title: An early pregnancy HbA1c ≥5.9% (41 mmol/mol) is optimal for detecting diabetes and identifies women at increased risk of adverse pregnancy outcomes.
abstract: OBJECTIVE
  Pregnant women with undiagnosed diabetes are a high-risk group that may benefit from early intervention. Extrapolating from nonpregnancy data, HbA1c ≥6.5% (48 mmol/mol) is recommended to define diabetes in pregnancy. Our aims were to determine the optimal HbA1c threshold for detecting diabetes in early pregnancy as defined by an early oral glucose tolerance test (OGTT) at <20 weeks' gestation and to examine pregnancy outcomes relating to this threshold.
  
  
  METHODS
  During 2008-2010 in Christchurch, New Zealand, women were offered an HbA1c measurement with their first antenatal bloods. Pregnancy outcome data were collected. A subset completed an early OGTT, and HbA1c performance was assessed using World Health Organization criteria.
  
  
  RESULTS
  HbA1c was measured at a median 47 days' gestation in 16,122 women. Of those invited, 974/4,201 (23%) undertook an early OGTT. In this subset, HbA1c ≥5.9% (41 mmol/mol) captured all 15 cases of diabetes, 7 with HbA1c <6.5% (<48 mmol/mol). This HbA1c threshold was also 98.4% (95% CI 97-99.9%) specific for gestational diabetes mellitus (GDM) before 20 weeks (positive predictive value = 52.9%). In the total cohort, excluding women referred for GDM management, women with HbA1c of 5.9-6.4% (41-46 mmol/mol; n = 200) had poorer pregnancy outcomes than those with HbA1c <5.9% (<41 mmol/mol; n = 8,174): relative risk (95% CI) of major congenital anomaly was 2.67 (1.28-5.53), preeclampsia was 2.42 (1.34-4.38), shoulder dystocia was 2.47 (1.05-5.85), and perinatal death was 3.96 (1.54-10.16).
  
  
  CONCLUSIONS
  HbA1c measurements were readily performed in contrast to the low uptake of early OGTTs. HbA1c ≥5.9% (≥41 mmol/mol) identified all women with diabetes and a group at significantly increased risk of adverse pregnancy outcomes.
authors.affiliation: Department of Obstetrics and Gynecology, University of Otago, Christchurch Women's Hospital, Christchurch, New Zealand ruth.hughes@cdhb.health.nz.
authors.forename: Ruth C E
authors.initials: RC
authors.lastname: Hughes
authors.affiliation: Diabetes Center, Christchurch Hospital, Christchurch, New Zealand.
authors.forename: M Peter
authors.initials: MP
authors.lastname: Moore
authors.affiliation: Department of Obstetrics and Gynecology, University of Otago, Christchurch Women's Hospital, Christchurch, New Zealand.
authors.forename: Joanna E
authors.initials: JE
authors.lastname: Gullam
authors.affiliation: Department of Biostatistics, Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Khadeeja
authors.initials: K
authors.lastname: Mohamed
authors.affiliation: National Women's Health, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Janet
authors.initials: J
authors.lastname: Rowan
mesh_terms: D000328:Adult; D015331:Cohort Studies; D016640:Diabetes, Gestational / Q000175:diagnosis*; D005260:Female; D005951:Glucose Tolerance Test; D006442:Glycated Hemoglobin / Q000032:analysis*; D006801:Humans; D009520:New Zealand; D011225:Pre-Eclampsia / Q000175:diagnosis* / Q000453:epidemiology; D011247:Pregnancy; D011256:Pregnancy Outcome; D011446:Prospective Studies; D012306:Risk; D055815:Young Adult
chemical_list: D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human