Postpartum Glucose Tolerance Testing Research Articles

Prediction of Glucose Intolerance in Early Postpartum in Women with Gestational Diabetes Mellitus Based on the 2013 WHO Criteria.

Predictors for glucose intolerance postpartum were evaluated in women with gestational diabetes mellitus (GDM) based on the 2013 World Health Organization (WHO) criteria. 1841 women were tested for GDM in a prospective cohort study. A postpartum 75g oral glucose tolerance test (OGTT) was performed in women with GDM at 14 ± 4.1 weeks. Of all 231 mothers with GDM, 83.1% (192) had a postpartum OGTT of which 18.2% (35) had glucose intolerance. Women with glucose intolerance were more often of Asian origin [15.1% vs. 3.7%, OR 4.64 (1.26–17.12)], had more often a recurrent history of GDM [41.7% vs. 26.7%, OR 3.68 (1.37–9.87)], higher fasting glycaemia (FPG) [5.1 (4.5–5.3) vs. 4.6 (4.3–5.1) mmol/L, OR 1.05 (1.01–1.09)], higher HbA1c [33 (31–36) vs. 32 (30–33) mmol/mol, OR 4.89 (1.61–14.82)], and higher triglycerides [2.2 (1.9–2.8) vs. 2.0 (1.6–2.5) mmol/L, OR 1.00 (1.00–1.01)]. Sensitivity of glucose challenge test (GCT) ≥7.2 mmol/l for glucose intolerance postpartum was 80% (63.1%–91.6%). The area under the curve to predict glucose intolerance was 0.76 (0.65–0.87) for FPG, 0.54 (0.43–0.65) for HbA1c and 0.75 (0.64–0.86) for both combined. In conclusion, nearly one-fifth of women with GDM have glucose intolerance postpartum. A GCT ≥7.2 mmol/L identifies a high risk population for glucose intolerance postpartum.

A Pilot Randomised Controlled Trial of a Text Messaging Intervention with Customisation Using Linked Data from Wireless Wearable Activity Monitors to Improve Risk Factors Following Gestational Diabetes.

Gestational diabetes (GDM) is a highly prevalent disorder of pregnancy which portends a high risk for future type 2 diabetes. Limited evidence indicates lifestyle intervention prevents the development of diabetes, but most previously studied interventions are resource-intensive. Intervention programs that utilise newer technologies may be scalable at lower cost. This 6-month pilot randomized controlled trial tested the delivery of text messages linked to an activity monitor, adaptive physical activity goal setting, and limited face-to-face counseling, as an intervention to improve rates of post-partum glucose tolerance testing and lifestyle behaviours amongst women following a GDM pregnancy. Sixty subjects were randomised 2:1 intervention vs. control. Compared to control subjects, there were trends for intervention subjects to improve diet, increase physical activity, and lose weight. There was no difference between the groups in the rate of glucose tolerance testing. Only 46 (77%) subjects completed some, and 19 subjects completed all the elements of the final evaluation. Feedback regarding the text messages and activity monitor was highly positive. Overall, results suggest that a text message and activity monitor intervention is feasible for a larger study or even as a potentially scalable population health intervention. However, low completion rates necessitate carefully considered modification of the protocol.

Gestasyonel diabetes mellitus olgularında postpartum glukoz tolerans testi uygulamasının oranları ve uygulanmamasının nedenleri

Gestasyonel diabetes mellitus olgularında postpartum glukoz tolerans testi uygulamasının oranları ve uygulanmamasının nedenleri

Early Versus 6–12 Week Postpartum Glucose Tolerance Testing for Women With Gestational Diabetes

(Abstracted from J Perinatol 2018;38:118–121) Women with pregnancies complicated by gestational diabetes mellitus (GDM) are at a significantly increased risk of developing type 2 diabetes mellitus (T2DM), hypertension, and cardiovascular disease. Diabetes screening for women with GDM is recommended 6 to 12 weeks following delivery, although this is an arbitrary time point developed to coincide with the routine postpartum visit.

Identifying Characteristics of Antenatal 3-Hour GTT as Markers for Abnormal Postpartum Glucose Tolerance [20I

INTRODUCTION: GDM is diagnosed on the basis of blood glucose levels that exceed specific glycemic thresholds. We sought to identify characteristics of antenatal glucose testing that may serve as markers for abnormal postpartum testing. METHODS: IRB approved retrospective cohort study. A database was created from all women who underwent a postpartum 2-hour oral glucose tolerance test at the Carolinas Medical Center Diabetes Clinic in Charlotte, NC between 2012-2015. Inclusion criteria: singleton pregnancy, diagnosis of GDM, postpartum GTT completed 4-12 weeks post-partum. GDM was diagnosed by at least 2 elevated values on a completed 3-hour glucose tolerance test (Carpenter-Coustan). Data was indexed using two methods: clinical groups and by number of abnormal values. Four groups were defined: Group A; abnormal fasting value. Group B; all values < 200mg/dl. Group C; Any value ≥200mg/dl. Group D; Both an elevated fasting AND any value ≥200mg/dl. Patients were also grouped according to the number of abnormal values on 3h GTT; either 2, 3 or 4 abnormal values. Chi-square or Mantel-Haenszel tests were used for categorical variables. T-tests and generalized linear models were used for continuous variables. Poisson regression models were used to calculate relative risks (RR) and 95% confidence intervals. RESULTS: 407 patients met study criteria. 57% were diagnosed with abnormal 2-hour postpartum glucose tolerance (PGT). Groups A, C, and D had a greater RR of abnormal 2-hour PGT compared to Group B. Four abnormal values on 3-hour antenatal GTT compared with two abnormal values was associated with a higher risk of abnormal PGT. These results are not statistically significant. CONCLUSION: No statistically significant markers for abnormal PGT identified from the antenatal 3-hour GTT. The population in our study represents patients compliant with post-partum glucose tolerance testing. Our results may have been affected because patients with poor control of GDM are less likely to be compliant with postpartum glucose tolerance testing.

Early versus 6-12 week postpartum glucose tolerance testing for women with gestational diabetes.

ObjectiveTo estimate the accuracy of early oral glucose tolerance testing (GTT) to predict impaired glucose tolerance.Study DesignThis was a prospective cohort study. Women received an early 75-gram 2-hour GTT between postpartum days 2–4 and again 6–12 weeks postpartum. The ability of the early GTT to accurately detect impaired glucose tolerance and diabetes was assessed by calculating sensitivity, specificity, positive predictive value and negative predictive values. The routine 6–12 week postpartum GTT was considered the gold standard.ResultsThe early GTT was completed by 100% of subjects while only 31 of 58 (53%) women returned to complete the 6–12-week postpartum GTT. The early GTT had modest sensitivity for impaired glucose tolerance (62.5%) and overt diabetes (50%). However, it had excellent specificity (100%), PPV (100%) and NPV (96.7%) for diabetes. The NPV for impaired glucose tolerance with the early GTT was 80%.ConclusionRates of 6–12 week postpartum GTT completion among patients with gestational diabetes is poor. Appropriate postpartum management may improve by using the early GTT as a screening test.

Barriers to Postpartum Follow-Up and Glucose Tolerance Testing in Women with Gestational Diabetes Mellitus.

This study aims to examine factors associated with postpartum follow-up and glucose tolerance testing (GTT) in women with gestational diabetes mellitus (GDM). Case-control study of women with GDM at a single institution with available outpatient records (January 2008-February 2016). Women with pregestational diabetes mellitus were excluded. The postpartum follow-up, GTT completion, and the reason for GTT completion failure (provider vs. patient noncompliance) were assessed. Bivariable and multivariable analyses were performed to identify factors associated with postpartum follow-up and GTT completion. Of 683 women, 82.0% (n = 560) returned postpartum, and 49.8% (n = 279) of those completed GTT. Women with Medicaid and late presentation to care were less likely to return (adjusted odds ratio [aOR]: 0.3, 95% confidence interval [CI]: 0.2-0.6 and aOR: 0.4, 95% CI: 0.2-0.7), but if they did, both factors were associated with increased odds of GTT completion (aOR: 2.0, 95% CI: 1.3-2.9 and aOR: 3.5, 95% CI: 1.8-6.6). Patient and provider noncompliance contributed equally to GTT completion failure. Trainee involvement was associated with improved test completion (aOR: 4.6, 95% CI: 2.4-8.8). The majority of women with GDM returned postpartum, but many did not receive recommended GTT. Public insurance and late presentation were associated with failure to return postpartum, but better GTT completion when a postpartum visit occurred. Trainee involvement was associated with improved adherence to screening guidelines.

Immediate Postpartum Glucose Tolerance Testing in Women with Gestational Diabetes: A Pilot Study.

Objective Due to poor adherence for glucose testing at 6- to 12-week postpartum among women with gestational diabetes, we sought to determine whether a 2-hour glucose tolerance test (GTT) during postpartum hospitalization is predictive of 6- to 12-week postpartum glucose testing. Study Design An institutional review board–approved prospective cohort study was performed over 3 years. Patients underwent an inpatient fasting 75-g, 2-hour GTT on either postpartum days 2 through 4 and instructed to follow up in 6- to 12-weeks for postpartum glucose testing. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of the immediate GTT to predict abnormal 6- to 12-week postpartum glucose testing were determined. Results Eighty women enrolled in the study completed the immediate GTT; of these, only 35 (44%) underwent 6- to 12-week postpartum glucose testing. The sensitivity, specificity, PPV, and NPV of the immediate GTT were 100, 42.8, 30.4, and 100%, respectively. Conclusion More than 50% of our study patients did not undergo recommended postpartum glucose testing, coinciding with similar poor follow-up reported in the literature. With a high NPV and high sensitivity, a negative immediate GTT may obviate the need for the 6- to 12-week GTT, while a positive GTT may identify women who should follow up closely.

699: Disparities in postpartum glucose tolerance testing in women with gestational diabetes

699: Disparities in postpartum glucose tolerance testing in women with gestational diabetes

Improved Outcomes for Hispanic Women with Gestational Diabetes Using the Centering Pregnancy© Group Prenatal Care Model.

Objective To determine the impact of Centering Pregnancy©-based group prenatal care for Hispanic gravid diabetics on pregnancy outcomes and postpartum follow-up care compared to those receiving traditional prenatal care. Methods A cohort study was performed including 460 women diagnosed with gestational diabetes mellitus (GDM) who received traditional or Centering Pregnancy© prenatal care. The primary outcome measured was completion of postpartum glucose tolerance testing. Secondary outcomes included postpartum visit attendance, birth outcomes, breastfeeding, and initiation of a family planning method. Results 203 women received Centering Pregnancy© group prenatal care and 257 received traditional individual prenatal care. Women receiving Centering Pregnancy© prenatal care were more likely to complete postpartum glucose tolerance testing than those receiving traditional prenatal care, (83.6 vs. 60.7%, respectively; p<0.001), had a higher rate of breastfeeding initiation (91.0 vs. 69.4%; p<0.001), had higher rates of strictly breastfeeding at their postpartum visit (63.1 vs. 46.3%; p=0.04), were less likely to need medical drug therapy compared to traditional prenatal care (30.2 vs. 42.1%; p=0.009), and were less likely to undergo inductions of labor (34.5 vs. 46.2%; p=0.014). When only Hispanic women were compared, women in the Centering group continued to have higher rates of breastfeeding and completion of postpartum diabetes screening. Conclusion for Practice Hispanic women with GDM who participate in Centering Pregnancy© group prenatal care may have improved outcomes.

Early Postpartum Glucose Testing in Women with Gestational Diabetes Mellitus.

Objective Given that most women with gestational diabetes mellitus (GDM) never undergo the recommended 6 to 12 weeks postpartum glucose tolerance test (GTT), we assessed the feasibility of performing GTTs on postpartum day 2. Study Design Women with abnormal postpartum day 2 results were similar to women with normal postpartum day 2 results except that more women with abnormal results required medicine to treat their GDM (Table 1). [corrected]. We assessed the feasibility of this GTT and compared the results to the standard of care GTT at 6 to 12 weeks postpartum. We also evaluated maternal and pregnancy characteristics of women who return for 6 to 12 weeks GTTs compared with those lost to follow-up. Results In this study, 98 of 106 participants (92%) completed the postpartum day 2 GTT; 59% had normal glucose values at that time. Only 49 women returned at 6 to 12 weeks postpartum. Among women who had testing at both time points, the 2 days postpartum GTT were 100% sensitive and 94% specific for diabetes mellitus but less sensitive and specific for milder forms of abnormal glucose. Women who did not return for testing at 6 to 12 weeks postpartum were more likely to have less education, have Medicaid, and to have GDM previously (Table 2). [corrected]. Conclusion Performing GTTs on postpartum day 2 is feasible and should be further investigated as an alternative postpartum testing regimen in GDM.

A Korean multicenter study of prenatal risk factors for overt diabetes during the postpartum period after gestational diabetes mellitus.

To identify prenatal risk factors for postpartum diabetes among pregnant women with gestational diabetes mellitus (GDM). In a retrospective study, baseline characteristics and data from a postpartum 75-g glucose tolerance test (GTT) were reviewed for patients with GDM who had delivered in four Korean tertiary institutions from 2006 to 2012. Clinical characteristics were compared between women with and those without postpartum diabetes. Cutoffs to predict postpartum diabetes and diagnostic values were calculated from receiver operating characteristic (ROC) curves. Of 1637 patients with GDM, 498 (30.4%) underwent a postpartum 75-g GTT. Postpartum diabetes was diagnosed in 40 (8.0%) patients and impaired glucose intolerance in 157 (31.5%). Women with postpartum diabetes had higher glycated hemoglobin (HbA1c) levels at GDM diagnosis (P=0.008) and higher 100-g GTT values (P<0.05 for all). In ROC curve analysis, optimal cutoffs for predicting postpartum diabetes were 0.058 for HbA1c level and 5.3 mmol/L (fasting), 10.9 mmol/L (1h), 10.2 mmol/L (2h), and 8.6 mmol/L (3h) for 100-g GTT. The highest sensitivity was observed for 3-h 100-g GTT (76.9%) and the highest positive predictive value was for HbA1c at diagnosis (15.2%). HbA1c level at GDM diagnosis and 100-g GTT values could be used to identify patients at high risk of postpartum diabetes who should undergo postpartum screening.

Attendance for Postpartum Glucose Tolerance Testing Following Gestational Diabetes among South Asian Women in Australia: A Qualitative Study

Attendance for Postpartum Glucose Tolerance Testing Following Gestational Diabetes among South Asian Women in Australia: A Qualitative Study To conduct an in-depth exploration of the experiences of and perspectives on postpartum Glucose Tolerance Test (GTT) screening of South Asian women diagnosed with GDM in Melbourne, Australia. Using an exploratory qualitative methodology, this study was carried out in two phases: the first phase involved face-to-face in-depth interviews with 17 recent immigrant women from South Asia. In the second phase 23 GDM diagnosed women were interviewed.

Response to: Improving postpartum screening rates

1. Gupta y, Karla S (2014) Improving postpartum screening rates. Arch Gynecol Obstet. doi:10.1007/s00404-014-3213-9 2. Mendez-Figueroa H, Daley J, Breault p et al (2014) Impact of an intensive follow-up program on the postpartum glucose tolerance testing rate. Arch Gynecol Obstet. doi:10.1007/s00404-014-3157-0 We would like to thank Drs. Gupta and Kalra [1] for their comments regarding our study [2] evaluating a strategy aimed at improving postpartum glucose tolerance testing. This difficult clinical dilemma may only be overcome if the problem is addressed from different angles or in a multifactorial approach. We agree that other strategies should be evaluated in order to overcome suboptimal postpartum testing rates currently seen. These strategies should not only lead to increased detection of diabetes and prediabetes but also be cost-effective. Direct home visits, screening with hemoglobin A1C levels and self-administered OGTT may lead to increased testing rates and may be part of the

Impact of an intensive follow-up program on the postpartum glucose tolerance testing rate

Gestational diabetes mellitus (GDM) is a strong risk factor for the development of diabetes. We assessed the impact of a 1-year intensive follow-up demonstration program, using direct nurse and outreach worker case management, aimed at increasing compliance with postpartum oral glucose tolerance testing (OGTT). During the year of implementation, a nurse or bilingual outreach worker contacted patients to encourage attendance at their scheduled postpartum 2-h 75-g OGTT and assisted in overcoming obstacles to testing. All patients with GDM seen in our specialty clinic the previous year served as a control group for comparison. One hundred eighty-one patients treated during the year prior to implementation were compared to the 207 in the demonstration program. Baseline characteristics were similar in both groups. After the program's implementation, postpartum OGTT adherence increased from 43.1 to 59.4 % (p < 0.01, hazard ratio 1.59; 95 % confidence interval 1.20-2.12). Had the program been in place the previous year, we calculated that 12 additional cases of diabetes or prediabetes would have been detected, increasing the total number from 33 to 45 such cases. Implementation of direct nurse and outreach worker case management leads to a modest, but important increase in adherence to postpartum OGTT testing.

Evaluation of home testing to improve follow up after gestational diabetes (Fingerstick Assessments of Sugar Two-months postpartum or FAST).

Historically the rates of postpartum glucose tolerance testing for women with gestational diabetes (GDM) average a suboptimal 33%. Barriers include the need for new mothers to miss work and/or arrange for childcare in order to engage in a two-hour test at a commercial lab. This pilot study was initiated to test the theory that a home testing regimen would be accepted by patients and increase the rate of postpartum glucose assessments relative to published rates, without requiring additional health-care staff or resources to achieve this goal. Six weeks postpartum, women with GDM from an academic private practice were asked to check fingerstick blood glucose (FAST Protocol) four times a day for two days, and then obtain an oral glucose tolerance test (OGTT). The physician consultants saw the women each month during pregnancy and arranged the postpartum testing. Two of 69 refused to be consented. Twelve of the remaining 67(18%) women completed both the FAST regimen and the OGTT, three completed only the OGTT and five completed only the FAST regimen for a final follow-up rate of 20/67 (30%). The demands of caring for a newborn, or the annoyance of fingersticks, were barriers to compliance. In spite of intense physician involvement, this home testing regimen was not associated with an increase in the rates of women participating in postpartum glucose assessments.

Predictors of Postpartum Glucose Tolerance Testing in Italian Women with Gestational Diabetes Mellitus

Postpartum screening is critical for early identification of type 2 diabetes in women previously diagnosed with gestational diabetes mellitus (GDM). Nevertheless, its rate remains disappointingly low. Thus, we plan to examine the rate of postpartum glucose tolerance test (ppOGTT) for Italian women with GDM, before and after counseling, and identify demographic, clinical, and/or biochemical predictors of adherence. With these aims, we retrospectively enrolled 1159 women with GDM, in Calabria, Southern Italy, between 2004 and 2011. During the last year, verbal and written counseling on the importance of followup was introduced. Data were analyzed by multiple regression analysis. A significant increase of the return rate was observed following introduction of the counseling [adjusted odds ratio (AOR) 5.17 (95% CI, 3.83–6.97), P < 0.001]. Interestingly, previous diagnosis of polycystic ovary syndrome (PCOS) emerged as the major predictor of postpartum followup [AOR 5.27 (95% CI, 3.51–8.70), P < 0.001], even after stratification for the absence of counseling. Previous diagnosis of GDM, higher educational status, and insulin treatment were also relevant predictors. Overall, our data indicate that counseling intervention is effective, even if many women fail to return, whereas PCOS represents a new strong predictor of adherence to postpartum testing.

The DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial – study protocol

BackgroundPostpartum follow up of women who have been found to have gestational diabetes during pregnancy is essential because of the strong association of gestational diabetes with subsequent type 2 diabetes. Postal reminders have been shown to increase significantly attendance for oral glucose tolerance testing postpartum. It is possible that a short message service (text) reminder system may also be effective. This trial aims to assess whether a text message reminder system for women who have experienced gestational diabetes in their index pregnancy will increase attendance for oral glucose tolerance testing within six months after birth.Methods/DesignDesign: Single centre (Women’s and Children’s Hospital, South Australia), parallel group randomised controlled trial.Inclusion criteria: Women diagnosed with gestational diabetes in their index pregnancy (oral glucose tolerance test with fasting glucose ≥ 5.5 mmol/L and/or two hour glucose ≥ 7.8 mmol/L), with access to a mobile phone, whose capillary blood glucose profile measurements prior to postnatal discharge are all normal (fasting glucose < 6.0 mmol/L, postprandial glucoses < 8.0 mmol/L).Exclusion criteria: Pregestational diabetes mellitus, triplet/higher order multiple birth or stillbirth in the index pregnancy, requirement for interpreter.Trial entry and randomisation: Allocation to intervention will be undertaken using a telephone randomisation service (computer-generated random number sequence generation, with balanced variable blocks, and stratification by insulin requirement).Study groups: Women in the intervention group will receive a text reminder to attend for an oral glucose tolerance test at 6 weeks postpartum, with further reminders at 3 months and 6 months if they do not respond to indicate test completion. Women in the control group will receive a single text message reminder at 6 months postpartum.Blinding: Baseline data collection will be undertaken blinded. Blinding of participants and blinded collection of primary outcome data will not be possible for this study.Primary study outcome: Attendance for the oral glucose tolerance test within 6 months postpartum.Sample size: 276 subjects will be required to show an 18% absolute increase in the rate of attendance (α=0.05 two tailed, β=80%, 5% loss to follow up) from 37% to 55% in the intervention group.DiscussionGiven the heightened risk of impaired glucose tolerance and type 2 diabetes in women who have had gestational diabetes, ensuring the highest possible rate of attendance for postpartum glucose tolerance testing, so that early diagnosis and intervention can occur, is important. A text message reminder system may prove to be an effective method for achieving improved attendance for such testing. This randomised controlled trial will assess whether such a system will increase rates of attendance for postpartum oral glucose tolerance testing in women who have experienced gestational diabetes.Trial RegistrationAustralian New Zealand Clinical Trials Registry - ACTRN12612000621819

258: Evaluation of the impact of an intensive follow-up program on postpartum glucose tolerance testing

Gestational diabetes mellitus (GDM) is a strong risk factor for developing overt diabetes later in life, and studies have demonstrated that identification of prediabetes can enable interventions preventing subsequent diabetes. Various professional societies have stressed the importance of postpartum glucose tolerance testing (GTT) for patients with GDM, although few strategies have been evaluated. We assessed the impact of a one-year program sponsored by the Rhode Island Department of Health aimed at increasing postpartum GTT using direct nurse and patient navigator supervision.

Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon.

ObjectiveThis 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 MethodsIn 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.ResultsRoutine 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.ConclusionsPostpartum 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.