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Landmark and Archived Articles

Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Heather D. Clark, MD, MSc; Ian D. Graham, PhD; Alan Karovitch, MD, MEd; Erin J. Keely, MD. American Journal of Obstetrics & Gynecology, June 2009  

OBJECTIVE: Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates. 
STUDY DESIGN: Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests.
RESULTS: OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P.05).
CONCLUSION: Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse-Midwives Jean Y. Ko, PhD, Patricia M. Dietz, DrPH, Elizabeth J. Conrey, RD, PhD, Loren Rodgers, PhD, Cynthia Shellhaas, MD, MPH, Sherry L. Farr, PhD, Cheryl L. Robbins.Journal of Midwifery & Women’s Health   J Midwifery Womens Health. 2013 Jan-Feb;58(1):33-40. 

Introduction: Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement.
Methods: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening.
Results: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care.
Discussion: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies

A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes Kimberly K. Vesco, MD, MPH; Patricia M. Dietz, DrPH, MPH; Joanna Bulkley, PhD; F. Carol Bruce, BSN, MPH; William M. Callaghan, MD, MPH; Lucinda England, MD, MSPH; Terry Kimes, MS; Donald J. Bachman, MS; Karen J. Hartinger, RN; Mark C. Hornbrook, PhD. Am J Obstet Gynecol 2012;207:283.e1-6.

OBJECTIVE: We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM).
STUDY DESIGN: In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n 179) and July 2007 through June 2008 (n 200).
RESULTS: After the program’s implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07–1.75). 
CONCLUSION: Rates of postpartum diabetes testing can be improved with system changes and reminders. 

The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes?
 A.K. Shea, PhD, MSc; B.R. Shah, MD, PhD; H.D. Clark, MD, MSc; J. Malcolm, MD; M. Walker, MD, MSc; A. Karovitch, MD, MEd; E.J. Keely, MD  Vol 31, No 2, March 2011 – Chronic Diseases in Canada

Introduction: During regular care, women with previous gestational diabetes mellitus (GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral glucose tolerance test (OGTT), in the postpartum period. The current study examined whether the implementation of a reminder system improved screening rates. 
Methods: Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery. 
Results: Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%). 
Conclusion: Although the screening rates remain low, postpartum reminders doubled screening rates using the recommended test, the OGT.

Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus. Marina Stasenko, BA; Jennifer Liddell, RN, CDE; Yvonne W. Cheng, MD, MPH; Teresa N. Sparks, MD; Molly Killion, RN; Aaron B. Caughey, MD, PhD American  Journal of Obstetrics & Gynecology JUNE 2011 

OBJECTIVE: The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM). 
STUDY DESIGN: A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.
RESULTS: The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort (PI.001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, PI.001), Latinas (15% to 50%, PI .001), and Asians (43% to 59%, PI .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% (PI .414).
CONCLUSION: GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.

Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon. Monica L. Hunsberger, Rebecca J. Donatelle, Karen Lindsay, Kenneth D. Rosenberg. PLoS ONE 7(10): e47052. doi:10.1371/journal.pone.0047052 

Objective: This study examines obstetrician/gynecologists and family medicine physicians’ reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus. 
Research Design and Methods: In November–December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician/gynecologists and family medicine from a population of 2171.
Results: Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high
adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69–7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65–11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.
Conclusions: Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.
 
Window of Opportunity: Postpartum Screening of Women with Gestational Diabetes for Early Detection of Prediabetes and Type 2 Diabetes Cassandra E. Henderson, Jan Kavookjian, Harris Leitstein, June M. McKoy, Wambui Jane Murage, and Ruth D. Lipman. The Open Diabetes Journal, 2012, 5, 25-28

Abstract: Gestational diabetes is a condition characterized by glucose intolerance during pregnancy, with defined approaches for screening, treatment, and follow-up. It is associated with a variety of adverse birth outcomes, including excessive fetal weight gain and related increases in the rate of cesarean delivery and perinatal injury as well as increased risk for developing type 2 diabetes for women who have had gestational diabetes. A diagnosis of gestational diabetes may also be a manifestation of pre-existing type 2 diabetes. Nonetheless, a substantial proportion of women with a history of gestational diabetes fail to receive the recommended postpartum glucose screening. This failure to conduct follow-up screening of women with gestational diabetes after delivery represents a missed opportunity for earlier diagnosis of diabetes, and chance to increase the awareness of women of their future risk for developing diabetes. This paper explores the barriers contributing to the lack in follow-up screening and makes recommendations about addressing these problems. 
Archived articles (prior to 2009)
 
Gestational Diabetes Mellitus Diagnosed with a 2 hour, 75 g, Oral Glucose Tolerance Test and Adverse Pregnancy Outcomes Maria I. Schmidt, MD, PhD; Bruce B. Duncan, MD, PhD; Angela J. Reichelt, MD, PhD; Leandro Branchtein, MD, PhD; Maria C. Matos, MD, PhD; Adriana Costa E Forti, MD, PhD; Ethel R. Spichler, MD, PhD; Judith, M. D. C. Pousada, MD, PhD; Margareth M. Teixeira, MD, MS; Tsuyoshi Yamashita, MD for the Brazilian Gestational Diabetes Study Group. Diabetes Care, Volume 24, Number 7, July 2001

OBJECTIVE— To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes.
RESEARCH DESIGN AND METHODS— This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values ? 5.3 mmol/l (fasting), ?10 mmol/l (1 h), and ?8.6 mmol/l (2 h). WHO criteria require a plasma glucose ?7.0 mmol/l (fasting) or ?7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded.
RESULTS— Among the 4,977 women studied, 2.4% (95% CI 2.0 –2.9) presented with GDM by ADA criteria and 7.2% (6.5–7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73–2.18), preeclampsia (2.28, 1.22– 4.16), and perinatal death (3.10, 1.42– 6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06 –1.95), preeclampsia (1.94, 1.22–3.03), and perinatal death (1.59, 0.86 –2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria.
CONCLUSIONS— GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.
 
Preventing Type 2 DM: Public Health Implications For Women With a History of Gestational Diabetes Mellitus Lucinda J. England, MD, MSPH; Patricia M. Dietz, DrPH, MPH; Terry Njoroge, MPH; William M. Callaghan, MD, MPH; Carol Bruce, BSN, MPH; Rebecca M. Buus, PhD; David F. Williamson, PhD. American Journal of Obstetrics & Gynecology 2008 

There is now strong evidence that lifestyle modification can prevent or delay the development of type 2 diabetes mellitus in high-risk individuals. Women with gestational diabetes mellitus are at increased risk for type 2 diabetes and so are candidates for prevention programs. We review literature on type 2 diabetes risk in women with gestational diabetes, examine current recommendations for postpartum and long-term follow-up, and summarize findings from a 2007 expert-panel meeting. We found data to support that women with gestational diabetes have an increase in risk of type 2 diabetes comparable in magnitude with that of individuals with impaired glucose tolerance and/or impaired fasting glucose and that prevention interventions likely are effective in this population. Current recommendations from leading organizations on follow-up of women after delivery are conflicting and compliance is poor. Clinicians and public health workers face numerous challenges in developing intervention strategies for this population. Translation research will be critical in addressing this important public health issue.
 
Risk Perception for Diabetes Among Women With Histories of Gestational Diabetes Mellitus Catherine Kim, MD, MPH; Laura N. McEwen, PhD; John D. Piette, PhD; Jennifer Goewey, MHA; Assiamira Ferrara, MD, PhD; Elizabeth A. Walker PhD, RN  Diabetes Care, Volume 30, Number 9, September 2007

OBJECTIVE — To examine risk perception for diabetes among women with histories of gestational diabetes mellitus (GDM).
RESULTS — Ninety percent of women recognized that GDM was a risk factor for future diabetes, but only 16% believed that they themselves had a high chance of developing diabetes; perceived risk increased to 39% when women were asked to estimate their risk assuming they maintained their current lifestyle. Women who consumed three or more but less than five servings a day of fruits and vegetables reported lower odds of moderate/high risk perception (adjusted odds ratio [OR] 0.39 [95% CI 0.16 – 0.92]) than women who consumed less than three servings a day, although this association was not significant after further adjustment for income. Women who perceived themselves to be at moderate/high risk more often planned to modify their future lifestyle behaviors (9.1 [0.16 – 0.92]).
CONCLUSIONS — Despite understanding the association between GDM and postpartum diabetes, women with histories of GDM usually do not perceive themselves to be at elevated risk.
 
Modifiable Risk Factors for Developing Diabetes Among Women With Previous GDM Shumei Yun, MD, PhD, Nisreen H. Kabeer, MPH, Bao-Ping Zhu, MD, MS, Ross C. Brownson, PhD.  Prev Chronic Dis 2007 Jan. 

Introduction-Gestational diabetes mellitus (GDM) affects approximately 2% to 4% of all pregnant women in the United States each year. Women who have had GDM are at high risk for developing nongestational diabetes. The objective of this study was to assess the prevalence of modifiable risk factors for developing diabetes among women with previous GDM only.
Methods-Cross-sectional data for nonpregnant women from the 2003 Behavioral Risk Factor Surveillance System were used to estimate and compare the prevalence of modifiable risk factors among three groups: nonpregnant women with previous GDM only, nonpregnant women with current diabetes, and nonpregnant women without diabetes.
Results-In 2003, 7.6% of nonpregnant women aged 18 years and older in the United States had current self-reported physician-diagnosed diabetes, and 1.5% had previous GDM only. Compared with women without diabetes, women with previous GDM only had higher prevalence of no leisure-time physical activity (32.0% vs 25.7%), overweight (62.2% vs 49.0%), and obesity (29.4% vs 20.0%).
After adjusting for sociodemographic variables, women with previous GDM only were more likely to have no leisure-time physical activity (prevalence odds ratio [POR], 1.4; 95% confidence interval [CI], 1.2–1.7) and more likely to be overweight (POR, 1.8; 95% CI, 1.6–2.2) or obese (POR, 1.7; 95% CI, 1.4–2.1), compared with women with no diabetes.
Conclusion-Women with previous GDM are more likely to have modifiable risk factors for developing diabetes than women without diabetes. More attention to this issue is needed from health care providers and public health officials to encourage the promotion of healthy lifestyles during and after pregnancy.
 
Prevention, Screening and Diagnosis Articles
 
Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States Cora Peterson, PhD; Scott D. Grosse, PhD; Rui Li, PhD; Andrea J. Sharma, PhD; Hilda Razzaghi, PhD; William H. Herman, MD, MPH; Suzanne M. Gilboa, PhD.  Am J Obstet Gynecol 2015;212:74.e1-9.

OBJECTIVE: Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC) - preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.
STUDY DESIGN: Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.
RESULTS: We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.
CONCLUSION: Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.

An Early Pregnancy HbA1c $5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes Ruth C.E. Hughes, M. Peter Moore, Joanna E. Gullam, Khadeeja Mohamed, Janet Rowan. Diabetes Care Published Ahead of Print, published online September 4, 2014 

OBJECTIVE- Pregnant women with undiagnosed diabetes are a high-risk group that may benefit from early intervention. Extrapolating from nonpregnancy data, HbA1c ‡6.5% (48 mmol/mol) is recommended to define diabetes in pregnancy. Our aims were to determine the optimal HbA1c threshold for detecting diabetes in early pregnancy as defined by an early oral glucose tolerance test (OGTT) at <20 weeks’ gestation and to examine pregnancy outcomes relating to this threshold.
RESEARCH DESIGN AND METHODS-During 2008–2010 in Christchurch, New Zealand, women were offered an HbA1c measurement with their first antenatal bloods. Pregnancy outcome data were collected. A subset completed an early OGTT, and HbA1c performance was assessed using World Health Organization criteria.
RESULTS-HbA1c was measured at a median 47 days’ gestation in 16,122 women. Of those invited, 974/4,201 (23%) undertook an early OGTT. In this subset, HbA1c ‡5.9% (41 mmol/mol) captured all 15 cases of diabetes, 7with HbA1c <6.5% (<48mmol/mol). This HbA1c threshold was also 98.4% (95% CI 97–99.9%) specific for gestational diabetes mellitus (GDM) before 20 weeks (positive predictive value = 52.9%). In the total cohort, excluding women referred for GDM management, women with HbA1c of 5.9–6.4% (41–46 mmol/mol; n = 200) had poorer pregnancy outcomes than those with HbA1c <5.9% (<41 mmol/mol; n = 8,174): relative risk (95% CI) of major congenital anomaly was 2.67 (1.28–5.53), preeclampsia was 2.42 (1.34–4.38), shoulder dystocia was 2.47 (1.05–5.85), and perinatal death was 3.96 (1.54–10.16). 
CONCLUSIONS-HbA1c measurements were readily performed in contrast to the low uptake of early OGTTs. HbA1c ‡5.9% (‡41 mmol/mol) identified all women with diabetes and a group at significantly increased risk of adverse pregnancy outcomes.
 
Lack of Peri-conceptional Vitamins or Supplements Containing Folic Acid and Diabetes-associated Birth Defects Accepted manuscript: Correa, A., Gilboa, S.M., Botto, L.D., Moore, C.A., Hobbs, C.A., Cleves, M.A., Riehle-Colarusso, T.J., Waller, D.K., Reece, E.A., National Birth Defects Prevention Study. American Journal of Obstetrics and Gynecology 2011). 

OBJECTIVE: To examine the risk of birth defects in relation to lack of use of Peri-conceptional vitamins or supplements containing folic acid and diabetes.
STUDY DESIGN: The National Birth Defects Prevention Study (1997–2004), a multicenter, population-based case-control study of birth defects (14,721 case and 5,437 control infants). Cases were categorized into 18 types of heart defects and 26 non-cardiac birth defects. We estimated odds ratios for independent and joint effects of pre-existing diabetes and lack of Peri-conceptional use of vitamins or supplements containing folic acid.
RESULTS: The pattern of odds ratios suggested an increased risk of defects associated with diabetes in the absence versus the presence of Peri-conceptional use of vitamins or supplements containing folic acid.
CONCLUSIONS: Lack of Peri-conceptional use of vitamins or supplements containing folic acid may be associated with an excess risk for birth defects due to diabetes.
 
Preventing Type 2 DM: Public Health Implications For Women With a History of Gestational Diabetes Mellitus Lucinda J. England, MD, MSPH; Patricia M. Dietz, DrPH, MPH; Terry Njoroge, MPH; William M. Callaghan, MD, MPH; Carol Bruce, BSN, MPH; Rebecca M. Buus, PhD; David F. Williamson, PhD. American Journal of Obstetrics & Gynecology, 2008.

There is now strong evidence that lifestyle modification can prevent or delay the development of type 2 diabetes mellitus in high-risk individuals. Women with gestational diabetes mellitus are at increased risk for type 2 diabetes and so are candidates for prevention programs. We review literature on type 2 diabetes risk in women with gestational diabetes, examine current recommendations for postpartum and long-term follow-up, and summarize findings from a 2007 expert-panel meeting. We found data to support that women with gestational diabetes have an increase in risk of type 2 diabetes comparable in magnitude with that of individuals with impaired glucose tolerance and/or impaired fasting glucose and that prevention interventions likely are effective in this population. Current recommendations from leading organizations on follow-up of women after delivery are conflicting and compliance is poor. Clinicians and public health workers face numerous challenges in developing intervention strategies for this population. Translation research will be critical in addressing this important public health issue. 

New Study on Healthy Maternal Diet and Reduced Risks of Birth Defects October 3, 2011 online publication of the Archives of Pediatrics and Adolescent Medicine. The WIC Wire, May 2012, Volume 6, Issue 5, Utah Department of Health WIC Program.

This new study from the Stanford University School of Medicine has shown that women who ate better before and during their pregnancy gave birth to fewer infants who had anomalies of the brain and spinal cord, or orofacial clefts, such as cleft lip and cleft palate. Previous research has focused on one nutrient at a time. For example folic acid has been shown to protect against brain or spinal cord anomalies (examples are anencephaly and spina bifida). However, after fortification of the U.S. food supply with folic acid, these types of birth defects did not disappear completely. Thus, other single nutrient studies were conducted to assess possible diet - defect associations or connections.
 
Preventive Services for Women: New and Important Changes in Covered Services Rebekah E. Gee, MD, MPH.

Under the Patient Protection and Affordable Care Act of 2010 (ACA), coverage for a variety of important preventive health care services is required by new (non-grandfathered) health plans with no cost sharing as of September 23, 2010, when services are rendered by an in-network provider. However, although women's healthcare needs are widely recognized as different from those of men, no single body of recommendations specific to women's preventive services existed at the time the ACA was signed into law. As such, the law required coverage of: "with respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by [The Health Resources and Services Administration] (not otherwise addressed by the recommendations of the [U.S. Preventive Services] Task Force)."
 
A simple scoring method using cardiometabolic risk measurements in pregnancy to determine 10-year risk of type 2 diabetes in women with gestational diabetes. A. Barden, R. Singh, B. Walters, M. Phillips, and LJ Beili.  Nutrition & Diabetes (2013) 3, e72.   

OBJECTIVE: To examine if clustering of cardiometabolic risk factors in pregnancy predicts type 2 diabetes and cardiovascular disease (CVD) risk at 10 years in women with gestational diabetes mellitus (GDM).
STUDY DESIGN AND SUBJECTS: A prospective case–control study in 150 GDM and 72 overweight women with normal glucose tolerance (NGT) measured cardio-metabolic risk factors (body mass index (BMI), systolic blood pressure (SBP), fasting glucose, insulin, and triglycerides and high-density lipoprotein (HDL) cholesterol) at 28 weeks gestation and 6 months and 10 years after pregnancy. Cluster analysis of cardiometabolic risk factors in pregnancy was used to stratify GDM as ‘high’ and ‘low risk’ for diabetes and CVD risk at 10 years. The data in pregnancy were used to determine a simple method for assessing risk of future diabetes. RESULTS: BMI in the 150 GDM at study entry was similar to NGT, but 35% of GDM fell into a ‘high-risk cluster’ with elevated BMI, SBP, glucose, insulin and triglycerides and lower HDL levels. At 10 years, type 2 diabetes was sixfold higher in ‘high-risk’ GDM (odds ratio (OR) = 6.75, confidence interval (CI) = 2.0, 22.7, P=0.002) compared with ‘low-risk’ GDM and was not reported in NGT. The ‘high-risk’ cluster predicted type 2 diabetes better than BMI > 30 (OR= 2.13, CI= 0.71, 6.4, P= 0.179) or fasting glucose > 5.5 mmoll –1, (OR= 4.56, CI= 1.50, 3.85, P= 0.007). We determined that GDM with any four of the cardiometabolic risk factors (BMI > 30kgm –2, fasting glucose > 5.0mmoll –1 , insulin > 7.8 mUl –1 , triglycerides > 2.4mmoll –1 , HDL < 1.6 mmoll –1  or SBP > 105 mmHg) in pregnancy would be in a ‘high-risk’ cluster.
CONCLUSIONS: A metabolic syndrome-like cluster in pregnant GDM identifies risk for type 2 diabetes providing an opportunity to focus on rigorous lifestyle interventions after delivery to reduce the burden of disease attributed to this condition.
 
Follow-Up of Gestational Diabetes Mellitus in an Urban Safety Net Hospital: Missed Opportunities to Launch Preventive Care for Women Lois McCloskey, DrPH, Judith Bernstein, PHD, Michael winter, MPH, Ronald Iverson, MD, and Aviva Lee-Parritz, MD. Journal of Women’s Health, Volume 23, Number 4, 2014, Mary Ann Liebert, Inc. Inc.    

Background: Our study assessed the follow-up of gestational diabetes mellitus (GDM) in the postpartum period among a racially and ethnically diverse group of women receiving care in a major urban medical center.
Methods: We conducted cross-sectional analysis of clinical and administrative data on women aged 18–44 years who gave birth at Boston Medical Center (BMC) between 2003 and 2009, had GDM, and used BMC for regular care. We calculated the rate of glucose testing by 70 days and by 180 days after delivery and used logistic regression to assess the predictors of testing.
Results: By 6 months postpartum, only 23.4% of GDM-affected women received any kind of glucose test. Among these, over half had been completed by 10 weeks but only 29% were the recommended oral glucose tolerance test (OGTT). After accounting for sociodemographic and health service factors, women aged ? 35 years of age and women with a family practice provider were significantly less likely to be tested than their counterparts (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.32, 0.83 and OR 0.36; 95% CI 0.19, 0.71 respectively). Women who attended a primary care visit within 180 days after birth had three times higher odds of being tested than those without such a visit (OR 3.10; 95% CI 1.97, 4.87).
Conclusions: Despite widely disseminated clinical guidelines, postpartum glucose testing rates are exceedingly low, marking a critical missed opportunity to launch preventive care for women at high risk of type 2 DM. Failed follow-up of GDM by providers of prenatal and postpartum care also reflects a broader systems failure: the absence of a well-supported transition from pregnancy care to ongoing primary care for women.

 

Care and Treatment Articles

Current Standards of Care for Diabetes, January 2013, Diabetes Care Supplement http://care.diabetesjournals.org/content/36/Supplement_1.toc

Contains all the current standards of care for diabetes, and several interesting articles. There is no charge to download the articles in the supplement. The American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many years. These statements are published in one or more of the Association's professional journals. This supplement contains the latest update of the ADA's major position statement, “Standards of Medical Care in Diabetes,” which contains all of the Association's key recommendations. In addition, contained herein are selected position statements on certain topics not adequately covered in the “Standards.” ADA hopes that this is a convenient and important resource for all health care professionals who care for people with diabetes.
 
Obese Women with Diabetes May Need Different Workouts Than Men Health News Copyright © 2013 HealthDay. All rights reserved.

Small study found specific exercise program did less to improve their health (HealthDay News) -- Certain exercises that benefit the hearts of obese men with type 2 diabetes may not help women with the same health issues, according to a small new study.  The findings could help researchers and health care professionals develop targeted exercise routines for these women, the study authors said.  The investigators examined the cardiovascular responses -- such as heart rate and blood pressure – of about 75 obese men and women with diabetes.   
 
The Hyperglycemia and Adverse Pregnancy Outcome Study: Associations of GDM and obesity with pregnancy outcomes Patrick M. Catalano, MD; H. David McIntyre, MD; J. Kennedy Cruickshank, MD; David R, McCance, MD; Alan R. Dyer, PHD; Boyd E. Metzger, MD; Lynn P. Lowe, PHD; Elisabeth R. Trimble, MD; Donald R. Coustan, MD; David R. Hadden, MD; Bengt Persson, MD, PHD; Moshe Hod, MD; Jeremy J.N. Oats, MD; for the HAPO Study Cooperative  Research Group

OBJECTIVE - To determine associations of gestational diabetes mellitus (GDM) and obesity with adverse pregnancy outcomes in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study.
RESEARCH DESIGN AND METHODS - Participants underwent a 75-g oral glucose tolerance test (OGTT) between 24 and 32 weeks. GDM was diagnosed post hoc using International Association of Diabetes and Pregnancy Study Groups criteria. Neonatal anthropometrics and cord serum C-peptide were measured. Adverse pregnancy outcomes included birth weight, newborn percent body fat, and cord C-peptide > 90th percentiles, primary cesarean delivery, preeclampsia, and shoulder dystocia/birth injury. BMI was determined at the OGTT. Multiple logistic regression was used to examine associations of GDM and obesity with outcomes.
RESULTS - Mean maternal BMI was 27.7, 13.7% were obese (BMI 33.0 kg/m2), and GDM was diagnosed in 16.1%. Relative to non-GDM and non-obese women, odds ratio for birth weight > 90th percentile for GDM alone was 2.19 (1.93 – 2.47), for obesity alone 1.73(1.50 – 2.00), and for both GDM and obesity 3.62 (3.04 – 4.32).  Results for primary cesarean delivery and preeclampsia and for cord C-peptide and new born percent body fat > 90th percentiles were similar. Odds for birth weight > 90th percentile were progressively greater with both higher OGTT glucose and higher maternal BMI. There was a 339-g difference in birth weight for babies of obese GDM women, compared with babies of normal/underweight women (64.2% of all women) with normal glucose based on a composite OGTT measure of fasting plasma glucose and 1- and 2-h plasma glucose values (61.8% of all women).
CONCLUSIONS - Both maternal GDM and obesity are independently associated with adverse pregnancy outcomes. Their combination has a greater impact than either one alone.

Gestational diabetes and pregnancy outcomes - a systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria. Eliana M Wendland, Maria R Torloni, Maicon Falavigna, Janet Trujillo, Maria A Dode, Maria A Campos, Bruce B Duncan, Maria I Schmidt. BMC Pregnancy and Childbirth 2012, 12:23.

Background - Two criteria based on a 2h75g OGTT are being used for the diagnosis Of gestational diabetes (GDM), those recommended over the years by The World Health Organization (WHO), and those recently recommended by the International Association for Diabetes in Pregnancy Study Group (IADPSG), the latter generated in the HAPO Study and based on pregnancy outcomes. Our aim is to systematically Review the evidence for the associations between GDM (according to these criteria) and adverse outcomes.
Methods - We searched relevant studies in MEDLINE, EMBASE, LILACS, the Cochrane Library, CINHAL, WHO -  Afro library, IMSEAR, EMCAT, IMEMR and WPRIM. We included cohort studies permitting the evaluation of GDM diagnosed by WHO and or IADPSG criteria against adverse maternal and perinatal outcomes in untreated women. Only studies with universal application of a 75 g OGTT were included. Relative risks (RRs) and their 95% confidence intervals (CI) were obtained for each study.  We combined study results using a random – effects model. Inconsistency across studies was defined  by an inconsistency index (I 2 ) >50%.
Results-Data were extracted from eight studies, totaling 44,829 women. Greater risk of adverse outcomes was observed for both diagnostic criteria. When using the WHO criteria, consistent associations were seen for macrosomia (RR = 1.81; 95%CI 1.47 - 2.22; p < 0.001); large for gestational age (RR = 1.53; 95%CI 1.39 - 1.69; p < 0.001); perinatal mortality (RR = 1.55; 95% CI 0.88 - 2.73; p = 0.13); preeclampsia (RR = 1.69; 95%CI 1.31 - 2.18; p < 0.001); and cesarean delivery (RR  = 1.37;95%CI 1.24 - 1.51;  p < 0.001). Less data were available for the IADPSG criteria, and associations were inconsistent across studies (I2>73%). Magnitudes of RRs and their 95% CI’s were 1.73 (1.28 - 2.35; p = 0.001) for large for gestational age; 1.71 (1.38 - 2.13; p < 0.001) for preeclampsia; and 1.23 (1.01 -
1.51; p = 0.04) for cesarean delivery. Excluding either the HAPO or the EBDG studies minimally altered these associations, but the RRs seen for the IADPSG criteria were reduced after excluding HAPO. Conclusions-The WHO and the IADPSG criteria for GDM identified women at a small increased risk for adverse pregnancy outcomes. Associations were of similar magnitude for both criteria. However, high inconsistency was seen for those with the IADPSG criteria. Full evaluation of the latter in settings other than HAPO requires additional studies.
 
Weight Gain in Pregnancy: Is Less Truly More for Mother and Infant?  Linda A. Barbour, MD, MSPH Obstetric Medicine 2012; 5: 58-64. 

Although more than 50% of women gain weight above the Institute of Medicine (IOM) guidelines for weight gain in pregnancy and excessive weight gain is an independent risk factor for significant maternal and neonatal morbidity and offspring obesity, there is little consensus over the ideal weight gain during pregnancy. Surprisingly, the 2009 IOM guidelines varied minimally from the 1990 IOM guidelines, and many critics advocate lower weight gain recommendations. This review explores the energy costs of pregnancy, the relationship between gestational weight gain and birth weight, and considers what gestational weight gain minimizes both large-for-gestational age as well as small-for-gestational age infants. An extensive examination of the current data leads this author to question whether the current weight gain recommendations are too liberal, especially for obese pregnant women.
 
Gestational Diabetes and Hypertensive Disorders of Pregnancy as Vascular Risk Signals: An Overview and Grading of the Evidence Nerenberg K, Daskalopoulou SS, Dasgupta K. Can J Cardiol. 2014 Jul;30(7):765-773.

The occurrence of common pregnancy-related medical disorders identifies women at high risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, and preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the 2-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance surveillance of vascular risk factors in these women after pregnancy is underappreciated by the women themselves and their physicians. Although a prudent diet and physically active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low; qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.
 
The Clinical Approach to Obesity in Pregnancy Overcash RT1, Lacoursiere DY. Clin Obstet Gynecol. 2014 Jul 11

Over one third of reproductive age women are obese, and this marked prevalence is impacting pregnancy. Obese women face many challenges from preconception to postpartum. They are at increased risk for both maternal and fetal complications including gestational diabetes, hypertension, preeclampsia, congenital anomalies, stillbirth, fetal macrosomia, cesarean delivery, venous thromboembolism, wound complications, breast-feeding difficulty, postpartum depression, postpartum weight retention, and neonatal death. This discussion is designed to help clinicians understand how obesity affects pregnancy, how to counsel patients regarding gestational weight gain, and how to implement management strategies during pregnancy to optimize health outcomes for these patients.

Living with gestational diabetes in a rural community. Abraham K, Wilk N. Am J Matern Child Nurs. 2014 Jul-Aug;39(4):239-45.

PURPOSE: To explore the lived experiences of women with a recent history of gestational diabetes mellitus (GDM) who live in rural communities.
STUDY DESIGN AND METHODS: A phenomenological study exploring the lived experiences of 10 women aged 25 to 49 years with a history of GDM in the last 5 years. Data were collected through two semi structured short interviews that were conducted in person or by telephone.
RESULTS: Five themes emerged: Authentic emotion, Judgment, It's only a matter of time, I can't do this alone, and Missed opportunities. Strong emotions were experienced at the time of diagnosis. Some women felt judged by healthcare professionals and others based on having GDM. Some were concerned about future risk of developing Type 2 DM. There is a lack of understanding of GDM by women at the time of diagnosis and after they give birth. The majority of women in this study noted that healthcare professionals did not discuss future implications of Type 2 DM and the need for follow- up glucose testing. Many opportunities are missed to provide education and support to facilitate lifestyle interventions.
CLINICAL NURSING IMPLICATIONS: Self-management of GDM is more likely to be successful if women understand GDM and believe that they can manage it. Nurses should use every opportunity to provide women with GDM information and available resources. This may be important in rural communities where fewer resources are available for support. Nurses should recognize that negative emotions may affect motivation of women to understand and ask questions about GDM. Nurses can favorably influence the return rates for postpartum glucose testing by raising awareness of implications of GDM on future health.
 
Postpartum Care Articles
 
Identifying Postpartum Intervention Approaches to Reduce  Cardiometabolic Risk Among American Indian Women With Prior Gestational Diabetes, Oklahoma, 2012–2013 Emily J. Jones, PhD, RNC-OB; Michael Peercy, MPH, MT(ASCP)H; J. Cedric Woods, PhD; Stephany P. Parker, PhD; Teresa Jackson, MS, RD, LD; Sara A. Mata, PhD; Shondra McCage, MPH; Sue E. Levkoff, ScD, SM, MSW; Jacinda M. Nicklas, MD, MPH, MA; Ellen W. Seely, MD 

Introduction-Innovative approaches are needed to reduce cardiometabolic risk among American Indian women with a history of gestational diabetes. We assessed beliefs of Oklahoma American Indian women about preventing type 2 diabetes and cardiovascular disease after having gestational diabetes. We also assessed barriers and facilitators to healthy lifestyle changes postpartum and intervention approaches that facilitate participation in a postpartum lifestyle program.
Methods-In partnership with a tribal health system, we conducted a mixed method study with American Indian women aged 19 to 45 years who had prior gestational diabetes, using questionnaires, focus groups, and individual interviews. Questionnaires were used to identify women’s cardiometabolic risk perceptions and feasibility and acceptability of Internet or mobile phone technology for delivery of a postpartum lifestyle modification program. Focus groups and individual interviews were conducted to identify key perspectives and preferences related to a potential program.
Results-Participants were 26 women, all of whom completed surveys; 11 women participated in focus group sessions, and 15 participated in individual interviews. Most women believed they would inevitably develop diabetes, cardiovascular disease, or both; however, they were optimistic that they could delay onset with lifestyle change. Most women expressed enthusiasm for a family focused, technology-based intervention that emphasizes the importance of delaying disease onset, provides motivation, and promotes accountability while accommodating women’s competing priorities.
Conclusions-Our findings suggest that an intervention that uses the Internet, text messaging, or both and that emphasizes the benefits of delaying disease onset should be tested as a novel, culturally relevant approach to reducing rates of diabetes.
 
A1c Testing May Fail to Spot Post-Partum Diabetes Mellitus - This article originally posted 26 July, 2012 and appeared in Women's Health and OB-GYN Issue 636  Diabetes Care June, 2012. 
 
Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse-Midwives. Jean Y. Ko, PhD, Patricia M. Dietz, DrPH, Elizabeth J. Conrey, RD, PhD, Loren Rodgers, PhD, Cynthia Shellhaas, MD, MPH, Sherry L. Farr, PhD, Cheryl L. Robbins.  J Midwifery Womens Health 2013;00:1–8. 

Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement.
Methods: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening.
Results: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight  / obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care.
Discussion: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.
 
A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes. Vesco KK, Dietz PM, Bulkley J, et al.  Am J Obstet Gynecol 2012;207:283.e1-6.

OBJECTIVE: We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM).
STUDY DESIGN: In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n =179) and July 2007 through June 2008 (n = 200).
RESULTS: After the program’s implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P = .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07–1.75).
CONCLUSION: Rates of postpartum diabetes testing can be improved with system changes and reminders.
 
The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes? A.K. Shea, PhD, MSc; B.R. Shah, MD, PhD; H.D. Clark, MD, MSc; J. Malcolm, MD; M. Walker, MD, MSc; A. Karovitch, MD, MEd; E.J. Keely, MD Vol 31, No 2, March 2011 – Chronic Diseases in Canada 

Introduction: During regular care, women with previous gestational diabetes mellitus (GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral glucose tolerance test (OGTT), in the postpartum period. The current study examined whether the implementation of a reminder system improved screening rates. 
Methods: Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery. 
Results: Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%). 
Conclusion: Although the screening rates remain low, postpartum reminders doubled screening rates using the recommended test, the OGTT. 

Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus. Marina Stasenko, BA; Jennifer Liddell, RN, CDE; Yvonne W. Cheng, MD, MPH; Teresa N. Sparks, MD; Molly Killion, RN; Aaron B. Caughey, MD, PhD. American Journal of Obstetrics & Gynecology June 2011

OBJECTIVE: The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM).
STUDY DESIGN: A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.
RESULTS: The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort (P < .001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P < .001), Latinas (15% to 50%, P < .001), and Asians (43% to 59%, P = .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% (P = .414).
CONCLUSION: GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.

Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon. Hunsberger ML, Donatelle RJ, Lindsay K, Rosenberg KD (2012) Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon. PLoS ONE 7(10): e47052. doi:10.1371/journal.pone.0047052.  

Objective: This study examines obstetrician/gynecologists and family medicine physicians’ reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus.
Research Design and Methods: In November–December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician / gynecologists and family medicine from a population of 2171.
Results: Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69–7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65–11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.
Conclusions: Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.

Window of Opportunity: Postpartum Screening of Women with Gestational Diabetes for Early Detection of Prediabetes and Type 2 Diabetes. Cassandra E. Henderson, Jan Kavookjian, Harris Leitstein, June M. McKoy, Wambui Jane Murage, and Ruth d. Lipman The Open Diabetes Journal, 2012, 5, 25-28.

Abstract: Gestational diabetes is a condition characterized by glucose intolerance during pregnancy, with defined approaches for screening, treatment, and follow-up. It is associated with a variety of adverse birth outcomes, including excessive fetal weight gain and related increases in the rate of cesarean delivery and perinatal injury as well as increased risk for developing type 2 diabetes for women who have had gestational diabetes. A diagnosis of gestational diabetes may also be a manifestation of pre-existing type 2 diabetes. Nonetheless, a substantial proportion of women with a history of gestational diabetes fail to receive the recommended postpartum glucose screening. This failure to conduct follow-up screening of women with gestational diabetes after delivery represents a missed opportunity for earlier diagnosis of diabetes, and chance to increase the awareness of women of their future risk for developing diabetes. This paper explores the barriers contributing to the lack in follow-up screening and makes recommendations about addressing these problems. 
 
Prevention of Diabetes after Gestational Diabetes: Better Translation of Nutrition and Lifestyle Messages Needed Sharleen L. O’Reilly, Centre for Physical Activity and Nutrition Research, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia; E-Mail: sharleen.oreilly@deakin.edu.au; Tel.: +61-3-9244-6778; Fax: +61-3-9244-4219. External Editor: Samir Samman and Ian Darnton-Hill.  Received: 28 July 2014; in revised form: 14 October 2014 / Accepted: 10 November 2014 / Published: 21 November 2014

Abstract: Type 2 Diabetes Mellitus (T2DM) and Gestational Diabetes (GDM) are important and escalating problems worldwide. GDM increases the risk of complications in pregnancy and birth, as well as a 1 in 2 chance of developing T2DM later in life. The burden of GDM extends to offspring, who have an increased risk of obesity and diabetes—further perpetuating the cycle of diabetes within families. Clinical trial evidence demonstrates T2DM incidence reduced by up to 50% for women with GDM with nutrition and physical activity changes and the economic modeling suggests cost effectiveness. The key diet-related changes to reduce T2DM risk are reviewed, in addition to breastfeeding. The difficulties associated with the delivery of dietary and lifestyle behaviour change to women after GDM are discussed and focus on: complex healthcare system interactions needed for care delivery; women finding postpartum self-care challenging; and low levels of awareness being present across the board. In addition, studies currently underway
 
Reimbursement and Economic Impact Articles
 

Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States Cora Peterson, PhD; Scott D. Grosse, PhD; Rui Li, PhD; Andrea J. Sharma, PhD; Hilda Razzaghi, PhD; William H. Herman, MD, MPH; Suzanne M. Gilboa, PhD.  Am J Obstet-Gynecol 2015; 212:74.e1-9.

OBJECTIVE: Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC) - preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM in the United States. 
STUDY DESIGN: Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.
RESULTS: We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.
CONCLUSION: Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.
 
Gestational diabetes screening with the new IADPSG guidelines: a cost-effectiveness analysis  John F. Mission, MD; Mika S. Ohno, MD; Yvonne W. Cheng, MD, MPH; Aaron B. Caughey, MD, PhD   American Journal of Obstetrics & Gynecology October 2012

Preventive Services for Women: New and Important Changes in Covered Services  Rebekah E. Gee MD, MPH Diabetes Care 35:529-535, 2012
Screening for Gestational Diabetes Mellitus: Are the Criteria Proposed by the International Association of the Diabetes and Pregnancy Study Groups cost-effective?
Erika F. Werner, MD, MS; Christian M. Pettker, MD; Lisa Zuckerwise, MD; Michael Reel, MD, MBA; Edmund F. Funai, MD; Janice Henderson, MD; Stephen F. Thung, MD
CONCLUSIONS: The IADPSG recommendation for glucose screening in pregnancy is cost effective. The model is most sensitive to the likelihood of preventing future diabetes in patients identified with GDM using post delivery counseling and intervention.
 
Public Health, Population Health and Health Equity Articles
 
Racial differences in gestational age specific neonatal morbidity: further evidence for different gestational Loftin, R., Chen, A., Evans, A., Defranco, E.  American Journal of Obstetrics and Gynecology (2011), doi:10.1016/j.ajog.2011.12.017.

The effect of race/ethnicity on adverse perinatal outcomes among patients with gestational diabetes mellitus. Brian T. Nguyen, MD; Yvonne W. Cheng, MD, PhD; Jonathan M. Snowden, PhD; Tania F. Esakoff, MD; Antonio E. Frias, MD; Aaron B. Caughey, MD, PhD  OCTOBER 2012 American Journal of Obstetrics & Gynecology

The effect of race/ethnicity on adverse perinatal outcomes among patients with gestational diabetes mellitus Brian T. Nguyen, MD; Yvonne W. Cheng, MD, PhD; Jonathan M. Snowden, PhD; Tania F. Esakoff, MD; Antonio E. Frias, MD; Aaron B. Caughey, MD, PhD 

Hidden Metabolic Disturbances in Women with Normal Glucose Tolerance Five Years after Gestational Diabetes Yvonne Winhofer, Andrea Tura, Anita Thomas, Thomas Prikoszovich, Christine Winzer, Giovanni Pacini, Anton Luger, and Alexandra Kautzky-Willer. International Journal of Endocrinology, Volume 2015, Article ID 342938.  

Background. The study aimed to assess whether women with prior gestational diabetes (pGDM), despite maintenance of normal glucose tolerance (NGT) five years after delivery, display metabolic disturbances compared to healthy controls.
Methods. 45pGDM with NGT were compared to 18 women without a history of GDM (CON), matched for age (37.0 ± 4.1 versus 35.2 ± 5.3, = ns) and BMI (24.3 ± 3.1 versus 23.3 ± 3.3, ?? = ns). Metabolic parameters were derived from oral and intravenous glucose tolerance tests; furthermore lipid profile, C-reactive protein (CRP), adiponectin, leptin, and glucagon were assessed.
Results. Five years postpartum, pGDM had increased glucose concentrations during the OGTT (AUC: 1.12 ± 0.15 versus 1.0 ± 0.12mol/L ? min, ?? = 0.003) and insulin sensitivity was decreased compared to CON (OGIS: 467.2 ± 64.1 versus 510.6 ± 53.1 mL/min ? m2, ?? = 0.01). pGDM had lower adiponectin (8.1 ± 2.6 versus 12.6 ± 5.3, ?? < 0.008) but increased waist circumference and CRP compared to CON.
Conclusions. Despite diagnosis of normal glucose tolerance, pGDM are characterized by hyperglycemia and insulin resistance compared to healthy controls, accompanied by decreased adiponectin and increased CRP concentrations, thus linking metabolic disturbances to an increased cardiovascular risk in pGDM.
 
Gestational diabetes: The public health relevance and approach Balaji Vijayam, Vitull K. Gupta, Anil Kapura, Dr V. Seshiah; Diabetes Research and Clinical Practice 97 m(2012)
 
Analysis of Pregnancy Outcomes Using the New IADPSG Recommendation Compared with the Carpenter and Coustan Criteria in an Area with a Low Prevalence of Gestational Diabetes Katrien Benhalima, Myriam Hanssens, Roland Devlieger, Johan Verhaeghe, and Chantal Mathieu; Hindawi Publishing Corporation  International Journal of Endocrinology Volume 2013, Article ID 248121

 

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