Eva Anderberg

A simplified oral glucose tolerance test in pregnancy : compliance and results

Background. To describe a reliable method for a general oral glucose tolerance test (OGTT) during pregnancy, to evaluate adherence to the method, and to compare the frequency of reported gestational diabetes mellitus (GDM) and perinatal outcome in affected pregnancies in Skåne, using direct diagnostic OGTT, with those from a comparable area, Halmstad‐Ljungby‐Växjö (HLV), using random glucose measurements (RGM) to identify women for the OGTT. Methods. The OGTT program and quality assurance in Skåne is described. Antenatal records on deliveries in May 2003 were scrutinised to ascertain if OGTT had been performed. Frequencies of GDM, prematurity and large for gestational age (LGA) infants were estimated using a population‐based perinatal database (PRS). Results. OGTT was performed in 93% of pregnant women in Skåne. In 2000–2003 GDM frequency in Skåne was twice as high as in HLV (1.9 versus 1%), while the frequency of LGA and prematurity among infants of mothers who were diagnosed with GDM were similar. Conclusions. Decentralised general OGTT is a reliable and effective method to diagnose GDM. OGTT is twice as sensitive as RGM, and the severity of GDM in the cases identified with OGTT did not differ from the severity of those identified with RGM.

Genetic prediction of postpartum diabetes in women with gestational diabetes mellitus

AIMS To examine whether genetic variants that predispose individuals to type 2 diabetes (T2D) could predict the development of diabetes after gestational diabetes mellitus (GDM). METHODS 13 SNPs (FTO rs8050136, CDKAL1 rs7754840 and rs7756992, CDKN2A/2B rs10811661, HHEX rs1111875, IGF2BP2 rs1470579 and rs4402960, SLC30A8 rs13266634, TCF7L2 rs7903146, PPARG rs1801282, GCK rs1799884, HNF1A rs1169288, and KCNJ11 rs5219) were genotyped in 793 women with GDM after a median follow-up of 57 months. RESULTS After adjustment for age and ethnicity, the TCF7L2 rs7903146 and the FTO rs8050136 variants significantly predicted postpartum diabetes; hazard ratio (95% confidence interval 1.29 (1.01-1.66) and 1.36 (1.06-1.74), respectively (additive model) versus 1.45 (1.01-2.08) and 1.56 (1.06-2.29) (dominant model)). Adjusting for BMI attenuated the effect of the FTO variant, suggesting that the effect was mediated through its effect on BMI. Combining all risk alleles to a weighted risk score was significantly associated with the risk of postpartum diabetes (hazard ratio 1.11, 95% confidence interval 1.05-1.18, p=0.00016 after adjustment for age and ethnicity). CONCLUSIONS The TCF7L2 rs7903146 and FTO rs8050136 polymorphisms, and particularly a weighted risk score of T2D risk alleles, predict diabetes after GDM. Further studies in other populations are needed to confirm our results.

Trends in the prevalence of gestational diabetes mellitus in southern Sweden, 2003-2012.

There is accumulating evidence that gestational diabetes is a growing problem. The lack of internationally standardized diagnostic procedures prevents consistent diagnosis and the burden of gestational diabetes must be determined in country‐specific studies. In southern Sweden, gestational diabetes is defined as a 2‐h capillary plasma glucose concentration of ≥10.0 mmol/L during a universal 75‐g oral glucose tolerance test. We report the crude prevalence of gestational diabetes during the years 2003–2012. Of 156 144 women who gave birth, 2.2% were diagnosed with gestational diabetes. When the effect of time on the prevalence of gestational diabetes was assessed in a log‐linear Poisson model, an overall increase in prevalence of 35% was predicted, corresponding to an average annual increase of 3.4%. Predicted prevalence was 1.9 (95% CI 1.8–2.0) in 2003 and 2.6 (95% CI 2.4–2.7) in 2012 (p < 0.0001). Due to a simultaneous rise in birth rate, the number of women diagnosed with gestational diabetes increased by 64%.

The impact of gestational diabetes mellitus on pregnancy outcome comparing different cut-off criteria for abnormal glucose tolerance.

Objective. To examine pregnancy outcomes in relation to different categories of glucose tolerance during pregnancy. Design. Prospective observational cohort study. Setting. Patient recruitment and data collection were performed in four delivery departments in southern Sweden. Population. Women delivering during 2003–2005; 306 with gestational diabetes mellitus, 744 with gestational impaired glucose tolerance and 329 randomly selected controls. Methods. All women were offered a 75 g oral glucose tolerance test during pregnancy. On the basis of their capillary 2‐hour plasma glucose concentrations, three groups were identified: gestational diabetes mellitus (>10.0 mmol/l), gestational impaired glucose tolerance (8.6–9.9 mmol/l) and controls (<8.6 mmol/l). Data for the groups were compared using a population‐based database. Main outcome measures. Maternal and fetal outcomes. Results. For the gestational diabetes mellitus group, adjusted odds ratios (95% confidence intervals) for hypertensive disorders during pregnancy and induction of labor and emergency cesarean section were 2.7 (1.3–5.8), 3.1 (1.8–5.2) and 2.5 (1.5–4.4), respectively; and for Apgar score <7 at 5 minutes, need for neonatal intensive care >1 day and large‐for‐gestational age infant were 9.6 (1.2–78.0), 5.2 (2.8–9.6) and 2.5 (1.3–5.1), respectively. The increases in odds ratios for the gestational impaired glucose tolerance group were less pronounced but still significant for hypertension during pregnancy, induction of labor, large‐for‐gestational age infant and use of neonatal intensive care >1 day, with odds ratios (95% confidence interval) 2.0 (1.0–4.1), 1.8 (1.1–3.0), 2.1 (1.1–3.9) and 2.1 (1.1–3.8), respectively. Conclusions. These data indicate that even limited degrees of maternal hyperglycemia may affect the outcome of pregnancy.

Prevalence of impaired glucose tolerance and diabetes after gestational diabetes mellitus comparing different cut-off criteria for abnormal glucose tolerance during pregnancy.

Objective. To determine the prevalence of diabetes and impaired glucose tolerance after gestational diabetes mellitus in relation to different categories of glucose tolerance during pregnancy. Design. Prospective study. Setting. Four delivery departments and three hospitals in southern Sweden took part in recruitment and follow‐up. Population. Women undergoing a 75g oral glucose tolerance test during pregnancy delivering in 2003–2005. Methods. At first follow‐up, one to two years after delivery, 29% of eligible women with abnormal glucose tolerance during pregnancy had an oral glucose tolerance test – 160 with gestational diabetes and 309 with gestational impaired glucose tolerance – in addition to 167 control women. Cut‐off levels defining gestational diabetes and impaired glucose tolerance were two‐hour capillary blood glucose levels of 9.0 and 7.8mmol/l or plasma glucose 10.0 and 8.6mmol/l, respectively. Main outcome measures. Frequency of abnormal test results at follow‐up. Results: Diabetes was diagnosed in 11% and impaired glucose tolerance in 24% of women with gestational diabetes vs. 4 and 23% in those with gestational impaired glucose tolerance, respectively. Combining women with abnormal test results during pregnancy revealed diabetes or impaired glucose tolerance in 29% as compared to 10% among controls; the odds ratio (95% confidence interval) for having abnormal test results was 3.3 (1.8–5.9) in a multivariate logistic regression analysis. Conclusions: Lowering the cut‐off level for gestational diabetes to include the category of impaired glucose tolerance would identify a high percentage of women with diabetes and impaired glucose tolerance postpartum, who constitute target groups for intervention and/or diabetes prevention.

Diabetes and pregnancy: women's opinions about the care provided during the childbearing year.

BACKGROUND The extended programmes for pregnant women with diabetes, needed to improve pregnancy outcome, might negatively influence the experience of expecting a baby. AIM To investigate opinions about care during pregnancy, childbirth and the postnatal period among women with diabetes mellitus (DM) and gestational DM (GDM). METHOD A four-part questionnaire was constructed, covering the childbearing year, with a focus on treatment and information. A total of 156 women were asked to participate (53 DM, 103 GDM), three refused. The questionnaire was anonymous. RESULTS The reply frequency was 94%. Of all answers, 95% fell in neutral-satisfied range (Lickert scale 2-5). Three answering patterns deviated positively (care on Specialist Antenatal Clinic, accessibility, and participation-responsibility-respect). Four patterns deviated negatively (information flow, preparation, postpartum care and postpartum check-up). Increased supervision caused problems with time for the family and at work. Comments showed focus on diabetes, forcing the healthy pregnancy aspects into the background. The answers concerning treatment indicated satisfaction (4 + 5 Lickert scale). Women with GDM felt badly prepared before the glucose tolerance test. It was doubtful whether they had been able to make an informed choice about participating. Lack of knowledge among staff was pointed out. Need for more written material was expressed. CONCLUSION Satisfaction with care was shown. A discussion about the implication of informed choice with both staff and mothers are needed. Sharper implementation of the diabetes-care-chain was also an area for improvement.

HLA-DQB1 genotypes and islet cell autoantibodies against GAD65 and IA-2 in relation to development of diabetes post partum in women with gestational diabetes mellitus.

AIMS To study HLA-DQB1 genes and islet cell autoantibodies against glutamic acid decarboxylase 65 (GADA) and insulinoma antigen-2 (IA-2A) in relation to diabetes post partum in mothers with diagnosed gestational diabetes mellitus (GDM). METHODS During 2003-2004, women undergoing a 75 g oral glucose tolerance test (OGTT) during pregnancy were invited to participate in the Mamma Study. Cut-off level defining GDM was a 2-h capillary blood glucose of 7.8 mmol/L. 1-2 years after delivery a 75 g OGTT was performed, GADA and IA-2A were measured and HLA-DQB1 genes analysed. Data were available for 452 mothers with previous GDM and 168 randomly selected control subjects. RESULTS HLA-DQB1*0602 was negatively associated with GDM (p=0.033) and with development of diabetes post partum (p=0.017), whereas high risk HLA were not associated with GDM or with diabetes. The presence of GADA post partum was positively associated with diabetes post partum (p=0.0009), but not with impaired glucose tolerance. CONCLUSIONS Mothers with GDM and HLA-DQB1*0602 were less likely to develop diabetes after pregnancy, and type 1 diabetes associated high risk HLA genes did not predict type 1 diabetes post partum. Additionally, GADA were positively associated with diabetes development.

Use of healthcare resources after gestational diabetes mellitus: A longitudinal case-control analysis.

Aims: To analyse whether gestational diabetes mellitus (GDM) was associated with increases in healthcare utilisation after delivery. Methods: A longitudinal case–control registry-based study of 579 women with GDM delivered in 1995–2001. Two controls for each case were selected from the Swedish National Board of Health and Welfare, matched for year of birth, year of delivery, and municipality of residence. Data regarding healthcare utilisation was provided by the Patients’ Administrative System in Skåne County, Sweden, covering the period from the years of delivery up to year 2009. Results: Women with previous GDM had higher mean number of contacts and total cost in the years after delivery as compared to controls, also when excluding utilisation related to subsequent pregnancies and childbirth. By year 2009, 31% of women with prior GDM were diagnosed with diabetes, compared to 1% of controls. Women diagnosed with diabetes were more likely to use health care (odds ratio 14.22, 95% confidence interval 5.87–34.45) controlling for age and time since delivery, whereas cases not diagnosed with diabetes did not differ from controls. The average annual cost of healthcare utilisation was 101% higher (p<0.001) for women with diabetes 10 years after delivery compared to controls. Conclusions: GDM was associated with higher healthcare utilisation postpartum for women who had a diabetes diagnosis. The results call for implementation of structured programmes to follow up women with GDM postpartum for early detection of diabetes and effective management, which may have the potential for improved health and savings in healthcare costs.

A Simplified Oral Glucose Tolerance Test in Pregnancy: Compliance and Results

BACKGROUND To describe a reliable method for a general oral glucose tolerance test (OGTT) during pregnancy, to evaluate adherence to the method, and to compare the frequency of reported gestational diabetes mellitus (GDM) and perinatal outcome in affected pregnancies in Skåne, using direct diagnostic OGTT, with those from a comparable area, Halmstad-Ljungby-Växjö (HLV), using random glucose measurements (RGM) to identify women for the OGTT. METHODS The OGTT program and quality assurance in Skåne is described. Antenatal records on deliveries in May 2003 were scrutinised to ascertain if OGTT had been performed. Frequencies of GDM, prematurity and large for gestational age (LGA) infants were estimated using a population-based perinatal database (PRS). RESULTS OGTT was performed in 93% of pregnant women in Skåne. In 2000-2003 GDM frequency in Skåne was twice as high as in HLV (1.9 versus 1%), while the frequency of LGA and prematurity among infants of mothers who were diagnosed with GDM were similar. CONCLUSIONS Decentralised general OGTT is a reliable and effective method to diagnose GDM. OGTT is twice as sensitive as RGM, and the severity of GDM in the cases identified with OGTT did not differ from the severity of those identified with RGM.

Prevalence of diabetes mellitus after pregnancy with gestational diabetes mellitus using different cut-off criteria for abnormal glucose tolerance

Background and aims: The association between type 2 diabetes and different forms of cognitive impairment is well established. The mechanism behind the association is however still unrevealed. We ha ...