Gestational diabetes

In most cases, gestational diabetes does not have any symptoms. Therefore, screening is essential for diagnosing the condition.

Some women might experience mild symptoms such as:

• Increased urination
• Increased thirst
• Fatigue
• Nausea
• Vomiting
• Weight loss despite increased eating

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

• Blurred vision
• Delayed wound healing
• Genital itching

Diabetes is characterized by high blood glucose levels. Normally, glucose levels are maintained by a hormone called insulin, which facilitates the utilization of glucose. During pregnancy, insulin sensitivity is reduced by approximately 56% due to:

• Placental hormones: Human placental lactogen (hPL), human placental growth hormone (hPGH), growth hormone (GH), adrenocorticotropic hormone (ACTH), prolactin (PRL), estrogens, and gestagens.
• Inflammatory chemicals: 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 increases by 30% in the third trimester of pregnancy.

In most cases, the body adapts by increasing insulin secretion. However, gestational diabetes occurs when insulin secretion cannot meet the increased demand.

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Gestational diabetes increases the risk of developing type 2 diabetes in both the mother and baby. It can also contribute to obesity in the child's later life. It is advisable to get tested for diabetes during the second and third trimesters of pregnancy.

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

• Age: The prevalence of diabetes is more common in women over 30 years of age. Women aged 35-39 are at the highest risk of developing gestational diabetes.
• Being overweight and obesity: Pregnant women with a BMI greater than 25 have a higher chance of developing complications such as diabetes during pregnancy. Being overweight or obese can cause hormonal imbalances, negatively affecting ovulation and menstrual cycles.
• Decreased physical activity: There is an increased risk of gestational diabetes in women who lead a sedentary lifestyle.
• Western diet: Studies suggest that the "Western pattern" diet, which includes red meat, processed meat, refined grain products, sweets, french fries, and pizzas, is associated with an increased risk of gestational diabetes mellitus (GDM).
• Lack of vitamins and minerals: Deficiencies in certain vitamins and minerals predispose women to develop gestational diabetes. Women whose intake of Vitamin C is less than 70 mg/day have a 1.8 times increased risk of GDM. Lack of Vitamin D is also associated with an increased risk of gestational diabetes.
• Dyslipidemia: This condition refers to high levels of bad cholesterol and low levels of good cholesterol in the blood. Triglyceride levels greater than 250 mg/dl and HDL levels less than 35 mg/dl indicate a risk of gestational diabetes.
• Polycystic ovarian syndrome (PCOS): Pregnant women with PCOS have a higher chance of developing gestational diabetes. More than twice the percentage of pregnancies with diabetes is observed in women with PCOS.
• High glycosylated hemoglobin (Hba1c): Hba1c is a blood test marker that reflects glucose control over the last three months. Pregnant women with Hba1c greater than 5.7% and abnormal oral glucose tolerance tests (OGTT) have an increased risk of diabetes.
• Previous history of GDM: Women with a prior history of gestational diabetes are six times more prone to it in subsequent pregnancies.
• Family history: A history of diabetes in first-line relatives increases the risk of gestational diabetes.
• High-risk race or ethnicity: Women belonging to certain races, including African American, Hispanic or Latino, American Indian, Alaska Native, or Native Hawaiian, are more prone to gestational diabetes.
• History of delivery of infant >4000 g: Women who have previously given birth to an infant weighing 4000 grams or more have a higher chance of developing gestational diabetes in future pregnancies.
• Season: Recent studies suggest that the likelihood of developing gestational diabetes is higher in summer.
• In vitro fertilization (IVF): There is a 50% increase in the risk of diabetes during pregnancy resulting from in vitro fertilization (IVF), where a woman's egg and a man's sperm are joined in a laboratory setting.
• Other medical conditions: The presence of cardiovascular disease and hypertension in women is also a risk factor for diabetes during pregnancy.

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

1. Screening

There are two types of screening:

• Universal screening: This involves screening for diabetes in all women between 24 and 28 weeks of pregnancy. Screening in the third and fourth trimesters is crucial because insulin resistance is well-established during this period.
• Selective screening: This is conducted only in the presence of specific risk factors. It is performed in the first trimester, as high blood sugar levels at this stage may indicate pre-existing type 1 or type 2 diabetes rather than gestational diabetes.

2. Blood tests

Two tests are recommended to confirm gestational diabetes:

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

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Gestational diabetes is not completely preventable, but certain measures can lower the risk. These include:

• Go for pre-pregnancy counselling: This involves a comprehensive assessment of diabetes and associated complications to evaluate the potential for any medical conditions during pregnancy. Starting the treatment plan before pregnancy can be beneficial.
• Engage in physical activity: Physically active women have a 38% lower chance of developing diabetes during pregnancy. Exercising three times a week can reduce the risk of gestational diabetes by 24%, even in overweight individuals. Here are 9 exercise tips during pregnancy. Click to know!
• Modify your diet: Dietary changes can help reduce the risk of gestational diabetes, particularly in overweight and obese women. It is crucial to ensure that nutrient-dense foods are included in the diet during pregnancy. Are you a new mom-to-be? Listen to our experts discuss what to eat and what not to eat during the first trimester. Watch now
• Monitor your weight: Women who gain excessive weight during pregnancy are at a higher risk of developing gestational diabetes. While weight gain is common during pregnancy, it is important to adhere to the following recommendations:
  • For women who were underweight before pregnancy (BMI less than 18.5): 12.5 to 18 kilograms of weight gain during pregnancy.
  • For women with an average weight before pregnancy (BMI between 18.5 and 24.9): 11.5 to 16 kilograms of weight gain during pregnancy.
  • For women who were overweight before pregnancy (BMI 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.
  It is advisable to keep weight within these limits to reduce the risk of gestational diabetes. Keep track of your weight with our wide range of weighing scales. Shop now

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 carbohydrates, fats, and proteins considering the health of the fetus. The eating plan created by the doctor/dietitian should always be followed, which usually includes:

• Bedtime eating to prevent the development of ketosis overnight
• Frequent meals—three small to moderate-sized meals and 2-3 snacks to maintain optimum blood glucose levels
• 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, and 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

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

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

Studies have shown that 20–30 minutes 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.

3. Insulin

The injection of insulin is recommended when the individual is unable to achieve optimal glucose levels 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 use
• Acceptability by patients
• Significantly less maternal weight gain
• Less maternal hypoglycemia
• Reduction in complications associated with GDM such as preterm delivery, early pregnancy loss, and neonatal hypoglycemia

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. This 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.

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. If your diet does not meet your bodily Vitamin C demand, consider filling the gaps with Vitamin C supplements.
• 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 properties. It can be consumed by sipping the water boiled with its pieces or added to 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 consumed in moderation as it can stimulate involuntary contractions during pregnancy. It is always better to consult your healthcare provider before starting it.

The blood glucose usually returns to normal after the delivery of the baby. However, some women may develop type 2 diabetes later in life. Poor glucose control during pregnancy can lead to:

• Spontaneous abortion: Women with persistently high blood glucose during pregnancy are at a higher risk of early miscarriage.
• Unexplained stillbirths: Miscarriages occurring after the 20th week of pregnancy are termed stillbirths. Uncontrolled blood glucose over an extended period can lead to stillbirths. Additionally, excessive lactic acid production due to diabetes can cause fetal death.
• Preterm delivery: Gestational diabetes can result in preterm labor before 37 weeks of pregnancy. Babies born prematurely may experience long-term intellectual and developmental challenges.
• Cesarean delivery: Diabetes during pregnancy increases the likelihood of cesarean delivery due to the presence of a large baby.

Other complications can be categorized as follows:

• Maternal complications:
  • Preeclampsia
  • Type 2 diabetes
  • Diabetic ketoacidosis (formation of ketone 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)
• Fetal complications:
  • Macrosomia (large fetus weighing about 4000 g to 4500 g)
  • 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

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.

• Chinese herbal medicine: This includes several medicines prepared from plant products such as leaves, stems, flowers, roots, and seeds. Studies show that Chinese herbal medicines can be effective in managing gestational diabetes.
• Yoga: Yoga plays a significant role in controlling blood sugar levels. It helps manage stress and balances other vital parameters while also aiding in building strength, endurance, and flexibility in the mother.

The management of diabetes after delivery depends upon its severity during pregnancy. Gestational diabetes mellitus (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 for recurrence.

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

• Maintain a healthy weight
• Stay active
• Make healthy food choices
• Breastfeed your baby, as it provides essential nutrition and helps the mother control her weight

Neonatal Care

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