Dr Lucy Mackillop, Chief Medical Officer, Sensyne Health discusses the future of treating gestational diabetes
Diabetes in Pregnancy is characterised by high levels of glucose in the blood (hyperglycaemia) which may develop during pregnancy (a condition known as gestational diabetes mellitus, or GDM) or in some cases, may already be present in the form of pre-existing type 1 or type 2 diabetes. GDM is increasing in prevalence worldwide, driven by demographic and lifestyle changes. In 2019, it was estimated that 20% of pregnant women in the UK were affected by hyperglycaemia in pregnancy.
If not managed effectively, diabetes in pregnancy can cause serious maternal and neonatal complications during pregnancy and after birth. Complications can include for the baby pre-term birth, birth trauma and an increased risk of stillbirth, and for the mother, pre-eclampsia and an increased risk of caesarean section. However, the risk can be greatly reduced if the condition is detected early and well managed through regular recording of blood glucose levels, lifestyle advice and pharmacological treatment if needed.
Achieving healthier outcomes for women and their babies is a UK Government priority with the target of halving the rates of stillbirths and maternal death by 2030. Initiatives such as ‘Saving Babies Lives’ and ‘Each Baby Counts’ served to address this target. In addition, national guidelines, such as NICE’s Diabetes in pregnancy: management from preconception to the postnatal period, aim to standardise and improve the diagnosis and management of diabetes in pregnancy.
Traditional approaches to GDM
One of the most effective ways of managing gestational diabetes is by implementing lifestyle changes. This includes following a healthy, balanced diet, increasing the activity levels if they are low and self-monitoring blood glucose levels. Around 70% of women who develop gestational diabetes are able to control their blood glucose with these lifestyle measures, with the remainder requiring pharmacological treatment to maintain good glycaemic control.
GDM is traditionally diagnosed by challenging the body to a high dose of glucose. The woman is asked to fast overnight before having this test. Blood is taken in the morning to measure the fasting blood glucose level. The woman is then given a sugary drink and the blood test is repeated two hours later. This is called an oral glucose tolerance test (OGTT). If she is not able to control the glucose level in her blood in response to the glucose dose she is given, she has gestational diabetes. However, the lack of international standardisation of this process causes some difficulties. The quantity of glucose given as well as the time at which the woman has a blood test differs in different countries, meaning that there is no universally agreed way of diagnosing GDM and this can cause confusion among both patients and clinicians.
GDM can be thought of as a syndrome due to the variety of factors that can impact how one handles glucose – from the body fat percentage to age through genetics. While the traditional approach to diagnosing the disease has been around giving patients the same test and then expecting everyone to behave in the same way, today we have the opportunity to use technologies such as machine learning and data analytics to provide more personalised diagnostics and care.
Moving towards data driven improvements in care
How can we further improve GDM diagnosis and treatment? With an anonymised real-world database of pregnant women with or at risk of diabetes, we can use this to help explore metrics that may better predict individual risk of birth outcomes related to hyperglycaemia and in so doing, challenge the use of OGTTs as the gold standard.
As GDM is a syndrome, so different phenotypes or subpopulations exist. Characterising these phenotypes may lead to more individualised care. For example, we need to be able to better understand what the optimum timing is for birth for women with GDM. This is likely to be different for different subpopulations of women with GDM. By creating anonymised real-world datasets generated by regular monitoring of blood glucose levels using remote monitoring technology, and applying advanced data analytic techniques, we can identify the metrics and patterns that are associated with different outcomes and, therefore, inform clinicians of individual risk prediction based on individual, routinely collected patient data.
Furthermore, clinicians may be able to identify, based on data collected during pregnancy, which mothers and their babies are particularly vulnerable to longer-term health conditions such as type 2 diabetes or cardiovascular disease later in life. This can lead to the development of postnatal interventions for the highest risk groups. Genetics is likely to be an important factor and technologies now exist to take a blood test from a pregnant woman and find the baby’s DNA. Scientists could in future perform genetics sequencing on that DNA and further refine prediction algorithms. Within the next couple of decades, I hope that we will be able to offer genetic testing to uncover genetic predispositions for diabetes, cardiovascular disease, or other illnesses in babies before they are born, which will allow us to apply earlier interventions to prevent these.
[1] Development of a Real-Time Smartphone Solution for the Management of Women with or at High Risk of Gestational Diabetes; J Diabetes Sci Technol 2014 vol. 8 no.
Gestational Diabetes in the U.S.
Gestational diabetes is a type of diabetes that occurs during pregnancy and is normally diagnosed during the 24th to 28th week, but managing the condition can help mother and baby stay healthy. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD) in the U.S. stress that the health of mother and baby can be protected by managing blood glucose levels.
Also, high blood glucose levels during pregnancy can cause problems such as the baby being born too early, weighing too much (this makes delivery difficult) or having low blood glucose (also called hypoglycaemia), straight after birth and breathing problems. (1)
This aspect of diabetes is just one example of the wider work that the NIDDKD in the U.S encompasses, part of the U.S. Department of Health and Human Services, National Institutes of Health. NIDDKD produces knowledge concerning treatments for diseases that are “among the most chronic, costly, and consequential for patients, their families, and the Nation,” we read. (2)
Consider the wider picture here, let’s briefly look at the role of Griffin P. Rodgers, Director of the NIDDK since 2007. Rodgers provides scientific leadership and manages a staff of more than 630, not to mention a budget of over $2.25 billion. NIDDK’s mission is to support and conduct medical research and research training, for example. Other aspects of their work include disseminating science-based information on diabetes, digestive diseases, nutritional disorders and obesity to name a few, but whatever they are doing they seek “to improve people’s health and quality of life”. (3)
References
https://www.niddk.nih.gov/about-niddk
https://www.niddk.nih.gov/about-niddk/meet-director
