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Songwon Lecture 2025
Diabetes, obesity and metabolism Postpartum Glucose Intolerance in Women with a History of Gestational Diabetes Mellitus: An In-Depth Review
Keypoint
- The global prevalence of gestational diabetes mellitus (GDM) is increasing, and postpartum glucose intolerance is one of the major metabolic complications after delivery in affected women.
- Several factors have been associated with an increased risk of postpartum glucose intolerance among women with prior GDM, including ethnicity, genetic predisposition, advanced maternal age, obesity, pre-pregnancy body mass index, gestational weight gain, previous GDM, family history of diabetes, hyperglycemia during pregnancy, insulin treatment, and dyslipidemia.
- Lifestyle interventions, including weight loss, may reduce the risk of postpartum glucose intolerance.
- Given this elevated risk, appropriate postpartum monitoring and management strategies are essential for women with a history of GDM.
Kyung-Soo Kimorcid, Soo-Kyung Kim, Yong-Wook Cho
Endocrinology and Metabolism 2026;41(1):26-33.
DOI: https://doi.org/10.3803/EnM.2025.2852
Published online: February 3, 2026

Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea

Corresponding author: Kyung-Soo Kim. Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea, Tel: +82-31-780-3455, Fax: +82-31-780-5208, E-mail: kks982@hanmail.net
• Received: December 15, 2025   • Revised: December 22, 2025   • Accepted: December 23, 2025

Copyright © 2026 Korean Endocrine Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Gestational diabetes mellitus (GDM) is increasing in prevalence worldwide, and postpartum glucose intolerance represents one of the major complications after delivery in women with GDM. A wide range of risk factors for postpartum glucose intolerance have been identified, including ethnicity, genetic predisposition, age, obesity, pre-pregnancy body mass index, gestational weight gain, history of GDM, family history of diabetes, degree of hyperglycemia, insulin treatment, lipid profiles, and other metabolic factors. Lifestyle interventions, including weight loss, are thought to reduce the risk of postpartum glucose intolerance. Careful attention should be paid to the screening of postpartum glucose intolerance in women with GDM, and concerted efforts should be made to prevent or delay the development of diabetes and other metabolic disorders.
  • Keywords: Diabetes, gestational; Glucose intolerance; Postpartum; Pregnancy; Diabetes mellitus, type 2
The Songwon Medical Scientist Award is the highest scientific award of the Korean Endocrine Society to honor an individual below 45 years old who has made excellent scientific contributions and planned outstanding research proposal to progress in the field of endocrinology and metabolism. The Songwon Medical Scientist Award is named after the pen name of Professor Kab Bum Huh, who had been emphasizing the importance of research and educations in field of not only endocrinology but also overall medicine. Professor Kyung-Soo Kim received the Songwon Medical Scientist Award at the 2025 Symposium for Academia, Research, and Industry & Autumn Congress of the Korean Endocrine Society in October 2025.
Gestational diabetes mellitus (GDM) is defined as ‘any degree of glucose intolerance with onset or first recognition during pregnancy that is not clearly overt diabetes’ [1]. GDM is one of the most common medical complications of pregnancy, and its prevalence is increasing globally [2,3]. The reported prevalence of GDM varies substantially depending on the population studied and the diagnostic criteria applied. A systematic review examining diagnostic criteria for GDM reported worldwide prevalence estimates ranging from 2% to 24.5% using World Health Organization criteria, 3.6% to 38% using Carpenter and Coustan criteria, 1.4% to 50% using US National Diabetes Data Group criteria, and 2% to 19% using International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria [4]. In Korea, the prevalence of GDM among Korean women increased to 12.70% during the period from 2011 to 2015 [5]. In 2019, the International Diabetes Federation estimated that 1 in 6 live births worldwide were complicated by GDM [6].
GDM has a wide range of adverse implications for both mothers and their offspring [7,8]. Adverse perinatal outcomes associated with GDM include preeclampsia, cesarean section, macrosomia, neonatal hypoglycemia, and hyperbilirubinemia, with increased risks observed in women affected by GDM [9–11]. Offspring born to mothers with GDM have a higher likelihood of developing obesity, impaired glucose tolerance (IGT), and type 2 diabetes mellitus (T2DM) during childhood or early adulthood [12,13]. In addition, women with GDM themselves are at substantially elevated risk of developing IGT, T2DM, and cardiovascular or metabolic diseases after delivery [14–16]. To identify not only women with overt diabetes but also those with IGT, in whom progression to diabetes may be delayed or prevented, many clinical guidelines recommend screening women with GDM for persistent diabetes or prediabetes at 4 to 12 weeks postpartum using a 75-g oral glucose tolerance test (OGTT) and non-pregnancy diagnostic criteria [17]. This article aims to provide an in-depth review of postpartum glucose intolerance in women with a history of GDM.
Postpartum screening in women with GDM is essential for the early detection and prevention of T2DM. Currently, the American College of Obstetricians and Gynecologists, the American Diabetes Association, and the Korean Diabetes Association recommend that women with a history of GDM undergo a 75-g OGTT between 4 and 12 weeks postpartum [17–19], whereas the International Federation of Gynecology and Obstetrics recommends screening between 6 and 12 weeks postpartum [20].
In general, GDM is associated with up to a 20-fold increase in lifetime risk of developing T2DM [21,22]. However, depending on study design, diagnostic methods, and ethnicity, reported prevalence estimates of postpartum diabetes range widely from 2.6% to 70% [14]. A meta-analysis and systematic review of 20 studies involving 67,956 women with GDM demonstrated that women with a history of GDM have an approximately 10-fold increased risk of developing T2DM, most commonly within the first 5 years following the index pregnancy [21]. The Hyperglycemia and Adverse Pregnancy Outcomes Follow-Up Study showed that more than 50% of women whose OGTT values met untreated IADPSG diagnostic thresholds for GDM had developed IGT after 14 years of follow-up [12]. A prospective cohort study conducted in Korea reported a cumulative incidence of postpartum diabetes of 23.8% over a median follow-up duration of 4 years and projected an incidence of 50.0% over an 8-year follow-up period among women with prior GDM [23]. Although relatively few studies have specifically investigated postpartum glucose intolerance, a meta-analysis of 18 articles reported that the incidence within 1 year postpartum among women with GDM was 34.5% [24]. In one study that performed a 75-g OGTT at 6 to 12 weeks postpartum, the prevalence of postpartum glucose intolerance was 44.8% among 348 women with GDM [25].
Although hemoglobin A1c (HbA1c) is not currently recommended for the screening of glucose intolerance in postpartum women with GDM, it is very attractive for the postpartum screening because it is easy, reproducible and reflects mean blood glucose levels over time. A study enrolled 699 women with GDM have shown that HbA1c had misclassified nearly half of postpartum women with GDM compared with those who were identified using the 75-g OGTT in this study [26]. However, HbA1c had a high specificity and negative predictive value for identifying postpartum glucose intolerance. They suggested that HbA1c may not be sensitive enough for accurate diagnosis, but it is highly specific for diagnosing overt diabetes at 6 to 12 weeks postpartum in women with previous GDM. In a meta-analysis including six studies, because the area under the summary receiver operating characteristic curve was 0.67 with a Q-value of 0.63, HbA1c did not appear to be a sensitive test for the detection of abnormal glucose tolerance in women with GDM [27]. It might be because not only iron deficiency and blood loss at delivery but also age, race and diseases that change the erythrocyte lifespan might influence HbA1c levels [28].
Well-established risk factors for postpartum glucose intolerance in women with GDM include maternal age, pre-pregnancy body mass index (BMI), family history of diabetes, history of GDM, insulin use during pregnancy, gestational age at diagnosis, weight gain during pregnancy, postpartum BMI, HbA1c level at diagnosis, fasting blood glucose level at diagnosis, 1-hour postprandial blood glucose level at diagnosis, 2-hour postprandial blood glucose level at diagnosis, postpartum HbA1c level, fasting blood glucose level measured 6 to 12 weeks postpartum, 2-hour postprandial blood glucose level measured 6 to 12 weeks postpartum, low-density lipoprotein (LDL)-cholesterol level at diagnosis, triglyceride level at diagnosis, and other related metabolic parameters [29–31].
Ethnicity
Previous studies have reported that the incidence of glucose intolerance within 1 year postpartum varies by ethnicity [32–34]. In general, the incidence is highest among Asian populations with GDM and lowest among Caucasian populations [32]. A study that recruited 368 women of European, Asian, and African ethnicities with a history of GDM demonstrated that the prevalence rates of IGT (44% vs. 28%) and metabolic syndrome (49% vs. 28%) were higher among Asian women than among European women at 20 months postpartum [33]. In addition, another study showed that women of Asian ethnicity had a 5-fold higher risk of developing diabetes 1 to 2 years postpartum and exhibited a 22% reduction in β-cell compensation, as measured using the disposition index [34].
Genetic predisposition
Genetic information may be useful for predicting the risk of progression to T2DM in women with a history of GDM [23,35]. In a study of 634 Korean women with prior GDM, genetic variants in cyclin-dependent kinase inhibitor 2A/2B (CDKN2A/2B) and hematopoietically expressed homeobox (HHEX) were associated with early conversion to T2DM (≤8 weeks postpartum), whereas variants in CDK5 regulatory subunit-associated protein 1-like 1 (CDKAL1) were associated with late conversion (>1 year postpartum) [23]. In cohorts of women with a history of GDM from diverse ancestral backgrounds, a 1-standard deviation increase in the genome-wide T2DM polygenic risk score (PRS) was associated with a 1.44-fold increased risk of incident T2DM, and women with a PRS in the top 10% had a 2.86-fold increased risk [35].
Age
Numerous studies have demonstrated that advanced maternal age is an independent risk factor for postpartum glucose intolerance in women with GDM [24,36,37]. One observational study found that when maternal age exceeded 30 years, the positive association between GDM and the risk of postpartum glucose intolerance was significant and persistent over time [36]. In a meta-analysis of 170,139 women, the incidence of postpartum T2DM among women with GDM older than 30 years was 2.42 times higher than that among women younger than 30 years [37]. Another meta-analysis of 18 studies reported that increasing age was associated with a higher risk of glucose intolerance one year postpartum in women with GDM (mean difference, 1.71; 95% confidence interval [CI], 0.50 to 2.91) [24].
Obesity, pre-pregnancy BMI, and weight gain
Obesity is a well-recognized risk factor for GDM and is also associated with an increased risk of postpartum glucose intolerance [38,39]. A study of 454 Caucasian women reported that a pre-pregnancy BMI ≥25 kg/m2 showed the strongest association with postpartum prediabetes (adjusted odds ratio [OR], 3.04; 95% CI, 1.73 to 5.34) [38]. A meta-analysis further demonstrated that the risk of developing postpartum T2DM among women with GDM who were overweight before pregnancy was 1.57 times higher than that among women with normal pre-pregnancy weight [39].
In addition, excessive weight gain during pregnancy is associated with the development of glucose intolerance within 1 year postpartum in women with GDM [40,41]. In a study including 1,695 women with GDM, each 5-kg increment in weight gain after the diagnosis of GDM was associated with a 27% higher risk of T2DM (adjusted hazard ratio, 1.27; 95% CI, 1.04 to 1.54) [40]. This association may be explained by the fact that excessive gestational weight gain and fat accumulation increase insulin resistance, thereby further exacerbating hyperglycemia in women with GDM [41].
Being overweight in the postpartum period is also associated with abnormal glucose metabolism in women with GDM [42]. Another study similarly demonstrated that the risk of developing postpartum glucose intolerance among women with GDM who retained excess postpartum weight was 2.47 times higher than that among women who returned to their pre-pregnancy weight [43]. A prospective cohort study including 418 Korean women with GDM (baseline BMI 23.3 kg/m2) showed that participants in the highest tertile of postpartum BMI change had an approximately twofold higher risk of developing diabetes compared with those in the lowest tertile [44].
History of GDM
GDM may represent an early stage in the natural course of T2DM and is recognized as a major risk factor for the subsequent development of T2DM [45]. A history of GDM is also a risk factor for recurrent GDM, and the recurrence rate of GDM among pregnant women previously diagnosed with GDM has been reported to be as high as 70% [46]. As the number of GDM recurrences increases, progressive β-cell dysfunction in pregnant women may become irreversible, thereby increasing the likelihood of postpartum glucose intolerance in women with GDM [47]. A retrospective study of 454 Caucasian women demonstrated that the risk of glucose intolerance at 6 to 12 weeks postpartum among women with a history of GDM was 1.27 times higher than that among women diagnosed with GDM for the first time [38]. In a meta-analysis of 18 studies, the incidence of abnormal glucose metabolism within 1 year postpartum in women with a history of GDM was 2.62 times higher than that in women without a history of GDM [24].
Family history of diabetes
A family history of diabetes is an important risk factor for post-partum glucose intolerance in women with GDM [48]. A meta-analysis that followed women with GDM from 3 months to 15 years postpartum showed that the incidence of glucose intolerance among women with a family history of diabetes was 1.06 times higher than that among women without a family history of diabetes [49]. Another meta-analysis of 18 studies demonstrated that the incidence of glucose intolerance within 1 year postpartum among women with GDM and a family history of diabetes was 1.96 times higher than that among women without a family history of diabetes [24].
Hyperglycemia
Multiple studies have reported that fasting plasma glucose levels during pregnancy are consistently associated with the development of postpartum diabetes [50,51]. Abnormal glucose values at all three time points of the OGTT at diagnosis are significantly associated with the occurrence of glucose metabolism abnormalities within 1 year postpartum in women with GDM [24]. Various glycemic indices, including 1- and 2-hour plasma glucose levels during OGTT and the area under the OGTT curve, have been shown to be associated with the development of postpartum diabetes [52–54]. Elevated HbA1c levels during pregnancy are also a recognized risk factor for postpartum glucose intolerance in women with GDM [31,55]. In addition, high fasting and 2-hour postprandial blood glucose levels measured at 6 to 12 weeks postpartum are associated with the occurrence of abnormal glucose metabolism within 1 year postpartum in women with GDM [24]. Among women with GDM, elevated HbA1c levels at 6 to 12 weeks postpartum have been associated with an increased risk of developing abnormal glucose metabolism in the future [56].
Insulin treatment
The need for insulin treatment in women with GDM indicates a greater degree of hyperglycemia, and therefore, women with GDM who require insulin during pregnancy are at increased risk for postpartum glucose intolerance. In addition, the requirement for insulin to control blood glucose levels during pregnancy suggests more severe pancreatic dysfunction in these patients, characterized by impaired pancreatic β-cell function and a marked reduction in insulin secretion. Because pancreatic function in such patients may not return to normal within a short period after delivery, this dysfunction may ultimately lead to the development of postpartum glucose intolerance [37]. The Pregnancy and Neonatal Diabetes Outcomes in Remote Australia study reported that the incidence of abnormal glucose metabolism postpartum among women with GDM who used insulin during pregnancy was 3.98 times higher than that among women who did not use insulin [57]. In a meta-analysis of 18 studies, the risk of developing glucose intolerance within 1 year postpartum among women with GDM who used insulin during pregnancy was 2.41 times higher than that among women who did not use insulin [24].
Lipids
During normal pregnancy, blood lipid levels physiologically increase to meet the growth and developmental needs of the fetus [58]. Plasma cholesterol, triglyceride, and LDL-cholesterol levels, and other lipid components rise as pregnancy progresses and gradually decrease after delivery, typically returning to normal levels by 4 to 6 weeks postpartum. However, in women with GDM, blood lipid levels increase more markedly during pregnancy and are more difficult to normalize in the early post-partum period. Because elevated triglyceride levels may exacerbate insulin resistance by inhibiting insulin signaling as well as glucose transport and utilization, hypertriglyceridemia has been associated with postpartum glucose intolerance in women with GDM [59]. A retrospective cohort study of 498 women with a history of GDM found that abnormal mid-trimester triglyceride and LDL-cholesterol concentrations were associated with postpartum abnormal glucose metabolism (adjusted OR, 1.786; 95% CI, 1.142 to 2.425; and adjusted OR, 1.621; 95% CI, 1.323 to 2.051) [60].
Numerous studies have demonstrated that lifestyle interventions can prevent or delay the onset of diabetes in high-risk populations. It is therefore reasonable to expect that lifestyle interventions implemented during and after pregnancy may also reduce the risk of postpartum glucose intolerance, although relatively few studies have directly examined this association. The Diabetes Prevention Program Outcomes Study (DPPOS) demonstrated that intensive lifestyle modification and metformin therapy reduced the cumulative incidence of diabetes in women with a prior diagnosis of GDM by 35% and 40%, respectively [61]. However, participants in the DPPOS were enrolled more than 12 years after delivery rather than during pregnancy or the immediate postpartum period. The Diet, Exercise, and Breastfeeding Intervention study found that women who lost more than 2 kg showed reductions in fasting and 2-hour glucose levels, along with increased 2-hour insulin levels, at 12 months postpartum among women with a history of GDM [62]. In contrast, a prospective randomized controlled interventional trial involving 450 women with GDM and postpartum IGT reported that fewer women in the lifestyle intervention group developed postpartum diabetes over a 3-year follow-up period compared with the control group; however, this difference did not reach statistical significance (15% vs. 19%) [63]. Further studies are warranted to clarify the metabolic benefits of lifestyle interventions for postpartum glucose intolerance in women with GDM. Nevertheless, it is reasonable to assume that lifestyle modifications leading to weight loss, whether implemented during pregnancy or after delivery, may exert beneficial effects on metabolic abnormalities, including postpartum glucose intolerance.
The prevalence of GDM is increasing worldwide, and postpartum glucose intolerance represents one of the major complications following delivery in affected women. Multiple factors, including ethnicity, genetic predisposition, age, obesity, pre-pregnancy BMI, gestational weight gain, history of GDM, family history of diabetes, hyperglycemia, insulin treatment, lipid abnormalities, and other related factors, have been associated with an increased risk of postpartum glucose intolerance in women with GDM (Fig. 1). Lifestyle interventions, particularly those resulting in weight loss, are thought to reduce the risk of postpartum glucose intolerance; however, additional studies are needed to confirm their effectiveness. Despite guideline recommendations, the completion rate of the postpartum 75-g OGTT remains suboptimal, as mothers caring for a newborn often find it difficult to attend the laboratory for a 2-hour test after overnight fasting and may underestimate the importance of postpartum glucose testing. Therefore, increasing awareness of the elevated risk of postpartum glucose intolerance in women with GDM and promoting appropriate postpartum management are critical.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

ACKNOWLEDGMENTS

This work was supported by the Korean Endocrine Society for Songwon Award 2025.

Fig. 1
Various risk factors for postpartum glucose intolerance in women with gestational diabetes mellitus (GDM).
enm-2025-2852f1.jpg
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    • Diabetes in Pregnancy in Korea: Prevalence, Clinical Characteristics, and Postpartum Comorbidities
      Joon Ho Moon, Han Na Jung, Bongseong Kim, Seung-Hyun Ko, Soo Heon Kwak, Kyung-Do Han, Sung Hee Choi
      Diabetes & Metabolism Journal.2026; 50(2): 280.     CrossRef

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      Postpartum Glucose Intolerance in Women with a History of Gestational Diabetes Mellitus: An In-Depth Review
      Endocrinol Metab. 2026;41(1):26-33.   Published online February 3, 2026
      DOI: https://doi.org/10.3803/EnM.2025.2852
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    Postpartum Glucose Intolerance in Women with a History of Gestational Diabetes Mellitus: An In-Depth Review
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    Fig. 1 Various risk factors for postpartum glucose intolerance in women with gestational diabetes mellitus (GDM).

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    Postpartum Glucose Intolerance in Women with a History of Gestational Diabetes Mellitus: An In-Depth Review
    Endocrinol Metab : Endocrinology and Metabolism
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