An Early Pregnancy HbA1c ≥5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes

OBJECTIVE Pregnant women with undiagnosed diabetes are a high-risk group that may benefit from early intervention. Extrapolating from nonpregnancy data, HbA(1c) >= 6.5% (48 mmol/mol) is recommended to define diabetes in pregnancy. Our aims were to determine the optimal HbA(1c) 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. RESEARCH DESIGN AND METHODS During 2008-2010 in Christchurch, New Zealand, women were offered an HbA(1c) measurement with their first antenatal bloods. Pregnancy outcome data were collected. A subset completed an early OGTT, and HbA(1c) performance was assessed using World Health Organization criteria. RESULTS HbA(1c) 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, HbA(1c) >= 5.9% (41 mmol/mol) captured all 15 cases of diabetes, 7 with HbA(1c) < 6.5% (< 48 mmol/mol). This HbA(1c) 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 HbA(1c) of 5.9-6.4% (41-46 mmol/mol; n = 200) had poorer pregnancy outcomes than those with HbA(1c) < 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 HbA(1c) measurements were readily performed in contrast to the low uptake of early OGTTs. HbA(1c) >= 5.9% (>= 41 mmol/mol) identified all women with diabetes and a group at significantly increased risk of adverse pregnancy outcomes.