ArticlesType 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis
Introduction
Gestational diabetes mellitus is defined as glucose intolerance that is first detected during pregnancy.1 In the USA, this condition affects 135 000 pregnancies (3–5% of all pregnancies) per year.2, 3 Shortly after delivery, glucose homoeostasis is restored to non-pregnancy levels, but affected women remain at high risk of developing type 2 diabetes mellitus in the future.4, 5
For any population and ethnic group, the risk of gestational diabetes indicates the underlying frequency of type 2 diabetes.2, 6 The incidences of gestational diabetes and type 2 diabetes are rising throughout the world, with huge health-care and economic costs.6, 7 Diabetes predisposes individuals to cardiovascular, renal, and retinal diseases, costing US$91·8 billion per year in the USA.8
Women who have had gestational diabetes are advised to have their glucose tolerance assessed 6 weeks after delivery.9 However, low rates of attendance at the 6-week follow-up10, 11 suggest that health-care professionals, women with gestational diabetes, or both, do not realise the importance of this disorder as an early warning sign of the susceptibility to develop type 2 diabetes in the future; therefore an opportunity to promote health and prevent disease is missed. Moreover, no consensus exists on how and whether mothers should continue to be monitored after this period.
The association between gestational diabetes and type 2 diabetes mellitus has implications for the elucidation of the causes of these disorders, and for the prediction and possible prevention or delay of the development of type 2 diabetes in women. We therefore did a comprehensive systematic review and meta-analysis to quantify the overall risk of women with gestational diabetes mellitus developing type 2 diabetes mellitus, and to assess the effect of factors that might modify this risk.
Section snippets
Search strategy and selection criteria
We did an electronic search of Embase from 1974 to Jan 31, 2009, and Medline from 1960 to Jan 31, 2009, without language restrictions. Search term combinations were “gestational diabetes”, “diabetic pregnancy”, “diabetes mellitus”, “type 2 diabetes mellitus”, “NIDDM”, and “non-insulin dependent diabetes mellitus”. All reference lists from the main reports and relevant reviews were hand searched for additional eligible studies.
We identified retrospective and prospective cohort studies, reported
Results
Figure 1 shows the study selection process (reasons for exclusion are listed in webappendix pp 1–13). 48 of 68 full-text reports meeting all the inclusion criteria were subsequently excluded because of the absence of an appropriate control or reference population. The 20 remaining studies (table),5, 15, 16, 17, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 contributed 675 455 women with type 2 diabetes to the meta-analysis, and 31 867 of these had previous pregnancies affected
Discussion
Women who have had gestational diabetes have at least a seven-fold increased risk of developing type 2 diabetes mellitus in the future compared with those who have had a normoglycaemic pregnancy. The strength of the association between gestational diabetes and type 2 diabetes, and the knowledge that many of the risk factors are the same (ie, a family history of diabetes, raised body-mass index, increased age, and Asian and black ethnic origin), suggest that the two disorders might have an
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