Earlier treatment for gestational diabetes can prevent complications – Lancet

Managing gestational diabetes much earlier in pregnancy can prevent complications and improve long-term health outcomes, international experts have said.

Authors of a new Lancet Series have challenged current approaches to managing gestational diabetes. They have called for starting treatment much earlier to prevent complications during pregnancy and beyond.

Gestational Diabetes Mellitus (GDM) is a type of diabetes that can be diagnosed during pregnancy and where blood glucose levels are higher than average but not as high as diabetes. It is the most common medical pregnancy complication worldwide, affecting one in seven (14 per cent) of pregnancies.

The current approach to GDM management focuses on late GDM, typically after 24 weeks of pregnancy. The Lancet series authors argue that, by starting treatment before 14 weeks, complications for mother and baby can be prevented.

“Our new series emphasises the urgent need for a major shift in how GDM is first diagnosed and managed, not only during pregnancy but throughout the lifetime of mothers and their babies,” said series lead Prof David Simmons of Western Sydney University, Australia.

“GDM is an increasingly complex condition, and there isn’t a one-size-fits-all approach to managing it. Instead, a patient’s unique risk factors and metabolic profile should be considered to help guide them through pregnancy and support them afterward to achieve the best health outcomes for women and babies everywhere.”

As obesity continues to increase worldwide, along with impaired glucose tolerance and rates of type 2 diabetes (T2D) rates in women of reproductive age, GDM prevalence has also increased two to threefold across multiple countries over the last 20 years. The current GDM prevalence rates range from over 7 per cent in North America and the Caribbean region to almost 28 per cent in the Middle East and North Africa region.

Between 30 and 70 per cent of women with GDM experience high blood glucose (hyperglycemia) from early pregnancy (20 weeks gestation or sooner). These women have worse pregnancy outcomes compared to women whose GDM is not present until later in pregnancy (24-28 weeks).

Even later in pregnancy, in studies where GDM was not managed adequately (e.g., where insulin was needed but not used), GDM was associated with increased risks of cesarean delivery (16 per cent), pre-term delivery (51 per cent), and large for gestational age babies (57 per cent). Other studies that looked at GDM pregnancies requiring insulin therapy found it was associated with a more than two-fold increased risk of neonatal intensive care unit admission.

Women diagnosed with GDM have a 10-fold higher risk of developing T2D later in life compared to women who did not experience GDM. They are also more likely to have co-existing hypertension, dyslipidaemia (high blood lipid levels), obesity, and fatty liver, with a two-fold higher risk for 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 own impacts, these feelings of guilt and shame can lead to additional adverse outcomes if patients avoid testing glucose levels or taking insulin because of them.

Recent studies have suggested that GDM diagnosis may be associated with an increased risk of subsequent postpartum depression. Conversely, treatment of late GDM is associated with lower rates of depression at three months postpartum, while treatment of early GDM is associated with improvement of quality of life at 24 to 28 weeks gestation.

“GDM is a tremendous public health challenge. Women who experience it need support from the medical community, policymakers, and society as a whole to ensure they can effectively access proper treatment, reduce the stigma associated with GDM, and improve their overall pregnancy experience,” said co-author Dr Yashdeep Gupta of the All-India Institute of Medical Science.

The World Health Organisation’s current diagnostic criteria for GDM recommends testing at 24-28 weeks gestation without prior screening.

However, recent evidence suggests that GDM has foundations before pregnancy and can be present in early pregnancy. Overall, 30-70 per cent of GDM can be found early using oral glucose tolerance testing and includes those at most significant risk of requiring insulin therapy and experiencing pregnancy complications.

Recent studies also showed that among women with early GDM, identification, and treatment before 20 weeks gestation (compared to 24-28 weeks) not only reduced pregnancy complications and postpartum complications, including neonatal respiratory distress and length of stay in neonatal intensive care units, but also improved quality of life mid-pregnancy and increased breastfeeding initiation, which can reduce the likelihood of developing obesity, T2D, and other long-term conditions.

“The benefits of early GDM detection are clear – we can keep mothers and babies healthier during pregnancy and hopefully continue that path for a lifetime. What is needed now is earlier testing and an approach to managing GDM that takes the available resources, circumstances, and personal wishes of the patient into consideration,” said co-author Dr Helena Backman of Örebro University, Sweden.

The authors will present their recommendations at the latest scientific session of the American Diabetes Association this Monday, 24 June. Their Lancet series papers can be accessed here.