Gestational diabetes is categorized as diabetes which only manifests itself during pregnancy which can be harmful for the maternal and fetal health, equally. The principle governing gestational diabetes remains the same as type 2 diabetes which is marked by abnormally increased blood glucose levels which develop insulin tolerance causing ill-regulated blood glucose levels.
Although the principle remains the same as type 2 diabetes, the prime difference between type 2 diabetes (insulin independent diabetes) and gestational diabetes is only the duration of the disease.
Often gestational diabetes is diagnosed later during the pregnancy, however it can be present between the 24th and 28th week of gestation. According to the Centers of Disease Control and Prevention (CDC), out of all pregnancies recorded in the United States, 9.2% women suffered from gestational diabetes in year 2014.
The disease burden has been on an increase and requires experts to have a prognosis model for prevention or early detection of the disease. When, the disease prevalence was looked through different ethnicities, it was found that the disease was less common in white American women, on the contrary; the prevalence was more pronounced in Hispanics, Native American women, Black Americans and women from Asian origin.
What Are The Causes Of Gestational Diabetes?
Many women who are pregnant or who aspire to enter motherhood any time soon will find it worrisome that they are prone to developing a disease. Thereby, it is crucial for them to know why this disease develops and if their risk of getting gestational diabetes high.
By now, we know that pregnancy is marked by different physiological changes in the body to prepare to nurture a growing embryo in the womb; these changes are brought by changes in different hormonal levels.
As pregnancy is also accompanied with weight gain, the cumulative changes in the maternal body consequently result in ineffective usages of insulin leading to insulin resistance. As insulin resistance begins to develop in the body, the body’s need to produce increased insulin amounts become evident for counteracting the effects of insulin resistance.
By this time, the likelihood of the mother to develop gestational diabetes is increased but it only is diagnosed if the following condition also takes place.
In pregnancy cases which later develop gestational diabetes, with the surge of hormones in the maternal system, the body is unable to make adequate amount of insulin secreted by the pancreas to maintain normal blood glucose levels. Adding more to the causes leading to the diagnosis of gestational diabetes, it is speculated by the American Diabetes Association (ADA) that the action of insulin is blocked by the placental hormones which blocks the influence of increases insulin resistance.
Now by this time, when the pancreas fails to produce sufficient amounts of insulin; the onset of gestational diabetes is observed.
Symptoms And Signs Of Gestational Diabetes
Signs of gestational diabetes are not noticeably distinctive, thereby it is recommended to have a screening test for it during your visits to the doctor. However, it is associated with frequent urination, increased thirst and fatigue.
Management Of Gestational Diabetes
Gestational diabetes can be managed easily if one heeds the advice of their doctor. Some of the precautions that need to be taken include:
- Monitor your blood glucose properly
- Prenatal visits
- Make healthy food choices and consult a dietitian or doctor to make a meal plan and adhere to it to manage adequate blood glucose levels
- Stay physically active as exercise and activity naturally control high blood glucose
- Take insulin or oral hypoglycemic as advised by your physician. Some doctors prescribe medication to control the blood glucose.
Who Is At A Risk Of Getting Gestational Diabetes?
For the management of gestational diabetes, it is important to distinguish between low risk group and high risk group pregnant women. Some of the common risk factors that can increase one’s likelihood of getting gestational diabetes are listed below.
- Family history of type 2 diabetes
- History of pre-diabetes
- History of PCOS (Polycystic Ovary Syndrome)
- Being overweight which translates as having a BMI over 30kg/m2
- Previous gestational diabetes
- Previous pregnancy with a large baby (delivery of a baby weighing more than 9lbs or 4.5 kg)
- Mother being more than 25 years of age
- Mother being treated for AIDS/HIV
- Belonging to an ethnic group with increased disease prevalence, including Pacific Islander Americans, American Indians, Asian Americans, Hispanics or African Americans.
High Iron Levels And The Risk Of Gestational Diabetes
Taking iron supplementation is important in pregnancy and a large percentage of educated women who are in their reproductive age are well aware of the importance of taking iron supplements during pregnancy. However, recent work of experts has raised questions about taking the right dose of iron supplements. Exceeding the optimal iron levels can lead to increasing risk of diabetes by disrupting the glucose metabolism in the human system.
Previously, the link of elevated iron intake had been linked with the risk of type 2 diabetes in non-pregnant women; it is just recently known that the risk of gestational diabetes is also elevated by increased iron intake.
In a study published in Diabetologia and also covered by the British Medical Journal recently found that the iron regulatory biomarkers had a direct relation with gestational diabetes which included plasma hepcidin, ferritin and soluble transferrin receptor. The risk of gestational diabetes was 16% higher between 15 and 26 weeks of gestation and thereby it is important for you to sit with your doctor and decide the amount of iron supplements required which is safe for you and your baby.
According to World Health Organization (WHO) normal daily iron intake during pregnancy should be 30 to 60 mg of elemental iron. A 30 mg dose of iron equates to 150 mg of ferrous sulfate heptahydrate, 250 mg of ferrous gluconate or 90mg if ferrous fumarate. Optimal level of iron is required to reducing the risk of maternal anemia, low birth weight and iron deficiency however it is important to not take excessive iron supplement amounts which can increase your risk of developing gestational diabetes.
What Is The Diagnosis For Gestational Diabetes? Can The Likelihood Of Gestational Diabetes Be Prevented?
Experts believe that the incidence rate of gestational diabetes has increased over the years and it is a need of the hour to have an early screening test for timely detection and prevention of gestational diabetes. In this regard, the experts are try to form a framework and devise prognosis models which reduces the disease burden, is convenient for the clinician and the patients and is cost effective to be adopted by healthcare systems at large.
A study published in the British Medical Journal (BMJ) looked at the prognosis models and found out salient features which can be used as predictors of gestational diabetes behind the condition can go on to because harm to the maternal and fetal health.
Currently some clinical guidelines recommend a population based screening strategy for predicting the risk rate of developing gestational diabetes through the use of an oral glucose tolerance test. In some facilities this tests is given to all the pregnant women whereas in other cases only high risk group is asked to take this test. Before discussing into the pros and cons of using oral glucose tolerance test, here is a brief account of the test for you to grasp the concept easily.
Oral Glucose Tolerance Test (OGTT)
Before you walk in for taking this test, you are asked by your doctor to fast for 8 hours or longer, meaning that during your fast you will not be able to eat or drink anything except water. Following this fast, your fasting blood glucose level will be checked and then you will be asked to drink a sugary beverage. After you consume this drink containing 75 grams of sugar, your blood glucose levels will be checked at 1 hour, 2 hour and sometimes even 3 hour intervals and the obtained results will work as a predictor for estimating your likelihood of having gestational diabetes.
According the guidance released by the National Institute for Health and Care Excellence (NICE), OGTT should be taken earlier in the first or second trimester and upon getting normal results, the test should be repeated during the 24-28 week of pregnancy.
The diagnosis criteria based on the results of OGTT suggests a diagnosis of gestational diabetes when:
- The fasting plasma glucose level is measured as 5.6 mmol/liter or a value above it.
- The 2-hour plasma glucose level is measured as 7.8 mmol/liter or a value above it.
However, the effectiveness of this test is found to be low in recent times. As the tests largely give negative results, the procedure puts a significant burden on the resources of healthcare institutes and the pregnant women. Similarly, with the negative results, the incidence rate of gestational diabetes in low-risk groups also remains under-represented and as many as over 7% of the cases of gestational diabetes miss their diagnosis.
Early Diagnosis Of Gestational Diabetes
Thereby, it is the need of the hour to have better screening modality for early diagnosis of this condition. Proposing to be a tailor made screening methodology, it is believed that a screening process will enable only the relevant group undergo diagnostic tests which can save a lot of resources and time.
It is to note that although many prognosis models are developed till date, none of them are commonly used clinical practice at large. However the proposed model uses a set of predictors for the gestational diabetes onset which include:
- Maternal age
- Body mass index
- History of gestational diabetes
- History of macrosomia
Making use of this approach contrary to the one currently used will help getting rid of the problems met with the present clinical gestational screening process. Being cheap and easy to use, new gestational diabetes prognosis model will help make tailor-made screening procedures for different regions populations and ethnicity based risk factors. Specifically, the measures in consideration will take into account, clinical practice implementation based on; availability of predictors, population characteristics, Incidence of gestational diabetes mellitus for making it an effective tool for early gestational diabetes detection and also for prior prevention of the condition.
By making use of these screening procedures; preventive care to stay protected against gestational diabetes will include lifestyle modifications which include exercise and a personalized diet plan. In this regard, it is not advised to use drugs for the prevention of this condition as being the primary intervention used. However in high risk population a popular type 2 diabetes drug known as metformin can be used for disease prevention.
How Can You Reduce Your Chances Of Getting Gestational Diabetes?
As you prepare to get pregnant, it is important for you to be well-versed about your risk of getting gestational diabetes. If you are overweight then it is a sign of danger for you and required your attention immediately. Thereby, in this case, you need to start reducing your weight by eating health and having a routine for exercise.
But how exactly do you know if you are overweight? If your current weight is 20% or more than your ideal weight, then you are prone to having gestational diabetes, once you get pregnant.
It is important to know that once you are pregnant, you shouldn’t be continuing with your weight loss exercise as it can now influence fetal development negatively. Consulting your doctor will help you devise a lifestyle modification routine for you which is helpful for both, a healthy fetal development and management of gestational diabetes risk.
Foods That Can Help Your Prevent Getting Gestational Diabetes
- Your food intake should have a good percentage of fresh fruits and vegetable.
- You should reduce your daily fat intake and only 30% or less should your daily calorie count should come from eating fat rich food.
- You should also take smaller portions of meals.
How Does Gestational Affect The Health Of Mother?
Some of the problems that the mother faces are:
- Difficult delivery: may occur due to a large baby
- Increased chances of a C-section: a large baby may mean that a cesarean section is needed to deliver the baby
- High blood pressure and preeclampsia: swollen ankles, high blood pressure and protein in the urine is called preeclampsia that may be dangerous for both the mother and the baby and may need constant monitoring to prevent complications. Mothers with gestational diabetes are at an increased risk of developing preeclampsia.
- As a long term effect of gestational diabetes, these women are at a greater risk of developing type 2 diabetes later in life.
- Depression can also be result of this condition.
How Does Gestational Diabetes Affect The Health Of The Child?
According to ADA, some of these risks are:
- Large baby: mothers with gestational diabetes have large babies, because the excess glucose crosses the placenta and reaches the baby. Not only does this cause the baby’s pancreas to work overtime to produce insulin, but it also causes storage of this extra glucose as fat. This condition is often referred to as macrosomia which can make the delivery process hard and dangerous for the baby.
- Risk of hypoglycemia: due to the excessive insulin produced by the pancreas, such babies are at risk of hypoglycemia right after birth, which is a condition marked by low blood glucose levels.
- Respiratory distress syndrome: babies born to mothers with gestational diabetes also are at risk of having breathing condition called respiratory distress syndrome
- Babies are also at risk of dying soon after birth
- Shoulder dystocia at birth due to large bodies is likely to take place which means that during vaginal delivery, the baby’s anterior shoulder gets stuck in the pubic bone of the mother. This condition requires the doctor to perform certain maneuvers.
- Babies are at a greater chance of having jaundice at the time of birth, which can be treated by placing the child under a special light and breastfeeding the child.
- Risk of diabetes later in life: such babies can also have a high risk of developing diabetes later in life, along with an increased chance of being obese.
Gestational Diabetes Management Through What You Eat
Once you have been diagnosed with gestational diabetes, you should not begin to panic and that’s the first rule of your disease management. You should take intelligent measures to have a track of your blood glucose levels and manage it accordingly.
You need to have optimal blood glucose level goals, which come directly from the recommended glycemic goals from the American Diabetes Association and mentioned below:
- Before taking your meals, your blood glucose level should measure as 95mg/dl or less.
- 1 hour after you have had your meal, your blood glucose level should measure as 140mg/dl or less.
- 2 hours after you have had your meal, your blood glucose level should measure as 120mg/dl or less.
During this time, you should have a good communication with your obstetrician and a dietician who can guide you through your meal plans and diabetes treatment.
A healthy meal plan can ensure the safety of both mother and baby. A good diet plan to manage gestational diabetes should tell the mother:
- What to eat (Food groups)
- How much to eat (Amounts)
- When to eat (Timing)
A balanced diet constitutes eating a variety of healthy foods with the most important point being avoiding processed products as much as possible during pregnancy. The general recommendations for pregnant women to prevent gestational diabetes include:
- Eat 3 medium sized meals per day
- Do not eat more than 2 snacks per day
- Balance the amounts of carbohydrates, fats, and proteins in your meals
- Eat ample quantities of fruits and vegetables
- Eat reasonable quotas of lean meats and unsaturated fats
- Eat adequate portions of whole grains
- Avoid sugary foods in diet, e.g., sweet drinks, fruit juices, desserts etc.
- Read the ‘Nutrition Facts’ panel to make healthier grocery choices
Carbohydrates: The Mother Of All Foods
Carbs (carbohydrates) are very important when it comes to managing gestational diabetes, since your body needs them to maintain blood glucose levels. Although carbs are needed to maintain your energy levels, they should not be consumed in excess.
According to The National Institutes of Health (NIH), a pregnant woman should consume more than 6 servings of healthy starchy foods which are also loaded with vitamins and minerals, everyday e.g. whole-grain breads, whole-grain crackers, whole grain cereals, barley, oats, beans, brown rice, whole-wheat pasta, starchy vegetables e.g. corn and peas.
Most importantly, half of all dietary calories should be consumed via healthy carbs, i.e., high-fiber whole grain carbohydrate sources. Carbs can even be consumed through fruits and vegetables in which case learning to count the amount of carbs in specific foods can prove very useful. Moreover, pregnant women are recommended to eat at least 2 servings and not more than 4 servings of whole fruits e.g. banana, apple, oranges with all fruits being consumed whole instead of only drinking their juices.
Most importantly, foods rich in starchy or sugary carbs such as white bread, rice and pasta should be consumed in low amounts.
If your blood glucose level remains high even after keeping check on the types of carbohydrates being consumed, then further cutting back on carbs is not the right answer. In this regard, consulting a doctor or a dietician is the solution.
Fat: Which Ones To Avoid, Which Ones To Look
If you are suffering from gestational diabetes or if you fear suffering from gestational diabetes, then you should be careful with your fat intake. To make it simple, please be reminded that saturated fats should be avoided. To get your require amount of fats, switch to eating polyunsaturated, better known as healthy’ fats. For assuring that you are eating ample quantities of health fats during your pregnancy, you should be eating foods that include fish, nuts, avocado, flaxseed, tofu, olive, soybean oil, sunflower oil, corn oil.
This is also worth noting that directly your fat intake do not affect your blood glucose levels but increased fat consumption does intervene with your health in a rather indirect manner. Eating foods rich in unhealthy fats leads to weight gain that eventually disrupts the insulin levels secreted into the bloodstream.
Thereby, it is important for you to know that your favorite processed foods cannot make their way to your dining table. Yes, you will have to give up on the processed foods you consume. If you can’t completely give up on them, then just try to limit your consumption of processed foods.
Similarly, foods like lean meats, eggs, chicken and dairy products are also rich sources of saturated fat. Thereby, the consumption of these foods should be carefully watched by you and eaten in moderation quantities only.
Oh and don’t try to cheap on yourself by consuming large quantities of hamburgers, bacon, salad dressings and margarine, they are rich source of fatty foods which you have to keep a strict check on.
For cooking purposes, you should prefer cooking your food in canola oil, olive oil and peanut oil.
Proteins: The Real Deal
Proteins are your friends you must know this by now. You should be taking at least 2 portions of protein daily during your pregnancy. You should particularly consider eating plant based proteins. On the other hand, the animal source proteins which include fish, lean meats, eggs, butter and cheese should be consumed in optimal amounts.
It is however suggested that you should include yogurts, milk, legumes and beans in your diet during pregnancy to get the required protein quantities. These sources of proteins do not interfere with your blood glucose levels regulation thereby they help in gestational diabetes management.
Calcium And Iron: Keeping Fit With Minerals
Unsurprisingly, calcium and iron are important for you to consume in the right quantities during your pregnancy. During gestation, women are recommended to have 3 serving of foods enriched with iron and calcium, daily.
These foods can include fortified soy milk, yogurt, milk and cheese. You should be drinking 2-3 glasses of milk daily to keep your calcium intake, just about right.
Similarly, for the optimal of iron during your pregnancy, you should include foods fish, apple, chicken, and green vegetables, including broccoli, potatoes and spinach. But again, all these foods should be consumed in moderate amounts.
Additional Prenatal Tests Required Once You Are Diagnosed With Gestational Diabetes
Once you are diagnosed with gestational diabetes, you will have to take additional precautions and care to ensure that the fetal development is not influenced by your disease. Thereby some recommended additional tests would include:
- Examination of fetal growth with ultrasound imaging test to see if the growth of the fetus larger than the normal size at a particular gestation week.
- Kick counts is good way to keep a check on the movement of your baby.
- A nonstress test is useful for observing the heart rate of the baby and recording the fetal activity.
Gestational Diabetes In Pregnancy Women Who Suffer From Type 1 or Type 2 Diabetes
According to the guidance provided by NICE UK, if a pregnant woman suffers from type 1 diabetes, then it is advised that she tests her fasting, pre-meal, 1 hour post meal and bedtime blood glucose levels every day to keep a track of her blood glucose levels during pregnancy.
Similarly, for the pregnant women who suffer from type 2 diabetes and who take insulin injections are advised to test their fasting, pre-meal, 1 hour post meal and bedtime blood glucose levels on a daily basis during pregnancy.
However, for women who are managing their type 2 diabetes during pregnancy through oral medications, diet or exercise therapy are advised to record their blood glucose levels daily by taking their fasting and 1 hour post meal reading daily. For these women it is advised that their optimal blood sugar levels be maintained at an average as:
- During fast, it should be 5.3 mmol/liter
- 1 hour after taking meals, it should be 7.8 mmol/liter
- 2 hours after taking meals, it should be 6.4 mmol/liter
In addition to this, the HbA1c tests should be routinely taken which is a measure for blood pigment which carries oxygen and binds with glucose in the bloodstream known as hemoglobin A1c. For diabetes patients, this reading is a good indication of how well diabetes is being controlled.
It is recommended that women with pre-existing diabetes should get the HbA1c test during initial visits to their doctor and this should be repeated in second and third trimester as well. At 10th week of gestation or before, first HbA1c levels measurement should be taken, ideally.
If the measure is above 48mmol.mol/(6.5%) then it puts the maternal health at risk during pregnancy.
In addition to performing the standard blood tests, women who have a pre-existing diabetes are recommended to undergo retinal assessment between 16 and 20 weeks of her pregnancy to observe if diabetic retinopathy is present.
Ultrasound assessment for them is a little more stringent as well and ideally these women should follow a schedule recommended by NICE UK. According to the guidelines, the following ultrasound appointments should be planned.
- During the 10th week or before: the viability of pregnancy should be confirmed. Preferably it should be done between 7 and 9 week of gestation.
- During the 20th week: ultrasound monitoring should be carried out for the detection of structural abnormalities in the fetus. This includes examination of fetal heart which should now have 4 chambers, outflow tracts and 3 vessels.
- During the 28th week: fetal growth and amniotic fluid volume levels should be observed with ultrasound monitoring.
- During 32th week: Ultrasound monitoring should be carried out again to observe the fetal growth and volume of amniotic fluid.
- During 34th week: No additional monitoring is required which is any different from non-diabetic women.
- During 36th week: Ultrasound monitoring is carried out again to observe the fetal growth and amniotic fluid volume.
At this time, it is important for the doctor to discuss a few details about birth giving process which includes communicating with the pregnant woman about, the mode, timing and management of birth, the options of anesthesia and pain-relief medications, changing of the dosage of glucose level reducing medications, post natal child care, contraception and the initiation of breastfeeding and its effect on blood glucose level management.
Type 1 Diabetes And Ketone Test
Ketone testing strips and a meter should also be provided to the pregnant women, who suffer from type 1 diabetes. Ketone is produced by the body when the body doesn’t have enough glucose or if insulin quantities produced to use glucose are not sufficient. As a result, the energy of the body is generated by the break out of fats which leads to the production of ketones as a byproduct.
Commonly associated with type 1 diabetes, the ketone buildup in the bloodstream leads to the blood becoming acidic which can also result in severe condition called diabetic ketoacidosis (DKA). DKA can lead to low potassium levels (hypokalemia), low blood sugar levels (hypoglycemia) and swelling in the brain, if not timely managed. Thereby, it is important for women who are pregnant with type 1 diabetes to routinely monitor their ketone levels.
- Normally, the test of ketones is considered negative when the levels are less than 0.6 mmol/liter
- Call your doctor is the levels range from low to moderate, stretching between 0.6mmol/liter and 1.5 mmol/liter
- You need to receive medical attention on emergency basis , if the levels are high or very high, which are measured as 1.6 to 3 mmol/liter and a value greater than 3.0 mmol/liter; respectively.
Pregnant women are with pre-existing diabetes are recommended to take tests for high ketone levels (ketoanaemia) and urgently seek help from doctor in case of hyperglycemia.
Breastfeeding With Diabetes
Fin women who have pre-existing diabetes should stop taking their diabetes controlling medication after giving birth and this should be followed by careful blood glucose level monitoring for the reassessment of diabetes drug dosage.
On the other hand, the medications for managing gestational diabetes should also be stopped at this stage.
Reduced blood glucose level is common concern in the postnatal period, thereby it is important for the women to have a snack or meal before and during breastfeeding their infants.
For the sufferers of type 2 diabetes who breastfeed their child, the diabetes drugs like glibenclamide and metformin can be continued to be taken while other drugs are advised to be avoided.
Talking particularly about the baby, it is important for the mother to breastfeed the baby as soon as her condition is stable which can be as soon as 30 minutes following birth. If the pre-feeding capillary plasma glucose levels of the baby are below 2.0 mmol/liter, then it is crucial for the mother to feed her child after every 2-3 hours.
However, if proper breastfeeding is done but two consecutive plasma glucose levels are below the optimal value and signal towards hypoglycemia, then additional feeding measures such as intravenous dextrose or tube feeding is required to be considered.