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Gestational diabetes mellitus: risks and management during and after pregnancy

Abstract

Gestational diabetes mellitus (GDM) carries a small but potentially important risk of adverse perinatal outcomes and a long-term risk of obesity and glucose intolerance in offspring. Mothers with GDM have an excess of hypertensive disorders during pregnancy and a high risk of developing diabetes mellitus thereafter. Diagnosing and treating GDM can reduce perinatal complications, but only a small fraction of pregnancies benefit. Nutritional management is the cornerstone of treatment; insulin, glyburide and metformin can be used to intensify treatment. Fetal measurements complement maternal glucose monitoring in the identification of pregnancies that require such intensification. Glucose testing shortly after delivery can stratify the short-term diabetes risk in mothers. Thereafter, annual glucose and HbA1c testing can detect deteriorating glycaemic control, a harbinger of future diabetes mellitus, usually type 2 diabetes mellitus. Interventions that mitigate obesity or its metabolic effects are most potent in preventing or delaying diabetes mellitus. Lifestyle modification is the primary approach; use of medications for diabetes prevention after GDM remains controversial. Family planning enables optimization of health in subsequent pregnancies. Breastfeeding may reduce obesity in children and is recommended. Families should be encouraged to help children adopt lifestyles that reduce the risk of obesity.

Key Points

  • Gestational diabetes mellitus (GDM) is caused by reduced pancreatic β-cell function, which results from the full spectrum of causes of β-cell dysfunction in young women

  • GDM is associated with a modest increase in adverse perinatal outcomes, an increased risk of obesity in offspring and a high risk of subsequent development of diabetes mellitus in mothers

  • GDM is treated nutritionally; insulin or oral antidiabetic agents can be added if maternal glucose levels and/or fetal growth parameters indicate a sufficiently high risk of perinatal complications

  • Long-term management of mothers includes assessment of the level and type of diabetes risk, and lifestyle and/or pharmacological approaches for women at risk of type 2 diabetes mellitus

  • Long-term management of offspring should focus on detection and mitigation of the development of obesity and its complications

  • A great need exists for high-quality clinical evidence to determine optimal approaches for the management of GDM during and after pregnancy

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Figure 1: Insulin sensitivity–secretion relationships during the third trimester and after pregnancy in Hispanic women with GDM (n = 99) and age-matched and BMI-matched Hispanic women with normal glucose tolerance (n = 7).
Figure 2: Suggested management of women with prior gestational diabetes mellitus when risk appears to be for T2DM.

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T. A. Buchanan researched data, wrote and reviewed and/or edited the article before submission. A. H. Xiang and K. A. Page provided a substantial contribution to discussions of the content, wrote and reviewed and/or edited the manuscript before submission.

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Correspondence to Thomas A. Buchanan.

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T. A. Buchanan declares associations with the following companies: Allergan (grant support), Bristol-Myers Squibb (paid consultant), Novo Nordisk (paid speaker or speakers bureau), Takeda (grant support, advisory panel, paid speaker or speakers bureau), Tethys Bioscience (stock options). The other authors declare no competing interests.

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Buchanan, T., Xiang, A. & Page, K. Gestational diabetes mellitus: risks and management during and after pregnancy. Nat Rev Endocrinol 8, 639–649 (2012). https://doi.org/10.1038/nrendo.2012.96

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