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Original Research ORIGINAL RESEARCH William A. Alto, MD, MPH Maine-Dartmouth Family No need for routine Practice Residency, Fairfield, Maine glycosuria/proteinuria screen in pregnant women Practice recommendations investigating glycosuria as a predictor for I Screening for gestational diabetes gestational diabetes mellitus, or proteinuria using urine dipsticks for glycosuria is as a predictor for preeclampsia (1 exam- ineffective with low sensitivities. False- ined both). Because every study used positive tests outnumber true positives different dipstick methods of determining 11:1. A 50-g oral glucose challenge is a results, or definitions of abnormal, each better test. Tests for glycosuria after this was evaluated separately. blood test are not useful (B). Results Glycosuria is found at some point in about 50% of pregnant women; I Proteinuria determined by dipstick in it is believed to be due to an increased pregnancy is common and a poor pre- glomerular filtration rate.3 The renal dictor for preeclampsia with a positive threshold for glucose is highly variable predictive value between 2% and 11%. and may lead to a positive test result for If the blood pressure is elevated, a glycosuria despite normal blood sugar. more sensitive test should be used (B). High intake of ascorbic acid or high I After urinalysis at the first prenatal visit, urinary ketone levels may result in false- routine urine dipstick screening should positive results. Four published studies be stopped in low-risk women (B). assessed the value of glycosuria as a screen for gestational diabetes.4–7 All used Abstract urine dipsticks. Three of the 4 most likely Objective More than 22 million prenatal overestimate the sensitivity of glycosuria visits occur in the US each year.1 Each for predicting gestational diabetes. pregnant woman averages 7 visits. Most Conclusions Routine dipstick screening include urine testing for glucose and pro- for protein and glucose at each prenatal tein to screen for gestational diabetes and visit should be abandoned. Women who preeclampsia. Is there sufficient scientific are known or perceived to be at high risk evidence to support this routine practice? for gestational diabetes or preeclampsia Methods We searched Medline (1966– should continue to be monitored closely 2004), the Cochrane review, AHRQ at the discretion of their clinician. National Guideline Clearinghouse, the Institute for Clinical Systems Improve- ment, and Google, searching for studies outine dipstick testing is time- CORRESPONDING AUTHOR on proteinuria or glycosuria in pregnancy. consuming and expensive, especial- William A. Alto, MD, MPH, The reference list of each article reviewed ly when carried out over multiple 4 Sheridan Drive, Fairfield, R ME 04937. E-mail: was examined for additional studies, but visits. False-positive test results are fre- [email protected] none were identified. We found 6 studies quent and often lead to further laboratory 978 VOL 54, NO 11 / NOVEMBER 2005 THE JOURNAL OF FAMILY PRACTICE Routine glycosuria/proteinuria screen in pregnant women L TABLE 1 Accuracy of glycosuria for predicting gestational diabetes mellitus DIAGNOSTIC STUDY SENSITIVITY SPECIFICITY LR+ LR– PREVALENCE ODDS RATIO TEST QUALITY N (95% CI) (95% CI) (95% CI) (95% CI) PV+ PV– OF GDM (95% CI) ≥2 determinations 2b 500 27% 83% 1.6 0.87 7% 96% 4.4% 1.9 Urine dipstick (13%–48%) (80%–87%) (0.8–3.4) (0.7–1.1) (0.7–5.0) glycosuria ≥100 mg/dL [trace]4 ≥2 determinations 2b 2745 7% 98% 4.5 0.94 13% 97% 3.1% 4.9 Urine dipstick (3%–15%) (98%–99%) (2.0–10.5) (0.9–1.0) (2.0–11.8) glycosuria ≥250 mg/dL [1+]5 ≤ 1 determination 2b 607 36% 98% 20 0.65 27% 99% 1.8% 30.4 Urine dipstick (15%–64%) (97%–99%) (7.4–52.3) (0.41–1.0) (7.8–119) glycosuria ≥100 mg/dL [1+]6 1 determination 2b 766 11% 93% 1.5 .96 7% 95% 4.1% 1.6 Urine dipstick (4%–25%) (91%–95%) (0.6–4.0) (0.9–1.1) (0.5–4.6) glycosuria >75–125 mg/dL7 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. examinations. Today, when our care of of determining results, or definitions of patients is squeezed by both time and abnormal, each was evaluated separately. monetary constraints, we have a rare opportunity to make office visits more FAST TRACK I productive and to save patients the burden What the evidence shows High ascorbic of unnecessary work-ups. Found at some point in about 50% of women, glycosuria is believed to be due to acid intake an increased glomerular filtration rate.3 or high urinary I Review methods The renal threshold for glucose is highly ketone levels We searched Medline from 1966 to variable and may lead to a positive test September 2004 for English language arti- result for glycosuria despite a normal can cause cles using keyword searching for “protein- blood sugar. High intake of ascorbic acid false-positive uria” or “glycosuria” and “prenatal” or or high urinary ketone levels may result in glycosuria results “pregnancy.” We explored the Cochrane false-positive results. There have been 4 review, AHRQ National Guideline published studies designed to assess the Clearinghouse, the Institute for Clinical value of glycosuria as a screen for gesta- Systems Improvement, and Google. The tional diabetes mellitus.4–7 All used urine reference list of each article reviewed was dipsticks (TABLE 1). examined for additional studies, but none were identified. Watson: Urine test All 6 identified studies that investigated a poor screening instrument glycosuria as a predictor for gestational dia- In an observational prospective study of betes mellitus or proteinuria as a predictor 500 women, Watson evaluated glycosuria for preeclampsia are reviewed in this analy- (trace, ≥100 mg/dL) detected on 2 separate sis. One study examined both. Because prenatal visits (17% of women) as a pre- every study used different dipstick methods dictor of gestational diabetes.4 Gestational www. jfponline.com VOL 54, NO 11 / NOVEMBER 2005 979 ORIGINAL RESEARCH diabetes was defined as an abnormal 50-g (P<.05) between glycosuria and maternal glucose screen at 28 weeks gestation con- body mass index, age, history, multiparity, firmed by an abnormal 100-mg 3-hour or birth weight of an infant greater than 4 oral glucose tolerance test (OGTT). kg. Many of these are considered risk fac- He reported that glycosuria used as a tors for gestational diabetes. Over 8% of screening test for gestational diabetes had a women with a normal 1-hour screen had sensitivity of 27% and a specificity of 83% glycosuria in the third trimester. Requiring with a negative predictive value (PV–) of 2 positive urine tests and analyzing data 96% and a positive predictive value (PV+) collected before the third trimester lowered of 7% in a population with an unusually sensitivity and the PV+. high prevalence of gestational diabetes of The authors recommended continuing 4.4%. The high prevalence of gestational glycosuria testing in the first two trimesters diabetes in this cohort increased the PV+ of and then stop testing after the blood screen urine screening for glycosuria. Women with for gestational diabetes at 24 to 28 weeks severe glycosuria (>250 mg/dL, 2+) on 2 although they noted that there was no evi- determinations during the first 2 trimesters dence to support an improved pregnancy had a 21% chance (PV+) of being diag- outcome because of earlier identification in nosed as having gestational diabetes. gestational diabetes. The author concluded that urine test- ing for glucose was a poor screening test Hooper and Buhling: Urine glucose and was not worthwhile after the 28-week screening should be abandoned blood glucose challenge. He believed urine In a retrospective study by Hooper of 610 testing during the first 2 trimesters was patients who did not have glycosuria at the indicated to early identify those 3.8% of first prenatal visit, I calculated a sensitivity women with severe (2+) glycosuria (sensi- of 36%, specificity of 98%, a NPV of tivity 18%, PV– 96%). However, the inci- 99%, and a PPV of 27% using a single gly- dence of glycosuria was not increased in cosuria value of ≥100 mg/dL in a popula- those women with gestational diabetes tion with a prevalence of gestational dia- FAST TRACK when compared with those with normal betes of 1.8%.6 The author advised that Testing for glucose screening values. urine screening for gestational diabetes and preeclampsia be abandoned. gestational Gribble: No evidence supports In a prospective German study, 1001 diabetes before improved outcomes from earlier women were followed throughout their 28 weeks, as identification of gestational diabetes pregnancy.7 Glycosuria was detected in Gribble et al retrospectively examined 2745 8.2% of patients. Twenty-seven percent might be prompted charts of women at low risk for gestational (267/1001) had an abnormal 50-g (>140 by urine test diabetes in their first 2 trimesters of preg- mg/dL) glucose screening test result, 178 results, does not nancy.5 Two urine dipstick screening deter- (67% of them) completed a 3-hour 75-g change pregnancy minations positive for glycosuria (≥250 glucose diagnostic test and 37 (4.1%) had mg/dL) during the first 2 trimesters before a gestational diabetes. outcomes blood glucose screening test were 7% sensi- Of the 729 patients with a normal 50- tive and 98% specific with a PV– of 97% g screening test, 52 (7%) had glycosuria and a PV+ of 13% in a population with a while of the 37 with gestational diabetes, 4 prevalence of gestational diabetes of 3.1%.5 (11%) had glycosuria.
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