While there are two commonly known types of Diabetes Mellitus

·        Type 1, previously known as insulin-dependent diabetes mellitus and

·        Type 2, previously known as Non-insulin-dependent diabetes mellitus

Gestational diabetes can be looked upon as a condition in which a woman, previously without diabetes, develops a state of high blood sugar level during pregnancy. It is not caused by a lack of insulin as in Type 1 diabetes, but by a state of insulin resistance in which the body does not respond to insulin and the level of normal insulin is insufficient to overcome this resistance, this makes the cells unable to take glucose in, which causes a buildup of glucose in the blood and presents as a state of diabetes. 10-15% of pregnancies are complicated by Gestational diabetes.

It is important to diagnose GDM as undiagnosed diabetes in pregnancy can affect the health of the mother, as well as the baby. Women need to be educated enough to realize the effects of Gestational diabetes and the importance of its timely diagnosis.

 

 

Risks to mother

• There is an increased risk of miscarriage

• Increased risk of Hypertensive disorder in pregnancy also known as pre-eclampsia

• A large for gestational age baby increases the risk of trauma to mother during vaginal birth as well as increased rates of operative delivery

• There is an increased risk of infections to the mother

 

 

Risks to infant

• Infants born to diabetic mothers are large for their gestational age, this is known as macrosomia (macro- meaning large, and soma- meaning body)

• Macrosomic infants are difficult to deliver vaginally and this increases the chances of an operative delivery including forceps delivery or a Caesarian section if forceps delivery fails

• Difficult delivery can result in shoulder dystocia, where a baby gets stuck, increasing the risk of injury to the baby and hence more babies need to be admitted to Neonatal Intensive Care Units which affects the hospital

• There is a risk of congenital malformations, and

• Increased risk of Stillbirth

 

 

Screening for Gestational Diabetes

Screening is designed to detect newly developed diabetes during pregnancy as well as previously undiagnosed Type 2 diabetes that may present during pregnancy. Screening is targeted at high-risk women who include women from an ethnic group with high rates of type 2 diabetes, a family history of Diabetes Mellitus, obese women, women with a history of diabetes in a previous pregnancy, and women with a history of a previously large for gestational age baby.

 

 

How is GDM diagnosed?

While there are no set diagnostic criteria, and different hospitals in different countries, have a separate set criterion. Screening usually involves a

• Glucose challenge test, followed by a

• Glucose tolerance test     

The results of these tests are interpreted according to the guidelines used in that particular hospital or country. Two recognized guidelines are NICE guidelines (2015) and WHO guidelines (2013).

• NICE guidelines diagnose GDM when fasting glucose level is greater than 5.6 mmol/l or a 2 hour (post 75g glucose load) of 7.8 mmol/l

• WHO guidelines diagnose GDM when fasting glucose level is greater than 5.1 mmol/l or a 1-hour post 75g glucose load level of 10 mmol/l or a 2 hour of 8.5 mmol/l

 

 

When to diagnose GDM

The American Diabetes Association recommends screening for previously undiagnosed Type 2 Diabetes Mellitus at the first prenatal visit in women who are at high risk. This testing should be repeated at 24-28 weeks gestation. Women without risk factors can be offered testing at 24-28 weeks of gestation.

 

 

Monitoring and Management

Women should be educated to control their blood sugar levels. This can be achieved by regular testing of blood by finger prick at home using Glucometers, or by regular testing of urine glucose levels.

Ultrasonography can detect asymmetries in fetal growth. These women should also have their blood pressure checked regularly, and urine protein monitoring for early detection of hypertensive disorders.

Nutritional counseling should be offered by a registered dietitian. Most women are able to control their blood sugar levels by dietary modifications limiting high carbohydrate diets as recommended.

If not controlled by dietary modification, next step would be to start anti-diabetic medication, the first drug of choice being Metformin.

Metformin usually controls GDM but if it fails, Insulin is given. This comes in injection pens given subcutaneously one or two times a day or as necessary.

 

 

Prognosis

Gestational diabetes usually resolves spontaneously once the pregnancy is complete. This requires testing of blood glucose levels at 6-12 weeks post-partum. An important consideration here is that women who develop gestational diabetes are at a higher risk of developing Type 2 diabetes Mellitus later in life. This requires testing at regular intervals once the pregnancy is over for early diagnosis and management.

 

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