Model for individual prediction of diabetes up to 5 years after gestational diabetes mellitus.

AIMS: To identify predictors of diabetes development up to 5 years after gestational diabetes mellitus (GDM) and to develop a prediction model for individual use. METHODS: Five years after GDM, a 75-g oral glucose tolerance test (OGTT) was performed in 362 women, excluding women already diagnosed with diabetes at 1- to 2-year follow-up or later (n = 45). All but 21 women had results from follow-up at 1-2 years, while 84 women were lost from that point. Predictive variables were identified by logistic regression analysis. RESULTS: Five years after GDM, 28/362 women (8 %) were diagnosed with diabetes whereas 187/362 (52 %) had normal glucose tolerance (NGT). Of the latter, 139/187 (74 %) also had NGT at 1- to 2-year follow-up. In simple regression analysis, using NGT at 1-2 years and at 5 years as the reference, diabetes at 1- to 2-year follow-up or later was clearly associated with easily assessable clinical variables, such as BMI at 1- to 2-year follow-up, 2-h OGTT glucose concentration during pregnancy, and non-European origin (P < 0.0001). A prediction model based on these variables resulting in 86 % correct classifications, with an area under the receiver-operating characteristic curve of 0.91 (95 % CI 0.86-0.95), was applied in a function-sheet line diagram illustrating the individual effect of weight on diabetes risk. CONCLUSIONS: The results highlight the importance of BMI as a potentially modifiable risk factor for diabetes after GDM. Our proposed prediction model performed well, and should encourage validation in other populations in future studies.

The relative importance of maternal body mass index and glucose levels for prediction of large-for-gestational-age births.

BACKGROUND: The risk of gestational diabetes mellitus (GDM) increases substantially with increasing maternal body mass index (BMI). The aim of the present study was to evaluate the relative importance of maternal BMI and glucose levels in prediction of large-for-gestational-age (LGA) births. METHOD: This observational cohort study was based on women giving birth in southern Sweden during the years 2003-2005. Information on 10,974 pregnancies was retrieved from a population-based perinatal register. A 75-g oral glucose tolerance test (OGTT) was performed in the 28 week of pregnancy for determination of the 2-h plasma glucose concentration. BMI was obtained during the first trimester. The dataset was divided into a development set and a validation set. Using the development set, multiple logistic regression analysis was used to identify maternal characteristics associated with LGA. The prediction of LGA was assessed by receiver-operating characteristic (ROC) curves, with LGA defined as birth weight > +2 standard deviations of the mean. RESULTS: In the final multivariable model including BMI, 2-h glucose level and maternal demographics, the factor most strongly associated with LGA was BMI (odds ratio 1.1, 95% confidence interval [CI] 1.08-1.30). Based on the total dataset, the area under the ROC curve (AUC) of 2-h glucose level to predict LGA was 0.54 (95% CI 0.48-0.60), indicating poor performance. Using the validation database, the AUC for the final multiple model was 0.69 (95% CI 0.66-0.72), which was identical to the AUC retrieved from a model not including 2-h glucose (0.69, 95% CI 0.66-0.72), and larger than from a model including 2-h glucose but not BMI (0.63, 95% CI 0.60-0.67). CONCLUSIONS: Both the 2-h glucose level of the OGTT and maternal BMI had a significant effect on the risk of LGA births, but the relative contribution was higher for BMI. The findings highlight the importance of concentrating on healthy body weight in pregnant women and closer monitoring of weight during pregnancy as a strategy for reducing the risk of excessive fetal growth.

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%.

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.

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.

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.

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.

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.

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.