Although it is usually managed by an endocrinologist or perinatologist, an experienced obstetrician could also manage GDM. Often, the patient is referred to an endocrinologist. The endocrine provider, along with the diabetes educator and RD, focus on nutrition counseling and diabetes management so the obstetrician can focus on maternal and fetal health.
Q: What is the recommended follow-up?
Since embryonic and fetal development occurs at such a rapid rate, time is of the essence for getting a patient’s blood glucose to goal. While treating diabetes in general can be challenging, this is usually not the case with GDM. Most women with GDM are motivated to take care of themselves for the well-being of their developing baby. The influence of a baby developing inside a mother is so strong that diabetic women who become pregnant often take better care of themselves than they do when they are not pregnant.
The patient’s daily responsibilities should include eating a healthy and diet checking her blood glucose levels throughout the day. These readings must be recorded. Clinic visits should occur often, with emailing of glucose readings between visits as needed. The frequency of visits varies among practices, depending on the patient’s level of glucose control and intensity of the treatment regimen.
Q: Why is postpartum testing important?
After delivery, most cases of GDM usually resolve. However, approximately 5% to 10% of women with gestational diabetes are found to have diabetes immediately after pregnancy.2 To evaluate for persistent diabetes, a two-hour GTT should be done at six weeks’ postpartum. Although an A1C can now be used to diagnose diabetes, the ADA does not recommend checking it for this purpose.3
If the two-hour GTT result is normal, a woman should be screened for diabetes every three years for the rest of her life.3 If a diagnosis of impaired fasting glucose or impaired glucose tolerance is made, then she should be tested for diabetes on an annual basis or in the interim if she develops classic symptoms of hyperglycemia.3 If diabetes is diagnosed, she should be treated accordingly as a type 2 diabetic patient.
At this time, the patient should be counseled on lifestyle interventions and consider starting metformin therapy if appropriate. Diabetes education classes are available for prediabetes. To maintain good health and prevent/delay onset of type 2 diabetes, here are some tips to follow:
• The same diet as during pregnancy does not have to be followed, although healthy eating habits are always a good idea.
• Physical activity (approximately 30 min five times a week) will help shed weight gained during pregnancy.
• Breastfeeding promotes weight loss.10
• Patients should aim for weight loss of 7% of body weight.3
• Continue annual physical exams, keeping an eye on blood pressure, weight, and cholesterol levels.
It’s reasonable for the patient to check glucose levels occasionally after delivery. If elevated readings occur, the patient can make an appointment with her primary care provider or endocrinologist.
References
1. American Association for Clinical Chemistry. A New Definition of Gestational Diabetes. www.aacc.org/publications/cln/2010/may/Pages/CoverStory2May2010.aspx. Accessed June 30, 2013.
2. National Diabetes Statistics, 2011. www.diabetes.niddk.nih.gov/dm/pubs/statistics/#Gestational. Accessed July 22, 2013.
3. American Diabetes Association. 2012 Clinical Practice Recommendations. Diabetes Care. 2012;35(suppl 1). http://professional.diabetes.org/SlideLibrary/media/4839/ADA%20Standards%20of%20Medical%20Care%202012%20FINAL.ppt. Accessed June 24, 2013.
4. American Diabetes Association. Diabetes basics: your risk. www.diabetes.org/diabetes-basics/prevention/risk-factors. Accessed August 13, 2013.
5. American Diabetes Association. Diabetes Basics: What is Gestational Diabetes? www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html. Accessed August 13, 2013.
6. Johnson K. New criteria for gestational diabetes increase diagnoses (December 5, 2011). www.medscape.com/viewarticle/754733. Accessed August 13, 2013.
7. American Diabetes Association. Diabetes basics: how to treat gestational diabetes. www.diabetes.org/diabetes-basics/gestational/how-to-treat-gestational.html. Accessed August 13, 2013.
8. Moore TR. Glyburide for the treatment of gestational diabetes: a critical appraisal. Diabetes Care. 2007;30(suppl 2). http://care.diabetesjournals.org/content/30/Supplement_2/S209.full. Accessed August 13, 2013.
9. Lowes R. Levemir assigned more reassuring pregnancy risk category (April 2, 2012). www.medscape.com/viewarticle/761349. Accessed August 13, 2013.
10. Buchanan TA, Xiang AH, Page KA. Gestational diabetes mellitus: risks and management during and after pregnancy. Nat Rev Endocrinol. 2012;8(11):639-649.