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ORIGINAL RESEARCH |
From the Departments of Obstetrics and Gynecology, Medicine, Neurology, and Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, and the Department of Obstetrics and Gynecology, University of Illinois at Peoria, Peoria, Illinois.
Address reprint requests to: Robert C. Kaufmann, MD PO Box 19640 Springfield, IL 62794-9640 E-mail: rkaufmann{at}wpsmtp.siumed.edu
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Abstract |
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Methods: Questionnaires regarding follow-up testing and personal health history were sent to 66 patients with previous gestational diabetes who did not have diabetes when they participated in a follow-up study conducted 5 years earlier. A 2-hour glucose tolerance test (GTT) was offered to those whose last test was done more than 1 year previously.
Results: All 66 individuals returned the questionnaire and 20 (30.3%) reported having received a yearly 2-hour GTT. Of the remaining 46, 19 had been tested at least once in the previous 5 years, but 27 had not been tested. Of the patients who had been tested at least once in the 5-year period, their physicians initiated testing 61.5% of the time and the patients initiated the remainder. There were no significant differences between physician specialty and rate or appropriateness of the testing. Of 39 individuals who had been tested at least once in the 5-year period, eight had diabetes and four were glucose intolerant. Of 12 individuals who had not been tested in the past year and agreed to be tested in 1995, four had diabetes and two had glucose intolerance.
Conclusion: Although physicians and their gestational diabetic patients knew the risks of diabetes development, compliance with follow-up testing was poor and the risk of developing diabetes high.
Women who have a history of gestational diabetes are at increased risk of developing diabetes later in life.1–10 The risk increases with age, with up to 80% of women developing diabetes within 20 years of diagnosis of gestational diabetes. Most of these women (over 95%) develop type II diabetes, which can go undiagnosed for years10,11 because its course is insidious and usually does not produce symptoms until the onset of secondary complications. When diagnosis is delayed, significant problems can develop if the patient becomes pregnant. Poor glucose control during the first few weeks of pregnancy increases the risk of congenital anomalies in infants of diabetic patients12; however, good preconceptual control can reduce this risk.
Because type II diabetes is often asymptomatic, it is imperative that women with a history of gestational diabetes be tested yearly using a 2-hour glucose tolerance test (GTT) for early identification and treatment of diabetes.1–3,9,10,13–15 This study was undertaken to determine whether patients with previous gestational diabetes who had been informed of the importance of follow-up testing for diabetes were receiving appropriate follow-up care and, if appropriate care was being given, whether it was initiated by the patient or physician.
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Materials and Methods |
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Results |
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). In 11 (55%) of these 20 women testing was initiated by their physicians and the other nine women initiated testing. Twenty-six women (39.5%; CI 27.7, 51.3) saw their primary physician yearly but did not have a yearly 2-hour GTT as recommended. Of these 26 patients, 10 (38.5%) had been tested at least once in the 5-year period. Twenty women (30.3%; CI 19.2, 41.4) did not see a doctor yearly, but nine (45%) of them had been tested at least once in the 5 years. Overall, 39 patients (59.1%; CI 47.2, 71.0) were tested for diabetes at least once during the 5-year period. The physician initiated the testing in 24 (61.5%) of these patients with the remaining 15 (38.5%) patients initiating the testing.
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) with appropriate care being offered by 33.3% of the obstetrician-gynecologists, 44.4% of the family practitioners, and 30.8% of the internal medicine specialists (P = .7). The rates of physician-initiated testing compared with patient-initiated testing for diabetes were not significantly different among the three specialties, with physician-initiated rates of 73% for obstetrician-gynecologists, 58% for family practitioners, and 44% for internal medicine specialists (P = .3). Of the 39 women who had been tested for diabetes at least once in the past 5 years, eight had become diabetic and four were glucose intolerant. An additional 12 women who had never been tested or were last tested more than 1 year previously agreed to be tested; four had diabetes, two had glucose intolerance, and six had normal tests. Therefore, diabetes or glucose intolerance developed over a period of 5 years in 18 (58.1%) of 31 women who were tested within the past year.
There were no differences in age, gravidity, parity, subsequent number of pregnancies, or changes in diet, weight, and exercise between women grouped by testing status (Table 2). No individual reported signs or symptoms of diabetes regardless of whether they were known or found to have diabetes.
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Discussion |
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The lack of incorporation of practice guidelines into clinical practice is not a problem limited to the follow-up of gestational diabetes.18,19 The incorporation of guidelines for preconceptual control of diabetes to reduce infant birth defects into clinical practice was similarly problematic. Those studies used the same specialties (obstetrics and gynecology, family practice, and internal medicine) and required patient compliance and physician intervention before the development of overt symptoms of disease. A recent review of studies that attempted to change physician performance found that many commonly used strategies (ie, conferences, journals, and educational brochures) had little effect on changing physician behavior; however, patient-mediated interventions, outreach visits, reminders, and opinion leader discussions were successful for incorporating practice guidelines regarding preconceptual control of diabetes into medical practice.20,21 The strategies that were used to educate physicians and patients for successful implementation of that patient care guideline might be helpful in addressing the current problem.
Information sent to patients explaining the risk of developing diabetes resulted in 58% of the women (39 of 66) seeking testing for diabetes. The remaining 42% were not ignorant of the problem, nor were they unwilling to participate in two separate studies regarding the development of diabetes. All of the women who had not been tested for diabetes in the previous year but upon testing were diabetic had been asymptomatic and none reported any suspicion that they had diabetes. This finding is consistent with the known lack of symptoms associated with type II diabetes. Patient denial is a well-known complicating factor in diabetes, and this study shows that it might be a factor in patients who are known to be at risk but in whom the disease has not developed.
In our 1990 cross-sectional study, the incidence of diabetes increased linearly from 17.9% at 1 year to 36.8% at 16 years postpartum.1 During the 5-year period from 1990 to 1995, diabetes or glucose intolerance developed in 58.1% of the patients who were tested, according to the National Diabetes Data Group criteria.16 Although this rate is comparable to those of other studies,2–10 it is much greater than the 1.2% increase per year predicted from our previous study. This difference could have resulted from the design of the study, from bias induced by retroactive selection (ie, previous gestational diabetic patients were asked to participate long after their index pregnancy), or from selection bias for having a GTT in the present study. Nevertheless, the present study emphasizes the high rate of development of diabetes in patients with previous gestational diabetes and the importance of performing a yearly 2-hour GTT to screen for diabetes in patients with a history of gestational diabetes.
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Footnotes |
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Received July 27, 1998. Received in revised form November 14, 1998. Accepted November 19, 1998.
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References |
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2. Ali Z, Alexis SD. Occurance of diabetes mellitus after gestational diabetes mellitus in Trinidad. Diabetes Care 1990;13:527–9.[Abstract]
3. Dornhorst A, Bailey PC, Anyaoku V, Elkeles RS, Johnston DG, Beard RW. Abnormalities of glucose tolerance following gestational diabetes. Q J Med 1990;77:1219–28.[Medline]
4. Mestman JH. Follow-up studies in women with gestational diabetes mellitus. The experience at Los Angeles County/University of Southern California Medical Center. In: Weiss PA, Coustan DR, eds. Gestational diabetes. New York: Springer-Verlag, 1987:191–8.
5. Lam KSL, Li DF, Lauder IJ, Lee CP, Lung AWC, Ma JTC. Prediction of persistent carbohydrate intolerance in patients with gestational diabetes. Diabetes Res Clin Pract 1991;12:181–6.[Medline]
6. Grant PT, Oats JN, Heischer NA. The long-term follow-up of women with gestational diabetes. Aust N Z J Obstet Gynaecol 1986;26:17–22.[Medline]
7. Damm P, Kuhl C, Bertelsen A, Molsted-Pederson L. Predictive factors for the development of diabetes in women with previous gestational diabetes mellitus. Am J Obstet Gynecol 1992;167:607–16.[Medline]
8. O’Sullivan JB. Gestational diabetes: Factors influencing the rates of subsequent diabetes. In: Sutherland HW, Stowers JM, eds. Carbohydrate metabolism in pregnancy and the newborn. New York: Springer-Verlag, 1978:425–35.
9. Coustan DR, Carpenter MD, O’Sullivan PS, Carr SR. Gestational diabetes: Predictors of subsequent disordered glucose metabolism. Am J Obstet Gynecol 1993;168:1139–45.[Medline]
10. Steinhart JR, Sugarman JR, Connell FA. Gestational diabetes is a herald of NIDDM in Navajo women. Diabetes Care 1997;20:943–7.[Abstract]
11. Gregory KD, Kjos SL, Peters RK. Cost of non-insulin-dependent diabetes in women with a history of gestational diabetes: Implications for prevention. Obstet Gynecol 1993;811:782–6.
12. Fuhrmann K, Reiher H, Semmler K, Fischer F, Fischer M, Glockner E. Prevention of congenital malformations in infants of insulin-dependent diabetic mothers. Diabetes Care 1983;6:219–23.[Abstract]
13. Holt TA. Long term follow up of women who have had gestational diabetes [editorial]. Br J Gen Pract 1992;42:354–5.[Medline]
14. American College of Obstetricians and Gynecologists. Diabetes and pregnancy. ACOG technical bulletin no. 200. Washington DC: American College of Obstetricians and Gynecologists, 1994.
15. American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 1997;20(Suppl 1):S44–5.
16. National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes 1979;28:1039–57.[Medline]
17. Gabbe S, Hill L, Schmidt L, Schulkin J. Management of diabetes by obstetrician-gynecologists. Obstet Gynecol 1998;91:643–7.[Abstract]
18. Cook DJ, Greengold NL, Ellrodt AG, Weingarten SR. The relation between systemic reviews and practice guidelines. Ann Intern Med 1997;127:210–6.
19. Grimshaw JM. Towards effective professional practice. Therapie 1996;51:233–6.[Medline]
20. Davis DA, Thomson MA, Oxman AD, Hayns RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700–5.[Abstract]
21. Kitzmiller JL, Buchanan TA, Kjos S, Combs CA, Ratner RE. Preconception care of diabetes, congenital malformations, and spontaneous abortions. Diabetes Care 1996;19:514–41.[Medline]
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