C URR ENT C ONC EP TS
Current Concepts
G ESTATIONAL D IABETES M ELLITUS
SIRI L. KJOS, M.D., AND THOMAS A. BUCHANAN, M.D.
G
ESTATIONAL diabetes mellitus is defined
as glucose intolerance that is first detected
during pregnancy.1 This simple definition be-
lies the complexity of a condition that spans a spec-
trum of glycemia, pathophysiology, and clinical ef-
fects and for which there is a wide diversity of opinion
regarding detection and clinical management. There
is convincing evidence that mild maternal hypergly-
cemia is a risk factor for fetal morbidity,2 but that
morbidity occurs only in a minority of cases. Failure
to recognize and treat the condition will result in
unnecessary morbidity in some pregnancies, whereas
overly aggressive approaches to detection and treat-
ment will result in unneeded interventions in many
others. We will review current recommendations for
the detection and treatment of gestational diabetes,
with an emphasis on risk stratification to minimize
both undertreatment and overtreatment of individ-
ual women.
DETECTION OF GESTATIONAL DIABETES
The risks to the fetus increase in a continuous
fashion with increasing maternal glycemia.2-4 Thus,
there is no threshold of glycemia that discriminates
clearly between low-risk and high-risk pregnancies.
The diagnostic criteria for gestational diabetes could
be set high to identify only very-high-risk pregnan-
cies (and miss some at-risk pregnancies) or low to
identify all at-risk pregnancies (and many no-risk preg-
nancies). The latter approach was adopted by the
Fourth International Workshop-Conference on Ges-
tational Diabetes Mellitus1 and is described below.
Screening
Screening procedures identify pregnant women
who are at sufficient risk to warrant a diagnostic test,
the oral glucose-tolerance test. Screening of all preg-
nant women by measurement of serum or plasma
glucose between 24 and 28 weeks of gestation has
been recommended widely.5,6 However, some wom-
From the Department of Obstetrics and Gynecology (S.L.K., T.A.B.)
and the Department of Medicine (T.A.B.), University of Southern Califor-
nia School of Medicine, Los Angeles. Address reprint requests to Dr. Kjos
at 1240 N. Mission Rd., Rm. L1017, Los Angeles, CA 90033, or at
skjos@hsc.usc.edu.
©1999, Massachusetts Medical Society.
The New England Journal of Medicine
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en have clinical characteristics that indicate such a
low risk of gestational diabetes that screening may
not be warranted.1,7,8 Other women have high-risk
characteristics that warrant screening early in preg-
nancy. Accordingly, screening for gestational diabe-
tes should include an assessment of the clinical char-
acteristics of all pregnant women to determine the
risk of gestational diabetes (Table 1) and serum glu-
cose screening in women who do not have a low-risk
clinical profile (Table 2).1
The initial clinical assessment should be made at
the first antepartum visit. Women with high-risk
clinical characteristics should then undergo glucose
screening as soon as possible. A 50-g oral glucose-
challenge test9-11 is usually recommended for this pur-
pose, followed by an oral glucose-tolerance test if
the serum glucose concentration at screening is suf-
ficiently high (Table 2).1 However, if the suspicion of
overt hyperglycemia is very high (e.g., if polyuria
and polydipsia are present), measurement of serum
glucose during fasting may be sufficient to confirm
the diagnosis of diabetes (Table 3). Women who are
found to be at average or low clinical risk (Table 1)
at the initial clinical evaluation should be reassessed
between 24 and 28 weeks of gestation, along with
women at high risk who have not already received a
diagnosis of gestational diabetes by that time.
At 24 to 28 weeks, women with low-risk clinical
characteristics (Table 1) do not need further testing.1
The risk in these women is low,7,8,10 although the ef-
fect of not performing glucose screening has not
been evaluated thoroughly. Women with any clinical
characteristic placing them at risk (average or high
risk in Table 1) should undergo glucose testing. In
most populations, a two-step testing procedure will
limit the number of full glucose-tolerance tests that
are performed; step 1 is the 50-g, one-hour glucose-
challenge test (Table 2), and step 2 an oral glucose-
tolerance test performed in women whose one-hour
glucose-challenge test indicates an increased risk of
gestational diabetes. The frequency of positive screen-
ing tests and their specificity for the detection of
gestational diabetes vary according to the cutoff point
selected for the serum glucose concentration at one
hour (Table 2). In some groups (e.g., some Native
American peoples), the rates of diabetes and gesta-
tional diabetes are so high that proceeding directly
to the full oral glucose-tolerance test may be appro-
priate.1
Diagnosis
The diagnosis of gestational diabetes is based on
the results of an oral glucose-tolerance test, except
in women with severe hyperglycemia (Table 3), who
should be considered to have type 1 or type 2 dia-
betes and treated accordingly. There is no agree-
ment about the conduct or interpretation of the oral
glucose-tolerance test in pregnant women. The ap-
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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

TABLE 1. CLINICAL SCREENING FOR GESTATIONAL TABLE 3. DIAGNOSIS OF DIABETES DURING PREGNANCY.*
DIABETES MELLITUS.*

TIME OF
RECOMMENDATION FOR MEASUREMENT GLUCOSE CONCENTRATION
SERUM OR PLASMA DIABETES MELLITUS GESTATIONAL
RISK CATEGORY AND CLINICAL CHARACTERISTICS† GLUCOSE SCREENING TYPE 1 OR 2 DIABETES MELLITUS†

High risk (one or more of the following) At initial antepartum visit or milligrams per deciliter
Marked obesity as soon as possible there-
Diabetes in first-degree relative after; repeat at 24–28 Random‡§ »200 —
History of glucose intolerance weeks if no diagnosis After overnight fast§ »126 95
Previous infant with macrosomia of gestational diabetes
One hour after test — 180
Current glycosuria mellitus by that time
Average risk Between 24 and 28 weeks of Two hours after test — 155
The patient fits neither the low- nor the gestation Three hours after test — 140
high-risk profile
Low risk (all of the following) Not required *Diagnoses are based on recommendations of the Fourth International
Age <25 yr Workshop-Conference on Gestational Diabetes,1 with venous serum or
Belongs to low-risk race or ethnic group‡ plasma glucose concentrations measured by methods with high precision
No diabetes in first-degree relatives and appropriate quality control. To convert values for glucose to millimoles
Normal prepregnancy weight and weight per liter, multiply by 0.05551.
gain during pregnancy
†Values shown are for a 100-g, three-hour oral glucose-tolerance test. The
No history of abnormal blood glucose
serum glucose cutoff points for the 75-g, two-hour oral glucose-tolerance
concentrations
test are identical to the fasting, one-hour and two-hour values from the
No prior poor obstetrical outcomes
100-g, three-hour test.1 Two or more of the values must be met or exceeded
for a diagnosis of gestational diabetes to be made with the use of either test.
*Data are from Metzger et al.1
‡Values are measured at any time except during the oral glucose-chal-
†Assessment is performed at the initial antepartum visit and repeated at lenge test or oral glucose-tolerance test.
24 to 28 weeks of gestation in patients in whom gestational diabetes has
not been diagnosed. §Abnormal values should be present on at least two occasions.
‡Low-risk races and ethnic groups are those other than Hispanic, black,
Native American, South or East Asian, Pacific Islander, or Indigenous Aus-
tralian.

risk of fetal macrosomia and cesarean delivery in the

absence of specific treatment.15,16 However, most of
these women and their infants are not at risk for glu-
cose-related morbidity (Fig. 1).16
TABLE 2. SERUM OR PLASMA GLUCOSE SCREENING FOR The more inclusive criteria (Table 3) were adopted
GESTATIONAL DIABETES MELLITUS WITH THE by the Fourth International Workshop-Conference
50-g ORAL GLUCOSE-CHALLENGE TEST.*
on Gestational Diabetes Mellitus.1 Use of those cri-
teria increased the percentage of pregnant women
PROPORTION OF SENSITIVITY classified as having gestational diabetes from 4 per-
WOMEN WITH FORGESTATIONAL
SERUM GLUCOSE CUTOFF POINT† POSITIVE TEST‡ DIABETES MELLITUS‡ cent (according to the criteria of the National Dia-
betes Data Group5) to 7 percent in a group that
percent
consisted predominantly of white women.16 The in-
»140 mg/dl (7.8 mmol/liter) 14–18 ~80 cidence rates may be different in other races and eth-
»130 mg/dl (7.2 mmol/liter) 20–25 ~90 nic groups.17 The Fourth International Workshop-
Conference on Gestational Diabetes Mellitus1 (Table
*Recommendations are adapted from Metzger et al.1 Serum or plasma
glucose is measured one hour after the glucose challenge, which can be
3), the World Health Organization,18 and the Euro-
performed at any time of day, without regard to the time of the last meal. pean Diabetic Pregnancy Study Group19 have pro-
In women with very-high-risk clinical characteristics, diagnostic testing posed different criteria for interpreting the results
may be performed without prior glucose screening.1
of 75-g, two-hour glucose-tolerance tests in preg-
†Venous serum or plasma glucose concentration is measured by methods
with high precision and appropriate quality control. nant women. At present there are no data on peri-
‡The percentage may vary according to race or ethnic group and the natal or maternal outcomes to support the use of
glucose-tolerance-test criteria used for diagnosis. those criteria.
ANTEPARTUM IMPLICATIONS
AND TREATMENT
proach recommended in 1979 by the National Dia- Implications
betes Data Group5 was based on a three-hour, 100-g Antepartum morbidity in women with gestational
test with use of criteria developed to quantify the diabetes is limited to an increased frequency of hy-
risk of subsequent diabetes in the mother.12 Other cri- pertensive disorders. The data are most convincing for
teria, incorporating lower glucose concentrations,13,14 an association with preeclampsia20,21 and more con-
identify additional pregnant women with an increased troversial for an association with pregnancy-induced

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 C URR ENT C ONC EP TS

Macrosomia No macrosomia Cesarean No cesarean

Untreated Treated Untreated Treated

100 100
of Pregnancies

of Pregnancies
PercentageB

PercentageB
80 80
60 60
40 40
20 20
0 0
iv B

tiv nB

iv B

tiv nB
D B

D B
nl B

nl B
at en

at en
D M

D M
O M

O M
si ee

si ee
e

e
eg re

eg re
N D

N D
p GD

p GD
y

G
y
Po Scr

Po Scr
d G

d G
N Sc

N Sc
an by

an by
ho y

ho y
ks b

ks b
e

e
or ve

or ve
tiv

tiv
W iti

W iti
si

si
h os

h s
Po

Po
Po
P4t

4t
Figure 1. Rates of Macrosomia and Cesarean Delivery in Relation to Maternal Serum Glucose Classification in the Toronto Tri-
Hospital Gestational Diabetes Project.2
Classifications are based on the results of a one-hour, 50-g glucose screening test and a three-hour, 100-g oral glucose-tolerance
test in all women. “Screen Negative” indicates a one-hour serum glucose value of less than 140 mg per deciliter (7.8 mmol per liter)
on the 50-g test. “Positive by GDM 4th Workshop Only” indicates that the criteria for gestational diabetes mellitus of the Fourth
International Workshop-Conference on Gestational Diabetes Mellitus1 were met (see Table 3), but not the stricter criteria of the Na-
tional Diabetes Data Group (NDDG).5 The care providers were unaware of serum glucose concentrations for all pregnancies except
those complicated by gestational diabetes as defined by the NDDG; the values for women in this category were known, and the
women were treated. The horizontal line in each panel is the rate of the complication in the lowest glucose category. The rates of
macrosomia (birth weight >4000 g) and cesarean delivery rose with increasing degrees of maternal glycemia in the three untreated
groups, with care providers unaware of the women’s serum glucose concentrations, but only a minority of pregnant women in each
group had complications. The group with the highest glucose concentrations (Positive by GDM and NDDG), who were treated to
reduce their glucose concentrations, had the lowest proportion of infants with macrosomia but the highest rate of cesarean delivery.

hypertension.22 Careful monitoring of blood pres-
sure, weight gain, and urinary protein excretion is rec-
ommended, particularly during the second half of
gestation. Standard diagnostic criteria and treatment
of hypertensive disorders are applicable to women
with gestational diabetes.
The dominant antepartum clinical risks of gesta-
tional diabetes are to the fetus. Some studies have
reported an increased frequency of major congenital
anomalies,23-25 but the increase appears to be limited
to infants whose mothers have severe hyperglycemia
(e.g., initial fasting serum glucose concentrations
above 120 mg per deciliter [6.7 mmol per liter]25).
Accordingly, it is prudent to offer such women spe-
cial counseling and targeted ultrasound examinations
to detect fetal anomalies.
Historically, stillbirth was an important complica-
tion of diabetic pregnancies, including pregnancies
in women with untreated gestational diabetes.26 As
a result, maternal monitoring of fetal movements and
fetal cardiotocography are often recommended in
pregnancies complicated by gestational diabetes in
order to detect fetuses at risk of intrauterine death.
Several large clinical studies demonstrated no excess
perinatal mortality when these measures were insti-
tuted at term in women with gestational diabetes
and otherwise uncomplicated pregnancies who were
treated by diet or at 32 to 34 weeks of gestation in
women treated with insulin, women with hyperten-
sion, and women who had had a previous stillborn
infant.27-31 The rates of induction of labor and early
delivery among women with nonreassuring or suspi-
cious fetal heart-rate tracings were in the range of
9 to 13 percent.30,31 Whether routine cardiotocogra-
phy is beneficial or leads to unnecessary interven-
tions in pregnant women with well-controlled dia-
betes is not known.
Macrosomia, hypoglycemia, jaundice, respiratory
distress syndrome, polycythemia, and hypocalcemia
have been reported with varying frequency in the in-
fants of women with gestational diabetes.15,16,24,32-35
Macrosomia15,16,24,32-35 and associated complications
of labor and delivery15,16,24,34,35 are the most frequent
and serious types of morbidity. A simplistic view of
macrosomia is that it results from the delivery of ex-
cess glucose to the fetus as a consequence of mater-
nal hyperglycemia.36 Indeed, there appears to be a
weak positive correlation between the degree of ma-
ternal glycemia and birth weight3,34 or the frequency
of macrosomia.2-4 However, maternal glycemia ac-
counts for only a small fraction of the variance in the
birth weights of the infants of mothers with gesta-

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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne
tional diabetes.3 Other maternal factors that may con-
tribute to fetal macrosomia include obesity2,3 and high
serum concentrations of amino acids37,38 and lipids.39,40
Fetal responses to maternal diabetes vary as well, as
evidenced by the differences in the frequency of
macrosomia in the infants of women with gestation-
al diabetes who belong to different racial and ethnic
groups.17,41
Thus, excessive fetal growth in pregnancies com-
plicated by gestational diabetes should be viewed as
the result of a multifaceted maternal metabolic dis-
turbance superimposed on varied fetal responses to
that disturbance. The net result is a frequency of
macrosomia that is greater than in infants of nondi-
abetic pregnant women, but that affects only a minor-
ity of infants overall (approximately 20 to 30 percent
of infants whose mothers have gestational diabe-
tes).2,4,15-17,24,33-35,41 The excess rate of macrosomia as-
sociated with gestational diabetes is likely to decrease
as the cutoff levels are lowered to include more preg-
nancies.1,16
Antepartum Metabolic Treatment
Antepartum treatment of women with gestational
diabetes should be focused on the prevention of fetal
complications. Virtually all approaches have as their
foundation a program of nutritional education and
dietary treatment. The American Diabetes Associa-
tion42 recommends the provision of adequate calo-
ries and nutrients to meet the needs of pregnancy
and to minimize maternal hyperglycemia. Daily ca-
loric needs for women of normal weight in the sec-
ond half of pregnancy are 30 to 32 kcal per kilogram
of body weight. Dietary approaches that lower ma-
ternal serum glucose concentrations include limiting
carbohydrate intake to 40 percent of total calories,43
providing carbohydrates that have a low glycemic in-
dex,44 and reducing the total intake for overweight
women to 25 kcal per kilogram.45 One study found
that women who obtained less than 40 percent of
their total calories from carbohydrates had infants
with lower birth weights and fewer cesarean deliver-
ies than women with higher intakes.46
Once nutritional therapy has been initiated, two
general approaches can be used to identify women
whose fetuses are at sufficiently high risk to warrant
more intensive treatment: frequent measurement of
maternal blood glucose concentrations and assess-
ments of fetal development. The most common ap-
proach and the one backed by the greatest clinical
experience uses intensive monitoring to detect blood
glucose concentrations that are indicative of increased
fetal risk. Since there is not a maternal glycemic thresh-
old for fetal risk,2-4 recommendations have focused
on maintaining blood glucose concentrations in the
normal range for pregnancy in all women. Postpran-
dial hyperglycemia is more closely related to fetal
macrosomia than preprandial hyperglycemia in preg-
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nancies complicated by preexisting diabetes.47,48 That
observation led to recommendations for both pre-
prandial and postprandial blood glucose monitoring
in women with gestational diabetes, although that
practice has not been proved to be superior to pre-
prandial monitoring alone.49
Nonetheless, the Fourth International Workshop-
Conference on Gestational Diabetes Mellitus1 recom-
mended maintaining blood glucose concentrations
at less than 95 mg per deciliter (5.3 mmol per liter)
before meals and less than 140 and 120 mg per dec-
iliter (7.8 and 6.7 mmol per liter) one and two hours,
respectively, after meals. Some clinicians have used
more strict glycemic targets,50 although overly aggres-
sive treatment without preselection for mothers with
large fetuses51,52 may increase the rate of delivery of
small-for-gestational-age infants.4
Home blood glucose monitoring with memory-
capable meters appears superior to monitoring with
visually read strips in identifying women whose blood
glucose concentrations remain elevated while they
are receiving dietary therapy.53 Treatment based on
maternal hyperglycemia alone has been estimated to
be cost effective,54 even though all women being
treated must monitor their blood glucose concen-
trations, and many of them require insulin therapy.55
Since only a minority of fetuses of women with
gestational diabetes are at risk for hyperglycemia-
related morbidity (Fig. 1), some investigators have
combined simple measures of maternal glycemia with
fetal measurements to identify pregnancies at risk for
perinatal morbidity. One such approach uses serum
fructosamine concentrations to identify women with
low-risk pregnancies.56 In the remainder, measure-
ments of insulin in the amniotic fluid identify the
minority of fetuses with hyperinsulinism. Another ap-
proach uses measurements of fasting serum glucose
obtained every one to two weeks to identify the ma-
jority of women who maintain glucose concentra-
tions of less than 105 mg per deciliter (5.8 mmol per
liter) while receiving dietary therapy.51,52 Measure-
ments of the fetal abdominal circumference early in
the third trimester are then used to identify the mi-
nority of fetuses at risk for macrosomia at term. With
each of these two approaches, blood glucose moni-
toring by patients and treatment with insulin are
used only in the minority of pregnancies that have
some evidence of fetal hyperinsulinism (20 percent
of pregnancies complicated by gestational diabetes
in one study56) or macrosomia (one third of preg-
nancies complicated by gestational diabetes in anoth-
er study51). The rates of macrosomia and perinatal
complications are low with both of these fetus-based
approaches, but neither approach has been compared
directly with treatment based on maternal hypergly-
cemia alone for efficacy or cost effectiveness.
Women in whom there are signs of fetal morbidity
(according to approaches based on the characteris-
 C URR ENT C ONC EP TS
tics of the fetus) or in whom blood glucose concen-
trations exceed targets (according to glucose-based
or fetus-based approaches) are treated more inten-
sively, usually with insulin. Insulin therapy decreases
the frequency of fetal macrosomia50,51,53,57-59 and per-
inatal morbidity.50,53,58,59 Optimal insulin regimens
have not been determined, and tailoring of regimens
to achieve blood glucose targets in individual pa-
tients is recommended. In that regard, insulin treat-
ment to achieve postprandial blood glucose concen-
trations of less than 140 mg per deciliter resulted in
a lower average level of glycemia and better perinatal
outcomes than treatment to maintain preprandial
blood glucose concentrations of less than 105 mg
per deciliter in women who were not selected ac-
cording to fetal characteristics.60 The preprandial tar-
get of 105 mg per deciliter is higher than currently
recommended.1 Moreover, excess macrosomia has
been eliminated with insulin by reducing preprandi-
al blood glucose concentrations to approximately 80
mg per deciliter (4.4 mmol per liter) in women whose
fetuses have been identified as being at risk for mac-
rosomia by fetal ultrasonography.51 Thus, the timing
of measurements of blood glucose, the target glu-
cose concentrations, and fetal growth characteristics
should all be considered in designing insulin treat-
ment. Other options for intensifying treatment in-
clude the dietary modifications mentioned above and
aerobic exercise,61,62 which was associated with peri-
natal outcomes similar to the outcomes in insulin-
treated women in one small study.62
Route and Timing of Delivery
Gestational diabetes is not in itself an indication
for cesarean delivery. Nonetheless, the rates of cesar-
ean delivery among women with gestational diabetes
are more than double those for nondiabetic wom-
en.16,63-65 Some of the increase may be due to an in-
crease in the number of infants with macrosomia.66
However, knowledge that the mother has gestational
diabetes16 or has been treated with insulin51 can in-
crease the chances of cesarean section. To minimize
such iatrogenic morbidity, the route of delivery in
well-treated women should be based on the same
maternal and fetal considerations that apply to non-
diabetic pregnant women.
The timing of delivery, in the absence of maternal
or fetal jeopardy, should take into account fetal growth
patterns as well as the risks associated with the induc-
tion of labor and premature delivery. In one random-
ized, unblinded study of women with insulin-treated
diabetes (93 percent of whom had gestational diabe-
tes),67 routine induction of labor at 38 completed
weeks of gestation resulted in earlier delivery (39 vs.
40 weeks) and a smaller proportion of infants who
were large for gestational age (10 percent vs. 23 per-
cent) than did waiting for labor to begin spontane-
ously by 41 completed weeks of gestation. Among
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women whose labor was induced, neither the rate of
cesarean delivery (25 percent, vs. 31 percent among
women in whom labor was not induced) nor the fre-
quency of shoulder dystocia (0 percent vs. 3 per-
cent) was higher. This observation suggests that the
two approaches are clinically equivalent with regard
to the most serious types of perinatal morbidity, but
that waiting allows more time for accelerated fetal
growth.
Surfactant-deficient respiratory distress syndrome
is rare in term infants of mothers with gestational di-
abetes.68,69 Accordingly, testing of fetal lung matura-
tion is not recommended after 38 weeks of gestation
in cases in which there are reliable estimates of ges-
tational age and good maternal glycemic control.1
Before 38 weeks, the strength of the indication for
preterm delivery should determine whether assess-
ment of pulmonary maturity would alter the clinical
management of individual cases.
AFTER THE PREGNANCY
There is epidemiologic evidence that persons ex-
posed to maternal diabetes in utero have an in-
creased risk of obesity70-74 and abnormal glucose tol-
erance71,72,74,75 as children and young adults. The
associations have been reported not only in the off-
spring of women with type 1 or type 2 diabetes, but
also in the offspring of women with gestational dia-
betes.71,72,74 No interventions to prevent these long-
term complications have been tested. Recommenda-
tions for the care of the children include regular
evaluations of height, weight, and blood glucose
concentrations and appropriate diet and physical ac-
tivity to minimize the likelihood that obesity will
develop.1
Women with gestational diabetes have a 17 to 63
percent risk of nongestational diabetes within 5 to
16 years after the index pregnancy.12,76-83 The risk of
diabetes is particularly high in women who have
marked hyperglycemia during9,76,80-83 or soon after 80,83
pregnancy, women who are obese,81,82,84 and women
whose gestational diabetes was diagnosed before 24
weeks of gestation.79,83,85,86 Physiologic testing of wom-
en with gestational diabetes has revealed a limited
capacity of pancreatic beta cells to increase insulin
secretion in compensation for insulin resistance.84,87-93
Poor insulin secretion during pregnancy is predictive
of diabetes after delivery.80,81,94 The beta-cell defect
may be due to pancreatic autoimmunity in a small
minority of women,90,95-101 but its cause is unknown
in the majority, who have no circulating antibodies
to islet-cell antigens.
The observation that weight gain and an addition-
al pregnancy increase the risk of diabetes after ges-
tational diabetes102 suggests that insulin resistance
may accelerate the decline in beta-cell function that
leads to diabetes. Accordingly, treatment of women
with a history of gestational diabetes should include
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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne
measures to minimize insulin resistance (exercise,
maintenance of normal weight, and avoidance of drugs
that induce insulin resistance). Blood glucose con-
centrations should be reassessed after delivery and at
least every three years thereafter in keeping with the
recommendation of the American Diabetes Associa-
tion for the detection of diabetes in high-risk sub-
jects.103 More frequent testing is warranted in wom-
en who have impaired fasting or postchallenge blood
glucose concentrations.83,103
Finally, women with a history of gestational dia-
betes should use effective contraception to minimize
the chance that they will become pregnant with un-
treated hyperglycemia, which increases the risk of
birth defects in their infants. Long-term treatment
with low-dose combination oral contraceptives does
not appear to increase the risk of diabetes after ges-
tational diabetes.103-105 The copper-medicated intrau-
terine device is a highly effective contraceptive that
is metabolically neutral.106 In contrast, the use of a
contraceptive containing only progestin during breast-
feeding increased the rate of diabetes by a factor of
nearly three,104 an effect that was not explained by
breast-feeding itself.
Supported by grants from the National Institute of Diabetes and Diges-
tive and Kidney Diseases (R01-DK-46374) and the General Clinical Research
Center Branch, National Center for Research Resources (M01-RR-43); by
a Clinical Investigator Award from the American Diabetes Association; and
by a research grant from the Juvenile Diabetes Foundation International.
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