For doctors caring for pregnant patients with diabetes, management does not end at delivery. UCLA Health maternal-fetal medicine specialists Christina S. Han, MD, and Kimberly Zien Huynh, MD, emphasize that the postpartum period represents a critical opportunity to identify longterm metabolic risk, improve preventive care and alter health trajectories for mothers and babies.
That assertion is central to the doctors’ co-authored published review of best evidence-based care, “Postpartum Care for Patients with Diabetes: A Comprehensive and Whole-Life Approach.”
The review stresses the importance of postpartum care across the spectrum of diabetes encountered in pregnancy, including gestational diabetes mellitus (GDM), type 1 and type 2. While management differs substantially among these groups, all forms of diabetes during pregnancy warrant careful surveillance before, during and after delivery.
Metabolic stress
Pregnancy creates a temporary hypermetabolic state, characterized by increased insulin resistance and hepatic glucose production.
“Cells are dividing rapidly to create the fetus and the placenta,” Dr. Huynh explains. “It’s normal, even without the presence of diabetes, to see an increase in caloric intake. The metabolism also changes between the trimesters from initial storage of nutrition to a later catabolic state..”
In patients with diabetes during pregnancy, however, physiologic regulatory mechanisms may become dysregulated during pregnancy. Residual pancreatic β-cell dysfunction, low-grade inflammation and metabolic abnormalities may remain after childbirth.
“Maternal metabolic response may fail to maintain appropriate glucose balance, resulting in sustained hyperglycemia,” Dr. Huynh says.
Implications extend beyond maternal glucose control alone. Maternal diabetes is associated with increased risks for hypertensive disorders, caesarean delivery, various infections, thyroid dysfunction and long-term cardiometabolic disease. Fetal risks include congenital anomalies, abnormal growth patterns, neonatal hypoglycemia and future metabolic vulnerability.
Accordingly, surveillance for diabetes in pregnancy at UCLA Health begins early. Patients with risk factors such as obesity, family history, prior GDM or exposure to certain medications (such as corticosteroids and HIV medications) undergo early screening during pregnancy to ensure that they are not coming into pregnancy with undiagnosed diabetes.
Depending on severity and diabetes subtype, holistic management may involve maternal-fetal medicine specialists, endocrinologists, diabetes educators, registered dietitians, clinical nutritionists, pediatric cardiologists, lactation consultants, social workers and mental health professionals – members of the UCLA Diabetes and Endocrinologic Disorders of Pregnancy Program.
Dr. Han emphasizes that clinicians should view diabetes care chronologically, ideally beginning before conception – during “Trimester Zero” – whenever possible.
“Pregnancy is a window into an individual’s future,” she says. “Whatever manifests during pregnancy will help guide physicians in understanding how to personalize care for that individual.”
Postpartum monitoring
The intensity and duration of postpartum glycemic monitoring depends on diabetes subtype, treatment requirements, comorbidities and long-term metabolic risk.
Patients with GDM often experience normalization of glucose physiology following placental delivery, and may not require intensive postpartum monitoring. However, they are at significantly increased risk for future Type 2 diabetes as well as recurrent GDM in subsequent pregnancies.
Patients with high insulin requirements, Type 1 diabetes and Type 2 diabetes require glucose surveillance during postpartum and after discharge.
Additionally, monitoring extends beyond maternal glucose values alone.
“Neonates born to mothers with diabetes are at increased risk of low blood sugar at birth and future glucose abnormalities,” Dr. Huynh says, “because of both inherited predisposition and in utero exposure. So they require glucose surveillance in the first hours of life, and future monitoring and surveillance by their primary care physicians.”
Dr. Han adds, “If your parents have diabetes, you are very likely to develop diabetes.”
The doctors importantly address barriers to breastfeeding and lactation support in their published review. Breastfeeding is known to improve maternal metabolic health outcomes, mitigate cardiovascular risk and decrease risk of metabolic syndrome in infants, among other benefits.
However, barriers exist. Dr. Huyhn says patients with diabetes are more likely to undergo cesarean delivery because of fetal macrosomia. “Nursing is physically difficult because the mothers are recovering from major surgery,” she explains.
Some emerging research also suggests altered milk composition and supply in mothers with diabetes, although clinical significance remains under investigation. Individualized lactation support is often necessary for patients with diabetes during pregnancy.
Follow-up gap
Fragmentation between obstetric and primary care remains a major weakness in postpartum diabetes care nationwide.
“It is very much a significant gap,” Dr. Han says. “Unless the patient brings up diabetes during pregnancy themselves, or the doctor digs for that history, it may be missed. Taking a good pregnancy history should be required in all primary care visits.”
The doctors say food insecurity, limited health care access, disrupted work schedules and socioeconomic disparities can complicate diabetes management and contribute to mood disorders and other postpartum challenges.
“Women of color and patients of lower socioeconomic status are at increased risk for these metabolic syndrome phenotypes,” Dr. Huynh says. “Unfortunately, some of the psychosocial factors that go along with that would be intimate partner violence, mood disorders and generational trauma.”
At UCLA Health, integrated communication between obstetrics, endocrinology, cardiology, primary care and social workers reduces follow-up disconnects. Patients are transitioned back to primary care with clear follow-up recommendations, including postpartum glucose tolerance testing and ongoing annual hemoglobin A1C surveillance.
The health care network has also developed structured preconception counseling programs and postpartum referral pathways designed to address long-term cardiovascular and metabolic risk.
“We have worked really hard to build ties both before and after pregnancy with our primary care and social work colleagues,” Dr. Han says.
Ultimately, Drs. Han and Huynh say clinicians caring for reproductive-age patients must understand that postpartum diabetes care should not be viewed as the conclusion of pregnancy management, but rather as the beginning of a long-term strategy to improve lifelong health outcomes for mother and child.
