Gestational diabetes: Optimizing Dx and management in primary care
Understanding risk factors and glucose targets for gestational diabetes can help you identify at-risk patients and improve outcomes for mother and infant.
PRACTICE RECOMMENDATIONS
› Manage gestational diabetes mellitus (GDM) with lifestyle behavior changes first and add insulin as a secondary treatment only if glycemic targets are not being met. A
› Treat hyperglycemia in GDM with insulin, not metformin or glyburide; these agents cross the placenta to the fetus. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
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
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
