Contraception after gestational diabetes

Effect of prenatal counseling on postpartum follow-up and contraceptive use in women with gestational diabetes mellitus: a randomized controlled trial

BACKGROUND

Postpartum visit attendance for glucose screening and uptake of effective contraception is crucial after a pregnancy with gestational diabetes mellitus. Although postpartum women with recent gestational diabetes mellitus are generally advised in the early postnatal period to attend postpartum visits, data have shown suboptimal rates of postpartum glucose testing and of highly effective contraceptive use among these women. Compared with the early postnatal period, the antenatal period is when women and healthcare providers have more contact. This may facilitate a better relationship between the pregnant woman and her healthcare providers, thereby improving the women's trust in the providers' counseling.

OBJECTIVE

This study aimed to investigate if adding prenatal counseling to routine, early-postnatal counseling increases the rates of glucose screening and contraceptive use by 6 weeks postpartum among pregnant women with gestational diabetes mellitus.

STUDY DESIGN

A randomized controlled trial of 280 women diagnosed with gestational diabetes mellitus was conducted. Participants were randomly allocated (1:1, stratified using a permuted block method) to the intervention group (receiving prenatal counseling at 35-36 weeks of gestation plus routine, early-postnatal counseling) or the control group (receiving only routine, early-postnatal counseling). The 2 primary outcomes were glucose screening and highly effective contraceptive uptake by 6 weeks postpartum. The secondary outcome was the use of any contraceptive by 6 weeks postpartum. Data were analyzed according to the intention-to-treat principle.

RESULTS

The rate of postpartum glucose screening was 86.4% (121/140) in the intervention group, which was significantly higher than the rate of 50.7% (71/140) in the control group (adjusted relative risk, 1.70; 95% confidence interval, 1.27-2.28). The uptake of highly effective contraceptive methods was increased in the intervention group when compared with the control group (59.3% vs 30.7%; adjusted relative risk, 1.90; 95% confidence interval, 1.31-2.74). The uptake of any contraceptive method by 6 weeks postpartum was reported by 122 of 140 participants (87.1%) in the intervention group and by 77 of 140 participants (55.0%) in the control group (adjusted relative risk, 1.58; 95% confidence interval, 1.19-2.10).

CONCLUSION

Adding prenatal counseling to routine, early-postnatal counseling significantly increased the rates of glucose screening and contraceptive use by 6 weeks postpartum among pregnant women with gestational diabetes mellitus. Given that the incorporation of counseling on postpartum glucose testing and effective contraceptive use into standard prenatal care requires minimal increases in expenditure and manpower, implementation of this counseling strategy in clinical practice seems advisable.

Contraceptive Options Following Gestational Diabetes: Current Perspectives

Gestational diabetes mellitus (GDM) complicates approximately 7% of pregnancies in the United States. Along with risk factors related to pregnancy, women with a history of GDM also have an increased risk of developing type 2 diabetes mellitus later in life. These women require special consideration when discussing contraception and other reproductive health issues. GDM carries a category 1 rating in the US Medical Eligibility Criteria for all contraceptive methods, which supports safety of the various methods but does not account for effectiveness. Contraceptive options differ in composition and mechanisms of action, and concerns have been raised about possible effects of contraception on metabolism. Clinical evidence is limited to suggest that hormonal contraception has significantly adverse effects on body weight, lipid, or glucose metabolism. In addition, the majority of evidence does not suggest a relationship between development of type 2 diabetes mellitus and use of hormonal contraception. Data are limited, so it is challenging to make a broad, general recommendation regarding contraception for women with a history of GDM. A woman’s history of GDM should be considered during contraceptive counseling. Discussion should focus on potential medical comorbidities and the implications of GDM on future health, with special consideration of issues including bone health, obesity, cardiovascular disease, and thrombosis risk. Providers must emphasize the importance of reliable, highly effective contraception for women with GDM, to optimize the timing of future pregnancies. This approach to comprehensive counseling will guide optimal decision-making on contraceptive use, lifestyle changes, and planning of subsequent pregnancies.

Current Therapies for the Medical Management of Diabetes

Diabetes affects a large and diverse number of individuals who share in common its risks for complications but who differ greatly from one another in age, health, and a number of circumstances influential to successful treatment. Because type 2 diabetes comprises the majority of diabetes cases, a number of agents have been developed for its treatment. Their unique properties offer opportunities to overcome some of the treatment limitations of older medicines and enable a more individualized and flexible approach to glucose-lowering. At the same time, new medications are accompanied by greater costs and uncertainties about their long-term benefits or safety, and thus the present state of care for type 2 diabetes places focus on a process of shared decision-making between the clinician and patient as to which treatments can optimize health while minimizing harms. We review the major classes of diabetes agents and provide some guidance for how one might approach decision-making in choosing among them.

Gestational diabetes: risks, management, and treatment options

Gestational diabetes mellitus (GDM) is commonly defined as glucose intolerance first recognized during pregnancy. Diagnostic criteria for GDM have changed over the decades, and several definitions are currently used; recent recommendations may increase the prevalence of GDM to as high as one of five pregnancies. Perinatal complications associated with GDM include hypertensive disorders, preterm delivery, shoulder dystocia, stillbirths, clinical neonatal hypoglycemia, hyperbilirubinemia, and cesarean deliveries. Postpartum complications include obesity and impaired glucose tolerance in the offspring and diabetes and cardiovascular disease in the mothers. Management strategies increasingly emphasize optimal management of fetal growth and weight. Monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy can decrease comorbidities associated with GDM. Consensus is lacking on ideal glucose targets, degree of caloric restriction and content, algorithms for pharmacotherapy, and in particular, the use of oral medications and insulin analogs in lieu of human insulin. Postpartum glucose screening and initiation of healthy lifestyle behaviors, including exercise, adequate fruit and vegetable intake, breastfeeding, and contraception, are encouraged to decrease rates of future glucose intolerance in mothers and offspring.

GDM: postpartum management to reduce long-term risks

Diabetes prevalence has increased dramatically, with 1.3 million new cases diagnosed annually. Women with gestational diabetes mellitus (GDM) are at increased risk for developing overt diabetes later in life. In addition, their offspring, exposed to the diabetic environment in utero, are also at increased risk for developing obesity, glucose intolerance, and type 2 diabetes later in life. Diabetes begets diabetes. The GDM diagnosis provides the medical community with an opportunity to intervene with strategies to prevent and/or delay the onset of diabetes and its associated long-term complications. This article reviews the roles of medical nutrition therapy, physical activity, and pharmacotherapy in preventing type 2 diabetes in women with a GDM history.