COMMENTARY

Why Gestational Diabetes Follow-up Needs to Be Improved

Prof Kamlesh Khunti 

Disclosures

August 24, 2021

This transcript has been edited for clarity.

Hello, my name is Kamlesh Khunti, professor of primary care, diabetes, and vascular medicine, and general practitioner in Leicester.

Thank you for joining me for this session on gestational diabetes. This topic came about recently on Twitter, where there was a discussion about whether women post-delivery with gestational diabetes had regular monitoring or not.

Well, gestational diabetes is a relatively common complication of pregnancy. It is defined as glucose intolerance with onset of first diagnosis during the second or third trimester of pregnancy without either pre-existing type 1 or type 2 diabetes.

The International Diabetes Federation estimates suggest that globally hyperglycaemia in pregnancy affects about 15.8% of live births, with around 84% of these being due to gestational diabetes mellitus.

It is crucial that gestational diabetes is correctly diagnosed and managed, as it is associated with a considerable number of adverse events for the mother, and also adverse perinatal outcomes.

For example, for the mother gestational diabetes carries a lifetime risk of up to 60% for developing type 2 diabetes.

Studies also showed that type 2 diabetes is nearly 10 times higher in women with previous gestational diabetes than in healthy controls, with possible higher progression rates in the first 5 years. So, this is the time to really catch these women with a screening programme.

Women with a history of gestational diabetes are also at higher risk for development of cardiovascular disease, or to be diagnosed with non-alcoholic fatty liver disease, and also [increased] healthcare costs. Again, it is very important that we screen for them.

Guidelines, obviously, therefore recommend screening for future type 2 diabetes risk in women who have had gestational diabetes.

Those at high risk of diabetes or prediabetes need to be referred for a diabetes prevention programme. There is really good quality randomised controlled trial and meta-analysis evidence that lifestyle interventions or certain pharmacologic therapies, such as metformin, can prevent the risk of developing diabetes in the future.

The only way that women with previous gestational diabetes can be identified and referred for a prevention programme is to identify them following delivery.

However, as the Twitter discussion went, the rates of postpartum glucose screening in women with previous gestational diabetes remains substantially low, with only half of them attending screening programmes.

The NICE (National Institute for Health and Care Excellence) guidelines state that following labour, women affected by gestational diabetes during pregnancy should be offered lifestyle advice, including diet and exercise, and are recommended to undergo a fasting plasma glucose test.

The fasting plasma glucose should be performed at about 6 to 13 weeks postpartum, although in cases where it has not been performed by 13 weeks, either this test - the fasting plasma glucose - or a glycated haemoglobin (HbA1c) test can be performed after 13 weeks.

Women who receive a negative postpartum test result of type 2 diabetes should then be offered an annual HbA1c test. So, they really should be going on to our GP registers as being at high-risk of diabetes and then should be offered the annual HbA1c test as we do for other people with pre-diabetes.

However, as we mentioned, this is not currently happening consistently in clinical practice. For example, one retrospective cohort study of 127 primary care practices in the UK, reported that short term follow-up of women was only about 18.5%, and long-term [annual] follow-up of around  20% over a 5 year period.

Another study showed that only 38% of women with previous gestational diabetes received screening for type 2 diabetes up to 13 weeks postpartum, while only 16% of them received an annual HbA1c test. Only about one third were followed up.

So what should we be doing to increase screening rates? Well, there are some studies that have suggested potential interventions. But before we do all that, I think we really need to improve education and communication with the patient, or the person who has gestational diabetes.

Women with gestational diabetes should be informed that they are at high risk of diabetes and need a check postnatally and then annually for glucose intolerance.

This should be done in a culturally-competent manner using all ethnic languages to ensure that patients get the right information and they understand that information.

We also need to improve communication between hospitals and primary care where these patients will be screened. Currently this is not happening consistently, with some hospitals informing the GP practices about the gestational diabetes status while in other areas there is no such communication. I think this is where one of the areas that we can really improve on.

Studies have also shown the implementation of a central coordinator responsible for reminding women about the importance of screening could effectively achieve screening attendance rates of around 75%.

Another study has shown that early postpartum glycaemic assessment with a fasting plasma glucose performed before hospital discharge is associated with a total uptake of about 95%, and is therefore an effective strategy to increase screening of pregnant women with previous gestational diabetes, immediately postpartum.

However, still, we need to ensure that they're on the GP register, and therefore followed up on an annual basis.

So, in summary, there is strong evidence supporting postpartum screening for women who are diagnosed with gestational diabetes during pregnancy, to prevent type 2 diabetes.

However, postpartum screening for type 2 diabetes is suboptimal in the UK and globally, with only half of these women attending screening programmes, and therefore primary and specialist care should work collaboratively to ensure these women are screened in a timely manner, and if at high risk referred for a diabetes prevention programme.

Thank you very much for joining me.

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