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

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

Joseph N. Bottalico, DO

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. Semin Perinatol 31:176-184 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS gestational diabetes, recurrence, diabetes mellitus-type 2, diabetes risk factors, prevention, metabolic syndrome, preconception care

G an increased incidence of GDM. It is thus becoming more

estational diabetes mellitus (GDM) is defined as any

degree of glucose intolerance with onset or first recog- common to care for women who have had a previous preg- nition during pregnancy. The definition of GDM does not

nancy complicated by GDM.

preclude the possibility that unrecognized glucose intoler- ance may have existed before the pregnancy, and the defini- tion applies whether insulin, oral antidiabetic agents, or di-

The Epidemiology of

etary modification is used for treatment. Approximately 7%

Gestational Diabetes Recurrence

of all pregnancies in the United States are complicated by gestational diabetes resulting in more than 200,000 cases

Given that most of the risk factors for GDM persist or become annually, 1 but the prevalence ranges from 1% to 14% of all

worse in subsequent pregnancies, it is not surprising that pregnancies depending on the population studied and the

GDM has a high recurrence rate of 35.6% to 70%. The fact diagnostic tests employed.

that a wide range of recurrence rates have been reported in Gestational diabetes is often considered to be type 2 dia-

various studies is, in part, due to the variability of GDM betes unmasked by pregnancy. The two entities share com-

screening methods and the use of different diagnostic thresh- mon risk factors, a number of which are increasing in prev-

old values for various glucose tolerance tests. It is clear from alence, such as obesity and advancing maternal age. These

the literature, however, that a diagnosis of GDM confers an factors, combined with more universal screening, have led to

elevated risk of recurrent GDM in subsequent pregnancies in addition to an increased risk of later type 2 diabetes mellitus. Table 1 summarizes studies reporting rates of recurrence for

Division of Maternal Fetal Medicine, Department of Obstetrics and Gyne-

GDM.

cology, UMDNJ-School of Osteopathic Medicine, Stratford, NJ.

Philipson and Super 2 examined the recurrence of glucose

Address reprint requests to Joseph N. Bottalico, DO, Department of Obstet- rics and Gynecology, Division of Maternal Fetal Medicine, UMDNJ-

intolerance in 36 women with an index pregnancy compli-

School of Osteopathic Medicine, University Doctors Pavilion-Suite

cated by GDM. Oral or intravenous glucose tolerance tests

3500, 42 East Laurel Road, Stratford, NJ 08084-1504. E-mail: bottaljn

were used to document glucose intolerance or gestational

@umdnj.edu

diabetes. They reported that 55% (20 of 36) of women de-

176 0146-0005/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.

doi:10.1053/j.semperi.2007.03.006

Recurrent gestational diabetes 177

Table 1 Summary of Literature on Recurrence of Gestational Diabetes Including Diagnostic Criteria, Risk Factors, and Outcomes

Author Complications (Country-

Risk Factors for with Year)

Diagnostic Criteria

-BMI > 30 kg/m 2 -More large for USA-1999

Philipson 2 1979-1987 100 g OGTT (C/C criteria) or

IVGTT (25-28 weeks)

-Obesity

gestational age births

-More macrosomia Gaudier 3 1983-1990

50 g screen (>135 mg/dl) @

24-28 weeks. If screen ⴙ,

-Insulin required in

100 g OGTT (105/190/165/

index pregnancy

-Previous baby > 4kg Foster-Powell 9 1990-1996

145 mg/dl)

75 g 2-hour OGTT (100/180/

70% (82/117) -Maternal age

Australia-

145 mg/dl)

-Insulin required in

index pregnancy -Pre-pregnancy BMI -Weight gain between

pregnancies

68% (111/164) -Earlier GDM in index -Higher birth USA-1998

Spong 4 1988-1992

50 g screen (>140 mg/dl) @

24-26 weeks. If screen ⴙ,

pregnancy

weight

100g OGTT (105/190/165/

-Insulin required in

-More infants

145 mg/dl)

>4kg -Hospital admission in

index pregnancy