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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Diabetes In Pregnancy Series
Sponsored by The Indian Health Service Clinical Support Center
PART 2: Management, delivery, and postpartum
10. Long term management
Having GDM can be seen as “a red flag” that may help to encourage the patient to make or maintain the necessary life style changes that may delay or prevent the onset of overt disease. This may be the most important public health measure we perform when taking care of women with this entity.
Kim et al performed meta-analysis on a total of 28 studies. After the index pregnancy, the cumulative incidence of diabetes ranged from 2.6% to over 70% in studies that examined women 6 weeks postpartum to 28 years postpartum. Conversion of GDM to type 2 diabetes varies with the length of follow-up and cohort retention. Adjustment for these differences reveals rapid increases in the cumulative incidence occurring in the first 5 years after delivery for different racial groups. Targeting women with elevated fasting glucose levels during pregnancy may prove to have the greatest effect for the effort required.
The most sensitive test for use at the six-week postpartum visit is the 75 g 2-hour OGTT, but a fasting plasma glucose (FPG) can be diagnostic and may be logistically easier. Outside of pregnancy the laboratory criteria for the diagnosis of DM are:
Normoglycemia |
Impaired Fasting Glucose (IFG)/ Impaired Glucose Tolerance (IGT) |
Overt Diabetes |
FPG<100 mg/dL |
FPG ³100-125
mg/dL |
FPG³126
mg/dL |
2-hr PG<140 mg/dL |
2-hr PG ³140-199
mg/dL |
2-hr PG³200
mg/dL |
These values would need to be repeated on a subsequent day to confirm the diagnosis.
The postpartum visit may also be a good time to discuss preconception issues if another pregnancy is planned in the future. Glucose control should be the best possible before conception (FBS<100, 2-hr PPG<140, normal hemoglobin A1C), in order to minimize the risk of congenital malformations, and folic acid 1 mg daily should be taken for the same reason.
Pettitt 1994 et al showed the long-term effects on offspring of abnormal glucose tolerance detected during pregnancy were examined in 552 Pima Indian offspring 5-24 yr of age. Fasting hyperinsulinemia, presumably reflecting increased insulin resistance, occurred at an earlier age in the offspring of women who had abnormal glucose tolerance during pregnancy, and these offspring were more obese and had higher rates of abnormal glucose tolerance. When confounding factors were controlled, a 1 mM higher 2-h postload glucose concentration during pregnancy resulted in a significantly higher prevalence of diabetes in the offspring (odds ratio = 162). Maternal 2-h glucose concentration during pregnancy was also a significant predictor of glucose concentration during pregnancy in the offspring (P = 0.011). Thus, the metabolic abnormalities associated with the diabetic pregnancy result in long-term effects on the offspring, including insulin resistance, obesity, and diabetes, which in turn may contribute to transmission of risk for developing the same problems in the next generation.
