In general terms gestational diabetes includes Type 1, Type 2 and Diabetes diagnosed for the first time during pregnancy. In further discussion we will focus mainly on GDM.
When women with type 1 and Type 2 want to get pregnant it is very important that their management starts pre-conception, and if by chance that this has been missed they require very vigilant pregnant management.
There is a higher risk of early pregnancy loss in diabetes therefore it is important to make sure their pregnancy is well controlled, it is good to have their weight controlled, with body mass index being between 25 and 28 (Weight divided by your height squared in meters).
It is also important to start on Folic acid .5mgm daily as it protects against neural tube defects(defects within the brain and spinal cord), confirmation of the diagnosis should be done by 75 grams oral test and described in our previous post. Around 28 weeks of pregnancy.
Patient education is very important and they should be taught what diabetes is and how to take care of it themselves.
This includes dietary therapy, exercise, and maintenance of their blood sugars.
There is some controversy among the medical fraternity as to the level of glucose. In Australia it has been confirmed that the fasting level of 5.3 mmol/L and two hour post meals maintain at 7. If this was done the results of pregnancy are very satisfactory. This means that the pregnancy can be carried full term and the delivery be normal as the baby will not be too big.
During the antepartum management a fetal surveillance is also essential, this will again help the pregnancy to be carried to term. Ultrasound for fetal well being and fetal heart monitoring on a weekly basis help to make sure that the baby is doing well and fetal weight can be assessed.
This is usually started around 32 to 34 weeks of pregnancy.
The main complications of diabetes during pregnancy are, increased risk of miscarriage, high blood pressure, toxemia of pregnancy and large babies more than 4.5 kilograms or more in weight.
This leads to difficult delivery and can cause trauma to the baby, stuck shoulder, injury to the nerves causing palsy, the most common of these is called Erbs Palsy, fractures to the babies bones, neonatal asphyxia, neonatal hypoglycemia and even still birth.
Sometimes the baby can be small due to growth retardation, this can be due to high blood pressure and this has its own problems.
Pregnancy with diabetes should always be managed by a group of professionals, including obstetrician, endocrinologist interested in pregnancy, diabetic advisers, pediatrician and other specialists as required, for example renal physician and ophthalmologist.
Renal and eye diseases can become more complicated during pregnancy if there due to diabetes.
Coming back to the management of gestational diabetes:
1 - Routine testing on all pregnant women is universally accepted in Australia
2 - Try and control GDM by altering the lifestyle factors with the help of a diabetic adviser, dietitian and physio therapy. The diabetic adviser helps them to learn how to test their blood sugars and administer insulin if required.
3 - They can continue on their oral diabeteic treatment such as metformin.
4 - In a small number of cases, about 40% need insulin. the insulin therapy is usually controlled by the endocrinologist, they usually use several doses of rapid acting insulin.
5 - If there are no other problems the delivery can be at term. It is best to induce so that the diabetes can be controlled during labour. Continuous fetal heart monitoring is done during labour. A caesarian section is performed when ever required the baby is distressed or the baby appears to be too big for the pelvis.
6 - At birth the baby is looked after by the pediatrician who monitors the baby's blood sugars are less than 2mmol/L. They are treated with intravenous glucose.
7 - The mothers with GDM do not require any treatment after 24 hours of delivery.
Impaired glucose tolerance test merits careful follow up, this includes a OGTT at 6 weeks and at least once a year. In some non European countries the incidence of diabetes can be as high as 62 percent once they were found to have GDM.
As mentioned in the earlier post , the offspring of these mothers are likely to develop chronic illnesses such as diabetes, heart disease and strokes.
One of the key points GDM has adverse affects for pregnancy outcome and long term problems to the women and children, it is debated that due to the high prevalence of GDM the universal testing is important, and the management of GDM improves maternal and fetal outcomes. The women with GDM should be tested every 12 months. The increased number of women with GDM (almost double normal) has implication for resource allocation. The other areas where research is required is the universal screening , what is the optimal criteria for diagnosis of GDM , the cost benefit of team approach, the follow up programs for mothers and their babies and are there any possible prevention of the spreading of diabetes in these mothers and their offspring.
