WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.
The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.
Dr. Thomas R. Moore
For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.
And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.
"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.
"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."
Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.
For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."
The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.
At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.
In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).
"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.
A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.
The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA1c levels be as close to normal as possible before conception is attempted, he emphasized.