GDM is more than just T2D later in life

10th June 2026, A/Prof Chee L Khoo

diabetic retinopathy

We know that if a woman developed gestational diabetes mellitus (GDM), the risk of development of type 2 diabetes (T2D) later in life increases by 4-10 times. We also know that the same woman also have higher risk of developing elements of cardiovascular disease (CVD) including hypertension, atherosclerotic CVD ASCVD and heart failure (HF). We now have data linking the development of diabetic retinopathy (DR) and some of these women with GDM depending on the severity of their GDM and whether they develop T2D later on in life or not. This new information really allows us to focus on which women need extra care in retinopathy screening.

We reported that not just GDM but many pregnancy related disorders also increase T2D and hypertension risk later in life as well as increases in rates of ASCVD and heart failure. Adverse pregnancy outcomes (APOs) affect the future metabolic and cardiovascular risks of the offsprings but there is mounting evidence for many decades now that a history of APOs predicts later-life risk of CVD including coronary artery disease (CAD) and heart failure (HF) (1, 2). It is particularly important to optimise the management of these CV risk factors during (and before) pregnancy. It is also important to protect the future health of these women in primary care as we will be looking after them for decades to come and this open up opportunities for targeted prevention.

We also explored the different GDM subtypes are associated with different trajectories post partum. Women with GDM because of high fasting glucose, tend to have higher percentages of obesity and excessive weight gain during pregnancy. Compared with women who has GDM based on high post prandial readings, women with fasting hyperglycaemia are more likely to have prediabetes at 6 months post partum.

So, is GDM a risk factor for future retinopathy? In a nationwide, register-based cohort study 708,250 women giving birth in Denmark in 1997–2018 were followed up for 12 years (3). The GDM prevalence was 3.4%. Diabetes developed subsequently in 18,556 women (2.6%), and DR occurred in 655 of these. Naturally, not all the women who had GDM developed diabetes during the follow up period. Similarly, not all women who developed diabetes later in life had GDM during their pregnancies.

In the women who developed diabetes, previous GDM was associated with a threefold higher risk of diabetic  retinopathy (DR) (adjusted hazard ratio [aHR] 3.0 [95% CI 2.6–3.6]). 

As we have already seen, not all women with GDM are the same (4). The risk of DR increased with increased severity of the GDM. Women with GDM not on insulin were 2.4 X more likely to have retinopathy compared with women without GDM. Women who had GDM and on insulin were 5.6 X more likely to have retinopathy compared with women without GDM.

In women who developed hypertension later on life but had GDM earlier, there was a 2.7 X higher risk of DR compared with women who did not have GDM.

We can view pregnancy as a big physiological stress episode. Women who have high risk for various cardiometabolic conditions later in life will succumb to some of those conditions during pregnancy – dysglycaemia (GDM), dyslipidaemia, hypertension etc. These are adverse pregnancy factors which we need to inquire when we put on our preventative medicine hat in general practice.

Women who have GDM and developed T2D later in life has a much high risk of diabetic retinopathy compared with those who did not have GDM. The more severe the GDM is, the more likely diabetic retinopathy is.

References

  1. Parikh NI, Gonzalez JM, Anderson CAM, et al. 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:e902–16
  2. Honigberg MC, Zekavat SM, Aragam K, et al. Long-term cardiovascular risk in women with hypertension during pregnancy. J Am Coll Cardiol 2019;74:2743–54
  3. Maria Hornstrup Christensen, Christina Anne Vinter, Maria Houborg Petersen, Marianne Skovsager Andersen, Jakob Grauslund, Dorte Moeller Jensen; Diabetic Retinopathy in Parous Women With and Without Previous Gestational Diabetes Mellitus: A Nationwide Register-Based Cohort Study. Diabetes Care 20 May 2026; 49 (6): 1078–1085.
  4. Van JAD, Lo JC, Zhu Y, et al. Early Postpartum Glucose Tolerance Reclassification by Gestational Diabetes Subtype. JAMA Netw Open. 2025;8(11):e2542668