Gestational diabetes

Symptoms Of Gestational diabetes

In most of the cases, gestational diabetes does not have any symptoms. So, screening is very important to diagnose the condition. 

Some women might have mild symptoms such as:

• Increased urination
• Increased thirst
• Fatigue
• Nausea
• Vomiting
• Weight loss in spite of eating more

If the blood sugar levels are very high, women may experience: 

• Blurred vision
• Delayed wound healing
• Genital itching

Causes Of Gestational Diabetes

Diabetes is characterized by high blood glucose levels in the blood. Normally, the level of glucose is maintained by a hormone called insulin. Insulin helps in the utilization of the glucose. During pregnancy, the sensitivity of insulin is reduced by about 56% via: 

• Placental hormones: Such as human placental lactogen (hPL), human placental growth hormone (hPGH), growth hormone (GH), adrenocorticotropic hormone (ACTH), prolactin (PRL), estrogens, and gestagens. 

• Inflammatory chemicals: Such as tumor necrosis factor alpha (TNF-α), IL-6, resistin, and C-reactive protein (CRP).

• Glucose: Produced by the body for the fetus. Studies suggest that endogenous glucose production is increased by 30% in the third trimester of pregnancy. 

In most cases, adaptation occurs in the body by increasing the secretion of insulin. But, gestational diabetes happens if insulin secretion is not able to withstand the demand.

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Types Of Gestational Diabetes

Gestational diabetes is classified according to the treatment approach:

1. A1GDM

GDM that is managed without taking any medication is termed A1GDM. Here, the treatment approach includes dietary modifications.

2. A2GDM

The term A2GDM refers to blood glucose that needs to be managed with the help of medications.

Risk Factors For Gestational Diabetes

Gestational diabetes increases the risk of developing type 2 diabetes both in the mother and baby. It can also be turned out as a cause of obesity in the later life of the child. It is always advisable to get tested for diabetes in the second and third trimester of pregnancy.

The chances of developing diabetes in pregnancy increase with the following risk factors:

1. Age

The prevalence of diabetes is more common in women over 30 years of age. Women at the age of 35-39 are at the highest risk of developing gestational diabetes. 

There are several changes in the woman’s body as she turns 30. Explore what the 30s have in store for every woman!
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2. Being overweight and obesity

Pregnant women having BMI greater than 25 have more chances of developing complications such as diabetes during pregnancy. 

Being overweight or obese causes hormonal imbalances in women which in turn negatively affects their ovulation and menstrual cycles. Know more about how obesity can impact fertility, pregnancy, and childbirth. 

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3. Decreased physical activity

There is an increased risk of gestational diabetes in women living a sedentary lifestyle. 

4. Western diet

Studies suggest that the “Western pattern” diet that includes food such as red meat, processed meat, refined grain products, sweets, french fries, and pizzas is associated with an increased risk of GDM. 

5. Lack of vitamins and minerals

The deficiencies of certain vitamins and minerals also predispose women to develop gestational diabetes. It is seen that women whose intake of Vitamin C is less than 70 mg/day have 1.8 times increased risk of GDM. 

Note: Lack of Vitamin D is also associated with an increased risk of gestational diabetes. 

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6. Dyslipidemia

It refers to high levels of bad cholesterol and low levels of good cholesterol in the blood. The triglycerides greater than 250 mg/dl and HDL levels less than 35 mg/dl indicate the risk of gestational diabetes.

7. Polycystic ovarian syndrome (PCOS)

Pregnant women having PCOS have more chances of developing gestational diabetes. It is seen that more than twice the percentage of pregnancies with diabetes is observed in women with PCOS. 

8. High glycosylated hemoglobin (Hba1c)

HBa1c is a blood test marker that reflects the glucose control of the last three months. Pregnant women with Hba1c greater than 5.7 % and abnormal oral glucose tolerance test (OGTT) have an increased risk of diabetes. 

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9. Previous history of GDM

Studies suggest that women who have a prior history of gestational diabetes are six times more prone to it in the next pregnancy. 

10. Family history

The history of diabetes in the first-line relatives of the women also makes the woman more prone to gestational diabetes. 

11. High-risk race or ethnicity 

Women that belong to particular races are more prone to gestational diabetes. These include African American, Hispanic or Latino, American Indian, Alaska Native, or Native Hawaiian.

12. History of delivery of infant >4000 gms

Women who have previously birthed an infant weighing 4000 grams or more have more chances of developing gestational diabetes in the next pregnancy. 

13. Season

Recent studies suggest that the chance of getting gestational diabetes is more in summer.

14.  In vitro fertilization (IVF)

There is a 50% increase in diabetes in pregnancy that results from in vitro fertilization (IVF), where the joining of a woman's egg and a man's sperm happens in a laboratory setting.

15. Other medical conditions

The presence of cardiovascular disease and hypertension in women is also a risk factor for diabetes during pregnancy. 

Diagnosis Of Gestational Diabetes

The diagnosis of gestational diabetes in all pregnant women is very essential since it is mostly asymptomatic. It is diagnosed with the help of the following: 

1. Screening 

There are two types of screening:

• Universal screening: It involves screening of diabetes in all women between 24 and 28 weeks of pregnancy. The screening in the third and fourth trimesters is essential because insulin resistance is well-established during this period. 
  
  
• Selective screening: Selective screening is done only in the presence of the risk factors mentioned above. It is done in the first trimester. The high blood sugar level in this stage may indicate pre-existing type 1 or type 2 diabetes rather than gestational diabetes. 

2. Blood tests

There are two tests that are recommended to confirm gestational diabetes. These include:

• Glucose challenge test: It is also known as a glucose screening test. It is the first test that is performed to diagnose gestational diabetes. In this, the blood glucose is analyzed after 1 hour of consuming glucose-rich liquid. 
  
  
• Oral glucose tolerance test: In this, 75g of glucose is given in 100-200 ml of water after 8-12 hours of fasting. The blood glucose is measured at regular intervals – fasting, 1 hr, 2 hr, and 3 hr. High blood glucose at any two-time point confirms gestational diabetes. 

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Specialist To Visit

Gestational diabetes is managed by a team of doctors due to its multi-treatment approach. The speciality of doctors that can help include: 

• General physician

• Diabetologist: Help in the management of diabetes. 

• Endocrinologist: Specialize in managing endocrine disorders. 

The panel should also include:

• Nutritionist: Expert on the relationship between food and health

• Neonatologist: Diagnose and treat health conditions of newborn

• Obstetrician: Provide medical care during pregnancy, childbirth and postnatal care

If you suffer from any complications due to diabetes, then getting in touch with the respective specialist can help you to manage and prevent these problems. Some of the common specialists who can help are:

• Nephrologists: Specialize in diagnosing and treating kidney conditions.

• Neurologists: Diagnose and treat disorders that affect the brain, spinal cord, and nerves. 

• Podiatrists: Help with problems that affect your feet or lower legs.

• Dentists: Specialize in treating problems related to teeth. 

• Ophthalmologists: Experts in treating problems related to the eyes. 

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Prevention Of Gestational Diabetes

Gestational diabetes is not completely preventable but some measures can lower the risk of the same. These include:

1. Go for pre-pregnancy counselling

It consists of a complete assessment of diabetes and associated complications to check the possibility of any medical condition during pregnancy. This will help to start the treatment plan even before pregnancy. 

2. Indulge in some physical activity 

It is seen that physically active women have 38% lesser chances of developing diabetes during pregnancy. Exercising 3 times a week has been shown to reduce the risk of gestational diabetes by 24% even in overweight individuals. 

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3. Tweak diet

The risk of gestational diabetes can be reduced by dietary modifications, especially in overweight and obese women. However, it is important to make sure that the woman is getting nutrient-dense foods during pregnancy.

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3. Keep a check on your weight

Women who gain a lot of weight during pregnancy are more likely to develop gestational diabetes. Most of us think that putting on weight is very common during pregnancy. But there are some recommendations regarding weight gain: 

• For women who were underweight before pregnancy (BMI of less than 18.5): 12.5 to 18 kilograms of weight gain during pregnancy.

• For women with an average weight before pregnancy (BMI of between 18.5 and 24.9):11.5 to 16 kilograms of weight gain during pregnancy.

• For women who were overweight before pregnancy (BMI of between 25 and 29.9): 7 to 11.5 kilograms of weight gain during pregnancy.

• For women who were obese before pregnancy (BMI greater than 30): 5 to 9 kilograms of weight gain during pregnancy.

So, it is advisable to keep weight within this limit to reduce the risk of gestational diabetes. 

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Treatment Of Gestational Diabetes

Comprehensive care is very essential for the management of gestational diabetes. Diet and exercise are the pillars to manage it and medications are used in case of no response to these. The treatment includes:

1. Nutritional therapy

The management of gestational diabetes starts with modifications in the diet. The diet plan should be customized for each individual. It is highly advisable to consult a nutritionist. The meal should contain an appropriate amount of carbohydrate, fats, and proteins considering the health of the fetus. The eating plan created by the doctor/dietitian should always be followed which usually include:

• Bedtime eating to prevent the development of ketosis overnight
• 5 Frequent meals– three small to moderate sized meals and 2-3 snacks to maintain optimum blood glucose level
• Cultural preferences of the women to promote adherence
• Proteins to avoid hunger
  

Foods to eat

• Healthy fats from nuts, olive oil, fish oils, flax seeds, or avocados
• Fruits and vegetables—ideally fresh, the more colorful the better; whole fruit rather than juices
• High-fiber cereals and breads made from whole grains
• High-quality proteins such as eggs, beans, low-fat dairy, and unsweetened yogurt

Foods to avoid

• Trans fats or deep-fried foods
• Packaged and fast foods, especially those high in sugar, baked goods, sweets, chips, desserts
• White bread, sugary cereals, refined pastas 
• Processed meat and red meat
• Low-fat products that have replaced fat with added sugar, such as fat-free yogurt

2. Exercise

It plays a very important role in maintaining optimum blood glucose. The activities that can be included in the regimen are:

• Walking
• Swimming
• Selected pilates
• Low-intensity fitness exercises. 

Studies have shown that 20–30 min of activity 3–4 times a week has significantly reduced fasting and postprandial glucose. However, the exercise regimen should always be discussed with the doctor considering the safety of the baby. 

Here is a detailed video on the types of activities that can be safely performed during pregnancy.

3. Insulin

The injection of insulin is recommended when the individual is unable to achieve optimal glucose level even with diet and exercise. It is the first-line drug for gestational diabetes due to its safety and effectiveness. The dosage is based on the weight of the mother. 

The injection of insulin is self-administered by the patient. The insulin is usually taken in two halves – one half is taken at bedtime and the other half is divided between three meals. The injection is administered before meals to prevent the abrupt rise in glucose.

4. Metformin -  A new and safe prospect in managing gestational diabetes??

For several decades, insulin has been the most reliable treatment and the gold standard in the management of gestational diabetes. 

Metformin is an effective oral hypoglycemic drug and an established first-line treatment in type 2 diabetes currently. 

As it crosses the placenta, a safety issue remains an obstacle and, therefore, metformin is currently not recommended in the treatment of gestational diabetes. 

Nevertheless, recent research has supported metformin for its equivalent safety and efficacy compared to insulin along with the following reasons:

• Ease of its use

• Acceptability by the patients

• Significantly less maternal weight gain

• Less maternal hypoglycemia

• Reduction in the complications associated with GDM such as preterm delivery, early pregnancy loss, and neonatal hypoglycemia.

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5. Management of labor

Gestational diabetes can impact the time and type of delivery. It is very important to manage blood glucose during labor to avoid maternal and fetal complications.

Routine glucose monitoring at least 4 times a day is essential to track glucose fluctuations. It includes daily monitoring of fasting glucose and 1 or 2 hours after each meal. The level of glucose after meals helps to assess maternal and fetal complications. 
The frequency of monitoring is less in women whose glucose is diet controlled.

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Home-care For Gestational Diabetes

Along with exercise and diet, there are certain kitchen ingredients that have shown good results in the management of gestational diabetes:

• Vitamin C rich foods: Studies have shown that consuming approximately 600 mg of Vitamin C helps in alleviating blood glucose. Women with gestational diabetes are advised to include Vitamin C-rich foods in their diet. Common examples of such food items that can be safely used during pregnancy are tomatoes, oranges, blueberries, strawberries, kiwis, and grapes. 

• Indian gooseberry (Amla) is also a good source of Vitamin C that helps to control blood sugar levels. It makes the body more responsive to insulin. 
  
  

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• Fenugreek (Methi): It is known to keep diabetes in check while improving glucose tolerance, lowering blood sugar levels, and stimulating the secretion of insulin. It is always available in the Indian kitchen and can be easily included in the daily diet. 

• Drumstick (Moringa): It is rich in antioxidants and Vitamin C along with its anti-diabetic property. It can be consumed by sipping the water boiled with its pieces. It can also be added to the daal or curry. 

• Cinnamon (Dalchini): It is known to control blood glucose levels due to the presence of a bioactive compound that regulates insulin activity. It can be taken with warm water. However, it should be taken in moderation as it can stimulate involuntary contractions during pregnancy. It is always better to consult your healthcare provider before starting it.

Complications Of Gestational Diabetes

The blood glucose usually returns to normal after the delivery of the baby. But, some women can develop type 2 diabetes later in their lives. The poor glucose control during pregnancy can lead to:

1. Spontaneous abortion 

The women who have persistently high blood glucose during pregnancy are at high risk of early miscarriage. 

2. Unexplained stillbirths

Miscarriages that happen after the 20th week of pregnancy are termed as stillbirths. Uncontrolled blood glucose over a long period of time can cause stillbirths. The excessive production of lactic acid as a result of diabetes can also cause fetal death. 

3. Preterm delivery

Gestational diabetes can cause preterm labor before 37 weeks of pregnancy. Babies born this early might suffer from long-term intellectual and developmental problems. 

4. Cesarean delivery

Diabetes in pregnancy increases the chances of cesarean delivery due to a large baby.

The other complications can be categorized as:

1. Maternal complications

• Preeclampsia

• Type 2 diabetes

• Diabetic ketoacidosis (Formation of ketones bodies)

• Severe hypoglycemia (Low blood sugar levels)

• Diabetic nephropathy (Damage to the blood vessels of the kidneys)

• Diabetic neuropathy (Nerve damage)

• Diabetic retinopathy (Damage to the blood vessels of the eye).

2. Fetal complications

• Macrosomia (Large fetus weighing about 4000 gms to 4500 gms). 

• Hypoglycemia (Severe drop in blood glucose)

• Polycythemia (High number of red blood cells)

• Shoulder dystocia (failure to deliver the fetal shoulders during vaginal delivery)

• Hyperbilirubinemia (High levels of bilirubin in the blood)

• Respiratory distress (Difficulty in breathing)

• Hypocalcemia (Low level of calcium)

• Type 2 diabetes later in life

Alternative Therapies For Gestational diabetes

Some alternative therapies have shown promise in the management of gestational diabetes. However, it is crucial to consult the doctor before initiating any of them. 

1. Chinese herbal medicine

It includes several medicines that are prepared from plant products such as leaves, stems, flowers, roots, and seeds. Studies show that Chinese herbal medicines can be used in the management of gestational diabetes.

2. Yoga

Yoga plays a very important role in controlling blood sugar levels. It also keeps stress under control and helps in balancing the other vital parameters along with aiding in building strength, endurance capacity, and flexibility of the mother. 

Living With Gestational Diabetes

1. Postpartum Care for Diabetes

The management of diabetes after delivery depends upon its severity during pregnancy. GDM which is diagnosed in the third trimester usually resolves on its own after delivery. There is no need for immediate testing postpartum. However, a glucose tolerance test is advisable at 6 weeks postpartum to check recurrence.

Women with a history of gestational diabetes are at higher risk of developing type 2 diabetes within 20 years of diagnosis. The yearly evaluation of diabetes is recommended in such women. The following tips can reduce the chances of occurrence of diabetes in the future:

• Maintain a healthy weight

• Stay active

• Make healthy food choices

• Breastfeed your baby. It gives the right nutrition to the baby and also helps the mother to control her weight.

2. Neonatal care

A baby born to a diabetic mother has a higher chance of developing diabetes. Such neonates require a special care unit to monitor blood glucose at least for the first 48 hours. Early breastfeeding reduces the chances of developing diabetes both in the baby and the mother.