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Follow-up often poor after gestational diabetes
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Competing priorities and a low motivation for self-care often prevent women with gestational diabetes from undergoing continued postpartum monitoring for development of type 2 diabetes, including postpartum glucose testing, according to recent findings.
“Despite the high risk for type 2 diabetes after a pregnancy complicated by gestational diabetes, neither women nor their health care providers focus on the bigger picture of prevention of chronic disease over the life cycle,” Judith A. Bernstein, PhD, professor of community health sciences at Boston University School of Public Health, told Endocrine Today. “Immediate, pressing priorities get in the way for both patients and clinicians, and systems of care do not include fail-safes for ensuring that needed tests get done and communication occurs across specialties.”
The prevalence of gestational diabetes in the United States has increased considerably, from 0.3% in 1979-1980 to 5.8% in 2008-2010, according to recent data. Period of delivery, increasing maternal age and increasing BMI all contributed to the trend, according to researchers. Modified screening and diagnostic criteria, better dietary management and treatment have likely influenced the marked decrease in macrosomia (184%; 95% CI, 180-188); however, an increased rate of stillbirths (a 0.75% increase for 2008-2010 (95% CI, 0.74-0.76 vs. 1979-1981 data) highlights the risk with these pregnancies.
Besides risks to the infant, gestational diabetes also carries postpartum risks for the mother. After pregnancy, the condition will not resolve in 5% to 10% of women, whereas for others, the risk for developing type 2 diabetes — and the related comorbidities that often accompany it — remains high in the years after delivery.
A ‘gap in the system’
In a 2012-2013 qualitative study, Bernstein and colleagues interviewed 27 patients and 25 clinicians who managed gestational diabetes during or after pregnancy. Patients enrolled in the study during the third trimester of pregnancy after a diagnosis of gestational diabetes; a 1-hour at-home interview took place at 10 to 14 weeks’ postpartum. Interview questions to clinicians and patients covered knowledge, values and priorities, sources of information, challenges and recommendations for a single change that could be instituted to increase rates of testing and primary care linkage.
Researchers found that women were highly motivated to address their gestational diabetes diagnosis for the sake of their child, but less so for themselves.
“Most were aware of possible consequences of [gestational diabetes] for the child and seriousness of a diagnosis of diabetes if they actually had diabetes, but most were certain that there would be no future problems after delivery, in part because physicians were reassuring about their ability to provide good care,” the researchers wrote. “While some women wanted the truth about their diagnosis (‘Please don’t sugar coat’), some were afraid to hear what was said and thought pregnancy was ‘Not a time to hear more problems.’”
Complicating matters, screening tests for diabetes are time-consuming and inconvenient for new mothers, experts argue.
“Women with gestational diabetes are focused on caring for their children, especially for the first several years, and that may underscore some of the reasons they are not screened for diabetes,” Gang Hu, MD, MPH, PhD, assistant professor at the Chronic Disease Epidemiology Laboratory at Pennington Biomedical Research Center in Baton Rouge, Louisiana, told Endocrine Today. “Other major barriers can include the patient not seeing her doctor regularly, or a lack of communication and follow-up between health care providers and the patient. Other barriers include lack of awareness about the history of gestational diabetes and the need for testing, declining testing when offered by their physician, or being unable to complete the screening test.”
Those barriers to postpartum care can lead to adverse outcomes in the future, said Erica P. Gunderson, PhD, MS, MPH, senior research scientist in the cardiovascular and metabolic conditions section of Kaiser Permanente Northern California.
“This gap in the health care system represents a missed opportunity for early prevention of diabetes in women, particularly women at greatest risk with a diagnosis of gestational diabetes during pregnancy,” Gunderson told Endocrine Today. “A simple and accurate test is needed to identify women who would benefit most from early interventions to prevent diabetes.”
A push for screening
Guidelines from the American Diabetes Association regarding the management of diabetes in pregnancy note that gestational diabetes may represent pre-existing, undiagnosed type 2 diabetes for some women; for others, the risk for developing incident type 2 diabetes remains high.
A 2015 ADA position statement on the issue, published in Diabetes Care, states that women with gestational diabetes should be screened for persistent diabetes or prediabetes at 6 to 12 weeks’ postpartum via a 75 g oral glucose tolerance test, as changes in red blood cell mass during the weeks after delivery make the HbA1c test unreliable. Screenings should be repeated every 1 to 3 years thereafter, depending on other risk factors.
“Women with a history of gestational diabetes have a marked increase in risk for impaired glucose tolerance and type 2 diabetes later in life,” Hu said. “Postpartum screening for diabetes might find the high-risk group of women with a history of gestational diabetes, and early postpartum lifestyle interventions might decrease or delay postpartum diabetes risk.”
In a retrospective study of commercial insurance claims from all 50 states between 2000 and 2012, Emma Morton Eggleston, MD, MPH, of the department of population medicine at Harvard Medical School, and colleagues analyzed data from 447,556 women with at least one delivery and continuous enrollment 1 year before and after delivery. Within the cohort, 32,253 (7.2%) were diagnosed with gestational diabetes, but more than 75% received no screening for overt diabetes within 1 year postpartum (screening rate, 23%). During the first 12 weeks after delivery, just 13.1% received any testing; another 13.6% of women were tested between 12 and 52 weeks’ postpartum. Contrary to current guidelines, 17.1% of women were tested before 6 weeks’ postpartum.
Among all women with gestational diabetes, rates for the recommended 75 g OGTT increased slightly, from just 2% in 2001 to 7% in 2011, according to the researchers.
“[An] antepartum visit to nutrition or diabetes education was predictive of recommended screening, suggesting [the] benefit of these visits beyond nutrition guidance and [gestational diabetes] education,” the researchers wrote, adding that there was a “pressing need” for an appropriate, postpartum screening for diabetes.
Beyond the OGTT
A team of researchers, led by Gunderson and Michael B. Wheeler, PhD, professor in the department of physiology at the University of Toronto, recently developed a test using a single fasting blood sample and a technique known as targeted metabolomics.
Using the metabolomics approach, which also implemented machine learning, the researchers measured metabolites in stored, frozen fasting plasma glucose samples drawn at 8 to 9 weeks’ postpartum from women with recent gestational diabetes, but without diabetes confirmed via the 2-hour OGTT. The included women completed annual follow-up screenings with an OGTT to identify new-onset diabetes within 2 years.
The researchers found that clinical variables, combined with lipid species, predicted 21 cases of type 2 diabetes during 8.5 years of follow-up with 83% accuracy. The researchers noted that the signature has not yet been independently validated.
“Several metabolites were statistically significant predictors of incident [type 2 diabetes], and they were previously associated with [type 2 diabetes] in cross-sectional metabolomics studies, suggesting that [gestational diabetes] women at risk for progressing to [type 2 diabetes] present a more type 2-like metabolite profile within the very short time frame of 2 months’ postpartum compared to women who will remain nondiabetic,” the researchers wrote.
“Accurate and convenient testing methods, such as the metabolic signature, hold promise to improve screening in women because they take only a few minutes instead of 2 hours to complete the OGTT, and the test results are not influenced by changes in hemoglobin levels after delivery,” Gunderson said.
Wheeler said the researchers hope to conduct additional tests in women with gestational diabetes to evaluate racial and ethnic differences in prediction and to investigate high-risk groups with prediabetes to learn whether metabolomics will predict type 2 diabetes in the general population.
“In general, a next-generation blood test that is more simple and accurate than the current options could help to identify individuals who would benefit most from timelier and effective interventions to prevent type 2 diabetes,” Wheeler told Endocrine Today.
The focus of gestational diabetes research should shift, Bernstein said, to developing strategies to inform both women and their providers about the potential for successful prevention and the need to support women’s ability to take care of themselves, not just their newborns, during a challenging period in their lives.
“We need to knit together the fragmented fabric of women’s health care,” Bernstein said. “A complicated delivery should lead smoothly to transition to a primary care practitioner, with information exchanged easily across separate territories of obstetrics and internal medicine.” – by Regina Schaffer
- References:
- Allalou A, et al. Diabetes. 2016;doi:10.2337/db15-1720.
- American Diabetes Association. Diabetes Care. 2015;doi:10.2337/dc15-s015.
- Bernstein JA, et al. BMJ Open Diabetes Res Care. 2016;doi:10.1136/bmjdrc-2016-000250.
- Eggleston EM, et al. Obstet Gynecol. 2016;doi:10.1097/AOG.0000000000001467.
- Lavery JA, et al. BJOG. 2016;doi:10.1111/1471-0528.14236.
- For more information:
- Judith A. Bernstein, PhD, can be reached at jbernste@bu.edu.
- Erica P. Gunderson, PhD, MS, MPH, can be reached at erica.gunderson@.kp.org.
- Gang Hu, MD, MPH, PhD, can be reached at gang.hu@pbrc.edu.
- Michael B. Wheeler, PhD, can be reached at michael.wheeler@utoronto.ca.
Disclosures: Bernstein, Gunderson, Hu and Wheeler report no relevant financial disclosures.