Background <p>American Indian (AI) women are at high risk for pregnancy complications, including gestational diabetes (GDM). However, few large-scale studies address the relationship between cardiovascular and pregnancy health in this population.</p> Methods <p>The Strong Heart Study examined cardiovascular disease in Oklahoma, Arizona, and North and South Dakota starting in 1988. Female participants were asked about their number of livebirths, lost pregnancies, and pregnancy complications. Gestational diabetes was self-reported, diabetes outside of pregnancy was directly assessed at regular intervals, and CVD morbidity and mortality outcomes were adjudicated. The analytic dataset consisted of women with at least one follow-up after a pregnancy, and with self-reported information on GDM (<i>n</i> = 1685). Cardiometabolic disease was examined using time-to-event analysis (proportional hazards modeling) with age as the time axis, controlling for covariates (smoking, BMI, income, education, age at first birth).</p> Results <p>Mean age at last follow-up was 59.5 years. Median parity was 4, and 135 (8.0%) women reported a history of GDM for at least one pregnancy. History of GDM was associated with a higher likelihood of diabetes later in life (adjusted hazard ratio [aHR] 1.60, 95% CI 1.22–2.10). History of GDM was not associated with later cardiovascular disease (aHR 0.93, 0.57–1.51).</p> Discussion <p>History of GDM in this large-scale American Indian cohort was associated with the development of diabetes later in life. Associations were not as strong for cardiovascular disease outcomes, possibly because many participants were still relatively young. This study highlights a contributor to chronic disease in a high-risk population not well represented in the literature.</p>