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Gestational diabetes (GDM) has been on the rise in the last decade. This has been occurring due to the aging population of women having children (over age 25), increasing ethnic populations, increasing obesity, infertility treatments, etc. Pregnancy is a good test of a women’s ability to deal with an insulin resistant state. Pregnancy requires a women to triple her insulin production. Most women can do this and the other 6% are diagnosed with GDM.

A history of gestational diabetes signals an increased risk of developing type 2 diabetes. Type 2 diabetes will be diagnosed in approximately 60% of these women over the next 15-20 years. But having gestational diabetes does not mean a woman will necessarily have diabetes. These women and their health care providers should work together so that she is regularly screened, evaluated, treated as necessary and encouraged to make positive lifestyle choices.

Approximately 1/3 of these women will have abnormal lipid profiles. The current thought is that this is the early manifestation of the metabolic syndrome. For women that demonstrate these tendencies towards the metabolic syndrome lifestyle modifications are essential to delay or deter complications.

Of the group of women that had GDM studies have estimated that 10% may have polycystic ovary syndrome (PCOS). One of the hall marks of PCOS is the insulin resistance associated with this condition.

Insulin resistance and abnormal insulin levels are classic markers for both, the metabolic syndrome and PCOS. We recommend prevention and early intervention.

Women that had very elevated, early diagnosis during pregnancy, or required large insulin dosages, are encouraged to test their blood glucoses at home. Normal glucose control should be maintained since hyperglycemia can adversely affect a woman’s ability to breastfeed and heal.

Screening for type 2 diabetes or Glucose Intolerance (IGT), is done with a 75 gm oral glucose tolerance test. It is given six weeks or more after delivery. the rates of abnormalities postpartum are approximately 4-5 percent will have overt diabetes and another 15 percent will be diagnosed with IGT in the first year. If the test is negative, testing annually to every 3 years is recommended.

A lipid panel is recommended at five months postpartum or after the cessation of breast-feeding. Approximately one third of the women with GDM will have elevated lipid panels and therefore an increased risk of cardiovascular disease. If possible, it is useful to pass the laboratory data on to primary care providers so long-term care and follow-up will occur. Some of these women may already have a form Syndrome X characterized by abnormal lipid profiles and glucose intolerance. The abnormal lipid profile appears before a diagnosis of type 2 diabetes.

Weight Control has the greatest effect on the future development of type 2 diabetes. Women are encouraged to aim for their ideal body weight, but any weight loss is encouraged when appropriate. Weight loss of five to ten pounds will increase their glucose tolerance and thereby decrease their risk for diabetes.

A few studies have shown that a diet, which is higher in fat, especially animal source fat, are associated with an earlier diagnosis of diabetes in comparison to low fat diets. Polyunsaturated fats appear to be neutral. Monounsaturated are either neutral or potentially beneficial. There was also a lower reoccurrence of GDM in the low fat group. There was also a lower reoccurrence of GDM in the low fat group.

Breastfeeding is strongly recommended. In my practice, we see 4% with overt diabetes breastfeeding verses 9 % if they bottle feed. Lipid profiles are also better with breastfeeding. Many women utilize breastfeeding to assist with losing weight. It actually takes 500 more calories to breast feed per day then being pregnant. Weight loss of up to 4 1/2 lbs per month is recommended. A quicker weight loss may impact the woman’s breast milk production.

Breastfeeding for at least three months after delivery, in the Pima Indian and Finish studies, resulted in offspring which were leaner, and had less diabetes and/or a later onset of diabetes than those who were formula-fed.

Weaning often is a point that many women are at risk to gain weight. Women should be instructed to cut calories, when weaning, to prevent this unexpected weight gain.

Exercise is the next tool for women with a history of GDM to prevent diabetes. We recommend that these women exercise for 30 minutes per day, 5 days per week. This is based on the lifestyle verses metformin studies that demonstrated a 58% decrease in the diabetes incidence with exercise. Exercise also helps women attain and maintain their ideal body weight, increase their sensitivity to insulin and therefore decrease the overall risk for diabetes.

Women with a history of GDM that are planning another pregnancy should be screened with a 75 Gram Oral Glucose Tolerance test before attempting a pregnancy. If they have developed Type 2 diabetes between pregnancies their baby is at risk for birth defects.

Reoccurrence of GDM in future pregnancies is 35-67%. Any woman that had GDM should be screened early (as soon as possible) and again at the regular time of 24-28 weeks, if she was negative.

Subsequent pregnancies increase the risk of diabetes. Many women do not lose their pregnancy weight between pregnancies. This increases her risk for type 2 diabetes. Another theory is that the increased stress of numerous pregnancies burns out the beta cells quicker then in women who lose their pregnancy weight and have fewer pregnancies.

We recommend all of our women leave the hospital with a birth control method. Breastfeeding is not birth control as many clients believe.

BIRTH CONTROL

Method	Failure Rate	Effect on women with Hx of GDM	Considerations and recommendations
Natural family planning	14-47%	None	Client and Significant other must be: · Motivated · Willing to abstain from vaginal intercourse during fertile time · Woman should have regular menses
Barrier methods: Male condom, Female condom, Diaphragm, Cervical cap and Spermicidal	Up to 18-28%	None	Recommend for: · Motivated · Compulsive about correct use and use each time Consider for both male and female condoms provides increased protection from HIV and STD (sexually transmitted disease)
Intrauterine Device (IUD) Progesterone –T, Paragaurd (copper T 380A)	2% 0.8%	Metabolically neutral	Same criteria as general population. Preferable choice with monogamous women. Potential for pelvic inflammatory disease rare (1.6 cases per 1000 women years). Studies do not show benefit of prophylaxis on insertion or removal.
Low dose combination contraceptives (OC) (<0.05 mg of ethinyl estraliol or mestranol),	0-1%	Monitor fasting every 3-4 months. May cause minimal deterioration of glucose tolerance so lowest doses should be utilized.	Non-smoking Use lowest dose and potency to minimize deterioration of glucose tolerance. Before starting: · Baseline weight, · blood pressure · glucose pre and post prandial · fasting lipids After first cycle and every 3-4 months monitor: weight, blood pressure, and glycemic control. Must be taken at same time daily. May use 6-8 weeks after postpartum and after milk supply is established
Lunelle (monthly injectable) Ortho Evra (patch) Nuvaring (vaginal ring)	<1% 1-5% 1-5%	Potential vaginal irritation and/or infection	Breastfeeding not recommended with Nuvaring ring, Lunelle and Ortho Evra. All methods with lower blood levels of active hormones noted then with combination BCP.
Progestin only oral contraceptives also known as the mini pill or POP	0.5%	May cause deterioration of CHO intolerance Not recommended for women with previous GDM.	Not recommended for women with previous GDM or type 2 , and not currently taking insulin or oral hypoglycemics. Recommended for woman with contraindications to estrogen component of oral contraception
Long-acting progestin: Depoprovera (depo) Norplant	0.3% 0.09%	May cause deterioration of CHO intolerance Both methods associated with weight gain. Depo has a stronger association.	Depoprovera may cause deterioration of carbohydrate tolerance No deterioration with norplant has been noted Norplant may be recommended for women with compliance issues. Use same long term monitoring as OC
Tubal ligation	0.2-0.4%	No long-term effects	Risk associated with surgical procedure including possible infection, bleeding, temporary pain or soreness in the abdomen and anesthesia risk. This is considered permanent, irreversible procedure. Women or couples who are undecided about having children in the future should NOT chose this as a method.
Vasectomy (male sterilization)	0.2-0.4%	None	This is considered permanent, irreversible procedure. Couples or men who are undecided about having children in the future should NOT chose this as a method.

Adapted with permission from the California Sweet Success Guidelines for Care 2002.

The last area is stress. Stressors that decrease glucose tolerance should be avoided when possible. This includes medications and herbs, illness, social and environmental changes and so on. When unable to avoid stress women should be encouraged to learn how to manage stress.