乌鸦传媒

ORLANDO -- Earlier screening and treatment for gestational diabetes, as well as a "shift to a holistic life-course approach," are needed to reduce the toll it takes on women.

That was the conclusion of a series of papers published in and presented at the American Diabetes Association (ADA) annual meeting.

"One of the sort of very stark statistics that comes out from the series is that 30% of cases of diabetes in parous women is from women who have had gestational diabetes," said Jessamy Bagenal, MBBS, MPH, an editor for Lancet Diabetes & Endocrinology, who chaired the session.

"The evidence base and the guidelines from around the world are very clear on this. Women should be getting long-term screening and appropriate follow-up," she noted. "And yet most women don't seem to be getting any kind of follow-up at all. And, in fact, in many health systems, the information that is gathered during pregnancy in terms of their long-term cardiometabolic risk is simply lost between maternal care and primary care. And that's a huge failure."

The U.S. is not alone in this, she added. "As far as I can tell, there are no exemplar countries where people are providing the sort of optimal care that women who have gestational diabetes might need. Nobody, as far as I can tell, is measuring which women are receiving any type of follow-up."

Key messages from the group included:

• The need for early gestational diabetes testing for those with risk factors, ideally before 14 weeks' gestation
• Promoting health that prepares women, especially those with risk factors, for a healthy pregnancy and then healthy aging
• Improving antenatal care to include postpartum screening for glycemic status
• Tailored annual assessments after gestational diabetes to prevent or better manage complications like type 2 diabetes and cardiovascular disease

Early pregnancy screening is now recommended in some form in both international and ADA guidelines, said Hannah Wesley, MPH, PhD, of the Madras Diabetes Research Foundation in Chennai, India.

The global prevalence of early gestational diabetes is 0.7% to 14.7%, based on 20 studies that screened before 12 weeks.

However, one of the papers by the group noted that "as more women enter pregnancy with obesity and some degree of abnormal glucose or insulin regulation, gestational diabetes is becoming a more complex disease. Women are more frequently presenting with insulin resistance and hyperglycemia in early pregnancy, which even below type 2 diabetes glycemic thresholds are likely to carry higher risks of congenital anomaly and miscarriage."

The best metric for screening in early gestation hasn't become clear yet, said Arianne Sweeting, PhD, of the University of Sydney in Australia. Early fasting glucose has been found to have no or only weak association with outcomes. Two-hour oral glucose tolerance testing (OGTT) has the strongest evidence base. In the , OGTT better correlated with outcomes compared with HbA1c.

Treatment based on this early diagnosis improved outcomes for babies in the TOBOGM randomized trial. Immediate treatment of women first diagnosed before 20 weeks' gestation significantly reduced a composite of preterm birth, birth trauma, high birth weight, respiratory distress, phototherapy, stillbirth or neonatal death, and shoulder dystocia (24.9% vs 30.5%) compared with treatment dependent on confirmation as usual after repeat OGTT at 24 to 28 weeks' gestation.

Women diagnosed before 14 weeks' gestation and those with (162-199 mg/dL at 2 hours) derived the most benefit, Sweeting noted.

About one-third of those who had early gestational diabetes in the trial no longer had it at the repeat OGTT at approximately 24 to 28 weeks' gestation, and 17% initially without it developed it by the later point, said Patrick Catalano, MD, of the Mother Infant Research Institute at Tufts Medical Center in Boston.

"Keeping in mind we're talking about a categorical diagnosis and the difference in glucose may be very minor," he said at the session. "But clinically, people are going to treat based on a categorical diagnosis. So my point in showing these whole data is that what we need to do is keep in mind that [diagnosis in] early pregnancy is very unique. The criteria that we use may not be the same criteria that we use in late pregnancy and may account for some of these changes that we see when we repeat the GTT [glucose tolerance testing] later in pregnancy."

In terms of early diagnosis, "we need some consensus building in the ob/gyn and endocrinology spaces to really ascertain whether this is where we want to go," Bagenal said.

However, clinicians can act immediately to offer women better advice about future risk after gestational diabetes, she argued. "Part of that problem is because primary care and maternal care are very siloed," she told 乌鸦传媒. The other part is "a sort of a misplaced paternalistic view that women probably can't take the anxiety of learning that they might be at extra risk of diabetes later on, so we won't bother them with it. And, actually, what we're doing is denying them this sort of accurate information to be able to make the necessary steps that they could do after pregnancy to reduce their risk."

She suggested that the easiest thing for clinicians to do is to give patients the information that they need about their long-term risk profile. "Your risk now of getting diabetes in the next 10 years has increased by 10-50%, and you need yearly screening," she said. "Our health service isn't going to offer you that, but you need to advocate for yourself, and you need to make sure that you get that screening, and you need to take necessary lifestyle interventions to reduce your risk further in terms of diet, in terms of meal times, and in terms of exercise."

After diagnosis, the group's call to action paper argued for OGTT again at 6 to 12 weeks postpartum to assess the glycemic state and subsequent regular screening for both type 2 diabetes and cardiometabolic disease, "which can be incorporated alongside other family health activities ... At all stages in this life course approach, across both high-resource and low-resource settings, a more systematic process for identifying and overcoming barriers to preventative care and treatment is needed to reduce the current global burden of gestational diabetes."