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Prevalence of Screening for Diabetes Mellitus in Patients Previously Diagnosed with Gestational Diabetes: Factors Related to its Performance

Prevalência do rastreamento de diabetes mellitus em pacientes diagnosticadas previamente com diabetes gestacional: fatores relacionados à sua realização

Abstract

Objective

To determine how many patients underwent screening for diabetes mellitus (DM) in the puerperium after a diagnosis of gestational DM (GDM) and which factors were related to its performance.

Methods

The present is a prospective cohort study with 175 women with a diagnosis of GDM. Sociodemographic and clinico-obstetric data were collected through a questionnaire and a screening test for DM was requested six weeks postpartum. After ten weeks, the researchers contacted the patients by telephone with questions about the performance of the screening. The categorical variables were expressed as absolute and relative frequencies. The measure of association was the relative risk with a 95% confidence interval (95%CI), and values of p ≤ 0.05 were considered statistically significant and tested through logistic regression.

Results

The survey was completed by 159 patients, 32 (20.1%) of whom underwent puerperal screening. The mean age of the sample was of 30.7 years, and most patients were white (57.9%), married (56.6%), and had had 8 or more years of schooling (72.3%). About 22.6% of the patients used medications to treat GDM, 30.8% had other comorbidities, and 76.7% attended the postnatal appointment. Attendance at the postpartum appointment, the use of medication, and the presence of comorbidities showed an association with the performance of the oral glucose tolerance test in the puerperium.

Conclusion

The prevalence of screening for DM six weeks postpartum is low in women previously diagnosed with GDM. Patients who attended the postpartum consultation, used medications to treat GDM, and had comorbidities were the most adherent to the puerperal screening. We need strategies to increase the rate of performance of this exam.

Keywords
gestational diabetes; screening programs; postpartum period; diabetes mellitus

Resumo

Objetivo

Determinar quantas pacientes realizaram o rastreamento puerperal para diabetes mellitus (DM) após diagnóstico de DM gestacional (DMG) e quais fatores estão relacionados com a sua realização.

Métodos

Trata-se de um estudo com uma coorte prospectiva de 175 puérperas com diagnóstico de DMG. Informações sociodemográficas e clinico-obstétricas foram coletadas por meio de questionário, e solicitou-se a realização do rastreamento para DM às seis semanas de pós-parto. Após dez semanas, os pesquisadores contataram as pacientes por telefone com questões sobre a realização do rastreamento. As variáveis categóricas foram expressas em termos de frequências absoluta e relativa. A medida de associação foi o risco relativo com intervalo de confiança de 95% (IC95%), e valores de p ≤ 0,05 foram considerados estatisticamente significativos e testados por regressão logística.

Resultados

A pesquisa foi concluída por 159 pacientes, 32 (20,1%) das quais fizeram o rastreamento puerperal. A idade média da amostra foi de 30,7 anos, e a maioria das pacientes eram brancas (57,9%), casadas (56,6%) e tinham 8 ou mais anos de escolaridade (72,3%). Cerca de 22,6% utilizaram medicações para tratamento da DMG, 30,8% eram portadoras de outras comorbidades, e 76,7% compareceram na consulta pós-natal. O comparecimento na consulta pós-parto, a utilização de medicamentos e a presença de comorbidades demonstraram associação com a realização do teste oral de tolerância à glicose no puerpério.

Conclusão

O rastreamento de DM após seis semanas de puerpério é baixo em mulheres com diagnóstico prévio de DMG. Pacientes que compareceram na consulta pós-parto, utilizaram medicações para tratamento da DMG, e eram portadoras de comorbidades foram as mais aderentes à realização do rastreamento puerperal. Necessitamos de estratégias para aumentar a abrangência da realização desse exame.

Palavras-chave
diabetes gestacional; programas de rastreamento; período pós-parto; diabetes mellitus

Introduction

Diabetes mellitus (DM) is a chronic disease characterized by high levels of blood glucose due to insufficient insulin production or some degree of insulin resistance that can contribute to physical, psychological and clinical complications.11 International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels: IDF; 2019 It is estimated that ~ 9.3% of the world population of adults aged between 20 and 79 years live with this condition.11 International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels: IDF; 2019 Brazil is the South-American country with the highest prevalence of this disease, with 16.8 million adults affected, and the prevalence is higher among women (10.4% of the population) than among men (8.4% of the population).11 International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels: IDF; 2019

Women with hyperglycemia detected for the first time during pregnancy and with blood glucose levels that are not sufficient to achieve the diagnostic criteria for DM are characterized as having gestational DM (GDM).22 Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016 It is estimated that 15.8% of the patients who delivered live newborns worldwide were affected by hyperglycemia in 2019, and 83.6% of the cases were due to GDM.11 International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels: IDF; 2019

In Brazil, the diagnosis of GDM follows the consensus of the International Association of the Diabetes and Pregnancy Study Group (IADPSG): patients with fasting glucose levels between 92 mg/dL and 125 mg/dL or at least one altered value on the Oral Glucose Tolerance Test (OGTT) with 75 g of dextrose, performed between 24 and 28 weeks, with cutoff points of ≥ 92 mg/dL fasting, ≥ 180 mg/dL in the first hour, and ≥ 153 mg/dL in the second hour.22 Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016,33 Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P, et al; International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33(03):676–682. Doi: 10.2337/dc09-1848
https://doi.org/10.2337/dc09-1848...

When compared with pregnant women with normoglycemia, GDM carriers are ~ 7 to 10 times more likely to develop type-2 DM (DM2) after delivery.44 Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and metaanalysis. Lancet. 2009;373(9677):1773–1779. Doi: 10.1016/S01406736(09)60731-5
https://doi.org/10.1016/S0140-6736(09)60...
-55 Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, Gillies CL. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ. 2020;369:m1361. Doi: 10.1136/bmj.m1361
https://doi.org/10.1136/bmj.m1361...
The prevalence of hyperglycemia in patients with GDM varies from 25.9% in the first year postpartum to up to 53.7% when evaluated 5 years later.66 Miao Z, Wu H, Ren L, Ren L, Bu N, Jiang L, Yang H, et al. Long-Term Postpartum Outcomes of Insulin Resistance and β-cell Function in Women with Previous Gestational Diabetes Mellitus. Int J Endocrinol. 2020;2020:7417356. Doi: 10.1155/2020/7417356
https://doi.org/10.1155/2020/7417356...
Therefore, national and international protocols recommend performing the OGTT with 75 g of dextrose 6 weeks after delivery to screen for DM in patients diagnosed with GDM.22 Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016,77 American College of Obstetricians and Gynecologists. Practice Bulletin No. 180: gestational diabetes mellitus. Obstet Gynecol. 2017;130(01):e17–e37. Doi: 10.1097/AOG.0000000000002159
https://doi.org/10.1097/AOG.000000000000...
Early diagnosis of diabetes is important to avoid the impacts of prolonged hyperglycemia, such as increased incidence and mortality from cardiovascular diseases, since the diagnosis of GDM is also associated with higher rates of dyslipidemia, hypertension, vascular dysfunctions, atherosclerosis, and occurrence of cardiovascular events throughout life.88 Guo J, Chen JL, Whittemore R, Whitaker E. Postpartum lifestyle interventions to prevent type 2 diabetes among women with history of gestational diabetes: a systematic review of randomized clinical trials. J Womens Health (Larchmt). 2016;25(01): 38–49. Doi: 10.1089/jwh.2015.5262
https://doi.org/10.1089/jwh.2015.5262...

9 Miao ZR, Wu HH, Zhang YZ, Sun WJ, Lu DF, Yang HX, et al. Evaluation of the gestational diabetes mellitus diagnostic criteria recommended by the international association of diabetes and pregnancy study group for long-term maternal postpartum outcomes in mainland China. Medicine (Baltimore). 2020;99(08): e19242. Doi: 10.1097/MD.0000000000019242
https://doi.org/10.1097/MD.0000000000019...
-1010 Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, et al. Association of history of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US Women. JAMA Intern Med. 2017;177(12):1735–1742. Doi: 10.1001/jamainternmed.2017.2790
https://doi.org/10.1001/jamainternmed.20...
However, despite the recommendations, the rate of patients diagnosed with GDM who undergo postpartum screening is generally low, ranging from 19.5% to 54%.1111 Rotem R, Salem-Yaniv S, Sandler-Rahat H, Yohay D, Shanny S, Yahav L, et al. Adherence to postpartum diabetes mellitus screening, do associated pregnancy complications make a difference? Diabetes Res Clin Pract. 2020;159:107972. Doi: 10.1016/j.diabres.2019.107972
https://doi.org/10.1016/j.diabres.2019.1...
,1212 Stasenko M, Liddell J, Cheng YW, Sparks TN, Killion M, Caughey AB. Patient counseling increases postpartumfollow-up inwomen with gestational diabetes mellitus.Am J Obstet Gynecol. 2011;204 (06):522.e1–522.e6. Doi: 10.1016/j.ajog.2011.01.057
https://doi.org/10.1016/j.ajog.2011.01.0...

It has been observed that many patients fail to undergo DM screening during the puerperium. There is a need to create a program to follow up these patients, perform exams to enable the establishment of early diagnoses, and act in the prevention and treatment of this comorbidity that has such a great long-term impact for the patient and the public health system. Thus, the present research aimed to determine how many GDM patients among the population under study undergo the screening test in the puerperal period and what are the factors related to its performance.

Methods

The present is a prospective cohort study. The population consisted of patients diagnosed with GDM, hospitalized for delivery, in the public health system, between May and September 2021, at the Obstetrics service of Hospital Regional de São José Dr. Homero de Miranda Gomes, in the city of São José, state of Santa Catarina, Southern Brazil. The sampling was carried out by convenience, with an estimated sample size of 175 cases. The calculation was performed with the OpenEpi software, version 3, considering the significant variables from previous studies,1313 Tang Y, Guo J, LongQ, Yang J, Luo J, Yang S, et al. Factors influencing postpartum blood glucose screening among women with prior gestational diabetes mellitus in a rural community. J Adv Nurs. 2020;76(08):2151–2160. Doi: 10.1111/jan.14440
https://doi.org/10.1111/jan.14440...
,1414 de Gennaro G, Bianchi C, AragonaM, Battini L, Baronti W, Brocchi A, et al. Postpartum screening for type 2 diabetes mellitus in women with gestational diabetes: Is it really performed? Diabetes Res Clin Pract. 2020;166:108309. Doi: 10.1016/j.diabres.2020.108309
https://doi.org/10.1016/j.diabres.2020.1...
with bilateral significance (1-α) of 0.05 and power (1-β) of 0.80, and an estimated loss of up to 30%.

The inclusion criteria were patients diagnosed with GDM based on the aforementioned IADSPG consensus,22 Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016,33 Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P, et al; International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33(03):676–682. Doi: 10.2337/dc09-1848
https://doi.org/10.2337/dc09-1848...
who knew how to read and write in Portuguese. Patients with blood glucose levels in the laboratory screening that enabled the establishment of a diagnosis of previous DM or who had already had a diagnosis prior to pregnancy were excluded.

At first, during hospitalization, the patients answered a questionnaire through an interview with the researcher pertaining to: sociodemographic data (age, marital status, self-declared skin color, area of residence, years of schooling, family income in terms of the Brazilian minimum monthly wage of $213,09 according to federal law no. 14.158/2021 and commercial US dollar quotation at the beginning of the 2021, occupational status); obstetric history (parity, number of prenatal appointments, pregestational BMI, weight gain during pregnancy, mode of delivery, use of oral antidiabetics or insulin during pregnancy, birth weight, shoulder dystocia, amniotic fluid disorders diagnosed in any moment of pregnancy, gestational age at the time of the GDM diagnosis, history of GDM in previous pregnancies, breastfeeding during hospitalization, and associated comorbidities like hypertensive syndromes, thyroid disorders, and neurological or atopic diseases); family history of DM; and personal habits (sedentary lifestyle, smoking status). The data collected was complemented by the analysis of the hospital records and prenatal care documents. Birth weight greater than 4,000 g, presence of polyhydramnios, occurrence of shoulder dystocia and/or admission to the Neonatal Intensive Care Unit (NICU) were also grouped in a variable named “Composite outcome perinatal morbidity” for the statistical analysis.

The patients were informed of the importance of screening for DM six weeks after delivery. At the time of hospital discharge, they received a request for an OGTT test with 75 g of glucose (before and 2 hours after ingestion), which should be scheduled and performed at the Basic Health Unit of their hometowns, through the Brazilian Unified Health System.22 Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016

After four weeks of the period stipulated for the performance of the screening test, the researchers contacted the patients by telephone, asking if they had performed the requested test and if they kept breastfeeding in this period. The patients who failed to undergo the exam were asked why by the researchers. Patients who presented positive screening were instructed to seek their Basic Health Unit to continue the management of the disease.

After the collection the data was inserted in a Windows Excel (Microsoft Corp., Redmond, WA, United States) spreadsheet and later exported to the Statistical Package for the Social Sciences (PASW Statistics for Windows, SPSS Inc., Chicago, IL, United States) software, version 18.0 for the descriptive and analytical analyses. To describe the quantitative variables, means and standard deviations were calculated. The categorical variables were expressed as absolute (n) and relative (%) frequencies. The bivariate analysis was performed using the Chi-squared test to present the distribution of the variables. The measure of association used was the relative risk (RR) and 95% confidence interval (95%CI). Differences were considered statistically significant when p ≤ 0.05, and they were tested through logistic regression.

The present research project was submitted to the Research Ethics Committee and accepted under CAAE number 45699821.1.0000.0110, and data collection only started after the approval.

Results

The sample was composed of 175 puerperal women diagnosed with GDM, and all of them answered the questionnaire. In the second stage, 159 patients completed the survey, with a total of 16 losses: patients who did not answer the telephone contact, or whose number was wrong in the registration, or who requested exclusion from the study during the telephone contact (Fig. 1).

Fig. 1
Flowchart of the selection of the 175 patients who compose the study sample.

The age of the patients ranged from 17 to 44 years, with a mean of 30.7 years, and most (66.7%) were aged between 20 and 34 years, self-reported as white (57.9%), were married (56.6%), and reported 8 or more years of schooling (72.3%). The other sociodemographic characteristics are shown inTable 1.

Table 1
Sociodemographic characteristics of the 159 patients who completed the survey of the present study

As for the obstetric data, most patients were not primiparous (73.6%) and had completed prenatal care with more than 6 appointments (83.6%). Of the 159 patients who completed the survey, 76.7% attended the postnatal appointment, 22.6% used medications (oral antidiabetics or insulin therapy) to treat GDM, and 30.8% had other comorbidities. There was 1 case of shoulder dystocia during delivery. The rest of the obstetric data is presented inTable 2.

Table 2
Obstetrics and perinatal characteristics of the 159 patients who completed the survey of the present study

Of the total of 159 cases, 122 women (76.7%) attended the puerperal appointment. Among those, 43 (35.2%) reported they had been instructed about the OGTT and its performance. In total 32 patients (20.1%) underwent the exam 6 weeks postpartum. Among the 127 women who did not undergo the test, 51 (40.1%) reported having submitted the request for the exam at their Basic Health Unit and that the exam was not scheduled; 32 (25.2%) said they forgot to place the request; 7 (5.5%) reported they were instructed by the Basic Health Unit not to undergo it, or to do so at intervals not stipulated by the present study, and in 37 (29.2%) cases the justifications were different. Among the 32 OGTTs performed in the postpartum period, no case of DM was diagnosed, and glucose intolerance was evidenced in 2 exams. The univariate analysis (Table 3) showed that attending the postnatal consultation, having used medication for GDM, and having comorbidities were factors related to performing the screening test in the puerperium. After logistic regression, these variables remained significant, as shown inTable 4.

Table 3
Analysis of factors associated with the performance of postpartum screening of the 159 patients who completed the survey of the present study
Table 4
Logistic regression of the significant factors associated with the performance of postpartum screening of the 159 patients who completed the survey of the present study

Discussion

The focus of the present study is to establish the prevalence of DM screening in the puerperium and what are the factors associated with its performance. In the present study, about 1 in 5 women (20.1%) completed the OGTT screening 6 weeks postpartum. This index is similar to that found by Ortiz et al.,1515 Ortiz FM, Jimenez EY, BoursawB, Huttlinger K. Postpartum care for women with gestational diabetes. MCN Am J Matern Child Nurs. 2016;41(02):116–122. Doi: 10.1097/NMC.0000000000000215
https://doi.org/10.1097/NMC.000000000000...
who found a rate of 19%. The prevalence of DM screening in patients with a history of GDM is quite variable in the literature, ranging from 13.8% to 41%, but what all the studies1313 Tang Y, Guo J, LongQ, Yang J, Luo J, Yang S, et al. Factors influencing postpartum blood glucose screening among women with prior gestational diabetes mellitus in a rural community. J Adv Nurs. 2020;76(08):2151–2160. Doi: 10.1111/jan.14440
https://doi.org/10.1111/jan.14440...
,1414 de Gennaro G, Bianchi C, AragonaM, Battini L, Baronti W, Brocchi A, et al. Postpartum screening for type 2 diabetes mellitus in women with gestational diabetes: Is it really performed? Diabetes Res Clin Pract. 2020;166:108309. Doi: 10.1016/j.diabres.2020.108309
https://doi.org/10.1016/j.diabres.2020.1...
,1616 Cabizuca CA, Rocha PS, Marques JV, Costa TF, Santos AS, Schröder AL, et al. Postpartumfollow up of gestational diabetes in a Tertiary Care Center. Diabetol Metab Syndr. 2018;10:2. Doi: 10.1186/s13098-017-0303-4
https://doi.org/10.1186/s13098-017-0303-...

17 Napoli A, Sciacca L, Pintaudi B, Tumminia A, Dalfra MG, Festa C, et al; STRONG Study Collaborators and the AMD-SID Diabetes and Pregnancy Study Group. Screening of postpartum diabetes in women with gestational diabetes: high-risk subgroups and areas for improvements-the STRONG observational study. Acta Diabetol. 2021;58(09):1187–1197. Doi: 10.1007/s00592-021-01707-9
https://doi.org/10.1007/s00592-021-01707...

18 Farid H, Blake R, HackerMR, Erlinger AL, Modest AM. Strategies to improve postpartumglucose screening rates are needed. J Obstet Gynaecol Res. 2021;47(08):2641–2645. Doi: 10.1111/jog.14868
https://doi.org/10.1111/jog.14868...
-1919 Paul JC, Fitzpatrick JJ. Postpartum glucose screening amongwomen with gestational diabetes. Appl Nurs Res. 2020;56:151341. Doi: 10.1016/j.apnr.2020.151341
https://doi.org/10.1016/j.apnr.2020.1513...
show, including the current study, is that even though screening is indicated for all postpartum women with a history of GDM, its performance is still low. Screening is important, as it enables the establishment of the risks of developing DM, so physicians can prescribe behavioral or even pharmacological changes to prevent or delay the its diagnosis in this population and avoid the impacts of this comorbidity in the long term.88 Guo J, Chen JL, Whittemore R, Whitaker E. Postpartum lifestyle interventions to prevent type 2 diabetes among women with history of gestational diabetes: a systematic review of randomized clinical trials. J Womens Health (Larchmt). 2016;25(01): 38–49. Doi: 10.1089/jwh.2015.5262
https://doi.org/10.1089/jwh.2015.5262...

9 Miao ZR, Wu HH, Zhang YZ, Sun WJ, Lu DF, Yang HX, et al. Evaluation of the gestational diabetes mellitus diagnostic criteria recommended by the international association of diabetes and pregnancy study group for long-term maternal postpartum outcomes in mainland China. Medicine (Baltimore). 2020;99(08): e19242. Doi: 10.1097/MD.0000000000019242
https://doi.org/10.1097/MD.0000000000019...
-1010 Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, et al. Association of history of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US Women. JAMA Intern Med. 2017;177(12):1735–1742. Doi: 10.1001/jamainternmed.2017.2790
https://doi.org/10.1001/jamainternmed.20...
,2020 Aroda VR, Christophi CA, Edelstein SL, Zhang P, Herman WH, Barrett-Connor E, et al; Diabetes Prevention Program Research Group. The effect of lifestyle intervention and metformin onpreventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up. J Clin Endocrinol Metab. 2015;100(04): 1646–1653. Doi: 10.1210/jc.2014-3761
https://doi.org/10.1210/jc.2014-3761...

The main reason given for not performing the screening was failure to schedule the examination by the Basic Health Unit (40.1%), despite clear guidelines provided by the Brazilian Ministry of Health.22 Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016 This shows the fragility or lack or organizational alignment within the Brazilian public health care network. The other justifications, for the most part, were related to forgetfulness and other personal issues such as early return to work and difficulties with baby care. These cases could be avoided with more comprehensive assistance on the part of health agents.

Women who attended the postpartum appointments were more likely to undergo the screening test (RR: 1.213; 95%CI: 1.11–1.37). Corroborating the present study, Lawrence et al.2121 Lawrence JM, Black MH, Hsu JW, Chen W, Sacks DA. Prevalence and timing of postpartum glucose testing and sustained glucose dysregulation after gestational diabetes mellitus. Diabetes Care. 2010;33(03):569–576. Doi: 10.2337/dc09-2095
https://doi.org/10.2337/dc09-2095...
observed that patients who attended follow-up postnatal appointments were three times more likely to complete the DM screening. This is probably due to the relationship between seeking medical care at the primary care unit with the delivery of the exam request at the Basic Health Unit and the admission into the process of its performance and also the positive feedback on screening guidance during the appointment, although in the present study only 35.2% of the patients who attended the appointment reported having received guidance about the examination by the professionals who assisted them. In another study,2222 Rosenbloom JI, Blanchard MH. Compliance with postpartum diabetes screening recommendations for patients with gestational diabetes. J Womens Health (Larchmt). 2018;27(04):498–502. Doi: 10.1089/jwh.2017.6477
https://doi.org/10.1089/jwh.2017.6477...
whose focus was to observe the relationship between the level of training and the rate of DM screening, the authors found that puerperal women examined by resident physicians or midwives in their postnatal appointment, rather than by fully-trained physicians, tended to adhere more to the performance the test.

Another positive factor for the performance of the OGTT was the association with the need to use medication to treat GDM (RR: 2.455; 95%CI 1.54–4.21). Cabizuca et al.1616 Cabizuca CA, Rocha PS, Marques JV, Costa TF, Santos AS, Schröder AL, et al. Postpartumfollow up of gestational diabetes in a Tertiary Care Center. Diabetol Metab Syndr. 2018;10:2. Doi: 10.1186/s13098-017-0303-4
https://doi.org/10.1186/s13098-017-0303-...
showed that the use of insulin during pregnancy increases screening rates by ~ 6 times. This may be due to the perception that the use of medication implies a greater severity of the condition, which leads patients to be more concerned about the persistence of the disease in the puerperium, with a consequent greater demand for screening.

In the present study, we were able to show the association between the presence of comorbidities and adherence to screening (RR: 2.017; 95%CI: 1.23- 3.12). To the best of our knowledge, the present is the first study to show the correlation between these factors. This association may be due to the fact that women who have other morbidities, in addition to GDM, are already more concerned about their health; therefore, a higher rate of them chose to undergo screening.

Although these are the only significant associations in the present study, a few other articles1414 de Gennaro G, Bianchi C, AragonaM, Battini L, Baronti W, Brocchi A, et al. Postpartum screening for type 2 diabetes mellitus in women with gestational diabetes: Is it really performed? Diabetes Res Clin Pract. 2020;166:108309. Doi: 10.1016/j.diabres.2020.108309
https://doi.org/10.1016/j.diabres.2020.1...
,1717 Napoli A, Sciacca L, Pintaudi B, Tumminia A, Dalfra MG, Festa C, et al; STRONG Study Collaborators and the AMD-SID Diabetes and Pregnancy Study Group. Screening of postpartum diabetes in women with gestational diabetes: high-risk subgroups and areas for improvements-the STRONG observational study. Acta Diabetol. 2021;58(09):1187–1197. Doi: 10.1007/s00592-021-01707-9
https://doi.org/10.1007/s00592-021-01707...
,2323 Jones KE,YanY,Colditz GA,Herrick CJ. Prenatal counseling on type 2 diabetes risk, exercise, and nutrition affects the likelihood of postpartum diabetes screening after gestational diabetes. J Perinatol. 2018;38(04):315–323. Doi: 10.1038/s41372-017-0035-1
https://doi.org/10.1038/s41372-017-0035-...

24 Butalia S, Donovan L, Savu A, Johnson J, Edwards A, Kaul P. Postpartum diabetes testing rates after gestational diabetes mellitus in canadian women: a population-based study. Can J Diabetes. 2017; 41(06):613–620. Doi: 10.1016/j.jcjd.2016.12.013
https://doi.org/10.1016/j.jcjd.2016.12.0...

25 LiuZY, ZhaoJJ,GaoLL,WangAY.Glucosescreeningwithinsixmonths postpartum among Chinese mothers with a history of gestational diabetes mellitus: a prospective cohort study. BMC Pregnancy Childbirth. 2019;19(01):134. Doi: 10.1186/s12884-019-2276-9
https://doi.org/10.1186/s12884-019-2276-...
-2626 Quaresima P, Visconti F, Chiefari E, Puccio L, Foti DP, Venturella R, et al. Barriers to postpartum glucose intolerance screening in an italian population. Int J Environ Res Public Health. 2018;15(12): 2853. Doi: 10.3390/ijerph15122853
https://doi.org/10.3390/ijerph15122853...
also relate primiparity, advanced maternal age, history of GDM in previous pregnancies and family history of DM as factors that increase patient adherence to screening.

When interpreting the results of the present study, one should take into account that the patients received previous guidance on the performance of the screening and left the hospital with the request for the exam. The results might have been different if the guidance about the importance of the OGTT and the request for it depended on the primary care unit.

Conclusion

The rate of DM screening through the OGTT six weeks postpartum in women diagnosed with GDM is low. Women who attended the postpartum appointment, who needed medication for the treatment of GDM, and who had comorbidities were the most adherent to screening. It is essential to develop measures to cover a greater number of patients, such as follow-up programs, monitoring to prevent these women from leaving the hospital until the exam is performed, and improvements in the access to information regarding the importance of puerperal screening for DM, mainly in the primary health care setting.

References

  • 1
    International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels: IDF; 2019
  • 2
    Organização Pan-Americana da Saúde, Ministério da Saúde, Federação Brasileira das Associações de Ginecologia e Obstetrícia, Sociedade Brasileira de Diabetes. Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil. Brasília (DF): OPAS; 2016
  • 3
    Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P, et al; International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33(03):676–682. Doi: 10.2337/dc09-1848
    » https://doi.org/10.2337/dc09-1848
  • 4
    Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and metaanalysis. Lancet. 2009;373(9677):1773–1779. Doi: 10.1016/S01406736(09)60731-5
    » https://doi.org/10.1016/S0140-6736(09)60731-5
  • 5
    Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, Gillies CL. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ. 2020;369:m1361. Doi: 10.1136/bmj.m1361
    » https://doi.org/10.1136/bmj.m1361
  • 6
    Miao Z, Wu H, Ren L, Ren L, Bu N, Jiang L, Yang H, et al. Long-Term Postpartum Outcomes of Insulin Resistance and β-cell Function in Women with Previous Gestational Diabetes Mellitus. Int J Endocrinol. 2020;2020:7417356. Doi: 10.1155/2020/7417356
    » https://doi.org/10.1155/2020/7417356
  • 7
    American College of Obstetricians and Gynecologists. Practice Bulletin No. 180: gestational diabetes mellitus. Obstet Gynecol. 2017;130(01):e17–e37. Doi: 10.1097/AOG.0000000000002159
    » https://doi.org/10.1097/AOG.0000000000002159
  • 8
    Guo J, Chen JL, Whittemore R, Whitaker E. Postpartum lifestyle interventions to prevent type 2 diabetes among women with history of gestational diabetes: a systematic review of randomized clinical trials. J Womens Health (Larchmt). 2016;25(01): 38–49. Doi: 10.1089/jwh.2015.5262
    » https://doi.org/10.1089/jwh.2015.5262
  • 9
    Miao ZR, Wu HH, Zhang YZ, Sun WJ, Lu DF, Yang HX, et al. Evaluation of the gestational diabetes mellitus diagnostic criteria recommended by the international association of diabetes and pregnancy study group for long-term maternal postpartum outcomes in mainland China. Medicine (Baltimore). 2020;99(08): e19242. Doi: 10.1097/MD.0000000000019242
    » https://doi.org/10.1097/MD.0000000000019242
  • 10
    Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, et al. Association of history of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US Women. JAMA Intern Med. 2017;177(12):1735–1742. Doi: 10.1001/jamainternmed.2017.2790
    » https://doi.org/10.1001/jamainternmed.2017.2790
  • 11
    Rotem R, Salem-Yaniv S, Sandler-Rahat H, Yohay D, Shanny S, Yahav L, et al. Adherence to postpartum diabetes mellitus screening, do associated pregnancy complications make a difference? Diabetes Res Clin Pract. 2020;159:107972. Doi: 10.1016/j.diabres.2019.107972
    » https://doi.org/10.1016/j.diabres.2019.107972
  • 12
    Stasenko M, Liddell J, Cheng YW, Sparks TN, Killion M, Caughey AB. Patient counseling increases postpartumfollow-up inwomen with gestational diabetes mellitus.Am J Obstet Gynecol. 2011;204 (06):522.e1–522.e6. Doi: 10.1016/j.ajog.2011.01.057
    » https://doi.org/10.1016/j.ajog.2011.01.057
  • 13
    Tang Y, Guo J, LongQ, Yang J, Luo J, Yang S, et al. Factors influencing postpartum blood glucose screening among women with prior gestational diabetes mellitus in a rural community. J Adv Nurs. 2020;76(08):2151–2160. Doi: 10.1111/jan.14440
    » https://doi.org/10.1111/jan.14440
  • 14
    de Gennaro G, Bianchi C, AragonaM, Battini L, Baronti W, Brocchi A, et al. Postpartum screening for type 2 diabetes mellitus in women with gestational diabetes: Is it really performed? Diabetes Res Clin Pract. 2020;166:108309. Doi: 10.1016/j.diabres.2020.108309
    » https://doi.org/10.1016/j.diabres.2020.108309
  • 15
    Ortiz FM, Jimenez EY, BoursawB, Huttlinger K. Postpartum care for women with gestational diabetes. MCN Am J Matern Child Nurs. 2016;41(02):116–122. Doi: 10.1097/NMC.0000000000000215
    » https://doi.org/10.1097/NMC.0000000000000215
  • 16
    Cabizuca CA, Rocha PS, Marques JV, Costa TF, Santos AS, Schröder AL, et al. Postpartumfollow up of gestational diabetes in a Tertiary Care Center. Diabetol Metab Syndr. 2018;10:2. Doi: 10.1186/s13098-017-0303-4
    » https://doi.org/10.1186/s13098-017-0303-4
  • 17
    Napoli A, Sciacca L, Pintaudi B, Tumminia A, Dalfra MG, Festa C, et al; STRONG Study Collaborators and the AMD-SID Diabetes and Pregnancy Study Group. Screening of postpartum diabetes in women with gestational diabetes: high-risk subgroups and areas for improvements-the STRONG observational study. Acta Diabetol. 2021;58(09):1187–1197. Doi: 10.1007/s00592-021-01707-9
    » https://doi.org/10.1007/s00592-021-01707-9
  • 18
    Farid H, Blake R, HackerMR, Erlinger AL, Modest AM. Strategies to improve postpartumglucose screening rates are needed. J Obstet Gynaecol Res. 2021;47(08):2641–2645. Doi: 10.1111/jog.14868
    » https://doi.org/10.1111/jog.14868
  • 19
    Paul JC, Fitzpatrick JJ. Postpartum glucose screening amongwomen with gestational diabetes. Appl Nurs Res. 2020;56:151341. Doi: 10.1016/j.apnr.2020.151341
    » https://doi.org/10.1016/j.apnr.2020.151341
  • 20
    Aroda VR, Christophi CA, Edelstein SL, Zhang P, Herman WH, Barrett-Connor E, et al; Diabetes Prevention Program Research Group. The effect of lifestyle intervention and metformin onpreventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up. J Clin Endocrinol Metab. 2015;100(04): 1646–1653. Doi: 10.1210/jc.2014-3761
    » https://doi.org/10.1210/jc.2014-3761
  • 21
    Lawrence JM, Black MH, Hsu JW, Chen W, Sacks DA. Prevalence and timing of postpartum glucose testing and sustained glucose dysregulation after gestational diabetes mellitus. Diabetes Care. 2010;33(03):569–576. Doi: 10.2337/dc09-2095
    » https://doi.org/10.2337/dc09-2095
  • 22
    Rosenbloom JI, Blanchard MH. Compliance with postpartum diabetes screening recommendations for patients with gestational diabetes. J Womens Health (Larchmt). 2018;27(04):498–502. Doi: 10.1089/jwh.2017.6477
    » https://doi.org/10.1089/jwh.2017.6477
  • 23
    Jones KE,YanY,Colditz GA,Herrick CJ. Prenatal counseling on type 2 diabetes risk, exercise, and nutrition affects the likelihood of postpartum diabetes screening after gestational diabetes. J Perinatol. 2018;38(04):315–323. Doi: 10.1038/s41372-017-0035-1
    » https://doi.org/10.1038/s41372-017-0035-1
  • 24
    Butalia S, Donovan L, Savu A, Johnson J, Edwards A, Kaul P. Postpartum diabetes testing rates after gestational diabetes mellitus in canadian women: a population-based study. Can J Diabetes. 2017; 41(06):613–620. Doi: 10.1016/j.jcjd.2016.12.013
    » https://doi.org/10.1016/j.jcjd.2016.12.013
  • 25
    LiuZY, ZhaoJJ,GaoLL,WangAY.Glucosescreeningwithinsixmonths postpartum among Chinese mothers with a history of gestational diabetes mellitus: a prospective cohort study. BMC Pregnancy Childbirth. 2019;19(01):134. Doi: 10.1186/s12884-019-2276-9
    » https://doi.org/10.1186/s12884-019-2276-9
  • 26
    Quaresima P, Visconti F, Chiefari E, Puccio L, Foti DP, Venturella R, et al. Barriers to postpartum glucose intolerance screening in an italian population. Int J Environ Res Public Health. 2018;15(12): 2853. Doi: 10.3390/ijerph15122853
    » https://doi.org/10.3390/ijerph15122853

Publication Dates

  • Publication in this collection
    03 Feb 2023
  • Date of issue
    2022

History

  • Received
    21 Feb 2022
  • Accepted
    10 Aug 2022
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