Optimizing postpartum care for the patient with gestational diabetes mellitus

Abstract

Gestational diabetes mellitus (GDM) poses well-established risks to both the mother and infant. As over 50% of women with GDM will develop type 2 diabetes mellitus (T2DM) in their lifetime, performing postpartum oral glucose tolerance testing (OGTT) is paramount to initiation of appropriate lifestyle interventions and pharmacologic therapy. Nonetheless, test completion among women with GDM is estimated to be <50%, with particularly low rates in Latina patients, as well as patients with public insurance, low education levels, and low health literacy. Data suggest our current health services infrastructure loses patients in the postpartum gap between pregnancy-focused care and primary care. As previous studies have demonstrated strategies to promote OGTT completion for T2DM prevention, hereto is a proposal of best practices including 1) enhanced patient support for identifying long-term health care providers 2) patient-centered medical home utilization when possible 3) patient and provider test reminders, and 4) formalized obstetrician-primary care provider hand-offs using the “SBAR” (Situation Background Assessment Recommendation) mnemonic. These strategies deserve future investigation to solidify a multi-level approach for identifying and preventing the continuum of diabetes.

Diabetes During Pregnancy: Surveillance, Preconception Care, and Postpartum Care

“…43,44 As women with a history of GDM transition from pregnancy to postpartum, establishing communication between obstetrical and primary care providers is key to improving postpartum diabetes screening and monitoring. 45 A multilevel approach may need to be considered, which could include a reminder system incorporated into electronic medical records and an effective hand-off system of patient’s medical records involving a variety of healthcare settings, specialties, and levels of practitioners. 43,45,46 …”

“…45 A multilevel approach may need to be considered, which could include a reminder system incorporated into electronic medical records and an effective hand-off system of patient’s medical records involving a variety of healthcare settings, specialties, and levels of practitioners. 43,45,46 …”

Prevalence of glucose intolerance and metabolic syndrome within one year following delivery of a pregnancy complicated by gestational diabetes

“…Adherence to postpartum testing guidelines is notoriously poor. Only 50–60% of women diagnosed with GDM, who are seen for postpartum care, are administered any postpartum glucose testing in the year following delivery [ 6 , 16 ]. Even more do not get tested because they do not return for postpartum care.…”

“…One recent study found that almost half of all postpartum women are not seen for any postpartum care within 99 days of delivery, even when such services were available for free [ 17 ]. Patients may not return for postpartum care because they are anxious about their condition or the visit costs [ 16 ]. Low testing rates may also be explained by the fact that significant gaps exist in clinician knowledge and practice relating to postpartum care for women who have had GDM [ 18 ].The complexity of the oral glucose tolerance test itself or a failure of clinicians to order the test may also contribute.…”

“…Low testing rates may also be explained by the fact that significant gaps exist in clinician knowledge and practice relating to postpartum care for women who have had GDM [ 18 ].The complexity of the oral glucose tolerance test itself or a failure of clinicians to order the test may also contribute. Inadequate coordination of care between the woman’s obstetrician and her primary care provider has also been identified as a barrier to timely postpartum glucose tolerance testing [ 6 , 16 ]. This lack of testing is so prevalent that some experts have suggested oral glucose tolerance testing be done while the patient is still hospitalized on postpartum day two [ 19 ].…”