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Implications for practice and research
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Gestational diabetes mellitus (GDM) is an independent risk factor for stress, urge and mixed urinary incontinence (UI), up to 2 years postpartum.
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Postpartum UI and its effects on quality of life are more severe in women with GDM.
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Women with GDM should be informed of an increased risk of postpartum UI.
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Postpartum UI may be a strong motivating factor to increase control of GDM and, later, prevent the development of type 2 diabetes mellitus (DM).
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Research should compare those with good GDM control versus poor control to demonstrate the effect on postpartum UI.
Context
UI affects up to 50% of middle-aged and older women with significant economic, social and psychological consequences.1 ,2 DM is a well-known risk factor for UI, and GDM is a risk factor for the development of type 2 DM.3 Small cross-sectional studies have found UI is more common 2–5 years postpartum for women with GDM,4 ,5 but no large, prospective, longitudinal studies have investigated this relationship by type of UI.
Methods
Chuang et al recruited 6653 women with singleton pregnancies during late pregnancy from a tertiary care hospital in Taiwan. They were followed up to 2 years postpartum to investigate the association between GDM and postpartum UI in terms of incidence, severity and impact on quality of life. A baseline survey at 37–41 weeks gestation collected demographic, general, medical, obstetric and prepartum history. Intrapartum data were collected immediately after delivery. Participants completed the validated Sandvik Incontinence Severity Index at 6 weeks, 6 months, 1 year and 2 years postpartum. Quality of life was assessed at 6 weeks and 1 year with the validated seven-item incontinence impact questionnaire (IIQ-7). GDM was identified using a positive 100 g oral 3-h glucose tolerance test and two or more venous plasma glucose values exceeding prespecified thresholds. Investigators used generalised equations to construct logistic regression models to estimate the association of UI with GDM history.
Findings
Compared with women without GDM, women with GDM were significantly more likely to report stress UI (adjusted odds ratio (AOR) 1.97, 95% CI 1.56 to 2.51), urge UI (AOR 3.11, 95% CI 2.18 to 4.43) and mixed UI (AOR 2.73, 95% CI 1.70 to 4.40). Women with GDM were more likely to report moderate to severe stress UI throughout the study. Women with insulin-requiring GDM reported more severe functional impairment compared with those with GDM not requiring insulin, and women without GDM.
Commentary
This study provides compelling longitudinal evidence for the association between GDM and UI up to 2 years postpartum. It is among the first to include both the type and severity of UI among women with GDM. Interestingly, it suggests that UI may affect quality of life more significantly in women with insulin-requiring GDM.
Participants, both with and without GDM, demonstrated significant differences in prepartum and intrapartum factors, which were controlled for in logistic regression models. The authors did not distinguish instrumental deliveries from normal vaginal deliveries, yet instrumentation has been associated with postpartum UI.6 While the cohort followed in this study is large and 96% follow-up was achieved, only one tertiary care hospital and one ethnic group participated. Future studies should be multicentre, with a broad range of ethnic groups, and include weight in the analysis (postpartum weight loss or gain).
Prevalence of UI also decreased over time among participants both with and without a history of GDM. Longer follow-up of this cohort may help better characterise the natural history of postpartum UI in women with GDM. Given the strong evidence, clinicians should counsel pregnant patients with GDM about the increased incidence of postpartum UI. Following delivery, providers should also work with patients to minimise the burden of UI symptoms and prevent the development of type 2 DM.
Footnotes
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Competing interests None.