Gestational diabetes mellitus follow-up in Norwegian primary health care: a qualitative study

Background Women with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up. Aim To elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes. Design & setting Qualitative study in primary care in the region of Stavanger, Norway. Method Semi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically. Results Most women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change. Conclusion Women experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support.publishedVersio

Glycated albumin in pregnancy: LC-MS/MS-based reference interval in healthy, nulliparous Scandinavian women and its diagnostic accuracy in gestational diabetes mellitus

Glycated albumin (GA) may be a useful biomarker of glycemia in pregnancy. The aim of this study was to establish the reference interval (RI) for GA, analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), in healthy, nulliparous pregnant women. In addition, we assessed the accuracy of GA and glycated hemoglobin A1c (HbA1c) in the diagnosis of gestational diabetes mellitus (GDM). Finally, we explored the prevalence of GDM in healthy nulliparas, comparing three diagnostic guidelines (WHO-1999, WHO-2013 and the Norwegian guideline). The study was carried out at Stavanger University Hospital, Norway, and included a study population of 147 pregnant nulliparous women. An oral glucose tolerance test (OGTT) was performed and used as the gold standard for GDM diagnosis. Blood samples for analysis of GA and HbA1c were collected at pregnancy week 24–28. A nonparametric approach was chosen for RI calculation, and receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of GA and HbA1c. The established RI for GA in 121 pregnant women was 7.1–11.6%. The area under the ROC curves (AUCs) were 0.531 (GA) and 0.627 (HbA1c). According to the WHO-1999, WHO-2013 and the Norwegian guideline, respectively, 24 (16%), 36 (24%) and 21 (14%) women were diagnosed with GDM. Only nine women (6%) fulfilled the GDM-criteria of all guidelines. In conclusion, we established the first LC-MS/MS-based RI for GA in pregnant women. At pregnancy weeks 24–28, neither GA nor HbA1c discriminated between those with and without GDM. Different women were diagnosed with GDM using the three guidelines.publishedVersio

Glycated albumin and continuous glucose monitoring metrics across pregnancy in women with pre-gestational diabetes

Introduction: Glycated albumin (GA), a biomarker reflecting short-term glycaemia, may be useful to assess glycaemic control in pregnancy. We examined the association between GA and continuous glucose monitoring (CGM) metrics across gestation. Methods: In this prospective cohort study including 40 women with pre-gestational diabetes, blood samples for analysis of GA and glycated haemoglobin A1c (HbA1c) were collected at pregnancy week 12, 20, 24, 28, 32 and 36. In the CGM-group (n = 19), CGM data were collected from first trimester until pregnancy week 36. Receiver operating characteristic (ROC) curves were used to assess the accuracy of GA and HbA1c to detect poor glycaemic control, using CGM metrics as the reference standard. This study was conducted at Stavanger University Hospital, Norway, in 2016–2018. Results: Glycaemic control improved across gestation with more time spent in target range, coinciding with decreased glycaemic variability and lower mean GA level. There was statistically significant correlation between GA and most CGM metrics. The area under the ROC curves (AUC) for detecting time in range 25% for the pregnancy glucose target 63–140 mg/dl (3.5–7.8 mmol/L) were 0.78 and 0.82 for GA, whereas AUCs of 0.60 and 0.72 were found for HbA1c, respectively. Conclusions: Higher GA levels were associated with less time spent in target range, more time spent in the above range area and increased glycaemic variability. GA was more accurate than HbA1c to detect time above range >25% and time in range <70%.publishedVersio

Hyperglycemia in pregnancy. : Diagnostics, biomarkers, follow-up, and monitoring of glycemic control

Diabetes mellitus er blant de største globale folkehelseutfordringene i vår tid. Hyperglykemi affiserer ett av seks svangerskap og svangerskapsdiabetes (SVD) er den vanligste årsak. Gravide med hyperglykemi har økt risiko for de fleste svangerskapskomplikasjoner og kvinner med SVD har en tidoblet risiko for å utvikle diabetes mellitus type 2. Barn født av mødre med diabetes i svangerskapet har økt risiko for overvekt og diabetes. Det er kjent at god glykemisk kontroll reduserer risiko for både mor og barn, på kort og lang sikt. I dag benyttes HbA1c som markør på glykemisk kontroll, selv om metoden har kjente svakheter i svangerskap. Glykert albumin (GA) gjenspeiler blodsukkeret siste 2–3 uker. I Asia er bruken av GA utbredt, og GA er anbefalt brukt hos gravide. Ved Stavanger universitetssjukehus (SUS) er det utviklet en ny analysemetode for GA basert på væske kromatografi-massespektrometri (LC-MS/MS). Mål for denne avhandlingen var: å etablere referanseområdet for GA hos friske gravide ved LC-MS/MS; evaluere bruk av GA og HbA1c i diagnostikk av SVD; undersøke forekomsten av SVD etter ulike retningslinjer; undersøke norske kvinners erfaringer med oppfølging av SVD; kartlegge assosiasjonen mellom GA og kontinuerlig vevsglukose (CGM) data hos gravide med pre-gestasjonell diabetes; og studere GA og HbA1c i monitorering av glykemisk kontroll ved bruk av CGM data som referanse. Doktorgradsarbeidet inkluderer tre kliniske studier utført ved SUS i perioden 2016–2020, kvantitative og kvalitative studiedesign er benyttet. Referanseintervallet for GA i svangerskap ble etablert. Vi fant en tredobling i forekomst av SVD, men når vi sammenlignet forekomsten etter nye og gamle diagnostiske kriterier, var det en liten nedgang. Verken GA eller HbA1c egnet seg i diagnostikk av SVD. De fleste kvinnene påpekte manglende oppfølging av SVD etter fødsel. Glykemisk kontroll bedret seg under svangerskapet hos kvinner med pre-gestasjonell diabetes, samtidig med lavere glykemisk variabilitet og fallende GA-nivå. GA korrelerte med CGM data og analyser viste at GA var bedre enn HbA1c til å avdekke tid utenfor anbefalt målområde for CGM data. Konklusjoner er at verken GA eller HbA1c bør brukes til å diagnostisere SVD. GA kan benyttes i monitorering av glykemisk kontroll hos gravide med pre-gestasjonell diabetes og avdekket dårlig glykemisk kontroll bedre enn HbA1c. Forekomsten av SVD var 14%. Oppfølging av kvinner med SVD bør bli bedre.Diabetes mellitus is among the largest public health concerns of our time. Hyperglycemia affects one in six pregnancies, the majority due to gestational diabetes mellitus (GDM). Women with hyperglycemia have increased risk of most pregnancy complications, and women with prior GDM have a tenfold increased risk of diabetes mellitus. Offspring of mothers with GDM are more likely to develop diabetes mellitus and obesity. It is well known that good glycemic control reduces the risks for mothers and children, in the short and long run. Today, HbA1c is used to monitor glycemic control, even its known limitations in pregnancy. Glycated albumin (GA) reflects short-term glycemia (2–3 weeks). In Asia, GA is used frequently, also during pregnancy. Recently, a new method for GA measurement using LC-MS/MS was developed at Stavanger University Hospital (SUS). The aims of the thesis were to: Establish a reference interval (RI) for GA in healthy pregnancies analyzed by LC-MS/MS; evaluate the accuracy of GA and HbA1c in the diagnosis of GDM; explore the prevalence of GDM using different diagnostic criteria; elucidate Norwegian women’s experiences of GDM follow-up; explore the association between GA and continuous glucose monitoring (CGM) metrics across gestation in diabetic pregnancies; and investigate the accuracy of GA and HbA1c to detect poor glycemic control using CGM metrics as the reference. The thesis includes three clinical studies conducted at SUS in the years 2016–2020, quantitative and qualitative study designs have been utilized. The RI for GA in pregnancy was established. An almost threefold increase in GDM prevalence was found. However, when comparing the old and new diagnostic criteria, the prevalence declined slightly. Neither GA nor HbA1c differentiated between those with or without GDM. Most women experienced a lack of follow-up for GDM after delivery. Glycemic control improved across gestation in women with pre-gestational diabetes coinciding with decreased glycemic variability and lower mean GA level. GA correlated with CGM metrics, and GA was more accurate than HbA1c to detect time outside the recommended range for CGM metrics. In conclusion, neither GA nor HbA1c should be used in GDM diagnostics. GA may be used in monitoring glycemic control in women with pre-gestational diabetes, and was more accurate than HbA1c to detect poor glycemic control. The prevalence of GDM was 14%. Improvements in GDM follow-up after delivery are required.Doktorgradsavhandlin

Gestational diabetes mellitus follow-up in Norwegian primary health care: a qualitative study

Background Women with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up. Aim To elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes. Design & setting Qualitative study in primary care in the region of Stavanger, Norway. Method Semi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically. Results Most women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change. Conclusion Women experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support

Gestational diabetes mellitus follow-up in Norwegian primary health care: a qualitative study

Background Women with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach, aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up. Aim To elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes. Design & setting Qualitative study in primary care in the region of Stavanger, Norway. Method Semi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically. Results Most women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change. Conclusion Women experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support

Glycated albumin in pregnancy: LC-MS/MS-based reference interval in healthy, nulliparous Scandinavian women and its diagnostic accuracy in gestational diabetes mellitus

Glycated albumin (GA) may be a useful biomarker of glycemia in pregnancy. The aim of this study was to establish the reference interval (RI) for GA, analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), in healthy, nulliparous pregnant women. In addition, we assessed the accuracy of GA and glycated hemoglobin A1c (HbA1c) in the diagnosis of gestational diabetes mellitus (GDM). Finally, we explored the prevalence of GDM in healthy nulliparas, comparing three diagnostic guidelines (WHO-1999, WHO-2013 and the Norwegian guideline). The study was carried out at Stavanger University Hospital, Norway, and included a study population of 147 pregnant nulliparous women. An oral glucose tolerance test (OGTT) was performed and used as the gold standard for GDM diagnosis. Blood samples for analysis of GA and HbA1c were collected at pregnancy week 24–28. A nonparametric approach was chosen for RI calculation, and receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of GA and HbA1c. The established RI for GA in 121 pregnant women was 7.1–11.6%. The area under the ROC curves (AUCs) were 0.531 (GA) and 0.627 (HbA1c). According to the WHO-1999, WHO-2013 and the Norwegian guideline, respectively, 24 (16%), 36 (24%) and 21 (14%) women were diagnosed with GDM. Only nine women (6%) fulfilled the GDM-criteria of all guidelines. In conclusion, we established the first LC-MS/MS-based RI for GA in pregnant women. At pregnancy weeks 24–28, neither GA nor HbA1c discriminated between those with and without GDM. Different women were diagnosed with GDM using the three guidelines

Glycated albumin in pregnancy: LC-MS/MS-based reference interval in healthy, nulliparous Scandinavian women and its diagnostic accuracy in gestational diabetes mellitus

Glycated albumin (GA) may be a useful biomarker of glycemia in pregnancy. The aim of this study was to establish the reference interval (RI) for GA, analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), in healthy, nulliparous pregnant women. In addition, we assessed the accuracy of GA and glycated hemoglobin A1c (HbA1c) in the diagnosis of gestational diabetes mellitus (GDM). Finally, we explored the prevalence of GDM in healthy nulliparas, comparing three diagnostic guidelines (WHO-1999, WHO-2013 and the Norwegian guideline). The study was carried out at Stavanger University Hospital, Norway, and included a study population of 147 pregnant nulliparous women. An oral glucose tolerance test (OGTT) was performed and used as the gold standard for GDM diagnosis. Blood samples for analysis of GA and HbA1c were collected at pregnancy week 24–28. A nonparametric approach was chosen for RI calculation, and receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of GA and HbA1c. The established RI for GA in 121 pregnant women was 7.1–11.6%. The area under the ROC curves (AUCs) were 0.531 (GA) and 0.627 (HbA1c). According to the WHO-1999, WHO-2013 and the Norwegian guideline, respectively, 24 (16%), 36 (24%) and 21 (14%) women were diagnosed with GDM. Only nine women (6%) fulfilled the GDM-criteria of all guidelines. In conclusion, we established the first LC-MS/MS-based RI for GA in pregnant women. At pregnancy weeks 24–28, neither GA nor HbA1c discriminated between those with and without GDM. Different women were diagnosed with GDM using the three guidelines

Glycated albumin and continuous glucose monitoring metrics across pregnancy in women with pre-gestational diabetes

Introduction: Glycated albumin (GA), a biomarker reflecting short-term glycaemia, may be useful to assess glycaemic control in pregnancy. We examined the association between GA and continuous glucose monitoring (CGM) metrics across gestation. Methods: In this prospective cohort study including 40 women with pre-gestational diabetes, blood samples for analysis of GA and glycated haemoglobin A1c (HbA1c) were collected at pregnancy week 12, 20, 24, 28, 32 and 36. In the CGM-group (n = 19), CGM data were collected from first trimester until pregnancy week 36. Receiver operating characteristic (ROC) curves were used to assess the accuracy of GA and HbA1c to detect poor glycaemic control, using CGM metrics as the reference standard. This study was conducted at Stavanger University Hospital, Norway, in 2016–2018. Results: Glycaemic control improved across gestation with more time spent in target range, coinciding with decreased glycaemic variability and lower mean GA level. There was statistically significant correlation between GA and most CGM metrics. The area under the ROC curves (AUC) for detecting time in range 25% for the pregnancy glucose target 63–140 mg/dl (3.5–7.8 mmol/L) were 0.78 and 0.82 for GA, whereas AUCs of 0.60 and 0.72 were found for HbA1c, respectively. Conclusions: Higher GA levels were associated with less time spent in target range, more time spent in the above range area and increased glycaemic variability. GA was more accurate than HbA1c to detect time above range >25% and time in range <70%