8.        Pregnancy and Diabetes        

            All women who are in their childbearing years should receive pre-pregnancy counseling for optimizing
            metabolic control prior to conception. Counseling for family planning is essential to achieve this goal.

American Indian and Alaska Native women are at increased risk for developing gestational diabetes (GDM), as are women with certain other risk factors, including but not limited to the following:

· previous gestational diabetes          · obesity

· previous fetal macrosomia                · insulin resistance syndrome

· unexplained stillbirth                           · polycystic ovarian syndrome (PCOS)

· congenital anomaly                             · family history of diabetes

American Indian and Alaska Native women should be screened for pre-existing diabetes early in pregnancy.  If early screening is negative, a screen for GDM should be repeated at 24-28 weeks gestation.

Women with GDM are at increased risk of developing type 2 diabetes after delivery (about one third of all AI/AN women with GDM will develop diabetes within 5 years).  These women should be re-tested by OGTT at least 6-12 weeks post delivery to determine their glycemic status.  Women with a normal postpartum OGTT should be re-tested every 1-3 years.  Bear in mind that diagnostic standards for diabetes in breastfeeding women have not been established.  Blood glucose should be monitored in the postpartum and lactating period, including regular self blood glucose testing, as clinically appropriate.

All women with a history of GDM should receive counseling/education regarding lifestyle modifications that will reduce or delay the development of type 2 diabetes.  Moreover, the importance of maintaining optimal glucose control prior to and during any subsequent pregnancy should be stressed. Mothers should be made aware that children of GDM pregnancies should be monitored for obesity and abnormalities of glucose utilization.

Further recommendations and guidelines for the screening, diagnosis and treatment of GDM may be found in the most recent Clinical Practice Recommendations of the American Diabetes Association (published annually), Management of Diabetes in Pregnancy, 3^rd Edition (ADA), 2000, and Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2): B1-B167, 1998