case study of gestational diabetes mellitus

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• J Family Med Prim Care
• v.8(5); 2019 May

Early onset gestational diabetes mellitus: A case report and importance of early screening

Ahmad najmi.

1 Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, India

Shubham Atal

Balakrishnan sadasivam, pooja singh.

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Screening for GDM is usually done at 24–28 weeks of gestation. In this case, we report a 31–year-old woman who developed gestational diabetes at 6 weeks in two successive pregnancies. She was in the perceived high-risk group to develop gestational diabetes. The first pregnancy terminated in spontaneous abortion at 10 weeks. In the second pregnancy, institution of insulin therapy at diagnosis was associated with a successful outcome. This case highlights the need of screening for gestational diabetes at the first antenatal visit in the high-risk group.

Introduction

Gestational diabetes mellitus is a heterogeneous medical entity that includes women with pregnancy induced glucose intolerance and women with undiagnosed diabetes discovered during pregnancy.[ 1 , 2 ] Normal pregnancy is characterised by mild fasting hypoglycaemia, a moderate rise in postprandial plasma glucose, and hyperinsulinemia.[ 3 ] The postprandial hyperglycaemia is due to pregnancy induced physiological insulin resistance which may be due to involvement of hormones-like cortisol, prolactin, progesterone, and human placental lactogen.[ 4 ] GDM is known to be associated with adverse maternal and foetal outcomes like maternal hypertension, caesarean deliveries, development of diabetes, foetal macrosomia, need for neonatal ICU care, etc.[ 5 ] This case points out the need of screening for gestational diabetes early in the pregnancy in the high-risk group which includes women with history of previous GDM.

Case History

A 31-year-old woman, a housewife, presented to our hospital at six weeks of gestation of her first pregnancy in June 2017. Her body mass index was 23 and blood pressure was 124/78 mm Hg. There was no relevant past medical history. There was a strong family history of type 2 diabetes as both her parents were diabetic. To screen her, a 75 g oral glucose tolerance test (OGTT) was performed. The fasting plasma glucose was 106 mg/dl and 2 h value was 138 mg/dl. Based on the World Health Organisation 1999 criteria, GDM was diagnosed, and necessary dietary advice given.[ 1 ] The pregnancy terminated spontaneously in abortion at 10 weeks. Eight weeks after the abortion, a 75 g OGTT was repeated and this was found to be normal. She was advised to follow a normal diet and to undergo GDM screening as soon as the next pregnancy is detected. She conceived again in February 2018 and underwent a 75 g OGTT at six weeks’ gestation. The fasting value was 108 mg/dl and 2-h value was 210 mg/dl. The result of the glycated haemoglobin (HbA 1c ) testing done at the same time was 6.6% (reference range 6.6–8.3%). The diagnosis of gestational diabetes mellitus was made and insulin therapy in the form of twice daily injections of insulin aspart and once daily injection of insulin lispro was started. Follow ups were done at intervals of 2–4 weeks depending on the glycaemic control achieved. Her average fasting and two hour plasma glucose values were 86 mg/dl and 118 mg/dl, respectively with HbA 1c being less than 6.5%. The insulin doses were increased with advancing pregnancy. At the end of the pregnancy, the total daily insulin dose was 60 units. The weight gain during pregnancy was 12 kg. At 38 completed weeks, an elective caesarean section was planned. A live and healthy female baby was delivered weighing 2800 g. The baby had an uncomplicated neonatal course. The patient's plasma glucose values returned to normal by the next morning and insulin injections were stopped. She underwent a 75 g OGTT at six weeks postpartum, which was normal. She was informed of her high risk of developing type 2 diabetes in later life[ 2 ] and was advised to maintain normal body weight by appropriate dietary modifications and regular physical activity. She was also advised to undergo a 75 g OGTT every 3 years.[ 2 ]

The mechanism of GDM has not been understood properly till date. The most likely cause is human placental lactogen because of a 1000-fold rise in its level during pregnancy and its homology to the known insulin antagonist, the growth hormone.[ 4 ] As the level of this hormone rises with advancing pregnancy, the insulin resistance worsens with time.[ 4 ] It is at its maximum in the third trimester, necessitating a threefold rise in maternal insulin output to maintain euglycaemia.[ 4 ] Mothers with deficient β cell reserve become glucose intolerant at this time. So, gestational diabetes mellitus typically appears late in the second trimester or early in the third trimester.[ 4 ] Based on this fact, the current recommendation for screening for gestational diabetes mellitus is between 24 and 28 weeks of gestation.[ 1 , 3 , 6 ]

According to ADA guidelines 2019, insulin is the preferred medication for pre-existing type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin.[ 7 ] For gestational diabetes, insulin is the gold standard. Human insulin, both regular and NPH, and the rapid acting insulin analogues such as lispro and aspart have been licensed for usage in pregnancy. Insulin detemir has been approved for use in pregnancy while glargine is not approved in managing GDM.[ 8 ]

Poorly controlled diabetes both before and during the first trimester of pregnancy can cause major birth defects, spontaneous abortions, and stillbirths.[ 9 ] Despite this well-established fact, more than 60% of women with pre-existing diabetes have difficulty managing their glycaemic control during pregnancy.[ 2 ] Researchers and care providers agree that glycemic control is one of the most important modifiable risk factors in minimizing birth defects of infants born to women with pre-existing diabetes.[ 10 ] While type 1 diabetes management requires insulin and thus leaves little choice during pregnancy, type 2 diabetes may be managed with life-style modifications, oral anti-diabetic agents, and/or insulin. Among oral agents, several new molecular entities[ 11 ] have been added within the last ten years with limited data on pregnancy outcomes.

Gestational diabetes mellitus screening is usually done at 24–28 weeks of gestation since insulin resistance increases especially during the second trimester and hyperglycaemia occurs in women who do not have the ability to produce enough insulin in response to this blood glucose rise. But this case report shows that GDM screening early in the pregnancy, preferably in the first antenatal visit, and insulin therapy have a definite beneficial role in improving the outcome of the pregnancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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Ginny Lewis; Case Study: Complicated Gestational Diabetes Results in Emergency Delivery. Clin Diabetes 1 January 2001; 19 (1): 25–26. https://doi.org/10.2337/diaclin.19.1.25

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A.R. is a 33-year-old caucasian woman initially diagnosed with diabetes during a recent pregnancy. The routine glucose challenge test performed between 28 and 29 weeks gestation was elevated at 662 mg/dl. A random glucose completed 1–2 days later was also elevated at 500 mg/dl. A follow-up HbA 1c was elevated at 11.6%. Additional symptoms included a 23-lb weight loss over the past 3–4 weeks with ongoing “flu-like” symptoms, including fatigue, nausea, polyuria, and polydypsia.

A.R. had contacted her obstetrician’s office when her symptoms first appeared and was told to contact her primary care provider for the “flu” symptoms. She had called a nurse triage line several times over the previous 2–3 weeks with ongoing symptoms and was told to rest and take fluids.

She presented to her primary care provider 3 days after the HbA 1c was drawn for ongoing evaluation of hyperglycemia. At that time, she was symptomatic for diabetic ketoacidosis. She was hospitalized and started on an insulin drip.

A.R.’s hospitalization was further complicated with gram-negative sepsis, adult respiratory distress syndrome, and Crohn’s disease with a new rectovaginal fistula. She was intubated as her respiratory status continued to decline and was transferred to a tertiary medical center for ongoing management. She required an emergency Caesarian section at 30 1/7 weeks gestation due to increased fetal distress.

A.R. had no family history of diabetes with the exception of one sister who had been diagnosed with gestational diabetes. Her medical history was significant for Crohn’s disease diagnosed in 1998 with no reoccurrence until this hospitalization. Her pre-pregnancy weight was 114–120 lb. She had gained 25 lb during her pregnancy and lost 23 lb just before diagnosis.

A.R.’s blood glucose levels improved postpartum, and the insulin drip was gradually discontinued. She was discharged on no medications.

At her 2-week postpartum visit, home blood glucose monitoring indicated that values were ranging from 72 to 328 mg/dl, with the majority of values in the 200–300 mg/dl range. A repeat HbA 1c was 8.7%. She was restarted on insulin.

1.  What is the differential diagnosis of gestational diabetes versus type 1 diabetes?

2.  At what point during pregnancy should insulin therapy be instituted for blood glucose control?

3.  How can communication systems be changed to provide for integration of information between multiple providers?

Gestational diabetes is defined as “any degree of carbohydrate intolerance with onset first recognized during pregnancy. This definition applies whether insulin ... is used for treatment and whether or not the condition persists after pregnancy.” 1 Risk assessment is done early in the pregnancy, with average-risk women being tested at 24–28 weeks’ gestation and low-risk women requiring no additional testing. 1 , 2 A.R. met the criteria for average risk based on age and a first-degree family member with a history of gestational diabetes.

Screening criteria for diagnosing diabetes include 1 ) symptoms of diabetes plus casual plasma glucose >200 mg/dl (11.1 mmol/l), or   2 ) fasting plasma glucose >126 mg/dl (7.0 mmol/l), or   3 ) 2-h plasma glucose >200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test (OGTT). 3 For women who do not meet the first two criteria, a glucose challenge test (GCT) measuring a 1-h plasma glucose following a 50-g oral glucose load is acceptable. For those women who fail the initial screen, practitioners can then proceed with the OGTT. 1  

In A.R.’s case, she most likely would have met the first criterion if a casual blood glucose had been measured. She had classic symptoms with weight loss, fatigue, polyuria, and polydypsia. Her 1-h plasma glucose following the glucose challenge was >600 mg/dl, which suggests that her casual glucose would also have been quite high.

Medical nutrition therapy (MNT) is certainly a major part of diabetes management. However, with this degree of hyperglycemia, MNT would not be adequate as monotherapy. Treatment for gestational diabetes includes the use of insulin if fasting blood glucose levels are >95 mg/dl (5.3 mmol/l) or 2-h postprandial values are >120 mg/dl (6.7 mmol/l). 1  

Several days passed from the time of A.R.’s initial elevated blood glucose value and the initiation of insulin therapy. While HbA 1c values cannot be used for diagnostic purposes, in this case they further confirmed the significant degree of hyperglycemia.

Plasma blood glucose values initially improved in the immediate postpartum period. A.R. was sent home without medications but instructed to continue home glucose monitoring.

At her 2-week postpartum visit, whole blood glucose values were again indicating progressive hyperglycemia, and insulin was restarted. A.R.’s postpartum weight was 104 lb—well below her usual pre-pregnancy weight of 114–120 lb. Based on her ethnic background, weight loss, abrupt presentation with classic diabetes symptoms, and limited family history, she was reclassified as having type 1 diabetes.

In immune-mediated, or type 1, diabetes, b-cell destruction can be variable, with a slower destruction sometimes seen in adults. 3 Presentation of type 1 diabetes can also vary with modest fasting hyperglycemia that can quickly change to severe hyperglycemia and/or ketoacidosis in the presence of infection or other stress. 3 A.R. may have had mild hyperglycemia pre-pregnancy that increased in severity as the pregnancy progressed.

The final issue is communication among multiple health care providers. A.R. was part of a system that uses primary care providers, specialists, and triage nurses. She accessed all of these providers as instructed. However, the information did not seem to be clearly communicated among these different types of providers. A.R. called triage nurses several times with her concerns of increased fatigue, nausea, and weight loss. The specialist performed her glucose challenge with follow-up through the primary care office. It seems that if all of these providers had the full information about this case, the diagnosis could have been made more easily, and insulin could have been initiated more quickly.

1.  Hyperglycemia diagnosed during pregnancy is considered to be gestational diabetes until it is reclassified in the postpartum period. Immune-mediated diabetes can cause mild hyperglycemia that is intensified with the increased counterregulatory hormone response during pregnancy.

2.  Insulin therapy needs to be instituted quickly for cases in which MNT alone is inadequate.

3.  The GCT is an appropriate screening test for an average-risk woman with no symptoms of diabetes. In the face of classic symptoms of diabetes, a casual plasma glucose test can eliminate the need for the glucose challenge.

4.  As part of the health care industry, we need to continue to work on information systems to track patient data and share data among multiple providers. Patients can become lost in an ever-expanding system that relies on “protocols” and does not always allow for individual differences or for cases with unusual presentation.

Ginny Lewis, ARNP, FNP, CDE, is a nurse practitioner at the Diabetes Care Center of the University of Washington School of Medicine in Seattle.

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Risk Factors for Gestational Diabetes Mellitus: A Case-Control Study

Affiliation.

• 1 Midwifery Department, Fateme Zahra Fertility & Infertility Research Health Center, Health Research Institute (FNA, AB, SO) and Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
• PMID: 33786034
• PMCID: PMC7958210
• DOI: 10.1177/1559827618791980

Background : The underlying causes of gestational diabetes mellitus (GDM) are important because they are effective for the diagnosis and prevention of this condition. The aim of this study was to identify the risk factors for GDM and the possible etiological agents. Materials and Methods : This case-control study was conducted with 100 women with GDM and 100 healthy pregnant women at a tertiary care hospital, affiliated to Babol University. GDM was identified by impaired oral glucose tolerance test based on the Carpenter and Coustan criteria. Healthy women were randomly selected from the prenatal health care clinic of the same center and were matched to gestational age of 24 to 28 weeks. Descriptive and inferential statistics were used for data analysis via the SPSS software. Results : After adjusting variables, multivariate analysis identified 4 significant risk factors of GDM, including prepregnancy low physical activity (odds ratio [OR] = 2.85, 95% confidence interval [CI]= 0.97-8.34), advanced maternal age (OR = 1.24, 95% CI = 1.13-1.35), body mass index ⩾ 30 kg/m 2 (OR = 1.10, 95% CI = 1.02-1.20), and family history of diabetes mellitus (OR = 5.62, 95% CI = 2.26-13.96). Conclusion : We observed significant associations between low prepregnancy physical activity and obesity with GDM risk. Thus the finding of this study can help devise strategies for the prevention of GDM.

Keywords: body mass index; gestational diabetes mellitus; physical activity; risk factors.

© 2018 The Author(s).

• Research article
• Open access
• Published: 07 February 2020

Women’s experiences of a diagnosis of gestational diabetes mellitus: a systematic review

• Louise Craig 1 ,
• Rebecca Sims 1 ,
• Paul Glasziou 1 &
• Rae Thomas   ORCID: orcid.org/0000-0002-2165-5917 1  

BMC Pregnancy and Childbirth volume  20 , Article number:  76 ( 2020 ) Cite this article

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Gestational diabetes mellitus (GDM) - a transitory form of diabetes induced by pregnancy - has potentially important short and long-term health consequences for both the mother and her baby. There is no globally agreed definition of GDM, but definition changes have increased the incidence in some countries in recent years, with some research suggesting minimal clinical improvement in outcomes. The aim of this qualitative systematic review was to identify the psychosocial experiences a diagnosis of GDM has on women during pregnancy and the postpartum period.

We searched CINAHL, EMBASE, MEDLINE and PsycINFO databases for studies that provided qualitative data on the psychosocial experiences of a diagnosis of GDM on women across any stage of pregnancy and/or the postpartum period. We appraised the methodological quality of the included studies using the Critical Appraisal Skills Programme Checklist for Qualitative Studies and used thematic analysis to synthesis the data.

Of 840 studies identified, 41 studies of diverse populations met the selection criteria. The synthesis revealed eight key themes: initial psychological impact; communicating the diagnosis; knowledge of GDM; risk perception; management of GDM; burden of GDM; social support; and gaining control. The identified benefits of a GDM diagnosis were largely behavioural and included an opportunity to make healthy eating changes. The identified harms were emotional, financial and cultural. Women commented about the added responsibility (eating regimens, appointments), financial constraints (expensive food, medical bills) and conflicts with their cultural practices (alternative eating, lack of information about traditional food). Some women reported living in fear of risking the health of their baby and conducted extreme behaviours such as purging and starving themselves.

A diagnosis of GDM has wide reaching consequences that are common to a diverse group of women. Threshold cut-offs for blood glucose levels have been determined using the risk of physiological harms to mother and baby. It may also be advantageous to consider the harms and benefits from a psychosocial and a physiological perspective. This may avoid unnecessary burden to an already vulnerable population.

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Gestational diabetes mellitus (GDM) is diagnosed by elevated blood glucose in pregnancy though the definition has changed repeatedly since its first description in the 1960’s [ 1 , 2 ]. The most frequently reported perinatal consequence of GDM is macrosomia (usually defined as a neonate weighing over 4 kg) which can increase the risk of caesarean section and shoulder dystocia. For the mother, there are also potential longer-term consequences including an increased risk of type 2 diabetes post-pregnancy and/or in later life [ 3 ]. The investigators of a large international Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study aimed to identify a cut-point in the continuum to decide the blood glucose level (BGL) thresholds that should be used to define GDM [ 4 ]. However, a definitive cut-point was not identified and using the HAPO data the International Association of the Diabetes and Pregnancy Study Groups (IADSPG) consensus panel recommended a BGL threshold associated with the risk of adverse infant outcomes (such as risk of macrosomia, excess infant adiposity and neonatal hyperinsulinemia) [ 5 ]. This change was controversial, and there is currently a lack of an agreed standard for diagnosing high blood glucose in pregnancy.

Pregnancy can be a vulnerable period when a woman is adapting and responding to changes in body perceptions, such as loss of strength or fitness, which can result in reduced self-esteem and depression [ 6 ]. Many women report depression and anxiety during pregnancy which often includes worry for the baby’s wellbeing [ 7 , 8 ]. A diagnosis of a health condition such as GDM could have a detrimental effect on a pregnant woman’s quality of life due to fears that the illness may affect her and/or her baby [ 9 ]. This has potential to convert pregnancy, a natural process, into one associated with risks, ill-health and increased surveillance [ 10 ]. Understanding a women’s response to the GDM diagnosis and its psychological impact has emerged as an important issue [ 11 ]. Some studies report women describing the initial response as one of ‘shock’ [ 12 , 13 ], ‘sadness’ and ‘guilt’ [ 13 ]. A women’s acceptance of risk and fear of complications is likely to influence the acceptability of various interventions. Therefore, it is imperative to amalgamate the findings of these studies to synthesise the array of potential psychosocial consequences of a diagnosis of GDM.

In many countries the prevalence of GDM is rising [ 14 , 15 , 16 ]. Some of this is due to the increasing age at which women are becoming pregnant, an increase in obesity amongst women, more testing during pregnancy, and better recording during pregnancy. However, much of the rise has occurred since 2013 when some countries adopted the new IADPSG criteria and testing regimen for gestational diabetes. This resulted in the anomalous position that two women in two countries with exactly the same glucose levels may or may not be diagnosed with GDM depending on the country’s definition. Caution had been previously raised that the new IADPSG definition would increase prevalence of women diagnosed with GDM by two-to-three-fold [ 17 ].

Despite a significant increase in prevalence of GDM after the introduction of the new IADPSG criteria [ 15 , 16 ], some pre-post studies suggest negligible clinical improvement in the adverse outcomes measured [ 17 , 18 ]. Findings from a qualitative study of 19 women of different cultural backgrounds investigating women’s experiences of a GDM diagnosis reported that the diagnostic criteria itself was viewed as ‘confusing’ by some women and treatment for their ‘borderline’ condition unnecessary [ 19 ].

Although multiple studies have considered the impact of a diagnosis of GDM, a systematic review to synthesise the evidence around the emotional impact of a diagnosis at different stages, i.e. time of diagnosis, after diagnosis, at the delivery of the baby, and post-delivery, is lacking. The findings could inform healthcare clinicians of women’s attitudes and the consequences of a diagnosis and illuminate potential opportunities to provide support and advise. Therefore, in this systematic review, we aim to synthesise the evidence of the psychosocial experiences a diagnosis of GDM has on women during pregnancy and the postpartum period.

We followed the Enhancing Transparency in Reporting the Synthesis of Qualitative Research Guidelines (ENTREQ; Additional file  1 : Table S1) [ 20 ]. We included primary studies published in peer-review journals that:

included pregnant women with a current diagnosis or women with a history of GDM;

provided qualitative data on the psychosocial experiences of a diagnosis of GDM on women across any stage of pregnancy and/or the postpartum period; and

where participants have provided an account of their experience or perspective of living with GDM

No restrictions were placed on country, written language, or year of publication.

Studies were excluded, if:

the primary aim was to identify barriers and/or facilitators to service as these focused on the management of GDM rather than the GDM diagnosis; or

participants were women diagnosed with diabetes before pregnancy

Abstracts, letters, editorials and commentaries were also excluded.

Search methods for identification of studies

The search strategy (MEDLINE version provided in the Additional file  1 ) was developed using a combination of Medical Subject Headings terms centred around three key areas: i) gestational diabetes mellitus ii) diagnostic testing for gestational diabetes mellitus and iii) patient experiences. The Systematic Review Accelerator software was used to translate the search strategy for each of the different databases and to remove duplicated articles [ 21 ]. We searched CINAHL, EMBASE, MEDLINE and PsycINFO databases from inception to April 2018. Forward and backward citation searching of included studies was conducted.

Selection process

A single reviewer (LC) screened the titles and abstracts of retrieved references using Endnote Version X7.7.1. Potentially eligible full-texts were independently reviewed by LC and RS with conflicts resolved via discussion. Two full-text studies published in Portuguese were first translated using Google Translate and then validated by a researcher with both spoken and written Portuguese language skills located within our research network.

Data extraction

All data labelled as results or findings including themes, categories, theories were extracted and imported into NVivo Version 12 by LC. Study characteristics were extracted by LC which included study location, reported research aims, study design, methodology and the analytical approach. Information about the diagnostic criteria used to determine GDM in women was also extracted.

Data synthesis and analysis

To synthesise the findings, we used a thematic synthesis described by Thomas and Harden [ 22 ]. Thematic synthesis has the potential for conclusions to be drawn based on common aspects across otherwise heterogeneous studies and produce findings that directly inform health practitioners [ 22 , 23 ]. Coding was inductive, with codes derived from the data. First, extracted text relevant to patient experiences and perspectives was coded line by line. A subset of studies ( n  = 5) were coded independently by LC and RS to develop a coding framework. Disagreements were resolved by discussion. LC and RS coded a further subset ( n  = 4) and established an inter-rater reliability of Kappa = 0.87. Following this, LC applied the coding framework to the remaining studies. New codes were iteratively developed as new concepts arose.

Second, relationships between the codes were identified by LC to form the basis of descriptive themes across the studies. Similar codes were grouped to generate themes and less frequently used codes were classified into sub-themes. In the final stage, analytical themes were developed to ‘go beyond’ the primary studies to amalgamate and interpret the findings. The relevant quotes to support each theme were tabulated.

Quality assessment

As recommended by the Cochrane Qualitative Research Methods Group, we assessed the quality of the included studies using the Critical Appraisal Skills Programme Qualitative Checklist (CASP). This tool uses a systematic approach to appraise three key areas: study validity, an evaluation of methodological quality, and an assessment of external validity [ 24 ]. Critical appraisal was conducted by one reviewer (LC) for all studies, with second reviewer appraisal (RS) for a sub-set of included papers. The findings from the two reviewers were compared and any contrasting items were discussed and re-reviewed.

The search identified 840 studies. After deduplication and screening of titles and abstracts 88 full-text articles were assessed (Fig.  1 ). Seven further articles were identified through citation searching. Data were extracted from 41 studies meeting eligibility criteria and were included in the review [ 11 , 12 , 13 , 19 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ].

Prima flow diagram

Study characteristics

The studies reflected a variety of sampling methods and data collection methods. For example, interviews were conducted in 34 studies [ 10 , 12 , 13 , 25 , 27 , 28 , 30 , 31 , 32 , 34 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 60 , 61 ], focus group methods were used in three [ 19 , 32 , 37 ], and interviews and focus groups were used in two studies [ 29 , 51 ]. Two studies used a mixed method approach [ 26 , 59 ]. The sample sizes ranged from 6 to 57 women. Eighteen studies were conducted in Europe, 10 in Australia, 9 in North America, and 2 studies each in Asia and South America. Table  1 details the characteristics of the included studies.

Quality appraisal

Most studies were assessed as high quality (Additional file  1 : Table S2). Study aims were stated in all but one study [ 47 ]. As the purpose of all included studies was to explore or gain knowledge, opinions or attitudes about GDM, the qualitative methods employed in all the studies were appropriate. Different study designs were used and in some cases the lack of reporting details made judgments of the appropriateness of study methods difficult. Data were collected in a way that addressed the research issue, however, a few authors did not discuss or report details such as saturation of data [ 31 , 47 , 56 , 59 ]. The relationship between researcher and participants was considered in only two studies [ 51 , 61 ]. Appropriateness of data analysis was assessed as “unclear” when there was a lack of details about how themes were derived.

Thematic analyses

Eight themes were generated from the data synthesis: 1. initial psychological impact; 2. communicating the diagnosis; 3. knowledge of GDM; 4. risk perception; 5. management of GDM; 6. burden of GDM; 7. social support; and 8. gaining control. The relevant quotes to support each theme are presented in Table  2 .

Initial psychological impact

When initially diagnosed with GDM, most women reported reactions such as self-blame, failure, fear, sadness, concern and confusion. Women often focused on the uncertainty of diagnostic prognosis and some considered it to be a life-altering experience. Some women felt lost and unsure what to do next. Often women felt an overwhelming sense of vulnerability and guilt. In some cases, the diagnosis was received positively and was viewed as an opportunity for lifestyle improvements. For example, some women viewed the diagnosis as a ‘ wake up’ call and were grateful for the chance to intervene and potentially prevent adverse outcomes for their babies and themselves. Some women viewed gaining less weight than expected during their pregnancy as a benefit of having a GDM diagnosis.

Communicating the diagnosis

Communication with healthcare professionals (HCPs) and their families was a common theme throughout the findings of the included studies. Generally, the level and quality of communication with HCPs was mixed – with some women reporting positive and informative encounters, while others described brief encounters with overly technical language and unsupportive consultations. The main issues were limited time available to spend with the HCP, lack of continuity of care and lack of understanding about the role of the HCP at follow-up. In some instances, women felt that GDM was not a topic that HCPs were keen to discuss - ‘the nurses, they never talked to me about my gestational diabetes’. [ 23 ] The level and quality of information provided was often conflicting, confusing or insufficient. Areas of contention were appropriate foods and the dietary changes that should be made.

Some women formed a dependency on HCPs to know what to do and on the electronic reminders for follow-up appointments and monitoring. Often women reported having no choice in treatment resulting in them feeling threatened and frustrated. Often women were automatically booked in for a caesarean section without consultation or lived in fear of this occurring. One woman referred to GDM as being over medicalised. Receiving limited information also prompted women to independently seek information about the impact and management of GDM from other sources such as the internet. However, some women found the internet limited for specific information or confusing.

Knowledge of GDM

Women had varying levels of understanding of GDM which impacted on their initial reaction to the diagnosis. Those who were able to explain the cause of GDM were able to process and accept the diagnosis more readily than those who had little understanding of GDM, or were confused as to how GDM occurred. Lack of knowledge also extended to and impacted on relatives. Some women stated that they would have preferred to be more prepared to receive the diagnosis by having early knowledge about the testing for diabetes. Women reported being on a steep learning curve, especially the onerous approach of dietary trial and error whereby women learnt what foods would increase their blood glucose level (BGL) and what food to avoid. Women also reported challenges in adopting new habits to manage their GDM, including understanding food labels and nutritional values of food. Often this required a trial and error approach. There was also a lack of understanding about the impact of GDM on their baby with some women believing it would be transmitted to their baby via breastmilk.

Risk perception

Women’s perception of risk were reported before the diagnosis of GDM, after they were diagnosed in pregnancy, and after the delivery. Some women attempted to understand their level of risk in context of family history. Some were very surprised by the diagnosis, especially if they were asymptomatic; and some women found it difficult to come to terms with the diagnosis. There was uncertainty about the severity of the condition. Some women considered the condition to be mild, downplaying the disease and believing that too much ‘ fuss’ was being made about GDM and other women doubted the diagnosis and its seriousness. Women often discussed: the adverse effects that GDM would have on her baby; frustration that the focus was on risks to the baby and less so them; their worry about the consequences for the future; and questioned the impact of insulin on the baby. Women worried that their diet was too restrictive for their growing baby and would not provide the nutrients that the baby required. Some women held the view that GDM was a temporary condition and would disappear once the baby was born, and many women reverted to old eating habits after the baby’s birth. Often women referred to the birth as a ‘ moment of truth ’ or as an endpoint to their GDM. This was also reflected in the level of care that the women received after the birth of their baby.

Managing GDM

Dietary management-related stress was commonly reported amongst interviewed women and was experienced by both insulin and non-insulin users. Stress and frustrations often occurred as a consequence of an unexpected abnormal blood glucose reading following strict adherence to dietary advice. Maintaining stable BGL was an ongoing struggle and in some cases the burden proved too much, with a few women ceasing employment. Insulin users described the process as a ‘ roller coaster ’ as well as the emotional and physical discomfort of injecting, while non-insulin users often became obsessed with a well-controlled diet, with some women viewing this as a way to avoid the use of insulin. Conversely, some women felt relieved when they were transitioned onto insulin, as it reduced the need for dietary restriction.

Making lifestyle changes was considered stringent and restrictive by the majority of women, and for some required ‘ major restructuring’ to their diet and daily routines to incorporate exercise. Some women reported extreme behaviours, including falsifying blood glucose readings, self-starvation and hiding their condition, including from family members. Often the impact of non-adherence to lifestyle changes resulted in guilt and belief that the baby would know they have cheated. Other pregnancy related ailments and the need to care for other children interfered with the ability to make the required changes. Women who had a specific culture-related diet discussed the impact and difficulty of applying or tailoring the dietary recommendations to their diet.

The key motivator to making required lifestyle changes, despite the associated hardships, was to minimise the risks to their unborn baby. Women prioritised the health of the baby over their own health and were willing to do anything to ensure that the health of their baby was not compromised. Over time, management of the GDM became a part of their normal routine for many women. However, some women expressed a desire to have a ‘ normal’ pregnancy similar to their friends, discussing that a diagnosis of GDM made them feel as though their pregnancy was atypical, leading to defining their pregnancy as ‘ abnormal ’ or as an ‘ illness ’. For one woman, it made her feel like an ‘ illegal’ person.

Burden of GDM

Women reported that a diagnosis of GDM came with extra responsibility, which added pressure whilst trying to juggle life commitments such as work, childcare, and daily living responsibilities. Monitoring and treating GDM placed burden on women’s daily routines and most woman agreed that taking BGL measurements was time consuming and disruptive. There was a constant need to prudently plan meals and co-ordinate the attendance at additional hospital appointments, all of which were considered time intensive, especially with travel and wait times. Women expressed that GDM consumed a lot of their thinking time e.g., ‘ I think about diabetes everyday’ and felt that they had to acknowledge GDM all the time and became ‘ super-conscious’ . In some instances, women reported a GDM diagnosis took away some of the ‘ joy of pregnancy ’ . One woman described her pregnancy as a ‘ misfortune’ . Women mentioned the financial burden of buying healthier food – ‘it would take lots of money just because it is so expensive to eat healthy’. [ 25 ] Women also considered the physical burden of GDM such as fatigue and the side effects of treatment such as insulin. There was a longer-term impact on family planning, where in some cases women decided not to have another child because they were fearful of enduring a similar restrictive and stressful pregnancy due to GDM.

Social support

Social support, including family and HCP support, was an important aspect for women during their experience of a GDM diagnosis. Changes in lifestyle often had an overflow effect, with other family members adopting healthier lifestyles. Women not in their country of birth, and without family, often reported feeling isolated and lonely. Disappointment and isolation were also expressed by some women when they perceived a lack of healthcare system support. This often occurred postnatally when the expectations of postpartum care were high, however, in reality, support was absent. In some cases, women were stigmatised by their families and in a few cases received undesirable feedback that they were not doing enough to protect their unborn child.

Gaining control

Control was a frequently used word when women described living with and managing a GDM diagnosis. Initially women reported a lack of control especially over their emotions, however, over time women transitioned from feeling like a victim of diabetes, to being active agents in controlling their GDM. The terms ‘ balance’ and ‘ adjustment’ were used to describe how some women tried to offset the strict compliance and active self-management with reducing their risk to their unborn baby and their own future risk of developing diabetes after pregnancy. Some women reported feeling empowered as their pregnancies progressed, especially when they gained more knowledge about GDM and what action they could take to accept and make sense of the diagnosis. Taking control included realising the changes that were required to their lifestyle, self-initiated care, and self-education. Often investigating alternative options, such as natural remedies outside those recommended by HCPs, provided women with some autonomy in managing their condition and some believed that it was a safer option to medication.

Summary of main findings

This synthesis of the qualitative evidence of women’s experiences of being diagnosed with GDM highlighted the psychosocial consequences a diagnosis of GDM can have on women. The purported benefits of a GDM diagnosis identified from our review, were largely behavioural and included an opportunity to improve health, prevent excessive weight gain, control weight during pregnancy, and prompts to make healthy eating changes. However, the purported harms included the added responsibility (eating regimens, appointments), financial constraints (expensive food, medical bills), and conflicts with their cultural practices (alternative eating, lack of information about traditional food). The psychosocial consequences were wide reaching and often resulted in significant social isolation with women only sharing their diagnosis with partners. Furthermore, there were a few reports of over-medicalisation due to a GDM diagnosis, with the perception that HCPs were often authoritarian, focusing on physiological aspects, with little attempt to involve women in decision making. This is noteworthy considering a non-GDM pregnancy has already come under scrutiny as being over-medicalised with increasing levels of unnecessary intervention [ 62 ].

Women from studies included in our review frequently reported inconsistent information provision. Limited GDM information provision has been identified in another systematic review regarding healthcare seeking for GDM during the postpartum period [ 63 ]. In contrast, findings from another study which aimed to evaluate satisfaction with obtaining a diagnosis of GDM concluded that the majority of women were satisfied with their experience of being diagnosed [ 64 ]. Further, women in the latter study associated poor GDM control with perinatal complications and an increased risk of type 2 diabetes following pregnancy [ 64 ].

Another key finding from this review was low awareness of the potential risks of GDM, particularly in the long-term. Low health literacy levels could be one factor to explain knowledge deficits and understanding of GDM, especially given the sociodemographic diverse population included in this review. One study found that low literacy among disadvantaged women had a significant impact on their understanding of GDM information [ 65 ]. Other research found that women who live in an English-speaking country but primarily speak a non-English language, have lower rates of dietary awareness compared with their English speaking counterparts, and this may affect compliance to dietary interventions [ 66 ]. Therefore, it is important that new educational interventions are developed to target those with lower health literacy as well as cultural factors when diagnosing and managing multi-ethnic populations with GDM [ 66 ].

Interestingly, women with a borderline diagnosis of GDM did not seem as concerned as other women and in some cases were dismissive of the diagnosis and the potential consequences. Similarly, in a study which specifically included women with a borderline diagnosis of GDM, the majority of women reported that they were not worried by the diagnosis [ 67 ]. For some women, the potential transitory nature of GDM was emphasised and some reported that it didn’t seem like a real illness. The diagnostic criteria for GDM has previously been compared with the established criteria used to classify a condition as a disease. This comparison revealed disparity which Goer, in 1996, used to suggest that GDM did not pose a serious health risk, was neither easily nor accurately diagnosed, was not treated effectively and that treatment outweighed the risks of the condition [ 68 ]. Therefore, the levels of heightened psychological distress as reported by the women in our review, may actually be unnecessary and others have gone as far as saying that GDM is an example of ‘obstetric iatrogenesis’ [ 69 ].

The findings of this review did underline a few unmet service needs with recurring themes around the lack of individualised care and its continuity, lack of choice regarding important aspects of care such as birthing options, and the scarcity of comprehensive follow-up. There was a sense of abandonment amongst women after delivery in that they had experienced intensive intervention and then nothing. This could be viewed as a missed opportunity to capitalise on the motivation to make changes during pregnancy. Researchers have previously highlighted that adherence to postpartum screening and continued lifestyle modifications to prevent future diabetes seems to dissipate after birth, possibly because the driver to protect their unborn child is no longer there [ 70 ].

The studies included in our review had participants of varying cultures sampled from countries with different GDM definitions. However, there appeared no difference in the qualitative outcomes between studies/countries. In our review, the experiences of women diagnosed with GDM suggest psychosocial harms appear to outweigh the qualitative benefits. Quantitative studies [ 14 , 15 ] that report prevalence increases in GDM after the IADSPG [ 71 ] definition changed, also report minimal improvements to maternal and infant physical outcomes.

This synthesis of women’s experiences of a GDM diagnosis could be used to inform the content of communication materials both before and after a GDM diagnosis. For example, an awareness of GDM testing and basic information including cultural adaptations to dietary guidelines and addressing misconceptions around breastfeeding. There is also an opportunity for HCPs to use teachable moments with women who have been identified at risk of developing type 2 diabetes post-pregnancy and offer supportive, effective advice about lifestyle changes. This is particularly relevant considering a previous review highlighted a significant time is spent in sedentary behaviour during pregnancy [ 72 ]. A study which examined HCPs views of healthcare provision to women with GDM showed that HCPs themselves perceived that there was a shortfall in GDM education [ 73 ]. There are also signals for service improvement and potential for service redesign, such as increasing community-delivered care for women diagnosed with GDM. This would assist in alleviating the burden on women to attend hospital appointments and potentially offer flexible appointment times. Follow-up appointments post-pregnancy could be made with consideration of other appointments such as maternal and child health milestones and breastfeeding weaning classes, and could also focused on healthy eating for both mother and baby.

Strengths and limitations

This systematic review included studies with women of different demographic characteristics and multicultural samples. The themes identified were represented in the majority of studies which increased the internal validity. The relatively high participation rate in the included studies, and that most studies were conducted during pregnancy or shortly after delivery, contributes to the external validity of our study. Although some participants were interviewed antenatally and some postnatally, this distribution over different gestational stages assists the generalisability of the study findings.

The comparison of coding between authors, discussion of the results and reaching consensus was a robust approach to improve the credibility of the results. Overall, the quality of most studies was good, however, a third of the studies used convenience methods to recruit participants which could contribute to sampling bias and limit the external validity of our findings. Only two studies adequately described the facilitator’s prior experience and the relationship between the participants and the facilitator/researcher. Unfortunately, this review did not capture the perception of HCPs which might be used to explain some of the behaviours and attitudes of the women, particularly in relation to communication of the diagnosis and information provision. Finally, although the data were collected from diverse populations, the majority of the countries in which research were conducted in were high-income countries, which could be considered to have more established and evidence-based healthcare systems than low-income countries.

Further research

A previous study has suggested the need for more research on the benefits and harms of alternative treatment choices for women with GDM [ 33 ]. The findings from this review suggest a need for more investigation around the psychosocial benefits and harms of a diagnosis of GDM. Given some women viewed treatment of ‘borderline GDM’ as unimportant, a new model of care based on stratification or individual level of risk for pregnancy and birth complications could be further explored. This may reduce the need for all women to be labelled as having GDM and negate unnecessary anxiety and burden for those at the lower ‘borderline’ threshold. This would then potentially offer tailored treatment options, improve shared-decision making, and improve women’s knowledge about how a diagnosis of GDM might affect them.

Consequences of a GDM diagnosis are multidimensional and highly contextual. Despite the psychosocial challenges frequently experienced, many women (driven by the innate response to safeguard their unborn baby) were able to gradually adapt to the required lifestyle changes and monitoring regimens. Perhaps a question is whether some of them should have to. There is opportunity to improve lifestyle and to assist the prevention of diabetes after pregnancy, however, this needs to be managed alongside the potential harms of a GDM diagnosis such as the negative psychological impact and social isolation. In the context of rising prevalence [ 14 , 15 , 16 , 17 ], potential minimal clinical [ 14 , 15 , 16 ] improvements, and the wide range of psychosocial experiences identified in this study, the findings of this review highlight the need for HCPs to consider the implications that a GDM diagnosis may have on women. It is essential that women diagnosed with GDM receive consistent evidence-based information and ongoing psychological and social support.

Availability of data and materials

The datasets generated during the current systematic review are available from the lead author upon request.

Abbreviations

Blood glucose level

Critical Appraisal Skills Programme Checklist (Qualitative)

Enhancing Transparency in Reporting the Synthesis of Qualitative Research

• Gestational diabetes mellitus

Hyperglycemia and Adverse Pregnancy Outcomes

Health care professional

International Association of the Diabetes and Pregnancy Study Groups

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LC is supported by a National Health and Medical Research Council Partnership Centre for Health System Sustainability grant (#9100002). RS and RT are supported by a National Health and Medical Research Council Program grant (#1106452) and PG is supported by a NHMRC Research Fellowship (#1080042). The funders had no role in design, data collection, analysis, interpretation or writing of the manuscript.

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Table S1. Enhancing Transparency in Reporting the Synthesis of Qualitative Research Guidelines Checklist. Table S2. Assessment of quality of included studies using the CASP tool.

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Craig, L., Sims, R., Glasziou, P. et al. Women’s experiences of a diagnosis of gestational diabetes mellitus: a systematic review. BMC Pregnancy Childbirth 20 , 76 (2020). https://doi.org/10.1186/s12884-020-2745-1

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Received : 24 September 2019

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Interactive case study: Gestational diabetes

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Diabetes & Primary Care ’s series of interactive case studies is aimed at all healthcare professionals in primary and community care who would like to broaden their understanding of diabetes.

These two cases provide an overview of gestational diabetes (GDM). The scenarios cover the screening, identification and management of GDM, as well as the steps that should be taken to screen for, and ideally prevent, development of type 2 diabetes in the long term post-pregnancy.

The format uses typical clinical scenarios as tools for learning. Information is provided in short sections, with most ending in a question to answer before moving on to the next section.

Working through the case studies will improve our knowledge and problem-solving skills in diabetes care by encouraging us to make evidence-based decisions in the context of individual cases.

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By actively engaging with these case histories, I hope you will feel more confident and empowered to manage such presentations effectively in the future.

Holly is a 31-year-old lady who is now 26 weeks into her first pregnancy. She sees you with a 3-day history of dysuria and frequency of micturition. There is no history of abdominal pain or fever.

A urine dipstick reveals a positive test for nitrites and the presence of white cells. It also shows glycosuria ++.

What is your assessment of Holly’s situation?

Nadia is a 34-year-old lady of Indian ethnic origin who is now 24 weeks into her second pregnancy, her last pregnancy being 7 years ago. Nadia’s BMI is 32.4 kg/m 2 and her father has type 2 diabetes. GDM was not, however, diagnosed during her first pregnancy and her first baby was born at term weighing 3.8 kg.

How would you assess Nadia’s risk of acquiring gestational diabetes?

By working through this interactive case study, we will consider the following issues and more:

• The risk factors for developing gestational diabetes.
• Investigations and how to interpret them.
• Effects of gestational diabetes on outcomes for the mother and offspring.
• Which treatments for diabetes are considered safe and effective in gestational diabetes.
• What arrangements should be set in place for future screening of diabetes post-pregnancy.

Click here to access the case study .

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• Open access
• Published: 15 June 2022

The prevention of gestational diabetes mellitus (The role of lifestyle): a meta-analysis

• Abdullah H. Altemani   ORCID: orcid.org/0000-0001-7379-2537 1 &
• Riyadh A. Alzaheb 2  

Diabetology & Metabolic Syndrome volume  14 , Article number:  83 ( 2022 ) Cite this article

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Gestational diabetes mellitus (GDM) is the most common complication of pregnancy. The disease is on the rise worldwide with deleterious consequences on the fetus, mother, and children. The study aimed to review the role of lifestyle in the prevention of GDM. We searched PubMed, SCOPUS, Web of Science, Cochrane Library, EBSCO, and Google Scholar from the first published article up to December 2021; articles were eligible if they were controlled trials, prospective cohorts, and case–control. Out of 5559 articles retrieved, 66 full texts were screened, and 19 studies were included in the meta-analysis. (6 studies assessed the effects of diet, and 13 were on exercise). The dietary intervention showed significant positive effect on GDM, odd ratio = 0.69, 95% CI , 0.56–84, P-value for overall effect = 0.002. The DASH diet was better than Mediterranean Diet (odd ratio, 0.71, 95% CI, 68–74, P-value < 0.001). Regarding exercise, no significant prevention was evident on GDM, odd ratio, 0.77, 95% CI , 0.55–1.06, P-value = 0.11. However, a significant prevention of gestational diabetes was found when the exercise was mild-moderate (odd ratio = 0.65, 95% CI , 0.53–80, P < 0.0001) and started in the first trimester (odd ratio, 0.57, 95% CI , 0.43–0.75, P < 0.0001. No significant effect was found when the exercise was vigorous (odd ratio = 1.09, 95% CI , 0.50–2.38, P = 0.83) and started during the second trimester of pregnancy (odd ratio, 1.08, 95% CI , 0.65–1.80, P = 0.77. Diet and early mild-moderate exercise were effective in GDM prevention. Exercise during the second trimester and moderate-vigorous were not. Further studies assessing the type, duration, and frequency of physical activity are needed.

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy, it affects 5–6% of pregnant women in the USA according to the Carpenter-Coustan criteria, and the rate would increase to 15–20% when the International Association of Diabetes in Pregnancy Study Groups criteria is applied. GDM is on the rise due to increasing age and obesity [ 1 ]. The rate of obesity and overweight is rapidly increasing globally and in particular, for the Gulf countries including the Kingdom of Saudi Arabia, this is mirrored by the high prevalence of obesity-related disorders including diabetes [ 2 ]. Diabetes mellitus is more prevalent among Saudi females mainly due to an unfriendly diet. The rapid development in Saudi Arabia substantially shifted the diet from the healthy traditional diet to a more Westernized diet with deleterious consequences [ 3 ]. GDM increases both maternal and fetal complications including excess fetal growth, cardiovascular disease, impaired glucose metabolism, and pregnancy-related hypertensive disease. Physical activity and dietary modifications are the mainstay of management with insulin, Glyburide, and metformin used when normoglycemia is not achieved [ 4 ]. Lifestyle modifications need great effort from both the healthcare professionals and the patients and are usually faced with numerous barriers that may lead to poor glycemic control [ 5 ]. The role of lifestyle in the prevention of GDM is a matter of controversy. The available evidence regarding the lifestyle modification effects on GDM is weak due to the different diets included; furthermore, no single diet fits all. Mediterranean diet is the only diet that is recommended to patients with diabetes mellitus [ 6 ]. Besides, both diet and exercise might be affected by the type, timing, and amount (exercise is also affected by the duration). In addition, non-adherence is a substantial factor compromising the quality of studies [ 7 ]. Individual food items were extensively studied, but nutrients are not consumed in isolation either they are consumed in different combinations (dietary patterns). In addition, dietary patterns mimic real-world scenarios and can be translated into simple and easy-to-follow recommendations. Dietary Approaches to Stop Hypertension (DASH), Alternate Healthy Eating Index diet (AHEI), and Mediterranean Diet (MedDiet) were shown to reduce diabetes, mortality, and cardiovascular disease. However, their effects on gestational diabetes prevention are scarce [ 8 , 9 , 10 , 11 ]. Tobias and colleagues in their retrospective cohort showed that aHEI lowered the risk of GDM by 46%, followed by the DASH diet (34%), and MedDiet (24%) [ 12 ]. The previous observation was supported by another study (57%, 46%, and 40% reduction in aHEI diet, DASH diet, and MedDiet respectively) [ 13 ]. Another study showed a higher reduction in GDM among patients adherent to MedDiert compared to the DASH diet (80% vs. 71%) [ 14 ] A randomized trial supported the above observations and showed the beneficial effects of the DASH diet on glycemic and lipid parameters [ 15 ]. Further randomized controlled trials showed the beneficial effects of the DASH diet on insulin resistance and glycemic parameters [ 16 ]. To the best of our knowledge, no review compared different dietary patterns in the prevention of gestational diabetes mellitus. Therefore, the current review assessed the effects of MedDiet, DASH diet, and aAEI diet on the prevention of gestational diabetes and assessed if one diet is superior. In addition, this meta-analysis assessed the effectiveness of exercise (throughout, first and second trimester).

Articles selection according to PICOS

We searched PubMed, SCOPUS, Web of Science, Cochrane Library, EBSCO, and the first 100 articles in Google Scholar from the first published article up to December 2021, articles were eligible if they were controlled trials, prospective cohorts, and case–control studies and published in English. Article in languages other than English, other methodologies (case series, and case reports were not included. The trials must fulfill the following outcomes to be included:

The effect of the Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH), Alternate Healthy Eating Index diet (AHEI) on GDM prevention

The effect of first and second-trimester exercise on GDM prevention.

We excluded diabetes mellitus prevention programs carried on patients with type 2 diabetes mellitus or women with established GDM.

Literature search and data extraction

The two authors (A.H, and R.A) searched the mentioned databases for relevant articles, out of 5559 articles retrieved, 66 full texts were screened, and 19 studies were included in the meta-analysis. Fig.  1 . In the current review, 6 studies assessed the effects of diet, and 13 were on exercise. Of them, eight assessed exercises in the first trimester and five in the second trimester. We did not specify any criteria for GDM diagnosis due to the different methods that might be applied during the long period of the search engine. The retrieved data were exported to an excel sheet detailing the author's names, country of origin of the study, the number of patients and control subjects, and the total number of events in the interventional and exercise groups (Tables 1 , 2 ). The details of exercise including the type, duration, and intensity, the diet type, and the compliance when reported were also recorded. In this review we concentrated on dietary habits and detailed exercise (timing and duration). Tables 3 , 4 and Fig.  1 .

Exercise and diet in the prevention of gestational diabetes (The PRISMA Chart)

Quality assessment of the cited trials

The quality of the included studies was assessed using a modified Cochrane risk of bias. Table 5 .

Data analysis

We use RevMan (version 5, 4) for data analysis, the data were entered manually, and dichotomous variables were compared. The fixed effect was applied unless a significant heterogeneity (> 50%) was observed. A P-value of 0.05 is significant except when a significant heterogeneity.

Ethical consideration

We did not include studies published by the authors.

The dietary intervention included three studies [ 18 , 19 ] with significant positive effect on GDM, odd ratio = 0.69, 95% CI , 0.56–84, P-value for overall effect = 0.002, with no significant heterogeneity, I 2  = 0.0%. Fig.   2 .

The effects of diet on gestational diabetes prevention

The DASH diet showed superiority to MedDiet Mediterranean Diet [ 13 , 14 , 15 ] (odd ratio, 0.71, 95% CI, 68–74, P-value < 0.001). Furthermore, the Alternate Healthy Eating Index diet was better than the DASH diet (odd ratio, 0.69, 95% CI, 53–91, P-value, 0.008). Fig.  3 and 4 .

A comparison between Dietary Approach to Stop Hypertension (DASH) and Alternate Healthy Eating Index diet (AHEI)effects on gestational diabetes

A comparison between Dietary Approach to Stop Hypertension (DASH) and Mediterranean diet effects on gestational diabetes

Regarding exercise, there were thirteen studies [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ] with no significant prevention on GDM (total patients 4202 and 418 events), odd ratio, 0.77, 95% CI , 0.55–1.06, P-value for overall effect = 0.11, with significant heterogeneity, I . 2  = 62% and P-value for heterogeneity, 0.002. Fig.   5

The effects of exercise on gestational diabetes prevention

However, when a sub-analysis was conducted, significant prevention of gestational diabetes was found when the exercise started in the first trimester (odd ratio, 0.57, 95% CI , 0.43–0.75, P-value for overall effect < 0.0001, with significant heterogeneity, I 2  = 40%. Fig.   6 .

The effects of exercise during the first trimester of pregnancy on gestational diabetes prevention

No significant effect was found when the exercise started during the second trimester of pregnancy [ 22 , 25 , 26 , 28 , 30 ] (odd ratio, 1.08, 95% CI , 0.65–1.80, P-value for overall effect = 0.77, with significant heterogeneity, I 2  = 51%. Fig.  7 .

The effects of exercise during the second trimester on gestational diabetes prevention

It is interesting to note that mild-moderate intensity exercise was effective in gestational diabetes prevention (odd ratio = 0.65, 95% CI , 0.53–80, P-value for overall effect < 0.0001, with significant heterogeneity, I 2  = 36.0%. Fig.  8 ), while vigorous activity was not (odd ratio = 1.09, 95% CI , 0.50–2.38, P-value for overall effect = 0.83, with no significant heterogeneity, I 2  = 51.0%. Fig.  9 ).

The effects of mild-moderate exercise on gestational diabetes prevention

The effects of vigorous exercise on gestational diabetes prevention

The present meta-analysis showed that diet was effective in gestational diabetes prevention, while exercise was not. However, a sub-analysis showed that exercise was effective only when introduced in the first trimester; physical activity started in the second trimester was not effective. In addition, mild-moderate exercise was effective in contrast to vigorous physical activity. Previous studies with a low quality of evidence showed the efficacy of combined diet and exercise [ 33 , 34 ]. The meta-analyses lack a face-to-face comparison between different forms of diets. In addition, they did not report the timing and intensity of exercise. Another study showed similar results but only among obese women [ 35 ]. Dietary supplementation with myo-inositol reduced GDM in a study that included four trials and lacked generalization [ 36 ].

Special types of diets

Alternate healthy eating index-2010.

The AHEI-2010 is a measure of diet quality based on food items predictive of major chronic disease risk, particularly cardiometabolic disease including stroke and diabetes, and malignancies. It emphasizes a high intake of legumes and nuts, cereals, vegetables and fruits, omega-3 fats, and polyunsaturated fatty acids while limiting the intake of red and processed meats, sodium, sugary beverages, and alcohol [ 37 ].

The effect of the Alternate Healthy Eating Index-2010 in reducing GDM ranged from 19–46%, interestingly, when the diet is combined with other risk factors reduction (physical activity, smoking, and normal body weight) the risk reduction may be as high as 83% [ 38 ]. A 41% lower risk of gestational diabetes was observed among patients adherent to aHEI [ 39 ]. A genetic interaction increases the like hood of developing GDM among patients on aHEI diet [ 40 ]. In addition, health education and self-efficacy substantially improved the quality of aHEI [ 41 ], the included studies showed that Alternate Healthy Eating Index is superior compared to the DASH diet and MedDiet [ 13 , 14 , 15 ] .

Mediterranean diet (MedDiet)

The Mediterranean diet is a diet with high fruits and vegetables, bread, legumes, olive oil, cereals, fish, and limited animal products [ 42 ].

The Mediterranean diet is promising for the prevention of GDM, however, the results are contradictory. A recent meta-analysis of the randomized controlled trial showed the efficacy of MedDiet in preventing GDM [ 43 ]. A recent review examined the role of MedDiet in modulating immune response and inflammation during COVID-19 and showed that MedDiet reduced interleukin-6 and inflammatory markers [ 44 ]. A recent case–control study showed that MedDiet reduced GDM incidence [ 45 ], interestingly, women who have rs7903146 T-allele showed a high reduction of GDM compared to their counterparts who are not indicating a gene-diet interaction [ 46 ]. The protective effect of MedDiet ranged from 15 to 38% depending on compliance, genetic factors, and the diagnostic method used (8% when the American Diabetes Association was used and 24% If The International Association of the Diabetes and Pregnancy Study Groups was used [ 38 ]. Although MedDiet was effective in preventing gestational diabetes mellitus, DASH diet and aAEI showed superiority [ 13 , 14 , 15 ].

Dietary approaches to stop hypertension (DASH)

Dietary Approaches to Stop Hypertension (DASH) originally developed for hypertension consists of high intakes of fruits, vegetables, legumes, and nuts, moderate low-fat dairy products, and low consumption of sodium, animal protein, and sweets [ 47 ], of the three studies investigating the effects of the DASH diet on gestational diabetes showed superiority when compared to MedDiet. However, the DASH diet was inferior to Alternate Healthy Eating Index [ 13 , 14 , 15 ].

Western and prudent diet

Zhang and colleagues found a positive association between Western and a negative association of prudent diet with GDM risk, while Radesky et al. found no associations. [ 48 , 49 ].

Physical activity

In the present study, exercise was effective in the first trimester and not during the second trimester; previous studies showed lifestyle before gestation was effective in reducing diabetes. However, exercise during pregnancy was not [ 50 ]. Other studies showed early pregnancy (before the 15 th week) lifestyles were effective [ 51 ] in line with our findings. The effect of physical activity on GDM prevention depends on the time and duration of physical activity. Exercise before or in early pregnancy was effective in reducing GDM in the majority of studies [ 52 , 53 , 54 , 55 ], while few studies showed no significant reduction. [ 56 , 57 ]. A leisure time of physical activity of 150 h/week before pregnancy was associated with 68% risk reduction, and the benefits increased with longer duration [ 57 ].

Davenport and colleagues found that exercise of moderate intensity is effective in the prevention of GDM when adopted prenatally in line with our findings [ 58 ], the same conclusion was shown by other studies [ 59 ]. Davenport et al. study was limited by including all types of articles except case studies. A meta-analysis from China showed that diet and exercise were effective in reducing GDM when introduced earlier (before the 15th week), an effect that was not robot after that [ 51 ]. Other studies published in Spain and Australia [ 9 , 60 ] and concluded the effectiveness of dietary advice and moderate exercise combination in GDM prevention in contradiction to the present result, a plausible explanation might be the different methods of exercise and the type of diet adopted. The earlier adoption of 50–60 min of moderate physical activity and targeting at-risk women with a high body mass index was found to be more effective [ 61 ]. However, an update of the same study showed a limited ability to inform practice due to the risk of bias observed in the included studies [ 62 ]. Further studies limited by including retrospective, cross-sectional, and case–control studies support the above findings regarding exercise [ 63 ]. We found only one meta-analysis assessing the effect of early and late exercise on GDM. However, the small number of included studies and the high heterogeneity limited the studies [ 64 ]. The study found no effect throughout pregnancy. A non-linear negative association between exercise before and during early pregnancy was observed by the previous literature. The association was steeper at lower levels; however, the benefits plateaued at 8–10 h a week, a finding that may explain the contradiction between various studies assessing the effects of exercise on GDM [ 24 ]. The compliance to exercise, duration, timing, and type of exercise might greatly influence the outcomes. To best inform Obstetric guidelines, studies putting the previous parameters into consideration are warranted.

The strength of the current meta-analysis is that it is the first to compare different types of diets and define the time, intensity, duration, and frequency of exercise.

Limitations

The study limitations were including some observational studies, the limitations to the English language, and the significant heterogeneity observed.

The Dietary Approaches to Stop Hypertension, Alternate Healthy Eating Index diet, and Mediterranean Diet were effective in reducing gestational diabetes mellitus. The DASH diet showed superiority to the Mediterranean. Furthermore, the Alternate Healthy Eating Index diet was better than the DASH diet. Data regarding physical activity were conflicting. Early mild-moderate physical activity was effective, while late, moderate-vigorous exercise was not. Randomized control trials and genetic studies are needed for the individualization of dietary patterns.

Availability of data and materials

The data used in this manuscript are available upon request.

Abbreviations

Mediterranean diet

Dietary Approaches to Stop Hypertension

Alternate Healthy Eating Index diet

• Gestational diabetes mellitus

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Acknowledgements

The authors would like to acknowledge the financial support for this work from the Deanship of Scientific Research, University of Tabuk, Ministry of Education, Saudi Arabia. Grant No. S-0097-1439.

This study was funded by the Deanship of Scientific Research, University of Tabuk, Ministry of Education, Saudi Arabia under the grant No. (S-0097-1439).

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Abdullah H. Altemani

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Altemani, A.H., Alzaheb, R.A. The prevention of gestational diabetes mellitus (The role of lifestyle): a meta-analysis. Diabetol Metab Syndr 14 , 83 (2022). https://doi.org/10.1186/s13098-022-00854-5

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Case Studies

Case 9: gestational diabetes.

A 28-year-old G 4 P 2 presents to your office for a routine prenatal visit at 24 weeks’ gestation. Her physical examination is unremarkable and fetal wellbeing is reassuring. You recommend testing for gestational diabetes mellitus (GDM).

1. What is GDM?

Show Answer

Correct answer: GDM refers to any form of glucose intolerance with the onset of pregnancy or first recognized during pregnancy, and complicates approximately 5% of all pregnancies. It likely includes some women who have undiagnosed pregestational diabetes.

2. Should everyone be screened for GDM? If so, at what gestational age should they be screened?

Correct answer: Patients with GDM are typically asymptomatic. There is a small cohort of pregnant women in whom routine screening for GDM is not cost-effective. These are women under age 25 who have normal body mass index (BMI 2 ), no first-degree relatives with diabetes, no risk factors (such as a history of GDM, insulin resistance/PCOS [polycystic ovarian syndrome], a prior macrosomic infant, a prior unexplained late fetal demise, and women with persistent glycosuria), and who are not members of ethnic or racial groups with a high prevalence of diabetes (such as Hispanic, Native American, Asian, or African–American). As such patients are rare, most experts and organizations recommend screening for GDM in all pregnant women. The ideal time to screen for GDM is 24–28 weeks of gestation. For women at high risk of developing GDM (listed above), early screening for GDM is recommended at the first prenatal visit. If the early screen is negative, it should be repeated at 24–28 weeks.

3. Her 1-hour GLT is 182 mg/dL. Does she have GDM?

Correct answer: The most common screening test for GDM is the glucose load test (GLT) – also known as the glucose challenge test (GCT) – which is a non-fasting 50-g oral glucose challenge followed by a venous plasma glucose measurement at 1 hour. Most authorities consider the GLT to be positive if the 1-hour glucose measurement is >140 mg/dL. Use of a lower cut-off (such as >130 mg/dL) will increase the detection rate of women with GDM, but will result in a substantial increase in the false-positive rate.

There is no GLT cut-off that should be regarded as diagnostic of GDM . A definitive diagnosis of GDM requires a 3-hour glucose tolerance test (GTT). In pregnancy, the GTT involves 3 days of carbohydrate loading followed by a 100-g oral glucose challenge after an overnight fast. Venous plasma glucose is measured fasting and at 1 hour, 2 hours, and 3 hours. Although there is agreement that two or more abnormal values are required to confirm the diagnosis, there is little consensus about the glucose values that define the upper range of normal in pregnancy (see below). Most institutions use the National Diabetes Data Group (NDDG) or Carpenter and Coustan cut-offs. Measurement of glycated hemoglobin (HbA1c) levels is not useful in making the diagnosis of GDM, although it may be useful in the diagnosis of pregestational diabetes.

Plasma glucose values (mg/dL) (mmol/L) *

Sacks et al.

Carpenter and Coustan

* Values in parentheses are mmol/L.

4. All four values of her 3-hour GTT are elevated and her fasting glucose level is 127 mg/dL. How would you manage her GDM? How long would you allow her to try dietary restriction before adding a hypoglycemic agent?

Correct answer: GDM poses little risk to the mother. Such women are not at risk of diabetic ketoacidosis (DKA), which is primarily a disease of absolute insulin deficiency. However, GDM has been associated with an increase in infant birth trauma and perinatal morbidity and mortality. The risk to the fetus/infant is directly related to its size. Fetal macrosomia is defined as an estimated fetal weight (not birthweight) of ≥4,500 g. It is a single cut-off that is unrelated to gestational age, the sex of the baby, or the presence or absence of diabetes, or to the actual birthweight.

The goal of antepartum treatment of GDM is to prevent fetal macrosomia and its resultant complications by maintaining maternal blood glucose at desirable levels throughout gestation, defined as a fasting glucose level 95 mg/dL, treatment can be started immediately because “you can’t diet more than fasting.”

Insulin (which has to be given several times a day by injection) remains the “gold standard” for the medical management of GDM. The use of oral hypoglycemic agents has traditionally been avoided in pregnancy because of concerns over fetal teratogenesis and prolonged neonatal hypoglycemia. However, recent studies suggest that second-generation hypoglycemic agents (glyburide, glipizide) do not cross the placenta, are safe in pregnancy, and can achieve adequate glycemic control in 85% of pregnancies complicated by GDM.

5. The estimated fetal weight at 38 weeks’ gestation is 4,600 g (10 lb 2 oz). She has had six prior uncomplicated vaginal deliveries. How would you counsel her about delivery?

Correct answer: As noted above, the complications of GDM are related primarily to fetal macrosomia, including an increased risk of cesarean section delivery, operative vaginal delivery, and birth injury to both the mother (vaginal, perineal, and rectal trauma) and fetus (including orthopedic and neurologic injury). Shoulder dystocia with resultant brachial plexus injury (Erb’s palsy) is a serious consequence of fetal macrosomia, and further increased in the setting of GDM because the macrosomia of diabetes is associated with increased diameters in the upper thorax of the fetus.

The use of elective cesarean section delivery to reduce the risk of maternal and fetal birth injury in the setting of fetal macrosomia remains controversial. According to current ACOG guidelines, an elective cesarean section delivery at or after 39 weeks’ gestation should be recommended for all non-diabetic women who have a fetus with an estimated fetal weight (EFW) ≥5,000 g (or ≥4,500 g in a diabetic individual) to minimize the risk of birth trauma. Furthermore, it is recommended that a discussion be held about the safest route of delivery with non-diabetic women who have a fetus with an EFW ≥4,500 g (or ≥4,000 g in a diabetic individual) and that this discussion be documented in the medical record.

6. After extensive counseling, the couple decline elective cesarean section delivery. She is now 38 weeks’ gestation. How should she be managed at this point in time?

Correct answer: If the patient declines elective cesarean section delivery, spontaneous labor should be awaited. Induction of labor for so-called “impending macrosomia” does not decrease the risk of cesarean section delivery or intrapartum complications, and is therefore not routinely recommended. If she is still undelivered at 41 weeks’ gestation, she should be counseled again about induction of labor and/or elective cesarean section.

During labor, maternal glucose levels should be maintained at 100–120 mg/dL to minimize the risk of intrapartum fetal hypoxic–ischemic injury. Continuous fetal monitoring is recommended throughout labor and the progress of labor should be carefully charted. Internal monitors such as an intrauterine pressure catheter (IUPC) and/or fetal scalp electrode can be used, if indicated. Neonatal blood glucose levels should be measured within 1 hour of birth and early feeding encouraged.

Delivery of the fetus and placenta effectively removes the source of the anti-insulin (counter-regulatory) hormones that cause GDM. As such, no further management is required in the immediate postpartum period. A 2-hour non-pregnant GTT should be performed at 6–8 weeks postpartum in all women with GDM to exclude pre-gestational diabetes.

See Chapter 45.

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Gestational Diabetes Mellitus Case Study

Gestational diabetes mellitus (GDM), also known as type III diabetes mellitus, is one of the most common types of diabetes mellitus and considered the most common complication of pregnancy. This health problem is like pregnancy-induced hypertension (PIH) that develops during pregnancy and disappears after the delivery of the fetus, or as the maternal body returns to its pre-pregnant state. Gestational diabetes mellitus may or may not with co-existing maternal diabetes. It heightens the level of diabetes (if with previous diabetes) by a notch in response to the rise in fetal carbohydrate demand. 40% of pregnant mothers who develop GDM will eventually develop non-insulin-dependent diabetes mellitus (NIDDM or type II DM) within 5 years.

FACTS ABOUT INSULIN

Knowing the facts about insulin facilitates the understanding of gestational diabetes mellitus. Or any form of diabetes for that matter. This creates/develops ideas on how and why such health problems occur.

• The insulin is a normal body hormone that is produced by the beta cells of the Islets of Langerhans in the pancreas.
• The release of insulin is regulated by negative feedback in response to high glucose levels. The high glucose level may come from excessive glucagon action or high carbohydrate intake.
• The insulin secretion of the pancreas and its action on the liver makes it maintain a normal value of 80-120 mg/dL.
• Carbohydrates— utilization of glucose by the cells
• Proteins— conversion of amino acids to replace muscle tissues
• Fats— conversion of excess glucose to fatty acids and store them to adipose tissues
• Endothelial and nerve cells are the only cells/tissues that can use glucose even without insulin.
• Low insulin level causes the rise in plasma glucose concentration and glycosuria.
• Diabetes mellitus develops as the body secretes a low amount or as body cells reject its utilization.

ANATOMY AND PHYSIOLOGY

A normal body uses insulin as a channel for glucose to enter the cells for utilization. This process is also applicable to the fetus (during pregnancy) for growth and development. As the fetus grows, the maternal body executes an automatic response by doubling the level of glucose level through lowering insulin secretion and with the aid of some gestational hormones that antagonize the effects of insulin, a process known as a protective mechanism. Along with this, this mechanism causes the rise of placental lactogen, estrogen, and progesterone to cause the following effects: 1. antagonizes the effects of insulin, 2. prolong the elevation of stress hormones (cortisol, epinephrine, and glucagon), and 3. degradation of insulin by the placenta. The total effect of these mechanisms raises the maternal glucose level for fetal usage. Hyperglycemia normally occurs with a protective mechanism that predisposes a pregnant mother in the triggering of her pre-diabetic state or heightens an existing diabetes mellitus.

The effects of pregnancy on diabetes mellitus are summarized as:

• The first trimester— glucose level is relatively stable or may decrease
• The second trimester— there is a rapid increase in glucose level
• The third trimester— there is a rapid decrease in glucose level and return to its pre-pregnant state.

CAUSES AND INCIDENCE

The primary cause is almost the same as the other types of diabetes . The inability of the body to produce or synthesize a sufficient amount of insulin in response to glucose level (as in type I DM), or the body’s rejection of insulin (as in type II DM) shows a significant relationship on the development of any form of diabetes. The existence of either of these problems, plus, the interaction of the protective mechanisms in pregnancy doubles the occurrence of GDM.

The incidence of gestational diabetes mellitus is almost 3% in all pregnancies and 2% in all women with diabetes before pregnancy.

GDM causes a high incidence of fetal morbidity and unwanted complications such as polyhydramnios and macrosomia in fetus.

RISK FACTORS

For some clear and unclear pathological reasons, the following are considered the risk factors in the occurrence/development of GDM:

• Family history of DM
• Age of 45 or older (when got pregnant)
• Previous delivery of a baby weighing 9 lbs or more
• History of any autoimmune disease
• Belonging to/with ethnic background from African Americans, Latino, and Native Americans
• History of previous GDM
• With any level of hypertension
• With elevated high-density lipoprotein

SIGNS AND SYMPTOMS

The clinical manifestations of gestational diabetes mellitus coincide with the signs and symptoms of the other types of diabetes mellitus. These are popularly known as the “3 P’s” or polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (frequent urination). Aside from these manifestations, there are also other signs and symptoms that are general manifestations and pregnancy-specific manifestations.

PATHOPHYSIOLOGY

COMPLICATIONS

The chronic effects or the uncontrolled glucose level during pregnancy would lead to the development of the following complications:

• Urinary tract infection (UTI)
• Infertility
• Preterm labor and delivery
• Pregnancy-induced hypertension (PIH)- pre-eclampsia and eclampsia
• Congenital anomalies
• Spontaneous abortion

Also, a woman who developed or experienced gestational diabetes mellitus is expected to have type II diabetes mellitus within 5 years for the rest of her life.

The prognosis or the chance of the mother and/or fetus for survival depends on the maternal ability to tolerate and adjust to high glucose levels, medical management, and obedience to the treatment regimen. This means that the more cooperative and responsive the mother to the treatment regimen is, the better chances of both maternal and fetal well being are.

The performance of the following diagnostic tests aims to determine the level of diabetes present in the pregnant mother and determine its extent of damage or impending effects. This serves as the basis for the plan of care for the mother and the fetus.

• Blood glucose monitoring— this can either be done through fasting blood sugar (FBS) or randomly. This reveals the glucose level and indicates the plan of care needed.
• Glucose tolerance test (GTT)— to evaluate the response of insulin to loading glucose.
• Glycated hemoglobin (Glycohemoglobin)— measures glycemic control by evaluating the attachment of glucose to freely permeable erythrocytes during their whole life cycle.
• C-peptide Assay (connecting peptide assay)— useful when the presence of insulin antibodies interferes with direct insulin assay.
• Fructosamine assay— is much more useful than glycosylated hemoglobin tests in cases of hemoglobin variants.
• Urine glucose and ketone monitoring— may be performed in cases where blood glucose monitoring is not available, but, is not as accurate as of the former.
• Amniocentesis
• Non-stress test

NURSING DIAGNOSES

• Altered nutrition, more or less than body requirements related to weight gain.
• High-risk pregnancy: high risk for infection, ketosis, fetal demise, cephalopelvic disproportion, polyhydramnios, congenital anomalies, preterm labor.
• Knowledge deficit related to disease and insulin use and interaction.

The overall goal of management for gestational diabetes mellitus is the control of the maternal glucose level and keep it on a normal or near-normal level to prevent the development of complications that might compromise both the mother and the fetus. The most significant of these managements is the use of insulin. This is the most potent, yet, requires accuracy and monitoring of its unwanted effect (hypoglycemia) that brings immediate danger to both the mother and the fetus. Proper timing, dosage, and knowledge on counteractions of its over-reaction are vital concepts to be incorporated in health education.

Along with this, health promotion and disease prevention activities like diet, exercise, and fetal monitoring are of great importance.

NURSING MANAGEMENTS

History taking on:

• First presentation of the manifestations of diabetes (3 P’s)
• First diagnosis of DM
• Family members with DM

Review of systems:

• Weight gain, increasing fatigue/weakness/tiredness
• Skin lesions, infections, hydration, signs of poor wound healing
• Changes in vision—floaters, halos, blurred vision, dry/burning eyes, cataract, glaucoma
• Gingivitis, periodontal disease
• Orthostatic hypotension, cold extremities, weak pedal pulses
• Diarrhea, constipation, early satiety, bloating, flatulence, hunger and thirst
• Frequent urination, nocturia, vaginal discharge
• Numbness and tingling of the extremities, decrease pain and temperature sensation

Intervention

1. Nutrition

• Assess the timing and content of meals
• Instruct on importance of a well-balanced diet
• Explain the importance of exercise
• Plan for a weight reduction course

2. Insulin use

• Encourage verbalization of feelings
• Demonstrate and explain insulin therapy
• Allow the client to do self-administration
• Review mastery of the whole process

3.   Injury from hypoglycemia

• Monitor maternal blood glucose level
• Instruct on insulin-activity-diet interaction
• Teach on the signs and symptoms of hypoglycemia
• Teach/present list of things/foods that need to be available at all times (in cases of hypoglycaemic attacks)
• Have an identification band indicating the health condition (DM) for fainting instances

4.  Activity tolerance

• Plan for regular exercise
• Increase carbohydrate intake before exercise
• Instruct to avoid exercise if blood glucose level exceeds 250 mg/dL and urine ketones are present
• Advise to use abdomen for insulin injection if arms and legs are used for exercise

5.  Skin integrity

• Avoid alcohol use, instead, lotion
• Teach on proper foot care
• Advice to stop smoking and alcohol use

6. Fetal well-being

• Continuous monitoring of fetal activities and fetal heart tone
• Monitor fetal activities during maternal activities
• Monitor early signs of labor
• Advice to report of any discharge coming from the vagina
• Monitor daily weight and advice to report on rapid weight gain

7. Educative

• Teach on lifestyle modifications
• Advice to see  psychologists with other family members for therapy on the possibilities of fetal abnormalities
• Advice to call emergency response team in cases of emergency
• Advise to religiously follow health instructions  
• Bodyweight is within the normal range for the age of gestation.
• Demonstrates proper technique in self-administration of insulin
• No episodes of hypoglycemia as claimed by the client
• No skin problems/lesions
• Verbalizes readiness on the possible fetal defects.
•   Stable fetal heart rate

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• Published: 06 April 2024

Impact of postpartum weight change on metabolic syndrome and its components among women with recent gestational diabetes mellitus

• Chadakarn Phaloprakarn 1 ,
• Sasiwan Suthasmalee 1 &
• Siriwan Tangjitgamol 1 , 2  

Reproductive Health volume  21 , Article number:  44 ( 2024 ) Cite this article

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Metrics details

While postpartum weight changes may affect the levels of metabolic parameters, the direct effects of weight changes in the postpartum period on changes in the prevalence rates of metabolic syndrome and its components remain unstudied. This study aimed to investigate the effects of postpartum weight changes between 6 weeks and 6 months on changes in the prevalence rates of metabolic syndrome and its components in women who have recently experienced gestational diabetes mellitus.

This prospective cohort study included 171 postpartum women with recent gestational diabetes mellitus, who underwent serial weight and metabolic risk factor assessments at 6 weeks and 6 months postpartum. Weight changes between these time points were classified as weight loss (> 2 kg), weight stability (± 2 kg), or weight gain (> 2 kg). Metabolic syndrome comprised the following metabolic risk factors: large waist circumference, elevated blood pressure, elevated fasting plasma glucose levels, high triglyceride levels, and low high-density lipoprotein cholesterol levels.

Of the 171 women in our cohort, 30 women (17.5%) lost > 2 kg of body weight, while 85 (49.7%) maintained a stable weight and 56 (32.8%) gained > 2 kg. The weight loss group experienced significant changes in the prevalence rates of the following metabolic risk factors compared to the weight stability and weight gain groups: large waist circumference (% change: − 26.7 vs − 5.9 vs 5.4, respectively; p  = 0.004), elevated fasting plasma glucose levels (% change: − 3.4 vs 18.9 vs 26.8, respectively; p  = 0.022), and high triglyceride levels (% change: − 30.0 vs 0 vs − 7.2, respectively; p  = 0.024). A significantly greater decrease in the prevalence of metabolic syndrome was also found in the weight loss group than in the other two groups (% change: − 20.0 vs 11.8 vs 14.2, respectively; p  = 0.002).

Conclusions

Weight changes from 6 weeks to 6 months postpartum significantly altered the prevalence rates of metabolic syndrome and its components in women with recent gestational diabetes mellitus. Early postpartum weight loss can reverse metabolic risk factors and reduce the prevalence of metabolic syndrome.

Trial registration

Thai Clinical Trials Registry: Registration no. TCTR20200903001. Date of registration: September 3, 2020. Date of initial participant enrolment: September 7, 2020.

Plain language summary

Metabolic syndrome (MetS) is a frequent diagnosis with consequences for the occurrence of cardiovascular diseases. Women with gestational diabetes mellitus (GDM) are especially vulnerable to the development of MetS. In this study, we investigated how postpartum weight changes, specifically between 6 weeks and 6 months postpartum, impact MetS and its components in women who have recently experienced GDM. The results of our study showed that women who lost > 2 kg of body weight between 6 weeks and 6 months postpartum had significant decreases in the prevalence rates of metabolic risk factors, leading to a lower prevalence of MetS, compared to women who maintained a stable weight (± 2 kg) or gained > 2 kg. Our findings suggest that such weight loss is beneficial for preventing MetS; thus, strategies should be developed to support women with GDM in achieving postpartum weight loss. These strategies may include personalized dietary counseling, exercise programs, and behavioral support tailored to the specific needs and challenges faced by this population.

Peer Review reports

Metabolic syndrome (MetS) has emerged as a global epidemic in recent decades [ 1 ], with variations in the prevalence across different ages, sexes, and ethnicities [ 2 , 3 ]. Among women of reproductive age, the incidence rates of MetS and its components appear to be on the rise in recent years [ 4 ]. MetS encompasses a collection of metabolic risk factors, including abdominal obesity, elevated blood pressure (BP), elevated fasting plasma glucose (FPG) levels, high triglyceride (TG) levels, and low high-density lipoprotein cholesterol (HDL-C) levels [ 5 , 6 ]. As an important risk factor for type 2 diabetes mellitus (T2DM) and cardiovascular diseases [ 7 , 8 ], MetS warrants special attention.

Gestational diabetes mellitus (GDM) is a common medical complication of pregnancy. Compared to pregnant women without GDM, those with GDM often exhibit an elevated body mass index, BP, and TG level, along with a lower HDL-C level [ 9 , 10 , 11 ]. Furthermore, these metabolic risk factors have been observed to persist and even worsen in the postpartum period among women who have experienced GDM [ 12 , 13 , 14 , 15 , 16 ]. This persistence of metabolic abnormalities contributes to a higher prevalence of postpartum MetS in women with GDM compared to normoglycemic pregnant women [ 15 , 16 ].

Given that abdominal obesity, as indicated by a large waist circumference (WC), is a common metabolic risk factor found after GDM [ 13 ], early postpartum weight loss may help improve a large WC and other metabolic risk factors, thereby reducing the risk of MetS. Several studies have reported significant effects of postpartum weight changes on changes in the levels of metabolic parameters such as WC, FPG, and TG in women with recent GDM [ 17 , 18 , 19 ]. However, no study has explored the direct effects of postpartum weight changes on changes in the prevalence rates of MetS and its components in this population.

To address this gap, we designed a longitudinal study to follow women with recent GDM after childbirth, assessing how postpartum weight changes were associated with alterations in MetS and its components over time. By examining such associations, insights can be gained into the potential benefits of weight management interventions in this population. Such findings can inform clinical practice and public health strategies aimed at reducing the long-term metabolic risks associated with GDM.

The objective of this study was to investigate the impact of weight changes occurring between 6 weeks and 6 months postpartum on changes in the prevalence rates of MetS and its components among women with recent GDM.

Study design and study population

This prospective cohort study was conducted between September 7, 2020, and July 31, 2023, as part of a study exploring strategies to improve the metabolic health of postpartum women with a history of GDM. The study protocol was approved by the Vajira Institutional Review Board (approval no. 017/2563) and performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The protocol was registered with the Thai Clinical Trials Registry (registration no. TCTR20200903001).

The study population included women aged ≥ 18 years with recent GDM who delivered a live infant at the Faculty of Medicine Vajira Hospital, Bangkok, Thailand, between September 7, 2020, and January 31, 2023. Inclusion criteria were women who underwent antenatal care and GDM screening at the hospital. The exclusion criteria were pregnancy during the 6 months of study involvement, loss to follow-up, and refusal to participate.

Sample size

Given that no study has directly explored the effects of postpartum weight changes on changes in the prevalence rates of MetS and its components among women with a history of GDM, the sample size was calculated based on data from a previous study that explored the effects of weight changes between 3 and 12 months on changes in the levels of metabolic parameters in this population [ 17 ]. Based on the findings that changes in WC among women in the weight loss, weight stability, and weight gain groups were − 5.4 ± 5.1 cm, − 1.8 ± 4.6 cm, and 1.4 ± 4.6 cm, respectively, the sample size was calculated using the data on WC changes in the weight stability and weight gain groups because this yielded the largest sample. With 80% power at a two-sided significance level of 0.05, at least 99 participants were required (33 each with weight loss, weight stability, and weight gain). Allowing for a dropout rate of 25%, the total sample size required was 132 (44 in each group).

Institutional practices for GDM screening and diagnosis

The institutional practices for GDM screening and diagnosis have been described in detail in our previous work [ 20 ]. In brief, we followed the standard recommendation that all pregnant women undergo GDM screening using a 50-g glucose challenge test, followed by a 100-g oral glucose tolerance test (OGTT) using the Carpenter and Coustan criteria if the screening result was abnormal [ 21 ]. Blood samples were collected by phlebotomists and sent to the hospital laboratory. The initial management of women with GDM consists of dietary and lifestyle modifications, followed by insulin therapy if fasting or postprandial plasma glucose levels remain high despite dietary management [ 21 ].

After delivery, all women with GDM are scheduled for a postpartum checkup and T2DM screening using a 75-g, 2-h OGTT at 6 weeks postpartum [ 22 ].

Participant recruitment and follow-up

Consecutive women with pregnancies complicated by GDM, who delivered between September 7, 2020, and January 31, 2023, were approached by a researcher at the postnatal ward on the second day after delivery. These women received a study outline and were invited to participate in the study. All interested women were screened for eligibility. Written informed consent was obtained from all eligible women before the beginning of the study.

At enrollment, the clinical characteristics of the participants were collected from their medical records. These included age, weight, parity, family history of diabetes mellitus, severity of GDM, and gestational age at delivery. Participants were scheduled for serial assessments of weight and metabolic risk factors at 6 weeks and 6 months postpartum.

At 6 weeks postpartum, data on breastfeeding practices were collected from the participants upon their postpartum visit. Physical examinations, including measurements of weight, WC, and BP, were performed by a nurse who had been trained to ensure standard and accurate measurements. The body weight was measured without shoes and with light clothing using the Tanita Model WB-3000 digital scale (Tanita Corporation, Tokyo, Japan). WC was measured in the horizontal plane midway between the lowest ribs and the iliac crest with the participants in a standing position. After 10 min of rest, the BP was recorded to the closest 2 mmHg using the Nova-Presameter Desk mercury sphygmomanometer (Rudolf Riester GmbH, Jungingen, Germany) with the arm supported at heart level. Three separate BP readings were taken at 1-min intervals. The average of the last two readings was used for the analysis.

Venous blood samples were drawn to determine FPG, fasting lipid, and 2-h postprandial glucose (PG) levels. Fasting lipids included total cholesterol, TG, low-density lipoprotein cholesterol, and HDL-C levels. If participants were diagnosed with T2DM, MetS, or both, they were referred to an endocrinologist for further management.

At 6 months postpartum, the same data were collected for all participants. Blood samples were collected to determine FPG, fasting hemoglobin A1c (HbA1c), and fasting lipid levels.

Laboratory measurements

All blood samples for FPG, HbA1c, and lipid analyses were collected in the morning after overnight fasting for 12 h and sent to the hospital’s laboratory. A standard 75-g OGTT was performed to measure 2-h PG levels. Plasma glucose and lipid levels were measured using the automated analyzer Cobas c503 (Roche Diagnostics, Mannheim, Germany). HbA1c levels were measured using a Cobas c513 analyzer (Roche Diagnostics).

All devices were calibrated in-house daily and annually using external validation. Our laboratory has received National Glycohemoglobin Standardization Program certification for HbA1c assays and is traceable to the Diabetes Control and Complications Trial reference method. The HbA1c and blood chemistry analyses were approved by the Randox International Quality Assessment Scheme.

Stratification of participants, outcome assessment, and definitions

We stratified participants into three groups according to weight changes from 6 weeks to 6 months postpartum: weight loss (> 2 kg), weight stability (± 2 kg), and weight gain (> 2 kg) [ 17 ]. The outcome measures included changes in the prevalence rates of MetS and its components.

The presence of MetS was established using the joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention [ 5 ]. MetS was defined as the presence of three or more of the following five metabolic components: large WC (≥ 80 cm), elevated BP (systolic BP ≥ 130 mmHg, diastolic BP ≥ 85 mmHg, or both, or treatment with antihypertensive drugs), elevated FPG levels (≥ 100 mg/dL, or treatment with antidiabetic medications), high TG levels (≥ 150 mg/dL, or treatment with drugs for elevated TG levels), and low HDL-C levels (< 50 mg/dL, or drug treatment for reduced HDL-C levels). Those with FPG levels ≥ 126 mg/dL, 2-h PG levels ≥ 200 mg/dL, or HbA1c levels ≥ 6.5% were diagnosed as having T2DM [ 23 ].

Statistical analyses

All analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corporation, Armonk, NY, USA). Categorical variables are presented as numbers and percentages and were compared using the chi-squared test. Continuous variables are described as means and standard deviations. Differences in the means of continuous variables between the three groups were analyzed using a one-way analysis of variance. When the overall analysis was significant, intergroup comparisons were made using the least significant difference method as a post-hoc test.

Changes in the means of variables over time (between 6 weeks and 6 months postpartum) within each group were analyzed using paired t-tests. The differences in changes between the three groups were analyzed using a one-way analysis of covariance, controlling for weight at 6 weeks postpartum and exclusive breastfeeding at 6 months postpartum, which were previously identified as factors affecting the prevalence of MetS or metabolic risk factors [ 17 , 24 ]. Changes in the prevalence rates of MetS and its components over time within a group were calculated using McNemar’s test. The differences in changes between the three groups were compared using the chi-squared test. Statistical significance was defined as a two-sided p  < 0.05.

The study flow diagram, which is in line with the STROBE statement, is shown in Fig.  1 . Of the 220 enrolled participants, 49 were excluded due to loss to follow-up before completing 6 months of participation in the study. There were no significant differences in delivery characteristics between participants who completed the study and those who were lost to follow-up (all p  > 0.05). The 171 participants finally included were stratified into three groups: weight loss (> 2 kg; n  = 30), weight stability (± 2 kg; n  = 85), and weight gain (> 2 kg; n  = 56).

STROBE flow diagram. GDM gestational diabetes mellitus, STROBE Strengthening the Reporting of Observational Studies in Epidemiology

Participant characteristics

The mean age and mean weight at delivery of the 171 included participants were 32.5 ± 5.9 years and 75.4 ± 14.2 kg, respectively. Approximately 15.8% ( n  = 27) of participants had class A2 GDM. The mean gestational age at delivery was 37.8 ± 1.4 weeks. The clinical characteristics of the participants in each weight change group are shown in Table  1 .

Changes in the levels of metabolic parameters

Changes in the levels of metabolic parameters over time within and between the groups are shown in Table  2 . The weight loss group showed a significantly greater decrease in WCs and a significantly smaller increase in FPG levels than the other two groups. In addition, the weight loss group showed a significantly greater decrease in TG levels than the weight stability group. The weight stability group showed a significantly greater decrease in WCs than the weight gain group. The results of the one-way analysis of covariance showed that the weight at 6 weeks postpartum and exclusive breastfeeding at 6 months postpartum have no significant effect on changes in the metabolic parameter levels.

Changes in the prevalence rates of metabolic risk factors

At 6 weeks postpartum, a large WC (67.3%; n  = 115) was the most commonly detected metabolic risk factor, followed by a high TG level (32.7%; n  = 56), low HDL-C level (28.7%; n  = 49), elevated BP (23.4%; n  = 40), and elevated FPG level (15.8%; n  = 27) levels.

At 6 months postpartum, the prevalence rates of these metabolic risk factors in the order of decreasing frequency were as follows: a large WC (61.4%; n  = 105), low HDL-C level (37.4%; n  = 64), elevated FPG level (33.3%; n  = 57), high TG level (25.1%; n  = 43), and elevated BP (18.1%; n  = 31).

Changes in the prevalence rates of metabolic risk factors over time within and between the groups are summarized in Table  3 . The weight loss group had significantly greater decreases in the prevalence rates of large WC and high TG level than the other two groups. The weight loss group also showed a significantly greater decrease in the prevalence of high TG levels than the weight stability group. The changes in the prevalence rates of the five metabolic risk factors were not significantly different between the weight stability and weight gain groups.

Changes in the prevalence of MetS

The weight loss group experienced a significantly greater decrease in the prevalence of MetS than the other two groups (Table  3 ). Changes in the prevalence of MetS between the weight stability and weight gain groups did not differ significantly.

The main findings of this study were that postpartum women with recent GDM who lost > 2 kg of weight between 6 weeks and 6 months postpartum had significant improvements in metabolic parameters, leading to significantly lower rates of MetS and its components than those in women who maintained a stable weight (± 2 kg) or gained > 2 kg.

Our observation of a greater decrease in WCs and a smaller increase in FPG levels in the weight loss group than in the other two groups aligned with the results of previous studies, including women with recent GDM with a longer postpartum evaluation interval [ 17 , 18 , 19 ]. A study including 206 Australian women revealed significant improvements in WCs and TG levels among women who lost > 2 kg within 6 weeks to 12 months postpartum when compared to those whose weight remained stable or increased [ 17 ]. Another study involving 72 American women showed a significantly smaller increase in FPG levels in women who lost > 2 kg within 12 months postpartum than in those who maintained or gained weight [ 18 ]. Likewise, a study including 75 American women demonstrated significant correlations of weight changes between baseline (6 weeks postpartum) and 6 and 12 months postpartum with the changes in FPG and TG levels [ 19 ]. Although our study and those performed in Australia and the United States differed in terms of population characteristics (such as ethnicity and weight at delivery) and the postpartum time points at which weight changes were examined, the consistent results among these studies indicate that postpartum weight changes have the potential to impact metabolic parameters in women with a history of GDM.

To date, no study has explored how changes in postpartum weight affect the prevalence rates of MetS and its components, specifically in women with GDM. The results of our study showed that women who lost weight experienced significantly greater decreases in the prevalence rates of large WCs and high TG levels than those who maintained or gained weight. Among the two metabolic risk factors that significantly improved after weight loss, a greater reduction in the prevalence of large WCs was observed (from 66.7% to 40.0%, Δ: − 26.7%).

Moreover, we found that weight loss during the early postpartum period reduced the prevalence of MetS. The MetS prevalence decreased significantly from 36.7% at 6 weeks postpartum to 16.7% at 6 months postpartum in women who lost weight. Conversely, women with weight stability or weight gain exhibited an increase in MetS rates (from 14.1% to 25.9% and from 30.4% to 44.6%, respectively).

Our findings were consistent with those of a previous study conducted in Iran [ 13 ], which also identified a large WC as the most prevalent metabolic risk factor at 6 weeks postpartum among women with recent GDM. In contrast, a study including an American population revealed that low HDL-C levels were more common than a large WC among early postpartum women with a history of GDM [ 25 ]. These different findings may be attributed to the diverse definitions of large WCs or differences in body build among the populations studied. Our study and the study performed in Iran defined a large WC as ≥ 80 cm, whereas the study performed in the United States defined a large WC as ≥ 88 cm. Given that WC is a surrogate clinical measure of visceral adiposity, which predisposes individuals to MetS and subsequent T2DM and cardiovascular diseases, preventive measures to reduce a large WC are paramount.

Our findings underscore the metabolic implications of weight changes in the first 6 months after delivery in patients with GDM and highlight the benefits of > 2 kg postpartum weight loss in women with recent GDM. At present, there are no specific recommendations on the timing of MetS screening commencement following GDM or on the continuation of follow-up processes. The results of our study may be used to establish practice guidelines for the early detection of metabolic risk factors and MetS in women with a history of GDM. Special attention should be paid to those with weight stability or weight gain between 6 weeks and 6 months postpartum, who comprised 82.5% of this population.

Further research is needed to confirm the metabolic benefits of weight loss over a longer duration, beyond the first 6 months postpartum. Considering that postpartum women face several barriers to lifestyle modifications in terms of time constraints, childcare demands, and lack of motivation [ 26 ], interventional studies that include strategies to address these barriers should be considered to promote weight loss in the early postpartum period in women with recent GDM.

A strength of this study is its prospective serial evaluation of metabolic risk factors. In addition, the data collection procedures were standardized and reliable. All blood samples were tested using standardized assays in a single certified laboratory. Additionally, this study added new evidence that improvements in metabolic parameters resulting from weight loss in the early postpartum period could lead to subsequent decreases in the prevalence rates of MetS and its components among women with recent GDM.

Nevertheless, this study had some limitations. First, the relatively small number of women with weight loss of > 2 kg may have limited our ability to detect subtle differences in the extent and prevalence rates of some metabolic risk factors. A larger sample size would have provided more statistical power and potentially yielded more robust results. Second, this study was conducted at a specific hospital in Thailand and focused on a specific population of postpartum women with recent GDM. Therefore, the generalizability of the findings to other populations or settings may be limited. The results may not be applicable to women with different demographic characteristics or healthcare systems. Third, we excluded women who were lost to follow-up, which may have introduced selection bias. This omission could affect the representativeness of the sample and potentially influence the study's results. Fourth, our study defined a large WC as ≥ 80 cm, which may not be consistent with other definitions used in different populations or settings. This variation in defining metabolic risk factors could impact the comparability of the findings across studies and limit the generalizability of the results. Finally, this study focused on weight changes and metabolic parameters within the first 6 months postpartum. However, the long-term effects of weight loss on metabolic improvements beyond this timeframe remain unknown. It would be valuable to investigate whether the observed benefits persist or change over a longer duration.

Weight changes from 6 weeks to 6 months postpartum had a significant impact on the prevalence rates of MetS and its components in women with a history of GDM. Early postpartum weight loss reversed metabolic risk factors and possibly reduced the prevalence of MetS. Given the increasing prevalence of MetS among women of reproductive age and the availability of risk-reducing strategies, we propose that all postpartum women with GDM should undergo screening for metabolic risk factors, alongside screening for T2DM.

Availability of data and materials

The datasets used and analyzed in this study are available from the corresponding author upon reasonable request.

Abbreviations

Blood pressure

Fasting plasma glucose

• Gestational diabetes mellitus

Hemoglobin A1c

High-density lipoprotein cholesterol

• Metabolic syndrome

Oral glucose tolerance test

Postprandial glucose

Strengthening the Reporting of Observational Studies in Epidemiology

Type 2 diabetes mellitus

Triglycerides

Waist circumference

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Acknowledgements

The authors thank our laboratory staff for their support.

This work was supported by the Navamindradhiraj University Research Fund and the Faculty of Medicine Vajira Hospital, Navamindradhiraj University Research Fund. The funders played no role in the study design, data collection, data analysis, data interpretation, decision to publish, or manuscript writing.

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CP, SS, and ST conceived the study. CP wrote the first draft of the manuscript. CP and SS acquired data. CP performed the statistical analyses. CP, SS, and ST interpreted the data and contributed to the revision of the manuscript. CP is the study guarantor, has full access to all data in the study, and takes responsibility for the integrity of the data and accuracy of the data analysis. All authors critically revised the manuscript and approved its final version.

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Phaloprakarn, C., Suthasmalee, S. & Tangjitgamol, S. Impact of postpartum weight change on metabolic syndrome and its components among women with recent gestational diabetes mellitus. Reprod Health 21 , 44 (2024). https://doi.org/10.1186/s12978-024-01783-4

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DOI : https://doi.org/10.1186/s12978-024-01783-4

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Influence of Anemia on Prevalence of Gestational Diabetes among Pregnant Women in Tripoli, Libya

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Gestational diabetes mellitus (GDM) is raised globally leading to substantial maternal and foetal morbidity. This study aimed to determine the prevalence of GDM among pregnant women delivering in different private polyclinics in Tripoli, Libya. A cross-sectional study was conducted among pregnant women who were admitted to gynecology department of in different medical polyclinics, Tripoli, Libya from Jan to Dec 2022. The prevalence of GDM in pregnant women increased with increase of the gestational age to reach maximum (86%) at the third trimester of gestation. About 31% (96 patients) anemic pregnant women were observed in 312 GDM. Careful surveillance is required for these pregnancies in high-risk units for early detection and treatment of possible complications, in order to try to reduce maternal and neonatal morbidities.

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I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval was obtained from the research committee at Faculty of Medical Technology, the University of Tripoli, and a permission letter was obtained from different medical polyclinics before going ahead with the study.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

Data available upone request

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