Journal of Obstetrics and Gynaecology

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Comparison of one hour versus 90 minute

postprandial glucose measurement in women with
gestational diabetes; which one is more effective?

Oktay Kaymak, Dicle İskender & Nuri Danışman

To cite this article: Oktay Kaymak, Dicle İskender & Nuri Danışman (2021): Comparison
of one hour versus 90 minute postprandial glucose measurement in women with gestational
diabetes; which one is more effective?, Journal of Obstetrics and Gynaecology, DOI:
10.1080/01443615.2021.1920005

To link to this article: https://doi.org/10.1080/01443615.2021.1920005

Published online: 23 Jun 2021.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
https://doi.org/10.1080/01443615.2021.1920005

ORIGINAL ARTICLE

Comparison of one hour versus 90 minute postprandial glucose measurement in

women with gestational diabetes; which one is more effective?
Oktay Kaymaka, Dicle _Iskenderb and Nuri Danışmana
a
Department of Perinatology, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey; bDepartment of Hematology, Dr. Abdurrahman
Yurtaslan Ankara Oncology Research and Training Hospital, Ankara, Turkey

ABSTRACT KEYWORDS
In the present study, we aimed to compare postprandial 90 minute measurements and postprandial Gestational diabetes;
1 hour (PP1-HR) measurements for prediction of foetal growth disturbances and pregnancy complica- postprandial; glucose
tions. This was a prospective study conducted in Acıbadem Mehmet Ali Aydınlar University Altunizade
Hospital in Department of Perinatology. The study group consisted of patients diagnosed with gesta-
tional diabetes. In each antepartum visit, the patients fasting plasma glucose as well as PP1-HR and
90 minute measurements were made. Perinatal and neonatal data were obtained from each patient.
The rate of large for gestational age infants was increased in patients when either PP1-HR measure-
ment above 140 mg/dl or postprandial 90 minute measurement above 165 mg/dl compared to patients
with normal PP1-HR or postprandial 90 minute measurement. Preterm delivery rate was increased in
patients with postprandial 90 minute measurement above 165 mg/dl but not in patients with PP1-HR
measurement above 140 mg/dl. The optimal cut-off for postprandial 90 minute measurement was
165 mg/dl based on receiver operating characteristics curve. Our preliminary data show that postpran-
dial 90 minute measurements are superior to PP1-HR measurements in predicting large for gestational
age infants.

IMPACT STATEMENT

What is already known on this subject? Gestational diabetes (GDM) is defined as any degree of
glucose intolerance with onset or first recognition in pregnancy. Maternal hyperglycaemia has been
linked to metabolic alterations in the foetus and thus brings about foetal macrosomia as well as
other pregnancy complications such as preterm delivery and preeclampsia.

What the results of this study add? The findings of the present study suggest that postprandial
90 minute predicted more cases of LGA infants than postprandial 1-hour (PP1-HR) measurements.
In addition, the rate of preterm deliveries was found to be increased in patients with mean post-
prandial 90 minute measurements above 165 mg/dl compared to patients with postprandial
90 minute measurements below 165 mg/dl. However, the rate of preterm deliveries was similar in
patients with elevated PP1-HR measurements and patients with normal PP1-HR measurements.

What the implications are of these findings for clinical practice and/or further research? Our
study is the first to investigate the usefulness of postprandial 90 minute in a prospective design.
Our preliminary data show that postprandial 90 minute measurements are superior to PP 1 meas-
urements in predicting LGA babies. It also correlates better with preterm deliveries.

Introduction form of hyperglycaemia may be linked to adverse pregnancy

Gestational diabetes (GDM) is defined as any degree of glu-
cose intolerance with onset or first recognition in pregnancy
(Metzger and Coustan 1998). Maternal hyperglycaemia has
been linked to metabolic alterations in the foetus and thus
brings about foetal macrosomia as well as other pregnancy
complications such as preterm delivery and preeclampsia
(HAPO 2009; Yogev et al. 2010; Landon et al. 2011; Hartling
et al. 2013). It has been more than a decade since the initial
results of Hyperglycaemia and Adverse Pregnancy Outcomes
(HAPO) study group have published their initial result
(Metzger et al. 2008). HAPO study revealed that even milder
outcomes. Achieving postprandial normoglycaemia in preg-
nancy is a generally accepted task (Sacks 1993; Combs and
Moses 2011). Either postprandial 1 hour (PP1-HR) or post-
prandial 2 hour (PP2-HR) measurements are generally used.
However so far only few studies have compared both meas-
urements and have failed to describe a clear superiority of
one measurement over the other (de Veciana et al. 1995;
Moses et al. 1999; Sivan et al. 2001; Weisz et al. 2005; Ozgu-
Erdinc et al. 2016).
Currently, self-monitoring of blood glucose is generally
employed in routine practice. Continuous glucose monitoring
(CGM) systems exist which measure interstitial fluid glucose

CONTACT Dicle _Iskender diclekoca@yahoo.com Department of Hematology, Dr. Abdurrahman Yurtaslan Ankara Oncology Research and Training Hospital,
Ankara, Turkey
ß 2021 Informa UK Limited, trading as Taylor & Francis Group
2 O. KAYMAK ET AL.
using an electrochemical method (Marquez-Pardo et al.
2020). Studies on CGM are relatively scarce and cost effect-
iveness of widespread implementation of this method in
GDM is yet to be proven (Polsky and Garcetti 2017).
However, data from CGM in GDM patients have shown that
glycaemic peaks can be different from PP1-HR or PP2-HR
measurements. Ben-Haroush et al. have found that postpran-
dial glucose peak occurs at approximately 90 minutes in dia-
betic pregnancies (Ben-Haroush et al. 2004). In addition, this
90 minute peak was observed throughout the day and was
not affected by the level of glycaemic control. Based on
these findings, we have postulated that postprandial
90 minute measurements could reflect glycaemic profile bet-
ter than PP1-HR measurement. Therefore in the present
study, we aimed to compare postprandial 90 minute meas-
urements and PP1-HR measurements for prediction of foetal
growth disturbances and pregnancy complications.
Materials and methods
This was a prospective study conducted in the perinatology
units of Acı badem Mehmet Ali Aydı nlar University,
Altunizade Hospital and Zekai Tahir Burak research and
Training between January 2015 and December 2018. The
study group consisted of patients diagnosed with GDM
based on 75 g oral glucose tolerance test (ACOG 2018).
Patients with multiple gestations or pre-existing diabetes or
pre-existing medical conditions such as severe heart disease
were excluded from the study. Patients who were lost to fol-
low up or patients with less than three follow up visits were
also excluded. No control group was recruited because this
was a comparison of PP1-HR and 90 minute measurements
and each patient was assigned as her own control. The man-
agement protocol for GDM was composed of 1800–2200 cal-
orie diet with the meal composition of 40–45%
carbohydrates, 20% protein and 40% fat initially. In each
antepartum visit, the patients fasting plasma glucose (FPG) as
well as PP1-HR and postprandial 90 minute measurements
were made. Patients received insulin based on PP-1 HR meas-
urements or fasting plasma blood glucose levels if these
measurements exceeded 95 mg/dl for FPG or 140 mg/dl for
PP1-HR measurements on more than two occasions.
The following perinatal and neonatal data were obtained
from each patient; maternal age, gestational weeks at deliv-
ery, method of delivery and presence of perinatal complica-
tions which include preterm deliveries preeclampsia as well
as birth trauma. Among neonatal data, the following were
recorded: neonatal birth weight, gender and presence of
neonatal complications such as neonatal intensive care unit
(NICU) admissions, neonatal hypoglycaemia, hyperbilirubinae-
mia and presence of foetal malformations.
Macrosomia was defined when birth weight exceeded
4000 g. Deliveries occurring prior to 37 weeks of gestation
were recorded as preterm deliveries. The diagnosis of shoul-
der dystocia was made when there was a delay of 60 seconds
or more between the delivery of the head and that of the
body or when ancillary manoeuvres other than gentle down-
ward traction to affect delivery were used. Preeclampsia was
defined as persistent elevation of blood pressure greater
than 140/90 mmHg after 20 weeks of gestation with new
onset proteinuria or other signs and symptoms suggesting
systemic involvement. The study was approved by the local
ethics committee.
Statistical analysis was performed using SPSS version 18
(Statistical Package for the Social Sciences, Chicago, IL).
Student’s t-test was performed for parametric variables
between groups that distribute normally. For parametric vari-
ables without normal distribution, Mann–Whitney’s U test
was performed. Chi-square test was performed for non-para-
metric variables between groups. Kappa statistics was per-
formed to assess the level of agreement between cut-off
values of PP-1HR measurement postprandial 90 minute meas-
urement. Receiver operating characteristic (ROC) curve was
performed to assess diagnostic ability of postprandial
90 minute PP1-HR measurements in the prediction of LGA
infants. Best-cut-off for each postprandial 90 minute PP1-HR
measurements was calculated by Youden’s index which is
sensitivity þ specificity  1. A p value less than .05 was con-
sidered significant.
Results
The present study included 123 participants with a diagnosis
of GDM. Characteristics of the study population are given in
Table 1. The mean age of the study population was 32.9.
Nulliparas consisted of 22% of the study population. Patients
with a history of GDM comprised 16% of the population.
Mean gestational age at enrolment was 25.3 weeks and
approximately 42% of the study population required insulin
therapy. Mean FPG was 89 mg/dl, PP-1HR measurement was
141 mg/dl and postprandial 90 minute measurement was
161 mg/dl.
Obstetrical and neonatal outcomes are given in Table 2.
Mean gestational age at delivery was 38 weeks. The preterm
delivery rate was 13.8% and primary caesarean delivery rate
was 16.3%. Large for gestational age babies comprised 17.1%
of the study population. 8.9% of the babies were admitted to
NICU. The rates of hyperbilirubinaemia, neonatal hypogly-
caemia and shoulder dystocia were 6.5%, 4.1% and 1.6%,
respectively.
The optimal cut-off for postprandial 90 minute measure-
ment was 165 mg/dl based on ROC curve (Figure 1).
Table 1. Characteristics of the study population.
Participants (n: 123)
Age (years) 32.9±5.3
Body mass index 27.6±5.7
Parity
0 27 (22%)
1 38 (30.9%)
2 56 (47.1%)
History of gestational diabetes 20 (16.3%)
Weight gain in pregnancy (kg) 11.6±4.4
Gestational age at enrolment (weeks) 25.3±3.1
Prenatal insulin therapy 52 (42.3%)
Plasma glucose (mg/dl)
Fasting 89±23
60 minute 141±19
90 minute 164±14
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Postprandial 90 minute measurements predicted more LGA 90 minute measurement above 165 mg/dl compared to
infants than PP1-HR measurements. Similarly, the predictive patients with normal PP1-HR measurement or postprandial
ability of postprandial 90 minute measurement above 90 minute measurement. Preterm delivery rate was increased
165 mg/dl was superior to PP1-HR measurement above in patients with postprandial 90 minute measurement above
140 mg/dl. Table 3 provides a comparison of obstetrical and 165 mg/dl but not in patients with PP1-HR measurement
neonatal outcomes according to postprandial glucose values. above 140 mg/dl. The other comparisons were similar in
The rate of LGA infants was increased in patients when either patients with elevated or normal PP1-HR measurement or
PP1-HR measurement above 140 mg/dl or postprandial postprandial 90 minute measurement.
Table 4 provides the number of positive and negative test
Table 2. Obstetrical and neonatal outcomes. in each postprandial category according to cut-off values
Participants (n: 123) defined above. In 22 of 69 patients, PP1-HR measurements
Gestational age at delivery (weeks) 38±1.9 were above 140 mg/dl but were below 165 mg/dl cut-off in
Caesarean
Primary 23 (18%)
postprandial 90 minute measurement. Four patients with
Repeat 20 (16.3%) postprandial 90 minute measurements above 165 mg/dl had
Preeclampsia 12 (9.8%) PP1-HR measurements below 140 mg/dl. The overall agree-
Preterm delivery 17 (13.8%)
Neonatal birthweight (g) 3409±612 ment between two postprandial glucose measurements was
Large for gestational age 21 (17.1%) 78.8%, with a positive agreement of 68.1% and negative
Intensive neonatal care 11 (8.9%) agreement of 92.6% (Table 5). There was a moderate agree-
Hyperbilirubinaemia 8 (6.5%)
Neonatal hypoglycaemia 5 (4.1%) ment between two postprandial glucose measurements
Shoulder dystocia 2 (1.6%) (Kappa coefficient: 0.59, p < .001). When patients were cate-
gorised based on prenatal insulin therapy, patients who had
prenatal insulin had significantly higher FPG, PP1-HR and
postprandial 90 minute glucose levels than patients receiving
diet only (Table 6).

Figure 1. Receiver operating characteristic curve of postprandial 1 hour and
90 minute values for prediction of large for gestational age neonates.
Discussion
To the best of our knowledge, this is the first study that eval-
uated postprandial 90 minute glucose level in the prediction
of perinatal complications. The findings of the present study
suggest that postprandial 90 minute predicted more cases of
LGA infants than PP1-HR measurements. In addition, the rate
of preterm deliveries were found to be increased in patients
with mean postprandial 90 minute measurements above
165 mg/dl compared to patients with postprandial 90 minute
measurements below 165 mg/dl. However, the rate of pre-
term deliveries was similar in patients with elevated PP1-HR
measurements and patients with normal PP1-HR measure-
ments. PP1-HR measurements and postprandial 90 minute
measurements were moderately correlated with a total agree-
ment of 78.8%. Importantly, fewer patients had postprandial
90 minute measurements above cut-off. But despite this
postprandial 90 minute measurements were superior in the
prediction of LGA.

Table 3. Obstetrical and neonatal outcomes according to postprandial glucose values.

Postprandial 1 hour Postprandial Postprandial
Postprandial 1 hour blood glucose 90 minute blood 90 minute blood
blood glucose <140 mg/dl glucose >165 mg/dl glucose <165 mg/dl
>140 mg/dl (n: 69) (n: 54) p (n: 51) (n: 72) p
Large for 16 (23.2%) 5 (9.3%) .042 16 (31.4%) 5 (6.9%) .001
gestational age
Primary caesarean 14 (20.3%) 9 (16.7%) .609 11 (21.6%) 12 (16.7%) .492
Preeclampsia 5 (7.2%) 7 (13%) .289 7 (13.7%) 5 (6.9%) .212
Preterm delivery 5 (9.3%) 12 (17.4%) .195 11 (21.6%) 6 (8.3%) .036
Intensive 5 (7.2%) 6 (11.1%) .456 4 (7.8%) 7 (9.7%) .719
neonatal care
Hyperbilirubinaemia 4 (5.8%) 4 (7.4%) .719 4 (7.8%) 4 (5.6%) .612
Neonatal 2 (2.9%) 3 (5.6%) .459 2 (3.9%) 3 (4.2%) .946
hypoglycaemia
Shoulder dystocia 1 (1.4%) 1 (1.9%) .861 0 2 (2.8%) .230
4 O. KAYMAK ET AL.
Table 4. Level of agreement between postprandial glucose cut-off values.
Postprandial 1 hour blood glucose <140 mg/dl
Postprandial 90 minute blood glucose <165 mg/dl
(n: 72)
Postprandial 90 minute blood glucose >165 mg/dl
(n: 51)
Table 5. Level of agreement between postprandial glucose cut-off values.
% agreement
Postprandial 90 minute blood and 78.8
postprandial 1 hour blood glucose
values (n: 123)
Postprandial 90 minute is comparative data while postprandial 1 hour is the reference data.
Table 6. The mean and minimum–maximum values for fasting plasma glucose, postprandial 1 hour and postprandial 90 minute measurements in gestational
diabetes patients.
Fasting plasma glucose (mean (minimum–maximum))
Postprandial 1 hour blood glucose (mean (minimum–maximum))
Postprandial 90 minute blood glucose measurement (mean (minimum–maximum))
Currently, either PP1-HR or PP2-HR blood glucose meas-
urement is recommended by different organisations (Grant
and Kirkman 2015; ACOG 2018). Few studies which compared
these two methods have not found a clear superiority of one
method over the other (de Veciana et al. 1995; Moses et al.
1999; Sivan et al. 2001; Weisz et al. 2005; Ozgu-Erdinc et al.
2016). However, it was suggested by some authors that fol-
low up based on PP1-HR measurements enabled better gly-
caemic control as there were a higher number of patients
requiring insulin and fewer infants with LGA were observed
in this group (de Veciana et al. 1995). Others have suggested
use of both PP1-HR and PP2-HR measurements since PP1-HR
measurements were higher in the morning while PP2-HR
measurements were higher at night (Sivan et al. 2001).
Importantly according to ACOG statement the reason no
study has demonstrated the superiority of either approach
may be because postprandial glucose peaks at approximately
90 minutes, between the two time points (ACOG 2018). This
statement provides a solid evidence for the design of present
study which aimed to investigate the importance of post-
prandial 90 minute measurements in the prediction of peri-
natal complications.
Ben-Haroush et al. have studied postprandial glycaemic
profile by CGM in patients with GDM (Ben-Haroush et al.
2004). They have found that postprandial glucose peak
occurred at approximately 90 minutes. Importantly, this
90 minute peak occurred at each patient regardless of gly-
caemic control as well as the time of the day when measure-
ment was made. Other studies have also investigated
postprandial time to peak in patients with GDM. Significant
differences were observed in terms of postprandial glycaemic
peak time in studies. Bu €hling et al. in their initial work have
found that patients with GDM had a peak of 54 minutes on
average which was slightly longer than non diabetic preg-
nant patients (Bu €hling et al. 2004). In their later work
Postprandial 1 hour blood glucose >140 mg/dl
(n: 54) (n: 69)
50 22
4 47
%negative agreement % positive agreement Kappa statistics p
92.6 68.1 0.59 <.001
Diet (n: 71) Insulin (n: 52) p
83 (55–89) 99 (85–133) <.001
133 (112–168) 151 (145–196) <.001
155 (128–171) 179 (140–233) <.001
however, peak glucose levels were achieved at 82 minutes
which was similar to non-diabetic pregnant patients with a
time to peak of 74 minutes (Bu €hling et al. 2005). Despite lack
of consensus in terms of time for glycaemic peak, based on
findings of Ben-Haroush et al. and latter work of Bu €hling
et al. it can be stated that the glycaemic peak occurs at
around 90 minutes (Ben-Haroush et al. 2004; Bu €hling et al.
2005). Since continuous blood glucose monitoring was not
used in the present study we were unable to show that gly-
caemic peak occurred indeed at around 90 minutes. But
based on previous mentioned work of Bu €hling et al. and
Ben-Haroush et al., we set postprandial 90 minute measure-
ment as an alternative time to screen postprandial hypergly-
caemic peak.
Recently, Sever et al. have compared glucose measure-
ments in patients with GDM at postprandial 60, 90 and
120 minutes (Sever et al. 2021). They have found that post-
prandial 90 minutes to be higher than postprandial 60 and
120 minute measurements after breakfast. However, post-
prandial 60 minute measurements were highest at lunch and
dinner. The authors have failed to define an optimal cut-off
for any postprandial measurement to predict composite peri-
natal complications including macrosomia, polyhydramnios,
gestational hypertension, preeclampsia, NICU requirement
and malpresentation. However, postprandial 90 minute meas-
urements were more likely to be related with complications
at a cut-off of 130 mg/dl. The study contradicts the observa-
tions of Ben-Haroush et al. as the authors have found fluctua-
tions of peak blood glucose measurements depending on
the time of the day (Ben-Haroush et al. 2004; Sever et al.
2021). Their cut-off for postprandial 90 minute was also lower
than our cut-off which might in part be due to the difference
of glycaemic control between two study populations.
Moreover, the authors have not investigated the rate of LGA

in their study population which was found to be predicted
by postprandial 90 minute measurements in our study.
Defective carbohydrate metabolism is central to the
pathogenesis of impaired glucose tolerance (Dinneen 1997).
Gestational diabetes is the only setting in which PPG moni-
toring has been shown to improve outcomes (de Veciana
et al. 1995). Therefore, optimal control of postprandial hyper-
glycaemia is crucial in the GDM. It has been previously stated
that postprandial blood glucose peak has been shown to be
more strongly associated with pregnancy complications
(Louie et al. 2012). It has also been stated PP2 hour measure-
ment may be too long and may miss some of the glucose
peaks (Bu€hling et al. 2005). These missed peaks may lead to
less optimal reflection of the actual hyperglycaemic status
and hence may lead to lower correlation to perinatal out-
come parameters. Thus, the authors stated that optimal tim-
ing to detect glucose peaks in the setting of GDM is
€hling et al.
somewhere between 45 and 120 minutes (Bu
2005). Our study indicates that PP 90 minute is more optimal
than PP1 measurements since it correlates better with LGA
infants than PP1-HR.
We would like to acknowledge several limitations of the
present study. First in the present cohort, blood glucose CBM
technique was not employed; therefore, we were unable to
confirm that postprandial glycaemic peak indeed occurred at
90 minutes. Second although patients with at least three
measurements were included in the study some patients
have a relatively short antenatal period in which their gly-
caemic statuses were screened. This will remain an
unscreened period in some patients and who could not have
received optimal care during this period. This might limit the
validity of our data since suboptimal glycaemic control in
such patients makes our study population less homogenous.
Another handicap is the absence of cord c-peptide levels
which provides valuable data on neonatal hyperglycaemia.
Despite these limitations, our study is the first to investi-
gate the usefulness of postprandial 90 minute in a prospect-
ive design. Our preliminary data show that postprandial
90 minute measurements are superior to PP1 measurements
in predicting LGA babies. It also correlates better with pre-
term deliveries. We believe when confirmed with future stud-
ies with larger sample size the value of postprandial
90 minute can be confirmed.
Disclosure statement
All authors have no conflicts of interest to declare.
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