Objective
The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM).
Study Design
A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.
Results
The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort ( P < .001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P < .001), Latinas (15% to 50%, P < .001), and Asians (43% to 59%, P = .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% ( P = .414).
Conclusion
GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.
Each year, between 2% and 10% of pregnancies in the United States are complicated by gestational diabetes mellitus (GDM), defined as insulin resistance with initial onset or recognition during pregnancy. The incidence of GDM varies widely amongst populations, with significantly higher rates among Asian, Hispanic, Native American, and potentially African American women compared with whites. Women diagnosed with GDM are at increased risk for a variety of pregnancy complications including gestational hypertensive disorders, fetal macrosomia, shoulder dystocia, and cesarean delivery.
Although well-controlled GDM has not been shown to be associated with increased perinatal mortality, all women with GDM, regardless of the level of control of GDM, are at increased risk for developing type 2 diabetes mellitus (T2DM) and cardiovascular disease, such as hypertension, later in life. In fact, a recent metaanalysis reported that women with GDM were 7 times more likely than women with normoglycemic pregnancies to develop T2DM, with mean postpartum follow-up varying from 6 weeks to 28 years. Given the increased risk for T2DM and hypertension, women with a history of GDM carry a higher lifetime risk of atherosclerosis and coronary artery disease. Because heart disease is the leading cause of death for women in the United States, early diabetes screening and prevention may be crucial parts of health maintenance.
Taking into account the long-term implications, early identification of postpartum T2DM risk and glucose intolerance is imperative and can be done by postpartum glucose screening. The American Congress of Obstetricians and Gynecologists Committee on Obstetrics Practice recently released a committee opinion recommending that all women with GDM be screened 6-12 weeks postpartum using either a 2 hour oral glucose tolerance test (OGTT) or a fasting blood glucose (FBG). Furthermore, the American Diabetes Association advocates continued diabetes screening at least every 3 years after initial GDM diagnosis.
Although the value of postpartum glucose screening has been well documented, there is evidence that such tests are significantly underutilized. In several recent US-based retrospective studies, the frequency of postpartum screening, using either the OGTT or the FBG, varied from 23% to 54%. Although these study populations differed widely by socioeconomic and racial/ethnic breakdowns, all agree that the rate of glucose screening postpartum is subpar. Reasons proposed for such lack of follow-up include confusion over the recommended guidelines, poor bridging from antepartum to postpartum care, lack of patient awareness, and the patient’s lack of interest in personal health.
Given this background, we designed a retrospective study to examine the effectiveness of an education intervention on postpartum follow-up of diabetes mellitus screening among women diagnosed with gestational diabetes. The study aim was to examine whether antepartum written and verbal counseling on the importance of postpartum glucose screening would increase rates of follow-up.
Materials and Methods
A retrospective cohort study of women with GDM delivering at the University of California, San Francisco (UCSF), from 2002 to 2009 was conducted. Institutional review board approval was obtained from the Committee on Human Research at UCSF. UCSF is a large academic medical center serving the socioeconomically and racially/ethnically diverse population of the San Francisco Bay Area.
According to institutional protocol, all pregnant women receiving care at this institution undergo screening for GDM between 24 and 28 weeks or during the first trimester if risk factors for diabetes mellitus are present. GDM is diagnosed based on the Carpenter-Coustan criteria (2 elevated values on a 3 hour glucose tolerance test with thresholds of 95 mg/dL fasting, 180 mg/dL at 1 hour, 155 mg/dL at 2 hours, and 140 mg/dL at 3 hours after the glucose load). At discharge from the hospital postpartum, all women with GDM are given a laboratory requisition to obtain glucose testing prior to their 6 week postpartum visit. Those who do not have the test by that visit are given another slip and encouraged to obtain testing as quickly as possible.
Women received either an FBG test, or a 2 hour OGTT. The FBG is a plasma glucose level drawn the morning after an overnight fast. The OGTT is an FBG followed by a 75 g oral glucose load and a plasma glucose test 2 hours later. Plasma glucose was measured by the glucose oxidase technique in the clinical laboratory at UCSF. Women delivering between 2002 and 2006 received antepartum and postpartum GDM care as directed by this protocol.
To augment the standard protocol, women with GDM delivering between 2007 and 2009 were also given antepartum verbal and written counseling on the importance of postpartum follow-up. At the 37-38 week visit, all GDM patients, regardless of GDM subtype, had a 5-10 minute meeting with a registered nurse who is a certified diabetes educator. They were specifically educated about the increased risk for T2DM and were instructed to return for glucose screening prior to their postpartum appointment. All questions were answered and at the conclusion of the session, the patients were given a 2 page handout with the following information: follow-up recommendations with instructions for obtaining an OGTT prior to the postpartum visit, instructions for blood sugar follow-up in the future, recommendations for weight loss and exercise as T2DM preventative strategies, and UCSF-based diabetes resources. Of note, the diversity of women with GDM mandates that counseling be conducted in the patient’s primary language. Non–English-speaking patients were provided all information in their primary language of choice via translator phone or UCSF interpreter services.
Once the 2 subcohorts were identified (women preeducational intervention [2002-2006] and posteducational intervention [2007-2009]), data were abstracted from medical records and laboratory reports to obtain follow-up information on the postpartum glucose testing that was done within 6 months of delivery and other clinical data, including maternal demographics and clinical characteristics, as well as perinatal outcomes. To make sure that women who obtained follow-up after the standard 6-12 week cutoff were included, we chose a 6 month cutoff.
The primary outcome examined was whether the patients obtained postpartum glucose testing. Medical records were reviewed for documentation of FBG or OGTT within 6 months of delivery. The outcomes were compared between the pre- and postintervention groups. Associations with maternal race/ethnicity, age, GDM subtype (A1 vs A2), and preterm birth were examined.
Data were abstracted and recorded using Excel (Microsoft, Redmond, WA), and statistical analyses were conducted with STATA version 9.0 software (Statacorp, College Station, TX). Dichotomous outcomes were compared with the χ 2 test, except when the cell sizes were less than 10, and the Fisher’s exact test was utilized instead. Multivariable logistic regression controlled for potential confounders (maternal race/ethnicity, age, GDM subtype, and preterm birth). Results were considered statistically significant if P < .05 and/or if 95% confidence intervals did not contain 1.0.
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