Now you've had baby, has your diabetes gone?

blood testGestational diabetes increases your risk of developing type 2 diabetes after the pregnancy. Statistics from Diabetes UK state that there is a seven-fold increased risk in women with gestational diabetes developing type 2 diabetes in later life. NICE state that up to 50% of women diagnosed with gestational diabetes develop type 2 diabetes within 5 years of the birth.

A 2002 publication from Diabetes Care comparing 28 studies found that elevated fasting levels during pregnancy was the most common risk factor associated with future risk of type 2 diabetes:

Cumulative incidence of type 2 diabetes increased markedly in the first 5 years after delivery and appeared to plateau after 10 years. An elevated fasting glucose level during pregnancy was the risk factor most commonly associated with future risk of type 2 diabetes.

Post birth diabetes testing

It is recommended that you should have a fasting glucose blood test at 6 weeks post-partum OR a HbA1c blood test after 13 weeks post-partum to check that you are clear of diabetes.

It is no longer recommended that a repeat GTT is performed to check that the diabetes is clear (NICE guidelines Feb 2015).  However it may still be offered in Scotland and Ireland or in hospitals which are not following the NICE recommendations.

Many ladies have concerns over taking a fasting glucose test whilst breast feeding, or attending for blood tests whilst their newborn is still very young.  If you have these concerns then you may want to opt for a HbA1c blood test after 13 weeks post-partum. You do not need to fast and it is one simple blood test that can be taken at your local GP surgery.

 

warning2High levels after giving birth

You should eat a normal diet following the birth of your baby. Some hospitals will advise to continue testing blood sugar levels after giving birth. Be prepared that you may see some high readings if you do this. It can take a while for your hormones to settle, hence the reasoning behind the recommendation of being properly tested for diabetes after at least 6 weeks.

If you feel unwell or experience hypo or hyper type symptoms then you should test your blood sugar levels and consult a medical professional.

 

Test results

The World Health Organization (WHO) advises that the range of blood glucose indicative of diabetes mellitus is as follows:

  • fasting venous plasma glucose (FPG) ≥7.0 mmol/l; or venous plasma glucose ≥11.1 mmol/l at two hours after a 75 g oral glucose load (oral glucose tolerance test (OGTT)).
  • HbA1c of 48 mmol/mol (6.5%) is recommended as the cut-off point for diagnosing diabetes

 

Below you will find 3 guidelines

  1. NICE guidelines for England & Wales
  2. SIGN guidelines for Scotland
  3. HSE guidelines for Ireland

 

NICE guidelines for England & Wales

Information and follow-up after birth

Women diagnosed with gestational diabetes

1.6.8 Test blood glucose in women who were diagnosed with gestational diabetes to exclude persisting hyperglycaemia before they are transferred to community care. [2008]

1.6.9 Remind women who were diagnosed with gestational diabetes of the symptoms of hyperglycaemia. [2008]

1.6.10 Explain to women who were diagnosed with gestational diabetes about the risks of gestational diabetes in future pregnancies, and offer them testing for diabetes[10] when planning future pregnancies. [2008, amended 2015]

1.6.11 For women who were diagnosed with gestational diabetes and whose blood glucose levels returned to normal after the birth:

  • Offer lifestyle advice (including weight control, diet and exercise).
  • Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude diabetes (for practical reasons this might take place at the 6‑week postnatal check).
  • If a fasting plasma glucose test has not been performed by 13 weeks, offer afasting plasma glucose test, or an HbA1c test if a fasting plasma glucose test is not possible, after 13 weeks.
  • Do not routinely offer a 75 g 2‑hour OGTT. [new 2015]

 

Test results

1.6.12For women having a fasting plasma glucose test as the postnatal test:

  • Advise women with a fasting plasma glucose level below 6.0 mmol/litre that:
    • they have a low probability of having diabetes at present
    • they should continue to follow the lifestyle advice (including weight control, diet and exercise) given after the birth
    • they will need an annual test to check that their blood glucose levels are normal
    • they have a moderate risk of developing type 2 diabetes, and offer them advice and guidance in line with the NICE guideline on preventing type 2 diabetes[11].
  • Advise women with a fasting plasma glucose level between 6.0 and 6.9 mmol/litre that they are at high risk of developing type 2 diabetes, and offer them advice, guidance and interventions in line with the NICE guideline onpreventing type 2 diabetes[11].
  • Advise women with a fasting plasma glucose level of 7.0 mmol/litre or above that they are likely to have type 2 diabetes, and offer them a diagnostic test to confirm diabetes. [new 2015]

1.6.13 For women having an HbA1c test as the postnatal test:

  • Advise women with an HbA1c level below 39 mmol/mol (5.7%) that:
    • they have a low probability of having diabetes at present
    • they should continue to follow the lifestyle advice (including weight control, diet and exercise) given after the birth
    • they will need an annual test to check that their blood glucose levels are normal
    • they have a moderate risk of developing type 2 diabetes, and offer them advice and guidance in line with the NICE guideline on preventing type 2 diabetes[11].
  • Advise women with an HbA1c level between 39 and 47 mmol/mol (5.7% and 6.4%) that they are at high risk of developing type 2 diabetes, and offer them advice, guidance and interventions in line with the NICE guideline onpreventing type 2 diabetes[11].
  • Advise women with an HbA1c level of 48 mmol/mol (6.5%) or above that they have type 2 diabetes and refer them for further care. [new 2015]

Yearly testing

1.6.14Offer an annual HbA1c test to women who were diagnosed with gestational diabetes who have a negative postnatal test for diabetes. [new 2015]

 

Future pregnancies

1.6.15Offer women who were diagnosed with gestational diabetes early self‑monitoring of blood glucose or an OGTT in future pregnancies. Offer a subsequent OGTT if the first OGTT results in early pregnancy are normal (see recommendation 1.2.6).[2008, amended 2015]

NICE guidelines, recommendations for postnatal care following GDM

 

SIGN guidelines for Scotland

7.12 Follow up of women with GDM A diagnosis of GDM identifies women at increased risk of developing type 2 diabetes in future. Rates of progression to type 2 diabetes in women with previous GDM vary widely (between 15 and 50% cumulative incidence at five years) and will be influenced by other risk factors such as ethnicity, obesity, and exercise. A Cochrane review concluded that diet combined with exercise or diet alone enhances weight loss post-partum. Both pharmacological and intensive lifestyle interventions reduce onset of type 2 diabetes in people with impaired glucose tolerance, including women with previous gestational diabetes. No robust evidence was identified to determine when follow-up testing should be carried out. C Women who have developed GDM should be given diet, weight control and exercise advice. Women who have developed GDM should be reminded of the need for pre-conception counselling and appropriate testing to detect progression to type 2 diabetes;

  • Where diabetes is not apparent immediately after delivery, glucose tolerance should be reassessed at least six weeks postpartum with a minimum of fasting glucose and with 75 g OGTT if clinically indicated.
  • An annual assessment of glycaemia using fasting glucose or HbA1c should be carried out thereafter.

The World Health Organization (WHO) advises that the range of blood glucose indicative of diabetes mellitus is as follows:

  • fasting venous plasma glucose (FPG) ≥7.0 mmol/l; or venous plasma glucose ≥11.1 mmol/l at two hours after a 75 g oral glucose load (oral glucose tolerance test (OGTT)).
  • HbA1c of 48 mmol/mol (6.5%) is recommended as the cut-off point for diagnosing diabetes

SIGN GUIDELINES - Management of diabetes 116 (section 7.12)

 

HSE guidelines for Ireland

5.5 Postnatal Care

5.5.1 Blood glucose monitoring in the postnatal period

● Once the placenta is delivered, maternal blood glucose and insulin levels may rapidly return to normal.

● Insulin therapy should be discontinued immediately postpartum.

● SMBG should be discontinued once blood glucose returns to normal levels.

● Overt diabetes should be suspected and investigated if hyperglycaemia persists .

● A 75g OGTT, using the WHO criteria for the non-pregnant population should be performed at 6 weeks postpartum and yearly thereafter

 

WHO recommendations for the diagnostic criteria for diabetes and intermediate hyperglycaemia in the non pregnant population:

Diabetes diagnosis:

Fasting plasma glucose ≥7.0mmol/l or 2hr plasma glucose* ≥11.1mmol/l

Impaired Glucose Tolerance (IGT) diagnosis:

Fasting plasma glucose

Impaired Fasting Glucose (IFG) diagnosis:

Fasting plasma glucose 6.1 to 6.9mmol/l  or 2hr plasma glucose*

HSE GUIDELINES - Guidelines for the Management of Pre-gestational and Gestational Diabetes Mellitus from Pre-conception to the Postnatal period 

 

Annual testing

It is advised to be tested annually for diabetes following gestational diabetes with a HbA1c blood test. Type 2 diabetes is when your body either does not produce enough insulin, or the body’s cells do not react to the insulin causing insulin resistance.

Knowing the risk factor of being diagnosed with type 2 diabetes later in life is higher, it is advisable to look and dietary and lifestyle choices which could impact and lessen your chances of being diagnosed.

We very rarely see ladies being diagnosed as type 1 diabetics following gestational diabetes, but gestational diabetes may be the flagstone for testing for type 1 diabetes.

 

Complications later in life for your baby

As a result of gestational diabetes, your baby has a sixfold increase in risk of developing diabetes and has a higher risk of obesity (having a body mass index of more than 30) later in life.

Future pregnancies

Jo's iPhone summer 2014 069After having gestational diabetes, you are at increased risk of having gestational diabetes in any future pregnancies. It's very important to speak to your GP if you are planning another pregnancy or when you fall pregnant. They may arrange for you to monitor your own blood glucose from the early stages.  Some hospitals will assume that you have gestational diabetes in a subsequent pregnancy and will treat you as such from the start.  Other hospitals will get you to perform an earlier GTT (glucose tolerance test), this is commonly around 16 weeks. Following a negative GTT, a repeat GTT is usually offered.

It is well established that women with a single gestational diabetes pregnancy are at risk for gestational diabetes in their future pregnancies. Among women receiving antenatal care in one health system and who had at least two pregnancies (n = 65 132) [19], women with gestational diabetes in their first pregnancy had a 41% risk of gestational diabetes in their second pregnancy, compared with 4% among women without gestational diabetes in their first pregnancy. Among women who had three pregnancies (n = 13 096), 57% of women who had gestational diabetes in their first two pregnancies also had gestational diabetes in their third pregnancy [19]. These prevalences are similar to those reported in another health system, which noted that, among women with a gestational diabetes pregnancy, 38% had gestational diabetes in a subsequent pregnancy compared with 3.5% among women without gestational diabetes in their first pregnancy [20].

Maternal outcomes and follow-up after gestational diabetes mellitus

Research

Maternal outcomes and follow-up after gestational diabetes mellitus

In a meta-analysis of 20 reports [21], women with gestational diabetes had a sevenfold increased risk of diabetes compared with women without gestational diabetes (relative risk 7.43, 95% CI 4.79–11.51).

While weight gain between pregnancies and at the subsequent pregnancy were inconsistently associated with gestational diabetes risk in older reports [38], more recent reports suggest that maternal weight gain in between pregnancies might play a larger role in gestational diabetes recurrence, perhaps because of the steady increase in maternal pre-conception BMI over the past decade [17]. In one recent examination of 22 351 women, women had a significant increase in their odds of gestational diabetes in their subsequent pregnancy with each unit of BMI gained between pregnancies [20]. Specifically, women who gained 1–1.9 kg/m2 had a 1.7 increased odds of future gestational diabetes; women who gained 2.0–2.9 kg/m2 had a 2.5 increased odds and women who gained over 3 kg/m2 had a 3.4 increased odds [20]. While less than 10% of women lost weight between pregnancies, women who were overweight or obese at their index pregnancy, but who then lost weight (approximately 2.0 kg/m2) significantly lowered their risk of future gestational diabetes by almost 80% (odds ratio 0.26, 95% CI 0.14–0.47). Of note, women who were not overweight at their index gestational diabetes pregnancy, but lost weight after their index pregnancy, did not significantly reduce their odds of future gestational diabetes. This suggests that attributable risk for gestational diabetes attributable to weight was low in these women, and that weight loss may not be an ideal target for intervention in this subpopulation [20].

for every 1 kg increase in pre-pregnancy weight, there was a 40% increase in odds of developing Type 2 diabetes

Gestational Diabetes and the Incidence of Type 2 Diabetes - A systematic review

Long-Term Health Outcomes in Offspring Born to Women with Diabetes in Pregnancy

A low disposition index in adolescent offspring of mothers with gestational diabetes: a risk marker for the development of impaired glucose tolerance in youth

Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies.

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Post birth diabetes testing