Current Commentary

Classification of Diabetes in Pregnancy

Time to Reassess the Alphabet
David A. Sacks,

MD,

and Boyd E. Metzger,

MD

The White classification is a system of alphabetically

designated categories of diabetes in pregnancy based on
age at onset, duration of disease, and the presence or
absence of vascular complications. The original classification system underwent several revisions, each progressively increasing in detail and complexity. Individual
authors and institutions have modified the classes,
resulting in identically lettered classes having different
definitions. Some publications make reference to the
class of diabetes by letter without providing a reference
defining that class. Despite a 1994 American College of
Obstetricians and Gynecologists Bulletin, which suggested that the White classification system was less
helpful, publications still appear using lettered designations with and without modifications and with and
without attendant definitions of terms. A clinically useful
system of disease classification should consist of clearly
defined, mutually exclusive, easily remembered categories. The current American Diabetes Association classification of diabetes fulfills these requirements and is
applicable to diabetes during pregnancy. Adoption of
such a system by the obstetrics community in verbal and
written medical communication will likely enhance
patient care and facilitate accurate data collection and
comparison.
(Obstet Gynecol 2013;121:3458)
DOI: http://10.1097/AOG.0b013e31827f09b5

eaningful medical discourse depends upon

clearly defined, generally accepted diagnostic categories and standardized laboratory proceFrom the Department of Research and Evaluation, Kaiser Permanente Southern
California, Pasadena, California; and the Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of
Medicine, Chicago, Illinois.
Corresponding author: David A. Sacks, MD, 3032 Copa de Oro Drive, Los
Alamitos, CA 90720-5209; e-mail: dasacks@att.net.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2013 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/13

VOL. 121, NO. 2, PART 1, FEBRUARY 2013

dures.1 So began a clinical opinion, published in

1982, addressing the ambiguity of nomenclature for
the classification of diabetes mellitus during pregnancy in use at that time. The authors expressed specific concern about the persistent use in medical
publications of the terms Class A diabetes and
Class B diabetes absent universally accepted definitions of these terms. Thirty years hence, publications
are still appearing using the same alphabetical terminology despite persistence of a lack of agreement of
definitions of the terms used. Our intent is to briefly
review the history of the evolution of this classification
system and to propose terminology and classification
for diabetes during pregnancy that would be both
clinically applicable and universally understood.
In 1924, 2 years after the first injection of insulin
had been administered at the Joslin Clinic in Boston,
Dr. Priscilla White launched her career at that
institution caring for pregnant women who had
diabetes. The addition of insulin to the physicians
armamentarium made it possible for young women
who had diabetes to survive to an age when they
could reproduce as well as to live long enough
to develop major vascular complications.2 In 1949,
Dr. White reviewed 439 cases of diabetic pregnancies
delivered at New England Deaconess Hospital during
the previous 15 years3 in an effort to determine possible causes and means of prevention of perinatal
wastage. Five percent of the women included in this
report had diabetes based on the results of a glucose
tolerance test, although the diagnostic criteria that
were used and timing of administration of that test
relative to pregnancy are unclear. It seems likely that
the majority of the other 95% consisted of women
who had what is now referred to as type 1 diabetes.
Maternal factors found to be associated with fetal and
neonatal deaths included early age at onset and long
duration of diabetes and the presence of hypertensive
disorders and vascular and renal complications.
Based on these observations, Dr. White developed
a classification system for diabetes in pregnancy

OBSTETRICS & GYNECOLOGY

345

(Box 1, part A). Although it was noted that patients in

Class A require no insulin and little dietary regulation, this aspect of patient management was not incorporated into the definition.
A revision of the classification system was published in 1965.4 Major changes included redefining
Class A as chemical diabetes with no definition of
the latter term supplied. Vascular complications were
moved to Class D, and Class R (proliferating retinopathy) was added. A further modification was presented
in 1972.5 In it Dr. White expanded the definition of
Class A diabetes to include gestational diabetes, subdivided Class D into five subcategories, which now
included hypertension, and, although not deleting
Class E, remarked that calcified pelvic arteries were
no longer sought. A subsequent iteration of the White
classification subdivided Class C and added classes for
cardiopathy, multiple pregnancy losses, and renal
transplant.6 A final version deleted the division of Classes C and D into enumerated subclasses, removed
Classes E and G, and added gestational diabetes as
a separate class7 (Box 1, part B). Despite these modifications, a remaining problem is that not all classes are
mutually exclusive. For example, a woman and who is
now 24 years of age whose diabetes became manifest at
age 8 years would fall into either Class C by virtue of
her having had diabetes for 15 years or Class D
because of her age at onset of the disease.
Some recent publications have modified the White
designations to include categories and definitions that
are not universally understood or used. Examples
include the creation of Classes AB8 and FR9 and the
designation of membership in Classes BD by duration
of disease but not by age at onset.10 The lack of a universally accepted definition of members of a class identified by the same letter or letters of the alphabet
renders comparison of data from different institutions
difficult at best and inaccurate at worst.
Perhaps more attention has been paid to the
definition of Class A diabetes than to that of any of
the other classes. Dr. Whites 1965 and 1978 revisions
included the term gestational diabetes for Class A.4,6
Although no definition or citation defining gestational
diabetes was provided in those revisions, the term was
first used by Carrington in 1957.11 In an article
accompanying the final version of the White classification,7 Drs. Hare and White noted that the White
classification was intended to apply to women whose
onset of diabetes antedated their pregnancies. Thus,
the term Class A diabetes had been intended to
apply only to women whose diabetes had been
identified before pregnancy and who required
diet alone to maintain glycemic control during

346

Sacks and Metzger

Box 1. The White Classification of Diabetes in

Pregnancy: A) Initial (1949) Version and B) Final
(1980) Version
A. 1949 (3)*
Class A: Diagnosis of diabetes made on a glucose tolerance test, which deviates but slightly from the normal
Class B: Duration less than 10 y and
Onset age 20 y or older and
No vascular disease
Class C: Duration 1019 y or
Onset 1019 y of age or
Minimal vascular disease (eg, retinal arteriosclerosis
or calcified leg vessels)
Class D: Duration 20 y or longer or
Onset younger than 10 y of age or
More evidence of vascular disease, eg, retinitis,
transitory albuminuria, or transitory hypertension
Class E: Calcified pelvic arteries on X-ray
Class F: Nephritis
B. 1980 (7)
Gestational diabetes: Abnormal glucose tolerance test,
but euglycemia maintained by diet alone; diet alone
insufficient, insulin required
Class A: Diet alone, any duration or onset age
Class B: Onset age 20 y or older and duration less than
10 y
Class C: Onset age 1019 y or duration 1019 y
Class D: Onset age younger than 10 y, duration over
20 y, background retinopathy, or hypertension (not
preeclampsia)
Class R: Proliferative retinopathy or vitreous hemorrhage
Class F: Nephropathy with over 500 mg/d proteinuria
Class RF: Criteria for both Classes R and F coexist
Class H: Arteriosclerotic heart disease clinically evident
Class T: Prior renal transplantation
* Data from White P. Pregnancy complicating diabetes. Am J
Med 1949;7:60916.
Republished with permission of the American Diabetes
Association, from Hare JW, White P. Gestational diabetes
and the White classification. Diabetes Care 1980;3:394;
permission conveyed through Copyright Clearance Center, Inc.

pregnancy. In an effort to prevent further confusion,

they created a separate class for gestational diabetes to
indicate those women whose glucose intolerance was
first recognized during pregnancy, taking note that for
some of the latter, diet would prove insufficient for
care (Box 1, part B). However, in its 1986 Technical
Bulletin on diabetes in pregnancy,12 the American
College of Obstetricians and Gynecologists (the College) retained the designation Class A for gestational diabetes and divided it into two mutually
exclusive subcategories. Class A diabetes referred to
those whose onset or first recognition of carbohydrate
intolerance occurred during pregnancy. Membership
in Class A-1 required both a fasting glucose level less
than 105 mg/dL and a postprandial glucose less than

Classification of Diabetes in Pregnancy

OBSTETRICS & GYNECOLOGY

120 mg/dL and required management with diet only.

Those designated as belonging to Class A-2 had fasting glucose levels 105 mg/dL or greater, postprandial
glucose concentrations 120 mg/dL or greater, or both,
and require the addition of insulin. However, in
another article published the year prior to as this document, the terms Class A-1, Class A-2, and Class
B-1 were used for women who had a post100-g
glucose tolerance test with interclass differences based
only on fasting plasma glucose (respectively, less than
105 mg/dL; 105129 mg/dL, and 130 mg/dL or
greater).13 In the 1994 College Technical Bulletin,
which replaced the 1986 Bulletin, it was noted that
Improvements in fetal assessment, neonatal care,
and metabolic management of the pregnant woman
have rendered the White classification system less
helpful.14 Despite this pronouncement, the alphabetical designation of diabetes in pregnancy continues to
appear in publications dealing with this topic. When
used, the terms Class A-1 and Class A-2 rarely refer to
the quantitative definitions supplied in the 1986 College publication but usually refer to patients whose
selection of treatment by diet or diet and medication,
respectively, was dictated by institutional protocol.
The current College Practice Bulletin on gestational
diabetes, which replaced the 1994 document, makes
no reference to any alphabet-based classification system of diabetes in pregnancy.15
The prevalence of the different types of diabetes
during pregnancy as well as that of diabetes-related
vascular changes has changed over time. Although the
prevalence of pre-existing diabetes and gestational
diabetes varies from one population to the next, one
large multicenter study reported a prevalence of 1.82%
for the former and 7.6% for the latter.16 Recent data
demonstrate that although vascular disease remains
significantly associated with some adverse maternal
and perinatal outcomes, no significant differences exist
between women who have pregestational diabetes
when compared according to their assignment to the
White classes. The authors did, however, find that the
presence of vascular complications was associated with
greater risk of adverse outcomes.17
For a clinical disease classification to be of value, it
must consist of mutually exclusive, clearly defined, easyto-remember categories that are relevant to patient care.
Classifying diabetes in pregnancy by the age at onset,
duration, or onset and duration of disease is of
extremely limited value in deciding on a course of
patient management. Knowing that the diabetic patients
primary mechanism of disease is insulin resistance (ie,
type 2) rather than the absence of endogenous insulin
(ie, type 1) aids the clinician in deciding whether the

VOL. 121, NO. 2, PART 1, FEBRUARY 2013

patient may be responsive to an oral hypoglycemic, if

she will need a relatively large or small increment in her
insulin dose in response to hyperglycemia, or both.
Knowing that the patient was first recognized to be glucose-intolerant during pregnancy suggests that an initial
trial of diet and exercise during pregnancy may be prudent, reserving medication if the patients hyperglycemia remains unaltered despite initial care with diet and
exercise and also indicating the need for postpartum
testing for glucose intolerance.
The current system of classification of diabetes of
the American Diabetes Association18 contains four
mutually exclusive, clearly defined categories. Assignment to one of the first three (type 1, type 2, and other)
is based on mechanism of disease. Membership in the
fourth category, gestational diabetes, is limited to those
women whose glucose intolerance was first diagnosed
during pregnancy exclusive of those women who meet
criteria defining overt diabetes (ie, types 1 or 2). The
addition of a notation (eg, retinopathy, nephropathy,
hypertension) to the patients class designation would
give further notice to her caregivers of complications
requiring additional evaluation and possible treatment
during pregnancy (Box 2). Under this proposed classification system, for example, a 35-year-old pregnant
woman whose insulin-resistant diabetes had its onset
at age 25 years and who had chronic hypertension
would now be classified as diabetes, type 2, hypertension rather than the less descriptive Class D diabetes. Adoption of such a system by the obstetrics
community would likely not only improve verbal
and written communication in the clinical setting, but
also facilitate meaningful comparisons of data from different venues. We submit this suggested classification
system to our colleagues for their consideration, evaluation, and, hopefully, endorsement.
Box 2. Proposed Classification System for
Diabetes in Pregnancy
Gestational diabetes: Diabetes diagnosed during pregnancy that is not clearly overt (type 1 or type 2) diabetes
Type 1 diabetes: Diabetes resulting from beta-cell destruction, usually leading to absolute insulin deficiency
a. Without vascular complications
b. With vascular complications (specify which)
Type 2 diabetes: Diabetes resulting from inadequate insulin
secretion in the face of increased insulin resistance
a. Without vascular complications
b. With vascular complications (specify which)
Other types of diabetes (eg, genetic in origin, associated with
pancreatic disease, drug-induced or chemically induced)
Data from American Diabetes Association. Standards of medical
care in diabetes2012. Diabetes Care 2012;35(suppl 1):S1163.

Sacks and Metzger

Classification of Diabetes in Pregnancy 347

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Classification of Diabetes in Pregnancy

OBSTETRICS & GYNECOLOGY