Missed Opportunities for Early Diabetes Screening in Pregnancy

Abstract

Objective This study aimed to identify characteristics of women at risk of undiagnosed type 2 diabetes mellitus (T2DM) that fail to receive early pregnancy screening.

Study Design This was a retrospective case–control study of at-risk women who initiated care at the University of North Carolina at Chapel Hill at <21 weeks from January 2015 to December 2015. In 2013, the American College of Obstetricians and Gynecologists and the American Diabetes Association recommended women with prior GDM, glucose intolerance, or body mass index (BMI) ≥ 30 kg/m² receive early pregnancy screening for undiagnosed T2DM. We defined early screening as 1-hour 50-g glucose challenge test or hemoglobin A1c at <21 weeks' gestation. Cases were women who did not have early screening, and controls were women who did. Modified Poisson regression with robust error variance estimated relative risks of factors associated with missed early screening.

Results Of the 1,932 women who initiated care at <21 weeks, 257 (13%) women were at risk of undiagnosed T2DM and, thus, candidates for early screening. However, 129 (50.2%) women were not screened. Higher BMI and prior GDM were associated with a lower relative risk of missed screening.

Conclusion Higher BMI and prior GDM increased the likelihood of early diabetes screening, but only half of at-risk women were screened. Provider education and best practice alert systems are needed to increase screening for undiagnosed T2DM.

Keywords

screening - diabetes - early - pregnancy - obesity

Publication History

Received: 01 April 2019

Accepted: 28 June 2019

Article published online:
17 August 2019

• References

• 1 Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017
• 2 Rosenn B, Miodovnik M, Kranias G. et al. Progression of diabetic retinopathy in pregnancy: association with hypertension in pregnancy. Am J Obstet Gynecol 1992; 166 (04) 1214-1218
• 3 Gordon M, Landon MB, Samuels P, Hissrich S, Gabbe SG. Perinatal outcome and long-term follow-up associated with modern management of diabetic nephropathy. Obstet Gynecol 1996; 87 (03) 401-409
• 4 Sibai BM, Caritis S, Hauth J. et al; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Risks of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes mellitus. Am J Obstet Gynecol 2000; 182 (02) 364-369
• 5 Balsells M, García-Patterson A, Gich I, Corcoy R. Maternal and fetal outcome in women with type 2 versus type 1 diabetes mellitus: a systematic review and metaanalysis. J Clin Endocrinol Metab 2009; 94 (11) 4284-4291
• 6 Agha MM, Glazier RH, Moineddin R, Booth G. Congenital abnormalities in newborns of women with pregestational diabetes: a time-trend analysis, 1994 to 2009. Birth Defects Res A Clin Mol Teratol 2016; 106 (10) 831-839
• 7 Jovanovic-Peterson L, Peterson CM, Reed GF. et al. Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early Pregnancy Study. The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study. Am J Obstet Gynecol 1991; 164 (1 Pt 1): 103-111
• 8 Mitanchez D, Yzydorczyk C, Siddeek B, Boubred F, Benahmed M, Simeoni U. The offspring of the diabetic mother--short- and long-term implications. Best Pract Res Clin Obstet Gynaecol 2015; 29 (02) 256-269
• 9 Weintrob N, Karp M, Hod M. Short- and long-range complications in offspring of diabetic mothers. J Diabetes Complications 10 (05) 294-301
• 10 The Diabetes Control Complications Trial Research Group. Pregnancy outcomes in the Diabetes Control and Complications Trial. Am J Obstet Gynecol 1996; 174 (04) 1343-1353
• 11 American College of Obstetricians and Gynecologists. Pregestational diabetes mellitus. ACOG Practice Bulletin No. 201. Obstet Gynecol 2018; 132 (06) e228-e248
• 12 Janz NK, Herman WH, Becker MP. et al. Diabetes and pregnancy. Factors associated with seeking pre-conception care. Diabetes Care 1995; 18 (02) 157-165
• 13 Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med 2016; 374 (09) 843-852
• 14 American College of Obstetricians and Gynecologists. Practice Bulletin No. 137: gestational diabetes mellitus. Obs Gynecol 2013; 122: 406-416
• 15 Metzger BE, Buchanan TA, Coustan DR. et al. Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 2007; 30 (Suppl. 02) S251-S260
• 16 American Diabetes Association. Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 01) S11-S24
• 17 Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004; 159 (07) 702-706
• 18 Mission JF, Catov J, Deihl TE, Feghali M, Scifres C. Early pregnancy diabetes screening and diagnosis: prevalence, rates of abnormal test results, and associated factors. Obstet Gynecol 2017; 130 (05) 1136-1142
• 19 Battarbee AN, Yee LM. Barriers to postpartum follow-up and glucose tolerance testing in women with gestational diabetes mellitus. Am J Perinatol 2018; 35 (04) 354-360
• 20 Werner E, Has P, Kanno L, Sullivan A, Clark M. Barriers to postpartum glucose testing in women with gestational diabetes mellitus. Am J Perinatol 2019; 36 (02) 212-218
• 21 Morgan JL, Baggari SR, Chung W, Ritch J, McIntire DD, Sheffield JS. Association of a best-practice alert and prenatal administration with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination rates. Obstet Gynecol 2015; 126 (02) 333-337
• 22 American College of Obstetricians and Gynecologists. Practice Bulletin No. 180: gestational diabetes mellitus. Obs Gynecol 2017; 130: e17-e31