<strong>2008</strong> CLINICAL PRACTICE GUIDELINES S174 glucose, IGT and type 2 diabetes (141,142). The cumulative incidence increases markedly in the first 5 years postpartum and more slowly after 10 years (143,144). At 3 to 6 months postpartum, risks of dysglycemia are in the 16 to 20% range, and the cumulative risks increase to a 30 to 60% range, depending on time since the index pregnancy and the population studied.The strongest predictor of early postpartum development of diabetes is elevated FPG during pregnancy (145,146). Some women with GDM, especially lean women
Long-term risks in offspring There is compelling evidence that offspring exposed to GDM are at increased risk of obesity and IGT, especially if large for gestational age and born to obese mothers (58,159-162). In a <strong>Canadian</strong> cohort of children exposed to GDM, 7% had IGT at age 7 to 11 years (162). In the Pima Indian population, as many as 70% of offspring exposed to diabetes in utero had type 2 diabetes at age 25 to 35 years (163). Breastfeeding may lower the risk (82,138,164). The importance of tight glycemic control during pregnancy to prevent these outcomes is not clearly established.The need for increased surveillance of these children requires further study. Planning subsequent pregnancies Women with previous GDM should plan future pregnancies in consultation with their healthcare providers (165,166). Glucose tolerance should be assessed prior to conception to assure normoglycemia at the time of conception, and any glucose abnormality should be treated. In an effort to reduce the risk of congenital anomalies and optimize pregnancy outcomes, all women should take a folic acid supplement of 0.4 to 1.0 mg (48). OTHER RELEVANT GUIDELINES Screening for Type 1 and Type 2 <strong>Diabetes</strong>, p. S14 Targets for Glycemic Control, p. S29 Chronic Kidney Disease in <strong>Diabetes</strong>, p. S126 Type 1 <strong>Diabetes</strong> in Children and Adolescents, p. S150 REFERENCES 1. Yogev Y, Ben-Haroush A, Chen R, et al. Diurnal glycemic profile in obese and normal weight nondiabetic pregnant women. Am J Obstet Gynecol. 2004;191:949-953. 2. Nielsen LR, Ekbom P, Damm P, et al. HbA1c levels are significantly lower in early and late pregnancy. <strong>Diabetes</strong> Care. 2004; 27:1200-1201. 3. Langer O, Conway DL. Level of glycemia and perinatal outcome in pregestational diabetes. J Matern Fetal Med.2000;9:35- 41. 4. Parretti E, Mecacci F, Papini M, et al. 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Outcome of pregnancy complicated by pre-gestational diabetes – improvement in outcomes. Aust N Z J Obstet Gynaecol. 2002;42:478-481. 11. Hadden DR, Cull CA, Croft DJ, et al. Poor pregnancy outcome for women with type 2 diabetes. Diabetic Med. 2003;20: 506-507. 12. Dunne F, Brydon P, Smith K, et al. Pregnancy in women with type 2 diabetes: 12 years outcome data 1990-2002. Diabet Med. 2003;20:734-738. 13. Farrell T, Neale L, Cundy T. Congenital anomalies in the offspring of women with type 1, type 2 and gestational diabetes. Diabetic Med. 2002;19:322-326. 14. Boulot P, Chabbert-Buffet N, d’Ercole C, et al; <strong>Diabetes</strong> and Pregnancy Group, France. French multicentric survey of outcome of pregnancy in women with pregestational diabetes. <strong>Diabetes</strong> Care. 2003;26:2990-2993. 15. dos Santos Silva I, Higgins C, Swerdlow AJ, et al. Birthweight and other pregnancy outcomes in a cohort of women with pregestational insulin-treated diabetes mellitus, Scotland, 1979- 95. 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