Fourth Trimester and Diabetes Risk
The fourth trimester describes the time from delivery through the first 12 weeks postpartum. During this phase, attention often shifts to the newborn. However, for those who experienced gestational diabetes mellitus (GDM), engaging with their health care team can set the stage for long-term health and well-being.
Although only about 10% of individuals are affected by GDM, their risk of developing type 2 diabetes increases tenfold after delivery¹. Despite this heightened risk, studies ²,³ demonstrate that postpartum follow-up remains suboptimal. Comprehensive postpartum care planning started before delivery supports physical and psychological health for the long run
Screening for Elevated Blood Glucose After Delivery
Individuals with GDM usually transition off diabetes medications in the postpartum period ¹; however, it is important to ensure appropriate medication care plans are in place based on the individual’s need. As prior existing pre-diabetes or diabetes may be found in up to one-third ² of individuals during this stage, both the American Diabetes Association and ACOG recommend oral glucose tolerance testing (OGTT) using pre-pregnancy criteria at 4-12 weeks 3 after delivery. OGTT is recommended instead of A1c testing, within the first 12 weeks postpartum, because of changes in blood volume, blood loss during delivery, and the rapid glycemic variations after birth.
However, we know barriers follow-up care and screenings exist. One health system’s retrospective study ¹ showed that while most women receive care from an OB-GYN after delivery, only 29% completed the recommended blood glucose screening. Among those
with abnormal results, just 11% were prescribed glucose-lowering medications, and 21% received a referral for diabetes risk reduction. This study is not unique ¹,² in its findings, and it highlights the need for proactive outreach and post-delivery care.
Screening for Cardiometabolic Risk & Continuity of Care
Ongoing and additional screenings are recommended due to increased cardiometabolic health risks. If postpartum OGTT results are found normal, repeat pre-diabetes and diabetes screening is recommended at least every 1-3 years. ¹ Home blood pressure monitoring is recommended for individuals with history of hypertension. Checking a lipid panel within the first year postpartum for assessment of ASCVD risk, however lipid levels may take up to 3 months to return to pre-pregnancy levels and should not be performed before 6 weeks postpartum due to pregnancy-related changes in lipid metabolism. Routine screening for post-partum depression is also recommended, given the higher prevalence of depression symptoms during and post-GDM, impacting self-care and metabolic outcomes.
In addition to early screening, intervention strategies require a multidisciplinary approach focusing on recovery, prevention, and empowerment. Coordination between OB-GYN, primary care, diabetes care teams, and pediatric groups ensures continuity of care. Education on lifestyle and behavioral health management should be delivered with empathy and flexibility, recognizing the competing demands of new motherhood. A Diabetes Prevention Program subgroup analysis of women who received lifestyle
interventions 10 years after GDM found a 50% decreased incidence of development of diabetes, and a more recent meta-analysis 5 found lifestyle interventions reduced the incidence of diabetes by 24%. Interventions with a registered dietitian can support lactation, restore nutrient balance, and promote cardiometabolic risk reduction.
Encouraging a gradual return to physical activity, beginning with gentle movement and progressing to regular moderate exercise, is associated with improved insulin sensitivity, diabetes risk reduction, and enhanced mood. Incorporating lactation consultants into postpartum care supports ACOG recommendations for exclusive breastfeeding the first 6 months of life and continued up to 2 years of age with solid foods transition. Though challenges such as delayed milk production and reduced supply may occur 6 due to the history of insulin resistance, breastfeeding offers many health benefits and significantly lowers the risk of developing type 2 diabetes for both mother and child. 4 Finally, establishing a clear transition plan to primary care that promotes annual visits, family planning, and ongoing lifestyle support may enhance long-term health maintenance.
Flexible care delivery models that meet women where they are in this stage of life may further help overcome barriers and reduce disparities in postpartum follow-up.
Keeping Connected After Delivery
The fourth trimester represents a pivotal opportunity to ensure postpartum care and support to engage lifelong health. This time often shifts focus to the newborn, but for women with a history of GDM, this period is not only about recovery but also prevention of type 2 diabetes, cardiovascular disease, and future pregnancy complications. The diabetes care team can support postpartum screenings, nutrition, lifestyle interventions, and transition of care that close postpartum care gaps. Proactively outreaching and engaging during this critical phase can connect individuals to resources and long-term chronic disease prevention.
Christine Craig, MS, RDN, CDCES
Founder: Nutrition for Daily Living
References:
- American Diabetes Association Professional Practice Committee; 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2025. Diabetes Care 1 January 2025; 48 (Supplement_1): S306–S320. https://doi.org/10.2337/dc25-S015
- Thomas D, Benson G, Gan A, et al. Fourth Trimester: Assessing Women’s Health Equity and Long-Term Cardiovascular Outcomes in a Large Midwestern Health System in 2021. Circulation: Cardiovascular Quality and Outcomes. 2023;17(1) https://doi.org/10.1161/CIRCOUTCOMES.123.010157
- D’Amico R, Dalmacy D, Akinduro JA, et al. Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes. JAMA Netw Open. 2023;6(2):e2254765.
- Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D; on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and the Stroke Council. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart
Association. Circulation. 2021;143:e902–e916. - Bracco, P.A., Reichelt, A.J., Alves, L.F. et al. Lifestyle intervention to prevent type 2 diabetes after a pregnancy complicated by gestational diabetes mellitus: a systematic review and meta-analysis update. Diabetol Metab Syndr. 2025;17(66)
https://doi.org/10.1186/s13098-025-01606-x - Geddes DT, Gridneva Z, Perrella SL. Breastfeeding after gestational diabetes mellitus: maternal, milk and infant outcomes. Curr Opin Clin Nutr Metab Care. 2025 May 1;28(3):257-262.
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