Postpartum Diabetes Testing Research Articles

Postpartum Glucose Tolerance Testing Among Patients With Gestational Diabetes During the Coronavirus Disease 2019 Pandemic.

Introduction The impact of the coronavirus disease (COVID-19) COVID-19 pandemic on the care of pregnant patients with gestational diabetes (GDM)is largely unreported. The objective of this study was to compare the completion of postpartum oral glucose tolerance testing (GTT) prior to and during the COVID-19 pandemic among patients with GDM. Methods This was a retrospective review of patients diagnosed with GDM between April 2019 and March 2021. Medical records of patients diagnosed with GDM prior to and during the pandemic were compared. The primary outcome was the difference in the completion of postpartum GTT prior to and during the COVID-19 pandemic. Completion was defined as testing between four weeks to six months postpartum. Secondary objectives were: 1) to compare maternal and neonatal outcomes prior to and during the pandemic among patients with GDM, and 2) to compare pregnancy characteristics and outcomes by compliance with postpartum GTT. Results There were 185 patients included in the study, of whom 83 (44.9%) delivered prior to the pandemic and 102 (55.1%) delivered during the pandemic. There was no difference in completion of postpartum diabetes testing prior,compared to during the pandemic (27.7% vs 33.3%, p=0.47). Postpartum diagnosis of pre-diabetes and type two diabetes mellitus (T2DM) did not differ between groups (p=0.36 and p=1.00, respectively). Patients who completed postpartum testing were less likely to have preeclampsia with severe features compared to patients who did not (OR 0.08, 95% CI 0.01-0.96,p=0.02). Conclusion Completion of postpartum testing for T2DM remained poor prior to and during the COVID-19 pandemic. These findings underscore the need for the adoption of more accessible methods of postpartum testing for T2DM among patients with GDM.

1118 Characteristics of patients with gestational diabetes that follow up postpartum for type 2 diabetes testing

To identify characteristics of patients with gestational diabetes mellitus that follow up postpartum for type 2 diabetes mellitus testing. Case-control study of patients with GDM who delivered at a single site from 2011 to 2019. Cases were defined as patients with recent pregnancy with GDM who followed up for a postpartum type 2 diabetes testing, done with 2h oral glucose tolerance testing (OGTT) at 6 weeks postpartum. Controls were patients with recent pregnancy with GDM who did not follow up for postpartum OGTT. Bivariable analyses and multivariable logistic regression were used to identify factors independently associated with postpartum 2h OGTT follow up. Of 930 patients included in the analysis, 236 (25.4%) followed up for a postpartum 2h OGTT. Patients who followed up were more likely to be non-Hispanic white, have a lower BMI both earlier in pregnancy and at the time of delivery, be nulliparous, identify as married and deliver at a later gestation (Table 1). After controlling for confounders, Hispanic ethnicity was least likely to follow-up (aOR 0.23, 95% CI 0.07-0.83) and married status (aOR 1.88, 95% CI 1.0-3.54) was associated with a postpartum follow up for a 2h OGTT (Table 2). In patients who did follow up, 65.4% of the 2h OGTT were normal. Only a quarter of patients with GDM followed up for a 6-week postpartum diabetes testing with 2h OGTT. Married status had higher odds of follow-up and Hispanic ethnicity were least likely to follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Postpartum Diabetes Testing Rates after Gestational Diabetes Mellitus in Canadian Women: A Population-Based Study.

We assessed the rate and type of postpartum glycemic testing in women with impaired glucose tolerance of pregnancy (IGTp) and gestational diabetes mellitus (GDM). We examined whether the likelihood of testing was modulated by patients' characteristics and pregnancy outcomes. Our population-level cohort study included data from 132,905 pregnancies between October 1, 2008, and December 31, 2011, in Alberta, Canada. Laboratory data within 270 days before and 1 year after delivery were used to identify pregnancies involving IGTp/GDM and postpartum glycemic testing, respectively. Logistic regression was used to identify maternal and pregnancy factors associated with postpartum testing. A total of 8,703 pregnancies were affected by IGTp (n=3669) or GDM (n=5034) as defined by the prevailing Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. By 1 year postpartum, 55.1% had undergone glycemic assessments. Of those, 59.7% had had 75 g oral glucose tolerance tests, 17.4% had had glycated hemoglobin tests without oral glucose tolerance tests and 22.9% had had only fasting or random glucose tests. Women with IGTp or GDM, respectively, who were younger, smokers and residing in rural areas and whose labours were not induced were less likely to be tested postpartum. Having large for gestational age infants was also associated with a lower likelihood of postpartum testing in women with GDM. Despite a universal health-care system in Canada, many women with IGTp or GDM do not undergo postpartum glucose testing. Maternal and pregnancy characteristics influence postpartum testing and provide valuable information for creating targeted strategies to improve postpartum testing in this group of high-risk women.

Interventions to Improve Rate of Diabetes Testing Postpartum in Women With Gestational Diabetes Mellitus.

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. In the USA, four million women are screened annually for GDM in pregnancy in part to improve pregnancy outcomes but also because diagnosis predicts a high risk of future type 2 diabetes mellitus (T2DM). Therefore, among women with GDM, postpartum care should be focused on T2DM prevention. This review describes the current literature aimed to increase postpartum diabetes testing among women with GDM. Data suggest that proactive patient contact via a health educator, a phone call, or even postal mail is associated with higher rates of postpartum diabetes testing. There may also be utility to changing the timing of postpartum diabetes testing. Despite the widespread knowledge regarding the importance of postpartum testing for women with GDM, testing rates remain low. Alternative testing strategies and large randomized trials addressing postpartum testing are warranted.

Women's views on postpartum testing for type 2 diabetes after gestational diabetes: Six month follow-up to the DIAMIND randomised controlled trial

BackgroundThis study assessed the views of the women who participated in the DIAMIND randomised trial of postpartum SMS reminders to test for type 2 diabetes after gestational diabetes (GDM) on their preferred type of postpartum reminder system and barriers and facilitators to completion of postpartum diabetes testing. MethodA written questionnaire was sent to women with recent GDM who participated in the DIAMIND trial (n=276) via post or email at six months after the birth of their baby. Results208 women (75%) returned the study questionnaires. Preferred postpartum reminder types were: SMS (67%), email (17%), postal (12%) and voice call (1%). Women who had not yet completed an OGTT indicated that they planned to undertake one in the future (61%). Common barriers to postpartum OGTT completion included: not having enough time (73%), inadequate childcare (30%), and a need to focus on the health of the baby (30%). The most common facilitator was having a shorter test (33%). ConclusionsImproved childcare quality and access as well as more research into a shorter, more convenient test procedure for type 2 diabetes screening are needed. Reminder systems for postpartum diabetes screening should be electronic where possible.

The discordance between HbA1c and glucose tolerance testing for the postpartum exclusion of diabetes following gestational diabetes

AimsTo assess the concordance between the HbA1c and the oral glucose tolerance test (OGTT) for the diagnosis of diabetes and prediabetes following gestational diabetes (GDM) in an ethnically diverse population. MethodsWomen with GDM underwent a concurrent OGTT and HbA1c test 6–12 weeks postpartum. ResultsThere were 114 women with GDM who had a 75g 2-h OGTT and HbA1c at 9.0±3.2 weeks postpartum. Five subjects had diabetes using OGTT criteria, and 4 by HbA1c criteria. No subjects had diabetes on both criteria. The overall concordance between the OGTT and HbA1c for the diagnosis of diabetes, prediabetes, or normal glucose tolerance was only 54% (κ coefficient 0.058, p=0.41). Gravidity, the 2-h glucose level on the OGTT during pregnancy, and the 3rd trimester HbA1c predicted discordance between the postpartum OGTT and HbA1c. ConclusionsThere is poor concordance between the OGTT and HbA1c for the diagnosis of diabetes and prediabetes following GDM. This reflects that the two tests measure different aspects of dysglycemia. In the post-GDM population, the HbA1c misses cases of diabetes as identified by the OGTT. We recommend that the OGTT be retained for postpartum diabetes testing following GDM.

Understanding Why Some Women with a History of Gestational Diabetes Do Not Get Tested for Diabetes

BackgroundThe proportion of women with previous gestational diabetes mellitus (GDM) receiving postpartum diabetes testing is far less than desired. Even in health care systems with high testing rates, some women remain untested. We explored what helps and what hinders women to obtain recommended testing. MethodsIn this mixed methods study, we recruited 139 patients with a history of GDM in their most recent pregnancy (6 months to 4.5 years before study enrollment) from a delivery system that had instituted a quality improvement program to increase postpartum diabetes testing rates. We determined whether they had received a postpartum diabetes test according to American Diabetes Association guidelines. Using survey data, we ran logistic regression models to assess correlates of testing status, and we conducted in-depth interviews with 22 women to provide greater context to their survey responses. ResultsOf the 139 women, 21 women (15%) did not complete recommended diabetes testing. From the survey data, women who visited a primary care provider had 72% (95% CI, 0.09–0.83) lesser odds of not having been tested. From the qualitative interviews, difficulty fitting testing around work and caregiver demands were the most common reasons for not testing. Untested women interpreted providers' reassurances that diabetes would resolve after delivery and lack of reminders to reschedule missed appointments and to complete diabetes testing as indicators that their physicians were not concerned about their diabetes risk. ConclusionsAmong hard-to-reach women, multiple demands on their time were common explanations for not receiving a postpartum diabetes test. Consistent messages regarding long-term diabetes risk during pregnancy, access to postpartum primary care and convenient lab appointments, and systematic reminders to providers and patients are approaches that, in combination, may influence more resistant women to test.

Risk Factors for Poor Compliance With Postpartum Oral Glucose Tolerance Testing in Women With Gestational Diabetes Mellitus

INTRODUCTION: Women with gestational diabetes mellitus (GDM) are at increased risk to develop overt diabetes; however, compliance with the postpartum 75-g oral glucose tolerance test (OGTT) is poor. We assessed rates of postpartum OGTT compliance at our institution and identified risk factors for the suspected poor compliance. METHODS: We performed a retrospective cohort study of singleton pregnancies with GDM who delivered at Columbia University Medical Center in 2011. Women were identified from institutional databases; data were abstracted from electronic medical records. Women with postpartum OGTT testing were compared with women without, and characteristics of these two groups—insurance status, parity, race, body mass index, and a history of prior GDM—were compared using χ2, Fisher's exact test, and Student's t test where appropriate. We also examined causes for noncompliance. RESULTS: Of the 6,272 women identified, 235 patients had GDM (4%). Of those, 21% had a postpartum OGTT (n=50). When compliant and noncompliant patients were compared, no significant differences existed in insurance status, age, race, parity, body mass index, or history of GDM. Privately insured patients were more likely to attend their postpartum visit than publicly insured patients (94% compared with 82%, P=.01). Patients who attended their postpartum visit were ordered for (63% compared with 53%, P=.19) and obtained postpartum OGTT (29% compared with 22%, P=.31) at similar rates. CONCLUSIONS: Compliance rates for postpartum diabetes testing are low. Regardless of compliance, the majority of women attended their postpartum visit; however, they were either not ordered a postpartum OGTT or failed to obtain it. These data are useful to develop a program targeting methods to increase compliance.

Postpartum Diabetes Testing Among Women with Recent Gestational Diabetes Mellitus: PRAMS 2009–2010

The objective of this study was to estimate rates of and factors associated with postpartum diabetes testing in women with recent gestational diabetes mellitus (GDM). Secondary data analysis was conducted using data from the 2009 and 2010 Pregnancy Risk Assessment Monitoring System from three states and one city (Colorado, Minnesota, Utah, and New York City). Frequency of postpartum diabetes testing was estimated overall and among women who attended a postpartum visit. Multivariable logistic regression was used to determine factors associated with postpartum diabetes testing. Approximately 8.2% [95% confidence interval (CI) 7.5-8.9] of women self-reported a history of GDM (n = 829), of which 48.5% (43.9-53.1) reported being tested for diabetes postpartum. Among the 90.0% (86.5-93.4) of women with recent GDM who attended the postpartum visit, 51.7% (46.1-57.2) reported being tested for diabetes postpartum. Women who received inadequate/intermediate prenatal care were half as likely to report postpartum testing compared with women who received adequate prenatal care [odds ratio 0.45 (95% CI 0.25-0.83)]. Women with a prepregnancy body mass index classified as obese were over twice as likely to report postpartum testing compared to normal weight women. Women with GDM are at increased risk of persistent glucose intolerance after delivery, yet postpartum testing rates remain around 50%, regardless of attendance to the postpartum visit. Improving adequacy of prenatal care might further increase postpartum testing rates. Continued efforts to translate postpartum testing into practice are needed among these women at risk for future type 2 diabetes.

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse‐Midwives

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. 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. 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. 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

We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM). 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). 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). Rates of postpartum diabetes testing can be improved with system changes and reminders.

Missed Opportunities for Type 2 Diabetes Testing Following Gestational Diabetes

Gestational diabetes mellitus (GDM) is a potent risk factor for type 2 diabetes. It occurs in about 4% of pregnant women. Nearly 1 in 5 women with GDM are affected by type 2 diabetes within 9 years after parturition. Previous studies have shown that a minority of women are tested for type 2 diabetes during the postpartum period. It is unclear from previous studies whether women are having postpartum ambulatory physician care visits, whether such testing is being offered at these visits, or how they are being counseled regarding the risk for type 2 diabetes and the need for testing. This retrospective population-based cohort study evaluated long-term trends for postpartum diabetes testing between women with and without GDM and also evaluated postpartum ambulatory physician care for women who had been diagnosed with GDM. Administrative health care databases were used to identify matching groups of women with and without GDM who delivered between 1994 and 2008 in Ontario. Among the 1,673,469 births occurring during the study period, 47,691 (2.8%) were complicated by GDM. The proportion of women with GDM receiving a postpartum oral glucose tolerance test (OGTT) within 6 months after parturition was determined, stratified by the specialty of the ordering physician. In addition, ambulatory care visits by all women with GDM to physicians from various specialties were recorded for up to 6 months after parturition. Fewer than 1 in 6 women had received a postpartum OGTT by the end of the study period. Although the absolute proportion of women with GDM tested increased slowly during the 14 years of observation (approximately 0.8% per year), less than 40% received any kind of test that might be used to diagnose diabetes mellitus, and less than 20% received an OGTT. There was no change in testing among women without GDM. Nearly all women with GDM (94%–97%) had postpartum ambulatory care visits to a family physician or obstetrician during the study, but less than 5% had an OGTT ordered by one of these physicians. These findings show that few women with GDM receive the recommended diabetes test within 6 months after parturition. The absence of testing despite postpartum ambulatory physician visits by virtually all these women represents a missed opportunity to diagnose diabetes in a high-risk population.

Missed opportunities for type 2 diabetes testing following gestational diabetes: a population‐based cohort study

Few women with gestational diabetes (GDM) are tested for type 2 diabetes in the postpartum period. Whether women are having physician visits that could be an opportunity to improve testing rates is unknown. This study sought to evaluate population-level trends in postpartum diabetes testing after GDM, and to evaluate postpartum physician care for these women. Population-based cohort study. Ontario, Canada. Women who delivered between 1994 and 2008. Using population-level healthcare databases, we identified 47,691 women with GDM. They were matched to women without GDM. An oral glucose tolerance test (OGTT) within 6 months postpartum, the specialty of the physician ordering the test, and ambulatory care visits with physicians from various specialties within 6 months postpartum were recorded. Most women with GDM did not receive an OGTT, although testing rates increased slowly over the 14 years of the study, compared with no change in testing for women who had not had GDM. Virtually all women with GDM had postpartum visits with a family physician or obstetrician, but few OGTTs were ordered by physicians from these specialties. Despite a slow increase in testing over time and high rates of postpartum visits to family physicians and obstetricians, few women with GDM received the recommended diabetes test. This represents a missed opportunity in a high-risk population. Interventions to change test ordering that target family physicians and obstetricians are most likely to increase the proportion of women with GDM who receive postpartum diabetes testing.

Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus

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). 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. 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). GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.

252: Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus

ObjectiveTo evaluate the efficacy of a campaign to increase the rates of postpartum follow-up in women with gestational diabetes mellitus.Study DesignA retrospective cohort study of all women diagnosed with gestational diabetes mellitus (GDM) who delivered at our institution 2002-2009 was conducted. Primary outcome was obtaining postpartum (PP) diabetes testing. The group was dichotomized into one cohort that delivered 2002-2007 and the other that delivered 2007-2009. Prior to 2007, GDMs were advised to obtain PP diabetes testing by their PP providers. In 2007, all women received a counseling session at their 37-38 week visit: a registered nurse supplied patients with written and verbal information about PP glucose testing. Univariate and multivariable statistical tests were utilized.ResultsThe overall PP diabetes testing frequency for women delivering after counseling was instituted was 53%, compared to 33% for women delivering prior to the implementation of counseling (p<0.001). When examined by race/ethnicity, Whites (28 to 53%, p<0.001), Latinas (15 to 50%, p<0.001), and Asians (43 to 59%, p=0.005) had increased PP diabetes testing. However, there was a nonsignificant decrease in African-American follow-up, 28% to 17% (p=0.414). Within the 2007-2009 cohort, positive predictors for follow-up included maternal age 35 and insulin use. The sole negative predictor was preterm delivery (Table).Tabled 1Predictors of increased postpartum diabetes testingCharacteristicaOR95%CICounseling Intervention2.061.49-2.86White1.00—African-American0.670.34-1.31Latina0.690.41-1.16Asian1.721.21-2.43Age ≥351.190.87-1.62Insulin Use2.131.54-2.95Preterm Birth0.800.68-0.94 Open table in a new tab ConclusionGDM often precedes the onset of type 2 diabetes. We have demonstrated that a simple, one-on-one counseling session with patients conducted several weeks prior to delivery increases the follow-up diabetes testing rate. Further efforts are needed to obtain universal testing in these women. ObjectiveTo evaluate the efficacy of a campaign to increase the rates of postpartum follow-up in women with gestational diabetes mellitus. To evaluate the efficacy of a campaign to increase the rates of postpartum follow-up in women with gestational diabetes mellitus. Study DesignA retrospective cohort study of all women diagnosed with gestational diabetes mellitus (GDM) who delivered at our institution 2002-2009 was conducted. Primary outcome was obtaining postpartum (PP) diabetes testing. The group was dichotomized into one cohort that delivered 2002-2007 and the other that delivered 2007-2009. Prior to 2007, GDMs were advised to obtain PP diabetes testing by their PP providers. In 2007, all women received a counseling session at their 37-38 week visit: a registered nurse supplied patients with written and verbal information about PP glucose testing. Univariate and multivariable statistical tests were utilized. A retrospective cohort study of all women diagnosed with gestational diabetes mellitus (GDM) who delivered at our institution 2002-2009 was conducted. Primary outcome was obtaining postpartum (PP) diabetes testing. The group was dichotomized into one cohort that delivered 2002-2007 and the other that delivered 2007-2009. Prior to 2007, GDMs were advised to obtain PP diabetes testing by their PP providers. In 2007, all women received a counseling session at their 37-38 week visit: a registered nurse supplied patients with written and verbal information about PP glucose testing. Univariate and multivariable statistical tests were utilized. ResultsThe overall PP diabetes testing frequency for women delivering after counseling was instituted was 53%, compared to 33% for women delivering prior to the implementation of counseling (p<0.001). When examined by race/ethnicity, Whites (28 to 53%, p<0.001), Latinas (15 to 50%, p<0.001), and Asians (43 to 59%, p=0.005) had increased PP diabetes testing. However, there was a nonsignificant decrease in African-American follow-up, 28% to 17% (p=0.414). Within the 2007-2009 cohort, positive predictors for follow-up included maternal age 35 and insulin use. The sole negative predictor was preterm delivery (Table).Tabled 1Predictors of increased postpartum diabetes testingCharacteristicaOR95%CICounseling Intervention2.061.49-2.86White1.00—African-American0.670.34-1.31Latina0.690.41-1.16Asian1.721.21-2.43Age ≥351.190.87-1.62Insulin Use2.131.54-2.95Preterm Birth0.800.68-0.94 Open table in a new tab The overall PP diabetes testing frequency for women delivering after counseling was instituted was 53%, compared to 33% for women delivering prior to the implementation of counseling (p<0.001). When examined by race/ethnicity, Whites (28 to 53%, p<0.001), Latinas (15 to 50%, p<0.001), and Asians (43 to 59%, p=0.005) had increased PP diabetes testing. However, there was a nonsignificant decrease in African-American follow-up, 28% to 17% (p=0.414). Within the 2007-2009 cohort, positive predictors for follow-up included maternal age 35 and insulin use. The sole negative predictor was preterm delivery (Table). ConclusionGDM often precedes the onset of type 2 diabetes. We have demonstrated that a simple, one-on-one counseling session with patients conducted several weeks prior to delivery increases the follow-up diabetes testing rate. Further efforts are needed to obtain universal testing in these women. GDM often precedes the onset of type 2 diabetes. We have demonstrated that a simple, one-on-one counseling session with patients conducted several weeks prior to delivery increases the follow-up diabetes testing rate. Further efforts are needed to obtain universal testing in these women.