with gestational diabetes in pregnancy are at higher risk for developing Type 2 diabetes , metabolic syndrome , cardiovascular disease and even Type 1 diabetes later in life . One study showed a sevenfold increased risk of developing Type 2 diabetes . 3
Another study showed that that upwards of 70 % of women with gestational diabetes will develop Type 2 diabetes within 22-28 years after the pregnancy . 4 In this study , the cumulative incidence of Type 2 diabetes increased markedly in the first five years after delivery . Elevated fasting glucose level during the pregnancy was a significant risk factor for future risk of Type 2 diabetes . In certain ethnic groups such as Latin American women , the timeline for disease may be significantly shorter .
The Fifth International Workshop on Gestational Diabetes Mellitus ( 2005 ) recommended that all women with gestational diabetes mellitus undergo a 75g 2-h glucose tolerance test six to 12 weeks after delivery to evaluate for impaired glucose tolerance or overt diabetes . Upwards of one-third of women will have impaired glucose metabolism at postpartum screening . Maintaining ideal body weight , regular exercise and healthy diet can significantly reduce the risk for later development of Type 2 diabetes . All women diagnosed with gestational diabetes should be referred to a primary care provider and those with impaired glucose tolerance or overt diabetes should be referred for preventive or medical therapy . If the postpartum screen is normal , the American College of Obstetricians and Gynecologists ( ACOG ) and the ADA recommend repeat testing every one to three years . 5
Despite the lack of consensus on optimal management of women who experienced adverse pregnancy outcomes , there are risk reducing interventions that can be implemented to mitigate long term risk for diseases .
Historically , a pregnancy is divided into three trimesters , however , more recently described is the fourth trimester which is the period between birth and 12 weeks postpartum . The ACOG now endorses the fourth trimester and recommends that health care providers view the postpartum period as an opportunity for intervention to improve the health of mothers beyond the pregnancy . The postpartum period should no longer be seen as an arbitrary cutoff at six weeks but rather an ongoing process tailored toward the individual patient and concluding with a comprehensive well woman visit no later than 12 weeks after birth . The ACOG asserts that insurance coverage policies be aligned to fit this model of care . 6
The American Rescue Plan Act , which was signed into law on March 11 , 2021 creates a new pathway that all states can use to extend Medicaid coverage for pregnant people to one year postpartum . This pathway known as a state plan amendment ( SPA ) will become effective April 1 , 2022 .
If the obstetrician gynecologist is not serving as the woman ’ s primary care provider , the patient should be referred to the appropriate primary care or subspecialist . Pregnancy complications
TWO PATIENTS IN ONE should be clearly documented in the electronic health records . It is recommended that the transition be a “ warm hand-off ” from the obstetrician to the primary care provider or specialist with conveyance of the adverse pregnancy outcome .
Preventive measures to reduce long-term cardiovascular risks include exercise , weight reduction or control and smoking cessation . Women should be encouraged to reach their pre-pregnancy weight by six to 12 months postpartum and to ultimately achieve ideal body weight . Pregnancy should no longer be seen as an isolated event in a woman ’ s life but rather as a unique opportunity to impact longterm maternal health .
On February 10 , 2022 , the Kentucky House Health and Family Services Committee passed House Bill 174 , co-sponsored by Representative McKenzie Cantrell and House Health and Family Services Committee Chair Representative Kim Moser .
The bill purports that postpartum is a vulnerable time for new mothers and their baby , and this is especially true for women on Medicaid , many of whom are at risk of losing their health insurance coverage just 60 days after the end of pregnancy . The reality is that half of maternal deaths are post-pregnancy and are overwhelmingly preventable . In Kentucky , the rate of Black mothers dying within one year of giving birth is more than twice the rate for white mothers . HB 174 seeks to extend Medicaid eligibility for new mothers for up to 12 months postpartum so they can have continuous , uninterrupted access to health care .
HB 174 bill has been sent to the House . Hopefully this bill will be passed , allowing Medicaid funds to ensure new moms can access continuous , uninterrupted health care up to 12 months postpartum .
For additional information on interpregnancy care , please refer to The American College of Obstetricians and Gynecologists - Society for Maternal-Fetal Medicine document , Obstetric Care Consensus No . 8 : Interpregnancy Care 7 .
References
1
Bokslag A , Teunissen PW , Franssen C , van Kersteren , F , Kamp O , Ganzevoort , W , Paulus WJ , de Groot CJ . ( Effect of early-onset preeclampsia on cardiovascular risk in the fifth decade of life . Am J Obset Gynecol 2017:216 ( 5 ): 523 . e1- 523 . e7
2
Brown MC , Best KE , Pearce MS , Waugh J , Robson SC , Bell R . Cardiovascular disease risk in women with preeclampsia : systematic review and meta-analysis . Eur J Epidemiol 2013:28:1-19 .
3
Bellamy L , Casas JP , Hingorani AD , Williams D . Type 2 diabetes mellitus after gestational diabetes : A systematic review and meta-analysis . Lancet 2009 ; 373:1773-9
4
Kim C , Newton KM , Knopp RH . Gestational diabetes and the incidence of type 2 diabetes : a systematic review . Diabetes care 2005 ; 25:1862-8
5
ACOG Practice Bulletin Number 190 , February 2018 Gestational Diabetes Mellitus
6
Ref Committee Opinion Number 736 May 2018 Optimizing postpartum care
7 Obstetric Care Consensus No . 8 : Interpregnancy Care . American College of
Obstetricians and Gynecologists ; Society for Maternal-Fetal Medicine . Obstet Gynecol . 2019 Jan ; 133 ( 1 ): e51-e72
Dr . Mureena Turnquest Wells is a board certified maternal fetal medicine specialist with Norton Children ’ s Maternal-Fetal Medicine .
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