Post-Partum management of women with Gestational Diabetes: an audit in a District General Hospital in the UK


Authors: (1) Indrajit Talapatra (MRCP): Speciality Doctor in Diabetes/Medicine, Royal Albert Edward Infirmary, Wigan WN12NN, UK


(2) Jane McAllister: Diabetes Specialist Nurse, Royal Albert Edward Infirmary, Wigan WN12NN, UK

(3) Ian Patrick Michael O’Connell (FRCP): Consultant in Diabetes/Medicine, Royal Albert Edward Infirmary, Wigan WN12NN, UK


Email Dr I Talapatra:


Introduction: Gestational diabetes (GDM) is defined as diabetes or any degree of glucose intolerance diagnosed or recognized for the first time in pregnancy.  The criteria according to various guidelines following oral glucose tolerance test (OGTT) are summarized below:


Table1: Criteria for Gestational Diabetes (OGTT is undertaken between 24-28 weeks)

NICE (National Institute of Clinical Excellence) 2008

IADPSG (International Association of Diabetes and Pregnancy Study Group) 2010

SIGN (Scottish Intercollegiate Network) 2010

Fasting >7 mmol/l or 2 hour >11.1 mmol/l

Fasting >5.1 mmol/l, 1 hour >10mmol/l or 2 hour > 8.5 mmol/l

Fasting >5.1mmol/l, 1 hour >10 mmol/l or 2 hour > 8.5 mmol/l



There is worsening of insulin resistance during gestation. Although Glucose tolerance returns to normal in the majority of women with gestational diabetes shortly after delivery, many studies have shown that there is an increased risk of developing diabetes in later life. One study from Denmark, which followed women for a median of six years, showed 34.4% women with GDM had abnormal glucose tolerance compared to 5.3% control women (1).  A further study showed 32.8% women with GDM had glucose intolerance or diabetes at 3 months after delivery compared to 3.2% in a control group (2).


Gestational diabetes can have significant health impacts on mother and child, including a higher risk for pre-eclampsia and miscarriage in mothers and shoulder dystocia, large for gestational age and macrosomia in babies and an increased risk of type 2 diabetes in mothers and children. In fact, women with gestational diabetes have a 35-60% chance of getting type 2 diabetes within 10-20 years post-partum (3). Despite these alarming statistics, a 2011 study published in Obstetrics and Gynaecology showed that only 68% of pregnant women got screened for gestational diabetes and only 19% of women diagnosed with GDM got screened post-partum (3). A federal task force recently issued a recommendation that all pregnant women get screened for GDM, regardless of risk factors, consistent with ACOG (American Clinical Obstetrics and Gynaecology guidelines).


The Risk Factors for development of diabetes in later life in women with gestational diabetes are summarized below (4)


Antepartum factors

Postpartum factors

High fasting glucose

High fasting glucose on postpartum OGTT

High glucose post-carbohydrate

High glucose at 2 hours on postpartum OGTT

Early Gestational age at diagnosis of GDM

Increasing maternal age

High maternal BMI at booking

Maternal weight gain following pregnancy

Previous history of GDM

Additional pregnancy

Insulin treatment during pregnancy





Aim of the audit : To find out if women who had gestational diabetes were managed appropriately postpartum.

Methods: Case notes of the patients with gestational diabetes who were supposed to attend for OGTT and the postpartum clinic between 1st January 2014 and 31st March 2014 were studied

Criteria : Guidelines of NICE(National Institute of Clinical Excellence), Diabetes Prevention Programme Research Group and those outlined in Diabetes in Pregnancy, Oxford Diabetes Library, 2012 were taken into account:

NICE GUIDELINES, March 2008 (5):


Criteria used for the audit:



Results: (1) No. of patients with gestational diabetes who were supposed to attend for OGTT between 1st January 2014 and March 31stMarch 2014: 43

(2) No of patients who actually attended the OGTT appointments (6 weeks after delivery): 33

(3) No of patients who attended the Post-partum clinic 1 week after OGTT: 28

Reasons: In 3 patients reasons were not known, 1 patient had no follow up appointment made and in 1 patient there was delay in follow up appointment (required clinical review prior to this)

(4) For the patients who had not attended, whether a letter of suggestions for glucose surveillance was generated to the GP (General Practitioner) with a letter also to the patient outlining: (1) need for post natal check, (11) need for annual surveillance; the patients were asked to take the initiative and access GPs for it, (111) access to diabetes team in future pregnancy, (1V) access to pre-conception clinic should diabetes develop in the interim.

Results (April 2014): 7 outstanding GP letters from DNAs (one of which was a ‘lost’ patient and in another patient there was delay in post natal OGTT);

3 outstanding patient letters from DNAs (those who did not attend).









Results for those who attended the post natal clinic (28 out of 43 or 64%):


No of patients on insulin and has the insulin been stopped?  


12 out of 28 (43%); insulin discarded following delivery in all 12 patients (100%)

Has the glucose been tested a few times following delivery?



The advice to patients to routinely do capillary blood glucose a few times following delivery is not given in our Trust. Only if they get the signs and symptoms of hyperglycaemia, they are asked to do the test

How many had pre-meal glucose >8.0 mmol/l and of them how many were again put on metformin?


Nil recorded

Whether breast feeding was encouraged


100%; also it is our hospital policy to strongly encourage and support breast feeding

Whether advice was given regarding diet and exercise



Referral was done to dietician in pregnancy and again advice was given at post natal review

Advice on contraception



Advice given to plan future pregnancy and have glucose test before conception


Advised annual surveillance with the GPs-100%. The patients are asked to approach the GPs themselves. (However this does not always happen, as we had seen patients in the past presenting with gestational diabetes during  subsequent pregnancies but had no annual surveillance with their GPs despite having gestational diabetes in their former pregnancies)

OGTT / FPG (fasting plasma glucose) and HbA1c  (Glycosylated haemoglobin) advised again in a year


OGTT advised (or FPG with HbA1c)- 100%

Annual FPG and HbA1c advised as alternate, if indicated by the patients’ original OGTT in pregnancy and their blood sugar pattern – i.e. if the patients had positive OGTT on the fasting value only and their pattern of home blood glucose monitoring showed high pre- breakfast blood glucose only on day to day tests then a FPG/HbA1c may be the recommended in a year’s time

Advice on increased risk of diabetes in later life










We aim to carry on doing ourselves or asking the GPs to do OGTT 6 weeks postpartum and OGTT or fasting plasma glucose with HbA1c 1 year thereafter to detect  in future more cases of impaired glucose tolerance or diabetes.

 The only goal of post-natal surveillance is not just to diagnose postnatal diabetes but will be to highlight to well-motivated women who have recent experience of a heritable tendency to diabetes that they can influence their own glucose metabolism, and that of their fledgling families. By highlighting IGT in the substantial proportion of women to whom this pertains, we hand them the power and responsibility to alter their own life style, activity levels and diet and of their families as well to prevent onset of future diabetes.






Declaration: This article is not under consideration for publication in any other journal. All the three authors contributed towards the preparation of the audit.


Conflict of Interests: None

We did not receive any grant from any Medical Company for preparation of the audit.



Copyright Priory Lodge Education Liited 2014 -

First Published August 2014

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