Current guidelines on the management of gestational diabetes … · 2019. 6. 13. · gestational diabetes mellitus: a content analysis and appraisal Mengxing Zhang1, Yingfeng Zhou1*,

RESEARCH ARTICLE Open Access

Current guidelines on the management ofgestational diabetes mellitus: a contentanalysis and appraisalMengxing Zhang1, Yingfeng Zhou1*, Jie Zhong1, Kairong Wang1, Yan Ding2 and Li Li2

Abstract

Background: Despite many guidelines for the management of gestational diabetes available internationally, littlework has been done to summarize and assess the content of existing guidelines. A paucity of analysis guidelineswithin in a unified system may be one explanatory factor. So this study aims to analyze and evaluate the contentsof all available guidelines for the management of gestational diabetes.

Method: Relevant clinical guidelines were collected through a search of relevant guideline websites and databases(PubMed, Web of Science, Embase, etc.). Fourteen guidelines were identified, and each guideline was assessed forquality using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Two independent reviewersextracted guideline recommendations using a “recommendation matrix” through which basic guideline informationand consistency between search strategy and selection of evidence, between selected evidence and interpretation,and between interpretation and resulting recommendations were analyzed.

Results: Fourteen documents were analyzed, and a total of 361 original recommendations for gestational diabetesmellitus (GDM) management were assessed. In all guidelines included, the recommendations were developed in fivedomains, namely, diagnosis of GDM, prenatal care, intrapartum care, neonatal care and postpartum care. Differentguidelines appeared to have significant discrepancy in consistency of guideline content, but overall, there wasconsistency between search strategy and selection of evidence, between selected evidence and interpretation, andbetween interpretation and resulting recommendations (scilicet 49.31, 57.20 and 58.17%, respectively).

Conclusion: Although commonality in most recommendations existed, there were still some discrepanciesbetween guidelines. Consistency of guidelines on the management of GDM in pregnancy is highly variable andneeds to be improved.

Keywords: Gestational diabetes mellitus, Content analysis method, Clinical practice guideline, Recommendation matrix

BackgroundGestational diabetes mellitus (GDM) is a special form ofdiabetes in women of child-bearing age and is a commongestational endocrine disease [1]. Due to its increasingprevalence, GDM results in significant short- and long-term impairments in the individual’s health and their off-spring’s health [2–6]. Consistent evidence from high-qualityrandomized controlled trials over the last few decades hasdetermined that proper management is effective in

ensuring pregnancy outcomes and long-term outcomes inGDM women [7, 8]. However, management of GDM in thereal world of clinical practice seems to be unsatisfactory [9],so it is necessary to standardize the management of GDM.Clinical practice guidelines (CPGs) are statements that

include recommendations intended to assist providers andrecipients of healthcare and other stakeholders to makeinformed decisions, and they are effective tools for dis-seminating medical knowledge [10]. With regard to themanagement of GDM, there are an abundance of availableguidelines [11–19]. Health professional organizations likethe American Diabetes Association (ADA) and the Na-tional Institute for Health and Care Excellence (NICE)

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected] University Centre for Evidence-based Nursing: A Joanna BriggsInstitute Centre of Excellence, School of Nursing, Fudan University, Shanghai,ChinaFull list of author information is available at the end of the article

Zhang et al. BMC Pregnancy and Childbirth (2019) 19:200 https://doi.org/10.1186/s12884-019-2343-2

update their management guidelines regularly [20, 21]. Inmainland China and Hong Kong, based on internationalguidelines on pregnancy and diabetes mellitus, contextualguidelines for GDM management have been establishedthrough expert consensus [22, 23]. As the most authorita-tive form, CPGs have the potential to influence the caredelivered by a large number of healthcare providers andconsequently the outcomes for patients, so it is universallyacknowledged that the methodological quality of guide-lines is very important and should be appraised [24, 25].Our previous research found that, in general, the qualityof GDM guidelines was relatively higher than that in theprevious year [26], while the domains of Rigor of Develop-ment, Stakeholder Involvement and Editorial Independ-ence of guidelines still needed to be improved.However, methodological quality of guideline is not

the only way to evaluate a guideline. Whether guide-lines provide valid recommendations is an aspect ofparticular importance to practitioners. It is noted thatthere may be conflict between methodological qualityand the validity of recommendations, and currentguidelines differ substantially in their management rec-ommendations [27]. Whether the recommendations arein accordance with evidence and whether the recom-mendations suit the local context are unknown. Thismakes it hard for the busy practitioners, confrontedwith conflicting guideline recommendations, to deter-mine which guideline to follow [27]. Many researchersare aware of the fact that it is imperative to find a uni-fied system for evaluating the validity of recommenda-tions. However, little work has been done in this area.In order to better ascertain the best treatment forGDM women and whether recommendations incurrent guidelines are valid or not, extracting and ap-praising the content of current guidelines are crucial.Therefore, the aim of this study was to extract andevaluate the recommendations included in guidelinesfor GDM management using a recommendation matrix(details in another article under review).

MethodsA search was conducted in CPGs for GDM manage-ment. The search strategy used the keywords “preg-nancy”, “gravida*”, “conception”, “maternity”, “diabetes”,“hyperglycemia”, “insulin resistance”, “glucose intoler-ance”, “guideline”, “criteria”, “recommendation” and“standard”. Information sources were identified from theNational Institute for Health and Care Excellence (NICE),New Zealand Guidelines Group (NZGG), Scottish Inter-collegiate Guidelines Network (SIGN), China Medlive,American Diabetes Association (ADA), Canadian DiabetesAssociation (CDA), International Diabetes Federation(IDF), PubMed, Web of Science, Embase, China National

Knowledge Infrastructure (CNKI), Wanfang Chinese Peri-odical Database and VIP Chinese Periodical Database.The eligibility criteria included: ①full guideline that wereavailable in English or Chinese; ②guidelines which con-tained recommendations regarding GDM interventions;③guidelines that were issued between 2009 and 2018.Two independent reviewers selected documents for inclu-sion and appraised the methodological quality with theAppraisal of Guidelines for Research & Evaluation(AGREE) II instrument.Based on the quality evaluations, the reviewers sum-

marized recommendations in guidelines and assessedthe content of guidelines by establishing a “recom-mendation matrix” (Table 1 as an example). For eachincluded document, we extracted the following infor-mation: title of guideline, author, development insti-tute (e.g. government, special organization, etc.), yearof publication, guideline type, methodological quality(appraised with AGREE II) and relevant recommenda-tions. For all recommendations extracted, we assessedwhether or not they explicitly recommended with theconsistency across search strategies, selection of evi-dence, evidence interpretation and resulting recom-mendations. Each of the recommendations was ratedon a seven-point scale (1-strongly inconsistent to 7-strongly consistent). A quality score was calculated inthe same way used in AGREE II [28], that is, for eachrecommendation, the score was calculated by sum-ming up all the scores of the individual items and byscaling the total as a percentage of the maximumpossible score [28]. If the guideline provided morecomplete information, we also extracted supportingevidence and the evidence level if the evidence hasbeen cited, and the likelihood of applying the recom-mendation in China. For all guidelines, the recom-mendations were divided into five domains, namely,diagnosis of GDM, prenatal care, intrapartum care,neonatal care and postpartum care.Initially, two researchers (Yingfeng Zhou and Mengx-

ing Zhang) independently analyzed one guideline withthe recommendation matrix in order to identify the val-idation and feasibility of the tool before determine thefinal result. Then the final form was used to extractrecommendations content from the other guidelines.Frequent communication occurred between two re-searchers throughout the process so as to maximizeinter-rater reliability. Any disagreements were settledthrough consultation with the study groups.Descriptive statistics were conducted in order to

characterize the recommendation content. For quantita-tive data, the statistical analysis was performed usingMicrosoft Office 2013 and SPSS Version 25.0. The totalnumber, percentages, and mean, and standard deviationwere calculated to describe the consistency of

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recommendations. In addition, a radar chart was alsoused to identify features of recommendation consistencyin different aspects.This article is part of a guideline adaptation project. The

Guideline Adaptation Project has been registered in theInternational Guideline Register Center (http://www.guide-lines-registry.cn), Registration number: IPGRP-2016CN015.

ResultsCharacteristics of included guidelinesCombining all searches yielded 108 relevant documents,of which 14 guidelines from international organizationswere included: ADA (American Diabetes Association),NCC-WCH (National Collaborating Centre for Women’sand Children’s Health), IDF (International Diabetes Feder-ation), FIGO (The International Federation of Gynecologyand Obstetrics), CMA (Chinese Medical Association),DDG (German Diabetes Association), A.N.D. (Academyof Nutrition and Dietetics), API (The Association of Physi-cians of India), CDA (Canadian Diabetes Association),HKCOG (The Hong Kong College of Obstetricians andGynecologists), American Endocrine Society, NZGG(New Zealand Guidelines Group), SIGN (Scottish Inter-collegiate Guidelines Network), and Queensland Depart-ment of Health. See Fig. 1 for the flow diagram of thedocument selection process. Characteristics of the final in-cluded items are shown in Table 2.According to systematically evaluation with AGREE II

instrument, the methodological quality of guidelines in-cluded varied. But generally, they scored well. Scores forsix AGREE II domains (Mean ± SD) were:88% ± 0.15(Scope and Purpose), 73% ± 0.30 (Stakeholder Involve-ment), 60% ± 0.29 (Rigor of Development), 89% ± 0.19(Clarity of Presentation), 70% ± 0.34 (Applicability),70% ± 0.41 (Editorial Independence).

Comparison and summary of recommendationsUsing the recommendation matrix, all relevant guidelineinformation and recommendations included were ex-tracted, and all health questions of each guideline wereplaced in the recommendation matrixes (Additional files1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14). For ex-ample, we extracted the NICE guideline, which is dis-played in Table 1. The NICE guideline was developedbased on evidence, and the development process was

Table 1 Recommendations Extraction (NICE guideline as anexample)

Basic information

Title of guideline Diabetes in pregnancy: Managementof diabetes and its complicationsfrom preconception to the postnatalperiod

Development institute NICE

Publication year Published 2008, updated 2015

Guideline type Evidence-based guideline

Guideline methodology Developed in accordance with theNICE guideline development process

Quality assessment ofevidence and grading ofstrength of recommendations

GRADE system

GuidelineCurrency

Literature searchdate

2014.6

Search strategy A comprehensive literature searchwas performed

Methodological quality of guideline

AGREE IIscores

Domain 1. Scopeand Purpose

100%

Domain 2.StakeholderInvolvement

100%

Domain 3. Rigorof Development

100%

Domain 4. Clarityof Presentation

100%

Domain 5.Applicability

100%

Domain 6.EditorialIndependence

100%

Overallassessment

Recommend Recommend withmodifications Would notrecommend

Recommendation extraction and assessment

Health questions What are the target ranges for bloodglucose in women with gestationaldiabetes during pregnancy?

Specific recommendation Advice pregnant women with anyform of diabetes to maintain theircapillary plasma glucose below thefollowing target levels, if these areachievable without causingproblematic hypoglycaemia: 1)fasting: 5.3 mmol/L(#1) and 2) 1 hafter meals: 7.8 mmol/L(#2) or 3) 2 hafter meals: 6.4 mmol/L.(#3)

Strength of recommendation Strong Week

Supporting evidence (#1) 1 secondary analysis of RCT data,1 RCT, very low(#2) 1 retrospective cohort study, verylow(#3) 1 secondary analysis of RCT data,very low

Consistency appraisal Search strategy and selection of

Table 1 Recommendations Extraction (NICE guideline as anexample) (Continued)

evidence 1 2 3 4 5 67

Evidence and interpretation 1 23 4 5 6 7

Interpretation and recommendation1 2 3 4 5 6 7

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distinctly clarified. The guideline group graded evi-dence and recommendations by Grading of Recom-mendations Assessment, Development and Evaluation(GRADE) system. With regard to health question “targetblood glucose values”, the results of recommendation ap-praisal revealed high consistency in search strategy and se-lection of evidence, evidence and interpretation, as well asinterpretation and resulting recommendations.

The effectiveness categorization of each domain basedons the recommendations was presented in Table 3. Thesimilarities and differences between the different guide-lines on each domain were discussed below.

Diagnosis of GDMThe first domain was diagnosis of GDM, which coveredthree health questions: risk factors of GDM, GDM

Fig. 1 Flow chart of the systematic literature search and selection

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Table 2 Characteristics of the 14 guidelines

Guidelines Country/region

Developmentinstitute

Publicationyear

Type Main content

1 Gestational Diabetes (2016)Evidence-Based NutritionPractice Guideline [11]

USA A.N.D. 2016 Evidence-based

The focus of this guideline is on nutritionpractice during the treatment of womenwith GDM. Topics include: ①Referral to anRDN; ②Nutrition Assessment; ③MNT;④Calories; ⑤Macronutrients; ⑥Vitaminsand Minerals; ⑦Meal and Snack Distribution;⑧High-Intensity Sweeteners; ⑨Alcohol;⑩Physical Activity; ⑪Nutrition Monitoringand Evaluation

2 Clinical Practice Guidelines:Diabetes and Pregnancy [12]

Canada CDA 2013 Evidence-based

“Diabetes and Pregnancy” is one of chaptersof the full guideline--“Clinical PracticeGuidelines”, which contains PregestationalDiabetes and GDM. GDM topics include:①Screening and diagnosis; ②Management(Lifestyle, Glycemic control, Monitoring,Pharmacological therapy, Intrapartumglucose management, Intrapartum insulinmanagement, Postpartum care, Planningfuture pregnancies)

3 Diabetes and Pregnancy: AnEndocrine Society ClinicalPractice Guideline [13]

USA EndocrineSociety

2013 Evidence-based

The Guideline addresses important clinicalissues in the contemporary management ofwomen with Pregestational Diabetes andwomen with GDM during and after pregnancy.GDM: ①Testing and diagnosis; ②Managementof elevated blood glucose; ③Glucose monitoringand glycemic targets; ④Nutrition therapy andweight gain targets; ⑤Blood glucose-loweringpharmacological therapy during pregnancy,Labor, delivery, lactation, and postpartum care.

4 Global Guideline on Pregnancyand Diabetes [14]

International IDF 2009 Evidence-based

The guideline is for pregnant women withknown diabetes or GDM, and topics include:①Pre-conception glycaemic control; ②Testingfor GDM; ③Management during pregnancy(Monitoring glucose levels, Lifestylemanagement, Insulin use during pregnancy, Oralglucose-lowering agents in pregnancy); ④Management after pregnancy (Breastfeeding, Follow-up of GDM, Prevention of type 2 diabetes inwomen who developed GDM).

5 Screening, Diagnosis andManagement of GestationalDiabetes in New Zealand:A clinical practice guideline [15]

NewZealand

NZGG 2014 Evidence-based

This guideline covers: ①Early screening ofwomen for probable undiagnosed diabetes;②Screening, diagnosis and management ofwomen with GDM; ③Follow-up of women withGDM to detect type 2 diabetes after birth.

6 Queensland Clinical Guideline:Gestational diabetes mellitus [16]

Queensland Departmentof Health

2015 Evidence-based

This guideline includes recommendations about:①Risk Assessment of GDM; ②Antenatal Care(Maternal and Fetal surveillance, Psychosocialsupport, Self-monitoring, Medical nutrition therapy, Physical activity); ③Pharmacological therapy;④Birthing Care; ⑤Postpartum care.

7 Management of diabetes:A national clinical guideline [17]

Scotland SIGN 2013 Evidence-based

This guideline provides recommendations basedon current evidence for best practice in themanagement of diabetes. “Management ofdiabetes in pregnancy” is one of updatedchapters, which only contains a fewrecommendations about pre-pregnancy care, nutritional management, optimization of glycemiccontrol, complication during pregnancy, fetal assessment, gestational diabetes, delivery, postnatalcare.

8 Initiative on gestational diabetesmellitus: A pragmatic guide fordiagnosis, management, and care

International FIGO 2015 Evidence-based

To address the issue of GDM, FIGO recommendsthe following: ①Public health focus; ②Universaltesting; ③Criteria for diagnosis; ④Diagnosis of

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screening and diagnostic criteria. Risk factors for GDMwere identified in five guidelines [12, 21–23, 29], mainly in-cluding personal and family history, relevant medical his-tory, past pregnancy and current history. It was noted thatthreshold of some risk factors were discrepant in differentguidelines. As an example, advanced maternal age, obesityBMI and macrosomia weighing in Hong Kong College ofObstetricians and Gynaecologists (HKCOG) guideline [22]had a much smaller value then in western countries. NICEguideline recommended that pregnant women with riskfactors should be screened, while other guidelines recom-mended that universal screening was preferred. As todiagnostic criteria, the International Association ofthe Diabetes and Pregnancy Study Groups (IADPSG)(2010) criteria was adopted by most guidelines. In thisstudy, eight guidelines [11, 13, 16–18, 22, 23, 29]

included used IADPSG (2010) criteria, recommendingthat GDM should be diagnosed at any time in preg-nancy if one or more of the following criteria weremet following a 75 g oral glucose tolerance test(OGTT): 1) fasting PG 5.1–6.9 mmol/L; 2) 1-h PG ≥10.0 mmol/L; 3) 2-h PG 8.5–11.0 mmol/L, while sixother guidelines recommended alternatives.

Prenatal carePrenatal care was a very crucial domain of GDM manage-ment. All guidelines agreed that it was necessary to encour-age GDM women to take prenatal care. All guidelines,excepting the A.N.D. guideline [11] that only mentionednutrition therapy, made recommendations in similar as-pects of prenatal interventions more or less, which mightrefer to health education, medical nutrition therapy,

Table 2 Characteristics of the 14 guidelines (Continued)

Guidelines Country/region

Developmentinstitute

Publicationyear

Type Main content

[18] GDM; ⑤Management of GDM; ⑥Lifestylemanagement; ⑦Pharmacological management;⑧Postpartum follow-up and linkage to care.

9 Consensus Evidence-basedGuidelines for Managementof Gestational DiabetesMellitus in India [19]

India API 2014 Evidence-based

The guideline presents an overview of followingconsensus: ①Screening for GDM; ②Diagnosticcriteria for GDM; ③Blood glucose targets andmonitoring; ④Oral anti-diabetic drugs; ⑤Insulintherapy; ⑥Continuous subcutaneous insulininfusion.

10 Standards of medicalcare in diabetes −2018 [20]

USA ADA 2018 Evidence-based

It is a general Standards of Medical Care inDiabetes. “Management of Diabetes inPregnancy” is a chapter of this guideline, whichinclude following relevant recommendations:①Preconception counseling; ②Glycemic targetsin pregnancy; ③Management of GDM;④Pregnancy and drug consideration

11 Diabetes in pregnancy:management from preconceptionto the postnatal period [21]

England NICE, NCC-WCH

2015 Evidence-based

The guideline focus on Management of diabetesand its complications from preconception to thepostnatal period: ①Preconception planning andcare; ②Gestational diabetes; ③Antenatal care forwomen with diabetes; ④Intrapartum care;⑤Postnatal care.

12 Gestational Diabetes Mellitus(GDM) – Diagnosis, Treatmentand Follow-Up. Guideline of theDDG and DGGG [29]

Germany DDG, DGGG 2018 Evidence-based

This guideline focus on: ①Screening anddiagnosis; ②Treatment (First medicalconsultation after GDM diagnosis; Physicalactivity; Dietary counselling; Recommendedweight gain; Blood glucose monitoring; Insulintherapy; Oral antidiabetic drugs and GLP-1 analogues); ③Obstetric care; ④Postpartum care.

13 Guidelines for the Management ofGestational Diabetes Mellitus [22]

Hong Kong HKCOG 2016 ExpertConsensus

This is an Expert Consensus focuson:①Diagnostic criteria and classification;②Screening for hyperglycemia in pregnancy;③Early detection of GDM and screening for pre-GDM in the first trimester; ④Management forhyperglycemia first detected in pregnancy;⑤Postnatal management.

14 Diagnosis and Management ofdiabetes in pregnancy: A clinicalpractice guideline (2014) [23]

China CMA 2014 ExpertConsensus

This is an Expert Consensus focus on:①Diagnosisof GDM and PGDM; ②surveillance duringpregnancy; ③counseling and treatment;④Timing and mode of delivery; ⑤Postnatalmanagement.

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Table 3 Recommendations summary

Health questions Description Guideline Recommendations (example)

Diagnosis of GDM

Risk factors Factors that make pregnant womenmore likely to get GDM and shouldbe recognized

2 evidence-based guidelines(NICE, CDA)2 expert consensus (HKCOG,CMA)

Assess risk of gestationaldiabetes using risk factorsin a healthy population.At the booking appointment,determine the following riskfactors for gestational diabetes:①BMI above 30 kg/m2;② previous macrosomia babyweighing 4.5 kg or above;③ previous gestational diabetes;④ family history of diabetes(first-degree relative withdiabetes); ⑤ minority ethnicfamily origin with a highprevalence of diabetes.

Screening Screening method to identify womenwho have GDM

9 evidence-based guidelines(NICE, NZGG, SIGN, ADA, FIGO,NGC, CA, API, IDF)2 expert consensus (HKCOG,CMA)

Use the 2-h 75 g oral glucosetolerance test (OGTT) to test forgestational diabetes in womenwith risk factors.Offer women with any of the otherrisk factors for gestational diabetesa 75 g 2-h OGTT at 24–28 weeks.

Diagnosticcriteria

Diagnostic criteria for GDM 7 evidence-based guidelines(SIGN, ADA, FIGO, NGC, A.N.D.,DDG Queensland)2 expert consensus (HKCOG,CMA)

GDM should be diagnosed at anytime in pregnancy if one or moreof the following criteria are metfollowing a 75 g glucose load:① fasting PG 5.1–6.9 mmol/l;② 1-h PG≥ 10.0 mmol/l; ③ 2-hPG 8.5–11.0 mmol/l

Prenatal Care

Healtheducation

Inform women with GDM relevantinformation

7 evidence-based guidelines(NICE, NZGG, SIGN, ADA, FIGO,IDF, A.N.D.)1 expert consensus (CMA)

Explain that:① in some women,gestational diabetes will respondto changes in diet and exercise;② the majority of women will needoral blood glucose-lowering agentsor insulin therapy if changes in dietand exercise do not control gestationaldiabetes effectively; ③ if gestationaldiabetes is not detected and controlled,there is a small increased risk of seriousadverse birth complications such asshoulder dystocia; ④ a diagnosis ofgestational diabetes will lead toincreased monitoring, and may leadto increased interventions, duringboth pregnancyand labor.

Medical nutritiontherapy

Medical nutrition therapy (MNT)recommendations for managementof GDM that assist in achievingand maintaining glycemia, andreducing the risk of adversematernal and neonatal outcomes

11 evidence-based guidelines(NICE, NZGG, SIGN, ADA, FIGO,NGC, CDA, API, IDF, Queensland, A.N.D.)2 expert consensus (HKCOG, CMA)

In women with GDM, the registereddietitian nutritionist (RDN) shouldprovide adequate amounts ofmacronutrients to support pregnancy,based on nutritionassessment, with guidance fromthe Dietary Reference Intakes (DRI).

Physical activity Physical activity recommendationsfor management of GDM.

6 evidence-based guidelines(NICE, ADA, FIGO, NGC, IDF, DDG)2 expert consensus (HKCOG, CMA)

Advice regular exercise (such aswalking for 30 min after a meal)to improve glycemic control.

Pharmacologicaltherapy

Pharmacological therapy formanagement of GDM, includinginsulin and oral hypoglycemicagents

5 evidence-based guidelines(ADA, CDA, API, IDF, DDG)1 expert consensus (CMA)

For women who are non-adherent toor who refuse insulin, glyburide ormetformin may be used as alternativeagents for glycemic control.

Blood glucose Effect blood glucose monitoring 9 evidence-based guidelines Self-monitoring of blood glucose is

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Table 3 Recommendations summary (Continued)

Health questions Description Guideline Recommendations (example)

monitoring method in predicting adverseoutcomes in women withGDM

(NICE, SIGN, ADA, FIGO, NGC,CDA, API, IDF, Queensland,)2 expert consensus (HKCOG, CMA)

recommended for all pregnantwomen with diabetes, 3–4 timesa day:• Fasting: once daily, following atleast 8 h of overnight fasting

• Postprandial: 2–3 times daily,1 or 2 h after the onset of meals,rotating meals on different daysof the week

Target bloodglucose values

Target ranges for blood glucose inwomen with GDM

7 evidence-based guidelines(NICE, NZGG, ADA, FIGO, NGC,CDA, API)2 expert consensus (HKCOG, CMA)

Targets for glucose control duringpregnancy:• Fasting glucose < 5.3 mmol/L• 1-h postprandial < 7.8 mmol/L• 2-h postprandial < 6.7 mmol/L

Ketonemonitoring

Ketone monitoring and targetranges in pregnancy in womenwith GDM

1 evidence-based guidelines(NICE)1 expert consensus (CMA)

Test urgently for ketoaemia if apregnant woman with any formof diabetes presents withhyperglyaemia or is unwell, toexclude diabetic ketoacidosis.

HbA1cmonitoring

HbA1c monitoring and targetranges in pregnancy in womenwith GDM

2 evidence-based guidelines(NICE, IDF)1 expert consensus (CMA)

Use HbA1c as an ancillary aid toself-monitoring. Aim for anHbA1c < 6.0%, orlower if safe and acceptable.

Continuousglucosemonitoring

continuous glucose monitoringrecommendations duringpregnancy

3 evidence-based guidelines(NICE, NGC, API)1 expert consensus (CMA)

Do not offer continuous glucosemonitoring routinely topregnant women with diabetes.

Fetal monitoring Screening for congenitalmalformations andmonitoring fetal growthand wellbeing

4 evidence-based guidelines(NICE, NZGG, SIGN, FIGO)1 expert consensus (CMA)

Offer women with GDM anultrasound scan at the time ofdiagnosis and at 36–37weeks. Further ultrasound scansshould be based on clinicalindications. Treatment decisionsshould not be based solely onfetal ultrasound.

Intrapartum Care

Timing andmode of birth

Optimal timing and modeof birth in womenwith GDM

4 evidence-based guidelines(NICE, NZGG, SIGN, FIGO)1 expert consensus (CMA)

Discuss the timing and mode ofbirth with pregnant womenwith diabetes during antenatalappointments, especially duringthe third trimester.

Glycemic control Maintaining maternal bloodglucose in target rangeduring labor and birth toreduce the incidence ofneonatal hypoglycemia andreduce fetal distress.

6 evidence-based guidelines(NICE, SIGN, FIGO, NGC, CDA, API)1 expert consensus (CMA)

Women should be closelymonitored during labor anddelivery, and maternal bloodglucose levels should be keptbetween 4.0 and 7.0 mmol/L inorder to minimize the risk ofneonatal hypoglycemia.

Neonatal Care

Neonatalhypoglycemia

Prevention, assessment andtreatment of neonatalhypoglycemia

3 evidence-based guidelines(NICE, NZGG, SIGN)1 expert consensus (CMA)

Measure the infant’s plasmaglucose at 1–2 h of age, 4 h,and then 4-hourly, preferablybefore feeds, until there havebeen three consecutivereadings > 2.6 mmol/L.

Initialassessment

Neonatal assessment andcriteria for admission tointensive or special care

2 evidence-based guidelines(NICE, NGC)1 expert consensus (CMA)

Carry out blood glucose testingroutinely in babies of womenwith diabetes at 2–4 h after birth.Carry out blood tests forpolycythemia, hyperbilirubinemia,hypocalcemia andhypomagnesemia for babieswith clinical signs.

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physical activity, pharmacological therapy, blood glucosemonitoring, target blood glucose values, ketone monitoring,HbA1c monitoring, continuous glucose monitoring andfetal assessment. The main principles included: ①offerall women ongoing treatment by multidisciplinaryhealth professionals once they were diagnosed; ②life-style intervention was a primary and essential compo-nent of management, especially nutrition therapy;③medical therapy should be started if needed toachieve glycemic targets; and ④ self-monitoring ofblood glucose regularly should be emphasized. How-ever, recommendations of a similar theme were not al-ways unanimous in different guidelines. For example,six guidelines [12, 14, 19, 20, 23, 29] recommended thatinsulin was the preferred medication for treating hyper-glycemia in GDM. On the contrary, other six guidelines[13, 16–18, 21, 22] did not regard insulin as the firstoption when drug treatment was required, since it wasproved that oral antidiabetic agents was safe and mighteven significantly reduce several adverse maternal andneonatal outcomes (Table 4). In addition, women’s pref-erences and the ability to adhere to medication andself-monitoring were also considered in differentguidelines.

Intrapartum careThe intrapartum care domain contained timing andmode of birth and glycemic control. Each guideline dif-fered slightly on recommendations for timing and modeof birth, however, commonality in the way in which tim-ing and mode of birth was decided was described, inother words, depending on whether there were maternal

or fetal complications. Recommendations for glycemiccontrol during labor and birth were similar for mostguidelines, namely, monitoring capillary plasma glucoseduring labor and birth, and ensuring that it was main-tained in normal glucose values (five guidelines [12, 13,17, 18, 21] recommended to maintain blood glucoselevels between 4 and 7mmol/L).

Neonatal careThe fourth domain was neonatal care, that is, neonatalhypoglycemia and neonatal initial assessment. Only fiveguidelines [12, 15, 17, 21, 23] mentioned recommenda-tions for neonatal hypoglycemia, advising to avoid neo-natal hypoglycemia through measuring the infant’splasma glucose frequently and early feeding. In addition,for newborns who had clinical signs associated with neo-natal complications, NICE guidelines also made add-itional recommendations for neonatal initial assessmentand criteria for admission to intensive or special care.

Postpartum carePostpartum care was a domain involving medicines andbreastfeeding after delivery, information and follow-upafter birth and postnatal testing. Most guidelines recom-mended that GDM women should discontinue bloodglucose-lowering therapy immediately after birth, butHKCOG guidelines [22] emphasized that those womencould also resume or continue to take metformin and glib-enclamide after birth as required. Early and exclusivelybreastfeeding was highly encouraged, for its benefits forboth mother and infant. Regarding postnatal education, itwas unanimously agreed in all guidelines that women

Table 3 Recommendations summary (Continued)

Health questions Description Guideline Recommendations (example)

Postpartum Care

Blood glucosecontrol

Including taking insulin, oralhypoglycemic agents to controlblood glucose and usingother medicines, as well asbreastfeeding after birth

6 evidence-based guidelines(NICE, NZGG, NGC, CDA, API, IDF)2 expert consensus (HKCOG, CMA)

Women should be encouragedon breastfeeding. They canresume or continue to takemetformin and glibenclamideimmediately after birth asrequired, but should avoidother forms of oralhypoglycemic agents whilebreastfeeding.

Information andfollow-up

Education interventions afterdelivery

8 evidence-based guidelines(NICE, NZGG, SIGN, ADA, FIGO,NGC, IDF, Queensland)2 expert consensus (HKCOG, CMA)

Women diagnosed withhyperglycemia in pregnancyshould be informed aboutthe increased risk of futureDM and hyperglycemia infuture pregnancy and shouldbe offered lifestyle adviceincluding weight control,diet and exercise.

Postnatal bloodglucose testing

Accuracy and timing ofpostnatal blood glucosetesting in women who had GDM

8 evidence-based guidelines(NICE, NZGG, SIGN, ADA, NGC,CDA, IDF, DDG)2 expert consensus (HKCOG, CMA)

Offer a postnatal test at 6–12weeks to exclude DM, eitherOGTT or HbA1c (with orwithout fasting glucose).

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diagnosed with GDM should be informed of the increasedrisk of GDM in a subsequent pregnancy and the increasedrisk for developing type 2 diabetes. Hence, it was import-ant to provide them with advice on how to maintain ahealthy lifestyle and information on postnatal testing. Rec-ommendations for postnatal testing were slightly different.

The method of postnatal testing can be OGTT or HbA1c(with or without fasting glucose). And testing time rangedfrom the initial month to 6 months, mainly between six to12 weeks after birth. Then assessment of glycemia usingfasting glucose or HbA1c should be carried out at regularintervals thereafter.

Table 4 Pharmacological therapy recommendations among different guidelines

Guidelines Recommendation

NICE, 2015 ① Offer metformin to women with gestational diabetes if blood glucose targets are not met using changes in diet andexercise within 1–2 weeks;② Offer insulin instead of metformin to women with gestational diabetes if metformin is contraindicated or unacceptable tothe woman;③ Consider glibenclamide for women with gestational diabetes: in whom blood glucose targets are not achieved withmetformin but who decline insulin therapy or who cannot tolerate metformin.

NZGG, 2014 Where women who have gestational diabetes and poor glycaemic control (above treatment targets) in spite of dietary andlifestyle interventions, offer oral hypoglycaemics (metformin or glibenclamide) and/or insulin therapy. In deciding whether touse oral therapy or insulin, take account of the clinical assessment and advice, and the woman’s preferences and her abilityto adhere to medication and self-monitoring.

SIGN, 2013 Metformin or glibenclamide may be considered as initial pharmacological, glucose-lowering treatment in women with gestational diabetes.

ADA, 2018 Insulin is the preferred medication or treating hyperglycemia in gestational diabetes mellitus as it does not cross the placentato a measurable extent. Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likelycrossing to a greater extent than glyburide. All oral agents lack long-term safety data.

FIGO, 2015 ① Insulin, glyburide, and metformin are safe and effective therapies for GDM during the second and third trimesters, and maybe initiated as first-line treatment after failing to achieve glucose control with lifestyle modification. Among OADs, metforminmay be a better choice than glyburide;② High resource: Insulin should be considered as the first-line treatment in women with GDM who are at high risk of failingon OAD therapy, including some of the following factors:• Diagnosis of diabetes < 20 weeks of gestation• Need for pharmacologic therapy > 30 weeks• Fasting plasma glucose levels > 110mg/dL• 1-h postprandial glucose > 140mg/dL• Pregnancy weight gain > 12 kg

Endocrine Society,2013

① We suggest that glyburide (glibenclamide) is a suitable alternative to insulin therapy for glycemic control in women withgestational diabetes who fail to achieve sufficient glycemic control after a 1-week trial of medical nutrition therapy and exerciseexcept for those women with a diagnosis of gestational diabetes before 25 weeks gestation and for those women with fastingplasma glucose levels > 110mg/dl (6.1 mmol/l), in which case insulin therapy is preferred;② We suggest that metformin therapy be used for glycemic control only for those women with gestational diabetes who donot have satisfactory glycemic control despite medical nutrition therapy and who refuse or cannot use insulin or glyburide andare not in the first trimester.

CDA, 2013 ① If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should beinitiated;② For women who are nonadherent to or who refuse insulin, glyburide or metformin may be used as alternative agents forglycemic control. Use of oral agents in pregnancy is off-label and should be discussed with the patient.

API, 2014 The use of OADs is currently not recommended for glycaemic management during pregnancy.

IDF, 2009 Insulin has been, and is likely to remain, the treatment of choice but there is now adequate evidence to consider the use ofmetformin and glibenclamide (glyburide) as treatment options for women who have been informed of the possible risks.Combination therapy has not been specifically studied.

Queensland, 2015 ① Metformin when compared to Insulin is effective at lowering blood glucose and is safe for pregnant women and theirfetuses;②I nsulin is safe to use in pregnancy.

HKCOG, 2016 ① Offer metformin if blood glucose targets are not met after diet and exercise therapy within 1–2 weeks;② Offer addition of insulin to diet therapy, exercise and metformin if blood glucose targets are not met.③ Consider glibenclamide for women in whom blood glucose targets are not achieved with metformin but who decline insulintherapy or who cannot tolerate metformin.

CMA, 2014 Insulin should be considered as the first-line treatment in women with GDM, and OADs is currently not recommended for glycaemic management during pregnancy.

DDG, 2018 ① The indication for insulin should first be considered within 1–2 weeks after the start of basic therapy (diet, exercise);② For pregnant women with GDM and suspected severe insulin resistance and when individually indicated, use of metformincan be considered following explanation of the off-label use.

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Assessment of consistencyA total of 361 original recommendations for GDM man-agement which were from 14 guidelines were included. Al-though some recommendations did not fall into any of theidentified themes, we undertook consistency appraisal ofthese as well. As presented in Table 5, different guidelinesappeared to have significant discrepancies in consistency ofguideline content. Even in the same guideline, consistencydiffered in three aspects: ①consistency between searchstrategy and selection of evidence, ②consistency betweenselected evidence and interpretation, and ③consistency be-tween interpretations and resulting recommendations.Among all guidelines included, NICE guidelines showedthe best average score of consistency in each aspect. How-ever, HKCOG guidelines and CMA guidelines received ex-tremely low scores in each aspect. Apparently, in this study,evidence-based guidelines rated relatively higher in con-tent consistency than expert consensus-based guidelines.Consistency appraisal of each guideline is presented inFig. 2. For consistency in each aspect, most guidelinesshowed the same tendency, that is, a guideline which re-ceived high average scores could also receive high scoresin the other two aspects, and, conversely, low averagescores in all aspects. When it came to all recommenda-tions, search strategy and selection of evidence wereslightly inconsistent. The radar chart showing comparableconsistency between search strategy and selection of evi-dence, between selected evidence and interpretation, andbetween interpretation and resulting recommendations

(scilicet 49.31, 57.20 and 58.17%, respectively) is presentedin Fig. 3.

DiscussionGestational diabetes mellitus is a challenging complica-tion of pregnancy that many women and doctors strug-gle with. In this review, we examined the existingguidelines on the management for GDM in 11 coun-tries or regions. Given that appropriate methodologiesand rigorous strategies in the guideline developmentprocess are crucial for guideline implementation [25],the development methods of the guidelines were mea-sured using the AGREE II instrument. In general, thequality of GDM guidelines, especially evidence-basedguidelines, was high. This could be explained by thefact that much progress has been made in the develop-ment of methodological and reporting criteria ofevidence-based guidelines within the past decade [30].Nonetheless, as the results in previous study revealed,the domains of Rigor of Development, Stakeholder In-volvement and, Editorial Independence still need to beimproved [26].It is noted that practice guidelines with the best meth-

odological quality were not necessarily the most valid intheir recommendations [27]. Thus it is important toemphasize that clinical practitioners should criticallyevaluate the methodological quality as well as the con-tent of the recommendations before adopting the rec-ommendations, which leads to another issue, that is,consistency appraisal. Despite many researchers beingaware of the crucial role of the appraisal of consistencybetween evidence and resulting recommendations, thereare no existing criteria for assessing content consistencyof guidelines. In guideline adaptation of some topics,qualitative analysis was used in content extraction,which formulated a general description of the researchtopic through generating categories without anyconsistency appraisal [31, 32]. In this review, we devel-oped a “recommendation matrix” on the basis of theCAN-Implement© method [33], and used the tool to ex-tract and assess guideline content. As a recommendationmatrix was used, not only relevant and potentially relevantrecommendations on all pre-specified healthcare aspectsfor GDM care were identified, but also consistency betweensearch strategy and selection of evidence, between selectedevidence and interpretation, and between interpretationand resulting recommendations was assessed. The resultsshowed that current guidelines on GDM care are of variedconsistency, and guidelines developed in internationallyrecognized guideline development methodology show bet-ter consistency. Also guidelines that have low consistencyin one aspect may also have low consistency in other twoaspects. This is probably because reporting quality ofguidelines is the cornerstone of consistency assessment.

Table 5 Consistency characteristics of guidelines

Guidelines N Mean (SD)

C1* C2* C3*

NICE 74 6.93 (0.34) 6.96 (0.26) 6.96 (0.26)

NZGG 38 6.55 (0.76) 6.39 (0.82) 6.53 (0.65)

SIGN 18 5.78 (1.11) 6.00 (0.91) 4.67 (0.59)

ADA 17 1.00 (0.00) 2.65 (1.17) 3.18 (1.24)

FIGO 40 1.20 (0.72) 1.83 (1.65) 3.45 (2.33)

Endocrine Society 25 5.04 (1.72) 6.68 (1.25) 5.88 (1.81)

CDA 17 3.53 (2.43) 4.18 (2.40) 3.88 (1.69)

API 22 5.45 (2.22) 5.45 (2.22) 5.04 (2.38)

IDF 13 1.00 (0.00) 3.38 (2.29) 2.77 (1.24)

Queensland 8 1.75 (0.71) 3.88 (1.36) 3.13 (1.25)

HKCOG 13 1.00 (0.00) 1.23 (0.60) 1.15 (0.55)

A.N.D. 15 6.00 (0.00) 5.67 (0.49) 5.93 (0.26)

DDG 21 1.05 (0.22) 1.43 (0.75) 2.24 (1.30)

CMA 40 1.00 (0.00) 1.30 (0.72) 1.15 (0.48)

Total 361 4.00 (2.74) 4.43 (2.59) 4.49 (2.42)

C1*: consistency between search strategy and selection of evidenceC2*: consistency between selected evidence and interpretationC3*: consistency between interpretation and resulting recommendations

Zhang et al. BMC Pregnancy and Childbirth (2019) 19:200 Page 11 of 15

Those guidelines with evidence tables or technical reportsnot published may also show low consistency. Thus,guideline development committees are strongly encour-aged to make use of guideline development manuals whendrafting guidelines.Regarding guideline content, five aspects were analyzed:

diagnosis of GDM, prenatal care, intrapartum care, neo-natal care, and postpartum care. Most recommendationsin guidelines focused on prenatal care, especially all kindsof therapies that might reduce the risk of adverse preg-nancy outcomes related to uncontrolled blood sugar pre-conception. This review generated similar results withthose from a previous study that international guidelines

were consistent in most of their recommendations [34].Nonetheless, although commonality in most areas existed,there were still some discrepancies among guidelines. Forexample, recommendations regarding oral hypoglycemicagents in the guidelines diverged. Some guidelines recom-mended that oral hypoglycemic agents be considered as aninitial pharmacological intervention, while some guidelinesonly considered insulin as an exclusive hypoglycemic medi-cine. Guidelines were supported with evidence, so incon-sistency may be caused by insufficient evidence onpharmacological interventions in the period in which theguidelines were developed [26]. However, it should bereminded that even though all evidence available was

Fig. 3 Consistency appraisal in all recommendations

Fig. 2 Consistency appraisal of guidelines

Zhang et al. BMC Pregnancy and Childbirth (2019) 19:200 Page 12 of 15

identified, consensus usually did not warrant similar rec-ommendations in different contexts. This was becausewhen a recommendation was developed, not only avail-able evidence, but benefits and harms, patients’ values andpreferences, as well as resource implications, should beappropriate considered [10].Since recommendations were well summarized, guide-

line adaptation was required to maintain the validity ofrecommendations in different health care systems.Guideline adaptation involves using knowledge synthesisof existing guidelines to produce recommendations, ra-ther than relying only on a review of primary literature,for the purpose of reducing duplication of effort [35]. Inmainland China and Hong Kong, there were only expertconsensus for GDM care [22, 23], without a nationalGDM management evidence-based guideline adapted tothe Chinese context previously. In this instance, it is rec-ommended to adapt the clinical practice guideline relatedto GDM management for the local context, providing sup-port for professionals to make better decisions in clinicalpractice. How to select, tailor and implement recommen-dations and supporting evidence extracted is the nextchallenging step.

LimitationDue to the language barriers, we only included guide-lines in English and Chinese. As a result, we only gotexisting guidelines on the management for GDM in 11countries or regions in this review. And yet, we have noidea whether other countries use the recommendationsprovided by a certain guideline or use recommendationsdeveloped in their own language.Another key limitation of this study is the subjectivity

in appraising the consistency between evidence and rec-ommendations. Although we attempted to minimizethese discrepancies by stating the assessment criteriaand through rigorous discussion, the results of theconsistency appraisal still varied because of different un-derstandings between researchers. Additionally, report-ing quality of some guidelines is not clear cut, whichwas another barrier in the process of content analysis.Apart from this, this is the first time that we used a “rec-ommendation matrix” in content analysis, and the toolwe developed may still need to be modified.

ConclusionThis paper describes the process used to extract andaccess the content of guidelines for GDM manage-ment. In conclusion, the recommendations were de-veloped in five aspects: diagnosis of GDM, prenatalcare, intrapartum care, neonatal care and postpartumcare. The consistency of guidelines on the manage-ment of GDM in pregnancy is highly variable and thisinconsistency needs to be addressed. Also, this review

has proven that a “recommendation matrix” can be atool to extract and assess consistency of guidelines.Additionally, our findings indicated that it is neces-sary to adapt and disseminate easily understandableevidence-based guidelines based on knowledge synthe-sis of existing guidelines in this paper.

AbbreviationsA.N.D: Academy of Nutrition and Dietetics; ADA: American DiabetesAssociation; API: The Association of Physicians of India; CDA: CanadianDiabetes Association; CMA: Chinese Medical Association; DDG: GermanDiabetes Association; DGGG: German Gynecology and Obstetrics Association;FIGO: The International Federation of Gynecology and Obstetrics;HKCOG: The Hong Kong College of Obstetricians and Gynaecologists;IDF: International Diabetes Federation; NCC-WCH: National CollaboratingCentre for Women's and Children's Health; NGC: National GuidelineClearinghouse; NICE: The National Institute for Health and Care Excellence;NZGG: New Zealand Guidelines Group; SIGN: Scottish IntercollegiateGuidelines Network; WHO: World Health Organization

AcknowledgementsWe would like to thank Siew Siang Tay for helping us to revise the finalversion of the article.

FundingThis study was undertaken under grant 2016 Project of Shanghai MunicipalCommission of Health and family Planning (No:201640324), and grant 2015Nursing Research Project of Fudan University (No:FNF201502). The fundershad no involvement in the study design, data collection and analysis,decision to publish or preparation of the manuscript.

Availability of data and materialsAll data analyzed during this study are included in this published article.

Authors’ contributionsAll authors have made substantial contributions and gave final approval ofthe conceptions, drafting, and final version of this manuscript. The authors’contributions are presented by their initials. MZ contributed to the datacollection, review of the guidelines, and content extraction and the writingof this manuscript. YZ contributed to the data collection, review of theguidelines, and content extraction and the writing of this manuscript. JZparticipated in the review of the guidelines, and helped to translate therecommendations. She also participated in the interpretation of data. KWparticipated in the review and translation of the guidelines. LL and YDparticipated in the recommendation appraisal, and helped to develop the“recommendation matrix” tool. All authors have seen and approved the finalversion of the manuscript.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsThe authors declared that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Fudan University Centre for Evidence-based Nursing: A Joanna BriggsInstitute Centre of Excellence, School of Nursing, Fudan University, Shanghai,China. 2Obstetrics and Gynecology Hospital, Fudan University, Shanghai,China.

Zhang et al. BMC Pregnancy and Childbirth (2019) 19:200 Page 13 of 15

Received: 14 December 2018 Accepted: 16 May 2019

Additional filesAdditional file 1: Recommendations Extraction of NICEguideline. The NICE guideline was developed in accordancewith the NICE guideline development process. There were74 relevant recommendations being extracted, which weredisplayed and appraised in Additional file 1. (XLSX 24 kb)Additional file 2: Recommendations Extraction of NZGGguideline. The NZGG guideline development teamfollowed a structured process for guideline development,and there were 38 relevant recommendations being ex-tracted, which were displayed and appraised in Additionalfile 2. (XLSX 19 kb)Additional file 3: RecommendationsExtraction of SIGN guideline. The SIGN guideline was de-veloped using a standard methodology according to SIGNguideline manual. There were 18 relevant recommenda-tions being extracted, which were displayed and appraisedin Additional file 3. (XLSX 16 kb)Additional file 4: Recom-mendations Extraction of ADA guideline. The ADA guide-line was developed using a standard methodology by theADA’s Professional Practice Committee. The guideline in-cluded general recommendations about all kinds of dia-betes, and there were only 17 relevant recommendationsbeing extracted, which were displayed and appraised inAdditional file 4. (XLSX 15 kb)Additional file 5: Recom-mendations Extraction of FIGO guideline. The FIGObrought together international experts to develop theguideline, and suggestions are provided for a variety of dif-ferent regional and resource settings. There were 40 rele-vant recommendations being extracted, which weredisplayed and appraised in Additional file 5. (XLSX 19 kb)Additional File 6: Recommendations Extraction of Endo-crine Society guideline. The Endocrine Society guidelinewas searched on the NGC website, which provided rec-ommendations for the management of the pregnantwoman with diabetes. Twenty-five relevant recommenda-tions were extracted and appraised, which were displayedin Additional file 6. (XLSX 16 kb)Additional file 7: Rec-ommendations Extraction of CDA guideline. The CDAguideline was developed following the process used to de-velop previous Canadian Diabetes Association clinicalpractice guidelines, and AGREE II were incorporated intothe guideline development process. There were 17 rele-vant recommendations being extracted, which were dis-played and appraised in Additional file 7. (XLSX 15 kb)Additional file 8: Recommendations Extraction of APIguideline. To develop API guideline, existing guidelines,meta-analyses, cross sectional studies, systematic reviewsand key cited articles were reviewed, and the recommen-dations were discussed at the national insulin summit.There were 22 relevant recommendations being extracted,which were displayed and appraised in Additional file 8.

(XLSX 17 kb)Additional file 9: Recommendations Ex-traction of IDF guideline. The guideline was developedthrough a non-formal evidence review and discussed by asmall Writing Group. There were 13 relevant recommen-dations being extracted, which were displayed and ap-praised in Additional file 9. (XLSX 14 kb)Additional file10: Recommendations Extraction of Queensland guide-line. The Queensland guideline was developed based onevidence, and there were 8 relevant recommendations be-ing extracted, which were displayed and appraised in Add-itional file 10. (XLSX 14 kb)Additional file 11:Recommendations Extraction of HKCOG guideline. TheHKCOG guideline was an expert consensus. It was up-dated taking reference to the recent evidence, WHO,NICE guideline and recommendations of other inter-national bodies. There were 13 relevant recommendationsbeing extracted, which were displayed and appraised inAdditional file 11. (XLSX 14 kb)Additional file 12: Rec-ommendations Extraction of A.N.D. guideline. The guide-line focused on nutrition practiece during the treatmentof women with GDM. There were 15 relevant recommen-dations being extracted, which were displayed and ap-praised in Additional file 12. (XLSX 15 kb)Additional file13: Recommendations Extraction of DDG guideline. Therecommendations of DDG guideline were based on theevidence from the literature, which was selected through asystematic external literature search. There were 21 rele-vant recommendations being extracted, which were dis-played and appraised in Additional file 13. (XLSX 15 kb)Additional file 14: Recommendations Extraction of CMAguideline. The CMA guideline was an expert consensus.There were 40 relevant recommendations being extracted,which were displayed and appraised in Additional file 14.(XLSX 19 kb)

Author details1Fudan University Centre for Evidence-based Nursing: A Joanna BriggsInstitute Centre of Excellence, School of Nursing, Fudan University, Shanghai,China. 2Obstetrics and Gynecology Hospital, Fudan University, Shanghai,China.

Received: 14 December 2018 Accepted: 16 May 2019

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