OBSTETRICS

Gestational diabetes: risk of recurrence in subsequent

pregnancies
Darios Getahun, MD, MPH; Michael J. Fassett, MD; Steven J. Jacobsen, MD, PhD
OBJECTIVE: We sought to examine the recurrence risk of gestational diabetes mellitus
(GDM) in a subsequent pregnancy and determine whether recurrence risk is modied by
race/ethnicity.
STUDY DESIGN: We used the Kaiser Permanente Southern California longitudinally linked
records (1991-2008) to study women with rst 2 (n65,132) and rst 3 (n 13,096) singleton
pregnancies. Adjusted odds ratios (ORs) were used to estimate the magnitude of recurrence.
RESULTS: Risks of GDM in the second pregnancy among women with and without previous
GDM were 41.3% and 4.2%, respectively (OR, 13.2; 95% condence interval, 12.0 14.6).
The recurrence risk of
GDM in the third pregnancy was stronger when women had GDM in both prior pregnancies
(OR, 25.9; 95% condence interval, 17.4 38.4). Hispanics and Asian/Pacic Islanders have
higher risks of recurrence.
CONCLUSION: A pregnancy complicated by GDM is at increased risk for subsequent GDM.
The magnitude of risk increases with the number of prior episodes of GDM. These recurrence
risks also showed heteroge- neity by race-ethnicity.
Key words: gestational diabetes, race/ethnicity, recurrence, subsequent pregnancy
Cite this article as: Getahun D, Fassett MJ, Jacobsen SJ. Gestational diabetes: risk of
recurrence in subsequent pregnancies. Am J Obstet Gynecol 2010;203:467.e1-6.
Gestational diabetes mellitus (GDM) is dened as carbohydrate intoler- ance of variable
severity, with onset or rst recognition during pregnancy.1 GDM complicates 3-14% of
pregnancies in the United States, and it is responsible for an important proportion of fetal and
maternal morbidity including pregnancy- induced hypertension, preeclampsia,
From the Department of Research and
Evaluation (Drs Getahun and Jacobsen) and
the Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology
(Dr Fassett), West Los Angeles Medical
Center, Kaiser Permanente Southern

California, Pasadena, CA.

Presented at the 137th Annual Meeting of the American Public Health Association,
Philadelphia, PA, Nov. 7-11, 2009.
Received Nov. 25, 2009; revised April 2, 2010; accepted May 19, 2010.
Reprints: Darios Getahun, MD, MPH, Department of Research and Evaluation, Kaiser
Permanente Southern California Medical Group, 100 Los Robles Ave., 2nd Floor, Pasadena,
CA 91101. Darios.T.Getahun@kp.org.
This study was supported by Kaiser Permanente Direct Community Benet funds.
0002-9378/$36.00
2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.05.032
urinary tract infections, cesarean deliv- ery, fetal macrosomia, birth trauma, and a variety of
relatively minor, transient neonatal maladaptations to extrauterine life (eg, hypoglycemia),
and developing future diabetes.1-9 In the United States, there is an increasing trend in GDM.
A recent study reported that the prevalence of GDM increased gradually between
1989-1990 and 2003-2004 by 122%, from 1.9-4.2%, respectively.10,11
Early detection and initiation of treat- ment is important because unrecognized
or untreated GDM is likely to lead to ad- verse maternal and fetal outcomes.12,13
Although maternal deaths are low, fetal and neonatal mortality remains much
higher than in the general popula- tion.13,14 Potential risk factors that have
been associated with GDM include ad- vanced maternal age, being from minor- ity
race/ethnicity groups, being over- weight or obese during pregnancy,15 being multigravida,
and having a previ- ous diagnosis of GDM.16
Limited numbers of studies examined the recurrence of GDM in subsequent pregnancies. In
their study, Gaudier et al17 noted a 52% increased risk of recur- rence of GDM in subsequent
pregnan- cies. Similarly, Moses18 found a 35% re- currence rate of GDM after following up
100 subsequent pregnancies. Despite the increased tendency of GDM to recur, lit- tle is
known with regard to the extent to which the number of prior GDM can in- uence risk of
GDM in future pregnan- cies. Furthermore, whether the risk is modied by maternal
race/ethnicity is unknown.
The purposes of this study were to ex- amine risks of recurrence: (1) of GDM in the rst 2
and rst 3 subsequent preg- nancies; and (2) in relation to maternal race/ethnicity.
MATERIALS AND METHODS

Data source
The study utilized population-based data from Kaiser Permanente Southern California
(KPSC) from 1991 through 2008 (n 540,956). We matched the perinatal service system,
hospital inpa- tient, and physician encounter records through a unique identier for each
individual. The matched records were further linked longitudinally to subse- quent
pregnancies. Information ex- tracted from the perinatal service system records includes
maternal sociodemo- graphic and behavioral characteristics, fetal and neonatal outcomes, and
labor and delivery complications. Information extracted from the hospital inpatient and
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physician encounter records include be- havioral factors, and medical and obstet- ric
complications and procedures.
For this retrospective cohort study de- sign, we formed 2 cohorts: a cohort of linked rst 2
singleton births and a sec- ond cohort of linked rst 3 consecutive singleton deliveries in all
KPSC facilities.
Denition of variables
Data on maternal characteristics were based on the study cohort that consisted of the rst 2
births. Self-reported mater- nal race was grouped as non-Hispanic white (white), nonHispanic black (Afri- can American), Hispanic, and non-His- panic Asian/Pacic Islander.
Other inde- pendent variables considered as either potential determinants or confounders for
recurrence of GDM included: mater- nal age ( 20, 20-29, 30-34, 35 years), maternal
education ( 12, 12, and 13 years of completed schooling), initiation of prenatal care (early or
rst trimester and none or late initiation), maternal smoking and alcohol consumption during pregnancy (yes/no), and interval be- tween a birth and a subsequent preg- nancy ( 6, 6-11,
12-17, 18-23, 24-29, 30-35, 36-41, 42-47, and 48 months). The International Classication of
Dis- eases, Ninth Revision, Clinical Modica- tion (ICD-9-CM) code 648.8 was used to
identify physician diagnosis of GDM (yes/no). We validated the accuracy of hospital-based
ICD-9-CM diagnosis codes for GDM by using a random sample of 1000 patients. Laboratory
records were reviewed and the results were compared with the diagnosis codes collected electronically. The estimated positive pre- dictive value and negative predictive value for GDM
were 90% and 85%, re- spectively. Based on this preliminary nding, the hospital-based ICD9-CM diagnosis codes seemed reasonable qual- ity in the ascertainment of GDM cases in this
study.
Data exclusions
From a total of 540,956 singleton births in the KPSC hospitals from 1991 through 2008, we
excluded the following categories: births at 20 weeks of gesta- tion and at 500 g (n 9357),
women with only 1 pregnancy during the study
period, and those who had 1 preg- nancy 1991 (n 443,178). We also ex- cluded women of
other race/ethnicity group due to small number (approxi- mately 3% of the cohort), as well
as ob- servations with missing data on race/eth- nicity (n 1756). The justication for limiting

the analysis to singleton preg- nancies is that multiple pregnancies are inherently at different
risks of adverse pregnancy outcomes. We excluded births with gestational age 20 weeks and
birth weights of 500 g to decrease errors in gestational age estimation and to mini- mize
medical center differences in re- porting live births that were at border- line of viability.
Furthermore, women who have a diagnosis of type 2 diabetes prior to their rst pregnancy (n
863), and those women who developed type 2 diabetes between their rst 2 (n 2850) and
between their second and third pregnancies (n 617) were excluded from the study. To
accomplish this, we used data extracted from postpartum medical encounter records.
Statistical analysis
We performed a retrospective cohort analysis to assess recurrence risks of GDM among
women with singleton pregnancies. Statistical analysis was per- formed in 4 steps. First, we
examined the distribution of maternal demographic and behavioral characteristics by GDM
status using rst and second births. Sec- ond, a conditional logistic regression model was
tted to examine the recur- rence of GDM in subsequent pregnan- cies (rst 2 and rst 3
pregnancies) after controlling for potential confounding variables (maternal age, maternal
race, maternal education, initiation of prena- tal care, interpregnancy interval [IPI], smoking
during pregnancy, and year of delivery). We assessed the interaction between GDM in a
pregnancy and the intervals between the rst 2 pregnancies. Third, we repeated the logistic
regression analysis after stratifying the data by race/ ethnicity in an attempt to clarify risk of
recurrences in the various categories. Odds ratios (ORs) and their 95% con- dence intervals
(CIs) were used to esti- mate risks of recurrence. Furthermore,
rst 2 as well as second and third birth
IPI-specic risks of recurrence were estimated.
All statistical analyses were performed using SAS (version 9.1; SAS Institute, Cary, NC). The
study was approved by the KPSC Institutional Review Board.
RESULTS
There were 65,132 pregnancies with rst 2 and 13,096 with rst 3 consecutive sin- gleton
births in the KPSC hospitals from 1991 through 2008, resulting in an inci- dence rate of 56
and 69 GDM pregnan- cies per 1000 births, respectively.
As shown in Table 1, GDM is more likely to occur in women giving birth at age 30 years,
with 13 years school- ing, Hispanic and Asian/Pacic Islander race/ethnicity group, and long
IPIs.
Table 2 shows overall risks and risks of GDM in subsequent pregnancies among pregnancies
without a history of GDM. The rate of GDM in second and third pregnancies in women
without a history of GDM was noted to be 42 and 47 per 1000 births, respectively.
As compared to women without pre- vious GDM in their rst pregnancies, women with a rst
pregnancy com- plicated by GDM were at signicantly increased risk (OR, 13.2; 95% CI,
12.0 14.6) of developing GDM during their second pregnancy (Table 3). As com- pared to
women without GDM in their rst and second pregnancies, women with pregnancies
complicated by GDM during their rst but not second preg- nancies were found to be at 6.3-

fold (95% CI, 4.59.0) increased risk for de- veloping GDM during their third preg- nancy.
This risk was even more pro- nounced in the third pregnancy for women who developed
GDM during their rst and second pregnancies (a 25.9-fold increased risk; 95% CI, 17.4
38.4). There were no signicant interac- tions between GDM in the rst preg- nancy and IPI
on the risk of GDM in the second pregnancy (P .467).
The race-specic risk of GDM in sub- sequent pregnancy is shown in Table 4. After
adjustment for maternal age, edu- cation, prenatal care, IPI, and year of de- livery, a history
of GDM in the rst preg- nancy was associated with signicantly
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www.AJOG.orgObstetrics RESEARCH
increased odds of GDM in the second pregnancy across the various race/ethnic groups.
Regardless of the GDM status of the rst pregnancy, a GDM in the second pregnancy was
associated with substan- tially higher odds of GDM in the third pregnancy for each
racial/ethnic group, with Asians/Pacic Islanders exhibiting the highest prevalence for most
of the categories. In comparison with women whose rst 2 consecutive pregnancies were not
complicated by GDM, the risk of recurrence of GDM in the third preg- nancy for those
experiencing the condi- tion in both their rst and second preg- nancy was 35.0-fold, 158.4fold, 17.3- fold, and 36.1-fold higher for white, African American, Hispanic, and Asian/
Pacic Islander women, respectively.
The results of analysis pertaining to ra- cial/ethnic disparity in the recurrence risk of GDM
revealed that Hispanics (OR, 1.6; 95% CI, 1.4 1.7) and Asian/ Pacic Islanders (OR, 2.1;
95% CI, 1.8 2.3) have much higher recurrence risk of GDM than whites.
Previous studies have reported that the effect of IPI on pregnancy outcomes differ by
maternal race/ethnicity.19 In an attempt to clarify whether the large racial and ethnic
differentials in the recurrence risk of GDM are modied by the IPI, we repeated the analysis
after stratifying the data by IPI categories. The results were essentially unchanged, indicating
that the effect of IPI was negligible (data not shown).
COMMENT
In this population-based retrospective co- hort study, we found that women with GDM in
their rst pregnancy are at higher risk of GDM in their subsequent pregnan- cies and the risk
for GDM increases further with subsequent pregnancies. In their ret- rospective review of 90
patients with GDM, Gaudier et al17 showed a 52% re- currence rate of GDM. Similarly, a
second study18 that followed up 100 singleton pregnancies with a history of GDM during
their preceding pregnancies reported a 35% (95% CI, 25.544.5) recurrence rate of GDM. In
the current study, using a large ethnically diverse pregnant population, we found a 13.2-fold
(95% CI, 12.014.6) inTABLE 1
Maternal characteristics at rst and second births by gestational diabetes status: Kaiser
Permanente Southern California, 1991-2008
No gestational diabetesGestational diabetes
Characteristicsn 61,462 (%)
n 3670 (%)
Maternal age, ya
......................................................................................................................................................
...............................................................................
20 12.7 4.1
......................................................................................................................................................
...............................................................................

20-29 59.2 52.2

......................................................................................................................................................
...............................................................................
30-34 21.4 31.2
......................................................................................................................................................
...............................................................................
35 6.7 12.5
......................................................................................................................................................
........................................................................................
Maternal racea
......................................................................................................................................................
...............................................................................
Non-Hispanic white34.023.5
......................................................................................................................................................
...............................................................................
Non-Hispanic black10.46.5
......................................................................................................................................................
...............................................................................
Hispanic43.847.7
......................................................................................................................................................
...............................................................................
Asian/Pacic Islander11.922.3
......................................................................................................................................................
........................................................................................
Maternal education, ya
......................................................................................................................................................
...............................................................................
12 17.9 14.8
......................................................................................................................................................
...............................................................................

12 26.8 25.5
......................................................................................................................................................
...............................................................................
13 55.2 59.6
......................................................................................................................................................
........................................................................................
Prenatal care begana
......................................................................................................................................................
...............................................................................
Early85.188.9
......................................................................................................................................................
...............................................................................
Late14.911.1
......................................................................................................................................................
........................................................................................
Smoking during pregnancy8.77.6
......................................................................................................................................................
........................................................................................
Alcohol during pregnancy0.10.1
......................................................................................................................................................
........................................................................................
Interpregnancy interval, moa
......................................................................................................................................................
...............................................................................
6 5.1 3.9
......................................................................................................................................................
...............................................................................
7-11 14.4 11.0
......................................................................................................................................................
...............................................................................

12-17 17.1 14.8

......................................................................................................................................................
...............................................................................
18-23 15.0 13.4
......................................................................................................................................................
...............................................................................
24-29 12.0 11.6
......................................................................................................................................................
...............................................................................
30-35 9.1 9.1
......................................................................................................................................................
...............................................................................
36 27.5 36.2
......................................................................................................................................................
........................................................................................
Data presented are based on study cohort that consists of rst 2 pregnancies.
a P value for differences in maternal characteristics .001 with 2 test.
Getahun. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet
Gynecol 2010.
creased risk of GDM in the second preg- nancy with known GDM in the rst preg- nancy.
But unlike the aforementioned studies that examined the recurrence of GDM in subsequent
pregnancies irrespec- tive of their GDM history (other than these 2 subsequent pregnancies),
the current study examined the recurrence of GDM in subsequent rst 2 or rst 3
pregnancies. For this study, we restricted the analysis to primiparous women who were
followed up longitudinally. Using this approach, we
were able to show that the risk of GDM is signicantly increased in the third preg- nancy if
rst pregnancy was without GDM and second pregnancy was with GDM as compared to if
the rst pregnancy was with GDM and second pregnancy was without GDM. The risk was
much higher if both rst and second pregnancies were compli- cated by GDM.
Women with a history of GDM and im- paired glucose intolerance are at increased risk of
adverse perinatal outcomes, future
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RESEARCH Obstetricswww.AJOG.org

TABLE 2
Risk of gestational diabetes during rst, second, and third singleton pregnancies: Kaiser
Permanente Southern California, 1991-2008
All women
Women with no previous GDM
No. of
No. of casesRisk ofNo. of No. of cases
Risk of
Pregnancy deliveries of GDM
GDM deliveriesof GDM
GDM
First

65,132

2531

3.9

......................................................................................................................................................
........................................................................................
Second65,13236705.662,60126244.2
......................................................................................................................................................
........................................................................................
Third13,0968997.012,3075804.7
......................................................................................................................................................
........................................................................................
GDM, gestational diabetes mellitus.
Getahun. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet
Gynecol 2010. type 2 diabetes, and cardiovascular disease. The early identication of these
patients and initiation of postpartum lifestyle inter- vention and pharmacologic therapy have
been shown to delay or even prevent future type 2 diabetes.20,21
Both American Collage of Obstetrics and Gynecology22 and American Diabe- tes
Association (ADA)23 recommended that women at risk of type 2 diabetes should be
counseled on the benets of lifestyle modications, which include diet modication, exercise,
as well as weight reduction and maintenance. It is possible in our study that the interven- tion
program targeted at reducing risk of future diabetes might have benetted women with rstbut not second-pregnancy GDM to lower their subsequent risk. We were unable to examine
the in- dependent contributions of postpartum lifestyle factors in the recurrence risk of GDM
because this information was un- available in the data source used for this study. Therefore
future studies should consider lifestyle factors when assess- ment of recurrence risk in
women with a history of GDM is desired.
Even though the adjusted risk for sec- ond-pregnancy GDM in women with rst-pregnancy
GDM seems similar among African Americans and whites, we noted an increased risk of
GDM among African Americans during their third pregnancy as compared to their white,
Hispanic, and Asian/Pacic IsTABLE 3

Recurrence risk of gestational diabetes in subsequent pregnancies based on gestational

diabetes histories
Subsequent birth
SecondTotal
GDM, Unadjusted ORaAdjusted OR
First birthbirth births, n %
(95% CI)
(95% CI)
First 2 pregnancies
(n 65,132)
......................................................................................................................................................
...............................................................................
No GDM 62,601 4.2 1.00 (Reference) 1.00 (Reference)
......................................................................................................................................................
...............................................................................
GDM 2531 41.3 16.1 (14.717.9) 13.2 (12.014.6)
......................................................................................................................................................
........................................................................................
First 3 pregnancies
(n 13,096)
......................................................................................................................................................
...............................................................................
No GDM No GDM 12,307 4.7 1.00 (Reference) 1.00 (Reference)
......................................................................................................................................................
...............................................................................
GDM No GDM 222 23.4 6.2 (4.58.5) 6.3 (4.59.0)
......................................................................................................................................................
...............................................................................
No GDM GDM 430 44.0 15.9 (12.919.5) 15.1 (12.019.1)
......................................................................................................................................................
...............................................................................
GDM GDM 137 56.9 26.7 (18.937.9) 25.9 (17.438.4)
......................................................................................................................................................
........................................................................................

CI, condence interval; GDM, gestational diabetes mellitus; OR, odds ratio.
a Adjustments were made for maternal age, race/ethnicity, education, prenatal care,
interpregnancy intervals, and year of birth.
Getahun. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet
Gynecol 2010.
lander counterparts. Differences be- tween African American women and white women in the
risk of GDM may account for some of the racial differential in pregnancy outcomes that
increase the risk of GDM.
Previous studies have found that African American and Hispanic women are more
likely than white women to have shorter IPI19,24 and it has long been recognized
that women with a short interval between pregnancies are at increased risk of a vari- ety of
adverse perinatal outcomes.25,26 In the current study, although the risk of re- currence in
GDM was substantial among Hispanic and Asian/Pacic Islander women compared with
their white coun- terparts, ndings of analyses stratied by IPI categories did not explain the
disparity in the recurrence of GDM by maternal race/ethnicity.
Although environmental factors and race-/ethnicity-related differences in life- style factors
may account partly for the ob- served heterogeneity of risk of recurrence in GDM among the
various race/ethnicity groups, genetic factors may play a more important role in the
development of the condition. There are 2 potential explana- tions for the increased
recurrence risk of GDM observed among Asian/Pacic Is- lander race/ethnicity group in our
study. First, throughout most Asian countries and for most Asians living in the United States,
rice is an important food staple with high glycemic index. Emerging evidence suggests that
foods with a high glycemic in- dex may cause elevated levels of serum glu- cose and insulin,
thereby increasing the risk of GDM.27 However, whether the con- sumption of foods with a
high glycemic in- dex predicts the recurrence of GDM in subsequent pregnancy has not been
sub- stantiated. Second, many recent epidemi- ological studies have documented the association between overweight and obesity as well as weight gain during pregnancy and
increased risk of GDM.28 Despite lower prevalence of overweight and obe- sity reported
among most Asian popula- tions, recent studies29,30 provide new evi- dence on excess
visceral adipose tissue accumulation among Asian subjects com- pared with subjects of
European ancestry, for a given body mass index category.
Therefore,thisareaofresearchmaybenet
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Obstetrics

RESEARCH

TABLE 4
Recurrence risk of gestational diabetes in subsequent
pregnancies based
on race/ethnicity and a history of gestational diabetes
mellitus
Subsequent
birth

Second
First birth

birth

Non-Hispanic
white
aOR (95%
% CI)

Non-Hispanic
black
aOR (95%
%CI)

Hispanic

Asian/Pacic
Islander

aOR (95%
aOR (95% CI)
%CI)
%

First 2 pregnancies
......................................................................................................................................................
......................................................................................................................................................
...........................................................
No GDM 3.0 1.0 (Reference) 2.7 1.0 (Reference) 4.6 1.0 (Reference) 7.4 1.0 (Reference)
......................................................................................................................................................
......................................................................................................................................................
...........................................................
GDM 39.2 18.4 (15.122.5) 37.7 21.6 (14.532.2) 41.2 12.7 (11.014.7) 44.7 9.6 (7.8
11.7)

......................................................................................................................................................
......................................................................................................................................................
....................................................................
First 3 pregnancies
......................................................................................................................................................
......................................................................................................................................................
...........................................................
No GDM No GDM 3.3 1.0 (Reference) 2.5 1.0 (Reference) 5.7 1.0 (Reference) 7.1 1.0
(Reference)
......................................................................................................................................................
......................................................................................................................................................
...........................................................
GDM No GDM 21.7 10.7 (5.521.1) 13.3 5.2 (1.126.8) 23.7 5.0 (3.08.1) 30.3 6.8 (2.8
16.8)
......................................................................................................................................................
......................................................................................................................................................
...........................................................
No GDM GDM 45.2 28.3 (17.044.1) 38.1 37.7 (11.1129) 41.4 12.4 (9.017.0) 51.2 13.4
(7.822.8)
......................................................................................................................................................
......................................................................................................................................................
...........................................................
GDM GDM 48.2 35.0 (14.883.1) 75.0 158.4 (22.8897) 55.2 17.3 (9.930.1) 62.9 36.1
(14.789.0)
......................................................................................................................................................
......................................................................................................................................................
....................................................................
CI, condence interval; GDM, gestational diabetes mellitus; OR, odds ratio.
a Adjustments were made for maternal age, education, prenatal care, interpregnancy interval,
and year of birth.
Getahun. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet
Gynecol 2010.
greatly from future studies that elucidate both genetic and lifestyle factors for GDM.
In the United States, the prevalence of overweight and obesity among women of childbearing
age increased from

16.5% in 1976-1980 to 32% in 2003- 2004.31,32 Previous studies have shown

that pregnant women who are overweight or obese are at an increased risk for GDM.15,33 Recent studies have also
shown that excess weight gain during
pregnancy is associated with increased risk of GDM.34,35 In light of these overwhelming evidences we speculate that the recent increase in the prevalence of overweight
and obesity among women of childbearing ages may have partly contributed to the higher
recurrence rate of GDM observed in this study.
In 1997, the ADA recommended a new screening practice36,37 and in 2000 the
modied criteria of Carpenter and Cous- tan38 were adopted. In 2000 the ADA39 embraced
the 1982 Carpenter and Cous- tan38 threshold instead of the 1979 Na- tional Diabetes Data
Group (NDDG)40 threshold to decrease risk of adverse fetal and maternal outcomes
associated with GDM. Plasma or serum glucose measure originally proposed by OSullivan
and Ma- han41 in 1964 was used in the NDDG cri- teria for GDM. In contrast, specic enzymatic assays based on that proposed by OSullivan and Mahan41 that set lower
plasma glucose thresholds for the diagno- sis of GDM than those of the NDDG threshold
(143 mg/dL) were used in the Carpenter and Coustan38 criterion. The higher prevalence rate
of GDM observed in this study may suggest that these guide- lines have, at least in part, the
additional effect of increasing the risk of recurrence of GDM. However, since ndings of the
cur- rent study are based on the rst 2 and the rst 3 consecutive births and the vast ma- jority
of consecutive births occurred within a 2.5-year interval period, if there is any effect of the
guidelines, it is expected to be minimal.
Current ADA recommendations are that all pregnant women be screened for GDM between
24-28 weeks gestation, with few exceptions including maternal age 25 years, normal body
weight, not being members of a racial/ethnic group with a high prevalence of diabetes, and no
family history of diabetes. All women in the KPSC system are screened for GDM between
24-28 weeks of gestation.
Our study is not without limitations. We relied on self-reported behavioral risk factors
(maternal smoking and alco- hol consumption during pregnancy) ob- tained from birth
certicate, hospital in- patient, and physician encounter records that have not been validated.
While, Buka et al42 reported that there is signif- icant agreement between self-reported
smoking and serum levels of nicotine metabolite cotinine, it is unclear how reliable selfreported alcohol consump- tion is during pregnancy. Another limi- tation is lack of data on
maternal prepregnancy weight and weight gain during pregnancy during the study pe- riod.
Although we included all women with their rst 2 and rst 3 pregnancies in the study, there is
a possibility that some women with GDM elect not to be- come pregnant again, to avoid
adverse perinatal outcome. Therefore, selection bias may affect our ndings. We care- fully
adjusted for several confounding factors, however, the potential for resid- ual confounding
remains.

In the current study, we were able to provide estimates of recurrence of GDM specically for
the non-Hispanic white, non-Hispanic black, and Hispanic race/ ethnicities. However, we
were not able to provide data by Asian/Pacic Islander sub- groups. For more detailed
subgroup anal- ysis, a large amount of data is required to reach any conclusive result. Thus,
future research should take into consideration the limitation of this study and further investigate the recurrence risk of GDM by Asian/Pacic Islander subgroups.
Equally, the strengths of the present study include: a large sample size, control- ling for
potential confounding factors, limiting the analysis to primiparous
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RESEARCH Obstetricswww.AJOG.org
women and following them up longitudi- nally for subsequent pregnancies, and pre- sentation
of risk disparities among the var- ious race/ethnicity groups. This study also provides
evidence of the validity of hospi- tal-based ICD-9-CM coding for the identi- cation of
patients with GDM.
In conclusion, the results of this study revealed that a previous pregnancy com- plicated by
GDM increases the risk of re- currence of GDM in subsequent preg- nancies, and that risk is
even higher in their third pregnancy if their rst and sec- ond pregnancies had been
complicated by GDM. Based on this nding, we suggest that health professionals be aware
and counsel potential pregnant women about their increased risk for recurrent GDM in
subsequent pregnancy. f
ACKNOWLEDGMENTS
We thank Vicki Chiu, MS, and Bianca P. Cheung for their technical support.
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