POST PARTUM EVALUATION AND

FOLLOW UP:
PREECLAMPSIA & DM GESTASIONAL
Dr. Muhammad Ilham Aldika Akbar dr. SpOG(K)
Departemen Obstetri Ginekologi Fakultas Kedokteran Universitas Airlangga
RS Universitas Airlangga
Surabaya
2023
POST PARTUM EVALUATION AND
FOLLOW UP: PREECLAMPSIA

Muhammad Ilham Aldika Akbar

“PREECLAMPSIA is not
just a problem of labour
& delivery, but it also a
huge problem for future
maternal health”

Muhammad Ilham Aldika Akbar J Am Heart Assoc. 2018;7:e009382

Cardiac changes in pregnancies complicated by hypertensive disorders of pregnancy
during pregnancy and throughout the postpartum.

Muhammad Ilham Aldika Akbar

Hypertension. 2023;80:231–241. DOI: 10.1161/HYPERTENSIONAHA.122.18730
A Retrospective Cohort Study of Hypertension, Cardiovascular Disease, and Metabolic Syndromes
Risk in Women with History of Early-onset and Late-onset Preeclampsia Five Years After Delivery
Aditiawarman, Noor Assyifa Zulhijayanti, Ernawati Darmawan, Muhammad Ilham Aldika Akbar

Preeclampsia Early Onset Late-Onset Control PE (total) Early Late-Onset

(total) PE PE (N=30) vs control Onset PE PE vs
vs Control Control
(N=62) (N=27) (N=35)
Systolic Blood Pressure (mm 141.90 ± 24.02 154.96 ± 23.48 131.83 ± 19.34 115.60 ± p<0.01 p<0.01 p<0.01
Hg) 14.25
Diastolic Blood Pressure 87.95 ± 16.71 96.00 ± 16.163 81.7 ± 14.49 66.53 ± p<0.01 p<0.01 p <0.01
(mm Hg) 11.41
Mean Arterial Pressure 105.90 ± 18.21 115.58+16.99 98.42+15.37 82.80 p<0.01 p<0.01 p <0.01
(mmHg) +11.65
Waist Circumferential (cm) 88.74 ± 10.90 93.14+11.89 85.34+8.81 83.46+12.09 P=0.03 p<0.01 p = 0.76

HDL (mg/dL) 51.61 ± 13.57 51.74+ 16.58 51.51+10.96 60.83+13.42 p<0.01 p=0.03 p = 0.01

LDL (mg/dL) 120.74 ± 70.08 140.70+ 64.23 105.34+ 71.39 83.70+ p<0.01 p<0.01 p = 0.31
36.29
Triglycerides (mg/dL) 263.68 ± 331.00+281.25 211.74+168.51 154.43+47.3 P=0.01 p<0.01 p = 0.43
230.42 4 3 54

Total cholesterol level 224.46 ± 257.30+104.63 199.17+93.03 175.47+46.9 P=0.02 p<0.01 p = 0.50
(mg/dL) 101.66 7
Fasting Blood sugar (mg/dL) 107.45 ± 64.01 104.81+ 37.88 109.48+ 79.01 84.30+ P=0.01 p =0.33 p = 0.15
21.98
 FUTURE HEALTH COMPLICATIONS IN WOMEN WITH
HYPERTENSIVE DISORDERS IN PREGNANCY

RECCURENCE OF HDP IN CARDIOVASCULAR RISKS AND METABOLIC DISORDERS

SUBSEQUENT PREGNANCY DISEASE • Obesity
• Gestational HT • Chronic HT • Insulin Resistance
• Preeclampsia • Coronary Artery Disease • Elevated Fasting Blood Sugar
• Eclampsia • Peripheral Vascular Disease • Dyslipidemia
• HELLP Syndrome • Heart Failure • Microalbuminemia
• Stroke
• CVD related mortalty

NEUROLOGICAL DISORDERS KIDNEY DISEASES

• Epilepsy • Chronic Kidney Diseases VENOUS
• Dementia • End-stage Kidney Diseases THROMBOEMBOLISM

TYPE 2 DIABETES MELLITUS

Muhammad Ilham Aldika Akbar
 SHORT TERM FOLLOW UP ANTI HYPERTENSIVE THERAPY

Women may develop pre- TARGET: Diastolic BP < 80 mmHg

BP measurement and
eclampsia complications (severe
control postpartum
HT or eclampsia) postpartum
1. No fetal concerns postpartum

2. Half of strokes and eclampsia

occur postpartum
NSAID BREASTFEEDING
3. Most antihypertensive agents
(ACE inhibitors captopril, enalapril,
Associated with lower and quinapril) are acceptable in
May be used for postpartum analgesia
long-term maternal breastfeeding
as long as BP is controlled and there is
hypertension in
no AKI or AKI risk factors (CKD, sepsis,
observational studies 4. Good BP control postpartum
or PPH)
result in less aortic stiffness and
lower BP (and cardiovascular risk)
long-term
Do not increase postpartum BP, antiHT
dose, maternal complications,
readmission rates, or opioid use Muhammad Ilham Aldika Akbar
 POSTPARTUM FOLLOW UP
Following a pregnancy complicated by HDP:

Women should be followed up within a Women should be followed up for

relatively short time postpartum, ideally blood pressure assessment every 6–
within the first week and at 6–12 12 months and cardiovascular
weeks. screening at least every 4–6 years

Int J Gynecol Obstet. 2023;160(Suppl. 1):22–34.

Muhammad Ilham Aldika Akbar
Muhammad Ilham Aldika Akbar Int J Gynecol Obstet. 2023;160(Suppl. 1):22–34.
 Inpatient Day 1-3 post partum
management Check blood pressure at least 4 times per day
of postpartum
hypertension Chronic HT or Gestational PE identified in pregnancy Newly onset HT identified
HT identified in pregnancy postpartum
Check platelet count,
transaminases, serum creatinine Asses symptoms of PE
at 48-72 hours post delivery Yes No
Manage Ensure
Blood test stable or improving according PE adequate
protocol pain relief
Yes
Yes
BP < 140/90 mm Hg without treatment or <150/100 with treatment & No symptoms of PE
Yes
No No
Discharged with individualised plan for community care

• BP > 160/100 mmHg: consider high dependency care and intensive monitoring
• Sustained BP > 150/100 mmHg: Start or increase antihypertensive drugs
• Sustained BP > 140/90 mmHg: Start antihypertensive drugs to avoid delayed discharged or readmission
• Switch methyldopa to other antiHt drugs
Muhammad Ilham Aldika Akbar BMJ 2013;346:f894 doi: 10.1136/bmj.f894
 Outpatient
management
of postpartum
hypertension

Muhammad Ilham Aldika Akbar

BMJ 2013;346:f894 doi: 10.1136/bmj.f894
 Outpatient
management
of postpartum
hypertension

Muhammad Ilham Aldika Akbar

BMJ 2013;346:f894 doi: 10.1136/bmj.f894
 Hypertension (ACC/AHA)
> 130/80 mmHg

Hypertension (ESC/ESH)
> 140/90 mmHg

Muhammad Ilham Aldika Akbar Circulation. 2022;146:868–877.

 When to Start AntiHypertension Therapy

American College of Cardiology/American Heart Association

• All adults with SBP ≥140 mmHg or DBP ≥90 mmHg.
• Adults with SBP 130–139 or DBP 80–89 mmHg and CVD or a 10-year atherosclerotic CVD
risk ≥10%, based on estimation using of the ACC/AHA Pooled Cohort Equations calculator.

European Society of Cardiology/European Society of Hypertension

• All adults with SBP ≥140 mmHg or DBP ≥90 mmHg.
• Consider in adults with SBP 130–139 mmHg or DBP 85–89 mmHg who are at very high risk
because of CVD, especially those with coronary heart disease.

Muhammad Ilham Aldika Akbar Circulation. 2022;146:868–877.

 ACC/AHA Office Blood Pressure Treatment Targets for
Antihypertensive Drug Therapy for Management of
Hypertension

A systolic blood pressure /diastolic blood pressure <130/80 mmHg target

recommended for all adults with hypertension, with the exception that a
systolic blood pressure < 130 mm Hg target is recommended for
noninstitutionalized , ambulatory, community living older adults (> 65 years)

Muhammad Ilham Aldika Akbar Circulation. 2022;146:868–877.

TARGET TEKANAN DARAH PADA HIPERTENSI DALAM KEHAMILAN
(ISSHP 2021)
KONTROL KETAT - TARGET TDD 85 mmHg

TDD< 80 mmHg TDD 81-85 mmHg TDD > 85 mmHg

Stop atau turunkan dosis Dosis dipertahankan Mulai atau naikkan dosis
obat anti HT obat anti HT

Target TDD < 85 mmHg Kontrol TD ketat (TDD < 85 mmHg) dibanding kurang
CHIPS trial (Magee, 2016) ketat (TDD< 100 mmHg) menurunkan risiko hipertensi
berat dan komplikasi berat PE (termasuk kematian)
Hypertension. 2016 Nov; 68(5): 1153–1159
Muhammad Ilham Aldika Akbar
Muhammad Ilham Aldika Akbar
BMJ 2013;346:f894 doi: 10.1136/bmj.f894
 SELF HOME BP MONITORING POSTPARTUM
PATHOPHYSIOLOGY
SBP reach peak at delivery – D5 PP
DBP peak at D5-D7 PP
Measure BP after D7-D10 PP
Routine check at hospital as
scheduled
WHEN
Twice daily readings in the
morning and afternoon
Home Self BP Monitoring
• The technique was acceptable
• 85% adherence
• A median accuracy of 94%
• Significant improvement in BP control
• Most marked at 6 weeks
• The DBP being a 4.5 mmHg lower 6
months pp, after stopping medication.

• Improve BP control Self-monitored BP to titrate antiHT achieved

• Well tolerated better BP control when using telemonitoring
• Better predictor of end-organ damage

Muhammad Ilham Aldika Akbar

Hypertension. 2023;80:231–241. DOI:10.1161/HYPERTENSIONAHA.122.18730
No action prompts an app notification to continue daily readings. App indicates application; BP, blood pressure; DBP, diastolic
BP; GP‚ general practitioner; HDP, hypertensive disorders of pregnancies; and SBP, systolic BP.
*Switch to twice daily readings until back in yellow/green.
Hypertension. 2023;80:231–241. DOI:10.1161/HYPERTENSIONAHA.122.18730

Muhammad Ilham Aldika Akbar

 Figure 3. Longitudinal diastolic
blood pressure (BP) trajectories
from Self-management of Post-
Natal Hypertension Trial (SNAP-
HT) into SNAP-HT Extension
from antenatal booking blood
pressure to 3.6±0.4 years
postpartum.

DBP was >7 mmHg lower

in those originally
randomized to postpartum
BP self-management
versus those treated with
standard care

Muhammad Ilham Aldika Akbar

Hypertension. 2023;80:231–241. DOI:10.1161/HYPERTENSIONAHA.122.18730
 LONG TERM FOLLOW UP
The development of HDP is a way of identifying women with underlying, though
often unrecognized, cardiovascular risk

American College of Cardiology (ACC)/AHA recommends

All women aged 20 years and older Aggressive cardiovascular risk

should be assessed for modification and secondary preventive
cardiovascular risk factors at least efforts to reduce cardiovascular events
every 4–6 years

Int J Gynecol Obstet. 2023;160(Suppl. 1):22–34.

Muhammad Ilham Aldika Akbar
 WHAT SHOULD BE EXAMINED
The ACOG Task Force recommends that women with a history of PE should have an annual
assessment of their blood pressure, BMI, glucose testing, and lipid profile.

BLOOD PRESSURE BMI & WAIST CIRCUMFERENCE LIPID PROFILE

• Target normal BP
• Broad anti HT agents
choices
• Collaboration with
cardiologists
• Promote a healthy lifestyle
• Good nutrition
• Reduction of sodium intake
• Physical activity,
• Appropriate body weight.
Check Oral glucose tolerance test,
lipid profile, and urinalysis to
determine the albumin-to-creatinine
ratio

If the LDL remain elevated, may used a Abnormal results: 6 months of lifestyle
moderate-intensity statin which would be modification followed by repeat
stopped at the beginning of her next pregnancy. testing.
Muhammad Ilham Aldika Akbar
Search Keywords: “10 year ASCVD risk calculator”

Results:
• Low-risk (<5%)
• Borderline risk (5% to 7.4%)
• Intermediate risk (7.5% to 19.9%)
• High risk (≥20%)

https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
 Schedule for Cardiovascular Follow-up After a Hypertensive Disorder of Pregnancy

6–8 weeks after delivery

Assessement of Cardiovascular Discuss future Encouragement of healthy Consider Statin therapy

risk factors: HT, obesity, smoking, CVD risk diet and lifestyles in women with 10-year
and dyslipidemia ASCVD risk 5-7.5%

Annualy or every 5 years, starting 6-12 months after delivery

Assessement of Cardiovoascular Encouragement of healthy

risk factors: HT, obesity, smoking, diet and lifestyles
and dyslipidemia

50 Years of Age

Cardiovascular risk assessment by e.g SCORE/JBS3/ASCVD risk calculator according to

International Cardiovascular Screening Prevention Program
Muhammad Ilham Aldika Akbar Benschop L, et al. Heart 2019;105:1273–1278.
INTERVENTIONS TO MINIMIZE MEDIUM TO
LONG TERM HEALTH RISK
• Postpartum recommendations include breastfeeding and lifestyle
modifications such as a heart-healthy diet and appropriate physical activity
• Longer breastfeeding duration is recommended to improve cardiometabolic risks
and reduce the risk of future CVD

• At least 150 min of moderate-intensity exercise or more than 75 min of high-

intensity exercise per week is recommended to reduce the risk of future CVD

• The DASH diet has been demonstrated to reduce the 10-year Framingham risk
score (FRS) for CVD by 13%
Muhammad Ilham Aldika Akbar
Association of Maternal Lactation With Diabetes and Hypertension A Systematic
Review and Meta-analysis
Rabel Misbah Rameez, MD; Divyajot Sadana, MD; Simrat Kaur, MD; Taha Ahmed, MD; Jay Patel, MD; Muhammad
Shahzeb Khan, MD, MSc; Sarah Misbah; Marian T. Simonson, MSLS, AHIP; Haris Riaz, MD; Haitham M. Ahmed, MD,
MPH

RESULTS:
Breastfeeding for more than 12
months was associated with a
relative risk reduction of 30%
for diabetes and a relative risk
reduction of 13% for
hypertension

JAMA Network Open. 2019;2(10):e1913401.

Duration of Lactation and Incidence of
Maternal Hypertension: A Longitudinal
Cohort Study
Alison M. Stuebe*, Eleanor B. Schwarz, Karen Grewen, Janet W. Rich-
Edwards, Karin B. Michels, E. Michael Foster, Gary Curhan, and John Forman

RESULTS:
The longer a mother continues to breastfeed her
child, the lower the mother's risk of developing
hypertension.

Am J Epidemiol. 2011;174(10):1147–1158
Muhammad Ilham Aldika Akbar
Recommended
Physical Activity
(CDC)

Muhammad Ilham Aldika Akbar

Cardiovascular Follow-up After a Hypertensive Disorder of
Pregnancy Based On Guidelines

ACOG Women with preterm delivery (<37 weeks) or recurrent pre-eclampsia:

annual blood pressure, lipids, fasting glucose and BMI
(2013, 2018)

RCOG Inform about increased CVD risk in the future

(2006)

Assessment of traditional cardiovascular risk markers may be beneficial

SOGC Encourage a healthy diet and lifestyle, especially, for overweight
(2014) women

Muhammad Ilham Aldika Akbar

 Cardiovascular Follow-up After a Hypertensive Disorder of
Pregnancy Based On Guidelines

NICE Discuss future CVD risk 6–8 weeks after pregnancy with healthcare
(2017) provider

Consider to evaluate and treat all women with a history of PE for

ASA cardiovascular risk factors such as hypertension, obesity, smoking and
(2014) dyslipidemia, starting 6 months to 1 year post partum.

ESC/ESH Annual check of blood pressure and metabolic factors by primary care
(2018) physician.

Muhammad Ilham Aldika Akbar

 Cardiovascular Follow-up After a Hypertensive Disorder of
Pregnancy Based On Guidelines

SOMANZ Cardiovascular risk assessment every 5 years

(2014)

Postpartum referral by the obstetrician to a cardiologist to monitor and

AHA control cardiovascular risk factors.
(2011/2018) Consider statin therapy in women with 10-year ASCVD risk of 5%–7.5%.

NVOG Cardiovascular risk assessment at the age of 50 years.

(2014)

Muhammad Ilham Aldika Akbar

Contraception in Women with Hypertension

Muhammad Ilham Aldika Akbar

 Preconception Care for Women with High Risk Preeclampsia
Appropriate Age
Nutrition & Dietary Supplement
Counseling and planning
Evaluating mothers BMI
for pregnancy
Nutritional status, dietary supplements,
Pregnant in right season taking iron, folic acid, and multivitamins
Blood pressure
Physical Activity
Hystory of PE
Screening Depression Moving, physically active, & EXERCISE

Thrombosis
Adherence to medical regimen
UTI and prenatal care routine

Relaxation, examining
Stress management psychosocial stress, Regular intake prescribed medications, &
reducing job strain prenatal check up

Muhammad Ilham Aldika Akbar International Journal of Preventive Medicine 2019, 10: 21
Preconception Care for Women with High Risk Preeclampsia

International Journal of Preventive Medicine 2019, 10: 21

Muhammad Ilham Aldika Akbar

 International Journal of Preventive Medicine 2019, 10: 21

Muhammad Ilham Aldika Akbar

POST PARTUM EVALUATION AND
FOLLOW UP: GESTATIONAL
DIABETES

Muhammad Ilham Aldika Akbar

 Absolute risk of DM Tipe 2 after GDM
increases linearly based on time:
20% at 10 years, 30% at 20 years,
40% at 30 years, 50% at 40 years, and
60% at 50 years
J Diabetes Res 2020;2020:3076463
GESTATIONAL
POSTPARTUM
DIABETES
Muhammad Ilham Aldika Akbar
1/3 develop diabetes or impaired
glucose tolerance
Diabetes care 2014;37:S81.
15-50% develop DM Tipe 2 later in life
Obstet Gynecol 2013;122:406–16.
343.3% demonstrate postpartum
abnormalities
Diabetes Care, vol 30, supp 2, July 2007
• Isolated Intolerance Fasting Glucose
(IFG) 6.3%
• Isolated Intolerance Glucose Test (IGT)
6.8%
• Combined IFG-IGT 6.8%
• Tipe 2 DM 4.7%
10 fold risk of developing DM Tipe 2
BMJ 2020;369:m1361
 Exclusive breastfeeding

Contraception

MANAGEMENT Follow up glucose status 6-12 weeks pp

POSTPARTUM
GESTATIONAL Diet, reduction of maternal weight, and planned exercise
30-60 min daily at least 5 days per week
DIABETES
Antidiabetic medications

Assasement Cardiovascular Risk and intervention

Preconception counseling
Muhammad Ilham Aldika Akbar
 FOLLOW UP GLUCOSE STATUS POSTPARTUM (ADA, 2022)

75 g OGTT at 4-12 weeks postpartum

• FPG > 126 mg/dL (7 mmol/L) OGTT is recommended

• 2h plasma glucose > 200 mg/dL (11.1 over HbA1C
mmol/L)

• HbA1C maybe lower

Normal One abnormal value Two abnormal value
postpartum by blood
loss delivery,
Repeat testing every IFG or IGT Confirmed Diabetes increased red blood
1-3 years turnover
• OGTT test is more
sensitive at detecting
Can use other test Repeat testing
glucose intolerance
(HbA1C, FPG, OGTT) weeks/month
Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243
MANAGEMENT OF POSPARTUM SCREENING RESULTS (ACOG, 2018)

Muhammad Ilham Aldika Akbar

LACTATION
• All women with GDM
should be supported to
breastfeed

• Breastfeeding has short

term and long term benefit
for mother and child health
Diabetes Care 2022;45(Suppl. 1):S232–S243

MOLECULAR METABOLISM 3 (2014) 284–292

Muhammad Ilham Aldika Akbar
Cumulative life-table risk of postpartum diabetes in women with GDM who breastfed for > 3 months compared
with those who did not breastfeed or breastfed for <3 months
Diabetes 2012, 61(12):3167–3171.
Muhammad Ilham Aldika Akbar
CONTRACEPTION
• All women with diabetes of childbearing potential should have family planning options
reviewed at regular intervals to make sure that effective contraception is implemented
and maintained.

• Women with diabetes have the same contraception options and recommendations as
those without diabetes.

• Long-acting, reversible contraception may be ideal for many women.

• The risk of an unplanned pregnancy outweighs the risk of any given contraception
option.

Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243

Contraception in Women with GDM

Muhammad Ilham Aldika Akbar

MANAGEMENT OF WOMEN WITH IGT OR PERSISTENT DM POSTPARTUM

Weight loss or weight maintenance medical nutrition therapy

and 30–60 min exercise daily at least 5 days per week

FAIILED

PHARMACOTHERAPY

ACARBOSE METFORMIN THIAZOLIDINEDIONES

Delays carbohydrate Decreases hepatic glucose
absorption and helps production and lipid oxidation,
with postprandial improves peripheral tissue
glucose control, but insulin sensitivity and helps
side effects limit usage with weight loss
Muhammad Ilham Aldika Akbar
(GLITAZONES)
Peroxisome proliferator–activated
receptor-Y agonists increase
insulin sensitivity and may
improve lipid balance and
cardiovascular and renal function
 Diabetes Care 2007;30(Suppl 2):S251–60

Muhammad Ilham Aldika Akbar

 Important to adjust insulin doses postpartum

Insulin sensitivity increases dramatically with delivery of the placenta

Insulin requirements in the immediate postpartum are roughly 34% lower than
prepregnancy insulin requirements

Insulin sensitivity then returns to pre-pregnancy levels over the following 1–2 weeks.

Adjust insulin dosage to prevent hypoglycemia in the setting of breastfeeding, erratic sleep,
and eating schedule

Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243

 Recommendations ADA (2022) on Postpartum Care of
Women with GDM

No Recommendations Grade Evidence

1 Insulin resistance decreases dramatically immediately postpartum, and C
insulin requirements need to be evaluated and adjusted as they are often
roughly half the prepregnancy requirements for the initial few days
postpartum.
2 A contraceptive plan should be discussed and implemented with all A
women with diabetes of reproductive potential
3 Screen women with a recent history of GDM at 4–12 weeks postpartum, B
using the 75-g oral glucose tolerance test and clinically appropriate
nonpregnancy diagnostic criteria
4 Women with a history of GDM found to have prediabetes should receive A
intensive lifestyle interventions and/or metformin to prevent diabetes.

Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243

 Recommendations ADA (2022) on Postpartum Care of
Women with GDM

No Recommendations Grade Evidence

5 Women with a history of GDM should have lifelong screening for the B
development of type 2 diabetes or prediabetes every 1–3 years.
6 Women with a history of GDM should seek preconception screening for E
diabetes and preconception care to identify and treat hyperglycemia and
prevent congenital malformations.
7 Postpartum care should include psychosocial assessment and support for E
self-care.

Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243

 Recommendations ADA (2022) on Preconception Care of
Women with GDM

No Recommendations Grade Evidence

Women with preexisting DM who are planning a pregnancy should ideally be
1 B
managed beginning in preconception in a multidisciplinary clinic including an
endocrinologist, MFM specialist, registered dietitian nutritionist, and diabetes care
and education specialist, when available

In addition to focused attention on achieving glycemic targets, standard

2 E
preconception care should be augmented with extra focus on nutrition, diabetes
education, and screening for diabetes comorbidities and complications.

Women with preexisting type 1 or type 2 DM who are planning pregnancy or who
3 B
have become pregnant should be counseled on the risk of development and/or
progression of diabetic retinopathy. Dilated eye examinations should occur ideally
before pregnancy or in the first trimester, and then patients should be monitored
every trimester and for 1 year postpartum as indicated by the degree of
retinopathy and as recommended by the eye care provider.

Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243

PRECONCEPTION CARE FOR WOMEN WITH GDM OR DIABETES

Muhammad Ilham Aldika Akbar Diabetes Care 2022;45(Suppl. 1):S232–S243

Recommendation Summary of Postpartum Care Women with GDM

Zhang et al. BMC Pregnancy and Childbirth (2019) 19:200

Muhammad Ilham Aldika Akbar