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One of the most common complications of pregnancy is gestational diabetes mellitus (GDM), which is seen in about 7% of all pregnancies in the U.S.1 Even when the disease fully resolves at the end of the pregnancy, clinicians should remain vigilant. Women with GDM have a 45% risk of recurrence with the next pregnancy and up to 63% risk of developing type 2 diabetes later in life.2
"Just having a diagnosis of GDM increases your risk for developing adult-onset diabetes as you age," says Sandra Sulik, MD, associate professor of family practice at Upstate Medical Center in Syracuse, N.Y. "The more pregnancies you have with GDM, the greater the risk for type 2 diabetes. The risk approaches 100% if you have three such pregnancies. This increasing risk makes it very important for the family practice physician to closely follow these patients for the rest of their lives."
POSTPARTUM GDM TREATMENT
To address these concerns, the American Diabetes Association (ADA) and others have included postpartum follow-up in their general guidelines for finding and treating GDM.1 The guidelines suggest that maternal glycemic status should be re-evaluated at least 6 weeks following delivery. If glucose levels are normal at this time, then retesting should occur at no more than 3-year intervals.
Two tests are commonly used in women who've had GDM. One is the fasting plasma glucose (FPG) test. The other is a 2-hour oral glucose tolerance test that looks at glucose levels 2 hours after the patient is given a 75-g glucose load. Those with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) should be tested annually (see table, "Criteria for Diagnosing IFG, IGT, and Diabetes").
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For the most part, the test used reflects physician preference. However, the FPG usually is used because it is easier to administer, more convenient and acceptable for the patients, and much less costly.
"Although the ADA guidelines say differently, as a family physician I would seriously consider doing an annual screening in these patients as part of the yearly health check-up," says Sagi Mathew, MD, assistant professor of family medicine at the Indiana University School of Medicine in Indianapolis. "In those patients with IGT or IFG, testing annually is definitely needed."
MANAGING TYPE 2 RISK FACTORS
General practice clinicians also should remember that the other risk factors for type 2 diabetes remain important considerations, especially when glucose levels return to normal following the pregnancy. Family history, obesity, hypertension, hypercholesterolemia, inactivity, and cardiovascular disease need to be assessed often in these women.
Certain indicators are associated with an increase in the risk of progressing to overt type 2 diabetes within 5 years. Among these are development of GDM before the 24th week of pregnancy, plasma glucose levels remaining at the high end of normal, elevated glucose levels postpartum, IGT, obesity, or a family history of diabetes.3
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"A very big issue is patient understanding and willingness to do their part to manage risk factors," Mathew says. "The primary care doctor can stress the importance of diet, exercise, and smoking cessation to help the woman understand the benefits, which makes it much easier to get folks to do the things they need to do."
As with other forms of diabetes, interventions can be undertaken to prevent the development of full-blown diabetes. The ADA guidelines suggest educating all women with GDM about lifestyle modifications that lessen insulin resistance.
"Just about any time a patient appears in the office is a good time to do counseling and teaching," Sulik says. "Even if she is seen for a sore throat or other problem, reinforce the need for diet and exercise and take a minute to ask about the symptoms of diabetes."
Medical nutrition therapy should include information about adequate calories and nutrients to maintain normal body weight. Physical activity is also very important.
"Daily exercise is something that should be stressed at every opportunity," says Jorge H. Mestman, MD, director of the Center for Diabetes and Metabolic Diseases at the Keck School of Medicine, University of Southern California in Los Angeles. "Even walking for 45 minutes 5 days a week can have an impact on the risk for diabetes."
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The primary care provider is in a unique position to counsel women with GDM, experts agree. Diet and exercise teaching can be done whenever a woman sees her provider for any reason. The annual check-up is a convenient time to perform glucose testing. Check-ups are also good opportunities to assess the woman for symptoms suggesting hypoglycemia and to do patient teaching to make sure she understands when she should seek medical attention should these symptoms develop.
In addition, the primary care clinician should be aware of emerging indications that children born to women with GDM also may be at increased risk for diabetes later in life.4 Currently the guidelines do not give specific guidance other than to closely follow the offspring of women with GDM for development of obesity and abnormalities of glucose intolerance.
"We emphasize to the primary care physician that GDM is not a benign
disease," Mestman says. "They have a unique opportunity to prevent
diabetes because they see these patients very early in the game when exercise,
diet, and normalizing weight can delay or possibly even prevent the onset of
diabetes." 
After GDM: Between Delivery and the Next Conception
The presence of gestational diabetes mellitus (GDM) in an earlier pregnancy greatly increases the likelihood of recurrence in subsequent pregnancies. When a GDM pregnancy ends, patients and providers should begin efforts to prevent GDM and mitigate damage that could occur to the fetus during the next pregnancy.
"If lifestyle changes in nutrition and exercise are not instituted in the interim, the chances are very high that GDM will occur with the next pregnancy," says Raul Artal, MD, professor and chair of the department of obstetrics, gynecology, and women's health at St. Louis University School of Medicine in Missouri. "This can result in multiple complications, including increased risk for fetal malformation and neonatal complications."
The primary care physician can play an important part in preventing these complications by thoroughly counseling women during health check-ups and other visits between delivery and the next conception. Maintaining normal blood glucose levels during this time can go a long way toward lessening problems should the woman get pregnant again.
"The most deleterious period to the fetus is the first 5 to 8 weeks following conception," Artal notes. "Elevated blood glucose levels at that time can result in significant congenital malformation. Thus, the glucose status of the woman is important even before conception."
For women who are contemplating having another child, Artal suggests immediate testing of fasting glucose levels to assess current status. In addition, glycated hemoglobin (A1C) testing should be considered to calculate longer-term response. If these results are normal, the pregnancy can safely begin or continue.
In those who have abnormal results, stabilization of glucose levels prior to conception should be the goal. Diet and oral hypoglycemic agents should be considered, in Artal's judgment. He recommends swift referral to an obstetrician who specializes in high-risk pregnancy to look for possible malformations and to closely track fetal development.
"The key words in these patients are `optimal control,'" Artal says. "It is always best to work to prevent disease from occurring."
References
2. Beckles GL, Thompson-Reid PE (Eds.): Diabetes and Women's Health Across the Life Stages: A Public Health Perspective. Atlanta, Centers for Disease Control and Prevention, 2001.
3. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 26 (Suppl. 1): S5–S20, 2003.
4. Goran MI, Bergman RN, Avila Q, et al.: Impaired glucose tolerance
and reduced beta-cell function in overweight Latino children with a positive
family history for type 2 diabetes. J Clin Endocrinol
Metab 89:207–212, 2004.
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