Module 2:

Unit 1: Pre- and

Antental Care
Screening for HiP!
 Objectives:
• Definition of a screening test
• Risk based vs universal HiP screening
Health in pregnancy • To examine the international
recommendations on HiP Screening
• To expand the current national
guidelines to include screening for HiP
using best practice guidelines
Health in pregnancy – Case study
• Shawntelle is a 36yr old P4+2 who presented to her local health centre complaining
of a 3 week history of vaginal itch and weight loss.
• Her UPT was positive.
• She had a Caesarean section for her last pregnancy because of concerns over weight
gain in her last trimester at that time. Her last baby was born 11 months ago and
weighed 9lbs, 1 oz.
• Her RBS done at the health centre was 337 mg/dL and she was sent for an HbA1c
test.
• She was booked for her ANC appointment in 4 weeks.
Health in pregnancy - Pre-test questionnaire

1. How would you BEST 2. When is the BEST timing

establish the diagnosis of for assessment of
Shawntelle’s glycaemic Hyperglycaemia in
status? pregnancy in Shawntelle?
• A. Perform an oral • A. At booking
glucose tolerance test • B. Repeat at 24 to 28 weeks
(OGTT) if negative at booking
• B. Perform a random • C. No need to repeat an
blood glucose OGTT if booking test
• C. Perform HbA1c positive
• D. All the above • D. All the above
HiP Screening – What is screening?
• A screening test is a medical test or procedure performed on a
defined asymptomatic population (or population subgroup) to assess their
likelihood of having a particular disease.
• Data from T&T suggests: 1
• 20 % enter pregnancy with abnormal glycaemia​
• 14 % more will be detected with routine screening
• ​There is a direct correlation with degrees of maternal glycemic control and
perinatal morbidity and mortality
• Improved outcomes from management of HiP has been proven!
HiP Screening 2

– Who?
• EVERYONE!
• UNIVERSAL SCREENING
• Recommended by:
• IADPSG
• WHO
• IDF
• ADA
• NICE
• FIGO
HiP Screening –
International
consensus.
• Hyperglycaemia and Adverse Pregnancy
Outcome (HAPO) study: 3
• International multicentre
prospective cohort study of risks of
hyperglycemia less severe than
overt diabetes
• > 25,000 women given the 75gm
OGTT at 24-32 weeks
• Clinicians blinded to results if not
overt diabetes
• Primary outcomes: Linear
relationships with worsening
glucose levels
HiP Screening – International
consensus.
According to the Federation of International Gynaecologists and
Obstetricians, screening for HiP is: 4
• particularly relevant to low-, low−middle, and middle-
resource countries, where 90% of all cases of GDM are
found and ascertainment of risk factors is poor owing to low
levels of education and awareness, and poor record keeping.

• In many of these countries there is little justification for

selective testing, as they also have ethnic populations
considered to be at high risk

• Aim towards achieving Sustainable Developmental Goals (#3)

HiP Screening – Current T&T
National Recommendations 5
HiP Screening – Current T&T
National Recommendations 5
HiP Screening: What test do we do?
• Oral Glucose Tolerance Test [OGTT]
WHO, FIGO, IADPSG (Min of Health T&T)
75 g-OGTT Normal Gestational Diabetes Diabetes Mellitus in
Mellitus (GDM) Pregnancy (DIP)
One or more of

FBS < 92 mg/dl 92-125 mg/dl ≥ 126 mg/dl

1hr post <180 mg/dl ≥ 180 mg/dl

2hr post <153 mg/dl >153 to 199 mg/dl ≥ 200 mg/dl

HiP Screening: Best practice guidelines -
1 STEP Screening
2
IADPSG 75G OGTT THRESHOLD GLUCOSE VALUES:

• Only 1 abnormal value needed for diagnosis.

HiP Screening – Other investigations

• Women should be screened for diabetic complications and co-

morbidities.
• Laboratory assessments should include: 6,7
• Lipid panel as part of cardiovascular risk assessment.
• Serum creatinine and spot urine albumin to creatinine
ratio for Diabetic nephropathy.
• Serum TSH for thyroid anomalies.
• The management of each patient should be individualized
according to the clinical condition, the risk factors, and the
availability of the necessary support.
Health in pregnancy – Case study
• Shawntelle is a 36yr old P4+2 who presented to her local health centre complaining
of a 3 week history of vaginal itch and weight loss.
• Her UPT was positive.
• She had a Caesarean section for her last pregnancy because of concerns over weight
gain in her last trimester at that time. Her last baby was born 11 months ago and
weighed 9lbs, 1 oz.
• Her RBS done at the health centre was 337 mg/dL and she was sent for an HbA1c
test.
• She was booked for her ANC appointment in 4 weeks.
Health in pregnancy - Post-test questionnaire

1. How would you BEST 2. When is the BEST timing

establish the diagnosis of for assessment of
Shawntelle’s glycaemic Hyperglycaemia in
status? pregnancy in Shawntelle?
• A. Perform an oral • A. At booking
glucose tolerance test • B. Repeat at 24 to 28 weeks
(OGTT) if negative at booking
• B. Perform a random • C. No need to repeat an
blood glucose OGTT if booking test
• C. Perform HbA1c positive
• D. All the above • D. All the above
References:
1. Shastri Motilal, Surujpal Teelucksingh, Bharat Bassaw, Siara Teelucksingh, Samuel Ramsewak. 2016. Variability in Screening
Practices for Gestational Diabetes in Trinidad. Caribbean Medical Journal ISSN 0374-7042; 1-4 Retrieved from:
https://issuu.com/jgeurekatt/docs/cmj_primary_care_guidelines_issue
2. Panel* IA of D and PSGC. International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis
and Classification of Hyperglycaemia in Pregnancy. Diabetes Care. 2010 Mar 1;33(3):676–82.
3. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, et al. Hyperglycemia and
adverse pregnancy outcomes. N Engl J Med. 2008 May 8;358(19):1991–2002.
4. Hod M, Kapur A, Sacks DA, Hadar E, Agarwal M, Renzo GCD, et al. The International Federation of Gynecology and Obstetrics
(FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care#. International Journal
of Gynecology & Obstetrics. 2015;131(S3):S173–211.
5. National Strategic Plan for the Prevention and Control of NCDs 2017-2021, MoH, GORTT
www.health.gov.tt/downloads/DownloadItem.aspx?id=385
6. S I, Tm A, A S, A S. Effect of pregnancy on diabetic nephropathy and retinopathy. J Coll Physicians Surg Pak. 2004 Feb 1;14(2):75–
8. 17.
7. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, et al. 2018 ESC Guidelines for
the management of cardiovascular diseases during pregnancy. The Task Force for the Management of Cardiovascular Diseases
during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2018 Sep 7;39(34):3165–241.