Volume 8: No. 6, November 2011
Postpartum Screening for
Diabetes Among Women With a History of Gestational Diabetes Mellitus
Alison Tovar, PhD, MPH; Lisa Chasan-Taber, ScD; Emma Eggleston, MD;
Emily Oken, MD, MPH
Suggested citation for this article: Tovar A,
Chasan-Taber L, Eggleston E, Oken E. Postpartum screening for diabetes among
women with a history of gestational diabetes mellitus. Prev Chronic Dis
http://www.cdc.gov/pcd/issues/2011/nov/11_0031.htm. Accessed [date].
To make recommendations for future clinical, public health, and research
practices for women with abnormal glucose tolerance during pregnancy, we
reviewed the latest evidence regarding rates of postpartum diabetes screening
and types of screening tests.
We searched PubMed for journal articles published from January 2008 through
December 2010 that reported on postpartum screening and studies designed to
prevent progression to type 2 diabetes among women with gestational diabetes
mellitus (GDM). Two authors independently reviewed titles and abstracts from 265
From 34% to 73% of women with GDM completed postpartum glucose screening.
Predictors of higher screening rates included older age,
nulliparity, and higher
income or education. Screening rates varied by race/ethnicity; Asian women were
more likely to be screened than were other racial/ethnic minorities. Women who
received prenatal care, who were treated with insulin during pregnancy, or who
completed a 6-week postpartum visit were also more likely to receive screening.
A moderate proportion of women screened had type 2 diabetes (1.2%-4.5%) or
Rates of postpartum screening among women with a history of GDM are low; only
half of women in most populations are screened. Our findings can inform future
screening initiatives designed to overcome barriers to screening for both
providers and patients. Well-designed lifestyle interventions specific to women
with a history of abnormal glucose tolerance during pregnancy and also studies
to determine the efficacy and safety of pharmacological interventions will be
important to help prevent progression to diabetes among these high-risk women.
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Type 2 diabetes mellitus, a global epidemic, affects approximately 21 million
people in the United States (1). According to the 2005-2006 National Health and
Nutrition Examination Survey (NHANES), the standardized total diabetes
prevalence was 17.4% among both men and women, which reflects an absolute
increase from the 1988-1994 NHANES of 3.7% among women compared with 2.1% among
men (2). During this period, the number of women with undiagnosed type 2
diabetes increased, whereas the number of men with undiagnosed diabetes
decreased. Given the damaging effect of prolonged undetected hyperglycemia,
prevention and early diagnosis of type 2 diabetes is cost-saving and of public
health importance (3).
Diagnosis of both gestational diabetes mellitus (GDM) and milder abnormal
glucose tolerance in pregnancy helps health care professionals identify women
who are at high risk for type 2 diabetes (4-7). GDM confers a 7-fold risk for
future type 2 diabetes (8), and up to one-third of women with type 2 diabetes
have been diagnosed with GDM (9). Although recommendations for postpartum
screening of women with a history of GDM exist (3,10), many women are not
screened. Furthermore, the most appropriate type and frequency of screening has
recently been the subject of active discussion and investigation (11-13).
This article is part of the “Best Practices for Screening Reproductive Aged
Women for Chronic Disease and Related Risk Factors” special collection in this
issue of Preventing Chronic Disease. We review the latest evidence
regarding postpartum screening rates and results among women with a history of
GDM and also discuss findings from observational studies and randomized trials
designed to prevent progression to type 2 diabetes among postpartum women with a
history of GDM. In addition, we make recommendations for future clinical, public
health, and research practice.
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To review postpartum screening rates and studies designed to prevent
progression to type 2 diabetes among women with a history of GDM, we searched
published journal articles in English from January 1, 2008, through December 31,
2010. We focused on the most recent literature to augment and update other
recent reviews. We searched PubMed by using the search terms 1) “gestational
diabetes” and “postpartum” or 2) or “gestational diabetes” and “follow-up.” We
also included additional articles that we identified by reviewing reference
lists of studies and review articles.
Study selection and data extraction
Our initial search returned 265 articles. Two authors (A.T. and E.O.)
independently reviewed titles and abstracts and obtained all potential articles
for additional review; they also conducted all data abstraction and reached
consensus through discussion about any disagreement. Articles that were deemed
irrelevant and excluded from the review were related to screening for GDM during
pregnancy only, screening for metabolic syndrome or cardiovascular disease, or
maternal or infant outcomes associated with GDM, type 1 diabetes, obesity during
pregnancy, fertility and obstetric complications, interventions during pregnancy
to improve GDM or improve pregnancy outcomes for mother or infant, or articles
related to other diseases during pregnancy such as preeclampsia or polycystic
ovary syndrome. Relevant articles reported on the following topics: 1)
recommendations for types of screening tests, 2) rates and results of diabetes
screening among women with prior GDM diagnosis at any time period postpartum, 3)
results and comparisons of different types of screening tests, 4) predictors of
and barriers to screening, and 5) interventions to improve rates of postpartum
diabetes screening. We identified 11 published studies that evaluated rates and
results of postpartum screening for diabetes among women with GDM (1-3) and 21
studies that discussed predictors of and barriers to screening or interventions
to improve rates of postpartum diabetes screening (4,5). We discuss findings for
the first postpartum year and the later postpartum period separately.
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Postpartum screening for type 2 diabetes among women with GDM
Both the American College of Obstetricians and Gynecologists (10) and the
American Diabetes Association (3,14) recommend that women whose pregnancy was
complicated by GDM be screened for persistent glucose abnormality at 6 to 12
weeks postpartum with either a fasting plasma glucose (FPG) test alone or with a
fasting 75-g, 2-hour oral glucose tolerance test (OGTT). The OGTT is more
sensitive, with reported sensitivities of 100% compared with 67% for FPG. The
FPG test may be more acceptable to women because it requires less time, which
could help overcome attrition in attendance for repeated follow-up testing in
addition to being more easily tolerated (13,15). Criteria for diagnosing
diabetes postpartum via a 75-g OGTT are similar to those for nonpregnant adult
women (3), and thus results can identify overt diabetes mellitus, impaired
fasting glucose (IFG), impaired glucose tolerance (IGT), or normal glycemia;
however, the FPG test can identify IFG but not IGT. Both the American College of
Obstetricians and Gynecologists and the American Diabetes Association recommend
that women with a history of GDM with a normal postpartum screening be
rescreened every 3 years, and women with IFG or IGT or both (prediabetes) should
be rescreened annually. Recent consensus guidelines recommend follow-up testing
with an OGTT at 1 year postpartum, FPG test yearly, and consideration of an OGTT
at 3 years (16).
Rates and results of postpartum screening for diabetes
We identified 11 studies published from 2008 through 2010 (17-27) that
evaluated rates of postpartum screening for diabetes among women with GDM; of
those, 8 were based on review of medical records and 3 were based on mailed
questionnaires or interviews
(Table). Together, these
studies included 32,240 women with pregnancies complicated by GDM from 1999
through 2008. Postpartum diabetes screening rates varied but were generally
poor: 34% to 73% (median, 48%) of women overall were screened.
Three of these studies included large, diverse populations of women receiving
care at health maintenance organizations (HMOs) in California and Oregon
affiliated with Kaiser Permanente. All 3 studies demonstrated substantial
increases in screening during recent years. For example, among 14,448 women with
GDM who received care at Kaiser Permanente Northern California, rates of
postpartum screening increased from 20% in 1995 to 56% in 2006 (18). Even in the
most recent years, however, fewer than 60% of women were screened. In 5 studies
of smaller populations seen at referral centers in the United States (San
Francisco, Texas), Canada, Poland, and Turkey, screening rates were similar
(33.7%, 57.0%, 48.2%, 37.2%, and 47.4%, respectively) (17,22,23,26,27). Morrison
et al surveyed Australian women whose mean (SD) duration since delivery was 21.2
(8.4) months. Respondents reported a higher overall screening rate of 73.2%,
although only 27.3% reported having been screened according to Australian
Diabetes in Pregnancy Society guidelines (a 75-g OGTT administered 6 to 8 weeks
Although the recommended timing of screening is 6 to 12 weeks postpartum, all
but 1 of the studies included longer follow-up (18). However, screening rates
were not markedly improved when the time window was broader. For example in
2006, screening rates were 50.3% in a study within 3 months of postpartum
follow-up (20), 48.2% to 51.0% in 2 studies within 6 months of postpartum
follow-up (19,22), and 55.9% in a study within 12 months of postpartum follow-up
(18). Among women seen at Kaiser Southern California who were screened within 6
months, 41% were screened from 7 days through 6 weeks postpartum, 46% from 6
through 12 weeks postpartum, and 12% from 12 weeks through 6 months postpartum
The type of screening tests included and results varied across the studies.
Ogonowski and Miazgowski and Swan et al included only OGTT (23,25). The other 9
studies included either FPG or OGTT (17-22,24,26,27) although, of these, 2 did
not report percentages of women screened with each test (17,21). In 4 studies,
79% to 100% of women were screened with FPG (18-20,27), whereas in the remaining
3 studies, most women (56%-95%) were screened with OGTT (22,24,26) (Table). A
number of women screened postpartum were found to have type 2 diabetes
(1.2%-4.5%) or prediabetes (12.2%-36%) (Table). In Turkey, Kerimoglu et al
reported that 50% (5 of 10) of the patients who received an OGTT and 7.4% (2 of
27) of the patients who received FPG were diagnosed with type 2 diabetes (27).
Other studies have found that up to one-third of women with GDM will have
abnormal postpartum screening (diabetes, IFG, or IGT) (28,29). According to
Kwong et al, using only FPG in postpartum screening would cause up to 75% of
women with IGT or type 2 diabetes to be missed (22). Similarly, Hunt et al found
that of the women with postpartum OGTT with IGT, approximately one-third had
outside range values on the 2-hour value alone (26). These findings are
consistent with a substantial literature that a single FPG has a sensitivity of
16% to 89% when compared with an OGTT (13,15,30).
Three studies of postpartum screening rates used different methods and did
not include test results. Almario et al identified women with GDM by using
laboratory data from a university teaching hospital and found that only
one-third of medical records included plans to perform postpartum screening
(21). Morrison et al mailed questionnaires to Australian postpartum women with a
history of GDM and found a higher rate of self-reported screening at any time
(73.2%) compared with the 38%-45% elsewhere at the time of the study, although
many fewer women (27.3%) received an OGTT within 6 to 8 weeks postpartum as per
Australian recommendations (24). Another survey of 77 Australian women with a
GDM pregnancy found that 61% self-reported postpartum diabetes screening (25).
Factors associated with likelihood of postpartum diabetes screening
Rates of diabetes screening among postpartum women with a history of GDM
differed by race and ethnicity, although findings varied (Table). For example,
Stasenko et al found that Hispanic women had the lowest follow-up frequency (18%
compared with 28% of white women and 29% of African American women) (17),
whereas Lawrence et al found Hispanic women in another population were more
likely to be screened (51% vs 48% of white women and 27% of African American
women) (19). Asian women were most likely to be screened compared with women of
other racial and ethnic backgrounds (odds ratio, 1.4; 95% confidence interval,
1.2-1.5) (18,19). Other patient characteristics associated with higher rates of
postpartum screening included older age,
nulliparity, and higher
income or education. Women who received prenatal care, were treated with insulin
during pregnancy, or completed a 6-week postpartum visit were also more likely
to receive a postpartum diabetes screening (Table).
Of the 21 additional studies identified, 3 discussed barriers to postpartum
screening (31-33). Barriers to postpartum screening included provider, patient,
and system-level issues. In surveys of providers in Massachusetts, North
Carolina, and Canada, providers commonly identified lack of patient attendance
at a postpartum visit as the primary reason for not completing postpartum
screening (31,32). However, in a chart review of data from 197 Massachusetts
women with pregnancies complicated by GDM from 2000 through 2001, Smirnakis et
al found that 94% of the women completed postpartum Papanicolaou screening,
whereas 67% received any postpartum glucose testing and only 37% had a FPG or
OGTT (34). Other barriers to postpartum screening identified by clinicians
included 1) clinicians’ perception that screening guidelines were “inconsistent,”
2) patient cost or inconvenience (31), 3) lack of documentation of GDM on
problem lists, and 4) poor communication between obstetricians and primary care
providers (33). Patients identified time pressure as a primary barrier (32).
Postpartum reminders may help to improve diabetes screening rates. In a
randomized trial of 223 women, mailed reminders resulted in improved screening
rates within 12 months postpartum when sent to physicians only (52%), patients
only (55%), or both (61%), compared with no reminders (14%) (35). However, only
48% of women seen at a Canadian diabetes referral clinic completed postpartum
glycemic screening, even though women were given laboratory requisitions before
delivery and received a telephone reminder if testing was not completed by 6
months postpartum (22). Ferrara et al reported that the proportion of women
receiving an OGTT increased from 17% in 2005 to 72% in 2006, when Kaiser
Permanente Northern California instituted a nurse-managed care program that
included greater attention to postpartum screening guidelines (18).
Factors associated with increased likelihood of abnormal postpartum
screening test results
Women who have a family history of diabetes, are from a high-risk
racial/ethnic group (eg, South Asian), have a higher prepregnancy or postpartum
body mass index (BMI) (>25 kg/m2), have a higher glucose or greater
number of abnormal glucose values on prenatal glycemic screening, who are
diagnosed with GDM earlier in pregnancy, or who require insulin during pregnancy
are more likely to have prediabetes or type 2 diabetes on postpartum screening
(7,13,28,36-41). Fewer studies have examined potentially modifiable
characteristics such as maternal diet (total energy intake, fat intake),
physical activity, and breastfeeding (37), but these studies suggest that
certain dietary patterns may play a role in increasing risk for developing type
Diabetes screening after the early postpartum period
Risks for abnormal glycemia persist even after the early postpartum period.
In a study by Retnakaran et al, among 70 women with GDM but normal OGTT at 3
months postpartum, 17% had prediabetes (IFG, IGT, or both) when reevaluated with
OGTT at 12 months postpartum, compared with 3% of 73 women with normal glucose
tolerance both during pregnancy and at 3 months postpartum (4). Even women with
lesser degrees of abnormal glucose during pregnancy were at elevated risk for
abnormal 12-month OGTT despite a normal 3-month OGTT (39). Risk factors for
abnormal 12-month screening included higher 3-month postpartum glucose, BMI, low
density lipoprotein cholesterol, triglycerides, and leptin, and lower high
density lipoprotein cholesterol and adiponectin (4).
Risks for prediabetes, type 2 diabetes, and metabolic syndrome continue to
increase over time, since pregnancy. Recent studies found that 16% to 30% of
women with GDM develop type 2 diabetes by 5 to 10 years postpartum (42-44), and
more cases accumulate even later. In a 2009 meta-analysis of 20 studies that
included 675,455 women and 10,859 type 2 diabetes events, women with a GDM
pregnancy had a nearly 7.5-fold increased risk of developing diabetes (8).
Within 5 years of a pregnancy complicated by GDM, women had a relative risk of
4.7, which increased to 9.3 in those who were examined more than 5 years
postpartum. In a 2010 population-based cohort study of more than 6,000 women
from northern Finland followed since their pregnancies in 1986, the cumulative
incidence of diabetes continued to increase even at 20 years postpartum. Rates
were particularly high among women with a history of GDM who were overweight
(26%), compared with controls who had no risk factors for GDM (0.7%) (45). Risk
factors for late progression to type 2 diabetes are similar to risk factors for
early progression and include low insulin sensitivity, insulin resistance and
progressive insulin secretory defect, and gain in weight and body fat.
Although we identified several recent screening studies completed within the
first postpartum year, we found no recent studies that evaluated rates of
diabetes screening in clinical settings after this time period. We found only 1
published intervention to promote longer-term follow-up of women with a history
of GDM; in South Australia beginning in 2002, women with GDM were invited to
provide contact information to a GDM registry, which then sent women annual
mailed reminders for glycemic screening and requests for diabetes screening
updates beginning at 15 months postpartum (46). Findings suggest that these
reminders helped promote screening. While 56% of women reported glycemic
screening in the first postpartum year (before the intervention began), 75%
reported having been screened during the second postpartum year. However, fewer
than half of eligible women responded to the update requests, and thus reporting
bias was likely.
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Because the prevalence of type 2 diabetes is increasing among all groups in
the United States and undiagnosed cases are particularly high among women,
prevention and early diagnosis of type 2 diabetes have become public health
priorities. A diagnosis of GDM identifies women who are at high risk for
developing type 2 diabetes. We found that even recent studies published from
2008 through 2010 documented poor rates of postpartum screening for diabetes
among women with pregnancies complicated by GDM.
Most of the studies we reviewed included follow-up periods longer than the
recommended 6 to 12 weeks postpartum. Nevertheless, screening rates were low.
This finding coincides with results from other studies, which suggest that some
barriers to screening (eg, lack of patient attendance, inconsistency of
screening guidelines, patient cost or inconvenience , and poor communication
between obstetricians and primary care providers ) may persist beyond the
recommended screening timeframe. Since risks for abnormal glycemia persist even
after the early postpartum period (4,39), ongoing screening is required for
women with a history of GDM every 1 to 3 years depending on the results of the
postpartum screen and the likelihood of a future pregnancy. Although we found no
recent studies that evaluated clinical screening for diabetes after the first
postpartum year, rates of screening over the long term are probably even lower
than during the early postpartum period. Further studies will be needed to
evaluate the prevalence, predictors, and outcomes of long-term screening.
According to Lawrence et al, Kwong et al, and Hunt and Conway, many women
with IGT or type 2 diabetes were likely missed when women were screened by using
only an FPG test (19,22,26). This finding is consistent with earlier studies
that found that the FPG test alone has poor sensitivity for diagnosis of
prediabetes and type 2 diabetes compared with OGTT (30); however, its greater
convenience may result in higher screening rates (47). Nevertheless, in 2007,
Kim et al simulated postpartum screening for diabetes with FPG, OGTT, and
hemoglobin A1c annually, every 2 years, and every 3 years over a period of 12
years, and found that OGTTs resulted in lower costs per case detected than FPG
or hemoglobin A1c testing (48). More recently, the American Diabetes Association
has allowed for the use of hemoglobin A1c as a screening test among the general
population at risk for diabetes (3). Whether this test will be recommended for
early postpartum screening remains unclear, but further research in this area is
needed as the convenience and low participant burden of the hemoglobin A1c has
the potential to increase screening rates.
Our review confirms that type 2 diabetes is common among postpartum women
with a history of GDM and that screening is acceptable to many women. According
to previous studies, screening is appropriate only if an effective intervention
exists and if early identification and treatment result in improved outcomes
(49). Findings from intervention studies, most notably the Diabetes Prevention
Program (DPP), provide evidence that lifestyle changes or pharmacotherapy can
prevent the onset of type 2 diabetes among women with a history of GDM who have
abnormal test results (IFG or IGT) on postpartum screening (50-56). However, the
lifestyle intervention in the DPP was intensive and expensive, limiting its
generalizability. Additionally, women with a GDM history entered the DPP an
average of 12 years postpartum. Given the demands of parenting an infant, it is
likely that few women in the early postpartum period could engage in such an
intensive program, yet early interventions are important. The first few
postpartum years represent a particularly high-risk period for development of
prediabetes or type 2 diabetes.
Randomized controlled trials of postpartum lifestyle interventions have not
targeted women with GDM in particular, yet a recent systematic review found that
6 of 8 lifestyle interventions were effective at promoting postpartum weight
loss (57). Recent studies (25,33,58) suggest that ample opportunity exists to
improve weight and related lifestyle behaviors among postpartum women with a
history of GDM. In addition to the traditional behavior change targets of diet
and physical activity, observational studies suggest that breastfeeding,
adequate sleep, and avoidance of television viewing may also help minimize
postpartum weight retention and diabetes risk (59-62).
We identified no studies of postpartum screening for diabetes among women
with GDM that also included information on prepregnancy or early pregnancy
glycemic status. Whereas historically GDM has been defined as “any degree of
glucose intolerance with onset or first recognition during pregnancy” (63), more
recently it has been recognized that this definition includes a spectrum of
glycemia entering pregnancy, including women with pregestational prediabetes or
type 2 diabetes and also those with transient abnormal glucose levels that
resolve after delivery. As more women become pregnant at older ages and with
higher weights, a fraction of women diagnosed with GDM may actually have
undiagnosed prediabetes or overt type 2 diabetes (64-66). Even women with
abnormal glucose levels during pregnancy that do not meet criteria for GDM are
at increased risk for postpartum prediabetes and type 2 diabetes (7,36). Recent
consensus guidelines recommend first-trimester screening among women at high
risk as well as thresholds that allow for diagnosis of overt diabetes at the
time of early third trimester screening, which will identify women who merit
especially close postpartum follow-up (67). As of 2011, these guidelines are
endorsed by the American Diabetes Association (14). Future studies with
information on women’s glycemic status throughout the reproductive years will be
invaluable in understanding the effect of abnormal glucose on outcomes during
and after pregnancy.
There were several limitations to this systematic review. Because most of
these studies were conducted within a large HMO system, where structural
interventions for follow-up are often in place, or in diabetes referral clinic
populations, postpartum screening rates are probably even lower among the
general population. Also, 2 of the identified studies that reported higher
screening rates were completed in Australia, a country with a different health
care system from that of the United States. Newly recommended guidelines for GDM
diagnosis will identify a much larger number of US women, perhaps 1 in 5
pregnant women, who will require treatment during pregnancy and screening
postpartum (67). Future research is needed to assess the success of structural
interventions in increasing postpartum screening rates in settings other than
large HMOs, and also other intervention strategies such as those delivered
directly to women via Internet, cell phone, or other technologies. Proven,
cost-effective, and readily generalizable strategies to promote both early and
ongoing postpartum diabetes screening among women with a history of GDM are
In conclusion, as rates of type 2 diabetes continue to increase, especially
among women, more prevention opportunities are needed. Among women who
experience glucose abnormalities during pregnancy, screening during the
postpartum period offers a window of opportunity for early identification of
diabetes and prediabetes. Although rates of screening have increased during the
past several decades, these rates are still not optimal and need to increase,
given the type 2 diabetes epidemic faced by both developed and developing
nations. Increasing rates of screening may be challenging; different players
(health care providers and public health workers) need to be involved. Future
work should focus on reducing barriers to screening for both providers and
patients. Lifestyle interventions specific to women with history of GDM are
needed, as are studies to determine the efficacy and safety of pharmacological
interventions among women of childbearing age.
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Corresponding Author: Alison Tovar, PhD, MPH, John Hancock Research Center on
Physical Activity, Nutrition, and Obesity Prevention, Friedman School of
Nutrition Science and Policy, Tufts University, 150 Harrison Ave, Room 243,
Boston, MA 02111. Telephone: 617-636-3546. E-mail:
Author Affiliations: Lisa Chasan-Taber, University of Massachusetts, Amherst,
Massachusetts; Emma Eggleston, Emily Oken, Harvard Medical School and Harvard
Pilgrim Health Care, Boston, Massachusetts. Dr Eggleston is also affiliated with
the Brigham and Women’s Hospital, Boston, Massachusetts.
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