Recurrent Gestational Diabetes: Risk Factors, Diagnosis, Management, and Implications

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Gestational diabetes mellitus (GDM) should be regarded as a sentinel event in a woman’s life that presents challenges and disease prevention opportunities to all providers of health care for women of reproductive age. Prediabetic risk factors are rising in prevalence and include dietary and lifestyle habits, which when superimposed on genetic predisposition contribute to the rising prevalence of type 2 diabetes and GDM. There is growing evidence that treatment of GDM matters, with a continuum of adverse pregnancy outcome risks proportional to degrees of maternal glucose intolerance. GDM in an index pregnancy increases the risk of recurrent GDM in subsequent pregnancies, and recurrence rates of up to 70% have been reported. GDM recurrence rates are influenced by maternal health characteristics and past pregnancy history. The risk of later metabolic syndrome and type 2 diabetes is increased in women with a history of GDM and women should be screened for postpartum glucose intolerance. Opportunities to prevent recurrent GDM and later type 2 diabetes require attention to risk factors and plasma glucose status with identification of impaired fasting glucose or impaired glucose tolerance.

Section snippets

The Epidemiology of Gestational Diabetes Recurrence

Given that most of the risk factors for GDM persist or become worse in subsequent pregnancies, it is not surprising that GDM has a high recurrence rate of 35.6% to 70%. The fact that a wide range of recurrence rates have been reported in various studies is, in part, due to the variability of GDM screening methods and the use of different diagnostic threshold values for various glucose tolerance tests. It is clear from the literature, however, that a diagnosis of GDM confers an elevated risk of

Increasing Prevalence of Pre-Diabetic Risk Factors in the United States

Since GDM may very well be a “tip of the iceberg” phenomenon for many women, it is important to consider the epidemiologic landscape affecting the first occurrence of GDM as well as the risks for recurrent GDM in subsequent pregnancies and the longer term risk of type 2 diabetes.

Excessive weight is an important public health concern in the United States, as well as other affluent societies. Pleis and coworkers11 reported that, by the end of 2000, 34% of adult Americans were overweight and

United States Diabetes Prevalence: Diagnosed and Undiagnosed

National estimates on diabetes prevalence have been published by the Centers for Disease Control and Prevention (CDC) in Atlanta.16 The total prevalence of frank diabetes mellitus among women age 20 years or older in the United States in 2005 was 9.7 million, or 8.8% of all women in this age group. The prevalence of diabetes by race and ethnicity among people 20 years of age or older in the United States in 2005 was an estimated 8.7% prevalence for all non-Hispanic whites, 13.3% for

Diagnosis of GDM

GDM is a condition that lacks international consensus concerning the method of choice for screening and specific criteria for diagnosis. The Fourth International Workshop-Conference on Gestational Diabetes in 1998 recommended a screening strategy based on risk assessment for detecting gestational diabetes and that risk assessment for GDM should be undertaken at the first prenatal visit.7 Women can then be classified as either low-risk, average-risk, or high-risk. High-risk women should be

Gestational Diabetes Management, General and Recurrent

Despite the debate over screening strategies, there is a clear association between maternal carbohydrate intolerance and perinatal complications. The rates of excessive fetal growth and neonatal morbidity rise with the degree of maternal hyperglycemia. The Toronto Tri-Hospital Gestational Diabetes Project was a prospective study on the impact of increasing maternal carbohydrate intolerance on both maternal and fetal outcomes.20 Women with GDM were compared with a cohort of 3637 women with

Prevention of Gestational Diabetes Recurrence

There are limited data examining interventions to prevent recurrence of GDM. Medication interventions to prevent GDM have been studied in women with polycystic ovary syndrome (PCOS). Affected women are characteristically obese, have insulin resistance and hyperinsulinemia, all of which are risk factors for primary (and probably recurrent) GDM.26, 27 Metformin increases insulin sensitivity and reduces insulin resistance. It has been found to be a safe and effective treatment for the metabolic

Contribution of GDM to Glucose Tolerance Status

There is epidemiologic evidence associating GDM with insulin resistance, glucose intolerance, and type 2 diabetes.29 The development of overt diabetes mellitus appears to require an associated defect in insulin secretion. There may be a finite level of pancreatic “beta cell reserve” that is further depleted with recurring GDM. Insulin resistance is another significant factor for many women who eventually develop GDM.

Verma and coworkers30 examined the prevalence of the insulin resistance

Postpartum and Long-Term Management after Gestational Diabetes

The definition of GDM encompasses a fairly wide spectrum of disease. The degree of glucose intolerance and the time of onset varies, ranging from transient mild hyperglycemia limited to pregnancy to unrecognized pregestational diabetes to pregestational metabolic syndrome (insulin resistance) with or without features of PCOS. Although data are lacking, it is likely that women with GDM who were most likely to have had unrecognized pregestational diabetes in their index pregnancy include: those

Diabetes Prevention in Women with Previous GDM

The TRIPOD study demonstrated that the drug troglitazone improved glucose tolerance after GDM in high-risk Hispanic women.36 Treatment with troglitizone delayed or prevented the onset of type 2 diabetes in treated women compared with controls, with a 55% reduction in the average annual diabetes incidence rates over a median follow-up period of 30 months. The proposed mechanism of this protective effect was the preservation of pancreatic beta cell function which appeared to be mediated by a

Future Direction

The concept of gestational diabetes mellitus being an issue only for obstetricians and gynecologists needs to be replaced with the idea that GDM is a “tip of the iceberg” phenomenon. GDM is often the culmination of years of unrecognized and unmodified diabetes risk factors that lead to overt and occult clinical manifestations during pregnancy. It is clear that an index case of gestational diabetes increases the risks of not only recurrent gestational diabetes in subsequent pregnancies, but also

Acknowledgments

The author would like to express his gratitude to Naomi Spina for her expert assistance in the preparation of this manuscript and John Smulian, MD, MPH, for his valuable editorial contributions.

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