COMMENTARY

Gestational Diabetes: A Worldwide Controversial Topic

Chantal Mathieu, MD, PhD

Disclosures

August 01, 2014

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Gestational Diabetes: Find It Early

Hello. I am Chantal Mathieu, Professor of Medicine at the Catholic University of Leuven, Belgium, and Head of Endocrinology at the University Hospital Gasthuisberg. Today I want to discuss the topic of gestational diabetes. Gestational diabetes has been a very hot topic for many years because it has a great impact on the health of the woman, not only during pregnancy but also later on. It is also one of the most predictive factors for the development of type 2 diabetes later in life.

Gestational diabetes affects not only the health of the mother but also the health of the baby, and so it becomes a doubly important problem. Screening for gestational diabetes has been a topic of debate for many years, and different screening strategies have been proposed over the years.[1,2,3] In recent times, the International Association of the Diabetes and Pregnancy Study Groups (IADPSG)[2] has proposed a new way of screening for gestational diabetes. They highlight several points. First, they put the emphasis on screening for preexisting diabetes before pregnancy, or if possible, in the very early weeks of pregnancy. This is very important because of the rise of type 2 diabetes at younger ages. Now we see more young women in their twenties and thirties presenting with preexisting type 2 diabetes without knowing it. Screening for preexisting type 2 diabetes is very important, because it will give rise to macrosomia and complications during pregnancy. Therefore, finding these women early is important. How should we do this? With just a simple measurement of fasting glycemia, we will already help many mothers and babies.

Which Screening Strategy?

The second point is more difficult -- namely, screening for gestational diabetes later in pregnancy. The IADPSG proposes a screening strategy involving an oral glucose tolerance test (OGTT) in every pregnant woman, but there the debate starts because, in many countries, it is obvious that this puts many constrains on the costs of the follow-up of women who are pregnant. Moreover, many people question whether it is worthwhile to do this universal screening in all pregnant women. It would depend on ethnic background, for example.

Worldwide, people are now trying to tease out in what circumstances universal screening might be beneficial and in what circumstances a more progressive screening strategy might be appropriate. For instance, in Europe, we are trying to put together a consortium where we will investigate whether screening on the basis of questionnaires or a preexisting challenge test with 50 g of glucose in a nonfasting state may help to predict which women need an OGTT vs universal screening with an OGTT in everybody.

Treating Without Being Too Glucocentric

A third point is how to proceed once you have diagnosed gestational diabetes. It is essential in these women that we are not too glucocentric. Indeed, gestational diabetes is not only a problem of a failing beta cell or a beta cell that is not able to cope with the increased insulin resistance during pregnancy, but there is also the issue of lifestyle and the obesity that we see in many pregnant women now. We shouldn't be too glucocentric; we have to bring up lifestyle advice. We have to discuss healthy eating and exercise with pregnant women, because that will affect not only the glucose challenges we see in these women with gestational diabetes but also their weight and weight gain during pregnancy. We know from studies that glucose affects not only the weight of the baby but also the weight gain of the mother, so lifestyle changes, education, and coaching for these women will bring more results than just treating the glucose.

However, in some women, when glucose is too high, it is necessary to introduce pharmacologic treatment, and insulin is still the preferred treatment. You need to determine when the glucose excursions are happening. In most women, this will be mainly a postprandial issue, so introducing fast-acting insulin analogs at mealtime is an elegant solution during pregnancy. In women in whom fasting glycemia is also too high, a slow-acting insulin might have to be introduced before bedtime.

Follow for Onset of Type 2 Diabetes

After excluding newly diagnosed type 2 diabetes, screening for gestational diabetes, and tackling gestational diabetes, we have the baby. Are we done then? No, and that is the fourth very important message. In women with gestational diabetes, there is a very high risk for later development of type 2 diabetes, a chance of 1 in 3 to 1 in 2. These women should be followed up with an OGTT 2-3 months after delivery and then a yearly follow-up, ideally with an OGTT. Furthermore, a yearly fasting glucose test will allow you to detect the development of type 2 diabetes early in these women.

Gestational diabetes is a controversial topic but it is highly rewarding to take care of pregnant women with this condition. Thank you for your attention.

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