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Gestational Diabetes

Some women who have never had diabetes before may be suffering from diabetes during their pregnancy. This condition is-called gestational diabetes. In gestational diabetes, the mother's blood sugar (glucose) levels are more than normal during pregnancy. This is a short-life condition which occurs only during pregnancy and the blood sugar levels will return to normal soon after delivery.

4% of all pregnant women will develop gestational diabetes and 70% of them will recur gestational diabetes. Although gestational diabetes usually goes off after delivery, many of them will develop type 2 diabetes. Untreated diabetes will adversely affect the health of the baby and mother.

Changes in the Body That Cause Diabetes

Our pancreas will produce a hormone called insulin, which helps the blood sugar (glucose) to enter our cells to be used or stored. When a woman is pregnant, her placenta will produce some hormones that help the baby to grow and develop. These same hormones will make the mother's cells become more resistant to the insulin and lead to insulin resistance. Subsequently, the mother's pancreas will have to work hard to produce more insulin to overcome the resistance in the cells. If the pancreas reserve is good, then insulin production will increase to meet the demand by the mother. However, if the pancreas reserve is limited, then insulin production will be insufficient and the blood sugar levels will rise and gestational diabetes will develop subsequently.

Gestational diabetes usually starts after the third month of pregnancy, this is because the placenta has grown large and produced large amount of hormones. For those mothers who have diabetes before her pregnancy starts, her blood sugar levels will rise further because of insulin resistance due to the placental hormones. Her diabetes worsens and she will require more medications.

Women Who Are at Risk of Gestational Diabetes

All pregnant women will potentially suffer from gestational diabetes and many women who had it do not have any risk factor.  However, some women are at higher risk of getting it. The risk factors are:

1.
Age: Pregnant women who are older than 35 years of age are more likely to develop gestational diabetes.
2.
Family or personal history: You are at greater risk if you have prediabetes,  strong family history of diabetes (immediate family members having diabetes) or previous history of gestational diabetes.
3.
Weight: Overweight women (80kg and above) before she gets pregnant.
4.
History of big baby: Mothers who have delivered baby more than 3.5kg are at greater risk.
5.
Twins pregnancy: Mothers who have twins pregnancy or hydramnions are at greater risk.

Screening and Diagnosis

Some affected women may have signs and symptoms of diabetes, such as more than 80kg, sugar in the urine, excessive weight gain or have risk factors stated above. However, most mothers with gestational diabetes are asymptomatic, they do not have noticeable signs and symptoms. That is why gestational diabetes screening is part of the  routine antenatal check-up between 24 and 28 weeks of pregnancy in many clinics. This screening is commonly known as glucose tolerance test (GTT). The test is performed as listed below.

1.
You have to fast at least 8 hours prior to the test.
2.

You will be given a glass of glucose drink containing 75g of glucose to drink.

3.
Blood sugar test will be done before you take the drink and 2 hours after you have taken the drink.
4.
If you blood sugar level is higher than 140 mg/dl, you will be diagnosed with gestational diabetes.
5.

Table below shows the normal blood sugar level for GTT according to World Health Organization (WHO) Diabetes Criteria.
Fasting
2 Hours
≤ 7.0 mmol/ l
≤ 7.8 mmol/ l

   Effects on Fetus

1.
Intrauterine death (IUD): There is increased risk of stillbirth in the last 2 months of pregnancy.
2.
Excess fetal growth: Excess blood sugar levels will produce big baby (macrosomia) which may lead to difficulties during delivery later. Babies that more than 4kg in size will have risk of shoulder distortion (shoulder obstruction) during delivery.  
3.
Low blood sugar (hypoglycemia) in the newborn: The high blood sugar levels make baby produces more insulin in order to reduce the sugar levels in blood stream while he is in the uterus. The excess insulin will cause hypoglycemia in baby shortly soon after birth and he will need to be fed frequently. In severe case, intravenous (IV) glucose solution may needed or else the baby will suffer brain damage.
4.
Respiratory distress symptom: Baby of gestational diabetes mother is at higher risk of having difficulty in breathing and need ventilator support.
5.
Neonatal jaundice is more common.
6.
Higher risks of developing type 2 diabetes and obesity in his later life.

Effects on Pregnant Women

1.
The pregnant woman will have increased risk of pre-eclampsia ( high blood pressure and excess protein in urine during pregnancy) in her last 4 months of pregnancy.
2.
She will be at risk of infections, vaginal moniliasis, wound infection that heals poorly.
3.

50% of the women will develop type 2 diabetes in her later life.

Treatment

The aim of gestational diabetes treatment is to maintain the blood sugar levels within the normal rate (≤ 7.0 mmol/ l during fasting). These pregnant women who have gestational diabetes will need frequent blood sugar testing to monitor her blood sugar profile before breakfast (fasting), before lunch, before dinner and 2 hours after dinner. This blood sugar profile will be done weekly or monthly. You can help to control your blood sugar as doing the followings:

1.
Diet: Decrease your carbohydrate consumption such as rice, cake and sweet tea. Take more fruits, vegetables and whole grains.
2.
Exercise: Practice mild exercises such as gardening, swimming and walking. Exercise helps to improve body's ability to process and utilize the sugar from the body store.
3.
Medication: When both diet and exercise are not work for you, you will need insulin injections to lower your blood sugar levels. The nurse will teach you how to inject the insulin in your tummy which needs to be taken 3 times a day.

Delivery: Sometimes when diabetes control is difficult or complications arise such as pre-eclampsia, it is necessary  to deliver the baby before the due date.

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