Many women with gestational diabetes do not receive type 2 diabetes screening after birth
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Women in the United Kingdom who had gestational diabetes were not often screened for type 2 diabetes in accordance with national guidelines, a recent analysis showed.
According to the CDC, 6% of pregnant women in the United States develop gestational diabetes.
Previous research has shown that 35% to 60% of women with gestational diabetes will develop type 2 diabetes within 10 to 20 years after their pregnancy. In addition, a meta-analysis showed that women with gestational diabetes were seven times more likely to develop subsequent type 2 diabetes than those without gestational diabetes, Rebecca Ward, PhD, manager of the Centre for Systems Modeling and Quantitative Biomedicine at University Hospitals of the North Midlands NHS Trust, and colleagues wrote in The International Journal of Clinical Practice.
In 2008, the U.K.’s National Institute of Health and Care Excellence (NICE) recommended hyperglycemia assessments in women with gestational diabetes soon after delivery and in the long term. In 2015, NICE updated its guidance to recommend fasting plasma glucose testing for women with gestational diabetes around 6 weeks post-delivery, followed by annual testing.
For their study, Ward and colleagues calculated the proportion of diabetes tests conducted post-delivery among a cohort of 251 women who had gestational diabetes and gave birth between 1999 and 2007, and a second cohort of 260 women who had gestational diabetes and gave birth between 2015 and 2016. In the earlier group, the initial postpartum diabetes test was arranged by antenatal staff members and in the later one, the test was coordinated by primary care professionals. Subsequent tests were overseen by primary care in both groups.
Ward and colleagues reported that in the 1999 to 2007 cohort, 59.8% of women had the recommended postpartum diabetes testing at around 6 weeks compared with 35% in the 2015 to 2016 cohort (P < .001). Only 13.5% of women in the earlier cohort and 14.2% in the later cohort underwent the first annual diabetes test on time.
“Our findings are consistent with other studies investigating follow-up to 1-year postpartum,” the researchers wrote. “It is reasonable to assume that the consistently low testing rates in the years beyond this initial period, as our study demonstrates, may reflect practice in other geographical areas.”
In addition, among the 1999 to 2007 cohort during a median follow-up of 12.3 years, the proportion of women tested in any given year averaged 34.2%, with a progressive decline in the proportion of women receiving an annual diabetes test with time since delivery (P = .002).
During the follow-up period, 85 women from the entire 1999 to 2007 cohort had blood test results that indicated they had diabetes. The median time to presumed diabetes diagnosis was 5.2 years (range = 0.11-15.95). Further analysis indicated that 18.8% of women had blood test results in the diabetes range within 5 years of pregnancy, and 37.8% had similar results within 10 years, according to the researchers.
Possible reasons for the gap in universal diabetes testing include confusion regarding who should arrange the postpartum diabetes tests as well as new mothers not having enough time, lacking sufficient childcare and putting greater emphasis on the baby’s health, Ward and colleagues wrote.
Interventions such as sending mobile app reminders to new mothers with a history of diabetes or asking clinical laboratories to take the lead on scheduling may increase the number of diabetes tests and reduce the incidence of diabetes in these women, Ward and colleagues concluded.
References
CDC. Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth — United States, 2012–2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6743a2.htm. Accessed July 28, 2021.
Ward RJ, et al. Int J Clin Pract. 2021;doi:doi: 10.1111/ijcp.14447.
The authors report no relevant financial disclosures.
Perspective
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Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, FADCES, FCCP
This retrospective study showed that most women with a history of gestational diabetes are not following postpartum guideline recommendations for screening for type 2 diabetes. These findings are concerning since this can delay diagnosis and contribute to long-term microvascular and macrovascular complications of diabetes.
Women with gestational diabetes are at an increased risk for type 2 diabetes and, therefore, should be regularly screened for this condition after delivery. The American Diabetes Association’s Standards of Care recommends screening women for gestational diabetes at 4 to 12 weeks postpartum, using the 75-g oral glucose tolerance test and lifelong screening every 1 to 3 years after that. The United Kingdom, where this study took place, has a similar recommendation of screening at 6 to 8 weeks postpartum and annually thereafter. Unlike the U.S., the U.K. recommends initial postpartum screening with a fasting glucose.
There are many barriers to the initial and ongoing postpartum screening for type 2 diabetes. One barrier that Ward and colleagues mention is the uncertainty of who is responsible — obstetricians or primary care physicians. In the United States, a 2-hour 75-g oral glucose tolerance test is often performed and requires fasting overnight, which is often difficult due to competing demands of a new baby. Although a fasting glucose test does require fasting, it only requires one lab draw, shortening the time and could, in theory, remove at least one of the barriers to initial gestational diabetes screening. Despite the increased convenience of this latter test, 40.2% women in one part of the study were still not tested within 8 weeks postpartum.
The Ward study, along with many others, reinforces the delay in diagnosing type 2 diabetes in this high-risk population. Efforts should be made to identify solutions to increase initial and ongoing type 2 diabetes screening in women with a history of gestational diabetes. For example, making screening more convenient and offered by a variety of providers in a variety of locations, and researching other innovative and convenient tools such as providing a woman with a professional, blinded continuous glucose monitor to wear for a few days after delivery.
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