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Gestational diabetes - symptoms, diagnosis, treatment

 
Diabetes is diagnosed when a person has too much glucose (sugar) in the blood. Gestational diabetes is a variation of the disease that occurs during pregnancy, and is the result of the mother not being able to produce enough insulin.

Gestational diabetes may not present obvious symptoms but may be diagnosed during routine pregnancy screening. The condition can adversely affect the pregnancy and health of the baby but can be managed with diet modification and exercise and, if necessary, medication.

General information

Diabetes mellitus (commonly known as diabetes) is a group of diseases characterised by high blood glucose levels over a prolonged period of time. This page deals with gestational diabetes. Other variations of diabetes include:

Gestational diabetes accounts for 90% of cases of diabetes in pregnancy, while pre-existing type 2 diabetes accounts for 8% of such cases. It usually develops during the second half of pregnancy but can occur as early as the 20th week.

Gestational diabetes is common, with 3000–4000 women being diagnosed with the condition or its recurrence each year in New Zealand. The prevalence of gestational diabetes is increasing (8–9% per year) and is higher in Māori (5–10%), Pacific peoples (4–8%), and Asian Indians (4%) than in New Zealand Europeans (3%). The increasing rate of gestational diabetes appears to be related to increasing rates of obesity.

Causes

The exact cause of gestational diabetes is not known. However, pregnancy does affect how the body metabolises (breaks down) glucose. Glucose is absorbed into the bloodstream following a meal. The body then uses insulin (a hormone produced by the pancreas gland) to promote the uptake of glucose into cells so that it can be broken down and used as an energy source. In doing so, insulin lowers the level of glucose in the blood.

During pregnancy, the body produces an excess of certain hormones that can block the effects of insulin. The reduced insulin activity leads to less efficient uptake of glucose into cells and hence the accumulation of glucose in the blood. Usually the pancreas compensates by increasing insulin production during pregnancy (to about three times the normal amount). However, if the pancreas cannot increase insulin production sufficiently to compensate for the loss of insulin activity, blood glucose levels rise and cause gestational diabetes.

Risk factors

It is not understood why some women develop gestational diabetes and others do not. However, certain factors increase a woman’s risk of the developing the condition. These risk factors include:

  • Increasing age (especially women aged 35 years or older)
  • Family history (having a parent or sibling with diabetes)
  • Previous history of gestational diabetes
  • Previous history of prediabetes (a slightly elevated blood glucose level that may precede the development of type 2 diabetes)
  • Having previously given birth to a large baby (>4 kg)
  • Excess weight (body mass index [BMI] of 27 kg/m2 or higher)
  • Ethnicity. Women who are Māori, Pacifica, or Asian Indian are more likely to develop gestational diabetes than women how are New Zealand European
  • Polycystic ovary syndrome.

Signs and symptoms

Gestational diabetes does not cause obvious signs or symptoms in most expectant women. It is usually diagnosed during routine screening at the time of pregnancy. Women who are diagnosed in early pregnancy may have underlying diabetes that has not been previously recognised.

Diagnosis

A two-step screening process for gestational diabetes is usually used:

  1. Oral (1-hour) glucose challenge (polycose) test: A blood sample is taken one hour after drinking a glucose solution. A blood glucose level of below 7.8 mmol/L is considered normal. If the result is higher than normal, a second test is recommended.
  2. Oral (3-hour) glucose tolerance test: After an overnight fast, a blood sample taken before drinking a solution containing a higher concentration of glucose and again every hour for three hours after. Gestational diabetes is indicated if at least two of the blood glucose level tests are higher than normal.

It is recommended that all pregnant women should have a screening test for diabetes during the second trimester, i.e. at weeks 24–28 of pregnancy. Women with risk factors for gestational diabetes may be tested earlier in pregnancy, probably at their first pre-natal visit.

Once a diagnosis of gestational diabetes has been made, continued glucose control testing and testing for diabetic complications is recommended for the remainder of the pregnancy. This may include self-monitoring as part of an overall management plan. Tests to monitor the baby’s health during pregnancy may also be done.

Blood glucose checks will likely be done after delivery and again in six to twelve weeks to ensure that levels have returned to normal. Levels return to normal in most women but they will still need to have their diabetes risk assessed at least every three years. Future tests indicating diabetes or prediabetes may indicate the need to start a diabetes management plan.

Complications

Gestational diabetes that is not carefully managed can result in uncontrolled blood glucose levels, which may cause problems for pregnant mothers and their baby.

Complications affecting babies born to mothers with gestational diabetes include:

  • Excessive birth weight. High levels of glucose in the mother’s bloodstream can trigger the baby to produce high levels of insulin, potentially causing the baby to grow larger than is normal (macrosomia). Large babies are at higher risk of problematic delivery
  • A higher risk of early (premature) birth. Also, early delivery may be necessary if the baby is large
  • Respiratory distress syndrome, especially if they are born early. Respiratory distress syndrome is a condition that makes breathing difficult
  • Low blood glucose (hypoglycaemia) may develop soon after birth because the baby’s own insulin production is high. Treatment to normalise the baby's blood glucose level may be necessary
  • A higher risk of type 2 diabetes later in life.

Complications affecting mothers with gestational diabetes include:

  • Preeclampsia, which is a serious form of high blood pressure that only occurs during pregnancy. It can be life-threatening for both mother and baby
  • A higher risk of developing gestational diabetes during a future pregnancy
  • A higher risk of developing type 2 diabetes later in life
  • Caesarean section is more likely if the baby is large
  • Induction of labour if the baby is growing too big
  • Polyhydramnios, which is the production of too much (amniotic) fluid around the baby. It can lead to preterm delivery.

Keeping blood glucose levels within the normal range, reduces the risk of complications and increases the likelihood of a straightforward pregnancy and delivery.

Treatment

The aim of treatment is to keep the mother’s blood glucose levels within normal healthy limits (less than 5.0 mmol/L before breakfast and less than 6.0 mmol/L two hours after the start of each meal).

Blood glucose level self-monitoring
This involves checking and recording blood glucose levels four or five times per day (on waking up in the morning and after meals) to ensure that they stay within their normal range. Post-pregnancy follow-up blood glucose level checks are also important as gestational diabetes increases the risk of developing type 2 diabetes later in life.

Diet
A high-fibre low-fat diet based on fruits, vegetables, and whole grains is recommended to reduce the risk of diabetes. As it is not advisable to lose weight during pregnancy, weight gain goals may be set by a doctor and a meal plan developed by a dietician.

Physical activity
Physical activity helps the body to control its blood glucose levels. Moderately intense exercise for 30 minutes a day on most days of the week is generally recommended. Walking, cycling, and swimming/water walking are suitable forms of exercise during pregnancy.

Medications
Although some women with gestational diabetes can maintain normal blood glucose levels with diet and exercise alone, others will need insulin injections and possibly the addition of an oral diabetes medication (eg: metformin). Medication is stopped after delivery of the baby.

Prevention

Adopting healthy habits before pregnancy will help to reduce the risk of gestational diabetes. These include:

  • Eating healthy foods
  • Keeping physically active
  • Maintaining bodyweight within the normal body mass index range
  • Getting prenatal care early and having regular check-ups.

Further information and support

For further information and support contact your doctor, practice nurse, or any of the following organizations.

Diabetes New Zealand
Postal address: PO Box 12441, Thorndon, Wellington
Freephone: 0800 DIABETES (0800 342 238)
Email: admin@diabetes.org.nz
Website: www.diabetes.org.nz

Diabetes Help (Tauranga)
Phone: 07 571 3422
Website: www.diabeteshelp.org.nz

References

Diabetes Clinic Staff (2013). Gestational diabetes mellitus (GDM). Diabetes Clinic: National Women’s Health Auckland City Hospital. http://nationalwomenshealth.adhb.govt.nz/Portals/0/A%20to%20Z/G%20to%20L/G/G%20Gestational%20Diabetes.pdf [Accessed: 29/10/16]
Ministry of Health Staff (2014). Screening, diagnosis and management of gestational diabetes in New Zealand: A clinical practice guideline. Wellington: Ministry of Health. https://www.health.govt.nz/system/files/documents/publications/screening-diagnosis-management-of-gestational-diabetes-in-nz-clinical-practive-guideline-dec14-v2.pdf [Accessed: 29/10/16]
Moore, T.R. (2016). Medscape drugs and diseases: Diabetes mellitus and pregnancy. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/127547-overview [Accessed: 29/10/16]
Mayo Clinic Staff (2014). Gestational diabetes. Mayo Clinic: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/definition/CON-20014854 [Accessed: 29/10/16]
O’Toole, M.T. (Ed.) (2013). Gestational diabetes mellitus (GDM). Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). St Louis: Elsevier Mosby.

Created: November 2016

 

 

 

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