Gestational diabetes and postpartum care -
During late pregnancy, insulin resistance increases a lot. This can cause some women to develop a type of diabetes called gestational diabetes. And having gestational diabetes can put you at higher risk of postpartum depression. Some research has found that having gestational diabetes can also increase your risk of postpartum depression.
Postpartum depression includes intense symptoms of sadness, anxiety, and hopelessness that can occur up to a year after birth. It could affect your ability to care for your baby and handle daily life activities.
Around 1 in 8 women have symptoms of depression after giving birth. Depression can also occur before and during pregnancy. Yet less than half of pregnant women with depression receive the treatment they need. If you have depression before, during, or after pregnancy, talk to your doctor about your symptoms.
There are several treatment options and resources to help you manage your symptoms. Getting the right treatment will help you take care of yourself and your baby. Research has found that it could be mental, physical, or a combination of factors.
Managing gestational diabetes can be a major source of stress for some pregnant women, and stress itself could be a risk factor for postpartum depression. The daily challenges of managing diabetes can bring on symptoms of depression and anxiety.
Association of insurance status with provision of recommended services during comprehensive postpartum visits. Thayer SM, Lo JO, Caughey AB.
Gestational diabetes: importance of follow-up screening for the benefit of long-term health. American College of Obstetricians and Gynecologists. Interpregnancy Care. Published online January Accessed September 8, Bose Brill S, May S, Lorenz AM, et al.
Mother-Infant Dyad program in primary care: evidence-based postpartum care following gestational diabetes. Jones EJ, Hernandez TL, Edmonds JK, Ferranti EP. Continued disparities in postpartum follow-up and screening among women with gestational diabetes and hypertensive disorders of pregnancy: a systematic review.
Bernstein JA, Quinn E, Ameli O, et al. Lewey J, Levine LD, Yang L, Triebwasser JE, Groeneveld PW. Patterns of postpartum ambulatory care follow-up care among women with hypertensive disorders of pregnancy. American Diabetes Association. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes ACOG Practice Bulletin No.
Picón MJ, Murri M, Muñoz A, Fernández-García JC, Gomez-Huelgas R, Tinahones FJ. Hemoglobin A 1c versus oral glucose tolerance test in postpartum diabetes screening.
Carter EB, Martin S, Temming LA, Colditz GA, Macones GA, Tuuli MG. Early versus week postpartum glucose tolerance testing for women with gestational diabetes. Ratner RE, Christophi CA, Metzger BE, et al; Diabetes Prevention Program Research Group.
Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. Herman WH, Ye W, Griffin SJ, et al. Early detection and treatment of type 2 diabetes reduce cardiovascular morbidity and mortality: a simulation of the results of the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care ADDITION-Europe.
Ramsey ML, Gokun Y, Sobotka LA, et al. Cystic fibrosis transmembrane conductance regulator modulator use is associated with reduced pancreatitis hospitalizations in patients with cystic fibrosis. Butler AM, Layton JB, Li D, et al. Predictors of low uptake of prenatal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis immunization in privately insured women in the United States.
Venkatesh KK, Chiang CW, Castillo WC, et al. Changing patterns in medication prescription for gestational diabetes during a time of guideline change in the USA: a cross-sectional study. Mishra GD, Chung HF, Cano A, et al.
EMAS position statement: predictors of premature and early natural menopause. Lindh I, Skjeldestad FE, Heikinheimo O, et al. Reproductive changes among women in their 40s: a cross-sectional study. Khalil A, Syngelaki A, Maiz N, Zinevich Y, Nicolaides KH. Maternal age and adverse pregnancy outcome: a cohort study.
Palmsten K, Huybrechts KF, Mogun H, et al. Harnessing the Medicaid Analytic eXtract MAX to evaluate medications in pregnancy: design considerations.
Wang X, Xie L, Pengetnze YM, et al. Timely preterm-birth prediction among pregnant women in Medicaid without preterm-birth history. Medicare Program: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Policy Issues and Level II of the Healthcare Common Procedure Coding System.
November 3, Hamel MS, Werner EF. Interventions to improve rate of diabetes testing postpartum in women with gestational diabetes mellitus.
Venkatesh KK, Germann K, Joseph J, et al. Association between social vulnerability and achieving glycemic control among pregnant individuals with pregestational diabetes. See More About Public Health Cardiology Pregnancy Cardiovascular Risk Factors Obstetrics Obstetrics and Gynecology Women's Health Diabetes Diabetes and Endocrinology.
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Weekly Email. Monthly Email. Save Preferences. Privacy Policy Terms of Use. This Issue. Views 4, Citations View Metrics. X Facebook More LinkedIn. Original Investigation. February 6, Akinduro, MD, MS 3 ; et al Madison Hyer, MS 2 ; Stephen Thung, MD 4 ; Shengyi Mao, MD 1 ; Naleef Fareed, PhD 2 ; Seuli Bose-Brill, MD 1.
Author Affiliations Article Information 1 Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus.
visual abstract icon Visual Abstract. Key Points Question How many patients with gestational diabetes GD have appropriate primary care follow-up and diabetes-related care post partum? Data Source. Study Variables. Statistical Analysis. Primary Care Follow-up.
Diabetes-Related Care Trends. Diabetes-Related Care Among Those With Primary Care Follow-up. Blood Glucose Testing in the First 12 Weeks.
Outcomes Associated With Comorbidities on Primary Care Follow-up. Back to top Article Information. Access your subscriptions. Access through your institution.
Add or change institution. Studies have reported inconsistent findings regarding a potential association between ketonuria and impaired cognitive outcome in offspring [ ].
Goal — The goal of pharmacotherapy is to manage glucose levels so that the majority are no higher than the upper limit of the target range, without inducing any episodes of hypoglycemia.
Indications for pharmacotherapy. We initiate pharmacotherapy when over 30 percent of the blood glucose values in a week are above target glucose thresholds see 'Glucose target' above.
Our general approach is described in the algorithm algorithm 1. Randomized trials regarding when to initiate pharmacotherapy have not been performed. In a meta-analysis including only two trials, compared with conventional hyperglycemia-based management in patients with a broad GDM severity spectrum, initiation of pharmacotherapy based on ultrasound findings of a large AC increased the percent of patients requiring insulin treatment 34 versus 23 percent, relative risk [RR] 1.
Rates of pregnancy-associated hypertension and cesarean birth were similar in both groups; data on frequency of maternal hypoglycemia were not provided. Based on these and other findings, it is reasonable for patients with sonographic signs of fetal overgrowth to receive insulin to decrease the risk of large for gestational age and macrosomia despite having less than 30 percent of glucose values above target threshold.
Does early metformin initiation improve glycemic control and reduce need for insulin? Whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care was investigated in a randomized trial [ 64 ].
Patients assigned to the metformin group had favorable trends in some secondary outcomes, but the trial was not powered to evaluate these individually:. There was no significant difference in maternal morbidity eg, gestational hypertension or preeclampsia , need for neonatal intensive care unit NICU care, or neonatal hypoglycemia.
Given these mixed findings, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. Choice of pharmacotherapy — The pharmacotherapy options in pregnant patients who require pharmacotherapy are insulin and some insulin analogs or selected oral antihyperglycemic agents metformin or glyburide.
We favor insulin because it is effective, easily adjusted based on glucose levels, and safe for the fetus, whereas data are lacking regarding long-term outcomes of offspring exposed to oral antihyperglycemic drugs in utero.
We believe that oral antihyperglycemic agents are a reasonable alternative to insulin for patients in whom pharmacotherapy is indicated but who decline to take, or are unable to comply with, insulin therapy.
Our approach is generally consistent with national and international guidance [ 1,24,43,65,66 ]. Some guidelines consider oral antihyperglycemic drugs an acceptable first-line approach in selected patients, such as those with normal fasting blood glucose levels and modest postprandial hyperglycemia [ ].
See 'Society guideline links' below. Meta-analyses comparing use of oral antihyperglycemic agents with insulin therapy have generally found that both approaches can improve some pregnancy outcomes in patients with GDM or type 2 diabetes [ 61, ].
There is a trend toward more frequent maternal hypoglycemia with use of insulin [ 71 ], and some patients on oral agents need supplemental insulin to achieve and maintain glucose levels in the target range [ 74 ]. However, it is difficult to draw firm conclusions about the optimal approach because of inconsistencies in criteria for GDM, glucose targets, patient adherence to treatment, clinical outcome measures across studies, and lack of long-term safety data [ 71 ].
In randomized trials, compared with insulin, metformin :. In randomized trials, compared with insulin, glyburide :. Dose — The insulin dose required to achieve target glucose levels varies among individuals, but the majority of studies have reported a total dose ranging from 0.
Dose titration to blood glucose levels is based upon frequent self-monitoring. At least four daily glucose measurements are required fasting and one or two hours postprandial with the addition of pre-lunch and pre-dinner measurements as needed to optimize therapy and ensure timely dose increases as insulin requirements increase with pregnancy progression.
The insulin requirement in twin gestations complicated by GDM may double with pregnancy progression. We do not use insulin pumps in patients with GDM because there are no data to suggest that they are necessary or more effective than conventional therapy, and the cost of an insulin pump is not justified over the relatively short duration of a pregnancy.
However, case reports have described successful use in some pregnant people. Pragmatic approach to management of hyperglycemia — Hospitalization is not necessary to initiate insulin therapy; however, if teaching some patients the procedures they need to know is not possible in the outpatient setting, then an inpatient stay to utilize the expertise of the hospital's nursing staff may justify the cost of hospitalization.
One principle we have found useful is to start with the simplest regimen and increase the complexity as needed to address the particular situation. Typically, regardless of body weight, insulin dosing is based on the glucose levels recorded in the patient's blood glucose log.
Because any insulin regimen requires serial dosing adjustments in response to specific fasting or postprandial glucose levels, the starting dose should be considered just that, a starting point. Weekly glucose log review is recommended so that insulin doses can be adjusted as needed to meet target glucose levels as the pregnancy advances.
Some patients may be diagnosed with diabetes and therapy initiated early in pregnancy prior to 24 to 28 weeks screening ; these patients are managed differently and generally require slightly lower insulin doses since insulin resistance is lower early in pregnancy.
We prefer NPH due to the peak at four to six hours after the dose, which may also aid in covering postprandial lunch excursions. Levemir can also be used but is peakless and would not help as much with the lunch post-meal peak.
The upper end of this range is not likely to lead to hypoglycemia in patients with both obesity and GDM unless a meal is omitted after insulin is given.
If both post-breakfast and post-lunch glucose levels are elevated, increasing the morning NPH may be sufficient. The initial dose is 0. Dosing based on glucose levels and weight — An alternative approach to insulin therapy, somewhat more complex and likely most appropriate for individuals whose glucose levels are not well managed with simpler paradigms, is described below:.
A long-acting insulin analog insulin glargine or detemir may be used instead [ 77 ]. See "General principles of insulin therapy in diabetes mellitus". The starting dose is calculated by trimester of pregnancy and body weight: 0.
In patients with class II or III obesity, the initial doses of insulin may need to be increased to 1. Two-thirds of the total daily dose is administered in the morning, with two-thirds of the morning dose given as basal insulin and one-third given as rapid-acting insulin up to 15 minutes before breakfast.
One-third of the total daily dose is administered in the evening, with half of this dose given as rapid-acting insulin up to 15 minutes before dinner and the other half given as basal insulin as a nighttime dose usually at bedtime but before dinner is another option on an individualized basis.
A lunchtime dose of rapid-acting insulin may be added if there is continued postprandial lunch hyperglycemia. Hypoglycemia remote from meal or snack time is rare in patients with GDM treated with pharmacotherapy, and it is treated by administering 10 to 20 g of a fast-acting carbohydrate snack immediately.
Since the sugars in milk release more slowly into the bloodstream than pure sugar options, the glucose pattern seen with pure sugars ie, rapid elevation of glucose followed by a rapid decline may be dampened. See "Hypoglycemia in adults with diabetes mellitus", section on 'Reversing hypoglycemia'.
Patients who are feeling better may recheck their blood glucose 15 to 30 minutes after treatment. On the other hand, they may need to give themselves extra insulin to compensate for overtreatment of the symptoms.
If low glucose values are encountered more than once at the same time of day, insulin doses are adjusted downward accordingly. Type of insulin — Use of insulin preparations of low antigenicity may minimize transplacental transfer of insulin antibodies.
Human insulin is the least immunogenic of the commercially available preparations. The three rapid-acting insulin analogs lispro, aspart, glulisine are comparable in immunogenicity to human regular insulin , but only lispro and aspart have been investigated in pregnancy and shown to have acceptable safety profiles, minimal transfer across the placenta, and no evidence of teratogenesis.
Neonatal outcomes are similar to those of patients treated with regular insulin [ 61 ]. These two insulin analogs both improve postprandial excursions compared with human regular insulin and are associated with lower risk of delayed postprandial hypoglycemia.
Long-acting insulin analogs insulin glargine , insulin detemir have not been studied as extensively in pregnancy, but data from patients with preexisting pregestational diabetes and studies of placental transfer suggest that both detemir and glargine are safe and effective for use in pregnancy [ ].
See "Pregestational preexisting diabetes mellitus: Antenatal glycemic control", section on 'Type of insulin'. Based on available data, we prefer using human NPH insulin as part of a multiple injection regimen in pregnant people with GDM, especially given the peak at four to six hours after the morning dose, which can help decrease lunch postprandial blood glucose levels without an additional dose of rapid-acting insulin [ 86 ].
The body of data support the safety and effectiveness of NPH in pregnancy, and doses can be adjusted frequently and quickly in response to changing requirements in pregnant patients. If a longer-acting insulin analog is used, we prefer detemir insulin because it can be dosed twice a day, similar to NPH, with the advantage over NPH of more consistent absorption and less variability in absorption among patients.
Insulin detemir is preferred over insulin glargine because it has been studied more extensively in pregnancy and can be dosed twice per day more predictably than glargine, as previously mentioned. See "General principles of insulin therapy in diabetes mellitus", section on 'Safety'.
Oral hypoglycemic agents — Metformin and glyburide are the only noninsulin antihyperglycemic drugs used in pregnancy. Both oral hypoglycemic agents offer the advantage of significantly decreased cost compared with insulin.
Metformin is not associated with hypoglycemia. Choosing metformin versus glyburide — Clinically important pregnancy outcomes are generally similar for metformin and glyburide , with only limited evidence of benefit of one oral agent over the other. Fetal metformin levels are percent of the maternal level and glyburide levels are 70 percent of the maternal level, which has unknown long-term consequences [ ].
Although metformin and glyburide have not been associated with an increased risk of congenital anatomic anomalies, when either drug is prescribed, patients should be made aware that information regarding the long-term effects of transplacental passage, including possible fetal programming effects, are largely unknown, so caution is warranted until more data are available [ ].
Metformin — A typical dosing regimen is to start metformin extended release XR mg orally once daily with dinner and, if tolerated, increase by mg eg, mg with dinner or mg with dinner plus mg with breakfast based on the degree of glucose elevations.
The dose can then be increased by to mg orally per week until reaching the usual effective dose of to mg orally per day divided into two doses maximum daily dose is mg [ 98 ]. An immediate release preparation is also available, but we prefer the XR as it may cause fewer gastrointestinal side effects and fewer daily doses may be needed.
The most common side effects of metformin are gastrointestinal, including a metallic taste in the mouth, mild anorexia, nausea, abdominal discomfort, and soft bowel movements or diarrhea.
These symptoms are usually mild, transient, and reversible after dose reduction or discontinuation of the drug. Symptoms can be mitigated by starting at a low dose with slow-dose escalation as needed. In a clinical trial, only 2 percent of study subjects discontinued metformin because of gastrointestinal side effects [ 98 ].
The ADA recommends avoiding metformin in patients with hypertension, preeclampsia, or at risk for intrauterine growth restriction due to the potential for growth restriction or acidosis in the setting of placental insufficiency [ 24,92 ]; however, any clinical impact of this effect has not been observed in human pregnancies.
The American College of Obstetricians and Gynecologists ACOG and the Society for Maternal-Fetal Medicine do not include this caveat in their recommendations. Glyburide — Starting doses of 2.
Twice-daily dosing is often necessary to maintain glucose levels in the target range. One group that investigated glyburide pharmacokinetics in pregnancy suggested pregnant patients take the drug 30 to 60 minutes before a meal, rather than with the meal, to improve efficacy [ 99 ].
In this study, plasma glyburide concentrations in pregnant patients with GDM did not increase until one hour after drug ingestion, peaked at two to three hours, and returned to baseline by 8 to 10 hours. Thus, the drug took longer to reach peak concentration and was metabolized more rapidly than in nonpregnant females.
Maternal hypoglycemia is the most common side effect, and the risk was higher than that in patients with GDM using insulin in a large trial Patients who fail to achieve glycemic control with oral pharmacotherapy — If oral pharmacotherapy alone does not adequately manage glucose levels, supplemental insulin can be prescribed and may be easier for the patient than switching to a multidose insulin only regimen.
In contrast to nonpregnant patients, dual use of oral agents eg, metformin plus glyburide is not recommended in pregnancy because of minimal safety and efficacy data [ 88 ] and concerns about adverse fetal effects since both drugs cross the placenta.
See "Pregestational preexisting and gestational diabetes: Intrapartum and postpartum glucose management". See "Gestational diabetes mellitus: Obstetric issues and management".
MATERNAL PROGNOSIS — Most patients with GDM are normoglycemic after giving birth. However, they are at high risk for recurrent GDM and developing prediabetes impaired glucose tolerance or impaired fasting glucose or overt diabetes over the subsequent five years.
Optimum interpregnancy care to minimize these risks has not been well-studied in randomized trials [ ]. Feasibility trials of a web-based lifestyle intervention and a telephone-based intervention reported less postpartum weight retention in patients with GDM assigned to the intervention, suggesting this type of behavioral intervention may have a favorable impact [ , ].
Recurrence — GDM in one pregnancy is a strong predictor of recurrence in a subsequent pregnancy [ ]. In a study including over 65, pregnancies, the frequency of GDM in the second pregnancy among patients with and without previous GDM was 41 and 4 percent, respectively [ ]. Risk factors for recurrence include high birth weight in the index pregnancy, older maternal age, high parity, high prepregnancy weight, and high weight between pregnancies [ , ].
Long-term risk — A history of GDM is predictive of an increased risk of developing type 2 diabetes, metabolic syndrome, cardiovascular disease CVD , and even type 1 diabetes. These risks appear to be particularly high in patients with both GDM and a hypertensive disorder of pregnancy [ ].
GDM has been called a "marker," "stress test," or "window" for future diabetes and CVD; it is not considered causal. The RR was 17 within the first five years after delivery and approximately 10 after that. The lifetime maternal risk for diabetes has been estimated to be as high as 50 to 60 percent [ , ].
Waist circumference and body mass index BMI are the strongest anthropometric measures associated with development of type 2 diabetes in patients with GDM [ 61, ], as they are in those without GDM.
Other major risk factors are gestational requirement for insulin and early gestational age at the time of diagnosis ie, less than 24 weeks of gestation [ ].
Additional risk factors for impaired glucose tolerance and overt diabetes later in life include autoantibodies eg, glutamic acid decarboxylase, insulinoma antigen-2 , high-fasting blood glucose concentrations during pregnancy and early postpartum, higher-fasting plasma glucose at diagnosis of GDM and high glucose levels in the GTT, the number of abnormal values on the glucose tolerance test, neonatal hypoglycemia, and GDM in more than one pregnancy [ 61,,,, ].
In one study, an additional pregnancy increased the rate ratio of type 2 diabetes threefold compared with individuals without an additional pregnancy RR 3. The authors hypothesized that repeated episodes of insulin resistance contribute to the decline in beta-cell function that leads to type 2 diabetes in many high-risk individuals.
Parity, large birth weight, and diabetes in a first-degree relative are less correlated with later diabetes. Specific human leukocyte antigen HLA alleles DR3 or DR4 may predispose to the development of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies [ ] or antibodies against glutamic acid decarboxylase or insulinoma antigen 2.
GDM in lean pregnant people, need for insulin treatment of GDM, diabetic ketoacidosis during pregnancy, and postpartum hyperglycemia also suggest preexisting unrecognized type 1 diabetes or high risk of developing type 1 diabetes [ ].
Although testing for antibodies is not routinely recommended, it is important for clinicians to be aware of this association. Distinguishing type 1 from type 2 diabetes, and monogenic forms of diabetes eg, maturity-onset diabetes of the young [MODY] from type 1 and type 2 diabetes, is reviewed in detail elsewhere.
See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults", section on 'Differentiating the cause' and "Classification of diabetes mellitus and genetic diabetic syndromes".
In one study of patients with mild GDM ie, normal fasting glucose level on glucose tolerance test [GTT] , approximately one-third developed metabolic syndrome within 5 to 10 years after giving birth [ ].
Even mild glucose impairment defined as an abnormal 50 g one-hour GTT followed by a normal g three-hour GTT appears to identify individuals at increased risk of future development of CVD, usually myocardial infarction or stroke [ ].
In these studies, the increased risk was related to development of type 2 diabetes later in life. More recent data demonstrate that the increased risk of CVD in patients with a prior history of GDM may be independent of the development of type 2 diabetes.
Meta-regression analysis showed that the rates of incident type 2 diabetes across the studies did not affect this risk and when individuals with type 2 diabetes were excluded, GDM was still associated with an increased risk of future CVD RR 1. The increased mortality risk was primarily due to CVD 0.
Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended for individuals with GDM, given their high risk for developing the disorder [ 24,43 ]. GTT — A common approach is to order a GTT to be performed 4 to 12 weeks after giving birth, using the 75 g GTT, as recommended by the American Diabetes Association ADA [ 24 ].
Criteria for diagnosis of diabetes and prediabetes are shown in the tables table 2A-B. Suboptimal adherence has been attributed to not ordering the test, lack of patient follow-up for postpartum care, patient burden associated with a fasting and a two-hour laboratory procedure, and patient difficulty with childcare [ ].
There is increasing evidence that performing the test while the patient is still hospitalized after birth increases adherence to nearly percent and provides reliable results [ , ].
At one year postpartum, the A1C was consistent with impaired glucose metabolism in 35 percent and diabetes in 4 percent of individuals tested. Fasting glucose — A fasting plasma glucose level is a reasonable alternative to the GTT but does not allow for diagnosis of impaired glucose tolerance.
A glycated hemoglobin A1C can be performed in patients in whom obtaining a fasting specimen is especially inconvenient but performs less well for diagnosis of diabetes or prediabetes in postpartum patients because of increased peripartum red cell turnover [ ].
See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults", section on 'Diagnostic tests'. They should have yearly assessment of glycemic status.
Approaches to prevention of type 2 diabetes are reviewed in detail separately. See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults", section on 'Prediabetes' and "Prevention of type 2 diabetes mellitus".
Higher intensity and longer duration of breastfeeding during the first two years postpartum is associated with a reduced risk of developing type 2 diabetes in observational studies. See "Gestational diabetes mellitus: Obstetric issues and management", section on 'Breastfeeding'.
They should also be given advice regarding contraception and the planning of future pregnancies, especially the importance of good glycemic management prior to conception. See "Overview of general medical care in nonpregnant adults with diabetes mellitus" and "Pregestational preexisting diabetes: Preconception counseling, evaluation, and management".
See 'Recurrence' above and 'Long-term risk' above. Lifestyle interventions are beneficial for reducing the incidence of type 2 diabetes in persons with prediabetes [ ] and these interventions diet and exercise, achieving a normal body mass index, avoiding smoking and excessive alcohol intake also appear to be beneficial in patients with a history of GDM, whether or not they meet criteria for prediabetes [ ].
The annual incidence of diabetes may be reduced by 30 to 50 percent or more compared with no intervention [ , ]. Pharmacotherapy eg, metformin , pioglitazone may also have a role in preventing future type 2 diabetes. In a multicenter randomized trial, both intensive lifestyle and metformin therapy reduced the incidence of future diabetes by approximately 50 percent compared with placebo in patients with a history of GDM; metformin was much more effective than lifestyle intervention in parous patients with previous GDM [ ].
This topic is discussed in detail separately. See "Prevention of type 2 diabetes mellitus". Reassessment of glycemic status should be undertaken at a minimum of every three years eg, every one to three years [ 24 ]. More frequent assessment may be important in patients who may become pregnant again, since early detection of diabetes is important to preconception and early prenatal care.
More frequent screening every one or two years may also be indicated in patients with other risk factors for diabetes, such as family history of diabetes, obesity, and need for pharmacotherapy during pregnancy. The best means of follow-up testing has not been defined. The two-hour 75 g oral GTT is the more sensitive test for diagnosis of diabetes and impaired glucose tolerance in most populations, but the fasting plasma glucose is more convenient, specific, and reproducible, and less expensive.
A1C is convenient and the preferred test for patients who have not fasted overnight. See "Screening for type 2 diabetes mellitus", section on 'Screening tests'.
See "Overview of primary prevention of cardiovascular disease". Follow-up of patients not screened for GDM — For patients who did not undergo screening for GDM, but diabetes is suspected postpartum because of newborn outcome eg, hypoglycemia, macrosomia, congenital anomalies , a postpartum GTT may be considered.
A normal postpartum GTT excludes the presence of type 1 or type 2 diabetes or prediabetes; it does not exclude the possibility of GDM during pregnancy and the future risks associated with this diagnosis. Indications for screening and tests used for screening are discussed separately. See "Screening for type 2 diabetes mellitus".
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
See "Society guideline links: Diabetes mellitus in pregnancy". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.
We suggest glucose self-monitoring before breakfast and at one or at two hours after the beginning of each meal. See 'Glucose monitoring' above. See 'Can the frequency of self-monitoring be reduced? Moderate exercise also improves glycemic control and should be part of the treatment plan for patients with no medical or obstetric contraindications to this level of physical activity.
See 'Rationale for treatment' above and 'Exercise' above. Calories are generally divided over three meals and two to four snacks per day and are composed of approximately 40 percent carbohydrate, 20 percent protein, and 40 percent fat.
Gestational weight gain recommendations are shown in the table table 1. See 'Medical nutritional therapy' above. Pharmacotherapy can reduce the occurrence of macrosomia and large for gestational age in newborns.
See 'Indications for pharmacotherapy' above. We start with the simplest insulin regimen likely to be effective based on the glucose levels recorded in the patient's blood glucose log and increase the complexity as needed. An alternative approach based on both patient weight and glucose levels is somewhat more complex and likely most appropriate for individuals whose glucose levels are not well managed with simpler paradigms.
See 'Insulin' above. The long-term effects of transplacental passage of noninsulin antihyperglycemic agents are not known. See 'Oral hypoglycemic agents' above. Testing can be performed while the patient is still in the hospital after giving birth.
Otherwise it is performed 4 to 12 weeks postpartum and, if results are normal, at least every three years thereafter.
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Select the option that best describes you. View Topic. Font Size Small Normal Large. Gestational diabetes mellitus: Glucose management and maternal prognosis. Formulary drug information for this topic.
No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Celeste Durnwald, MD Section Editors: David M Nathan, MD Erika F Werner, MD, MS Deputy Editor: Vanessa A Barss, MD, FACOG Contributor Disclosures.
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Nov 16, There were no significant maternal or neonatal harms from treatment of GDM.
Insulin Dose — The insulin dose required to achieve target glucose levels varies among individuals, but the majority of studies have reported a total dose ranging from 0.
Follow-up Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended for individuals with GDM, given their high risk for developing the disorder [ 24,43 ]. Electronic address: pubs smfm. SMFM Statement: Pharmacological treatment of gestational diabetes.
Am J Obstet Gynecol ; B2. Catalano PM, McIntyre HD, Cruickshank JK, et al. The hyperglycemia and adverse pregnancy outcome study: associations of GDM and obesity with pregnancy outcomes.
Diabetes Care ; Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med ; HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes.
Han S, Crowther CA, Middleton P. Interventions for pregnant women with hyperglycaemia not meeting gestational diabetes and type 2 diabetes diagnostic criteria.
Cochrane Database Syst Rev ; 1:CD Durnwald CP, Mele L, Spong CY, et al. Glycemic characteristics and neonatal outcomes of women treated for mild gestational diabetes. Obstet Gynecol ; Uvena-Celebrezze J, Fung C, Thomas AJ, et al. Relationship of neonatal body composition to maternal glucose control in women with gestational diabetes mellitus.
J Matern Fetal Neonatal Med ;
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: Gestational diabetes and postpartum care| Postnatal care in gestational diabetes - including further glucose screening - GPnotebook | Comparing the efficacy and safety of insulin Joint health performance dizbetes neutral protamine hagedorn insulin in Gestationnal of diabetes during pregnancy: a randomized, postpqrtum study. Dabetes Joint health performance ; Traditionally, restricting carbohydrate intake particularly simple carbohydrates has been favored because it appears to reduce postprandial hyperglycemia [ 19 ] and fetal overgrowth [ 20,21 ]. Metformin is not associated with hypoglycemia. See 'Maternal prognosis' above. If type 1 diabetes is suspected and confirmed 14insulin therapy is reinstituted. |
| Gestational Diabetes and Postpartum Depression | J Am Diet Assoc. A meal plan should be based on the person's schedule, food preferences, cultural choices, and blood sugar levels. Prevalence and timing of postpartum glucose testing and sustained glucose dysregulation after gestational diabetes mellitus. Kramer CK, Campbell S, Retnakaran R. American Diabetes Association. If you think you have depression, seek treatment as soon as possible. |
| Gestational Diabetes After Delivery | Diabetes Care | American Diabetes Association | Pastore I, Chiefari E, Vero R, et al. Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes — São Paulo, A. C farmacêutica. Buchanan TA, Xiang A, Kjos SL, Lee WP, Trigo E, Nader I, et al. Gestational diabetes: antepartum characteristics that predict postpartum glucose intolerance and type 2 diabetes in Latino women. Ratner RE. Prevention of type 2 diabetes in women with previous gestational diabetes. Weinert LS, Mastella LS, Oppermann ML, Silveiro SP, Guimarães LS, Reichelt AJ. Postpartum glucose tolerance status 6—12 weeks after gestational diabetes mellitus: a Brazilian cohort. Arq Bras Endocrinol Metab. Lawrence JM, Black MH, Hsu JW, Chen W, Sacks DA. Prevalence and timing of postpartum glucose testing and sustained glucose dysregulation after gestational diabetes mellitus. Tovar A, Chasan-Taber L, Eggleston E, Oken E. Postpartum screening for diabetes among women with a history of gestational diabetes mellitus. Prev Chronic Dis. PubMed PubMed Central Google Scholar. Hunt KJ, Conway DL. Who returns for postpartum glucose screening following gestational diabetes mellitus? Am J Obstet Gynecol. Ferrara A, Peng T, Kim C. Trends in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus: a report from the Translating Research Into Action for Diabetes TRIAD Study. Kerimoğlu OS, Yalvac S, Karcaaltincaba D, Kandemir O, Altınbaş SK, Dede H. Early post-partum diabetes mellitus screening rates in patients with his-tory of gestational diabetes. Stasenko M, Cheng YW, McLean T, Jelin AC, Rand L, Caughey AB. Postpartum follow-up for women with gestational diabetes mellitus. Am J Perinatol. Ogonowski J, Miazgowski T. The prevalence of 6 weeks postpartum abnormal glucose tolerance in Caucasian women with gestational diabetes. Almario CV, Ecker T, Moroz LA, Bucovetsky L, Berghella V, Baxter JK. Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes. International Association of Diabetes and Pregnancy Study Groups. Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. McCloskey L, Bernstein J, Winter M, Iverson R, Lee-Parritz A. Follow-up of gestational diabetes mellitus in an urban safety net hospital: missed opportunities to launch preventive care for women. J Womens Health. McGovern A, Butler L, Jones S, van Vlymen J, Sadek K, Munro N. Diabetes screening after gestational diabetes in England: a quantitative retrospective cohort study. Br J Gen Pract. Dietz PM, Vesco KK, Callaghan WM, Bachman DJ, Bruce FC, Berg CJ, et al. Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy. Obstet Gynecol. Vesco KK, Dietz PM, Bulkley J, Bruce FC, Callaghan WM, England L, et al. A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes. Clark HD, Graham ID, Karovitch A, Keely EJ. Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Shea AK, Shah BR, Clark HD, Malcom J, WalkerM Karovitch A, et al. The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes. Chronic Dis Can. CAS PubMed Google Scholar. Bernstein JA, McCloskey L, Gebel CM, Iverson RE, Lee-Parritz A. Lost opportunities to prevent early onset type 2 diabetes mellitus after a pregnancy complicated by gestational diabetes. BMJ Open Diabetes Res Care. Van Ryswyk EM, Middleton PF, Hague WM, Crowther CA. Aroda VR, Cristophi CA, Edelstein SL, Zhang P, Herman WH, Barret-Connor E, et al. The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program Outcomes Study 10 year followup. Download references. CAC: elaboration of the data bank, data collection, statistical analyses and article writing. RCAA: elaboration of the data bank, data collection and article writing. MBG: statistical analyses and article writing. PSR; JVM; TFLRC; ASNS; ALS; CAGM; HDS; ESGS; FOB: elaboration of the data bank, data collection. All authors read and approved the final manuscript. The trial was approved by the Ethics Committe of Hospital Universitário Pedro Ernesto—Rio de Janeiro. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil. Cabizuca, P. Rocha, J. Marques, T. Costa, A. Santos, A. Schröder, C. Mello, H. Sousa, E. Silva, F. Braga, R. You can also search for this author in PubMed Google Scholar. Correspondence to C. Open Access This article is distributed under the terms of the Creative Commons Attribution 4. Reprints and permissions. Cabizuca, C. et al. Postpartum follow up of gestational diabetes in a Tertiary Care Center. Diabetol Metab Syndr 10 , 2 Download citation. Received : 21 November Accepted : 20 December Published : 03 January Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Research Open access Published: 03 January Postpartum follow up of gestational diabetes in a Tertiary Care Center C. Cabizuca 1 , 2 , P. Rocha 1 , J. Marques 1 , T. While their rates of follow-up are higher than those with no diabetes diagnosis, they are lower than those with preexisting type 2 diabetes and significantly below the recommendation for universal follow-up. Overall, patients with GD had a RR of 0. Even once connected with primary care, there were low rates of diabetes-related care for patients with GD. There were also disparities in postpartum diabetes-related follow-up for patients living in super rural areas; to our knowledge, this is the first study to document rural disparities in postpartum diabetes follow-up in the US. Early follow-up of GD may help to prevent or detect type 2 diabetes earlier, allow opportunities for promotion of improving cardiovascular health, and prevent the significant morbidity related to uncontrolled diabetes. As GD prevalence increases, it is critical we determine how to increase follow-up rates. Another important and novel element of our data is that, of patients with GD who did receive blood glucose testing, the majority received hemoglobin A 1c in the first 12 weeks post partum, which is not an appropriate test in the immediate postpartum period. This may lead to patients with continued insulin resistance being missed due to the significant short-term glycemic changes as well as blood turnover associated with delivery. This suggests a lack of understanding on appropriate follow-up of pregnancy complications for primary care physicians, as hemoglobin A 1c is a common diabetes screen in other clinical settings. These rates may be remedied by raising awareness among primary care practitioners about the appropriate follow-up of GD. Postpartum follow-up has multiple challenges. It is often unclear which clinician, obstetrics or primary care, should be responsible for ensuring follow-up of pregnancy complications like GD. Primary care physicians may be less familiar with recommendations for surveillance of GD, especially because oral glucose tolerance tests are not widely used in other clinical situations. However, primary care physicians are uniquely suited to provide longitudinal care for patients outside of pregnancy and are often familiar with chronic care models that can provide systematic support. There are promising care models to help improve GD follow-up. Maternal-infant dyad clinics—with a joint encounter for parent and infant—have been shown to increase GD follow-up and appropriate screening. Patient contact with a health educator, via phone or mail, has also been shown to increase follow-up blood glucose testing. There were several limitations to this study. As this is based on insurance claims of patients with continuous private insurance enrollment, the follow-up rates of patients covered by public insurance eg, Medicaid or who are uninsured are not known. Our data would also not capture any blood glucose testing or follow-up that was not billed for or coded incorrectly. This study cannot comment on racial or socioeconomic disparities beyond rurality given the deidentified nature of the database, limiting the understanding of other inequities in follow-up rates. Further studies are needed to characterize follow-up in these patient populations. Previous data have shown worsened glycemic control among pregnant people with higher social vulnerability, 30 raising concern for potential inequity. This cohort study demonstrated concerningly low rates of postpartum engagement in what is, to our knowledge, the largest study of primary care follow-up in GD to date. A paradigm shift in how we view GD, not as an acute issue that resolves with birth but as a chronic disease process and independent cardiovascular risk factor, is necessary to ensure appropriate care of patients with GD. Further research is needed to characterize which patients are at the highest risk for not receiving appropriate postpartum follow-up, as well as identifying barriers to post-GD primary care transitions, to further target interventions. Published: February 6, Open Access: This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. Author Contributions: Ms Dalmacy and Mr Hyer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Acquisition, analysis, or interpretation of data: Dalmacy, Akinduro, Hyer, Mao, Fareed, Bose-Brill. Critical revision of the manuscript for important intellectual content: All authors. Administrative, technical, or material support: Thung, Mao, Fareed, Bose-Brill. Conflict of Interest Disclosures: None reported. Data Sharing Statement: See Supplement 2. full text icon Full Text. Download PDF Comment. Top of Article Key Points Abstract Introduction Methods Results Discussion Conclusions Article Information References. Flow Diagram of Participant Selection. View Large Download. HTD indicates hypertensive disorders of pregnancy; HTN, hypertension. Table 1. Characteristics of Sample and Proportions of Primary Care Follow-up. Table 2. Characteristics of Sample and Proportions of Diabetes-Related Care. Table 3. Characteristics of Sample and Proportions of Diabetes-Related Care Among Primary Care Follow-up. Table 4. Adjusted Relative Risk Among Women With a Diabetes or Gestational Diabetes Diagnosis Who Had at Least 1 Outpatient Follow-up. Supplement 1. Supplement 2. Data Sharing Statement. US Centers for Disease Control and Prevention. Gestational Diabetes. Updated August 10, Accessed April 30, Shah NS, Wang MC, Freaney PM, et al. Trends in gestational diabetes at first live birth by race and ethnicity in the US, doi: Dugan JA, Ma Crawford J. Managing gestational diabetes. e0 PubMed Google Scholar Crossref. Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, Gillies CL. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. m PubMed Google Scholar Crossref. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Kramer CK, Campbell S, Retnakaran R. Gestational diabetes and the risk of cardiovascular disease in women: a systematic review and meta-analysis. Geissler K, Ranchoff BL, Cooper MI, Attanasio LB. Association of insurance status with provision of recommended services during comprehensive postpartum visits. Thayer SM, Lo JO, Caughey AB. Gestational diabetes: importance of follow-up screening for the benefit of long-term health. American College of Obstetricians and Gynecologists. Interpregnancy Care. Published online January Accessed September 8, Pregnancy and Reproductive Health. Gestational Diabetes and Postpartum Care Gestational Diabetes Mellitus GDM is diagnosed only during pregnancy. Useful links. Find a Diabetes Program in Your Area. Diabetes Self-Management Education and Support DHCS - Diabetes Prevention Program. Data and Reports. Helpful Resources. |
| Gestational Diabetes and Pregnancy | Poprzeczny AJ, Louise J, Deussen AR, Dodd JM. Cochrane Database Syst Rev ; 1:CD All estimates derived from multivariable log-binomial regression models utilized a maximum likelihood model estimation and the Kenward-Roger method for computing denominator degrees of freedom. The distribution of postpartum glucose abnormalities in the BMI categories of the represented ethnic groups is presented in Table 4. Learn more about Diabetes Self-Management Education and Support Services. American Diabetes Association Professional Practice Committee. |
Contributor Disclosures. Csre read the Poetpartum at the end Hydration and growth and development in youth athletes this page. Many patients ahd achieve glucose target levels Gestational diabetes and postpartum care nutritional therapy siabetes moderate exercise alone, but up to 30 percent will Gestafional Gestational diabetes and postpartum care [ 1 ]. Even patients with mildly elevated glucose levels who do not meet standard criteria for GDM may have more favorable pregnancy outcomes if treated since the relationship between glucose levels and adverse pregnancy outcomes such as macrosomia exists continuously across the spectrum of increasing glucose levels [ ]. Glucose management in patients with GDM is reviewed here. Screening, diagnosis, and obstetric management are discussed separately.
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