Predicting Future Diabetes in Latino Women With Gestational Diabetes: Utility of Early Postpartum Glucose Tolerance Testing

We tested 32 routine clinical parameters for their ability to discriminate between a high risk and a low risk of non-insulin-dependent diabetes mellitus (NIDDM) within 5–7 years after pregnancies complicated by gestational diabetes mellitus (GDM). Latino women (n = 671) with GDM who did not have diabetes 4–16 weeks after delivery returned for at least one 75-g oral glucose tolerance test (OGTT) within 7.5 years. Multivariate analysis was used to identify parameters ascertained during or immediately after the index pregnancy that were independently associated with the development of diabetes during follow-up. Life table analysis revealed a 47% cumulative incidence rate of NIDDM 5 years after delivery for this cohort of patients who did not have diabetes at the initial postpartum examination. Four variables were identified as independent predictors of NIDDM: the area under the OGTT glucose curve at 4–16 weeks postpartum, the gestational age at the time of diagnosis of GDM, the area under the OGTT glucose curve during pregnancy, and the highest fasting serum glucose concentration during pregnancy. Examination of relative risks (RRs) of NIDDM between the highest and lowest quartiles of the cohort for each variable, adjusted for the other three variables, revealed that the postpartum OGTT provided the best discrimination between high-risk and low-risk individuals (adjusted RR = 11.5 [95% confidence interval 4.5–29.1] compared with adjusted RRs of only 0.5–2.5 for the other three variables). Women who met World Health Organization criteria for impaired glucose tolerance at the early postpartum examination had a 5-year unadjusted 80% risk of diabetes, which was much higher than the risk of NIDDM that has been reported for Latino people with impaired glucose tolerance who were not selected for a history of GDM. Our findings indicate that postpartum glucose tolerance testing is superior to other routine clinical parameters in defining the risk of NIDDM within 5–7 years after pregnancies complicated by GDM. Furthermore, a history of GDM appears to impart a specific risk for NIDDM that cannot be explained by the degree of glucose tolerance observed when patients are not pregnant.

[1]  L. Prencipe,et al.  Serum triglycerides determined colorimetrically with an enzyme that produces hydrogen peroxide. , 1982, Clinical chemistry.

[2]  R. DeFronzo,et al.  Pathogenesis of NIDDM: A Balanced Overview , 1992, Diabetes Care.

[3]  M. Harris.  Gestational Diabetes May Represent Discovery of Preexisting Glucose Intolerance , 1988, Diabetes Care.

[4]  R. N. Bergman,et al.  Role of glucose and insulin resistance in development of type 2 diabetes mellitus: results of a 25-year follow-up study , 1992, The Lancet.

[5]  E. A. Sims,et al.  Carbohydrate metabolism during pregnancy in control subjects and women with gestational diabetes. , 1993, The American journal of physiology.

[6]  E. Kaplan,et al.  Nonparametric Estimation from Incomplete Observations , 1958 .

[7]  P. Bennett,et al.  The natural history of impaired glucose tolerance in the Pima Indians. , 1988, The New England journal of medicine.

[8]  B. Metzger,et al.  Prepregnancy Weight and Antepartum Insulin Secretion Predict Glucose Tolerance Five Years After Gestational Diabetes Mellitus , 1993, Diabetes Care.

[9]  A. Cocurullo,et al.  Risk factors associated with persistence of glucose intolerance one year after gestational diabetes. , 1990, Diabete & metabolisme.

[10]  S. Haffner,et al.  Eight-year incidence of hypertension in Mexican-Americans and non-Hispanic whites. The San Antonio Heart Study. , 1992, American journal of hypertension.

[11]  J. Mestman.  Follow-up Studies in Women with Gestational Diabetes mellitus. The Experience at Los Angeles Country/ University of Southern California Medical Center , 1988 .

[12]  R N Bergman,et al.  Insulin sensitivity and B‐cell responsiveness to glucose during late pregnancy in lean and moderately obese women with normal glucose tolerance or mild gestational diabetes , 1991, American journal of obstetrics and gynecology.

[13]  David R. Cox,et al.  Regression models and life tables (with discussion , 1972 .

[14]  T. Buchanan,et al.  Gestational diabetes mellitus: the prevalence of glucose intolerance and diabetes mellitus in the first two months post partum. , 1990, American journal of obstetrics and gynecology.

[15]  P. Bennett,et al.  Gestational Diabetes: Infant and Maternal Complications of Pregnancy in Relation to Third-Trimester Glucose Tolerance in the Pima Indians , 1980, Diabetes Care.

[16]  S. Haffner,et al.  Predicting Diabetes: Moving Beyond Impaired Glucose Tolerance , 1993, Diabetes.

[17]  D. Porte,et al.  Abnormalities of islet B-cell function, insulin action, and fat distribution in women with histories of gestational diabetes: relationship to obesity. , 1985, The Journal of clinical endocrinology and metabolism.

[18]  J. O'sullivan.  The Boston Gestational Diabetes Studies: Review and Perspectives , 1989 .

[19]  E. A. Sims,et al.  Incidence and Significance of Islet Cell Antibodies in Women With Previous Gestational Diabetes , 1990, Diabetes Care.

[20]  U. Hanson,et al.  Follow-Up of Women With Previous GDM: Insulin, C-Peptide, and Proinsulin Responses to Oral Glucose Load , 1991, Diabetes.

[21]  R. Levy,et al.  Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. , 1972, Clinical chemistry.

[22]  B. Metzger,et al.  Gestational Diabetes Mellitus: Correlations Between the Phenotypic and Genotypic Characteristics of the Mother and Abnormal Glucose Tolerance During the First Year Postpartum , 1985, Diabetes.

[23]  E. Barrett-Connor,et al.  The effect of parity on the later development of non-insulin-dependent diabetes mellitus or impaired glucose tolerance. , 1989, The New England journal of medicine.

[24]  P. Fu,et al.  Enzymatic determination of total serum cholesterol. , 1974, Clinical chemistry.

[25]  P. Damm,et al.  Predictive factors for the development of diabetes in women with previous gestational diabetes mellitus , 1992, American journal of obstetrics and gynecology.

[26]  B V Howard,et al.  Impaired glucose tolerance as a disorder of insulin action. Longitudinal and cross-sectional studies in Pima Indians. , 1988, The New England journal of medicine.

[27]  S. Carr,et al.  Gestational diabetes: predictors of subsequent disordered glucose metabolism. , 1993, American journal of obstetrics and gynecology.

[28]  J. A. Scarlett,et al.  Receptor and postreceptor defects contribute to the insulin resistance in noninsulin-dependent diabetes mellitus. , 1981, The Journal of clinical investigation.

[29]  R. Leslie,et al.  Studies of diabetic twins. , 1991, Diabetes/metabolism reviews.

[30]  C. Mahan,et al.  CRITERIA FOR THE ORAL GLUCOSE TOLERANCE TEST IN PREGNANCY. , 1964, Diabetes.

[31]  Classification and Diagnosis of Diabetes Mellitus and Other Categories of Glucose Intolerance , 1979, Diabetes.

[32]  S. Haffner,et al.  Incidence of Type II Diabetes in Mexican Americans Predicted by Fasting Insulin and Glucose Levels, Obesity, and Body-Fat Distribution , 1990, Diabetes.