Worldwide, tri annually thereafter with annual FBG in

Worldwide,
diabetes mellitus (DM) is currently the fastest growing non-communica­ble
disease and has gained epidemic levelsi.Gestational
diabetes mellitus (GDM) is a significant risk factor for the development of
type 2 diabetes (T2DM).It is defined as “Any degree of glucose intolerance with onset or
first recognition during pregnancy”ii.GDM poses increased risk of adverse pregnancy outcomes including
maternal and perinatal mortality, obstructed labor, infections, spontaneous
abortion, congenital abnormalities and macrosomiaiii.Later
in life, women with GDM are not only at increased
risk for developing type 2 diabetes, but there is also increased risk of
cardiovascular disease iv’v.In
addition, children of women with GDM are at increased risk of obesity, glucose
intolerance, and overt diabetes mellitus in adult life vi.

The Fifth International
Workshop-Conference on GDM recommends intensive postpartum monitoring:
Random/fasting blood glucose (FBG) 1 to 3 days postpartum; OGTT 6 to 12 weeks
later, to be repeated 1 year postpartum and tri annually thereafter with annual
FBG in between vii.
Despite these
strategies, it has been noted that postpartum screening rates are low among
high risk mothers and range from 23 to 58% viii’ix.One
of the reasons for low screening rates is failure on the part of obstetrician to
provide appropriate test, along with patient non-compliance. The objective of
this study is therefore toassess the adherence of obstetricians to the
recommended guidelines for postpartum screening of GDM affected women. In
developing countries like Pakistan where appropriate obstetrical care is
lacking on a large scale, GDM may have particularly severe consequences for the
health and wellbeing of mother and child. Studies have shown that postpartum
diabetes screening has the potential for future prevention of Type 2 Diabetes
in the mother and offspring thus cost saving and reducing the burden of
disease.

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Rationale:

 

Women with
GDM affected pregnancy have a 20% chance ofdeveloping type 2 diabetes in the
first decade following pregnancy though the risk can be as high as 70% in
higherrisk populations.x’xiThe identification of pre-diabetes is important because up to
70% of affected individuals may eventually develop type 2 diabetes. Thus, the
high rates of pre-diabetes in the category of abnormal antepartum glucose
homeostasis suggest that the young women in these groups have an increased risk
of future type 2 diabetes. This risk is well established in women with GDM as compared to
women with normal OGTTs i.

In our
study we found that during the pre-intervention period 27.6% of women with GDM received
a documented order for postpartum glucose screening; this increased to 50.9%
after the intervention. Although the obstetrician compliance to postpartum DM
screening guidelines increased after intervention but the rate of screening is
still low.

Several
factors have been noted in our study that influenced postpartum glucose
tolerance testing.

Women with
GDM who had Cesarean section were four times more likely to get advice for OGTT
testing compared to women who delivered vaginally as almost all these women had
1st postoperative visit for removal of stitches.

In our
study it is evident that GDM women who were treated with metformin alone,
metformin and insulin or insulin alone were given requisition for postpartum
OGTT testing. Several studies have shown similar effect ii,
others have shown opposite effect iii.

 

One of the
reasons that patients did not get requisition seems that patients did not
return for their follow-up visit. This is in keeping with other studies iv
that have noted that attendance at the postpartum visit is a major factor in
glucose testing. This calls for looking into the factors leading to
noncompliance on the part of the patients as well.

Interestingly
it was found that full time faculty is more compliant towards DM screening
guidelines as compared to visiting obstetricians and the rate of advising
glucose tolerance testing has increased tremendously after intervention.

 Another factor is that though obstetrician
provided the requisition for OGTT but the patient had it performed at another
laboratory outside our hospital whose results may or may not be available.

 

Strengths:

Our study
differs from similar reports examining GDM postpartum care in the aspect of our
focus on actual obstetric practice since our hospital is basically a maternity
unit and we examined the postpartum paper work in medical records.

Intervention
in this study helped in refreshing the knowledge and improving the compliance
of obstetricians

Limitations:

This study
was limited to medical chart review for the documentation of OGTT testing by
obstetrician only, therefore itcould not determine whether defects in testing
were attributable to patient, or health care system barriers, or toall three
combined. Another limitation is that compliance of obstetricians was seen at
one secondary unit only, in view of global epidemic of DM it should be studied
in other centers also, including tertiary ones.

Conclusion:

Results
from our study combined withglobal recent reports of low rates of postpartum DM
screeningstrongly suggest that it is time for more strategic planning and not
only monitoring of obstetrician adherence but also in particular patient
education regarding consequences of DM and benefits of  detection of abnormal glucose tolerance in
early postpartum period.

iCarr DB, Newton KM, Utzschneider
KM, Tong J, Gerchman F, Kahn SE, et al. Modestly elevated glucose levels during
pregnancy are associated with a higher risk of future diabetes among women
without gestational diabetes mellitus. Diabetes Care. 2008;31(5):1037-9.

 

iiNielsen KK, Kapur A, Damm P, De
Courten M, Bygbjerg IC. From screening to postpartum follow-up—the
determinants and barriers for gestational diabetes mellitus (GDM) services, a
systematic review.BMC pregnancy and childbirth. 2014;14(1):41.

 

iiiHunt KJ, Conway DL. Who returns for
postpartum glucose screening following gestational diabetes mellitus? American
journal of obstetrics and gynecology. 2008;198(4):404. e1-. e6.

 

ivRussell MA, Phipps MG, Olson CL,
Welch HG, Carpenter MW. Rates of postpartum glucose testing after gestational
diabetes mellitus.Obstetrics & Gynecology. 2006;108(6):1456-62.

 

iNanditha A, Ma RCW, Ramachandran A,
Snehalatha C, Chan JCN, Chia KS, et al. Diabetes in Asia and the Pacific:
implications for the global epidemic. Diabetes care. 2016;39(3):472-85.

 

iiAmerican Diabetes A. Diagnosis and
classification of diabetes mellitus.Diabetes care. 2014;37(Supplement
1):S81-S90

 

 

iiiNielsen KK, CourtenMd, Kapur A. The
urgent need for universally applicable simple screening procedures and
diagnostic criteria for gestational diabetes mellitus—lessons from projects
funded by the World Diabetes Foundation.Global health action. 2012;5(1):17277.

 

ivVambergue A, Dognin C, Boulogne A,
Réjou MC, Biausque S, Fontaine P. Increasing incidence of abnormal glucose
tolerance in women with prior abnormal glucose tolerance during pregnancy:
DIAGEST 2 study. Diabetic Medicine. 2008;25(1):58-64.

 

 

vRetnakaran R, Shah BR. Mild glucose
intolerance in pregnancy and risk of cardiovascular disease: a population-based
cohort study. Canadian Medical Association Journal. 2009;181(6-7):371-6.

 

viClausen TD, Mathiesen ER, Hansen T,
Pedersen O, Jensen DM, Lauenborg J, et al. High prevalence of type 2 diabetes
and pre-diabetes in adult offspring of women with gestational diabetes mellitus
or type 1 diabetes. Diabetes care. 2008;31(2):340-6.

 

 

viiMetzger BE, Buchanan TA, Coustan
DR, De Leiva A, Dunger DB, Hadden DR, et al. Summary and recommendations of the
fifth international workshop-conference on gestational diabetes mellitus.
Diabetes care. 2007;30(Supplement 2):S251-S60.

 

 

viiiFerrara A, Peng T, Kim C. Trends in
postpartum diabetes screening and subsequent diabetes and impaired fasting
glucose among women with histories of gestational diabetes mellitus.Diabetes
care. 2009;32(2):269-74.

 

ixAlmario CV, Ecker T, Moroz LA,
Bucovetsky L, Berghella V, Baxter JK. Obstetricians seldom provide postpartum
diabetes screening for women with gestational diabetes. American journal of
obstetrics and gynecology. 2008;198(5):528. e1-. e5.

 

 

xFeig DS, Zinman B, Wang X,
HuxJE.Risk of development of diabetes mellitus after diagnosis of gestational
diabetes.Canadian Medical Association Journal. 2008;179(3):229-34.

 

xiKim SY, England L, Wilson HG, Bish
C, Satten GA, Dietz P. Percentage of gestational diabetes mellitus attributable
to overweight and obesity. American Journal of Public Health.
2010;100(6):1047-52

 

x

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