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GTT questionsFrom: MS GAIL M HART (YTDP43A@prodigy.com)Sun Mar 31 14:43:14 1996
-- [ From: Gail Hart * EMC.Ver #2.10P ] -- RE David Nagy<<There was a study by Joe Miller (I think while he was at MUSC), showing that if one screens only patients with risk factors, half as many women with abnormal GTT's will be ascertained.<<<<< Oh, everyone; my apologies..... My post read """(Now don't you'all yell at me OK?<G> I'm about to question a sacred cow, and just really your collective oppinion)""" but what I really MEANT to type was "" and I just really NEED your collective opinion"".. sorry , that missed word changed the entire meaning! Ok, back to today and an assortment of questions<G> David, about missing gestational diabetes if we only test those with risk factors and we will miss 50% of Gestational diabetics --- But, if there are no clinical indications of GD (which would then lead you to further testing and perhaps treatment)-- then would the outcome be changed? Is an abnormal GTT, with no clinical indications, truly very predictive of risk associated with GD? (Highly predictive, poorly predictive, somewhat predictive?) In some communities we are now managing women with borderline GTTs as if they are at the same risk as end-of-the-bell-curve diabetics. (They aren't, are they??) I'm very curious as to how many pregnancies are "truly" GD (proven by all the clinical signs/symptoms) compared to how many pregnancies are labled GD because of a GTT. Interpretation of test varies so much (is it true as reported that the GTT is not reproducible 50 to 70 percent of the time?); And the "borderline" interpretation fluctuates by region. I was even told of one practice group where TEN PERCENT of thier (low risk suburban white) population has been labled GD by GTTs! Surely the actual incidence can't be this high?? Do we know the rate of false positives and can it outweigh the value of the test? Also, if the main risk of GD is macrosomia (and is it true that the primary risks of GD all stem from this?), well, a good history and good prenatal care certainly shows us the developing AGA baby.. Large fetal size is a hand's-on symptom, and another indication for closely following of moms (and wouldn't post prandials be better anyway?). But what about the other item in Enkin et al Guide to Effective Care which says that there is no "convincing evidence" that """"treatment of women with an abnormal glucose tolerance test will reduce preinatal mortality or morbidity""" and that even trials of insulin plus diet regulation show an decrease in macrosomia """ but no signifiact effect on other outcomes such as use of ceserean section, the incidence of shoulder dystocia or perinatal mortality""". GTTs and the diagnosis of gestational diabetes are BIG issues to pregnant women; many of them are very fearful for their baby's safety. Before I have to put a woman through additional stress I want to make sure it's needed! "IF" the GTT is not such a great predicter (or not any better than history and clinical course) and "IF" the risks of GD are less than the popular perception (at least don't you think there is a "Continuum or disease", the women with a mild form are not as high risk as those with a severe form?), and "IF" treatment is not particularly effective.. "THEN" should I begin doing routine GTTs? I'm trying to set up a logic problem here of course<G>.. are any of the statements incorrect? Please correct me here.... My licensing board may soon begin REQUIREING us to do routine GTT screens, simply because "Everybody else is doing them" and "it's becoming the standard of care". (Though it's funny this comes at the same time an HMO is forbidding them..... well not really funny; this sounds like another incidence of HMOs restricting care rather than attempting to "Maintain Health"!) So I guess all of my questions boil down to --- "Should I do routine GTTs because they really ARE needed, even though thier value has not been proven by large, well controlled trials" -- or -- "Should I NOT do routine GTTs because they are not proven by large well controlled trials".... RE Murry Enkin<<<The question of whether or not routine glucose challenge tests during pregnancy have a net benefit is too important to leave unanswered. There is sufficient difference of opinion about this to demonstrate clinical equipoise, and make a methodologically sound randomized trial both ethical and necessary.<<<< Yet we are all caught up in the "standard of care" issue (at least here in US. Is it the same in other countries?).. We can find ourselves doing something "just because it is being done" rather than because it is proven to be good care. I think your use of "ethical and necessary" is strong, but appropriate. A GTT is not always an emotionally harmless test.. A positive result may set up the woman for multiple tests, weekly NSTs, scheduled inductions etc. This is often extremely stressful; it might even be harmful; but it might -- or it might not-- be benifical. Are we sure we can even prove it one way or the other? questions, questions.... (And thanks for answers!) Yours in the search for knowlege... Gail Hart, LDEM, Oregon USA
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