No need for routine glycosuria/proteinuria screen in pregnant women

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Original Research

No need for routine glycosuria/proteinuria screen in pregnant women

J Fam Pract. 2005 November;54(11):978-983

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References

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6. Hooper DE. Detecting GD and preeclampsia. J Repro Med 1996;41:885-888.

7. Buhling KJ, Elze L, Henrich W, et al. The usefulness of glycosuria and the influence of maternal blood pressure in screening for diabetes. Eur J Obstet Gynecol Reprod Biol 2004;113:145-148.

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The author concluded that urine testing for glucose was a poor screening test and was not worthwhile after the 28-week blood glucose challenge. He believed urine testing during the first 2 trimesters was indicated to early identify those 3.8% of women with severe (2+) glycosuria (sensitivity 18%, PV–96%). However, the incidence of glycosuria was not increased in those women with gestational diabetes when compared with those with normal glucose screening values.

FAST TRACK

Testing for gestational diabetes before 28 weeks, as might be prompted by urine test results, does not change pregnancy outcomes

Gribble: No evidence supports improved outcomes from earlier identification of gestational diabetes

Gribble et al retrospectively examined 2745 charts of women at low risk for gestational diabetes in their first 2 trimesters of pregnancy.⁵ Two urine dipstick screening determinations positive for glycosuria (≥250 mg/dL) during the first 2 trimesters before a blood glucose screening test were 7% sensitive and 98% specific with a PV–of 97% and a PV+ of 13% in a population with a prevalence of gestational diabetes of 3.1%.⁵

Less than 1% had glycosuria on their first prenatal visit and were excluded from the study. Only 7% of women (6/85) who were subsequently diagnosed with gestational diabetes had glycosuria during the first 2 trimesters of their pregnancy. There was no statistically significant association (P<.05) between glycosuria and maternal body mass index, age, history, multiparity, or birth weight of an infant greater than 4 kg. Many of these are considered risk factors for gestational diabetes. Over 8% of women with a normal 1-hour screen had glycosuria in the third trimester. Requiring 2 positive urine tests and analyzing data collected before the third trimester lowered sensitivity and the PV+.

The authors recommended continuing glycosuria testing in the first two trimesters and then stop testing after the blood screen for gestational diabetes at 24 to 28 weeks although they noted that there was no evidence to support an improved pregnancy outcome because of earlier identification in gestational diabetes.

Hooper and Buhling: Urine glucose screening should be abandoned

In a retrospective study by Hooper of 610 patients who did not have glycosuria at the first prenatal visit, I calculated a sensitivity of 36%, specificity of 98%, a NPV of 99%, and a PPV of 27% using a single glycosuria value of ≥100 mg/dL in a population with a prevalence of gestational diabetes of 1.8%.⁶ The author advised that urine screening for gestational diabetes and preeclampsia be abandoned.

In a prospective German study, 1001 women were followed throughout their pregnancy.⁷ Glycosuria was detected in 8.2% of patients. Twenty-seven percent (267/1001) had an abnormal 50-g (>140 mg/dL) glucose screening test result, 178 (67% of them) completed a 3-hour 75-g glucose diagnostic test and 37 (4.1%) had gestational diabetes.

Of the 729 patients with a normal 50-g screening test, 52 (7%) had glycosuria while of the 37 with gestational diabetes, 4 (11%) had glycosuria. Sensitivity was 11% with a PV–of 95%. The 50-gram glucose screening test was done at 33.8±3 weeks gestation, later than the 28 weeks recommended in this country. Also the cutoff values for the diagnosis of gestational diabetes were lower than those of the American Diabetes Association. Both changes would increase the incidence of gestational diabetes and the sensitivity of urine glucose screening. The authors recommended against screening for glycosuria.

Summary of the studies

Three of the 4 studies most likely overestimate the sensitivity of glycosuria for predicting gestational diabetes. All but Gribble et al included urine testing results collected in the third trimester, after the gold standard oral glucose screening test and diagnostic test were completed. Furthermore, most urine tests were probably done in the third trimester when prenatal visits occur more frequently and when glycosuria is more prevalent.⁷ Both of these factors would tend to falsely elevate the sensitivity of testing for glycosuria in the first and second trimesters, when it is theoretically most useful. Gribble et al reported that including third-trimester data did not change the predictive values of glycosuria for gestational diabetes; the other investigators did not.

TABLE 1
Accuracy of glycosuria for predicting gestational diabetes mellitus

DIAGNOSTIC TEST	STUDY QUALITY	N	SENSITIVITY (95% CI)	SPECIFICITY (95% CI)	LR+ (95% CI)	LR–(95% CI)	PV+	PV–	PREVALENCE OF GDM	ODDS RATIO (95% CI)
≥2 determinations Urine dipstick glycosuria ≥100 mg/dL [trace]⁴	2b	500	27% (13%–48%)	83% (80%–87%)	1.6 (0.8–3.4)	0.87 (0.7–1.1)	7%	96%	4.4%	1.9 (0.7–5.0)
≥2 determinations Urine dipstick glycosuria ≥250 mg/dL [1+]⁵	2b	2745	7% (3%–15%)	98% (98%–99%)	4.5 (2.0–10.5)	0.94 (0.9–1.0)	13%	97%	3.1%	4.9 (2.0–11.8)
≤1 determination Urine dipstick glycosuria ≥100 mg/dL [1+]⁶	2b	607	36% (15%–64%)	98% (97%–99%)	20 (7.4–52.3)	0.65 (0.41–1.0)	27%	99%	1.8%	30.4 (7.8–119)
1 determination Urine dipstick glycosuria >75–125 mg/dL⁷	2b	766	11% (4%–25%)	93% (91%–95%)	1.5 (0.6–4.0)	.96 (0.9–1.1)	7%	95%	4.1%	1.6 (0.5–4.6)
LR+, positive likelihood ratio; LR–, negative likelihood ratio; PV+, probability of disease given a positive test; PV–, probability of disease given a negative test; GDM, gestational diabetes mellitus; CI, confidence interval.