BackgroundThe best strategy to identify women with gestational diabetes mellitus (GDM) is unclear.Objectives To perform a systematic review to calculate summary estimates of the sensitivity and specificity of the 50-g glucose challenge test for GDM.Search strategy Systematic search of MEDLINE, EMBASE and Web of Science.Selection criteria Articles that compared the 50-g glucose challenge test with the oral glucose tolerance test (OGTT, with a 75-or 100-g reference standard) before 32 weeks of gestation.Data collection and analysis Summary estimates of sensitivity and specificity, with 95% confidence intervals and summary receiver operating characteristic curves, were calculated using bivariate random-effects models. Two reviewers independently selected articles that compared the 50 g glucose challenge test to the oral glucose tolerance test (OGTT, 75 or 100 gram, reference standard) before 32 weeks of gestation.Main results Twenty-six studies were included (13 564 women). Studies that included women with risk factors showed a pooled sensitivity of the 50-g glucose challenge test of 0.74 (95% CI 0.62-0.87), a pooled specificity of 0.77 (95% CI 0.66-0.89) (threshold value of 7.8 mmol/l), a derived positive likelihood ratio (LR) of 3.2 (95% CI 2.0-5.2) and a negative LR of 0.34 (95% CI 0.22-0.53). In studies with consecutive recruitment, the pooled sensitivity was 0.74 (95% CI 0.62-0.87) for a specificity of 0.85 (95% CI 0.80-0.91), with a derived positive LR of 4.9 (95% CI 3.5-7.0) and negative LR of 0.31 (95% CI 0.20-0.47). Increasing the threshold for disease (OGTT result) increased the sensitivity of the challenge test, and decreased the specificity.Author's conclusions The 50-g glucose challenge test is acceptable to screen for GDM, but cannot replace the OGTT. Further possibilities of combining the 50-g glucose challenge test with other screening strategies should be explored.

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Glucose challenge test for detecting gestational diabetes mellitus: a systematic review Sir, The sensitivity and specificity of screening tests are crucial to adequately detect, and thus efficiently prevent and treat, gestational diabetes mellitus (GDM). The fascinating report by van Leeuwen et al. 1 was a meta-analysis on the 50-g glucose challenge test (GCT), spanning 26 papers. The oral glucose tolerance test (OGTT), following the ingestion of 75 or 100 g of glucose, was used as the reference/diagnostic test for the meta-analysis, which found similar results among studies including women with risk factors and studies with consecutive recruitment: a pooled sensitivity of 0.74 and 0.74, and a pooled specificity of 0.77 and 0.85, respectively. Interestingly, GCT displayed only modest accuracy for GDM screening, with a positive likelihood ratio (LR) of 3.2 and 4.9, and negative LR of 0.34 and 0.32, respectively. As expected, a higher threshold for a positive OGTT increased the sensitivity and decreased the specificity of the GCT.Despite its relatively weak sensitivity and specificity values, the authors concluded that GCT is nevertheless acceptable for screening, but can't replace the OGTT. This conclusion is in agreement with the recent guidelines of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and the American Diabetes Association (ADA). Both associations recommend OGTT as a one-step screening and diagnosis combination. This limits the scope of the meta-analysis reported by van Leeuwen et al., but the degree of adherence to IADPSG/ADA guidelines has yet to be established.Other limitations are linked to the inherent drawbacks of GCT and OGTT, relating mainly to the length of time required to process blood samples in order to measure blood glucose (BG), as well as the actual time of day when women are tested. It is widely recognised that the nature of a sample (serum/plasma), its storage temperature, the time elapsed between sampling and centrifugation (in-tube glycolysis), and the use of a glycolysis inhibitor are all factors that can alter BG values. The impact of these factors was recently addressed in a study of 60 pregnant women. When tubes were processed systematically and centrifugation performed 5 minutes after blood collection, plasma BG values increased by 10 mg/l, uncovering fifteen cases of diabetes that were previously overlooked when the regular routine was used. 2Another key issue for screening accuracy is linked to the actual time of day when testing is performed. The literature supports a circadian variation of BG in pregnant women, with higher values for GCT and OGTT performed in the afternoon, observed in studies performed in relatively small cohorts.3,4 These all but forgotten results suggested that GCT cut-off values should be adjusted for morning versus afternoon testing. Unfortunately, no further recommendation has ever been issued regarding the best time of day for testing.The bottom line is that GDM may all too often be overlooked for reasons easily circu...

Objective To evaluate the reduction of pain by misoprostol compared with placebo prior to hysteroscopy in postmenopausal and premenopausal nulliparous women.Design Randomised multicentre double-blind placebo controlled trial.Setting Two Dutch teaching hospitals and one Dutch university medical centre.Population Postmenopausal and premenopausal nulliparous women undergoing office hysteroscopy.Methods Patients were randomised to receive either 400 microgram misoprostol or placebo 12 and 24 hours before hysteroscopy. Pain was quantified by the use of real time pain measurement using the continuous pain score meter (CPSM) and VAS scores.Main outcome measures Primary outcome was pain measured by the CPSM during passage of the hysteroscope through the cervical canal, quantified by the area under the curve (AUC). Secondary outcomes included VAS scores, other CPSM parameters, failures and side effects.Results In all, 149 patients were randomly assigned to either misoprostol (n = 74) or placebo (n = 75). The AUC during introduction did not significantly differ between the intervention and the placebo group. The VAS score during introduction, however, demonstrated a significant difference in premenopausal nulliparous women favouring misoprostol: 2.9 (95% CI 1.3-4.4) versus placebo 5.5 (95% CI 3.9-7.1), P = 0.02, as well as the AUC during the entire procedure: 618 (95% CI 410-827) versus 1126 (95% CI 671-1580), P = 0.04. Failures were equally distributed between the misoprostol (16%) and placebo group (13%). Intestinal side effects occurred significantly more frequently in the misoprostol group (67%) than in the placebo group (32%) 3), P < 0.01].Conclusion Misoprostol prior to hysteroscopy reduces pain in premenopausal nulliparous women but not in postmenopausal women. It does cause side effects.Keywords Hysteroscopy, misoprostol, pain, continuous pain score meter, CPSM.Tweetable abstract RCT: misoprostol versus placebo prior to hysteroscopy in 149 women significantly reduces some pain parameters.

To compare pain measured with a new electronic devicethe Continuous Pain Score Meter (CPSM)and the Verbal Rating Scale (VRS) during gynaecological procedures in an outpatient setting, and to correlate these outcomes with baseline anxiety and patient (in)tolerance to the procedure. Study design: This prospective cohort study was undertaken in two centres: a university hospital and a large teaching hospital in The Netherlands. Patients undergoing an outpatient hysteroscopy, colposcopy or ovum pick-up procedure for in-vitro fertilization in one of the two participating hospitals with availability of the CPSM were included. Pain was measured by both the CPSM and the VRS. Patient tolerance to the procedure was reported. Various outcomes of the CPSM were compared with those of the VRS and related to baseline anxiety scores.Results: Ninety-one of 108 included patients (84 %) used the CPSM correctly during the procedure, and it was possible to analyse the CPSM scores for 87 women (81 %). The CPSM scores were all linearly related to the VRS. The peak pain score on the CPSM (CPSM-PPS) had the strongest correlation with the VRS score for all three procedures. Higher CPSM-PPS was related to patient (in)tolerance to the procedure (p = 0.03-0.002). Anxiety at baseline was not correlated with pain perception, except for VRS during colposcopy (r = 0.39, p = 0.016). Conclusion:The majority of patients were able to use the CPSM correctly, resulting in detailed information on pain perception for each individual pain stimulus during three outpatient gynaecological procedures. The CPSM-PPS had the strongest correlation with the VRS score and patient (in)tolerance to the procedure.