For gestational diabetes, check prior status
Address contraception at each visit
Your new patient is a young mother of three. When you quiz her on complications incurred in her prior pregnancies, she discloses she was diagnosed with gestational diabetes mellitus (GDM) in the last pregnancy. What is your approach when it comes to family planning counseling for her?
GDM is a condition in which hyperglycemia occurs or is first recognized during pregnancy. It is associated with complications for the mother and baby during and after pregnancy. During pregnancy, women with GDM are at an increased risk of developing pre-eclampsia, having a caesarean birth, and developing type 2 diabetes in the future. Babies born to women with GDM are at an increased risk of macrosomia (birthweight greater than 4,000 g), birth trauma due to their size, respiratory distress syndrome, and other health complications.1Research indicates in utero exposure to hyperglycemia has long-lasting effects on the infant, increasing the risk of future obesity and type 2 diabetes mellitus.2
While gestational diabetes mellitus typically resolves after birth, women with the condition are at risk of developing it again in future pregnancies. It is critical to address contraception at each interconception visit with women with prior gestational diabetes, according to a new review on the subject.3Women with prior gestational diabetes mellitus must be counseled that GDM in one pregnancy not only increases the risk for the condition in further pregnancies, particularly in nonwhite women, but also that pregnancy might accelerate the rate of beta cell exhaustion and subsequent development of diabetes mellitus.4-6
Women who become diabetic during an interconception interval are at risk for unplanned pregnancy during periods of maternal hyperglycemia, the review article states. Women with a history of GDM must be monitored for manifestations of increasing insulin resistance, hyperglycemia, dyslipidemia, hypertension, and increased adiposity.3
Clinicians need to be strategic in thinking with patients with a prior history of GDM, says Ruth Mielke, PhD, RN, CNM, assistant professor in the School of Nursing at California State University, Fullerton and staff nurse midwife at Eisner Pediatric and Family Medical Center in Los Angeles. Use every visit — whether it’s for a weight check, a blood pressure check, or another reason — to review the patient’s contraceptive choices and ensure it is correctly and consistently used, says Mielke, who served as lead author of the current review article.
Program your electronic medical records to highlight history of GDM in the chronic diseases listing so it appears when the chart is reviewed, she suggests. If using traditional paper charting, use color coding to denote charts of patients with a GDM history, Mielke advises.
Postpartum care is key
Although the carbohydrate intolerance of women with GDM frequently resolves after delivery, it is estimated that up to one-third of affected women will have diabetes or impaired glucose metabolism at postpartum screening, and 15-50% will develop type 2 diabetes later in life.7-12According to a new GDM practice bulletin issued by the American College of Obstetricians and Gynecologists, either a fasting plasma glucose test or the 75-g, two-hour oral glucose tolerance test are appropriate for diagnosing overt diabetes in the postpartum period.13Although the fasting plasma glucose test is easier to perform, it is not as sensitive in teasing out other forms of abnormal glucose metabolism. Results of an oral glucose tolerance test can better detect impaired fasting glucose level and impaired glucose tolerance.13
Women in the postpartum period with impaired fasting glucose, impaired glucose tolerance, or diabetes should be referred for therapy. Women with impaired conditions might respond to lifestyle modification and pharmacologic interventions to decrease development of diabetes later in life. Repeat testing should be done at least every three years for women who had a pregnancy affected by GDM and who register normal results in postpartum screening.13Women with prior GDM who possess additional risk factors, such as obesity or family history of diabetes, should be tested annually. Lifestyle modifications that are effective in preventing and delaying development of diabetes should be encouraged.
Look at LARC methods
A general principle to remember when discussing birth control options with women following a pregnancy complicated by GDM is that another pregnancy would be significantly more hazardous for the woman than any contraceptive method, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.
Long-acting reversible contraceptive (LARC) methods, such as intrauterine contraception and the contraceptive implant, are good options for women with prior GDM, notes Mielke. They offer top-tier effectiveness and allow women to return to fertility when they are ready to have more children, she notes. With their set-it-and-forget-it’ convenience, LARC methods are a good fit for active young mothers.
For women with prior GDM, the U.S. Medical Eligibility Criteria for Contraceptive Use lists all contraceptive methods — combined and progestin-only pills, intrauterine devices, as well as the contraceptive ring, patch, injection, and implant— as "no restriction" or Category One.14
"With this as a foundation, contraception for women with prior GDM must be further tailored with each woman’s risk profile in mind (e.g. age, body mass index, cardiovascular risk)," states the review article.
- Tieu J, Bain E, Middleton P, et al. Interconception care for women with a history of gestational diabetes for improving maternal and infant outcomes. Cochrane Database Syst Rev 2013, 6:CD010211.
- Patel S, Fraser A, Davey Smith G, et al. Associations of gestational diabetes, existing diabetes, and glycosuria with offspring obesity and cardiometabolic outcomes. Diabetes Care 2012; 35(1):63-71.
- Mielke RT, Kaiser D, Centuolo R. Interconception care for women with prior gestational diabetes mellitus. J Midwifery Womens Health 2013; 58(3):303-312.
- Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25(10):1,862-1,868.
- Peters RK, Kjos SL, Xiang A, et al. Long-term diabetogenic effect of single pregnancy in women with previous gestational diabetes mellitus. Lancet 1996; 347(8996):227-230.
- Xiang AH, Kjos SL, Takayanagi M, Trigo E, et al. Detailed physiological characterization of the development of type 2 diabetes in Hispanic women with prior gestational diabetes mellitus. Diabetes 2010; 59(10):2,625-2,630.
- Kaaja RJ, Greer IA. Manifestations of chronic disease during pregnancy. JAMA 2005; 294:2,751-2,757.
- Buchanan TA, Xiang AH. Gestational diabetes mellitus. J Clin Invest 2005;115:48591.
- Russell MA, Phipps MG, Olson CL, et al. Rates of postpartum glucose testing after gestational diabetes mellitus. Obstet Gynecol 2006; 108:1,456-1,462.
- Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25:1,862-1,868.
- Chodick G, Elchalal U, Sella T, et al. The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study. Diabet Med 2010; 27:779-785.
- American College of Obstetricians and Gynecologists. Practice bulletin no. 137: gestational diabetes mellitus. Obstet Gynecol 2013; 122( 2) Pt 1:406-416.
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.