According to a study published in The Lancet, a shift in testing and management of gestational diabetes mellitus (GDM) at a very early stage of pregnancy (before 14 weeks) can prevent health complications for both mother and baby.
Managing gestational diabetes mellitus
The authors challenge the current approach to managing gestational diabetes mellitus – which focuses on late (24 weeks+) GDM – and call for improved detection and prevention efforts along with a personalized, integrated approach across the lifespan for those suffering from or at risk for GDM.
Gestational diabetes mellitus, also known as gestational diabetes, a type of diabetes found during pregnancy in which blood glucose levels are higher than average but not as high as diabetes, is the most common medical complication of pregnancy in worldwide, affecting one in seven (14%) pregnancies.
As obesity and other metabolic conditions continue to increase worldwide, more and more women of reproductive age will experience some degree of abnormal glucose/insulin regulation, leading to greater risks of pregnancy complications and health conditions later on in life, such as type 2. diabetes (T2D) and cardiovascular disease.
“Our new series highlights the urgent need for a major change in how gestational diabetes mellitus is first diagnosed and managed, not just during pregnancy but throughout the lives of mothers and their babies,” she said. stated the professor. David Simmons of Western Sydney University, Australia, responsible for the series.
“Gestational diabetes mellitus is an increasingly complex condition and there is no one-size-fits-all approach to managing it. Instead, a patient’s specific risk factors and metabolic profile should be taken into account to help guide them through pregnancy and subsequently support them achieve the best health outcomes for women and children around the world.”
As obesity continues to increase worldwide, along with impaired glucose tolerance and rates of T2D in women of reproductive age, the prevalence of GDM has also increased two- to threefold in multiple countries over the past 20 years. Current prevalence rates of GDM range from over 7% in North America and the Caribbean region to nearly 28% in the Middle East and North Africa region.
Between 30% and 70% of women with gestational diabetes mellitus have high blood glucose levels (hyperglycemia) from the beginning of pregnancy (20 weeks of gestation or earlier, also known as early GDM). These women have worse pregnancy outcomes than women whose GDM is present only later in pregnancy (24-28 weeks).
Even in later stages of pregnancy, in studies in which GDM was not adequately managed (eg, where insulin was needed but not used), GDM was associated with an increased risk of cesarean delivery (16%) , preterm birth (51%) and severe gestational losses. age of children (57%). Other studies examining pregnancies with GDM requiring insulin therapy found that it was associated with a more than double risk of neonatal intensive care unit admission.
Women diagnosed with gestational diabetes mellitus have a 10-fold greater 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, with a two-fold higher risk of developing cardiovascular disease during their lifetime.
Women with GDM also experience more significant risks of mental health conditions, including stress, depression, and anxiety, along with stigma and feelings of guilt and shame related to GDM during pregnancy. Beyond their impact, these feelings of guilt and shame can lead to further adverse outcomes if patients avoid testing glucose levels or taking insulin because of them.
Recent studies have suggested that the diagnosis of gestational diabetes mellitus may be associated with an increased risk of subsequent postpartum depression. In contrast, treatment of late GDM is associated with lower rates of depression at three months postpartum, while treatment of early GDM is associated with improved quality of life between 24 and 28 weeks of gestation.
“GDM represents a huge public health challenge. Women suffering from it need support from the medical community, policymakers and society as a whole to ensure that they can effectively access adequate care, reduce the stigma associated with GDM and improve their overall pregnancy experience,” she said the author of the series, Dr. Yashdeep Gupta of the All India Institute of Medical Science.
Gestational diabetes mellitus has historically been considered a pregnancy complication involving high blood glucose levels in the late second trimester. Current World Health Organization diagnostic criteria for GDM recommend testing at 24-28 weeks of gestation without prior screening.
However, recent evidence suggests that GDM has a basis before pregnancy and may be present early in pregnancy. Overall, 30-70% of GDM cases can be detected early using oral glucose tolerance testing and include those at the most significant risk of requiring insulin therapy and experiencing pregnancy complications.
Recent studies, such as the TOBOGM RCT, have shown that among women with early GDM, identification and treatment before 20 weeks of gestation (compared to 24 to 28 weeks) not only reduced pregnancy and postpartum complications, including neonatal respiratory distress and length of hospitalization. in neonatal intensive care units, but also an improvement in quality of life in the middle of pregnancy and an increase in the initiation of breastfeeding, which may reduce the likelihood of developing obesity, T2D and other long-term conditions.
“The benefits of early diagnosis of gestational diabetes mellitus are clear: we can keep mothers and babies healthier during pregnancy and, hopefully, continue this journey throughout their lives. What is needed now is timely testing and an approach to the management of GDM that takes into account available resources, the patient’s personal circumstances and wishes,” said series author Dr. Helena Backman of Örebro University , Sweden.
A better understanding of gestational diabetes mellitus and its effects can help researchers, clinicians, and policymakers develop new management approaches focused on better prevention and treatment of GDM complications from the preconception period through pregnancy and beyond.
Recommended strategies developed by the series authors include:
•Early GDM test in subjects with risk factors, ideally before the 14th week of gestation.
•Promote population-level health that prepares women, especially those with risk factors, for healthy pregnancy and, subsequently, healthy aging.
•Improve prenatal care that includes postpartum screening for glycemic status.
•Personalized annual assessments in women with previous gestational diabetes mellitus to prevent or better manage complications such as T2D (particularly in subsequent pregnancies) and cardiovascular disease.
•Further research on GDM and how to improve outcomes for women with GDM and their children throughout life.
“The time has come to move from targeted ‘late pregnancy’ services to an integrated and personalized life course strategy, in both high- and low-resource settings. This includes new systematic approaches to prevention, early treatment of gestational diabetes mellitus, identification and overcoming barriers, better health system integration, and further research to better understand how GDM affects women and their babies during pregnancy. pregnancy and throughout life,” said Prof. Simmons.
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