Download PDF
Am J Perinatol 2015; 32(03): 299-306
DOI: 10.1055/s-0034-1384637
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

SUGAR: Spotting Undiagnosed Glucose Abnormal Results—A New Protocol To Increase Postpartum Testing Among Women With Gestational Diabetes Mellitus

Michael P. Carson
1   Department of Medicine, Jersey Shore University Medical Center, Neptune, New Jersey
2   Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
3   Department of Medicine and Obstetrics, Gynecology and Reproductive Sciences, Rutgers-Robert Wood Johnson Medical School, Piscataway, New Jersey
,
Benjamin Morgan
2   Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
,
Debra Gussman
2   Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
3   Department of Medicine and Obstetrics, Gynecology and Reproductive Sciences, Rutgers-Robert Wood Johnson Medical School, Piscataway, New Jersey
,
Monica Brown
2   Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
,
Karen Rothenberg
2   Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
,
Theresa A. Wisner
2   Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey
› Author Affiliations
Further Information

Publication History

30 April 2014

03 June 2014

Publication Date:
05 August 2014 (online)

    Permissions and Reprints

Abstract

Objective Over 70% of women with gestational diabetes mellitus (GDM) will develop diabetes mellitus (DM), but only 30% follow through with the recommended postpartum oral glucose tolerance testing (OGTT). HbA1c is approved to diagnose DM, and combined with a fasting plasma glucose it can identify 93% of patients with dysglycemia. We tested the hypothesis that a single blood draw to assess for dysglycemia at the postpartum visit could improve testing rates compared with those required to obtain an OGTT at an outside laboratory.

Study Design Prospective cohort study of all women with GDM who delivered between July 2010 and December 2011. When insurance status required testing at an outside laboratory an OGTT was ordered, when insurance allowed testing at our center a random sugar and HbA1c were drawn at the postpartum visit (SUGAR Protocol).

Results Of the 40 women, 36 attended a postpartum visit. In the SUGAR arm, 19 of 19 (100%) were tested versus 9 of 17 (53%) in the OGTT arm; relative risk of testing was 1.9 (95% confidence interval, 1.2–3.0). 36% were glucose intolerant.

Conclusion This pilot study found that an in-office testing model doubled the rate of postpartum testing in this clinic population, and was reasonably sensitive at detecting dysglycemia.

Keywords

gestational diabetes mellitus - glucose intolerance - postpartum testing - pregnancy

Note

This article was selected for oral presentation at the 2012 International Society of Obstetric Medicine, Oxford, United Kingdom.


 

  • References

  • 1 American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2012; 35 (Suppl. 01) S64-S71
    CrossrefPubMedGoogle Scholar
  • 2 American College of Obstetricians and Gynecologists Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol 2001; 98 (3) 525-538
    PubMedGoogle Scholar
  • 3 American Diabetes Association. Standards of medical care in diabetes—2008. Diabetes Care 2008; 31 (Suppl. 01) S12-S54
    CrossrefPubMedGoogle Scholar
  • 4 Blumer I, Hadar E, Hadden DR , et al. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2013; 98 (11) 4227-4249
    CrossrefPubMedGoogle Scholar
  • 5 Dabelea D, Snell-Bergeon JK, Hartsfield CL, Bischoff KJ, Hamman RF, McDuffie RS. Kaiser Permanente of Colorado GDM Screening Program. Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort: Kaiser Permanente of Colorado GDM Screening Program. Diabetes Care 2005; 28 (3) 579-584
    CrossrefPubMedGoogle Scholar
  • 6 Getahun D, Nath C, Ananth CV, Chavez MR, Smulian JC. Gestational diabetes in the United States: temporal trends 1989 through 2004. Am J Obstet Gynecol 2008; 198 (5) e1-e5
    PubMedGoogle Scholar
  • 7 Beischer NA, Wein P, Sheedy MT, Steffen B. Identification and treatment of women with hyperglycaemia diagnosed during pregnancy can significantly reduce perinatal mortality rates. Aust N Z J Obstet Gynaecol 1996; 36 (3) 239-247
    CrossrefPubMedGoogle Scholar
  • 8 Carson MP, Frank MI, Keely E. Original research: postpartum testing rates among women with a history of gestational diabetes—systematic review. Prim Care Diabetes 2013; 7 (3) 177-186
    CrossrefPubMedGoogle Scholar
  • 9 CDC. gov. Overweight and Obesity. 2012. Available at: http://www.cdc.gov/obesity/data/trends.html . Accessed July 24, 2012
    PubMedGoogle Scholar
  • 10 Reinblatt SL, Morin L, Meltzer SJ. The importance of a postpartum 75 g oral glucose tolerance test in women with gestational diabetes. J Obstet Gynaecol Can 2006; 28 (8) 690-694
    PubMedGoogle Scholar
  • 11 Agarwal MM, Dhatt GS, Punnose J. Gestational diabetes: an alternative, patient-friendly approach for using the diagnostic 100-g OGTT in high-risk populations. Arch Gynecol Obstet 2006; 273 (6) 325-330
    CrossrefPubMedGoogle Scholar
  • 12 Stasenko M, Liddell J, Cheng YW, Sparks TN, Killion M, Caughey AB. Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus. Am J Obstet Gynecol 2011; 204 (6) e1-e6
    PubMedGoogle Scholar
  • 13 Hunt KJ, Logan SL, Conway DL, Korte JE. Postpartum screening following GDM: how well are we doing?. Curr Diab Rep 2010; 10 (3) 235-241
    CrossrefPubMedGoogle Scholar
  • 14 Dietz PM, Vesco KK, Callaghan WM , et al. Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy. Obstet Gynecol 2008; 112 (4) 868-874
    CrossrefPubMedGoogle Scholar
  • 15 Russell MA, Phipps MG, Olson CL, Welch HG, Carpenter MW. Rates of postpartum glucose testing after gestational diabetes mellitus. Obstet Gynecol 2006; 108 (6) 1456-1462
    CrossrefPubMedGoogle Scholar
  • 16 Kim C, Tabaei BP, Burke R , et al. Missed opportunities for type 2 diabetes mellitus screening among women with a history of gestational diabetes mellitus. Am J Public Health 2006; 96 (9) 1643-1648
    CrossrefPubMedGoogle Scholar
  • 17 Smirnakis KV, Chasan-Taber L, Wolf M, Markenson G, Ecker JL, Thadhani R. Postpartum diabetes screening in women with a history of gestational diabetes. Obstet Gynecol 2005; 106 (6) 1297-1303
    CrossrefPubMedGoogle Scholar
  • 18 Kwong S, Mitchell RS, Senior PA, Chik CL. Postpartum diabetes screening: adherence rate and the performance of fasting plasma glucose versus oral glucose tolerance test. Diabetes Care 2009; 32 (12) 2242-2244
    CrossrefPubMedGoogle Scholar
  • 19 Blatt AJ, Nakamoto JM, Kaufman HW. Gaps in diabetes screening during pregnancy and postpartum. Obstet Gynecol 2011; 117 (1) 61-68
    CrossrefPubMedGoogle Scholar
  • 20 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 (3) 569-576
    CrossrefPubMedGoogle Scholar
  • 21 Stasenko M, Cheng YW, McLean T, Jelin AC, Rand L, Caughey AB. Postpartum follow-up for women with gestational diabetes mellitus. Am J Perinatol 2010; 27 (9) 737-742
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Clark HD, van Walraven C, Code C, Karovitch A, Keely E. Did publication of a clinical practice guideline recommendation to screen for type 2 diabetes in women with gestational diabetes change practice?. Diabetes Care 2003; 26 (2) 265-268
    CrossrefPubMedGoogle Scholar
  • 23 Kim C, Herman WH, Vijan S. Efficacy and cost of postpartum screening strategies for diabetes among women with histories of gestational diabetes mellitus. Diabetes Care 2007; 30 (5) 1102-1106
    CrossrefPubMedGoogle Scholar
  • 24 Beischer NA, Wein P, Sheedy MT. A follow-up program for women with previous gestational diabetes mellitus. Med J Aust 1997; 166 (7) 353-357
    PubMedGoogle Scholar
  • 25 Dacus JV, Meyer NL, Muram D, Stilson R, Phipps P, Sibai BM. Gestational diabetes: postpartum glucose tolerance testing. Am J Obstet Gynecol 1994; 171 (4) 927-931
    CrossrefPubMedGoogle Scholar
  • 26 Kjos SL, Buchanan TA, Greenspoon JS, Montoro M, Bernstein GS, Mestman JH. Gestational diabetes mellitus: the prevalence of glucose intolerance and diabetes mellitus in the first two months post partum. Am J Obstet Gynecol 1990; 163 (1 Pt 1) 93-98
    CrossrefPubMedGoogle Scholar
  • 27 Ogonowski J, Miazgowski T. The prevalence of 6 weeks postpartum abnormal glucose tolerance in Caucasian women with gestational diabetes. Diabetes Res Clin Pract 2009; 84 (3) 239-244
    CrossrefPubMedGoogle Scholar
  • 28 Buchanan TA, Xiang A, Kjos SL , et al. Gestational diabetes: antepartum characteristics that predict postpartum glucose intolerance and type 2 diabetes in Latino women. Diabetes 1998; 47 (8) 1302-1310
    CrossrefPubMedGoogle Scholar
  • 29 Kjos SL, Peters RK, Xiang A, Henry OA, Montoro M, Buchanan TA. Predicting future diabetes in Latino women with gestational diabetes. Utility of early postpartum glucose tolerance testing. Diabetes 1995; 44 (5) 586-591
    CrossrefPubMedGoogle Scholar
  • 30 Pallardo F, Herranz L, Garcia-Ingelmo T , et al. Early postpartum metabolic assessment in women with prior gestational diabetes. Diabetes Care 1999; 22 (7) 1053-1058
    CrossrefPubMedGoogle Scholar
  • 31 Aberg AE, Jönsson EK, Eskilsson I, Landin-Olsson M, Frid AH. Predictive factors of developing diabetes mellitus in women with gestational diabetes. Acta Obstet Gynecol Scand 2002; 81 (1) 11-16
    CrossrefPubMedGoogle Scholar
  • 32 Clark HD, Graham ID, Karovitch A, Keely EJ. Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Am J Obstet Gynecol 2009; 200 (6) e1-e7
    PubMedGoogle Scholar
  • 33 Cypryk K, Czupryniak L, Wilczyński J, Lewiński A. Diabetes screening after gestational diabetes mellitus: poor performance of fasting plasma glucose. Acta Diabetol 2004; 41 (1) 5-8
    CrossrefPubMedGoogle Scholar
  • 34 International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009; 32 (7) 1327-1334
    CrossrefPubMedGoogle Scholar
  • 35 American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care 2010; 33 (Suppl. 01) S11-S61
    CrossrefPubMedGoogle Scholar
  • 36 Manley SE, Sikaris KA, Lu ZX , et al. Validation of an algorithm combining haemoglobin A(1c) and fasting plasma glucose for diagnosis of diabetes mellitus in UK and Australian populations. Diabet Med 2009; 26 (2) 115-121
    CrossrefPubMedGoogle Scholar
  • 37 Katon J, Reiber G, Williams MA, Yanez D, Miller E. Hemoglobin A1c and postpartum abnormal glucose tolerance among women with gestational diabetes mellitus. Obstet Gynecol 2012; 119 (3) 566-574
    CrossrefPubMedGoogle Scholar
  • 38 Kim C, Herman WH, Cheung NW, Gunderson EP, Richardson C. Comparison of hemoglobin A1c with fasting plasma glucose and 2-h postchallenge glucose for risk stratification among women with recent gestational diabetes mellitus. Diabetes Care 2011; 34 (9) 1949-1951
    CrossrefPubMedGoogle Scholar
  • 39 Megia A, Näf S, Herranz L , et al. The usefulness of HbA1c in postpartum reclassification of gestational diabetes. BJOG 2012; 119 (7) 891-894
    CrossrefPubMedGoogle Scholar
  • 40 Bennett WL, Ennen CS, Carrese JA , et al. Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: a qualitative study. J Womens Health (Larchmt) 2011; 20 (2) 239-245
    CrossrefPubMedGoogle Scholar
  • 41 Committee on Obstetric Practice. ACOG Committee Opinion No. 435: postpartum screening for abnormal glucose tolerance in women who had gestational diabetes mellitus. Obstet Gynecol 2009; 113 (6) 1419-1421
    Google Scholar
  • 42 American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 2004; 27 (Suppl. 01) S88-S90
    CrossrefPubMedGoogle Scholar
  • 43 Pan XR, Li GW, Hu YH , et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20 (4) 537-544
    CrossrefPubMedGoogle Scholar
  • 44 Ratner RE. Diabetes Prevention Program Research. An update on the Diabetes Prevention Program. Endocr Pract 2006; 12 (Suppl. 01) 20-24
    CrossrefPubMedGoogle Scholar
  • 45 The Diabetes Prevention Program Research Group. The Diabetes Prevention Program: baseline characteristics of the randomized cohort. Diabetes Care 2000; 23 (11) 1619-1629
    CrossrefPubMedGoogle Scholar
  • 46 Knowler WC, Barrett-Connor E, Fowler SE , et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346 (6) 393-403
    CrossrefPubMedGoogle Scholar
  • 47 Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med 2005; 143 (4) 251-264
    CrossrefPubMedGoogle Scholar
  • 48 Herman WH, Hoerger TJ, Brandle M , et al; Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med 2005; 142 (5) 323-332
    CrossrefPubMedGoogle Scholar
  • 49 McClean S, Farrar D, Kelly CA, Tuffnell DJ, Whitelaw DC. The importance of postpartum glucose tolerance testing after pregnancies complicated by gestational diabetes. Diabet Med 2010; 27 (6) 650-654
    CrossrefPubMedGoogle Scholar
  • 50 Costa A, Carmona F, Martinez-Roman S, Quintó L, Levy I, Conget I. Post-partum reclassification of glucose tolerance in women previously diagnosed with gestational diabetes mellitus. Diabet Med 2000; 17 (8) 595-598
    CrossrefPubMedGoogle Scholar
  • 51 Miller E, Hare JW, Cloherty JP , et al. Elevated maternal hemoglobin A1c in early pregnancy and major congenital anomalies in infants of diabetic mothers. N Engl J Med 1981; 304 (22) 1331-1334
    CrossrefPubMedGoogle Scholar
  • 52 Cnattingius S, Bergström R, Lipworth L, Kramer MS. Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med 1998; 338 (3) 147-152
    CrossrefPubMedGoogle Scholar
  • 53 Johnson K, Posner SF, Biermann J , et al; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care—United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep 2006; 55 (Suppl. 06) 1-23
    PubMedGoogle Scholar
  • 54 Iyoke CA, Ugwu GO, Ezugwu FO, Lawani OL, Onyebuchi AK. Retrospective cohort study of the effects of obesity in early pregnancy on maternal weight gain and obstetric outcomes in an obstetric population in Africa. Int J Womens Health 2013; 5: 501-507
    PubMedGoogle Scholar
  • 55 Heyl PS, Sappenfield WM, Burch D, Hernandez LE, Kavanaugh VM, Hill WC. Pregnancy-related deaths due to pulmonary embolism: findings from two state-based mortality reviews. Matern Child Health J 2013; 17 (7) 1230-1235
    CrossrefPubMedGoogle Scholar
  • 56 Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Improving reproductive performance in overweight/obese women with effective weight management. Hum Reprod Update 2004; 10 (3) 267-280
    CrossrefPubMedGoogle Scholar
  • 57 Kiddy DS, Hamilton-Fairley D, Bush A , et al. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 1992; 36 (1) 105-111
    CrossrefPubMedGoogle Scholar
  • 58 American College of Obstetricians and Gynecologists. ACOG Committee Opinion number 315, September 2005. Obesity in pregnancy. Obstet Gynecol 2005; 106 (3) 671-675
    CrossrefPubMedGoogle Scholar
  • 59 American College of Obstetricians and Gynecologists. ACOG Committee Opinion number 313, September 2005. The importance of preconception care in the continuum of women's health care. Obstet Gynecol 2005; 106 (3) 665-666
    CrossrefPubMedGoogle Scholar
  • 60 Tovar A, Chasan-Taber L, Eggleston E, Oken E. Postpartum screening for diabetes among women with a history of gestational diabetes mellitus. Prev Chronic Dis 2011; 8 (6) A124
    PubMedGoogle Scholar
  • 61 Shah BR, Lipscombe LL, Feig DS, Lowe JM. Missed opportunities for type 2 diabetes testing following gestational diabetes: a population-based cohort study. BJOG 2011; 118 (12) 1484-1490
    CrossrefPubMedGoogle Scholar
  • 62 Kerimoğlu OSY, Yalvaç S, Karcaaltıncaba D, Kandemir O, Altınbaş SK, Dede H. Early post-partum diabetes mellitus screening rates in patients with history of gestational diabetes. Arch Gynecol Obstet 2010; 282 (6) 613-616
    CrossrefPubMedGoogle Scholar
  • 63 Oldfield MD, Donley P, Walwyn L, Scudamore I, Gregory R. Long term prognosis of women with gestational diabetes in a multiethnic population. Postgrad Med J 2007; 83 (980) 426-430
    CrossrefPubMedGoogle Scholar
  • 64 Yanit KE, Snowden JM, Cheng YW, Caughey AB. The impact of chronic hypertension and pregestational diabetes on pregnancy outcomes. Am J Obstet Gynecol 2012; 207 (4) e1-e6
    PubMedGoogle Scholar
  • 65 Picón MJ, Murri M, Muñoz A, Fernández-García JC, Gomez-Huelgas R, Tinahones FJ. Hemoglobin A1c versus oral glucose tolerance test in postpartum diabetes screening. Diabetes Care 2012; 35 (8) 1648-1653
    CrossrefPubMedGoogle Scholar
  • 66 Carson MP, Lewis BG, Pagan ER, Evers M. Evaluation of home testing to improve follow up after gestational diabetes (Fingerstick Assessments of Sugar Two-months postpartum or FAST). Obstetric Medicine 2013; 6 (3) 120-124
    CrossrefPubMedGoogle Scholar