Pregnancy-induced DM

What is DM – Diabetes Mellitus

• Diabetes Mellitus,commonly known asdiabetes, is a metabolic disease that leads to high blood sugar. Insulin is a hormone made in the pancreas. It helps the body:

• In using the glucose for energy, and.
• In controlling the blood glucose levels

When a person hasdiabetes, one of the following two things happen:

• The body has a deficiency of insulin or
• The body is not able to use the insulin

If high blood sugar levels are ignored, it can damage the nerves, kidneys, eyes, or the other organs.

Following are some of the types of Diabetes:

• Type1 Diabetes or autoimmune disease: In this condition the immune system attacks and destroys cells in the pancreas where the insulin is made
• Type 2 diabetes: In this condition, the body’s resistance level to insulin increases.
• Prediabetes: In this condition, the blood sugar is higher than the average level but lesser than Type 2 diabetes.
• Gestational Diabetes or pregnancy-induced Diabetes Mellitus refers to the condition of high blood sugar during pregnancy.

Note: if your blood sugar is too high, you may experience the following:

• Fatigue
• Stomach pain
• Nausea and vomiting
• Breathlessness
• Frequent urination
• Dry mouth

What is pregnancy-induced DM or gestational diabetes?

• Pregnancy-induced Diabetes Mellitus or Gestational Diabetes Mellitus (GDM) is a condition in which the blood sugar levels are high during pregnancy. Commonly known as Gestational Diabetes, this condition typically develops between the 24^thand 28^th weeks of pregnancy. Studies show that, on average, about 2-5% of pregnant women develop Gestational Diabetes.

As per the estimates of CDC, GDM affects 2 to 10 percent of pregnancies in the United States.

What happens during pregnancy that causes DM/Pathogenesis

Pregnancy can cause diabetes due to:

• Hyperinsulinaemia– excess levels of insulin in the body
• Insulin resistance-inefficiency of the body to use the insulin

Either of these usually happens because the mother’s body is trying to provide adequate amounts of nutrition for the baby:

• Early stages of pregnancy: maternal hormones promote:
  • Release of insulin
  • Increased usage

Hence the maternal blood sugar levels decrease.

• Later stages of pregnancy: the levels of hormones like cortisol and estrogen increases, causing insulin resistance. These hormones are most active between 26^th and 33^rd week of gestation. That is why screening for Gestational Diabetes is done between the 24^th and 28^th weeks of pregnancy.

Note: Cortisol has a strong diabetogenic effect (leads to diabetes)

What are the symptoms of pregnancy-induced DM or Gestational diabetes?

Generally, three are no symptoms of Gestational Diabetes. However, some mild symptoms might include:

• Fatigue
• Sugar in urine (measured using tests performed by your healthcare providers)
• Unusual thirst
• Snoring
• Nausea
• Blurred vision
• The excessive urge to urinate
• Frequent infections in vaginal, bladder and skin

If you have gestational diabetes, it doesn’t necessarily mean that you will have diabetes in the future. However, having GDM does increase the risk of Type 2 diabetes later in life.

Therefore you should watch out for the following signs and symptoms of diabetes after the delivery of the baby:

• Frequent urination
• Increased sugar in blood or urine
• Persistent thirst

What are the causes of pregnancy-induced DM?

Following are some of the prime causes of pregnancy-induced diabetes:

• The inability of the body to make a sufficient amount of insulin
• Insulin resistance
• Obesity
• Family history of diabetes

When the body is not able to make the extra insulin your body needs during pregnancy, it leads to gestational diabetes.

During pregnancy, your body goes through multiple changes like weight gain in addition to producing individual hormones.  Due to so many changes, the cells in your body are not able to use the insulin properly – this condition is referred to as insulin resistance. Generally, every woman has some level of insulin resistance during pregnancy. However, while most women generate enough insulin to overcome the resistance, the ones who are not able to do so develop gestational diabetes

Gaining excessive amounts of weight during pregnancy or being overweight before pregnancy can also lead to gestational diabetes. This is because obesity also leads to insulin resistance.

How do I know if I am at risk of gestational diabetes and what are its warning signs?

Following are the risk categories of Gestational Diabetes

How is pregnancy-induced DM detected or diagnosed?

The tests for gestational diabetes are usually done between the 24^th and 28^th weeks of pregnancy. If you are at an increased risk of developing gestational diabetes, it is highly likely that your doctor will test you for it on your first visit after you become pregnant.

For the diagnosis of gestational diabetes, you will have to undergo certain blood tests. These tests include one or both of the following:

• Glucose Challenge Test:Also known as a glucose screening test, typically, this blood test is conducted before other tests.

In this test:

• First, you will drink a sweet liquid containing glucose
• One hour after drinking the liquid, your healthcare provider will draw your blood.
• If the blood glucose level is higher than 140, you may be asked to give an oral glucose tolerance test while fasting
• If the blood glucose level is higher than 200, you may have type 2 diabetes.

You don’t have to fast for this test.

Note: Fasting means neither eating nor drinking anything before the test. Drinking water is allowed while fasting.

• Oral Glucose Tolerance Test: Also known as OGTT, this test measures the blood glucose level 8 hours after fasting.

In this test:

• Your healthcare provider will draw your blood.
• Once the blood is drawn, you will have to drink the liquid containing glucose.
• Your blood will be drawn every two to three hours so that the doctor can diagnose gestational diabetes.
• You will be diagnosed with gestational diabetes if a high blood glucose level is recorded in any two of the readings taken after fasting or 1^st hour, 2^nd hour, or 3^rd

In some cases, your healthcare provider may recommend having the oral glucose tolerance test without having a glucose challenge test previously.

How can I manage my pregnancy-induced DM and can it be treated?

The blood glucose levels in women who have gestational diabetes can be managed to an extent by:

• Staying active: this can help a woman in reaching and maintaining healthy blood glucose levels. Staying active not only helps with an existing case of gestational diabetes but also acts as a prevention mechanism against future possibilities of type 2 diabetes. Additionally, physical activity also helps in controlling high blood pressure and cholesterol. It’s other benefits include:
  • Stress relief
  • Strengthening of heart and bones
  • Improvement in muscle strength
  • Maintaining flexibility of joint

Your health care provider can tell you about the physical activities suitable for you that would:

• Help you in achieving your target blood glucose levels and,
• Would be safe for you during your pregnancy

Regardless of whether you were active before or not, generally, it is suggested that you should try to get about 30 minutes of physical activity for 5 days of the week and 2 days rest.

However, if you are already doing this and still are not able to control your blood glucose levels, consult with your doctor. You can ask your doctor if it would be safe to increase the intensity of your physical activity by jogging or lifting small weights.

• Follow a nourishing diet: take the help of your health care provider to come up with a diet plan that would be good for you and your baby. The program should answer the three most essential questions:
  • What to eat?
  • How much to eat?
  • When to eat?

The food choice, the amount of food and the timing together will help you in achieving your target blood glucose levels.

Either to test for ketones or if your blood glucose levels are very high (above 200), your doctor may recommend checking your blood or urine daily.

To take care of the problem of high ketone levels, your doctor may recommend changes in:

• the type of food you consume
• the amount of food you consume
• meal times.

If a proper diet plan coupled with physical activity is inefficient in controlling your blood glucose levels, your doctor may recommend insulin injections.

Your healthcare provider will show you to give yourself insulin shots. Insulin is not harmful to the baby and is generally the first prescribed treatment for gestational diabetes.

Discuss with your healthcare provider to know what treatment is suitable for your requirements.

Note: Research work on the safety of medicines like metformin and glyburide during pregnancy is ongoing; however, nothing has been confirmed yet.

How will I know if my blood glucose levels are in the target range?

A blood glucose meter is the safest way to check your blood glucose levels. This device can tell you about your blood glucose level from a drop of blood (usually from your finger)

Generally, the daily target blood glucose for women who have gestational diabetes is:

• 95 or less: Before meals, at bedtime and overnight
• 140 or less: 1 hour after eating
• 120 or less: 2 hours after eating

However, the optimum measurements may vary from women to women, therefore talk to your doctor to know what targets are suitable based on your body.

How does DM affect pregnancy – complications

The complications due to Gestational Diabetes can affect both the baby and the mother

Some of the problems that the mother may face as a consequence of gestational diabetes include:

• Possible C-section: if a woman has gestational diabetes it is highly likely that she will have a Cesarean delivery
• High blood pressure and Preeclampsia: Preeclampsia is a severe complication that causes hypertension (high blood pressure) and can put the health of the mother and the baby at risk. Gestational diabetes considerably increases the risk of high blood pressure and preeclampsia.
• A high risk of diabetes in the future: If a woman has had gestational diabetes, it is highly likely that she may have gestational diabetes in her future pregnancies as well. Moreover, gestational diabetes increases the risk of developing type 2 diabetes in the future.

Some of the health risks that a newborn may face if the mother has gestational diabetes>

• Overweight: A mother who has gestational diabetes has very high blood sugar levels. Due to the high blood sugar, the babies can grow too large. If the baby becomes too large (greater than 9 pounds), it may get stuck in the birth canal and get injured, thereby precipitating the need for a C-section.
• Hypoglycemia (Low blood sugar): This condition is possible in babies born to mothers with gestational diabetes. Severe cases of hypoglycemia may lead to seizures in the baby. The blood sugar levels of the baby can be returned to normal by:
  • Prompt feedings
  • Intravenous glucose solution
• Early (preterm )delivery: Due to gestational diabetes, the chances of early labor and delivery are highly increased. Rapid delivery may also be recommended because the baby is large.
• Respiratory problems: a baby born early due to gestational diabetes may have difficulty breathing due to respiratory distress syndrome.
• Macrosomia and type 2 diabetes: Babies born to mothers with gestational diabetes can develop obesity and type 2 diabetes.

• Stillbirth: Gestational Diabetes can cause the death of the baby either before delivery or shortly after it.

How can I prevent the risk of gestational diabetes?

If you maintain good health and prepare your body for pregnancy you can prevent gestational diabetes

If you are overweight and are planning your pregnancy, before you become pregnantyou should try to cut the extra weight:

• By improving your diet
• increasing the amount of physical activity in your life.

With these simple lifestyle changes, you can improve the efficiency with which your body uses insulin and also ensure that your blood glucose levels are normal.

If you are already pregnant, don’t try to lose weight because during pregnancy you need to gain weight for the good health of your baby. However, gaining too much weight too quickly can put you at a risk of gestational diabetes

You should discuss with your doctor to know exactly how much weight gain and physical activity is appropriate for you during pregnancy.

If I have gestational diabetes, how can I reduce the risk of getting diabetes later in life?

Within 12 weeks from the delivery of your baby, you should get tested for diabetes. In this test, if the blood glucose levels are still high, it is highly likely that you may have type 2 diabetes. Even if the test results indicate that your blood sugar levels are healthy, you are still at risk of developing type 2 diabetes in the future. Therefore try to get tested for diabetes every three years.

There are some steps you can take to prevent type 2 diabetes later in life after pregnancy, such as:

• Increase physical activity and have a balanced diet to get back to a healthy weight
  • Breastfeeding your baby will not only ensure the right balance of nutrients for your baby but also help you in burning calories.
  • If you are overweight and your test results indicate a risk of diabetes, consult your doctor to find out about the lifestyle changes you can make to lose weight and permissible exercises. Your health care provider will assist you through the process.
  • If your test results show a risk of diabetes, your doctor may recommend medicines like metformin to prevent the onset of type 2 diabetes.

Reference:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406210/
2. https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational
3. https://www.diabetes.org/diabetes/gestational-diabetes/how-to-treat-gestational-diabetes
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311308/
5. https://www.ncbi.nlm.nih.gov/books/NBK43371/
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5740094/
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6274679/
8. https://www.cdc.gov/diabetes/basics/gestational.html#:~:text=Gestational%20diabetes%20is%20a%20type,pregnancy%20and%20a%20healthy%20baby.
9. https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes/gestational-diabetes#:~:text=Age%20(women%20who%20are%20older,known%20as%20impaired%20glucose%20tolerance

By -
Dr. Ruchika Singh

14-April-2023