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.
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
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.
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
factors have been noted in our study that influenced postpartum glucose
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.
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.
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.
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.
in this study helped in refreshing the knowledge and improving the compliance
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.
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.
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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
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determinants and barriers for gestational diabetes mellitus (GDM) services, a
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glucose among women with histories of gestational diabetes mellitus.Diabetes
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