Type 2 diabetes after a pregnancy with gestational diabetes among first nations women in Australia: The PANDORA study

Incidence of glucose intolerance and risk factors in patients with gestational diabetes mellitus one year postpartum: a systematic review and meta-analysis

PURPOSE

The purpose of this study is to explore the incidence and risk factors of glucose intolerance within one year postpartum in women with gestational diabetes mellitus (GDM), with the goal of informing the creation of effective preventive measures.

METHOD

A systematic literature search was conducted in PubMed, Embase, Cochrane Library, Web of Science, Ovid, Scopus, CINAHL, Wiley, China National Knowledge Infrastructure Database (CNKI), WANFANG Database, China Science and Technology Journal Database (CSTJ), and China Biology Medicine Database (CBM) for records published from January 1990 to August 2024. The index terms included 'gestational diabetes mellitus', 'glucose intolerance', 'postpartum', and 'risk factor'. Investigators assessed eligibility, extracted data, and evaluated the methodological quality. The meta-analysis was conducted using Stata 17.0 and Review Manager 5.4.

RESULT

Eighteen studies were included in the analysis, with 14 categorized as low risk of bias and 4 classified as medium risk of bias. The pooled incidence of glucose intolerance in women with GDM within 1 year postpartum was 34.5% (95% CI: 1.34-1.58). The following risk factors for glucose intolerance one year postpartum in women with GDM were identified: age (MD = 1.71; 95% CI: 0.50-2.91), pre-pregnancy BMI (MD = 1.75; 95% CI: 0.73-2.78), weight gain during pregnancy (MD = 1.25; 95% CI: 0.74-1.76), family history of diabetes (OR = 1.96; 95% CI: 1.58-2.42), fasting blood glucose at diagnosis (MD = 0.64; 95% CI: 0.39-0.88), 1-h postprandial blood glucose at diagnosis (MD = 1.24; 95% CI: 0.92-1.57), 2-h postprandial blood glucose at diagnosis (MD = 1.30; 95% CI: 0.72-1.87), history of GDM (OR = 2.62; 95% CI: 1.79-3.84), insulin use (OR = 2.41; 95% CI: 1.43-4.08), postpartum BMI (MD = 0.90; 95% CI: 0.24-1.55), diagnosed gestational weeks (MD = -1.82; 95% CI: -2.94--0.71), glycated hemoglobin (HbA1c) level at diagnosis (MD = 0.36; 95% CI: 0.14-0.58), HbA1c levels at 6-12 weeks postpartum (MD = 0.85; 95% CI: 0.42-1.29), fasting blood glucose levels 6 to 12 weeks postpartum (MD = 0.31; 95% CI: 0.05-0.57), 2-h postprandial blood glucose level 6 to 12 weeks postpartum(MD = 2.47; 95% CI: 0.68-4.26), Low-density lipoprotein (LDL) levels at diagnosis (MD = 0.20; 95% CI: 0.01-0.40), and triglyceride (TG) level at diagnosis(MD = 0.55; 95% CI: 0.34-0.75).

CONCLUSION

The incidence of glucose intolerance one year postpartum in women with GDM is relatively high. The subgroup analysis of this study revealed that the incidence is highest among Asian women and lowest among Caucasian women. 17 risk factors have been identified; these findings may help to better understand which GDM patients are more likely to experience glucose intolerance one year postpartum, and provide higher-level evidence for assessing the incidence and risk factors of glucose intolerance in GDM patients one year after delivery.

Values, principles and research priorities for the implementation of type 2 diabetes prevention after gestational diabetes: A global consensus from Asia, Africa, Americas, Europe and Oceania

AIMS

The implementation of type 2 diabetes prevention after gestational diabetes (GDM) is poor despite research evidence on efficacy. This is limited by the lack of knowledge of the priorities in real-world settings from the perspectives of local clinicians and women with lived experiences, particularly those from underserved populations. We report here a global consensus on the values, principles, and research priorities for the implementation of type 2 diabetes prevention in individuals after gestational diabetes (GDM), from the perspectives of clinicians and women from Asia, Africa, Oceania, the Americas, and Europe.

METHODS

A team of health professionals and researchers from five continents formed the Cardiometabolic Health Implementation Research in Postpartum individuals (CHIRP) team. The CHIRP team undertook a priority setting process using the Modified Delphi and Nominal Group Technique. Health professionals and women with a lived experience of GDM from five continents were invited to participate. Values, principles, and research priorities were voted on by all participants.

RESULTS

A total of 100 consumers and health professionals from 11 countries across the five continents participated in the consensus process. The top-ranked values and principles were 'universal access', 'evidence-based', and 'equity-driven'. The top-ranked research priorities were 'stress and mental well-being', 'information on exercise and diet', 'lactation and breastfeeding', 'exercise after childbirth', and 'physical environment for healthy eating'.

CONCLUSIONS

Addressing mental wellbeing through strategies that are universally accessible, evidence-based, and equity-driven will increase the success of the real-world implementation and knowledge translation of type 2 diabetes prevention in women with a history of GDM in global settings.

Risk factors associated with early postpartum glucose intolerance in women with a history of gestational diabetes mellitus: a systematic review and meta-analysis

PURPOSE

This meta-analysis was aimed at exploring the incidence and risk factors of glucose intolerance in women with gestational diabetes mellitus (GDM) at 6-12 weeks postpartum to inform the development of preventive strategies.

METHOD

We searched Pubmed, Embase, Web of Science, the Cochrane Library, Ovid, China Knowledge Resource Integrated Database (CNKI), Wanfang Database and China Biology Medicine Database for entries between January 1990 and September 2022. The search terms included gestational diabetes mellitus, postpartum, glucose intolerance and type 2 diabetes. The meta-analysis was conducted using Stata 14.0.

RESULT

We included 37 studies, with 21 and 16 having low and medium risk of bias, respectively. The incidence of glucose intolerance in women with GDM 6-12 weeks postpartum was 27% (95% CI: 0.22-0.33). The following risk factors for GDM 6-12 weeks postpartum were identified: insulin use during pregnancy (OR = 3.23; 95% CI: 2.35-4.44), family history of diabetes (OR = 2.94; 95% CI: 1.98-4.33), abnormal fasting glucose levels at 24-28 weeks of gestation (OR = 1.15; 95% CI: 1.07-1.25), high pre-pregnancy BMI (OR = 1.63; 95% CI: 1.23-2.15), abnormal triglyceride levels during 28-40 weeks of gestation (OR = 2.18; 95% CI: 1.18-4.03), abnormal HbA1c levels at 28-40 weeks of gestation (OR = 6.62; 95% CI: 4.71-9.30), history of previous GDM (OR = 2.11; 95% CI: 1.27-3.49), and high 1-h glucose levels at 24-28 weeks of gestation (OR = 1.16; 95% CI:1.06-1.28).

CONCLUSION

The incidence of glucose intolerance in GDM patients at 6-12 weeks postpartum was high. To prevent early postpartum glucose intolerance, healthcare providers should develop individualized interventions for GDM patients, depending on existing risk factors.

The incidence and risk factors of postpartum diabetes in women from Bangladesh, India and Sri Lanka (South Asia) with prior gestational diabetes mellitus: Results from the LIVING study

AIM

To study, the incidence and risk factors for postpartum diabetes (DM), in women with gestational diabetes mellitus (GDM) from South Asia (Bangladesh, India and Sri Lanka), followed for nearly two years after delivery.

METHODS

Women with prior GDM diagnosed using IADPSG criteria were invited at 19 centres across Bangladesh, India and Sri Lanka for an oral glucose tolerance test (OGTT) following childbirth, and were enrolled in a randomized controlled trial. The glycaemic category (outcome) was defined from an OGTT based on American Diabetes Association criteria.

RESULTS

Participants (n = 1808) recruited had a mean ± SD age of 31.0 ± 5.0 years. Incident DM was identified, between childbirth and the last follow-up, in 310 (17.1 %) women [incidence 10.75/100 person years], with a median follow-up duration of 1.82 years after childbirth. Higher age, lower education status, higher prior pregnancy count, prior history of GDM, family history of DM, and postpartum overweight/obese status were significantly associated with incident DM. Women in Bangladesh had a higher cumulative incidence of DM [16.49/100 person years] than in Sri Lanka [12.74/100 person years] and India [7.21/100 person years].

CONCLUSIONS

A high incidence of DM was found in women with prior GDM in South Asia, with significant variation between countries. Women from Bangladesh had a significantly higher pregnancy count, family history of DM and overweight/obese status, despite having significantly lower age, which could be responsible for their higher rates of DM. Registration of this study: The study was registered with the Clinical Trials Registry of India (CTRI/2017/06/008744), Sri Lanka Clinical Trials Registry (SLCTR/2017/001), and ClinicalTrials.gov (NCT03305939).

Risk of kidney disease following a pregnancy complicated by diabetes: a longitudinal, population-based data-linkage study among Aboriginal women in the Northern Territory, Australia

AIMS/HYPOTHESIS

The aim of this work was to investigate the risk of developing chronic kidney disease (CKD) or end-stage kidney disease (ESKD) following a pregnancy complicated by gestational diabetes mellitus (GDM) or pre-existing diabetes among Aboriginal women in the Northern Territory (NT), Australia.

METHODS

We undertook a longitudinal study of linked healthcare datasets. All Aboriginal women who gave birth between 2000 and 2016 were eligible for inclusion. Diabetes status in the index pregnancy was as recorded in the NT Perinatal Data Collection. Outcomes included any stage of CKD and ESKD as defined by ICD-10 coding in the NT Hospital Inpatient Activity dataset between 2000 and 2018. Risk was compared using Cox proportional hazards regression.

RESULTS

Among 10,508 Aboriginal women, the mean age was 23.1 (SD 6.1) years; 731 (7.0%) had GDM and 239 (2.3%) had pre-existing diabetes in pregnancy. Median follow-up was 12.1 years. Compared with women with no diabetes during pregnancy, women with GDM had increased risk of CKD (9.2% vs 2.2%, adjusted HR 5.2 [95% CI 3.9, 7.1]) and ESKD (2.4% vs 0.4%, adjusted HR 10.8 [95% CI 5.6, 20.8]). Among women with pre-existing diabetes in pregnancy, 29.1% developed CKD (adjusted HR 10.9 [95% CI 7.7, 15.4]) and 9.9% developed ESKD (adjusted HR 28.0 [95% CI 13.4, 58.6]).

CONCLUSIONS/INTERPRETATION

Aboriginal women in the NT with GDM or pre-existing diabetes during pregnancy are at high risk of developing CKD and ESKD. Pregnancy presents an important opportunity to identify kidney disease risk. Strategies to prevent kidney disease and address the social determinants of health are needed.

Postpartum uptake of diabetes screening tests in women with gestational diabetes: The PANDORA study

AIMS

To determine rates and predictors of postpartum diabetes screening among Aboriginal and/or Torres Strait Islander and non-Indigenous women with gestational diabetes mellitus (GDM).

METHODS

PANDORA is a prospective longitudinal cohort of women recruited in pregnancy. Postpartum diabetes screening rates at 12 weeks (75-g oral glucose tolerance test (OGTT)) and 6, 12 and 18 months (OGTT, glycated haemoglobin [HbA1C ] or fasting plasma glucose) were assessed for women with GDM (n = 712). Associations between antenatal factors and screening with any test (OGTT, HbA1C , fasting plasma glucose) by 6 months postpartum were examined using Cox proportional hazards regression.

RESULTS

Postpartum screening rates with an OGTT by 12 weeks and 6 months postpartum were lower among Aboriginal and/or Torres Strait Islander women than non-Indigenous women (18% vs. 30% at 12 weeks, and 23% vs. 37% at 6 months, p < 0.001). Aboriginal and/or Torres Strait Islander women were more likely to have completed a 6-month HbA1C compared to non-Indigenous women (16% vs. 2%, p < 0.001). Screening by 6 months postpartum with any test was 41% for Aboriginal and/or Torres Strait Islander women and 45% for non-Indigenous women (p = 0.304). Characteristics associated with higher screening rates with any test by 6 months postpartum included, insulin use in pregnancy, first pregnancy, not smoking and lower BMI.

CONCLUSIONS

Given very high rates of type 2 diabetes among Aboriginal and Torres Strait Islander women, early postpartum screening with the most feasible test should be prioritised to detect prediabetes and diabetes for intervention.

Insulin sensitivity, β cell function, and adverse pregnancy outcomes in women with gestational diabetes

BACKGROUND

The potential impact of β cell function and insulin sensitivity on adverse pregnancy outcomes in women with gestational diabetes mellitus (GDM) remains uncertain. We aimed to investigate the association between β cell dysfunction, insulin resistance, and the composite adverse pregnancy outcomes.

METHODS

This observational study included 482 women diagnosed with GDM during pregnancy. Quantitative metrics on β cell function and insulin sensitivity during pregnancy were calculated using traditional equations. The association of β cell dysfunction and insulin resistance with the risk of the composite adverse pregnancy outcomes was investigated using multivariable-adjusted logistic regression models.

RESULTS

Multivariable-adjusted odds ratios (ORs) of adverse pregnancy outcomes across quartiles of homeostatic model assessment for insulin resistance (HOMA-IR) were 1.00, 0.95, 1.34, and 2.25, respectively (P for trend = 0.011). When HOMA-IR was considered as a continuous variable, the multivariable-adjusted OR of adverse pregnancy outcomes was 1.34 (95% confidence interval 1.16-1.56) for each 1-unit increase in HOMA-IR. Multivariable-adjusted ORs of adverse pregnancy outcomes across quartiles of homeostatic model assessment for β cell function (HOMA-β) were 1.00, 0.51, 0.60, and 0.53, respectively (P for trend = 0.068). When HOMA-β was considered as a continuous variable, the multivariable-adjusted OR of adverse pregnancy outcomes was 0.57 (95% CI 0.24-0.90) for each 1-unit increase in HOMA-β. However, other quantitative metrics were not associated with the composite adverse pregnancy outcomes.

CONCLUSIONS

We demonstrated a significant association of β cell function and insulin sensitivity with the risk of adverse pregnancy outcomes. We have provided additional evidence on the early identification of adverse pregnancy outcomes besides the glycemic values.

Progression to type 2 diabetes mellitus after gestational diabetes mellitus diagnosed by IADPSG criteria: Systematic review and meta-analysis

Background

To estimate the progression rates to type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) diagnosed by the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria.

Methods

Systematic review and meta-analysis were conducted by searching Medline, Embase, and Cochrane between January 1, 2010 and December 31, 2021 for observational studies investigating progression to T2DM after GDM. Inclusion criteria were IADPSG-diagnosed GDM, studies with both GDM and controls, postpartum follow-up duration at least one year. Data were pooled by random effects meta-analysis models. Heterogeneity was assessed by I2 statistic. The pooled relative risk for incidence of T2DM and pre-diabetes between GDM participants and controls were estimated. Reasons for heterogeneity among studies were investigated by prespecified subgroup and meta-regression analysis. Publication bias was assessed by the Begg's and Egger's tests.

Results

This meta-analysis of six studies assessed a total of 61932 individuals (21978 women with GDM and 39954 controls). Women with IADPSG-diagnosed GDM were 6.43 times (RR=6.43, 95% CI:3.45-11.96) more likely to develop T2DM in the future compared with controls. For GDM women, the cumulative incidence of T2DM was 12.1% (95% CI: 6.9%-17.3%), while the pooled cumulative incidence of T2DM was estimated to be 8% (95% CI: 5-11%) in studies with 1 to 5 years of follow-up and increased to 19% (95% CI: 3-34%) for studies with more than 5 years of follow-up. Women with IADPSG-diagnosed GDM had 3.69 times (RR=3.69, 95% CI:2.70-5.06) higher risk of developing pre-diabetes (including impaired fasting glucose and/or impaired glucose tolerance) than controls. Meta-regression analysis showed that the study effect size was not significantly associated with study design, race, length of follow-up, and maternal age (P>0.05). Overall, the studies had a relatively low risk of bias.

Conclusions

Women with IADPSG-diagnosed GDM have higher risk of developing T2DM and pre-diabetes. The risk of T2DM in GDM women are higher with longer follow-up duration. Our results highlight the importance of promoting postpartum screening and keeping health lifestyle as well as pharmacological interventions to delay/prevent the onset of T2DM/pre-diabetes in GDM women.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier (CRD42022314776).

Association between hyperglycaemia in pregnancy and growth of offspring in early childhood: The PANDORA study

BACKGROUND

Few studies have assessed whether children exposed to in utero hyperglycaemia experience different growth trajectories compared to unexposed children.

OBJECTIVES

To assess association of type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) with early childhood weight, length/height and body mass index (BMI) trajectories, and with timing and magnitude of peak BMI in infancy.

METHODS

PANDORA is a birth cohort recruited from an Australian hyperglycaemia in pregnancy register, and women with normoglycaemia recruited from the community. Offspring growth measures were obtained from health records over a median follow-up of 3.0 years (interquartile range 1.9-4.0). This analysis included children born to Aboriginal mothers with in utero normoglycaemia (n = 95), GDM (n = 228) or T2D (n = 131). Growth trajectories (weight, length/height and BMI) were estimated using linear mixed models with cubic spline functions of child age.

RESULTS

After adjustment for maternal factors (age, BMI, parity, smoking, and socioeconomic measures) and child factors (age, gestational age at birth, and sex), children born to mothers with T2D or GDM had lower weight, length/height and BMI trajectories in infancy than children born to mothers with normoglycaemia, but similar weight and BMI by completion of follow-up. Children exposed to T2D had lower mean peak BMI 17.6 kg/m² (95% confidence interval [CI] 17.3-18.0) than children exposed to normoglycaemia (18.6 kg/m² [18.1-18.9]) (p = 0.001).

CONCLUSIONS

Maternal hyperglycaemia was associated with differences in early childhood growth trajectories after adjustment for maternal BMI. Exploration of associations between in utero hyperglycaemia exposure and growth trajectories into later childhood is required.