Factors associated with screening for glucose abnormalities after gestational diabetes mellitus: baseline cohort of the interventional IMPACT study

Hyperglycaemia in Pregnancy Is Less Frequent in Smokers: A French Observational Study of 15,801 Women

Background: We aimed to explore the still-debated association between smoking and hyperglycaemia in pregnancy (HIP). Methods: A multiethnic prospective study of 15,801 women who delivered at Jean Verdier University Hospital between 2012 and 2018. Of these, 13,943 (88.2%) were non-smokers, 624 (4.5%) former smokers, and 1234 (7.8%) current smokers. Universal HIP screening was proposed to the entire sample (IADPSG/WHO criteria). Results: A total of 13,958 women were screened for HIP. Uptake differed between non-smokers, former smokers, and current smokers (89.5%, 88.3%, and 75.7%, respectively, p < 0.0001). HIP prevalence in these groups was 19.9%, 15.4%, and 12.3%, respectively (p < 0.0001). After adjusting for age, body mass index, family history of diabetes, history of HIP, history of macrosomic baby, and ethnicity, current (odds ratio 0.790 [95% confidence interval 0.636-0.981], p < 0.05) but not former (1.017 [0.792-1.306]) smokers were less likely to have HIP than non-smokers. Furthermore, 1 h and 2 h oral plasma glucose test values were lower in current smokers than in non-smokers (p < 0.01). To exclude potential selection bias, we compared risk factors for HIP and HIP-related adverse pregnancy outcomes in current smokers according to HIP screening status. Compared with screened current smokers (n = 934), their unscreened counterparts (n = 300) were younger, less frequently employed, and more likely to be of non-European origin. Moreover, infant birthweight was lower in this group, and preterm deliveries and perinatal deaths were more likely (all p < 0.01). Conclusions: Smoking during pregnancy was independently associated with lower HIP prevalence. The low HIP screening rate in current smokers did not explain this finding.

Validation of the 'EPICES' social deprivation score in a population of women who have just given birth: a French cross-sectional study

OBJECTIVES

To assess the diagnostic performance of the EPICES score for identifying social deprivation during pregnancy in a population of women in the immediate postpartum period.

STUDY DESIGN

This cross-sectional survey took place between 5th June and 5th August 2017, among women who had just given birth in either of the maternity units in Clermont-Ferrand, France.

METHODS

A self-administered questionnaire was completed by women. The questionnaire came in two parts: the EPICES index and the criteria for social deprivation defined by French law. These criteria were chosen to define the reference standard. The women were classified into two groups, living in precarious circumstances or not, according to the criteria defined by the French law (reference standard). To determine the most relevant threshold of the EPICES score, the precision associated with the threshold (the fraction of those predicted positive who are true positives: positive predictive value) was balanced with its sensitivity. EPICES scores above the threshold were classified as deprived, those below as non-deprived.

RESULTS

Of the 947 women who gave birth during the study period, 700 (73.9%) completed the self-administered questionnaire. The best trade-off between precision and sensitivity was obtained with a threshold of 22. For this threshold value, the positive predictive value was 42.3% and the sensitivity 70.3%.

CONCLUSIONS

The EPICES score with a threshold validated in the population of pregnant women is a useful, rapid, and easy-to-use tool that makes it possible to identify maternal deprivation at an individual level.

Gestational diabetes: A link between OGTT, maternal-fetal outcomes and maternal glucose tolerance after childbirth

BACKGROUND AND AIM

The relationship among distribution of pathological values at the Oral Glucose Tolerance Test (OGTT), metabolic risk factors and pregnancy outcomes in women with Gestational Diabetes (GDM), has not been clearly identified. We retrospectively compared metabolic and therapeutic parameters, maternal-fetal outcomes and post-partum OGTTs, with respect to the number and distribution of altered values of diagnostic OGTT in pregnancy. Secondly, we assessed whether insulin therapy predictive factors were identifiable.

METHODS AND RESULTS

This analysis included 602 pregnant women with GDM, followed in Diabetes and Pregnancy Unit of Perugia Hospital from diagnosis to childbirth. All women were diagnosed diabetic upon 75g OGTT, according IADPSG criteria. Women were divided into 3 groups, respect to distribution of diagnostic blood glucose (BG) values at OGTT: Group 1: only fasting BG (OGTT0h); Group 2: 1 and/or 2h (OGTT1-2h); Group 3: both fasting and 1 h and/or 2h (OGTT0+1-2h) BG. Pregnant women with fasting hyperglycemia at OGTT (Groups 1 and 3) had similar metabolic characteristics (weight, prevalence of obesity, gestational weight gain, HbA1c), a greater need for insulin therapy, and a higher risk of impaired glucose tolerance persistence after childbirth, as compared to Group 2. No significant differences were observed in terms of maternal and neonatal outcomes (p > 0.05), except for a greater prevalence of caesarean sections in Group 3.

CONCLUSION

The metabolic characteristics of GDM women are mirrored by OGTT values at diagnosis, but are not associated with adverse pregnancy outcomes. Intensive management and a tailored treatment of GDM improve maternal-neonatal outcomes, regardless of diagnostic values distribution and pre-gestational metabolic characteristics.

Factors influencing postpartum blood glucose screening among women with prior gestational diabetes mellitus in a rural community

AIMS

The aims of the present study were: a) to investigate the current state of postpartum glucose screening in rural China; and b) to explore the factors influencing postpartum blood glucose screening among women with prior GDM based on Andersen's behavioural model of health service use.

DESIGN

A multisite, cross-sectional study design, conducted from November 2017 to January 2018.

METHODS

A total of 465 women with prior GDM were included from two county-level hospitals in rural China. The potential influencing factors for postpartum blood glucose screening based on Andersen's behavioural model, including predisposing, enabling, and need factors, were collected by self-reported questionnaires. Chi-square tests and logistic regression were used to explore the influence of these factors on whether screening of blood glucose level after delivery occurred.

RESULTS

The mean age of the women was 31.92 years old (SD 5.16) and the mean time after delivery was 16.73 months (SD 15.07). The postpartum glucose screening proportion was 32.7%. Women who did not have a full-time job (p= .011) (predisposing factor), had not received any treatment for GDM (p= .002), and were not informed about screening plans for diabetes by health professionals (p < .001) (enabling factor) were less likely to engage in postpartum glucose screening. The need factor, high actual risk of developing type 2 diabetes mellitus (T2DM), was not associated with postpartum blood glucose screening (p> .05).

CONCLUSIONS

In rural China, most women with prior GDM were not screened for T2DM after delivery. The women with prior GDM who did not have a full-time job or had not received any prior treatment for GDM should be the target population for health education on postpartum glucose screening.

IMPACT

There is a need for data on postpartum blood glucose testing rates among rural women. Future interventions aimed at increasing postpartum blood glucose screening are needed.

Postpartum lifestyle modifications for women with gestational diabetes: A qualitative study

The prevalence of gestational diabetes mellitus increased to 8% in France in 2012, and the risk of developing type 2 diabetes after receiving a gestational diabetes diagnosis increases 7-fold. Education delivered during pregnancy aims to reduce this risk by reminding women to maintain dietary and lifestyle modifications after delivery.

OBJECTIVE

The primary objective of this study was to describe and analyze the feelings and daily lifestyle changes, including physical activity and dietary changes, among women who experienced gestational diabetes and the roles played by their general practitioners during follow-up.

STUDY DESIGN

We conducted a qualitative study examining women's attitudes during the 6-12 months postpartum, after receiving a gestational diabetes diagnosis and associated education. All women participated in semi-structured, individual, telephone-based interviews.

RESULTS

Out of 47 patients contacted, we interviewed 16 women. All interviewed women modified their behaviors, at least slightly, and described changes that included more balanced diets and the incorporation of mild physical activity. Lack of time, lack of awareness regarding the long-term risk of developing type 2 diabetes, resistance to long-term dietary changes, and cultural habits were identified as the primary barriers to long-term lifestyle modifications, whereas family support was found to be beneficial. The reported interactions between each woman and her physician appeared to be weak.

CONCLUSION

Our study showed that educational attitudes and preventive interventions must be reinforced, especially during the long-term, and not only during the immediate postpartum period. Raising awareness among primary care physicians regarding the need to provide continuous education for this high-risk population appears to be necessary.

High prevalence of diabetes and abnormal glucose tolerance in Thai women with previous gestational diabetes mellitus

AIM

To determine the prevalence of and risk factors for abnormal glucose tolerance (AGT) in previous gestational diabetes mellitus (pGDM) women.

METHODS

100 pGDM women randomly selected from the database of the Department of Obstetrics/Gynecology. 75 g-OGTT were performed in subjects without known diabetes. AGT was diagnosed using the American Diabetes Association criteria.

RESULTS

The mean age, pre-gestational BMI, and time since delivery were 38 ± 5 years, 24.5 ± 5.7 kg/m2, and 46 ± 26 months. Overall, 81% of the subjects had AGT, including IGT (38%), IGT + IFG (5%), T2DM (38%). Plasma glucose (PG) at 1 h after a 50 g-glucose challenge test (GCT), PG at 1 h after 100 g-OGTT, HbA1c, and HOMA-IR were significantly greater in women with AGT than normal glucose tolerance (NGT) women. The proportion of women with ≥3 abnormal PG values during 100 g-OGTT was greater in AGT than NGT group (50.7% vs. 15.8%). Multivariate analysis showed that PG ≥ 150 mg/dl at 1 h after a 50 g-GCT and ≥3 abnormal PG values in 100 g-OGTTs were risk factors for developing AGT.

CONCLUSIONS

Eighty-one percent of pGDM women developed AGT within 4 years after delivery. Risk factors for AGT were PG ≥ 150 mg/dl at 1 h after a 50 g-GCT and ≥3 abnormal PG values in a 100 g-OGTT.

Glucose Intolerance after a Recent History of Gestational Diabetes Based on the 2013 WHO Criteria

Aims

Uncertainty exists on the prevalence of glucose intolerance in women with a recent diagnosis of gestational diabetes (GDM) based on a two-step screening strategy and the 2013 World Health Organization (WHO) criteria. Our aim was to evaluate the uptake of postpartum screening, the prevalence and the risk factors for glucose intolerance in women with a recent history of GDM.

Methods

Retrospective analysis of the medical records of women with a recent history of GDM diagnosed in a universal two-step screening strategy with the 2013 WHO criteria. All women with a history of GDM are advised to undergo a 75g oral glucose tolerance test (OGTT) around 12 weeks postpartum. Indices of insulin sensitivity (the Matsuda index and the reciprocal of the homeostasis model assessment of insulin resistance, 1/HOMA-IR) and an index of beta-cell function, the Insulin Secretion-Sensitivity Index-2 (ISSI-2) were calculated based on the OGTT postpartum. Multivariable logistic regression was used to adjust for confounders such as age, BMI, ethnicity and breastfeeding.

Results

Of the 191 women with GDM, 29.3% (56) did not attend the scheduled postpartum OGTT. These women had a higher BMI (28.6 ±6.8 vs. 26.2 ± 5.6, p = 0.015), were more often from an ethnic minority (EM) background (41.1% vs. 25.2%, p = 0.029) and smoked more often during pregnancy (14.3% vs. 2.2%, p = 0.001) than women who attended the OGTT postpartum. Of all women (135) who received an OGTT postpartum, 42.2% (57) had prediabetes (11.9% impaired fasting glucose, 24.4% impaired glucose tolerance and 5.9% both impaired fasting and impaired glucose tolerance) and 1.5% (2) had overt diabetes. Compared to women with a normal OGTT postpartum, women with glucose intolerance were older (32.5±4.3 vs. 30.8±4.8 years, p = 0.049), were more often obese (34.5% vs. 17.3%, p = 0.023), were more often from an EM background (33.9% vs. 18.4%, p = 0.040), less often breastfed (69.5% vs. 84.2%, p = 0.041) and had more often an abnormal fasting glycaemia at the time of the OGTT in pregnancy (55.6% vs. 37.3%, p = 0.040). In the multivariable logistic regression, an EM background [OR = 2.76 (1.15–6.62), p = 0.023] and the HbA1c level at the time of the OGTT in pregnancy [OR = 4.78 (1.19–19.20), p = 0.028] remained significant predictors for glucose intolerance postpartum. Women with glucose intolerance postpartum had a similar insulin sensitivity [Matsuda index 0.656 (0.386–1.224) vs. 0.778 (0.532–1.067), p = 0.709; 1/HOMA-IR 0.004 (0.002–0.009) vs. (0.004–0.003–0.007), p = 0.384] but a lower beta-cell function compared to women with a normal OGTT postpartum, remaining significant after adjustment for confounders [ISSI-2 1.6 (1.2–2.1) vs. 1.9 (1.7–2.4),p = 0.002].

Conclusions

Glucose intolerance is very frequent in early postpartum in women with GDM based on the 2013 WHO criteria in a two-step screening strategy and these women have an impaired beta-cell function. Nearly one third of women did not attend the scheduled OGTT postpartum and these women have an adverse risk profile. More efforts are needed to engage and stimulate women with GDM to attend the postpartum OGTT.

Psychosocial deprivation in women with gestational diabetes mellitus is associated with poor fetomaternal prognoses: an observational study

OBJECTIVE

To evaluate the prognoses associated with psychosocial deprivation in women with gestational diabetes mellitus (GDM).

DESIGN

Observational study considering the 1498 multiethnic women with GDM who gave birth between January 2009 and February 2012.

SETTING

Four largest maternity units in the northeastern suburban area of Paris.

PARTICIPANTS

The 994 women who completed the Evaluation of Precarity and Inequalities in Health Examination Centers (EPICES) questionnaire.

MAIN OUTCOME MEASURE

Main complications of GDM (large infant for gestational age (LGA), shoulder dystocia, caesarean section, pre-eclampsia).

RESULTS

Psychosocial deprivation (EPICES score ≥30.17) affected 577 women (56%) and was positively associated with overweight/obesity, parity and non-European origin, and negatively associated with family history of diabetes, fruit and vegetable consumption and working status. The psychosocially deprived women were diagnosed with GDM earlier, received insulin treatment during pregnancy more often and were more likely to have LGA infants (15.1% vs 10.6%, OR=1.5 (95% CI 1.02 to 2.2), p<0.05) and shoulder dystocia (3.1% vs 1.2%, OR=2.7 (0.97 to 7.2), p<0.05). In addition to psychosocial deprivation, LGA was associated with greater parity, obesity, history of GDM, ethnicity, excessive gestational weight gain and insulin therapy. A multivariate analysis using these covariates revealed that the EPICES score was independently associated with LGA infants (per 10 units, OR=1.12 (1.03 to 1.20), p<0.01).

CONCLUSIONS

In our area, psychosocial deprivation is common in women with GDM and is associated with earlier GDM diagnoses and greater insulin treatment, an increased likelihood of shoulder dystocia and, independently of obesity, gestational weight gain and other confounders with LGA infants.

Improving postpartum glucose screening after gestational diabetes mellitus: a cohort study to evaluate the multicentre IMPACT initiative

AIMS

To evaluate a mobilization campaign, the IMPACT initiative, which included multidisciplinary meetings, provision of information and a systematic prescription of an oral glucose tolerance test to improve the rate of glucose screening in women with gestational diabetes mellitus in the four largest maternity units in our area, starting in March 2011.

METHODS

We retrospectively compared the level of self-reported screening during the first 6 months postpartum of women who gave birth after having been diagnosed with gestational diabetes before (January 2009 to December 2010) and after the IMPACT campaign (April 2011 to February 2012).

RESULTS

We included 961 women (589 in the period before and 372 in the period after the campaign was initiated) with a mean ± SD age of 33.2 ± 5.3 years and BMI of 27.8 ± 5.3 kg/m². Multivariate analysis, stratified using a propensity score in order to limit bias caused by imbalance between both periods, showed that the postpartum screening rate was higher after the campaign began (48.9 vs 33.3%, odds ratio 1.7, 95% CI 1.1-2.5; P = 0.019) and higher in women who received insulin treatment during pregnancy (odds ratio 2.3, 95% CI 1.5-3.6; P < 0.001), consumed fruit and vegetables daily (odds ratio 1.6, 95% CI 1.1-2.4; P = 0.035) and did not smoke (smoking vs non-smoking: odds ratio 0.3, 95% CI 0.1-0.7; P = 0.01). There was no interaction between the campaign effect and these particular conditions. The proportion of oral glucose tolerance tests performed in women who underwent screening increased from 6.3 to 33.0%.

CONCLUSIONS

The IMPACT campaign increased postpartum screening, and the use the oral glucose tolerance test in particular. The effect of this initiative might be reinforced in women who are non-daily consumers of fruit and vegetables, smokers and those who do not receive insulin treatment during pregnancy.

Glucose intolerance after a recent history of gestational diabetes

Aim. Our aim was to evaluate the uptake of our current screening strategy postpartum and the risk factors for glucose intolerance in women with a recent history of gestational diabetes (GDM). Methods. Retrospective analysis of files of women with a recent history of GDM diagnosed with the Carpenter and Coustan criteria from 01-01-2010 till 31-12-2013. Multivariable logistic regression was used to adjust for confounders. Results. Of all 231 women with a recent history of GDM, 21.4% (46) did not attend the scheduled postpartum OGTT. Of the women tested, 39.1% (66) had glucose intolerance and 5.3% (9) had diabetes. These women were more often overweight (39.7% versus 25.3%, P = 0.009), were more often treated with basal-bolus insulin injections (52.0% versus 17.4%, P = 0.032), and had a lower beta-cell function and lower insulin sensitivity, remaining significant after adjustment for age, BMI, and ethnicity (insulin secretion sensitivity index-2 (ISSI-2) in pregnancy 1.5 ± 0.5 versus 1.7 ± 0.4, P = 0.029; ISSI-2 postpartum 1.5 (1.2-1.9) versus 2.2 (1.8-2.6), P = 0.020; Matsuda index postpartum 3.8 (2.6-6.2) versus 6.0 (4.3-8.8), P = 0.021). Conclusion. Glucose intolerance is frequent in early postpartum and these women have a lower beta-cell function and lower insulin sensitivity. One fifth of women did not attend the scheduled OGTT postpartum.