Clinical guidelines for women with a history of gestational diabetes and their offspring

Abstract

Purpose

GDM increases the risk of type 2 diabetes mellitus (T2DM) and also has adverse effects on the health status of offspring. This clinical guideline covers the postpartum period, with specific references to prevention, screening, diagnosis, and management of T2DM in mothers with a history of GDM and their children.

Methods

The present research is a clinical guideline for women who experienced GDM. Clinical questions were created based on the PICO framework at the outset, and appropriate evidence was searched in electronic databases like PubMed, Scopus, and WOS. Two rounds of the Delphi technique were employed to achieve consensus among experts and led to the final draft of the guideline, which consisted of six guiding questions and 37 clinical recommendations. Quality appraisal of the guidelines was conducted by the AGREE instrument, an instrument for assessing six domains of guideline quality based on 23 confirmed criteria.

Results

The final guideline includes 37 recommendations that are divided into six separate modules: risk factors, prevention, screening, diagnosis, and diagnostic measures, postpartum follow-up, education, and care, recurrent pregnancy, and pharmacologic interventions. The key recommendations in this guideline include lifestyle changes, commencement of metformin, and a structured postpartum follow-up plan to lower the risk of T2DM.

Conclusion

This Clinical practice guideline presents evidence-based suggestions to help prevent and manage T2DM in women with a history of GDM and in offspring, emphasizing lifestyle changes in exercise, diet, and breastfeeding. It reiterates the necessity of periodic glucose-tolerance screening tests, in addition to structured follow-up and patient education.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01689-3.

Introduction

The prevalence of gestational diabetes mellitus (GDM) differs significantly in various geographical locations and nations. Research that assessed the worldwide prevalence of GDM found that the Middle East and North Africa have the highest mean prevalence of 12.9%. Following that, Southeast Asia and Western Pacific regions both have a mean prevalence of 11.7%. South and Central America both have a mean prevalence of 11.2%, and Africa has documented a prevalence of 8.9%. The lowest prevalence average of 7% was in the Caribbean and North America. The lowest prevalence of GDM was reported in Europe, with an average of 5.8% [1]. Other reports have varying figures. For instance, the prevalence of GDM in Europe has been estimated to be 5.4% (range 3.8–7.8%) [2], and 10.1% (range 6.5–15.7%) in Asia [3]. Despite these variations, the prevalence of GDM is increasing at a very rapid pace throughout the world. For example, the overall prevalence in Iran is 3.41%, but in certain regions it reaches up to 18.6% [4].

Mothers with a history of GDM are considered a high-risk group for developing type 2 diabetes mellitus (T2DM) later in life [5]. Despite this, there is a lack of studies examining the possible risk of T2DM in mothers who have had GDM. A retrospective cohort study showed that women with a known history of GDM have a 9.6 times greater risk of later developing T2DM. In addition, it was found that the risk of T2DM in GDM patients, 15 years after they were first diagnosed, is 25.8% [6]. In a long-term follow-up study from Denmark, 40% of women with prior GDM developed T2DM, and 27% had impaired glucose tolerance. Impaired glucose tolerance was this study’s most significant independent predictor of T2DM [7].

In another study, 696 GDM women and 70 non-GDM women were followed for five years postpartum. The cumulative incidence of diabetes and impaired glucose tolerance (IGT) among the GDM group was 13.8% and 42.4%, respectively, compared to 0% and 2.8% in the control group (P < 0.05) [8]. A meta-analysis including 20 studies with varying follow-up durations evaluated 1,332,373 individuals (67,956 with GDM history and 1,264,417 controls). It found that the pooled relative risk of T2DM in women with GDM history was about 10-fold more significant than in healthy women (relative risk 9.51; 95% confidence interval, 7.14 to 12.67; P < 0.001). The cumulative incidence of T2DM in women with prior GDM was 16.46% (95% confidence interval, 16.16 to 16.77%) [9].

A 2020 meta-analysis comprising 170,139 women with GDM and 34,627 women who developed T2DM after GDM indicated that the overall incidence of T2DM after GDM was 26.20 per 1,000 person-years (95% confidence interval, 23.31 to 29.10) [10]. A 2021 meta-analysis of 1,809 studies and 39 cohorts comprised 2,847,596 women, of whom 78,893 developed T2DM six weeks or more after delivery. The crude relative risk of T2DM in women discovered six weeks or more after delivery was between 1.32 (95% confidence interval, 0.46 to 3.37) and 47.25 (95% confidence interval, 295 to 758.01) [11]. Additionally, a 2019 study highlighted that GDM can be a T2DM risk factor in children younger than 22 years. It showed that the incidence of diabetes in offspring born to mothers with gestational diabetes (per 10,000 people per year) was 4.52-fold higher than that in offspring born to mothers without gestational diabetes [12].

GDM poses adverse severe health consequences for both mothers and their children [13]. Children born to mothers with GDM are at increased risk for severe complications, including macrosomia, birth injuries, shoulder dystocia, neonatal hypoglycemia, and respiratory distress [14]. Mothers with GDM also face multiple complications, such as gestational hypertension, preeclampsia, and polyhydramnios [14]. Additionally, the recurrence rate of GDM in subsequent pregnancies is estimated to be 48% [15].

Neglecting follow-up of women who are diagnosed with GDM during pregnancy can result in adverse health consequences to both the mothers and offspring, potentially resulting in serious long-term complications [16]. Empirical findings show that offspring of mothers who develop GDM have an eight times higher risk of developing T2DM or prediabetes during young adulthood [17, 18]. These findings highlight that GDM not only elevates the risk of T2DM in mothers postpartum but also predisposes their offspring to T2DM and its complications [19]. In addition, it has been revealed that fetal exposure to maternal GDM is linked to higher incidences of childhood and adult obesity and T2DM, irrespective of obesity-related risk and hereditary predisposition. Such effects underscore the importance of handling GDM to reduce its long-term impact on mothers and children [20].

Therefore, it is essential to investigate and monitor the factors associated with the development of this condition. Identifying predictive factors, implementing prevention strategies, and providing short- and long-term guidance for mothers and others can help mitigate the onset of T2DM and other glucose tolerance disorders. Despite the high prevalence and rising incidence of T2DM, research indicates that mothers with a history of GDM and their children face a significantly elevated risk of developing T2DM. Furthermore, the general population is experiencing a high prevalence and increasing incidence of T2DM, which imposes substantial social, psychological, physical, and financial burdens on communities, families, and individuals [21–24].

While numerous clinical guidelines address GDM, there is a notable gap in guidelines specifically tailored for postpartum care for women with a history of GDM and their offspring. This guideline has been developed to address this gap, focusing on the prevention, early detection, and management of postpartum care for this vulnerable group of women and their children.

This clinical guideline is concerned about the postpartum period of life of women with a history of GDM, in addition the infants delivering from the mothers whit a history of GDM. Specifically, it aims to prevent, diagnose, and manage care for women with a history of GDM and their offspring to avert the onset of T2DM in the following years after giving birth. As far as infants are concerned, the guideline also provides for the monitoring and care of their health, particularly the long-term metabolic risk of having been born from GDM mothers. This would involve early screening, lifestyle change, and follow-up care to decrease the risk of future glucose tolerance disorders. The guideline does not deal with management of GDM during pregnancy. Despite the known high risk of developing T2DM among these mothers and their children, healthcare systems, in many countries, lack a structured and clear strategy for long-term follow-up of these patients and their children post-delivery. Therefore, education, promotion of a healthy lifestyle (including diet and physical activity), and timely pharmacotherapy when necessary are needed. This guideline includes related strategies for healthcare providers.

The result of this guideline can be used to improve the problems of follow-up and patient engagement in the healthcare system during the postpartum period, specifically regarding the long-term control of blood Glucose (BS) levels. It gives evidence-based practice recommendations for continued monitoring and preventive care, regardless of whether BG levels have normalized postpartum. By offering clear guidance for healthcare providers, including obstetricians, gynecologists, internists, endocrinologists, and primary care physicians, the guideline aims to improve adherence to follow-up protocol and deliver consistent care. Such a structured strategy can help overcome disengagement from BG control and preventive interventions, eventually reducing the risk of long-term complications such as T2DM.

Definitions of terms

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is an elevation in blood Glucose levels first diagnosed during pregnancy [25]. According to the definition provided in the American Diabetes Association’s standards of care, GDM is defined as diabetes diagnosed in the second or third trimester of pregnancy. T2DM, or prediabetes that was not diagnosed before pregnancy and is identified in the first trimester, does not fall within the definition of GDM [26].

GDM is classified under code O24 and its subcategories in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10).

Diabetes after gestational diabetes

Diabetes following gestational diabetes is not explicitly classified in the International Classification of Diseases, ICD-10. The codes available for this condition for women with a history of GDM in the ICD-10 include:

• E13.9 Other specified diabetes mellitus, without complications.

• O90.9 Complication of the puerperium, unspecified.

• Z86.3 Personal history of endocrine, nutritional, and metabolic diseases, conditions classifiable to E00-E90.

• O24.4 Diabetes mellitus arising in pregnancy, gestational diabetes mellitus not otherwise specified.

Code O24.4 also includes GDM during childbirth and the puerperium. By definition, postnatal and postpartum refer to the period after birth. More information regarding the definitions can be found in the source [27]. This clinical practice guideline defines the postpartum period as the time spanning from the delivery of the neonate to the subsequent years, encompassing the care of the infant and mother.

The ICD-10 codes for children of women with a history of gestational diabetes include:

• P70.0 Syndrome of the infant of a mother with gestational diabetes; fetus or newborn (with hypoglycemia) affected by maternal gestational diabetes.

• Z83.3 Family history of diabetes mellitus, conditions classifiable to E10-E14, O24.

Glucose tolerance test

The glucose tolerance test (GTT) determines an individual’s ability to maintain blood glucose (BG) homeostasis. This test involves measuring BG levels in a fasting state and at specified intervals before and after the administration of oral glucose (75–100 g) or intravenous infusion (0.5 g per kg) [26].

Oral glucose tolerance test

The oral glucose tolerance test (OGTT) is used to diagnose diabetes. The OGTT method involves providing a standard amount of glucose and measuring BG levels at various times over 2 h.

In non-pregnant individuals, 2-hour plasma glucose levels from the OGTT (2-h PG 75-g OGTT) of 140 mg/dL (7.77 mmol/L) lower are considered normal.

− 2-hour plasma glucose levels from the OGTT (2-h PG 75-g OGTT) between 140 and 200 mg/dL (7.77 and 11.10 mmol/L) are classified as impaired glucose tolerance (IGT) and fall within the prediabetes range in non-pregnant individuals.

− 2-hour plasma glucose levels from the OGTT (2-h PG 75-g OGTT) of 200 mg/dL (11.10 mmol/L) or higher are considered diagnostic for diabetes in non-pregnant individuals [26].

Fasting plasma glucose

Fasting plasma glucose (FPG) levels of 100 mg/dL (5.55 mmol/L) or lower are normal in non-pregnant individuals.

• FPG levels between 100 and 125 mg/dL (5.55 and 6.93 mmol/L) indicate impaired fasting glucose (IFG) in non-pregnant individuals.

• FPG levels of 126 mg/dL (7 mmol/L) or higher are considered diagnostic for diabetes in non-pregnant individuals [26].

HbA1c test

The HbA1c test is a hematological test used to diagnose the average glycemic index of red blood cells over three months. The American Diabetes Association recommends it as a measure for chronic blood glucose control in diabetes management and the diagnosis of prediabetes (between 5.7% and 6.4%) and diabetes (equal to or greater than 6.5%) in non-pregnant individuals [26].

Guideline methodology

With the need to develop a clinical guideline for the postpartum years and beyond in mothers with a history of GDM and their offspring, and with institutional grant funding, a project was initiated. The process was designed to include a comprehensive search of the relevant medical databases for the best evidence available to ensure the guideline would be as complete as possible. Other sources’ and countries’ clinical guidelines were also reviewed to inform the development process.

Search strategy

Evidence search for the relevant studies was carried out in high-standing medical databases, based on predetermined inclusion and exclusion criteria. Clinical questions were framed using the PICO model (Population, Intervention, Comparison, and Outcome), and a systematic search strategy was designed. Field experts took part in several sessions to formulate and shape the priority questions, which were organized around six priority areas: (1) risk factors (2), prevention (3), screening, diagnosis, and diagnostic measures (4), postpartum follow-up, education, and care (5), recurrent pregnancy, and (6) pharmacologic interventions. For each question, the elements of the PICO strategy were clarified, and a search strategy was developed.

Systematic searches were conducted in PubMed, Scopus, Web of Science (WOS), and Cochrane databases (Supplementary 1). A total of 7,313 articles were initially retrieved. Subtracting 1,598 duplicates from EndNote software, 5,715 articles remained for title screening by the guideline development group. Through title screening, 4,068 irrelevant articles were excluded, and 1,647 articles remained for abstract assessment. After abstract screening, 47 articles were shortlisted for full-text appraisal (Fig. 1).

Fig. 1.

PRISMA flowchart for the evidence analysis

Furthermore, clinical protocols from various countries were found by searching guideline repositories and the websites of relevant organizations. Thirty-six guidelines were found for analysis (Supplementary 2).

Selection criteria

The inclusion criteria for the literature review were developed to encompass studies published in English from 2012 to 2022 and restricted to primary empirical studies, systematic reviews, meta-analyses, clinical trials, and randomized controlled trials. Studies were excluded from synthesis if full texts could not be retrieved or if they were deemed letters to the editor, conference proceedings, or books.

The criteria for selecting clinical guidelines were their currency, availability in English, availability of the full version, and relevance to at least one of the clinical questions identified in this study.

Evaluation and critique

The evidence extracted from the clinical questions was evaluated using the methodology of Smith et al. (2005) to determine the strength of the evidence for localizing clinical strategies [28]. Table 1 shows the level of evidence used.

Table 1.

Level of evidence

Evidence Level (EL)	Description
Ia	Evidence from a meta-analysis of randomized controlled trials
Ib	Evidence from at least one randomized controlled trial
IIa	Evidence from at least one controlled study without randomization
IIb	Evidence from at least one other type of quasi-experimental study
III	Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
IV	Evidence from expert committee reports, opinions, or clinical experience of respected authorities, or both.

In the present clinical guideline, we applied the AGREE tool to assess and compare the quality of clinical guidelines (Table 2) [29]. The AGREE tool contains 23 primary criteria organized into six sections, each addressing a particular dimension of guideline quality. Two reviewers independently assessed each clinical guideline against the assessment tool during a structured meeting. Differences in scoring were resolved through discussion and consensus. The guidelines with a rating above 50% were part of the final decision. Based on this detailed evaluation process, ten clinical guidelines qualified and were chosen for the final review as indicated in the Table 3.

Table 2.

Grade of recommendations

Grade	Description
Grade A	Recommendation based on at least one randomized controlled trial of good quality and consistency addressing specific recommendations (Evidence level Ia, Ib)
Grade B	Recommendation based on well-conducted studies but no randomized controlled trials on the topic of recommendation (Evidence level IIa, IIb, III)
Grade C	Evidence from expert committee reports and/or clinical experiences of respected authorities (Evidence level IV)

Table 3.

Qualified clinical guidelines for final review

Row	Resource Name	Abbreviation	Address	Guidelines
1	New Zealand Ministry of Health	NZ 2014	https://www.health.gov.nz/	Diabetes in Pregnancy: Quick reference guide for health professionals on the screening, diagnosis, and treatment of gestational diabetes in New Zealand
2	American College of Obstetricians and Gynecologists	ACOG 2018	https://www.acog.org/	Gestational diabetes mellitus. ACOG Practice Bulletin No. 190
3	The American Diabetes Association	ADA 2024	https://professional.diabetes.org/	Management of Diabetes in Pregnancy: Standards of Care in Diabetes — 2024
4	Scottish Intercollegiate Guidelines Network	SIGN 2017	https://www.sign.ac.uk/	Management of diabetes: A national clinical guideline
5	The Australasian Diabetes in Pregnancy Society	ADIPS 2005	https://www.diabetessociety.com.au/ http://www.adips.org/	The Australasian Diabetes in Pregnancy Society consensus guidelines for the management of type 1 and type 2 diabetes in pregnancy
6	All Wales Maternity & Neonatal Network Guidelines	Wales 2023	https://wisdom.nhs.wales/	Strategy for Screening and Management of Gestational Diabetes
7	SOGC clinical practice guideline	SOGC 2019	10.4158/ep.13.s1.1	Guideline No. 393-Diabetes in Pregnancy
8	FIGO	FIGO 2015	https://www.worlddiabetesfoundation.org/	The International Federation of Gynecology and Obstetrics (FIGO) Initiative on Gestational Diabetes Mellitus: A Pragmatic Guide for Diagnosis, Management and Care
9	COGS	COGS 2018	https://www.ams.edu.sg/	Guidelines for the Management of Gestational Diabetes Mellitus: College of Obstetricians and Gynecologists, Singapore
10	Diabetes Canada’s Clinical Practice Guidelines	CDA 2019	https://guidelines.diabetes.ca/	Diabetes and Pregnancy

Recommendations were also extracted from existing clinical guidelines that met the quality threshold established through the AGREE tool evaluation. Recommendations from selected guidelines were identified based on their relevance to the clinical questions addressed in this guideline. Where possible, the evidence level (EL) and grade of recommendation were adopted from the original guideline’s reported methodology. In cases where the original guideline did not provide explicit grading or evidence levels, a default Grade C were assigned to reflect reliance on the guideline’s authority or expert consensus, unless additional primary evidence was referenced and evaluated. For each recommendation derived from a guideline, the source guideline is cited alongside the recommendation. If no grading or evidence level is specified, it indicates that the recommendation was assigned EL IV and Grade C. All recommendations, whether derived from primary studies or existing guidelines, were reviewed by the guideline development group to ensure applicability to the local context. This dual approach ensured consistency in grading recommendations while acknowledging the different nature of evidence derived from primary studies versus existing guidelines.

Reaching consensus

A checklist was designed and shared with professionals so that specialists could review the full texts from the selected evidence and clinical guidelines and extract clinical recommendations. Then the recommendations were summarized, and a preliminary draft of the clinical guideline was prepared. The first draft had 153 recommendations across six principal domains relating to GDM-affected mothers and their children. Each recommendation documented the author(s), year of publication, country of origin, first author’s name, methodology and type of evidence (e.g., systematic review, randomized controlled trial), the domain of the clinical question (e.g., risk factors, prevention, screening), and the specific recommendation to promote transparency and traceability of the evidence. This approach ensured the recommendations were based on valid evidence, while both in-course context and guideline objectives were adhered to.

The Delphi method was employed in two rounds to finalize recommendations. Initially, the recommendations were presented to a group of specialists. Feedback was collected from the experts, and after summarizing the recommendations according to the main domains, they were rewritten. Some recommendations were eliminated, while others were combined. In some cases, recommendations were condensed into one or more overarching recommendations. The following draft was prepared and shared with the specialists in the second round. Ultimately, a final consensus was reached.

Development of the final version of the clinical guideline

The final version of the clinical guideline was developed following several meetings with specialists. It includes six questions and 37 clinical recommendations, as listed in the Table 4.

Table 4.

Numbers of recommendations for each clinical question

Row	Clinical Question	# Of Recommendations
1	What are the risk factors for developing diabetes postpartum in women with a history of GDM and their offspring?	1
2	What measures should be taken to prevent and reduce the risk factors for diabetes in women with a history of GDM and their offspring?	11
3	What is the screening, diagnostic, and diagnostic measures for diabetes in women with a history of GDM and their children?	7
4	What is the postpartum care, follow-up actions, and necessary education for women with a history of GDM and their children?	9
5	What are the conditions for subsequent pregnancies in women with a history of GDM?	5
6	What are the pharmacological interventions for women with a history of GDM?	4

Guideline recommendation

Risk factors

Recommendation 1

In women with a history of GDM, more serious consideration should be given to the risk of developing T2DM in the years following childbirth if the following risk factors are present (although all women with a history of GDM and their children require follow-up and assessment for the development of T2DM in subsequent years):

During pregnancy

• Earlier gestational age (weeks of pregnancy) at the time of diagnosis of gestational diabetes [18, 30, 31]. Grade: B; EL: IIb.

• Younger maternal age at the time of gestational diabetes diagnosis [30, 32–35]. Grade: B; EL: IIb.

• Body mass index (BMI) before pregnancy greater than 24.9 kg/m² [36–38]. Grade: B; EL: III.

• HbA1C level at the time of diagnosis of gestational diabetes greater than 6.5% (if the test is performed) [33, 39]. Grade: B; EL: III.

• In OGTT, the one hour plasma glucose is more than 195 mg/dL [31, 39]. Grade: B; EL: III.

• High FPG at the time of diagnosis of GDM (greater than 100 mg/dL) [18, 32, 39–41]. Grade: B; EL: III.

Postpartum

• Weight gain after childbirth (weight gain of 5 kg or more in 1 to 2 years postpartum) compared to pre-pregnancy levels [42–44]. Grade: A; EL: Ib.

• Changes in BMI postpartum (Hazard ratio R 1.27, 95% Confidence Interval 1.04–1.56, p = 0.021) [37, 45, 46]. Grade: B; EL: III.

• Obesity (central), with increased waist circumference after childbirth [39, 43, 47]. Grade: B; EL: III.

• Birth weight of the newborn greater than 4000 g [38]. Grade: B; EL: III.

• Signs of diabetic fetopathy in the newborn [30]. Grade: B; EL: IIb.

• The need for continued insulin therapy postpartum [30, 38–40]. Grade: B; EL: IIb.

• Preterm birth before 37 weeks of gestation [38]. Grade: B; EL: III.

• Unhealthy fat consumption patterns [42]. Grade: A; EL: Ib.

• Traditional risk factors for T2DM(such as age, BMI, race/ethnicity, history of hypertension, history of hyperlipidemia, family history of diabetes, polycystic ovary syndrome (PCOS), poor dietary quality, and low physical inactivity) [48]. Grade: C; EL: IV.

• Serum Fructosamine concentration [30]. Grade: B; EL: IIb.

• Elevated levels of apoprotein CIII (Apo CIII) and ratios of apoproteins Apo CIII/Apo AI, Apo CIII/Apo AII, Apo CIII/Apo CII, and Apo CIII/Apo E postpartum [49]. Grade: B; EL: III.

• High concentrations of isoleucine, leucine, valine, and all branched-chain amino acids (BCAAs) in the diet and circulation [50]. Grade: B; EL: III.

Summary

Five kg (or more) weight gain within 1–2 years postpartum along with an unhealthy pattern of fat intake had a high association with the risk of T2DM in women previously diagnosed with GDM. These findings underscore the importance of postpartum weight management and dietary interventions as key strategies in T2DM risk reduction. These considerations should take center stage in follow-up by healthcare providers to improve long-term health outcomes.

Prevention

Recommendation 2

Lifestyle interventions or metformin should be recommended for the prevention of glucose tolerance disorders in women with a history of GDM [18, 34, 42, 51, 52]. Grade: A; EL: Ib; (ADA 2024, Grade: A)

Recommendation 3

Prevention of T2DM through lifestyle interventions in women with a history of GDM should be prioritized [53]. Grade: A; EL: Ia.

Recommendation 4

Preventive measures in the early years and early postpartum period are recommended to prevent the onset of T2DM in individuals with a history of GDM [9, 54]. Grade: A; EL: Ia.

Recommendation 5

It is recommended that preventive interventions be long-term to have the greatest impact, although some interventions show a reduced effect after three years [54]. Grade: A; EL: Ia.

Recommendation 6

Postpartum care should include psychosocial assessment and self-care support [52]. (ADA 2024, Grade E)

Recommendation 7

Psychosocial care should be offered to all individuals with diabetes mellitus, aiming to optimize health-related quality of life and its outcomes. Psychosocial care should be delivered using a collaborative, patient-centered, and culturally aware approach by trained healthcare professionals [52]. (ADA 2024, Grade: A)

Recommendation 8

The following lifestyle interventions are recommended for the prevention of T2DM postpartum in women with a history of GDM:

• Physical activity (regular exercise) (see recommendation 9) [18, 48, 54–58]. Grade: A; EL: Ia; (FIGO 2015, Grade: C); (NZ 2014, Grade: GPP)

• Healthy diet (see recommendation 10) [48, 54, 55, 57, 58]. Grade: A; EL: Ia; (FIGO 2015, Grade: C); (NZ 2014, Grade: GPP)

• Weight loss/maintenance of optimal weight/avoidance of obesity (see recommendation 11) [18, 41, 43, 48, 56, 57, 59]. Grade: A; EL: Ib; (FIGO 2015, Grade: C)

• Breastfeeding (see recommendation 12) [54, 60]. Grade: A; EL: Ia.

Recommendation 9

The following physical activities are recommended for preventing T2DM postpartum in women with a history of GDM (other underlying conditions, especially cardiopulmonary and physical conditions, should be considered):

• At least 150 min of moderate to vigorous physical activity per week [55]. Grade: B; EL: III.

• Moderate physical activity (such as brisk walking for 30 min daily) [56]. Grade: A; EL: Ib.

Recommendation 10

The following dietary measures are recommended for the prevention of diabetes postpartum in women with a history of GDM:

• Daily consumption of vegetables [55]. Grade: B; EL: III.

• Daily consumption of fruits [55]. Grade: B; EL: III.

• Daily consumption of low-fat dairy products [55]. Grade: B; EL: III; ADA 2024.

• Daily consumption of whole grain products [55]. Grade: B; EL: III.

• Daily intake of dietary fiber [55]. Grade: B; EL: III.

• Reduction of saturated to unsaturated fats ratio in the diet [55]. Grade: B; EL: III.

• Mediterranean diet1 (42). Grade: A; EL: Ib

Recommendation 11

Recommended weight management strategies for the prevention of diabetes postpartum in women with a history of GDM include:

• Moderate weight loss (5–10%) through dietary changes/caloric restriction or exercise programs [56, 59]. Grade: A; EL: Ib.

• Early weight loss (returning to pre-pregnancy weight) within the first year postpartum [62]. Grade: A; EL: Ib.

• Reduction of waist circumference in the first postpartum year [62]. Grade: A; EL: Ib.

Recommendation 12

Breastfeeding is recommended under the following conditions for the prevention of T2DM postpartum in women with a history of GDM:

• Continuation of breastfeeding for at least six months postpartum [55]. Grade: B; EL: III.

• Breastfeeding beyond 4 to 12 weeks postpartum [63]. Grade: B; EL: IIa.

• Longer duration (more than 24 months VS. less than 6 months) of each breastfeeding session [60, 64]. Grade: B; EL: III.

• Increased frequency of breastfeeding [60]. Grade: B; EL: III.

• Encouragement for mothers with a history of GDM who cannot or prefer not to breastfeed to use donated breast milk before formula feeding. The decision should be based on the mother’s preference [58]. (NZ 2014, Grade: GPP)

• Early feeding of infants born to mothers with GDM is recommended to prevent neonatal hypoglycemia and to stimulate breastfeeding [65]. (SIGN 2017, Grade: B)

Summary

Lifestyle modifications encompassing regular exercise, healthy eating, weight management, and breastfeeding are potential preventive measures for glucose tolerance disorders and T2DM in women with a history of GDM. Early and long-term preventive measures and psychosocial support would benefit health status. Health care providers should pay more attention to individual-specific needs in the form of tasks as a measure against T2DM to safeguard the health profile of this population.

Screening, diagnosis, and diagnostic measures

Recommendation 13

Telephone follow-up, mobile health programs, and eHealth initiatives are recommended to increase participation in screening programs [54]. Grade: A; EL: Ia.

Recommendation 14

For all women diagnosed with GDM, postpartum care centers or diabetes clinics should provide printed information (such as booklets, brochures, pamphlets, etc.) regarding the importance of postpartum screening and the risk of T2DM [58]. (NZ 2014, Grade: CONDITIONAL).

Recommendation 15

All women with GDM and their primary care providers should be reminded of the necessity to participate in screening three months postpartum at the time of hospital discharge [58]. (NZ 2014, Grade: CONDITIONAL).

Recommendation 16

To prevent delays in diagnosing T2DM in women with a history of GDM, it is recommended to establish a mechanism for transferring care from obstetricians or endocrinologists to primary care [66]. For example, when mothers visit a health center for infant vaccinations, a referral from the obstetrician or endocrinologist should be sent to inform the health center of the mother’s care for subsequent follow-up. Grade: B; EL: III.

Recommendation 17

It is recommended that plasma glucose levels in women with GDM be tested regularly postpartum [67, 68]. Grade: B; EL: III.

Recommendation 18

Recommended tests for women with a history of GDM include:

• Screening with FPG and 75 g OGTT 2hPG in the early postpartum period (4–12 weeks) [20, 69]. Grade: B; EL: III; (ACOG 2018; Grade: B).

• 75 g OGTT with non-pregnancy diagnostic criteria [8], meaning 75 g OGTT 2hPG diagnostic criterion greater than 200 mg/dl is recommended within 4 to 12 weeks postpartum [52]. (ADA 2024, Grade: B).

• In women with a history of GDM, OGTT is preferred over A1C during weeks 4 to 12 postpartum [52]. (ADA 2024, Grade: B).

• Screening with 75 g OGTT 2hPG between 6 weeks to 6 months postpartum is recommended [70]. (CDA 2018; Grade D, Consensus).

• Annual screening with FPG or HbA1c [71]. Grade: B; EL: III.

• For women with a history of GDM, even if their 75 g OGTT (2-hour plasma glucose) results are within the normal range at 4 to 12 weeks postpartum, regular follow-up testing is still recommended. This may include annual testing with A1C or fasting plasma glucose, or a 75 g OGTT every three years using non-pregnancy thresholds, repeated every 1 to 3 years [52]. (ADA 2024, Grade: B).

• In case of confirmed hyperglycemia, a positive diabetes screening in women with a history of GDM requires two concurrent abnormal values, including FPG of 126 mg/dl or more and 2hPG of 200 mg/dl or more. If either is positive, laboratory testing should be repeated to confirm T2DM postpartum [52]. (ADA 2024, Grade: B).

• FPG testing in women at lower risk is sufficient every 1 to 2 years [72]. (ADIPS 2005, Grade: C).

Recommendation 19

The recommendations regarding laboratory results for women with a history of gestational diabetes are provided in the Table 5 [20, 58, 73, 74]. (ADA 2024, Grade: B); (ACOG 2018; Grade: B); (Wales 2023; Grade: C); (NZ 2014, Grade: GPP); (SOGC 2019; Grade: A; Level: II-2).

Table 5.

Recommendations regarding of diagnostic criteria for women with a history of gestational diabetes

FPG at 4–12 weeks postpartum	HbA1C after week 13 postpartum)	75 g OGTT 2 h (4–12 weeks postpartum)	Outcome	Recommendation
FPG < 100 mg/dl	< 5.7%	< 140 mg/dl	Normal	• Lifestyle modification (healthy eating, physical activity, etc.) • Lifestyle counselling • Yearly HbA1C
FPG 100–125 mg/dl	5.7–6.5%	140–199 mg/dl	IFG or IGT or both	• Lifestyle modification (healthy eating, physical activity, etc.) • Lifestyle counselling • Yearly HbA1C • If IGT and IFG both diagnosed, Metformin recommended • Referral to a physician for Glucose management
FPG > = 126 mg/dl	> 6.5%	>= 200 mg/dl	Diabetes mellitus	• Confirmatory test • Repeat HbA1C or FPG • Referral to a physician for diabetes management

Summary

To make an early diagnosis and manage glucose intolerance disorders in women with a history of GDM, it is essential to use effective screening and diagnostic tools. Increasing participation in screening programs can be done with phone call follow-up, mobile health programs, and producing educational materials. It is recommended that FPG, HbA1C, and 75 g OGTT be carried out within 4 to 12 weeks postpartum and thereafter yearly to procure a prompt diagnosis and management of risks. Enhanced care transition procedures and personalized lifestyle recommendations based on diagnostic test results are crucial to early diagnosis and optimization of long-term health outcomes.

Postpartum follow-up, education, and care

Recommendation 20

Professional follow-up and psychosocial support during the postpartum period for women with a history of GDM and their children are recommended [54]. Grade: A; EL: Ia.

Recommendation 21

Postpartum care should support coordination between obstetric care providers and family physicians [75]. Grade: B; EL: III.

Recommendation 22

Family physicians, obstetricians, internal medicine specialists, pediatricians, and other health care providers should coordinate postpartum follow-up for mothers with a history of GDM with regular child care and vaccination programs to ensure follow-up for mothers and infants [57]. (FIGO 2015, Grade: C).

Recommendation 23

Postpartum education for women with a history of GDM is recommended as follows:

• Continuous education for mothers and their children about risk factors and strategies to reduce the risk of T2DM [54, 70]. Grade: A; EL: Ia; (CDA 2018; Grade C, Level 3).

• Healthy behavioral interventions to reduce the risk of GDM in Subsequent pregnancies and decrease the risk of developing T2DM [70]. (CDA 2018; Grade C, Level 3).

• Lifestyle modifications [58, 67, 76]. (NZ 2014, Grade: GPP); (COGS 2018; Grade: C).

• Planning for future pregnancies [57, 58, 65]. (FIGO 2015, Grade: C); NZ 2014; (SIGN 2017; Grade: C).

Recommendation 24

The following lifestyle interventions are recommended to prevent T2DM postpartum in women with a history of GDM:

• Physical activity (regular exercise) (see recommendation 9) [18, 48, 54–58]. Grade: A; EL: Ia; (FIGO 2015, Grade: C); (NZ 2014, Grade: GPP).

• Healthy diet (see recommendation 10) [48, 54, 55, 57, 58]. Grade: A; EL: Ia; (FIGO 2015, Grade: C); (NZ 2014, Grade: GPP).

• Weight loss/maintaining an ideal weight/avoiding obesity (see recommendation 11) [18, 41, 43, 48, 56, 57, 59]. Grade: A; EL: Ib; (FIGO 2015, Grade: C).

• Breastfeeding (see recommendation 12) [54, 60]. Grade: A; EL: Ia.

Recommendation 25

Postpartum care in women with a history of GDM to prevent diabetes includes:

• Management of obesity and overweight [41]. Grade: B; EL: III.

• Control of blood glucose [41]. Grade: B; EL: III.

• Recommend of screening tests [57, 58, 65, 77, 78]. Grade: B; EL: IIb; (FIGO 2015, Grade: C); (NZ 2014, Grade: GPP); (SIGN 2017; Grade: C).

• Early initiation of lifestyle interventions [73, 74]. (SOGC 2019, Grade: C); (Wales 2023; Grade: C).

• Designing educational programs that include diet, physical activities postpartum, and the importance of understanding the risk of T2DM after pregnancy [79]. Grade: B; EL: III.

• Follow-up by health center providers [20]. (ACOG 2018; Grade: C).

• Referral to a physician for preventive treatment in women with fasting glucose disorders, IGT, or prediabetes [22]. (ACOG 2018; Grade: C).

• Breastfeeding and feeding the newborn with breast milk [52, 57, 58, 65, 70, 76]. (ADA 2024, Grade: A); (FIGO 2015, Grade: C); (NZ 2014, Grade: GPP); (SIGN 2017; Grade: B); (CDA 2018; Grade D, Consensus); (COGS 2018; Grade: C).

Recommendation 26

For women with a history of GDM, the following screening recommendations are advised:

• Conduct an FPG and 75 g OGTT 2hPG screening test during the early postpartum period (4–12 weeks) [20, 69]. Grade: B; EL: III; (ACOG 2018; Grade: C).

• 75 g OGTT with non-pregnancy criteria is recommended at 4 to 12 weeks postpartum, with a diagnostic threshold of 2hPG equal to or greater than 200 mg/dl [52]. (ADA 2024, Grade: B).

• OGTT is preferred over A1C testing during weeks 4 to 12 postpartum for women with a history of GDM [52]. (ADA 2024, Grade: B).

• Conduct 75 g OGTT 2 h screening between 6 weeks to 6 months postpartum [70]. (CDA 2018; Grade D, Consensus).

• Annual screening for FPG or HbA1c is recommended [71]. Grade: B; EL: III.

• For women with a history of GDM, if 75 g OGTT 2hPG results are expected within 4 to 12 weeks postpartum, repeat testing (A1C annually, fasting plasma glucose annually, or 75 g OGTT every 3 years based on non-pregnant criteria) is recommended every 1 to 3 years [52]. (ADA 2024, Grade: B).

• For confirmed hyperglycemia, positive diabetes screening in women with a history of GDM requires two simultaneous abnormal values: FPG ≥ 126 mg/dl and 2hPG ≥ 200 mg/dl. If either value is positive, testing should be repeated to confirm diabetes [52]. (ADA 2024, Grade: B).

• For lower-risk women, an FPG test every 1 to 2 years is sufficient [72]. (ADIPS 2005, Grade: C)

Recommendation 27

The recommendations regarding laboratory results to follow up women with a history of gestational diabetes are provided in the Table 5 [20, 58, 73, 74]. (ADA 2024, Grade: B); (ACOG 2018; Grade: B); (Wales 2023; Grade: C); (NZ 2014, Grade: GPP); (SOGC 2019; Grade: A; Level: II-2).

Recommendation 28

Breastfeeding is recommended under the following conditions to prevent postpartum diabetes in women with a history of GDM:

• Continue breastfeeding for at least six months postpartum [55]. Grade: B; EL: III.

• Breastfeed for more than 4 to 12 weeks postpartum [63]. Grade: B; EL: IIa.

• Longer duration of each breastfeeding session is encouraged [60, 64]. Grade: B; EL: III.

• Increase the frequency of breastfeeding sessions [60]. Grade: B; EL: III.

• For mothers who cannot or choose not to breastfeed, encourage using donor breast milk before formula. The decision should be based on the mother’s preference [58]. (NZ 2014, Grade: GPP).

• Early feeding of infants born to mothers with GDM is recommended to prevent neonatal hypoglycemia and stimulate breastfeeding [65]. (SIGN 2017; Grade: B).

Summary

Women with histories of gestational diabetes should be followed up, educated, and cared for after childbirth to reduce the progression to type 2 diabetes and to improve long-term health outcomes. Having follow-up, psychosocial support, and care coordination between different health providers is important. A sustained emphasis should be placed on lifestyle interventions: regular physical activity, a healthy diet, weight management, and breastfeeding support. Continuous education about risk factors and healthy behaviors, alongside planning for future pregnancies, are crucial. Regular screening tests such as FPG, HbA1C, and 75 g OGTT should be performed between 4 and 12 weeks postpartum and once a year thereafter, for timely detection and management of glucose tolerance disorders. Implementing these approaches with individualized educational programs and early lifestyle intervention will significantly reduce the risk of T2DM and bring up well-being for mothers and their children.

Recurrent pregnancy

Recommendation 29

Women with a history of GDM planning Subsequent pregnancies should receive counseling about the risks associated with subsequent pregnancies and be advised to undergo early screening for diabetes before conception [20, 58, 65, 69]. (ACOG 2018; Grade: C); (SIGN 2017; Grade: C); (NZ 2014, Grade: GPP).

Recommendation 30

Women with a history of GDM who are considering another pregnancy should have an annual OGTT to monitor their glucose levels [72]. (ADIPS 2005, Grade: C)

Recommendation 31

Women with a history of GDM should be encouraged to maintain optimal weight and lifestyle and, metabolic health between pregnancies to reduce risks [57]. FIGO 2015.

Recommendation 32

Education on contraception methods should be provided until risk factors are resolved [58]. (NZ 2014, Grade: GPP).

Recommendation 33

Before hospital discharge, education regarding contraception to mitigate risk factors should be discussed with women who have had gestational diabetes and their partners [72]. (ADIPS 2005; Grade: C).

Summary

Women with a history of GDM and wishing to conceive in subsequent pregnancies need to receive adequate counseling on the risks that may follow Subsequent pregnancies and also swift diabetes screening for preconception. An oral glucose tolerance test should be performed annually, and strenuous encouragement should be placed upon the couple to remain healthy between each pregnancy to minimize risks. Contraceptive methods should be made known until risk factors have resolved. Contraception discussions should occur before hospital discharge to ensure informed decisions. These measures will help reduce risks and obtain better outcomes for the mother and future pregnancies.

Pharmacologic interventions

Recommendation 34

Consider metformin to reduce the risk of progression to diabetes in women with a history of GDM [48, 51, 52, 57, 67, 70, 80]. Grade: A; EL: Ia; (ADA 2024, Grade: A); (FIGO 2015, Grade: C); (CDA 2018; Grade B, Level 2).

Recommendation 35

Metformin should be considered for women with a history of GDM whose HbA1c is between 5.9% and 6.6% and who are unsuccessful in lifestyle modifications, especially those planning another pregnancy [58]. (NZ 2014, Grade: CONDITIONAL).

Recommendation 36

Metformin should be considered to prevent T2DM in adults, mainly those aged 25–59, those with a BMI ≥ 35 kg/m², and individuals with elevated fasting plasma glucose (≥ 110 mg/dl) or HbA1c (≥ 6%) [52]. (ADA 2024, Grade: A).

Recommendation 37

Troglitazone should not be used with prior gestational diabetes due to concerns regarding liver toxicity. Additionally, there is currently insufficient evidence to recommend the routine use of Pioglitazone, dipeptidyl peptidase-4 inhibitor vildagliptin, and sodium-glucose cotransporter-2 inhibitors based on existing studies [80]. Grade: A; EL: Ia.

Summary

Metformin is strongly suggested to lower the risk of progression to diabetes in women with a history of GDM, especially for those who unable to adhere to lifestyle modifications and are planning another pregnancy, in particular those with an HbA1c value between 5.9% and 6.6%. It also works on adults 25–59, persons with body mass index ≥ 35 kg/m² and hyperglycemia, or with raised fasting plasma glucose or HbA1c. Pharmacologic interventions, with the exception of metformin administration, are not indicated for other medications before more extensive evidence is established. When used with lifestyle modifications, such pharmacologic interventions can significantly reduce the risk of T2DM amongst these high-risk groups.

Strengths/limitations

This guideline takes an evidence-based approach to its recommendations with considering high-quality studies such as systematic reviews, randomized controlled trials, and meta-analyses. The guideline promotes a multidisciplinary team approach, encouraging collaboration among obstetricians, endocrinologists, primary care providers, and other healthcare professionals to ensure coordinated care. It places strong emphasis on prevention, recommending early screening, lifestyle interventions, and effective pharmacological strategies to lower the risk of type 2 diabetes mellitus (T2DM) in women with a history of gestational diabetes and their children. Additionally, the guideline highlights the importance of patient-centered care by advocating for psychosocial support, education, and personalized care plans tailored to the specific needs of this population. The recommendations represent a synthesis of international clinical guidelines, adapted to accommodate the diversity of healthcare systems worldwide, thereby enhancing their global applicability and relevance.

Although the guideline is thorough and well-developed, its implementation poses several challenges. Differences in the readiness of healthcare systems, resource availability, and the diverse characteristics of patient populations across regions can hinder its practical application. Moreover, the guideline focuses primarily on the postpartum period and largely overlooks the management of gestational diabetes mellitus during pregnancy—an omission that limits its value in comprehensive perinatal care. In addition, various multidimensional factors such as cultural, socioeconomic, and healthcare disparities must be considered to ensure the guideline’s effectiveness across diverse settings.

Conclusion

This clinical guideline provides evidence-based recommendations for the prevention, screening, diagnosis, and management of T2DM in women who experienced GDM and their children through the postpartum period. The key findings stress that lifestyle interventions, including regular physical exercises, healthy diet, weight management, and breastfeeding, play a major role in preventing T2DM. Pharmacologic interventions, with the exception of metformin administration, are not indicated for other medications before more extensive evidence is established.

The guideline identifies the need to promote prompt and recurrent glucose tolerance disorder screening through FPG, HbA1C, and OGTT tests. Structured postpartum follow-up, psychosocial support, and patient education are key in ensuring ongoing health benefits. By bridging the gaps of existing guidelines, this guideline aims to reduce the burden of T2D while improving the health outcomes of women and their offspring.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

MZ and MHK managed project administration. MZ, MHK, SE, MZ, and ZS were responsible for conceptualization, method design, original draft writing, and oversight. MZ, MHK, SE, MZ, ZS, NS, and ON were responsible for data curation, investigation, resources, validation, and writing, reviewing, and editing the manuscript. All authors read and approved the final manuscript.

Funding

No funding was received for conducting this study.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval

The protocol of the study was approved by the ethics committee of Golestan University of Medical Sciences, Gorgan, Iran (IR.GOUMS.REC.1401.132).

Competing interests

The authors declare no competing interests.

Conflicts of interests

The authors declare no conflicts of interest concerning the publication of this guideline.