Preference of Women for Gestational Diabetes Screening Method According to Tolerance of Tests and Population Characteristics.

Aims: To determine the preferred method of screening for gestational diabetes mellitus (GDM). Methods: 1804 women from a prospective study (NCT02036619) received a glucose challenge test (GCT) and 75g oral glucose tolerance test (OGTT) between 24-28 weeks. Tolerance of screening tests and preference for screening strategy (two-step screening strategy with GCT compared to one-step screening strategy with OGTT) were evaluated by a self-designed questionnaire at the time of the GCT and OGTT. Results: Compared to women who preferred one-step screening [26.2% (472)], women who preferred two-step screening [46.3% (834)] were less often from a minor ethnic background [6.0% (50) vs. 10.7% (50), p=0.003], had less often a previous history of GDM [7.3% (29) vs. 13.8% (32), p=0.008], were less often overweight or obese [respectively 23.1% (50) vs. 24.8% (116), p<0.001 and 7.9% (66) vs. 18.2% (85), p<0.001], were less insulin resistant in early pregnancy (HOMA-IR 8.9 (6.4-12.3) vs. 9.9 (7.2-14.2), p<0.001], and pregnancy outcomes were similar except for fewer labor inductions and emergency cesarean sections [respectively 26.6% (198) vs. 32.5% (137), p=0.031 and 8.2% (68) vs. 13.0% (61), p=0.005]. Women who preferred two-step screening had more often complaints of the OGTT compared to women who preferred one-step screening [50.4% (420) vs. 40.3% (190), p<0.001]. Conclusions: A two-step GDM screening involving a GCT and subsequent OGTT is the preferred GDM screening strategy. Women with a more adverse metabolic profile preferred one-step screening with OGTT while women preferring two-step screening had a better metabolic profile and more discomfort of the OGTT. The preference for the GDM screening method is in line with the recommended Flemish modified two-step screening method, in which women at higher risk for GDM are recommended a one-step screening strategy with an OGTT, while women without these risk factors, are offered a two-step screening strategy with GCT. Clinical Trial Registration: NCT02036619 https://clinicaltrials.gov/ct2/show/NCT02036619.

Self-Monitoring of Blood Glucose: A Complementary Method Beyond the Oral Glucose Tolerance Test to Identify Hyperglycemia During Pregnancy.

OBJECTIVES: To compare: 1) 75 g oral glucose tolerance test (OGTT) and self-monitoring of blood glucose (SMBG) in identifying gestational diabetes mellitus (GDM) and other hyperglycemic statuses in pregnant women; 2) pregnancy outcomes according to glycemic status; and 3) participants' opinions regarding both methods. METHODS: A prospective study in women with a 50 g glucose load test ≥7.2 mmol/L at 24 to 28 weeks' gestation and singleton pregnancy. Women underwent OGTT (blinded) at day 1, followed by 7 days of SMBG (4 daily measurements: fasting and 2 h postprandially) without modifying diet or lifestyle. GDM (OGTT+) was diagnosed using the criteria of the International Association of the Diabetes and Pregnancy Study Groups, while pregnancy hyperglycemia (SMBG+) was defined as ≥4/7 glucose values ≥5.3 after fasting or ≥6.7 mmol/L 2 h postprandially for any meal of the day. Equivalent management was provided to women with GDM and/or pregnancy-related hyperglycemia. RESULTS: We divided 103 participants (age: 29.5±5.0 years; prepregnancy body mass index: 25.3±5.4 kg/m2) into 4 groups according to test results: OGTT+/SMBG+ (n=12, 11.7%); OGTT+/SMBG- (n=14, 13.6%); OGTT-/SMBG+ (n=9, 8.7%); and OGTT-/SMBG- (n=68, 66.0%). Clinical characteristics and maternal outcomes were statistically similar between groups. Neonatal complication rates were greater in groups with hyperglycemia than in the OGTT-/SMBG- group, notably neonatal hypoglycemia (9/12, 7/14, 5/9 vs. 6/68; p<0.001). Participants reported no convenience difference between methods but would prefer OGTT for a future pregnancy. CONCLUSIONS: More than half of the women with OGTT+ were normoglycemic in daily life. Conversely, 11.7% of women with OGTT- had pregnancy hyperglycemia. OGTT+ and/or SMBG+ were equally associated with greater neonatal complications. This study suggests that alongside OGTT, SMBG could improve the care of pregnant women.

Factors influencing timely initiation and completion of gestational diabetes mellitus screening and diagnosis - a qualitative study from Tamil Nadu, India.

BACKGROUND: In 2007, universal screening for gestational diabetes mellitus (GDM) was introduced in Tamil Nadu, India. To identify factors hindering or facilitating timely initiation and completion of the GDM screening and diagnosis process, our study investigated how pregnant women in rural and urban Tamil Nadu access and navigate different GDM related health services. METHODS: The study was carried out in two settings: an urban private diabetes centre and a rural government primary health centre. Observations of the process of screening and diagnosis at the health centres as well as semi-structured interviews with 30 pregnant women and nine health care providers were conducted. Data was analysed using qualitative content analysis. RESULTS: There were significant differences in the process of GDM screening and diagnosis in the urban and rural settings. Several factors hindering or facilitating timely initiation and completion of the process were identified. Timely attendance required awareness, motivation and opportunity to attend. Women had to attend the health centre at the right time and sometimes at the right gestational age to initiate the test, wait to complete the test and obtain the test report in time to initiate further action. All these steps and requirements were influenced by factors within and outside the health system such as getting right information from health care providers, clinic timings, characteristics of the test, availability of transport, social network and support, and social norms and cultural practices. CONCLUSIONS: Minimising and aligning complex stepwise processes of prenatal care and GDM screening delivery and attention to the factors influencing it are important for further improving and expanding GDM screening and related services, not only in Tamil Nadu but in other similar low and middle income settings. This study stresses the importance of guidelines and diagnostic criteria which are simple and feasible on the ground.

Long-term consequences of feed restriction during late pregnancy in goats on feeding behavior and emotional reactivity of female offspring.

Feed restriction during pregnancy can have detrimental effects on offspring development both during the juvenile period and during adult life. Long-term effects of maternal feed restriction during the last third of pregnancy on growth, metabolism and behavior of female kids, with a focus on feeding behavior and emotional reactivity, were studied in goats. Female kids born to control (CONT, n=17) or born to feed restricted goats (REST, n=15) were artificially reared and monitored from birth to 24 months of age. Maternal feeding restriction globally reduced live weight (P<0.001) and body condition score (P=0.02) of REST compared to CONT offspring. Females from the REST group had a higher daily feed intake (P=0.05) and tended to eat more rapidly (P=0.09) than females from the CONT group at 12 months of age. One year later, REST goats still ate more than CONT goats (P=0.05). Glucose metabolism did not appear to be modified as no differences were observed in glucose or insulin responses to an intravenous glucose tolerance test. No differences in time budget were found at 12 months of age. However, the HPA axis response to an ACTH injection was greater in REST than in CONT goats: higher peak cortisol concentration (P=0.02) and a greater area under the curve were found (P=0.01) at 14 months of age. In conclusion, maternal feed restriction during late pregnancy modified both feeding behavior and the stress physiology of female offspring for up to 2 years of age. However, the changes observed were small.

Screening for type 2 diabetes following gestational diabetes: family physician and patient perspectives.

OBJECTIVE: To explore primary care provider (PCP) and patient perspectives on postpartum screening for type 2 diabetes (T2DM), including reasons for not completing oral glucose tolerance tests (OGTTs) specifically, preferred provider for organizing screening, and value of reminder letters for facilitating screening. DESIGN: A follow-up survey, administered by fax or telephone, to PCPs and patients who participated in a randomized controlled trial assessing effectiveness of postpartum postal reminders to enhance screening for T2DM in women with gestational diabetes mellitus (GDM). SETTING: The Ottawa Hospital, a university-affiliated tertiary centre in Ottawa, Ont. PARTICIPANTS: A total of 223 female patients with previously identified GDM and their respective PCPs were surveyed; 173 PCPs and 140 patients participated. MAIN OUTCOME MEASURES: Whether or not the patient was screened for T2DM post partum, the test used for screening, the factors contributing to the patient not being screened, perspectives on the importance of screening post partum, and opinions about which care provider should be responsible for screening in the postpartum period. RESULTS: Response rates were 78% (173 of 223) for PCPs and 63% (140 of 223) for patients. Only 37% of the PCP responders had their patients complete OGTTs, while 85% of patient responders reported that they had completed OGTTs. The most common reason PCPs gave for not screening was no postpartum visit from the patient for any reason. Time pressures were the most common reason provided by patients for not being screened. More than 95% of patients and providers agreed that screening for T2DM was important. Patients and PCPs agreed that PCPs should be responsible for screening. Reminder letters were perceived as helpful by more than 85% of patients and PCPs. CONCLUSION: This follow-up survey demonstrates that PCPs and patients value the importance of screening for diabetes, identify the PCP as pivotal to screening, and appreciate a reminder strategy. There continue to be barriers that affect screening rates, despite the perceived importance of screening by PCPs and patients.