Post-partum screening after gestational diabetes

Barriers to Postpartum Glucose Intolerance Screening in an Italian Population

Background: Gestational diabetes mellitus (GDM) is a strong risk factor for type 2 diabetes mellitus (T2D) and the postpartum period is crucial for early treatment in at-risk women. However, despite recommendations, only a fraction of women undergo a postpartum screening for glucose intolerance (ppOGTT). The present study aims to verify the reason(s) for poor adherence in our population. Research design and methods: This retrospective study includes 451 women in which GDM was diagnosed between 2015⁻2016. During 2017, we verified by phone interview how many women underwent ppOGTT at 6⁻12 weeks postpartum, as recommended by the Italian guidelines. The non-compliant women were asked about the reason(s) for failing to screen. The non-parametric Mann-Whitney test and the 2-tailed Fisher exact test were used to compare continuous and categorical features, respectively, among women performing or non-performing ppOGTT. Results: Out of 451 women with GDM diagnosis, we recorded information from 327. Only 97 (29.7%) performed ppOGTT. The remaining 230 women (70.3%) provided the following explanation for non-compliance: (1) newborn care (30.4%); (2) misunderstood importance (28.3%); (3) oversight (13.0%); (4) unavailability of test reservation in the nearest centers (10.4%); (5) normal glycemic values at delivery (8.3%); (6) discouragement by primary care physician (5.6%). Conclusions: In our population, most women with recent GDM failed to perform ppOGTT. Our results indicated that the prominent barriers could potentially be overcome.

Development of type 2 diabetes mellitus after gestational diabetes in a cohort in KSA: Prevalence and risk factors

OBJECTIVES

KSA has the highest prevalence of diabetes mellitus among Middle Eastern countries with a prevalence range of 21%-24%. Gestational diabetes (GDM) is a well-known risk factor for type 2 diabetes mellitus (T2DM). GDM is associated with a 7-fold increased risk of T2DM. Thus, this research assessed the prevalence and risk factors associated with the development T2DM in a cohort of patients with GDM in KSA.

METHODS

The medical records of patients with GDM who visited the outpatient clinics of a tertiary care hospital from 2011 to 2014 were included in this study. Patients with a prior diagnosis of diabetes mellitus before pregnancy and those with GDM who did not have postpartum diabetes screening were excluded.

RESULTS

A total of 123 women with GDM and underwent postpartum diabetes screening, 82 (67%) developed T2DM based on follow-up records. Approximately 45% (37/82) of patients who developed T2DM were screened ≤6 months after delivery, whereas 55%(45/82) were screened >6 months after delivery. Older patients, patients who had a higher number of pregnancies (gravidity and parity), and patients with previous GDM were more likely to develop T2DM.

CONCLUSION

In KSA, women who developed GDM, particularly those who are older, multigravid, and multiparous and who have a prior history of GDM, are at an increased risk of developing T2DM. Postpartum diabetes screening of patients with GDM within the recommended period need to be improved.

Postpartum glucose intolerance: an updated overview

The prevalence of type 2 diabetes mellitus has increased worldwide over the past three decades, as a consequence of the more westernized lifestyle, which is responsible for the increasing obesity rate in the modern adult's life. Concomitant with this increase there has been a gradual rise in the overall prevalence of gestational diabetes mellitus, a condition that strongly predisposes to overt diabetes later in life. Many women with previous gestational diabetes mellitus show glucose intolerance in the early postpartum period. Although the best screening strategy for postpartum glucose intolerance is still debated, numerous evidences indicate that identification of these women at this time is of critical importance, as efforts to initiate early intensive lifestyle modification, including hypocaloric diet and physical activity, and to ameliorate the metabolic profile of these high-risk subjects can prevent or delay the onset of type 2 diabetes mellitus. Nevertheless, less than one fifth of women attend the scheduled postpartum screening following gestational diabetes mellitus and they are at increased risk to develop type 2 diabetes mellitus later in their lives. Unsatisfying results have also come from early intervention strategies and tools that have been developed during the last few years to help improving the rate of adherence to postpartum glycemic testing, thereby indicating that more effective strategies are needed to improve women's participation in postpartum screening.

Sensitivity of postnatal fasting plasma glucose in identifying impaired glucose tolerance in women with gestational diabetes - 25 Years' data

Objective

To assess the uptake of postnatal oral glucose tolerance test and to determine the sensitivity of fasting postnatal blood sugar in predicting 2-h impaired glucose tolerance.

Methods

Retrospective study of 1961 women diagnosed with gestational diabetes mellitus. All women were offered oral glucose tolerance test six weeks post-delivery.

Results

Of 1961 women, 1090 (56%) returned for postpartum oral glucose tolerance test. A fasting plasma glucose of ≥6.1 mmol/l identified only 76 of 167 women with impaired glucose tolerance detected by a 2-h oral glucose tolerance test (sensitivity of 45.5%; 95%CI: 38.1–53.1). We observed a normal fasting glucose but an impaired 2-h glucose tolerance in 91 out of 968 (9.4%) women. Asian ethnicity, admission on special care baby unit and antenatal insulin therapy strongly predicted 2-h impaired postnatal blood glucose levels (P < 0.05).

Conclusion

Although fasting plasma glucose is a convenient method, it lacks sensitivity in identifying women with impaired glucose tolerance postnatally.

Early diabetes screening in women with previous gestational diabetes: a new insight

BACKGROUND

Gestational diabetes mellitus (GDM) is a risk factor for the development of diabetes mellitus (DM). However, there is a low return rate for this screening, so it is important to search for earlier methods for evaluation after delivery, to increase the number of pregnant women screened, so you can start the treatment or prevention of these early comorbidities. To determine the accuracy of the 75 g 2-h oral glucose tolerance test (OGTT) performed between 48-72 h after delivery for the diagnosis of DM using the OGTT after 6 weeks as the gold standard criterion, and to identify the optimal cutoff points for this exam for diabetes screening after a pregnancy complicated by GDM.

METHODS

82 women with previous GDM underwent an OGTT between 48-72 h postpartum and repeated the test 6 weeks after delivery.

RESULTS

The prevalence of DM and prediabetes based on the first OGTT was 3.7 and 32.9 %, respectively, and 8.5 and 20.7 %, respectively, at the second OGTT. For those with DM, the area under the curve (AUC) based on the fasting plasma glucose (FPG) was 0.77 (95 % CI 0.61-0.92), and based on 2-h OGTT was 0.82 (95 % CI 0.66-0.97). For patients with prediabetes, the AUC based on the FPG was 0.73 (95 % CI 0.59-0.86) and based on the 2-h OGTT was 0.74 (95 % CI 0.61-0.87). Using a FPG cutoff value of 78 mg/dl (4.3 mmol/L) and a 2-h OGTT cutoff value of 130 mg/dl (7.2 mmol/L) for DM, the specificity was 58.7 and 60 %, the sensitivity was 71.4 and 85.7 %, the positive predictive value was 13.9 and 16.7 and the negative predictive value was 95.7 and 97.9 %, respectively.

CONCLUSIONS

OGTT performed early in postpartum is a useful tool for identifying women with previous GDM who must perform an OGTT 6 weeks after delivery.

Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: the STAR MAMA program

Background

One of the fastest growing risk groups for early onset of diabetes is women with a recent pregnancy complicated by gestational diabetes, and for this group, Latinas are the largest at-risk group in the USA. Although evidence-based interventions, such as the Diabetes Prevention Program (DPP), which focuses on low-cost changes in eating, physical activity and weight management can lower diabetes risk and delay onset, these programs have yet to be tailored to postpartum Latina women. This study aims to tailor a IT-enabled health communication program to promote DPP-concordant behavior change among postpartum Latina women with recent gestational diabetes.

The COM-B model (incorporating Capability, Opportunity, and Motivational behavioral barriers and enablers) and the Behavior Change Wheel (BCW) framework, convey a theoretically based approach for intervention development. We combined a health literacy-tailored health IT tool for reaching ethnic minority patients with diabetes with a BCW-based approach to develop a health coaching intervention targeted to postpartum Latina women with recent gestational diabetes. Current evidence, four focus groups (n = 22 participants), and input from a Regional Consortium of health care providers, diabetes experts, and health literacy practitioners informed the intervention development. Thematic analysis of focus group data used the COM-B model to determine content. Relevant cultural, theoretical, and technological components that underpin the design and development of the intervention were selected using the BCW framework.

Results

STAR MAMA delivers DPP content in Spanish and English using health communication strategies to: (1) validate the emotions and experiences postpartum women struggle with; (2) encourage integration of prevention strategies into family life through mothers becoming intergenerational custodians of health; and (3) increase social and material supports through referral to social networks, health coaches, and community resources. Feasibility, acceptability, and health-related outcomes (weight loss, physical activity, consumption of healthy foods, breastfeeding, and glucose screening) will be evaluated at 9 months postpartum using a randomized controlled trial design.

Conclusions

STAR MAMA provides a DPP-based intervention that integrates theory-based design steps. Through systematic use of behavioral theory to inform intervention development, STAR MAMA may represent a strategy to develop health IT intervention tools to meet the needs of diverse populations.

Trial registration

ClinicalTrials.gov NCT02240420

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0426-2) contains supplementary material, which is available to authorized users.

Type 2 diabetes after gestational diabetes: greater than fourfold risk among Indigenous compared with non-Indigenous Australian women

BACKGROUND

Gestational diabetes is associated with a high risk of type 2 diabetes. However, progression rates among Indigenous women in Australia who experience high prevalence of gestational diabetes are unknown.

METHODS

This retrospective cohort study includes all births to women at a regional hospital in Far North Queensland, Australia, coded as having 'gestational diabetes' from 1 January 2004 to 31 December 2010 (1098 births) and receiving laboratory postpartum screening from 1 January 2004 to 31 December 2011 (n = 483 births). Women who did not receive postpartum screening were excluded from the denominator. Data were linked between hospital electronic records, routinely collected birth data and laboratories, with sample validation by reviews of medical records. Analysis was conducted using Cox-proportional regression models.

RESULTS

Indigenous women had a greater than fourfold risk of developing type 2 diabetes within 8 years of having gestational diabetes, compared with non-Indigenous women (hazards ratio 4.55, 95% confidence interval 2.63-7.88, p < 0.0001). Among women receiving postpartum screening tests, by 3, 5 and 7 years postpartum, 21.9% (15.8-30.0%), 25.5% (18.6-34.3%) and 42.4% (29.6-58.0%) Indigenous women were diagnosed with type 2 diabetes after gestational diabetes, respectively, compared with 4.2% (2.5-7.2%), 5.7% (3.3-9.5%) and 13.5% (7.3-24.2%) non-Indigenous women. Multivariate analysis showed an increased risk of developing type 2 diabetes among women with an early pregnancy body mass index ≥25 kg/m(2) , only partially breastfeeding at hospital discharge and gestational diabetes diagnosis prior to 17 weeks gestation.

CONCLUSIONS

This study demonstrates that, compared with non-Indigenous women, Indigenous Australian women have a greater than fourfold risk of developing type 2 diabetes after gestational diabetes. Strategies are urgently needed to reduce rates of type 2 diabetes by supporting a healthy weight and breastfeeding and to improve postpartum screening among Indigenous women with gestational diabetes. Copyright © 2015 John Wiley & Sons, Ltd.

Associations with low rates of postpartum glucose screening after gestational diabetes among Indigenous and non-Indigenous Australian women

OBJECTIVES

To explore factors associated with postpartum glucose screening among women with Gestational Diabetes Mellitus (GDM).

METHODS

A retrospective study using linked records from women with GDM who gave birth at Cairns Hospital in Far North Queensland, Australia, from 1 January 2004 to 31 December 2010.

RESULTS

The rates of postpartum Oral Glucose Tolerance Test (OGTT) screening, while having increased significantly among both Indigenous* and non-Indigenous women from 2004 to 2010 (HR 1.15 per year, 95%CI 1.08-1.22, p<0.0001), remain low, particularly among Indigenous women (10% versus 27%, respectively at six months postpartum). Indigenous women in Cairns had a longer time to postpartum OGTT than Indigenous women in remote areas (HR 0.58, 0.38-0.71, p=0.01). Non-Indigenous women had a longer time to postpartum OGTT if they: were born in Australia (HR 0.76, 0.59-1.00, 0.05); were aged <25 years (HR 0.45, 0.23-0.89, p=0.02); had parity >5 (HR 0.33, 0.12-0.90, p=0.03); smoked (HR 0.48, 0.31-0.76, p=0.001); and did not breastfeed (HR 0.09, 0.01-0.64, p=0.02).

CONCLUSIONS

Postpartum diabetes screening rates following GDM in Far North Queensland are low, particularly among Indigenous women, with lower rates seen in the regional centre; and among non-Indigenous women with indicators of low socioeconomic status.

IMPLICATIONS

Strategies are urgently needed to improve postpartum diabetes screening after GDM that reach women most at risk.