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DOI: 10.2337/dc06-2407
© 2007 by the American Diabetes Association
Online Letters: Observations |
Discrepancy Between Postnatal and Antenatal Management of Gestational Diabetes in the U.K.
1 Department of Endocrinology, University Hospital of North Staffordshire, Stoke-on-Trent, U.K.
2 University Hospital of Wales, Cardiff, U.K.
3 Prince Charles Hospital, Merthyr Tydfil, U.K.
4 Keele University, Staffordshire, U.K.
Address correspondence to Dr. F.W.F. Hanna, Consultant Physician and Endocrinologist, University Hospital of North Staffordshire, Stoke-on-Trent ST2 6QG, U.K
There has been no consensus for screening methodology, diagnosis, and management of gestational diabetes mellitus (GDM). We aimed to evaluate routine practice for GDM management across the U.K., including postnatal care. Questionnaires were sent to all members of the Association of British Clinical Diabetologists. They were asked to describe how patients were screened for GDM, the diagnostic criteria, and subsequent management and clinical targets, as well as postnatal care. Centers that did not initially respond were followed up by personal communication. Regional variability trends were assessed by subdividing the U.K. into 10 regions and then analyzing the data with the StatXact 
2 test (version 4; Cytel Software, Cambridge, Massachusetts), which has the ability to evaluate associations in two-way tables where there are small frequencies. In addition to providing an indication whether there is a trend in the variability in practice across the U.K., comparing the responses from individual regions also provided an indirect validation surrogate.
The response rate averaged 46% nationally (35–67%). Most (85%) units had a joint clinic, regardless of the size. Most (82%) centers routinely screened for GDM, one-half doing so universally and one-half screening high-risk pregnancies only.
Screening tests, cut-off values, timings, and subsequent action varied widely. The first screening test to be used varied, with 40% using glycosuria, followed by random plasma glucose (28%), high-risk features (11%), and fasting plasma glucose (6%). Cut-off values for random and plasma glucose were variable. The 75-g oral glucose tolerance test was the most likely confirmatory test to be used if initial screening is positive; however, clinicians relied on different cut-off values and timing. Most (95%) centers routinely assessed fetal growth.
Postpartum screening was undertaken by 90% of centers, using a 75-g oral glucose tolerance test (93%). Most (90%) centers counsel patients about their high risk for further GDM and type 2 diabetes.
Despite the significant variability of antenatal screening and management, postnatal care of GDM was more consistent.
Regional variability trends could not be detected between different regions in the UK. One potential limitation of the survey is the small (2%) proportion of questionnaires completed by obstetricians. However, as proven from the survey, in the U.K. most (85%) centers run joint clinics with both obstetrics and diabetes teams in partnership, with jointly agreed guidelines.
Our report confirms the wide variability in practice across the U.K., in contrast with the U.S., where it has been reported (>10 years ago) that despite the controversies surrounding the optimal management of GDM, program directors of residency and maternal-fetal fellowship programs were in agreement with many aspects of the diagnosis and management (1). The recently reported Australian Carbohydrate Intolerance Study in Pregnant Women confirmed that active treatment of GDM reduces serious perinatal morbidity and may also improve the woman's health-related quality of life (2). Moreover, with the accumulating evidence for rising prevalence of GDM (3), a confirmed long-term impact of hyperglycemia on fetal risks (4), and the potential for prevention studies (including the Diabetes Prevention Program [5] and the Troglitazone in the Prevention of Diabetes Trial [6]), this survey confirms the urgent need for consensus guideline development, especially for antenatal screening and management.
References
- Owen J, Phelan ST, Landon MP, Gabbe SG: Gestational diabetes survey. Am J Obstet Gynaecol 172:615–620, 1995[Medline]
- Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group: Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 352:2477–2486, 2005
[Abstract/Free Full Text] - Dabelea D, Snell-Bergeon JK, Hartsfield CL, Bischoff KJ, Hamman RF, McDuffie RS: Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort. Diabetes Care 28:579–584, 2005
[Abstract/Free Full Text] - Dabelea D, Hanson RL, Lindsay RS, Pettitt DJ, Imperatore G, Gabir MM, Roumain J, Bennett PH, Knowler WC: Intrauterine exposure to diabetes conveys risks to type 2 diabetes and obesity: a study of discordant sibships. Diabetes 49:2208–2211, 2000[Abstract]
- Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle or metformin. N Engl J Med 346:393–403, 2002
[Abstract/Free Full Text] - Buchanan TA, Xiang AH, Peters RK, Kjos SL, Marroquin A, Goico J, Ochoa C, Tan S, Berkowitz K, Hodis HN, Azen SP: Preservation of pancreatic ß-cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk Hispanic women. Diabetes 51:2796–2803, 2002
[Abstract/Free Full Text]
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