Gestational 3HR Challenge

Laboratory : Chemistry

PATIENT INFO

Patient Name:

Medical Record #:

BD: / / Sex: F M

PHYSICIAN INFO

Physician Name :

Address:

Ph: ( ) - Fax: ( ) -

Additional Report to:

Ph: ( ) - Fax: ( ) -

TESTS REQUESTED
Test Name:	ICD9 Code: (required)
1. Gestational 3HR Challenge
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

MG3HR MACH3

Specimen Type:

Blood

Tube Type:

Green top ( lithium heparin) tube

Collection Volume:

1.5 mL

Storage:

Shipping: Send Refrigerated; Storage: Room Temp: 8 hours; Refrigerated: 72 hours; Frozen: 3 days

Availability:

Mon-Fri, call for appointment

Methodology:

Roche- UV test

Special Instructions:

Separate plasma from cells ASAP. Prior to drawing patient, see Specimen Collection Procedure - Glucose Tolerance Testing. For outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Mahoning Valley).

Lab/Phone:

330-746-9623

TAT:

1 hour/draw

Additional Info:

Criteria for Diagnosis of Gestational Diabetes Mellitus(GDM) 100g, 3HR Glucose Challenge The Diagnosis of GDM is made when two or more of the following plasma glucose values are exceeded:

Fasting >=95 mg/dl

1HR Glucose >=180 mg/dl

2HR Glucose >=155 mg/dl

3HR Glucose >=140 mg/dl

CPT Code:

82951, 82952