Managing gestational diabetes early in pregnancy can prevent complications and improve health outcomes, experts say

A shift in testing for and treating gestational diabetes mellitus (GDM) to much earlier in pregnancy (before 14 weeks) could prevent health complications for both mother and baby, according to a new series published in The Lancet. Authors of the series challenge the current approach to gestational diabetes management – ​​which focuses on late gestational diabetes (more than 24 weeks) – and call for better detection and prevention efforts alongside a personalized, integrated life-course approach for those affected or at risk on gestational diabetes.

GDM, also known as gestational diabetes – a form of diabetes that occurs during pregnancy and in which blood glucose levels are higher than average, but not as high as diabetes – is the most common medical complication of pregnancy worldwide, affecting one in seven (14%) of affects women. pregnancies.

As obesity and other metabolic disorders continue to increase worldwide, more women of childbearing age will experience some degree of abnormal glucose/insulin regulation, leading to higher risks of pregnancy complications and health problems later in life, such as type 2 diabetes (T2D) and cardiovascular disease.

“Our new series highlights the urgent need for a major change in the way gestational diabetes is first diagnosed and treated, not just during pregnancy but throughout the lives of mothers and their babies,” said Prof. David Simmons of the Western Sydney University, Australia, head of the series.

“GDM is an increasingly complex condition, and there is no one-size-fits-all approach to treating it. Instead, a patient’s unique risk factors and metabolic profile must be considered to guide him or her during the pregnancy and support him afterwards.” achieving the best health outcomes for women and babies everywhere.”

GDM and its complications are increasing

As obesity continues to increase worldwide, along with impaired glucose tolerance and T2D rates in women of childbearing age, the prevalence of gestational diabetes has also doubled to tripled in multiple countries over the past two decades. Current prevalence rates for gestational diabetes range from over 7% in North America and the Caribbean to almost 28% in the Middle East and North Africa.

Between 30% and 70% of women with gestational diabetes experience high blood glucose (hyperglycemia) from early pregnancy (20 weeks gestation or earlier, also called early gestational diabetes). These women have worse pregnancy outcomes compared to women in whom GDM is not present until later in pregnancy (24-28 weeks).

Even later in pregnancy, in studies where GDM was not adequately treated (for example, when insulin was required but not used), GDM was associated with an increased risk of cesarean section (16%), preterm birth (51%), and large gestational diabetes. age babies (57%). Other studies of pregnancies with gestational diabetes requiring insulin therapy found that this was associated with a more than twofold increased risk of admission to the neonatal intensive care unit.

Women diagnosed with GDM have a 10-fold increased risk of developing T2D later in life compared to women who have not had GDM. They are also more likely to have coexisting hypertension, dyslipidemia (high blood lipid levels), obesity and fatty liver disease, with a twofold higher risk of developing cardiovascular disease during their lifetime.

Women with gestational diabetes also experience greater risks of mental health problems, including stress, depression and anxiety, along with stigma and feelings of guilt and shame associated with gestational diabetes. In addition to their own impact, these feelings of guilt and shame can lead to additional adverse consequences if patients avoid testing their glucose levels or use insulin because of these feelings.

Recent studies have suggested that a diagnosis of gestational diabetes may be associated with an increased risk of subsequent postpartum depression. Conversely, treatment of late gestational diabetes is associated with lower rates of depression at three months postpartum, while treatment of early gestational diabetes is associated with improvements in quality of life after 24 to 28 weeks’ gestation.

“Gestational diabetes is a huge public health challenge. Women affected by it need support from the medical community, policy makers and society at large to ensure they effectively access appropriate treatment, to reduce the stigma associated with gestational diabetes can reduce anxiety and improve their overall pregnancy experience,” said series author Dr. Yashdeep Gupta of the All India Institute of Medical Science.

Early diagnosis for better health outcomes for a lifetime

GDM has traditionally been considered a pregnancy complication associated with the management of high blood glucose levels late in the second trimester. The current World Health Organization diagnostic criteria for gestational diabetes recommend testing at 24 to 28 weeks’ gestation without prior screening.

However, recent evidence suggests that gestational diabetes has a pre-pregnancy basis and may be present early in pregnancy. Overall, 30-70% of gestational diabetes can be detected in its early stages using oral glucose tolerance tests. This includes those most at risk of needing insulin therapy and experiencing pregnancy complications.

Recent studies, such as the TOBOGM RCT, have shown that identification and treatment before the 20th week of pregnancy (compared to 24-28 weeks) in women with early gestational diabetes not only reduced pregnancy and postpartum complications, including neonatal respiratory problems and length of stay . in neonatal intensive care units, as well as improved quality of life in mid-pregnancy and better initiation of breastfeeding, which can reduce the risk of developing obesity, T2D and other long-term conditions.

“The benefits of early detection of gestational diabetes are clear: we can keep mothers and babies healthier during pregnancy and hopefully continue that path for a lifetime. What is needed now is earlier testing and an approach to managing gestational diabetes that use is made of available resources, circumstances and the patient’s personal wishes,” said series author Dr. Helena Backman of Örebro University, Sweden.

New strategies are urgently needed to improve GDM management

A better understanding of gestational diabetes and its effects can help researchers, clinicians and policymakers develop new management approaches that focus on improved prevention and treatment of gestational diabetes complications from preconception through pregnancy and beyond.

The recommended strategies developed by the authors of the series include:

• Early GDM testing in those with risk factors, ideally before 14 weeks’ gestation.
• Promoting health at the population level, preparing women, especially those with risk factors, for healthy pregnancy and healthy aging.
• Improve prenatal care, including postpartum screening for glycemic status.
• Tailored annual assessments in women with previous gestational diabetes to prevent or better manage complications such as T2D (particularly in subsequent pregnancies) and cardiovascular disease.
• More research into gestational diabetes and how to improve outcomes for women with gestational diabetes and their children across the lifespan.

“It is high time to move from ‘late pregnancy’ services to an integrated, personalized life cycle strategy in both high and low resource settings. This includes new, systematic approaches to prevention, early treatment of gestational diabetes, identifying and overcoming barriers to promote its uptake, better integration of the healthcare system and more research to better understand how gestational diabetes affects women and their children during pregnancy and throughout their lives,” said Prof. Simmons.