Primary Care Department, Touro University California connie.ha@tu.edu
Dr. Shubrook reported serving as a consultant or advisor to Abbott, AstraZeneca, Bayer, Lilly, and Novo Nordisk. The other authors reported no potential conflict of interest relevant to this article.
Noninsulin agents, such as metformin and sulfonylureas, are not currently recommended by ACOG or the ADA for use in GDM.
Also, if you work in an area where specialists are less accessible, you may be the clinician providing the majority of care to a patient with GDM. If this is the case, you’ll want to watch for the following risk factors, which should prompt a referral to specialty care:
a previous pregnancy with GDM20
a previous birth of an infant weighing > 4000 g44
baseline history of hypertension45
evidence of insulin resistance or polycystic ovary syndrome46,47
a history of cardiovascular disease20
a need to treat GDM with pharmacotherapy.48
Ensuring a smooth transition after the birth
Optimal communication and hand-offs throughout pregnancy and after delivery will benefit everyone. When the pregnant patient’s care has been managed by an obstetrician, it is important to address the following issues during the hand-off:
baseline medical problems
medical screenings and treatments in pregnancy (retinopathy and nephropathy screening)
aspirin initiation, if indicated
management of thyroid abnormalities
management of mental health conditions
postpartum glucose management and T2D screening postpartum
management of complications identified during pregnancy (retinopathy and nephropathy).
Timing and other elements of postpartum care.The first postpartum screen should occur at 4 to 12 weeks postpartum. OGTT is recommended instead of A1C at this time because A1C may still be lowered by the increased red blood cell turnover related to pregnancy and blood loss at delivery. Because women with GDM have a 50% to 75% lifetime risk of T2D,20 patients with normal test results should be re-tested every 1 to 3 years using any of the standard screening methods (A1C, fasting glucose, or OGTT).20
Postpartum visits present another opportunity to screen for diabetes and other postpartum complications, including depression and thyroid abnormalities.
After delivery it may be difficult for women to follow-up with their own personal health care because they are focused on the care of their baby. The increased use of telehealth may make postpartum follow-up visits easier to attend.
Visits present opportunities.Postpartum visits present another opportunity for PCPs to screen for diabetes and other postpartum complications, including depression and thyroid abnormalities. Visits are also an opportunity to discuss timely contraception so as to prevent an early, unplanned pregnancy. Other important aspects of postpartum care are outlined in TABLE 2.20,49
CORRESPONDENCE Connie L. Ha, BS, OMS IV, Department of Primary Care, 1310 Club Drive, Touro University California, Vallejo, CA 94592; connie.ha@tu.edu
