Low uptake of postpartum screening for Type 2 diabetes in women after a diagnosis of gestational diabetes

The Incidence and Management of Type 2 Diabetes Mellitus After Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) refers to a transient state of impaired glucose tolerance that develops during pregnancy, affecting a significant proportion of expectant mothers globally. This review aimed to comprehensively examine the subsequent incidence and management of type 2 diabetes mellitus (T2DM) in women who have previously experienced GDM. The transition from GDM to T2DM is a well-recognized continuum, with affected women facing an increased risk of developing T2DM postpartum. Several studies have demonstrated that women with a history of GDM face a substantially higher risk of developing T2DM compared to normoglycemic pregnant women. The long-term consequences of developing T2DM following GDM are significant, as it not only affects the health of the mother but also poses risks to the offspring. The most common risk factors associated with the progression of GDM to T2DM include pregnancy at an advanced age, insulin treatment during pregnancy, and delivering an overweight baby. As GDM women are at higher risk of developing T2DM, effective management strategies such as lifestyle changes, postpartum care, breastfeeding, screening tests, and gaining awareness of risk are crucial to mitigate the risk of T2DM in this population. The current review was conducted to guide healthcare providers and women with a history of GDM about the potential risks of T2DM and management strategies to prevent the condition. This review provides a summary of evidence on the incidence rate of T2DM in GDM patients, its associated risk factors, and approaches to mitigate this challenge.

Barriers to postpartum diabetes screening: a qualitative synthesis of clinicians' views

BACKGROUND

Gestational diabetes mellitus (GDM) is an important risk factor for developing type 2 diabetes mellitus (T2DM) later in life. Postpartum screening provides an opportunity for early detection and management of T2DM, but uptake is poor.

AIM

To explore barriers to screening from clinicians' perspectives to guide future interventions to increase uptake of postpartum screening.

DESIGN AND SETTING

Systematic review and qualitative synthesis.

METHOD

Qualitative studies included in a previous review were assessed, and then five electronic databases were searched from January 2013 to May 2019 for qualitative studies reporting clinicians' perspectives on postpartum glucose screening after GDM. Study quality was assessed against the Critical Appraisal Skills Programmes checklist. Qualitative data from the studies were analysed using thematic synthesis.

RESULTS

Nine studies were included, containing views from 187 clinicians from both community and hospital care. Three main themes were identified: difficulties in handover between primary and secondary care (ambiguous roles and communication difficulties); short-term focus in clinical consultations (underplaying risk so as not to overwhelm patients and competing priorities); and patient-centric barriers such as time pressures.

CONCLUSION

Barriers to diabetes screening were identified at both system and individual levels. At the system level, clarification of responsibility for testing among healthcare professionals and better systems for recall are needed. These could be achieved through registers, improved clinical protocols, and automatic flagging and prompts within electronic medical records. At the individual level, clinicians should be supported to prioritise the importance of screening within consultations and better educational resources made available for women. Making it more convenient for women to attend may also facilitate screening.

Utility of in-hospital post-delivery fasting plasma glucose to predict postpartum glucose status in women with hyperglycaemia first detected in pregnancy: A prospective cohort study

Background

Women with hyperglycaemia first detected in pregnancy (HFDP), including those with gestational diabetes mellitus (GDM), should undergo a glucose evaluation 4–12 weeks after delivery. Globally, suboptimal postpartum return rates limit the opportunity to intervene in women with sustained hyperglycaemia and pragmatic solutions should be sought to bridge this gap.

Objective

To assess the utility of postpartum in-hospital glucose evaluation to predict the outcome of the oral glucose tolerance test (OGTT) performed 4–12 weeks after delivery.

Methods

The study was performed prospectively at Tygerberg Hospital, Cape Town, South Africa. Women with HFDP, classified as GDM based on the modified National Institute for Health and Care Excellence criteria, who delivered between November 2018 and June 2019 were included in the study. Fasting plasma glucose (FPG) was performed 24–72 hours after delivery (t1) in the postnatal ward, provided glucose lowering medication was discontinued at delivery. An OGTT 4–12 weeks postpartum (t2) was scheduled for the total cohort. We compared glucose values and glucose categories at t1 and t2 and evaluated antenatal characteristics of women who returned, compared to the group that was lost to follow-up.

Results

In-hospital post-delivery glucose assessment (t1) was performed in 115 women. Glucose levels were significantly lower at t1 compared to antenatal diagnostic values (t0) and assessment at t2. Of the fourteen women with hyperglycaemia at t2, none had abnormal fasting glucose concentrations at t1. Women with HFDP who fulfilled criteria for overt diabetes at t0, all (24/115) had normal fasting glucose levels at t1 except for IFG in one (1/24). The antenatal characteristics of women with HFDP who returned at t2, were similar to the women who did not return.

Conclusion

Based on this study, in-hospital fasting glucose 24–72 hours postpartum cannot replace the OGTT 4–12 weeks postpartum. Pragmatic solutions for low postpartum return rates in women with HFDP should be pursued.

Association between neonatal birthweight and risk of maternal glucose intolerance after gestational diabetes mellitus

Aims/Introduction

To evaluate whether the neonatal birthweight (NBW) is associated with early postpartum glucose intolerance in women with gestational diabetes mellitus.

Materials and Methods

A total of 1,113 women diagnosed with gestational diabetes mellitus who completed an oral glucose tolerance test at 6–9 weeks postpartum between 1 April 2014 and 8 January 2020 were included in this observational prospective cohort study. They were grouped by neonatal birthweight quartiles, and the odds ratios of postpartum glucose intolerance for different levels of neonatal birthweight were assessed.

Results

A lower NBW quartile was associated with an increased maternal risk of postpartum glucose intolerance after gestational diabetes mellitus. The adjusted odds ratios for maternal glucose intolerance were 1.69 (95% confidence interval 1.13–2.51) in the lowest NBW quartile (NBW 1,980–2,930 g) when compared with the highest NBW quartile (NBW 3,410–4,610 g). The association between lower NBW and maternal glucose intolerance was significantly stronger in women who delivered a girl. Additionally, NBW ≥3,100 g appears to be associated with a lower risk of maternal glucose intolerance postpartum.

Conclusions

Our findings suggest that low NBW is a previously unrecognized risk factor for maternal glucose intolerance after gestational diabetes in early postpartum in South China.

Long-term maternal cardiometabolic outcomes 22 years after gestational diabetes mellitus

AIMS/INTRODUCTION

Women with gestational diabetes mellitus are at increased risk for type 2 diabetes. We characterized the association between maternal glycemia during pregnancy with long-term outcomes.

METHODS AND METHODS

In this prospective nested case-cohort study, participants were recalled for follow up with detailed evaluation including oral glucose tolerance test at 8, 15 and 22 years. Logistic regression was used to estimate the risk of developing impaired glucose tolerance/type 2 diabetes and metabolic syndrome at follow up. The association between maternal glycemia at pregnancy and follow up was evaluated by linear regression. We also charted trajectory of β-cell function during follow up.

RESULTS

The analysis included 121 women with a mean follow-up period of 22.5 years, and a mean age of 50.3 years. Gestational diabetes was associated with an adjusted odds ratio of 2.48 (95% confidence interval 1.03-5.99) for combined diabetes/impaired glucose tolerance at follow up (P = 0.04). Women with a pre-pregnancy body mass index ≥23 had an odds ratio of 5.43 (95% confidence interval 1.87-15.72) for metabolic syndrome at follow up, compared with those with body mass index <23 (P = 0.002). Both fasting and 2-h glucose during pregnancy were strongly associated with glycemic indices at follow up (P-value <0.001-0.016). Gestational diabetes was associated with impaired β-cell function that remained relatively stable after the index pregnancy.

CONCLUSIONS

Chinese women with a history of gestational diabetes have a high prevalence of impaired glucose tolerance/type 2 diabetes at 22-year follow up. Glucose levels during mid-pregnancy are strongly associated with those of middle age.

Incidence Rate of Type 2 Diabetes Mellitus after Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis of 170,139 Women

OBJECTIVE

The reported incidence of type 2 diabetes mellitus (T2DM) after gestational diabetes (GDM) varies widely. The purpose of this meta-analysis was to define the incidence rate of T2DM among women with a history of GDM and to examine what might modulate the rate. Research Design and Methods. We searched PubMed and Embase for terms related to T2DM after GDM up to January 2019. Large cohort studies with sample size ≥300 and follow-up duration of at least one year were included. Data from selected studies were extracted, and meta-analysis was performed using the random-effects model. Subgroups analyses were based on the sample size of gestational diabetes, geographic region, maternal age, body-mass index, diagnostic criteria, and duration of follow-up.

RESULTS

Twenty-eight studies involving 170,139 women with GDM and 34,627 incident cases of T2DM were identified. The pooled incidence of T2DM after GDM was 26.20 (95% CI, 23.31 to 29.10) per 1000 person-years. Women from Asia and those with older age and higher body mass index seem to experience higher risk of developing T2DM. The incidence rate of T2DM was lowest when applying IADPSG (7.16 per 1000 person-years) to diagnose GDM. The risk of developing T2DM after GDM increased linearly with the duration of follow-up. The increments per year of follow-up were estimated at 9.6‰. The estimated risks for T2DM were 19.72% at 10 years, 29.36% at 20 years, 39.00% at 30 years, 48.64% at 40 years, and 58.27% at 50 years, respectively.

CONCLUSIONS

The findings of very high incidence of T2DM after GDM add an important insight into the trajectory of the development of T2DM in the long-term postpartum periods, which could provide evidence for consultant and might motivate more women with GDM to screen for T2DM. This trial is registered with PROSPERO identifier CRD42019128980.

Postpartum monitoring of women with a history of gestational diabetes - A cross-sectional study of an inner-city population

This was a cross-sectional analysis (1980-2017) in Leicester to examine the proportion of women with a history of gestational diabetes (GDM) who (a) attended the 13-week postpartum screening and (b) attended annual type 2 diabetes mellitus (T2DM) screening and assessed the association between screening rates and sociodemographic factors. We found that women with a history of GDM were not adequately screened for type 2 diabetes in primary care. 62% did not have postpartum screening and 84% did not have the recommended annual screening. A significant association was found between South Asian ethnicity and not being screened annually. These results emphasise the need for better targeted education of pregnant women about the risks of T2DM and the need for more research across the UK into the screening of women with a history of GDM and the potential for a national screening programme.

Results of the first recorded evaluation of a national gestational diabetes mellitus register: Challenges in screening, registration, and follow-up for diabetes risk

OBJECTIVE

Gestational Diabetes Mellitus (GDM) increases the risk of type 2 diabetes. A register can be used to follow-up high risk women for early intervention to prevent progression to type 2 diabetes. We evaluate the performance of the world's first national gestational diabetes register.

RESEARCH DESIGN AND METHODS

Observational study that used data linkage to merge: (1) pathology data from the Australian states of Victoria (VIC) and South Australia (SA); (2) birth records from the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM, VIC) and the South Australian Perinatal Statistics Collection (SAPSC, SA); (3) GDM and type 2 diabetes register data from the National Gestational Diabetes Register (NGDR). All pregnancies registered on CCOPMM and SAPSC for 2012 and 2013 were included-other data back to 2008 were used to support the analyses. Rates of screening for GDM, rates of registration on the NGDR, and rates of follow-up laboratory screening for type 2 diabetes are reported.

RESULTS

Estimated GDM screening rates were 86% in SA and 97% in VIC. Rates of registration on the NGDR ranged from 73% in SA (2013) to 91% in VIC (2013). During the study period rates of screening at six weeks postpartum ranged from 43% in SA (2012) to 58% in VIC (2013). There was little evidence of recall letters resulting in screening 12 months follow-up.

CONCLUSIONS

GDM Screening and NGDR registration was effective in Australia. Recall by mail-out to young mothers and their GP's for type 2 diabetes follow-up testing proved ineffective.

Postpartum glucose follow-up and lifestyle management after gestational diabetes mellitus: general practitioner and patient perspectives

Background

Incidence of type 2 diabetes is high after gestational diabetes mellitus (GDM). We aimed to evaluate the adherence to follow-up six-weeks postpartum visits in secondary care after GDM and glucose monitoring in primary care longer than 12–14 months after delivery and the years thereafter. In addition, we examined the women’s lifestyle after delivery.

Methods

A cross-sectional follow-up survey among women with a history of GDM and their general practitioners (GP). Rates of attendance at the six-weeks postpartum visit and glucose testing were obtained from hospital records, over the period 2011–2012. Rates of annual follow-up postpartum glucose testing were assessed by a survey among their GP’s. Lifestyle of the women on diet and exercise was assessed by questionnaire in 2015.

Results

In total 197 women were eligible for the study. Of these, 156 (79%) attended the six-weeks postpartum visit at the diabetes outpatient clinic and in 145 (93%) of these women glucose testing was performed. In total 77 (39%) women responded to the invitation to participate in this study and filled in the lifestyle questionnaire. About one third of the women met the recommendations for sufficient physical activity. A majority of them did not fulfil the Dutch guidelines on healthy diet – fruit intake 35.1%, vegetables intake 7.8%. Of the 74 invited GP’s, 61 responded (82%), only 12 (20%) reported that they had performed a follow-up glucose testing within >12–14 months postpartum. Of these women, five were tested only in the first year of follow-up, five also in the second year, and two were tested for three consecutive years.

Conclusions

Despite the high attendance rate of six-weeks postpartum visit and glucose testing, we observed low rates of longer-term follow-up regarding postpartum glucose testing. Moreover, we found a suboptimal adherence to healthy lifestyle for women with a history of GDM.