Advocates call for earlier screening for gestational diabetes

Management of gestational diabetes should include earlier testing during pregnancy, as well as testing in the postpartum period, according to a series of papers published in The Lancet. Screening is usually done during the second half of pregnancy, but the authors note that diagnosis and treatment is especially beneficial before 14 weeks of pregnancy. 

21/06/2024 - 00:30 CEST
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Jardena Puder - diabetes gestacional EN

Jardena Puder

Head of the Diabetes and Pregnancy Clinic of the Woman-Mother-Child Department of the University Hospital of Lausanne (Switzerland)

Science Media Center Germany

The Lancet series includes 3 articles written by world-known experts in the Gestational Diabetes Mellitus [GDM] field. They envision GDM as an integrated life course approach that includes preconception and specific high-risk traits, risk constellations in early and later pregnancy, as well in the postpartum period. The pre- and perinatal as well as postpartum period are important periods for later health of a woman and her child. [It] impact[s] not only on pregnancy complications, and then in the longer term on the metabolic and cardiovascular health, but also other domains such as mental health and neurocognitive functions. They illustrate the heterogeneity of GDM, similarly to what is seen in diabetes, and suggest a more personalized approach. The authors very well illustrate the risk factors for GDM and also the extent of increased risk [for] each risk factor—such as for example family history of diabetes, previous GDM, polycystic ovary disease, age, hypothyroidism, pregnancy-induced hypertension and history of certain pregnancy complications. 

It is well known that around 30—70% of pregnant women have hyperglycemia before 20 weeks of gestation. We know from several cohort studies that these women have more GDM-risk factors and an increased risk of adverse pregnancy outcomes if left untreated as well as a higher risk of adverse postpartum metabolic health outcomes (this was also shown by a study performed in our center). So early GDM is on the continuum of adverse outcomes that are more pronounced. 

The question so far has been who should be screened, how should be screened and what cutoffs should be used. The authors rely mostly on the recently published ToBOGM study. The results of the study showed that when using 75 g oGTT in women with risk factors and using their higher pre-defined glycemic band of GDM definition (T0: 5.3-6.0/T 1 h: ≥10.6 /T 2h: 9.0-11.0 mmol/) and intervening before 14 weeks of gestational age reduced adverse perinatal outcomes and was also cost saving. The treatment includes lifestyle changes and pharmacotherapy. Of note that their definition of risk factors concerns many patients and could be relevant to around 50% of pregnant women according to the specific population profile (see list below**). 

Challenges of this include costs, limitations of structural medical resources in already full clinics and overloaded health systems, the burden of performing OGTT also early in pregnancy and the burden and barriers on the patient’s side. On the one hand, it is a wonderful opportunity to take care of a family’s health, but at the same time, this happens in a vulnerable period where women have to take care of their children, work, household and themselves. 

In Germany, there will be soon new Leitfaden [guidelines] published for the detection and treatment of GDM. The above cited publication hardly focuses on early GDM, but also mention an OGTT, but based on a publication from 2013 and does not clearly define the population to be screened. The recently published Swiss guidelines do not endorse an OGTT and also use other cut-offs. 

**GDM risk factors as defined in the ToBOGM study: 

• previous gestational diabetes 

• body-mass index [the weight in kilograms divided by the square of the height in meters] 

higher than 30 

• age ≥40 years 

• first-degree relative with diabetes 

• previous macrosomia 

• polycystic ovary syndrome 

• non-European ancestry

The author has declared they have no conflicts of interest
Call to action for a life course approach
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The Lancet
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David Simmons et al.

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