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Primary care physicians soon may need to follow more rigorous guidelines on diabetes testing for patients with histories of gestational diabetes mellitus (GDM).
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In recommendations published this summer, an international group of diabetes experts calls for screening these high-risk mothers twice during their first year postpartum. In a consensus statement, the experts also emphasize the need to use a 2-hour oral glucose tolerance test (OGTT), not the quicker fasting glucose (FG) method many physicians and patients prefer for its relative convenience.1 The group issued its recommendations from the American Diabetes Association (ADA)-sponsored Fifth International Workshop—Conference on Gestational Diabetes Mellitus. GDM professionals convene these workshops every few years to review GDM clinical research and update screening and treatment recommendations accordingly.
"Based on all the evidence reviewed, the feeling is very strong among experts on GDM that these women need to be tested for diabetes with OGTT at the first postpartum visit [at 6–12 weeks]," says Boyd Metzger, MD, conference chairman and professor of medicine at Northwestern University in Chicago.
The OGTT is more sensitive than the FG method and ultimately may be more cost-effective, some studies suggest.2 The working group recommends conducting an OGTT at the 1-year postpartum mark, as well as at the 6–12 week mark.
"We know a lot more now about the benefit of having that glucose tolerance information at these points in time," Metzger says. "Important health care counseling and planning for these women can and should be done with that information in hand."
For instance, glucose tolerance values can indicate whether a woman has type 2 diabetes, as well as how close she is to meeting the diagnostic criteria, says Metzger. That information can be used to inform the need for interventions, ongoing evaluations, and prepregnancy counseling if the woman plans to have more children, according to Metzger.
"As for relying on an FG test," he adds, "it's simply insufficient in terms of providing the information needed to accurately classify glucose tolerance status following GDM."
GUIDELINES REVISITED
ADA's Professional Practice Committee is now reviewing the work-shop recommendations to determine whether to revise its own clinical guidelines accordingly.
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Currently, ADA recognizes a history of GDM as a significant risk factor for developing type 2 diabetes—meaning physicians need to begin regularly screening these high-risk women much earlier than some other patients.
While most women with GDM return to normal blood glucose levels immediately after delivering their babies, 35–65% go on to develop type 2 diabetes within 10 years, according to ADA. Up to 14% are found to have type 2 diabetes within 20 weeks after pregnancy.1
The current ADA protocol is to screen these women at their first postpartum checkup (at 6–12 weeks) and then every 3 years thereafter, using either the 2-hour OGTT or the more convenient FG method.3
"We can all agree that these aren't women you wait until age 45 to start screening, and maybe you don't even wait 3 years [for follow-up exams]," says M. Sue Kirkman, MD, ADA's vice president for clinical affairs. But eliminating the quick-and-easy FG as a screening option may be a tougher sell, she says. "The bottom line is these women are hard to get good follow-up on already.
"Certainly the FG is less sensitive than the OGTT, but the ADA feels comfortable recommending [the FG method] because it's more feasible in terms of getting the greatest number of women tested," Kirkman says.
In one recent study of women who had GDM pregnancies, only 37% underwent either the FG test or an OGTT—at a median of >1 year delivery. In comparison, 94% of the same women had the recommended Pap test, at a median of 49 days postpartum.4
The specific reasons so few of these women are properly tested for diabetes after pregnancy likely vary, says Deborah Conway, MD, director of the Diabetes and Pregnancy program at the University of Texas Health Science Center at San Antonio.
"Realistically speaking, you're asking mothers who probably feel well and who have young children and often complicated socioeconomic circumstances to commit a whole morning to this testing," Conway says. "The first hurdle is patient compliance, but the next is probably physician knowledge and compliance. A lot of these women fall through the cracks between obstetric care and primary care."
ACTION NOW
Even as ADA considers its next steps regarding GDM follow-up, physicians can take immediate action to beef up their own vigilance:
Finally, Buchanan emphasizes the importance of following patients with GDM
histories for glycemic stability. "Some combination of glucose testing
and A1C [glycated hemoglobin] testing may be the best clinical strategy to see
if an intervention is working," he advises. 
Footnotes
The Fifth International Workshop—Conference on Gestational Diabetes Mellitus recommendations on diabetes screening for women with histories of gestational diabetes are available online at http://care.diabetesjournals.org/cgi/content/full/30/Supplement_2/S251.
References
2. Kim C, William H, Vijan S: Efficacy and cost of postpartum
screening strategies for diabetes among women with histories of gestational
diabetes mellitus. Diabetes Care 30: 1102–1106, 2007.
3. American Diabetes Association: Standards of care for
diabetes—2006. Diabetes Care 29 (Suppl. 1):S4
–S42, 2006.
4. Smirnakis KV, Chasan-Taber L, Wolf M, et al.: Postpartum diabetes
screening in women with a history of gestational diabetes. Obstet
Gynecol 106:1297–1303, 2005.
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