particular note are the reduced sensitivities of the early and later antenatal and postnatal screening and diagnostic criteria . 
 nice undertook a cost - effectiveness analysis using lower prevalence estimates and limited outcomes and still showed screening for gdm to be cost-effective.conclusionsthe latest nice recommendations appear to reduce access to proven , cost - effective management of gdm , an issue relevant in the current u.s . 
 health care policy debate . 
RESEARCH DESIGN AND METHODS
RESULTS
CONCLUSIONS
Screening
Detecting undiagnosed type 2 diabetes
Postnatal testing