Glucose tolerance in pregnancy and the long-term risk of cardiovascular disease

A Randomized Controlled Trial on the Effectiveness of Short Message Service (SMS) Reminders in Improving Postpartum Follow-up among Gestational Diabetes Mellitus Patients

Objective

This study assessed whether short message service (SMS) reminders would improve follow-up rate among gestational diabetes mellitus (GDM) patients by 12 weeks postpartum.

Methodology

In this single-center, single-blind randomized controlled trial, we assigned 308 patients with GDM to either of 2 arms, usual care alone versus usual care with SMS reminders. In the usual care group, 154 patients received a 10-minute short lecture on GDM and a 75 g oral glucose tolerance test (OGTT) request prior to discharge. In the SMS group, 154 patients received twice a week SMS reminders at 4 weeks, 8 weeks, and 10 weeks after delivery in addition to usual care. The primary outcome was clinic visit within 6 to 12 weeks postpartum with a 75 g OGTT result.

Results

In our population, the overall follow-up rate was 19.8% (61/308). Follow up rates were 20.1% (31/154) for the usual care group and 19.5% (30/154) for the SMS. The addition of SMS reminders was not associated with an increase in follow-up rate at 12 weeks postpartum (adjusted RR 0.98, 95% CI 0.63-1.52; p=0.932). The use of insulin or metformin for GDM control was associated with increased follow-up (adjusted RR 1.92, 95% CI 1.20-3.07; p=0.006).

Conclusion

SMS reminders did not improve postpartum follow-up rate among GDM patients at 12 weeks postpartum.

Health behaviour changes in partners of women with recent gestational diabetes: a phase IIa trial

BACKGROUND

We recently demonstrated that a gestational diabetes history in mothers is associated with higher postpartum incident diabetes not only in mothers but also in fathers. In the present study, we examined changes in health behaviours and cardiometabolic profiles in both mothers and partners who participated in a diabetes prevention program within 5 years of a gestational diabetes pregnancy.

METHODS

Couples were enrolled into a 13-week program that included 5 half-day group sessions and web/telephone-based support between sessions. It was designed in consultation with patients and previously studied in mothers. We computed mean changes from baseline (95% CI) for physical activity, eating, and sleep measures, and cardiometabolic parameters (fasting and 2-h post glucose load plasma glucose, BMI, blood pressure) in both partners and mothers.

RESULTS

Among 59 couples enrolled, 45 partners (76%) and 47 mothers (80%) completed final evaluations. Baseline cardiometabolic measures averaged within normal limits. Similar to mothers, partners increased physical activity (+ 1645 steps/day, 95%CI 730, 2561; accelerometer assessed moderate-to-vigorous physical activity + 36.4 min/week, 95% CI 1.4, 71.4) and sleep duration (+ 0.5 h/night, 95% CI 0.1, 0.9) and reduced the sodium-to-potassium ratio of food intake (- 0.09 95% CI -0.19, - 0.001). No conclusive changes were observed in glucose measures or insulin resistance; in analyses combining mothers and partners, systolic blood pressure decreased (- 2.7 mmHg, 95% CI -4.4, - 1.0).

CONCLUSIONS

Partners and mothers demonstrated improved physical activity, sleep, and dietary quality. Baseline cardiometabolic profiles averaged at normal values and there were no changes in glucose or insulin resistance; some blood pressure impact was observed. While strategies need to be developed to attract participants at higher cardiometabolic risk, this study demonstrates that partners of women within 5 years of a gestational diabetes diagnosis can be recruited and do achieve health behaviour change.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02343354 (date of registration: January 22, 2015).

Interventions to Improve Rate of Diabetes Testing Postpartum in Women With Gestational Diabetes Mellitus

PURPOSE OF REVIEW

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. In the USA, four million women are screened annually for GDM in pregnancy in part to improve pregnancy outcomes but also because diagnosis predicts a high risk of future type 2 diabetes mellitus (T2DM). Therefore, among women with GDM, postpartum care should be focused on T2DM prevention. This review describes the current literature aimed to increase postpartum diabetes testing among women with GDM.

RECENT FINDINGS

Data suggest that proactive patient contact via a health educator, a phone call, or even postal mail is associated with higher rates of postpartum diabetes testing. There may also be utility to changing the timing of postpartum diabetes testing. Despite the widespread knowledge regarding the importance of postpartum testing for women with GDM, testing rates remain low. Alternative testing strategies and large randomized trials addressing postpartum testing are warranted.

Cardiovascular Complications of Pregnancy

Pregnancy causes significant metabolic and hemodynamic changes in a woman's physiology to allow for fetal growth. The inability to adapt to these changes might result in the development of hypertensive disorders of pregnancy (hypertension, preeclampsia or eclampsia), gestational diabetes and preterm birth. Contrary to previous beliefs these complications are not limited to the pregnancy period and may leave permanent vascular and metabolic damage. There is in addition, a direct association between these disorders and increased risk of future cardiovascular disease (CVD, including hypertension, ischemic heart disease, heart failure and stroke) and diabetes mellitus. Despite abundant evidence of this association, women who present with these complications of pregnancy do not receive adequate postpartum follow up and counseling regarding their increased risk of future CVD. The postpartum period in these women represents a unique opportunity to intervene with lifestyle modifications designed to reduce the development of premature cardiovascular complications. In some cases it allows early diagnosis and treatment of chronic hypertension or diabetes mellitus. The awareness of this relationship is growing in the medical community, especially among obstetricians and primary care physicians, who play a pivotal role in detecting these complications and assuring appropriate follow up.

The long-term effects of stillbirth on women with and without gestational diabetes: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this study was to estimate the incidence of type 2 diabetes (primary objective) and hospitalisation for cardiovascular events (secondary objective) in women with previous gestational diabetes mellitus (GDM) and in those with normal glucose tolerance (NGT) in pregnancy, and to evaluate the role of stillbirth in differentiating the risks.

METHODS

This was a population-based cohort study using administrative data and involving 12 local health authorities. Women with GDM (n = 3,851) during the index period from 2002 to 2010 were propensity matched with women with NGT (n = 11,553). Information was collected on type 2 diabetes development and hospitalisation for cardiovascular events.

RESULTS

During a median follow-up of 5.4 years, the incidence rate per 1,000 person-years of type 2 diabetes was 2.1 (95% CI 1.8, 2.5) in women without GDM and 54.0 (95% CI 50.2, 58.0) among women with GDM and pregnancy at term (incidence rate ratio [IRR] 26.9; 95% CI 22.1, 32.7 compared with NGT and pregnancy at term). A history of stillbirth increased the risk of type 2 diabetes development by about twofold, irrespective of GDM status. No significant interaction between stillbirth and GDM on type 2 diabetes risk was found. GDM was associated with a significantly higher risk of cardiovascular events compared with NGT (IRR 2.4; 95% CI 1.5, 3.8).

CONCLUSIONS/INTERPRETATION

Pregnancy complicated by GDM and ending in stillbirth represents an important contributory factor in determining type 2 diabetes development. Women with GDM are at a high risk of future cardiovascular events. Women with pregnancy complicated by GDM and stillbirth deserve careful follow-up.

Gestational diabetes mellitus: screening and outcomes in southern italian pregnant women

Recent Italian guidelines exclude women <35 years old, without risk factors for gestational diabetes mellitus (GDM), from screening for GDM. To determine the effectiveness of these measures with respect to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria, we evaluated 2,448 pregnant women retrospectively enrolled in Calabria, southern Italy. GDM was diagnosed following the IADPSG 2010 criteria. Among 538 women <35 years old, without risk factors, who would have not been tested according to the Italian guidelines, we diagnosed GDM in 171 (31.8%) pregnants (7.0% of total pregnants). Diagnosis was made at baseline (55.6%), 1 hour (39.8%), or 2 hours (4.7%) during OGTT. Despite of appropriate treatment, GDM represented a risk factor for cesarean section, polyhydramnios, increased birth weight, admission to neonatal intensive care units, and large for gestational age. These outcomes were similar to those observed in GDM women at high risk for GDM. In conclusion, Italian recommendations failed to identify 7.0% of women with GDM, when compared to IADPSG criteria. The risk for adverse hyperglycaemic-related outcomes is similar in low-risk and high-risk pregnants with GDM. To limit costs of GDM screening, our data suggest to restrict OGTT to two steps (baseline and 1 hour).

Predictors of postpartum glucose tolerance testing in italian women with gestational diabetes mellitus

Postpartum screening is critical for early identification of type 2 diabetes in women previously diagnosed with gestational diabetes mellitus (GDM). Nevertheless, its rate remains disappointingly low. Thus, we plan to examine the rate of postpartum glucose tolerance test (ppOGTT) for Italian women with GDM, before and after counseling, and identify demographic, clinical, and/or biochemical predictors of adherence. With these aims, we retrospectively enrolled 1159 women with GDM, in Calabria, Southern Italy, between 2004 and 2011. During the last year, verbal and written counseling on the importance of followup was introduced. Data were analyzed by multiple regression analysis. A significant increase of the return rate was observed following introduction of the counseling [adjusted odds ratio (AOR) 5.17 (95% CI, 3.83–6.97), P < 0.001]. Interestingly, previous diagnosis of polycystic ovary syndrome (PCOS) emerged as the major predictor of postpartum followup [AOR 5.27 (95% CI, 3.51–8.70), P < 0.001], even after stratification for the absence of counseling. Previous diagnosis of GDM, higher educational status, and insulin treatment were also relevant predictors. Overall, our data indicate that counseling intervention is effective, even if many women fail to return, whereas PCOS represents a new strong predictor of adherence to postpartum testing.

Analysis of maternal and fetal cardiovascular systems during hyperglycemic pregnancy in the nonobese diabetic mouse

Preconception or gestationally induced diabetes increases morbidities and elevates long-term cardiovascular disease risks in women and their children. Spontaneously hyperglycemic (d)-NOD/ShiLtJ female mice, a type 1 diabetes model, develop bradycardia and hypotension after midpregnancy compared with normoglycemic, age- and gestational day (GD)-matched control (c-NOD) females. We hypothesized that onset of the placental circulation at GD 9-10 and rapid fetal growth from GD 14 correlate with aberrant hemodynamic outcomes in d-NOD females. To develop further gestational time-course correlations between maternal cardiac and renal parameters, high-frequency ultrasonography was applied to d- and c-NOD mice (virgin and at GD 8-16). Cardiac output and left ventricular (LV) mass increased in c-NOD but not in d-NOD mice. Ultrasound and postmortem histopathology showed overall greater LV dilation in d-NOD than in c-NOD mice at mid to late gestation. These changes suggest blunted remodeling and altered functional adaptation of d-NOD hearts. Umbilical cord ultrasounds revealed lower fetal heart rates from GD 12 and lower umbilical flow velocities at GD 14 and GD 16 in d-NOD versus c-NOD pregnancies. From GD 14 to GD 16, d-NOD fetal losses exceeded c-NOD fetal losses. Similar aberrant responses in pregnancies of women with diabetes may elevate postpartum maternal and child cardiovascular risk, particularly if mothers lack adequate prenatal care or have poor glycemic control during gestation.

Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus

OBJECTIVE

The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM).

STUDY DESIGN

A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.

RESULTS

The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort (P < .001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P < .001), Latinas (15% to 50%, P < .001), and Asians (43% to 59%, P = .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% (P = .414).

CONCLUSION

GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.

Outcomes in women with a history of gestational diabetes. Screening and prevention of type 2 diabetes. Literature review

Women with a history of gestational diabetes mellitus (GDM) are characterized by a high risk of type 2 diabetes mellitus (T2DM) (x 7), metabolic syndrome (x 2 to 5) and cardiovascular diseases (x 1,7). Women with lesser degrees of glucose intolerance share the same risks. T2DM may occur from post-partum (5 to 14%) to several years later, up to 25 years. Some factors associated with T2DM are identified: obesity, early diagnosis of GDM before 24 weeks gestation, high pregnancy OGTT blood glucose or insulin-therapy during GDM. Screening for T2DM only with fasting glucose provides less sensibility than with OGTT; HbA1c may supplant these dosages. The recurrence rate of GDM is between 30 and 84%, non-white ethnicity and insulinotherapy during GDM being the best proven predictors. High risk women need repeated life-long screenings for glycaemic abnormalities, or when another pregnancy is planned. Among obese women with history of GDM who show minor glycoregulation disturbances, modifications of lifestyle in intensive programs or metformin halve the risk of DT2. However, studies analysing practices show low adhesion to screening; without an intensive program, few women implement lifestyle modifications. These intensive programs should be implemented and proposed to high-risk women. Their therapeutic education should also include prevention of cardiovascular risk factors.

The association of adverse pregnancy events and cardiovascular disease in women 50 years of age and older

OBJECTIVE

This study investigates the association between a prior history of pregnancy complications and cardiovascular disease (CVD) among Kentucky women aged ≥50 years.

METHODS

Data were analyzed from participants (n = 3909) in the Kentucky Women's Health Registry (2006-2008). Primary outcomes were self-reported prevalence of CVD, including angina, heart attack, heart failure, and arrhythmia. Pregnancy complications used as predictors were preterm labor, preeclampsia, gestational diabetes mellitus (GDM), and third trimester bleeding. Logistic regression analyses were conducted to determine associations between prevalence of CVD and pregnancy complications, controlling for age, education, and smoking status.

RESULTS

Overall, 199 (5.1%) women reported angina, 79 (2.0%) reported heart attack, 44 (1.1%) reported heart failure, and 642 (16.4%) reported arrhythmia. One pregnancy complication was reported by 614 (15.7%) women, and two or more complications were reported by 130 (3.3%) women. In regression models adjusting for age, education, and smoking, compared to women who were never pregnant, women with no pregnancy complications had a similar risk of reporting heart attack (odds ratio [OR] 1.2, 95% confidence interval [CI] 0.5-2.7), but women with one pregnancy complication (OR 2.5, 95% CI 1.03-6.0) and two or more complications (OR 4.2, 95% CI 1.4-10.6) had an increased risk. Similar results were seen for angina and arrhythmia, but not heart failure.

CONCLUSIONS

Women who experience pregnancy complications are more likely to report prevalent CVD (including angina, heart attack, and arrhythmia), suggesting a link between adverse pregnancy events and CVD. Pregnancy complications may serve as signals for future CVD, presenting an opportunity for early intervention and prevention.

[Outcomes in women with history of gestational diabetes mellitus. Screening and prevention of type 2 diabetes mellitus. Literature review]

Women with a history of gestational diabetes mellitus (GDM) are characterized by a high risk of type 2 diabetes mellitus (T2DM) (X 7), metabolic syndrome (X 2 to 5) and cardiovascular diseases (X 1,7). Women with lesser degrees of glucose intolerance share the same risks. T2DM may occur from postpartum (5 to 14%) to several years later, up to 25 years. Some factors associated with T2DM are identified: obesity, early diagnostic before 24 weeks, high pregnancy OGTT blood glucose or insulinotherapy. Screening for T2DM only with fasting glucose provides less sensibility than with OGTT; HbA1c may supplant these dosages. The recurrence rate of GDM is between 30 and 84%, non-white ethnicity and insulinotherapy during GDM being the best proven predictors. High risk women need repeated life-long screenings for glycemic abnomalies, or when another pregnancy is planned. Among overweight or obese women with history of GDM who show minor glycoregulation disturbances, it is proved that modifications of lifestyle in intensive programs or metformin halve the risk of DT2. However, studies analysing practices show low adhesion to screening; without an intensive program, few women implement lifestyle modifications. These intensive programs should be implemented and proposed to high-risk women. Their therapeutic education should also include prevention of cardiovascular risk factors.

Postpartum screening following GDM: how well are we doing?

Once diagnosed with gestational diabetes mellitus (GDM), a woman has a sevenfold increased risk of developing type 2 diabetes relative to women who do not have diabetes during pregnancy. In addition, up to one third of women with GDM have overt diabetes, impaired fasting glucose, or impaired glucose tolerance identified during postpartum glucose screening completed within 6 to 12 weeks. Therefore, the American Diabetes Association, the World Health Organization, and the American College of Obstetricians and Gynecologists currently recommend postpartum glucose screening following GDM. However, despite this recommendation, in many settings the majority of women with GDM fail to return for postpartum glucose testing. Studies conducted to date have not comprehensively examined the health care system, the physician, or the patient determinants of successful screening. These studies are required to help develop standard clinical procedures that enable and encourage all women to return for postpartum glucose screening following GDM.