Glucose tolerance status of Asian Indian women with gestational diabetes at 6weeks to 1year postpartum (WINGS-7)

Open AccessPublished:May 03, 2016DOI:https://doi.org/10.1016/j.diabres.2016.04.050

      Highlights

      • 203/212 (95.8%) women with GDM recruited under WINGS Model of Care completed their postpartum OGTT.
      • 15.5% of women were detected to have dysglycemia by 12 weeks.
      • 38.1% were detected to have dysglycemia between 12 weeks and 1 year of delivery.
      • Overall 41/203 women (20%) developed dysglycemia within one year postpartum.
      • This calls for improving postpartum follow-up testing of GDM women.

      Abstract

      Aim

      To determine postpartum glucose tolerance status among women with gestational diabetes mellitus (GDM) recruited under the Women In India with GDM Strategy (WINGS) Model of Care (MOC).

      Methods

      Through the WINGS MOC programme, 212 women with GDM were followed till delivery between November 2013 and August 2015. All women were advised to return for a postpartum oral glucose tolerance test (OGTT) 6–12 weeks after delivery. A multivariate logistic regression (MLR) model was developed to identify the risk factors for postpartum dysglycemia which was defined as presence of diabetes (DM) or prediabetes.

      Results

      203/212(95.8%) women completed their postpartum OGTT. Of the 161 women (79.3%) who came back for the test between 6 and 12 weeks, 2(1.2%) developed DM, 5(3.1%), isolated IFG, 13(8.1%), isolated IGT and 5(3.1%) combined IFG/IGT [dysglycemia 25(15.5%)]. 136 women (84.5%) reverted to normal glucose tolerance (NGT). Of the 42 women who came back between 12 weeks and a year, 5(11.9%) developed DM, 10(23.8%), isolated IFG and 1(2.4%) combined IFG/IGT [dysglycemia 16(38.1%)]. 26/42 women (61.9%) reverted to NGT. Thus overall dysglycemia occurred in 41/203 women (20.2%). MLR showed that BMI ⩾25 kg/m2 was significantly associated with postpartum dysglycemia (odds ratio: 4.47; 95% confidence interval: 1.8–11.2, p = 0.001).

      Conclusion

      Among Asian Indian women with GDM, over 20% develop dysglycemia within one year postpartum, and BMI ⩾25 kg/m2 increased this risk four-fold. Early postpartum screening can identify high risk women and help plan strategies for prevention of type 2 diabetes in the future.

      Keywords

      1. Introduction

      With the prevalence of type 2 diabetes (T2DM) and prediabetes growing in epidemic proportions, it is extremely important to implement strategies to delay or prevent the onset of T2DM among high risk populations. The incidence of gestational diabetes mellitus (GDM), the most common metabolic disorder during pregnancy, is also increasing worldwide owing to advancing maternal age and increasing obesity rates [
      • Hunt K.J.
      • Schuller K.L.
      The increasing prevalence of diabetes in pregnancy.
      ,
      • Lipscombe L.L.
      • Hux J.E.
      Trends in diabetes prevalence, incidence, and mortality in Ontario, Canada 1995–2005: a population-based study.
      ]. Women with previous history of GDM are at seven fold higher risk of developing T2DM in the future compared to their counterparts without GDM [
      • Bellamy L.
      • Casas J.
      • Hingorani A.D.
      • Williams D.
      Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis.
      ,
      • Lauenborg J.
      • Hansen T.
      • Jensen D.M.
      • Vestergaard H.
      • Mølsted-Pedersen L.
      • Hornnes P.
      • et al.
      Increasing incidence of diabetes after gestational diabetes: a long-term follow-up in a Danish population.
      ]. GDM also confers an increased risk of short term and long term health consequences such as preeclampsia, fetal macrosomia, shoulder dystocia and cesarean delivery [
      • Chen Yogev
      • HodCoustan Oats
      • McIntyre
      • et al.
      Hyperglycemia and adverse pregnancy outcome (HAPO) study: preeclampsia.
      ,
      • Metzger B.E.
      • Lowe L.P.
      • Dyer A.R.
      • Trimble E.R.
      • Chaovarindr U.
      • HAPO Study Cooperative Research Group
      • et al.
      Hyperglycemia and adverse pregnancy outcomes.
      ]. This calls for improved screening and treatment for GDM with the aim of improving maternal and fetal outcomes [
      • Crowther C.A.
      • Hiller J.E.
      • Moss J.R.
      • McPhee A.J.
      • Jeffries W.S.
      • Robinson J.S.
      • et al.
      Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.
      ,
      • Langer O.
      • Yogev Y.
      • Most O.
      • Xenakis E.M.
      Gestational diabetes: the consequences of not treating.
      ].
      The American Diabetes Association (ADA) recommends that women with GDM be reassessed for glycemic status at 6 weeks postpartum [
      • American Diabetes Association
      Gestational diabetes mellitus.
      ]. The Fourth International Workshop on GDM also recommended that glucose tolerance should be reevaluated 6–12 weeks postpartum [
      • Metzger B.
      • Coustan D.R.
      Summary and recommendations of the 4th International Workshop-Conference on Gestational Diabetes Mellitus.
      ]. Despite the elevated risk for diabetes and the recommendations for close follow-up, opportunities for postpartum screening are frequently missed [
      • Ferrara A.
      • Peng T.
      • Kim C.
      Trends in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus: a report from the Translating Research Into Action for Diabetes (TRIAD) Study.
      ,
      • Lawrence J.M.
      • Black M.H.
      • Hsu J.W.
      • Chen W.
      • Sacks D.A.
      Prevalence and timing of postpartum glucose testing and sustained glucose dysregulation after gestational diabetes mellitus.
      ,
      • Russell M.A.
      • Phipps M.G.
      • Olson C.L.
      • Welch H.G.
      • Carpenter M.W.
      Rates of postpartum glucose testing after gestational diabetes mellitus.
      ,
      • Smirnakis K.V.
      • Chasan-Taber L.
      • Wolf M.
      • Markenson G.
      • Ecker J.L.
      • Thadhani R.
      Postpartum diabetes screening in women with a history of gestational diabetes.
      ,
      • Kim C.
      • Tabaei B.P.
      • Burke R.
      • et al.
      Missed opportunities for type 2 diabetes mellitus screening among women with a history of gestational diabetes mellitus.
      ,
      • Hunt K.J.
      • Conway D.L.
      Who returns for postpartum glucose screening following gestational diabetes mellitus?.
      ,
      • Clark H.D.
      • van Walraven C.
      • Code C.
      • Karovitch A.
      • Keely E.
      Did publication of a clinical practice guideline recommendation to screen for type 2 diabetes in women with gestational diabetes change practice?.
      ]. Postpartum screening rates usually vary from 14% in usual care, to 60% in randomized control trials [
      • Shea A.K.
      • Shah B.R.
      • Clark H.D.
      • Malcolm J.
      • Walker M.
      • Karovitch A.
      • Keely E.J.
      The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes?.
      ]. The Translating Research Into Action for Diabetes (TRIAD) study has shown that although rates of postpartum screening have increased since the 1990s, it was still only 53.8% in 2006 [
      • Ferrara A.
      • Peng T.
      • Kim C.
      Trends in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus: a report from the Translating Research Into Action for Diabetes (TRIAD) Study.
      ].
      Studies have shown that conversion to T2DM following GDM occurs earlier in South Asians compared to other ethnic groups [
      • Anjana R.M.
      • Shanthi Rani C.S.
      • Deepa M.
      • Pradeepa R.
      • Sudha V.
      • Divya Nair H.
      • Lakshmipriya N.
      • Subhashini S.
      • Binu V.S.
      • Unnikrishnan R.
      • Mohan V.
      Incidence of diabetes and prediabetes and predictors of progression among Asian Indians: 10-year follow-up of the Chennai Urban Rural Epidemiology Study (CURES).
      ,
      • Mukerji G.
      • Chiu M.
      • Shah B.R.
      Impact of gestational diabetes on the risk of diabetes following pregnancy among Chinese and South Asian women.
      ,
      • Jang H.C.
      Gestational diabetes in Korea: incidence and risk factors of diabetes in women with previous gestational diabetes.
      ]. In the current study, we sought to determine the frequency of dysglycemia in the early postpartum period, and to identify risk factors predicting postpartum dysglycemia in Asian Indian women with GDM followed prospectively throughout their pregnancy.

      2. Methodology

      The Women In India with GDM Strategy (WINGS) is a project undertaken by the International Diabetes Federation (IDF) and the Madras Diabetes Research Foundation (MDRF), Chennai, India with the support of Abbott Fund, to tackle the rising problem of GDM in low-middle income countries (LMIC) such as India []. The project was piloted in Chennai, India, with the aim of developing a model approach to care in LMICs to confront the widespread challenges in GDM screening and management. A WINGS GDM Model of Care (MOC) was developed and carried out in collaboration with several health centers in Tamil Nadu, India.
      According to the WINGS GDM MOC protocol, pregnant women <28 weeks of gestation were approached for screening for GDM and recruited under the model. For the purpose of this paper, “booking visit” refers to the first antenatal visit of the pregnant woman to the collaborating health center at which point they were screened. All baseline data collection was done at this booking visit, including anthropometry and body weight.
      Sample size was calculated using EpiTools software as was as follows: with 95% confidence interval (CI), desired precision estimate of ±0.02(2%), based on previous prevalence rate of 17.8% [
      • Seshiah V.
      • Balaji V.
      • Balaji M.S.
      • Paneerselvam A.
      • Arthi T.
      • Thamizharasi M.
      • Datta M.
      Prevalence of gestational diabetes mellitus in South India (Tamil Nadu) – a community based study.
      ] and drop-out rate of 20%, the sample size was estimated to be 1080.
      Under the IDF WINGS MOC, after screening 1124 pregnant women, 247 women were diagnosed with GDM using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and 3 were identified as having overt diabetes. Of the 247 women with GDM, 212 were followed up throughout their pregnancy and their pregnancy outcomes were measured. The remaining 35 women moved to their maternal hometown for continuing their antenatal care and delivered there and hence could not be followed up. The 212 women who were followed under the MOC were constantly reminded about the importance of postpartum follow-up testing and were advised to return for the same 6–12 weeks after delivery. All women who came for the follow-up testing were assessed by doing an oral glucose tolerance test (OGTT) using a 82.5 g oral glucose load (equivalent to 75 g of anhydrous glucose) after an overnight fast of at least 8 h. Venous samples were drawn at fasting and 1 h and 2 h after the glucose load.
      Blood samples were collected in sodium fluoride/Na2 EDTA vacutainer tubes to prevent glycolysis. Samples were transported to a central laboratory within one hour of collection in cool boxes which had gel packs to maintain the temperature between 2 and 8 °C. Plasma glucose was measured using an autoanalyser AU2700, (Beckman, Fullerton, CA). The intra- and inter assay coefficients of variation for the biochemical assays ranged between 3.1% and 7.6%. The central laboratory is certified by the College of American Pathologists (CAP), USA and the National Accreditation Board for Testing and Calibration Laboratories (NABL), Government of India. The study was approved by the Independent Ethics Committee of the Madras Diabetes Research Foundation (MDRF), and written informed consent was obtained from all participating women.

      2.1. Statistical analysis

      Analyses of data was done using Windows based SPSS statistical package (version 15.0, Chicago, IL). Descriptive analyses were performed for specific variables between women converting to diabetes and non converters and unadjusted comparisons between these groups were made using t-tests or Chi square tests. A multivariate logistic regression model was developed using dysglycemia [diabetes and or prediabetes (IGT or IFG or both)] as the dependent variable and predictor variables which were significant in the bivariate analysis as the independent variable.

      2.2. Definitions

      The following definitions were used to classify diabetes (DM) or prediabetes [impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT)] or normal glucose tolerance (NGT) after the postpartum follow-up OGTT [
      • American Diabetes, Association
      Diagnosis and classification of diabetes mellitus.
      ].
      Tabled 1
      Glycemic statusFasting plasma glucose level2-H plasma glucose
      Diabetes (DM)⩾126 mg/dl (7.0 mmol/l)⩾200 mg/dl (11.1 mmol/l)
      Isolated IFG100–125 mg/dl (5.5–6.9 mmol/l)<140 mg/dl (<7.8 mmol/l)
      Isolated IGT<100 mg/dl (<5.5 mmol/l)140–199 mg/dl (7.8–11 mmol/l)
      Combined IFG/IGT100–125 mg/dl (5.5–6.9 mmol/l)140–199 mg/dl (7.8–11 mmol/l)
      NGT<100 mg/dl (<5.5 mmol/l)<140 mg/dl (<7.8 mmol/l)
      For the purpose of this paper, women who developed dysglycemia (diabetes or prediabetes) are referred to as “converters” and those who reverted to NGT are referred to as “non converters”.

      3. Results

      203/212(95.8%) women completed their postpartum OGTT. Of these 203 women, 161(79.3%) came back for postpartum follow-up testing between 6 and 12 weeks, while the remaining 42(20.7%) women came back between 12 weeks and a year after the delivery. Of the 161 women (79.3%) who came back for the test between 6 and 12 weeks, 2(1.2%) developed DM, 5(3.1%), isolated IFG, 13(8.1%), isolated IGT and 5(3.1%) combined IFG/IGT while 136(84.5%) reverted to normal glucose tolerance (NGT). Of the 42 women who came back within a year, 5(11.9%) developed DM, 10(23.8%), isolated IFG and 1(2.4%) combined IFG/IGT, while 26(61.9%) reverted to NGT. Hence dysglycemia was detected in 25(15.5%) women between 6 and 12 weeks and in 16 women (38.1%) between 12 weeks and 1 year. Thus dysglycemia occurred in a total of 41/203 women (20.2%) within 1 year of delivery (Table 1).
      Table 1Postpartum follow up status and glucose tolerance status.
      S. no.Total GDM women followed up n = 203
      Period of follow up6–12 weeks (n = 161)12 weeks to 1 year (n = 42)
      Glucose tolerance status
      1 Normal glucose tolerance136(84.5%)26(61.9%)
      2 Isolated IFG5(3.1%)10(23.8%)
      3 Isolated IGT13(8.1%)
      4 Combined IFG/IGT5(3.1%)1(2.4%)
      5 Diabetes2(1.2%)5(11.9%)
      Dysglycemia (isolated IFG  + isolated IGT + combined IFG/IGT + Diabetes)25(15.5%)16(38.1%)
      Total dysglycemia25 + 16 = 41/203(20.2%)
      Age, BMI, gestational week at booking, HbA1c, family history of diabetes and PCOD were higher among women with GDM who converted to dysglycemia when compared to those who reverted back to NGT. However, only BMI, HbA1c (at booking) and previous history of GDM reached statistical significance (Table 2).
      Table 2Comparison of baseline clinical profile of GDM women of converters and non converters to dysglycemia.
      S. no.ParametersConverters to dysglycemia (n = 41)Non converters to dysglycemia (n = 162)p value
      1Age (in years)29.6 ± 4.228.6 ± 4.30.37
      2BMI at booking (kg/m2)28.0 ± 5.025.8 ± 4.70.01
      3Gestation week at booking (in weeks)19.2 ± 6.717.6 ± 7.20.56
      4Weight gain (in kg)6.4 ± 4.27.0 ± 4.10.32
      5Gestation week at delivery (in weeks)37.8 ± 1.637.9 ± 2.80.21
      6HbA1c at booking (%)5.5 ± 0.95.1 ± 0.80.01
      HbA1c at booking (IFCC units mmol/mol)(37 ± 6)(32 ± 4)
      7Hemoglobin (%)11.0 ± 1.311.4 ± 1.00.30
      8Family history of diabetes21(51.2%)71(43%)0.35
      9Previous history of GDM3(7.3%)13(7.9%)0.008
      10Polycystic ovarian disease4(9.8%)9(5.5%)0.39
      11Birth weight of the baby3.1 ± 0.602.9 ± 0.500.05
      p < 0.05 is considered significant.
      Multivariate logistic regression showed that a baseline BMI of ⩾25 kg/m2 [odds ratio (OR) 4.4, CI: 1.78–11.20, p value = 0.001] was significantly associated with postpartum dysglycemia after adjusting for HbA1c and previous history of GDM (Table 3).
      Table 3Multivariate logistic regression showing factors associated with conversion to dysglycemia.
      Risk factorsBSEOdds ratio95% CIp value
      1BMI ⩾25 kg/m21.490.4684.47
      Odds ratio adjusted for HbA1c at booking and previous history of GDM.
      1.785–11.2060.001
      2HbA1c at booking (%)−0.3210.2010.7250.488–1.0760.11
      3Previous history of GDM−0.3340.7090.7150.178–2.8770.637
      p < 0.05 is considered significant.
      Odds ratio adjusted for HbA1c at booking and previous history of GDM.

      4. Discussion

      Several studies have shown that GDM is an important risk factor for development of T2DM. Depending on various factors like ethnicity, protocols used, follow-up duration and the diagnostic criteria used, conversion rates vary from 2.6% to as high as 70% [
      • Kim C.
      • Newton K.M.
      • Knopp R.H.
      Gestational diabetes and the incidence of type 2 diabetes: a systematic review.
      ]. Studies from the west have shown that during a 5 year follow-up after GDM, the cumulative incidence rate of diabetes was 50% [
      • Metzger B.E.
      • Cho N.H.
      • Roston S.M.
      • Radvany R.
      Prepregnancy weight and antepartum insulin secretion predict glucose tolerance five years after gestational diabetes mellitus.
      ]. In a previous retrospective study, we showed that 56.3% of women with a history of GDM developed diabetes within 5 years after delivery [
      • Mahalakshmi M.M.
      • Bhavadharini B.
      • Kumar M.
      • Anjana R.M.
      • Shah S.S.
      • Bridgette A.
      • Choudhury M.
      • Henderson M.
      • Desborough L.
      • Viswanathan M.
      • Ranjani H.
      Clinical profile, outcomes, and progression to type 2 diabetes among Indian women with gestational diabetes mellitus seen at a diabetes center in South India.
      ]. Kale et al. [
      • Kale S.D.
      • Yajnik C.S.
      • Kulkarni S.R.
      • Meenakumari K.
      • Joglekar A.A.
      • Khorsand N.
      • et al.
      High risk of diabetes and metabolic syndrome in Indian women with gestational diabetes mellitus.
      ] from northern India reported conversion rates of 52% after a mean follow-up period of 4.5 years. The present study is of interest because we show that conversion to dysglycemia occurs rapidly. In this cohort, 15.5% of women were detected to have dysglycemia by 12 weeks while an additional 38.1% were detected to have dysglycemia between 12 weeks and 1 year of delivery, highlighting the importance of early screening for diabetes. It also shows the value of screening within 1 year window period in women who missed screening or screened negative at 12 weeks postpartum.
      Given that T2DM is an important sequel of GDM, close postpartum follow-up is essential. It is also important to identify women at greatest risk of postpartum T2DM, to help plan prevention and intervention strategies that could improve health outcomes.
      Previous investigations have demonstrated that conversion to dysglycemia is attributed to several risk factors including maternal age, BMI, family history of T2DM, previous history of GDM, HbA1c, weight gain during pregnancy and birth weight of the baby [
      • Cheung N.W.
      • Wasmer G.
      • Al-Ali J.
      Risk factors for gestational diabetes among Asian women.
      ,
      • Cypryk K.
      • Szymczak W.
      • Czupryniak L.
      • Sobczak M.
      • Lewiński A.
      Gestational diabetes mellitus – an analysis of risk factors.
      ]. Several studies have revealed that maternal BMI at baseline (independent of weight gain) is an independent risk factor for subsequent conversion to dysglycemia [
      • Metzger B.E.
      • Cho N.H.
      • Roston S.M.
      • Radvany R.
      Prepregnancy weight and antepartum insulin secretion predict glucose tolerance five years after gestational diabetes mellitus.
      ,
      • Coustan D.R.
      • Carpenter M.W.
      • O’Sullivan P.S.
      • Carr S.R.
      Gestational diabetes: predictors of subsequent disordered glucose metabolism.
      ,
      • Kaufmann R.C.
      • Schleyhahn F.T.
      • Huffman D.G.
      • Amankwah K.S.
      Gestational diabetes diagnostic criteria: long-term maternal follow-up.
      ,
      • Jang H.C.
      • Yim C.H.
      • Han K.O.
      • Yoon H.K.
      • Han I.K.
      • Kim M.Y.
      • Yang J.H.
      • Cho N.H.
      Gestational diabetes mellitus in Korea: prevalence and prediction of glucose intolerance at early postpartum.
      ]. A study from Denmark reported that BMI of ⩾25 kg/m2 was one of the main predictors of postpartum glucose abnormalities [
      • Lauenborg J.
      • Hansen T.
      • Jensen D.M.
      • Vestergaard H.
      • Mølsted-Pedersen L.
      • Hornnes P.
      • et al.
      Increasing incidence of diabetes after gestational diabetes: a long-term follow-up in a Danish population.
      ]. HbA1c is also reported as a predictor for diabetes following GDM [
      • Kugishima Y.
      • Yasuhi I.
      • Yamashita H.
      • Fukuda M.
      • Kuzume A.
      • Sugimi S.
      • Umezaki Y.
      • Suga S.
      • Kusuda N.
      Risk factors associated with abnormal glucose tolerance in the early postpartum period among Japanese women with gestational diabetes.
      ,
      • Ekelund M.
      • Shaat N.
      • Almgren P.
      • Groop L.
      • Berntorp K.
      Prediction of postpartum diabetes in women with gestational diabetes mellitus.
      ]. As seen in previous studies, the current study also revealed that BMI ⩾25 kg/m2 is an independent risk factors for postpartum dysglycemia in south Indian women. While other traditional risk factors demonstrated a trend towards increased risk for GDM, they did not reach statistical significance probably due to smaller sample size.
      Several organizations have put forth guidelines for postpartum follow-up. The American Diabetes Association (ADA) recommends that women with GDM should undergo screening for T2DM with OGTT, 6 weeks after delivery [
      • American Diabetes Association
      Gestational diabetes mellitus.
      ]. The National Institute for Health and Care Excellence (NICE) recommends fasting plasma glucose (FPG) testing at 6 weeks postpartum [
      • National Institute for Health and Clinical Excellence
      Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period.
      ], while WHO recommends an OGTT at 6 weeks or after [
      • World Health Organization
      Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus.
      ].
      Despite all these well established guidelines put forth by several highly respected organizations, postpartum screening rates have ranged from 23% to 58% between 5 weeks and 1 year following delivery [
      • Hunt K.J.
      • Logan S.L.
      • Conway D.L.
      • Korte J.E.
      Postpartum screening following GDM: how well are we doing?.
      ,
      • Almario C.V.
      • Ecker T.
      • Moroz L.A.
      • et al.
      Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes.
      ,
      • Dietz P.M.
      • Vesco K.K.
      • Callaghan W.M.
      • et al.
      Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy.
      ,
      • Kwong S.
      • Mitchell R.S.
      • Senior P.A.
      • Chik C.L.
      Postpartum diabetes screening: adherence rate and the performance of fasting plasma glucose versus oral glucose tolerance test.
      ,
      • Baker A.M.
      • Brody S.C.
      • Salisbury K.
      • et al.
      Postpartum glucose tolerance screening in women with gestational diabetes in the state of North Carolina.
      ,
      • Gabbe S.G.
      • Gregory R.P.
      • Power M.L.
      • et al.
      Management of diabetes mellitus by obstetrician-gynecologists.
      ]. Several potential explanations have been offered for such poor rates of postpartum follow-up screening. One is the uncertainty between primary and secondary care responsibilities for screening. In some settings, GDM follow-up is not considered a clinical priority [
      • Pierce M.
      • Modder J.
      • Mortagy I.
      • et al.
      Missed opportunities for diabetes prevention: post-pregnancy follow-up of women with gestational diabetes mellitus in England.
      ]. This could be due to lack of awareness among health care professionals about various guidelines. Patient related barriers include emotional stress and difficulty with adjusting to motherhood and difficulty to come for postpartum testing in fasting state when exclusively breastfeeding through the night [
      • Nielsen K.
      • Kapur A.
      • Damm P.
      • de Courten M.
      • Bygbjerg I.
      From screening to postpartum follow-up – the determinants and barriers for gestational diabetes mellitus (GDM) services, a systematic review.
      ].
      In the present study also, several barriers to postpartum screening were observed. Logistic issues such as distance from the hospital, demands of household tasks and lack of shared responsibility for the newborn impede postpartum screening. However, we were able to ensure a 95.8% follow-up rate which surpasses typically expected rates of follow-up seen in high, middle and low income settings. Review of latest evidence regarding rates of postpartum follow-up by Tovar et al. [
      • Tovar A.
      • Chasan-Taber L.
      • Eggleston E.
      • Oken E.
      Postpartum screening for diabetes among women with a history of gestational diabetes mellitus.
      ] shows that postpartum follow-up rates varied greatly but were generally reported to be poor: between 34% and 73%. One reason for the high success rate in this study could be because we constantly reminded our women during their pregnancy to return for postpartum follow-up between 6 and 12 weeks after delivery. Efforts were taken to increase the postpartum screening rates by sending reminders to the patients, by contacting them through phone calls and arranging home visits for testing. In our experience one important aspect which affects the postpartum follow-up is that many women move to their maternal homes for delivery, a social custom practiced in many parts of India. This was a major limitation of the study, as postpartum follow up testing which was planned to be completed within 12 weeks was delayed up to a year for women who went to their maternal homes for delivery did not return back for postpartum testing until the end of one year. In view of the rapid conversion to T2DM occurring in this population after GDM, it is important to emphasize in future programmes, the value of early post-partum screening even within 12 weeks, with cultural adaptations to achieve the same, including testing at the city where the mother resides. This would increase the scope for introducing preventive measures to reduce the risk of progression to dysglycemia. Another limitation is that we did not include diet and physical activity assessment or advise as part of WINGS post-partum follow up. Finally we did not collect data on exclusive breast feeding which is yet another limitation of our study.
      In summary, the WINGS project has demonstrated that through sustained efforts, a near total post-partum follow-up is achievable. The importance of this in Asian Indian women, is demonstrated by the high rates and rapid conversion to dysglycemia seen amongst our population. Early screening in the postpartum period particularly in overweight women can identify women who are likely to progress to dysglycemia and thus help plan preventive strategies for delaying the onset of T2DM in them.

      Disclosure

      The authors have approved the final article.

      Conflict of interest statement

      The authors declare that they have no conflict of interest.

      Acknowledgements

      The WINGS programme has been developed through a partnership between the International Diabetes Federation ( IDF ), in Brussels, Belgium, the Madras Diabetes Research Foundation ( MDRF ) in Chennai, India, and the Abbott Fund, the philanthropic foundation of the global healthcare company Abbott. We would also like to place on record our sincere thanks to the Director of Public Health and the Health Secretary, the Government of Tamil Nadu. We also thank the village health nurses, the doctors and the study participants for their support. This is the seventh publication from the WINGS project (WINGS-7).

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