gestational diabetes

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UNDERSTANDING DIABETES
What's new in diabetes care Introduction to diabetes Types of diabetes Diagnosis Risk factors & screening
MANAGING DIABETES
Treatment Oral medications Insulin therapy Dietary therapy Physical exercise
MONITORING DIABETES
Glucose monitoring Self blood glucose monitoring
DIABETIC COMPLICATIONS
Acute complications Diabetic eye disease Neuropathy Diabetic foot problems Nephropathy Large vessel disease
DIABETES RELATED PROBLEMS
Diabetes and the skin Metabolic syndrome Depression and diabetes Diabetes in pregnancy

Diabetes in pregnancy

What is gestational diabetes?
How is gestational diabetes diagnosed?
How is gestational diabetes managed?
How to manage pre-existing diabetes in pregnancy?

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What is gestational diabetes mellitus?

Gestational diabetes mellitus occurs when elevated blood sugar is first recognised in pregnancy. It usually appears during the last 6 months of pregnancy and takes the form of either impaired glucose tolerance (IGT) or diabetes. The IGT or diabetes resolves after delivery, but likely to recur in subsequent pregnancies. Lifetime risk of developing type 2 diabetes is about 30%.

If not treated, gestational diabetes can cause problems for mothers and babies. The mothers could have large babies, the babies are at higher risk for breathing difficuties (respiratory distress syndrome), etc.

Risk factors for the development of gestational diabetes include

Overweight or obesity
Previous glucose intolerance
Family history of type 2 diabetes and gestational diabetes
A macrosomic infant (big baby >4.0 kg birth weight)
Stillbirth or neonatal death during a previous pregnancy

How is gestational diabetes diagnosed?

The American Diabetes Associayion recommends that screening for gestational diabetes to be performed at 24-28 weeks of gestation. In the screening glucose challenge test, if the blood glucose level ≥7.8 mmol/l (140 mg/dl) 1-hr after a 50 g glucose load, a 100g 3-hrs glucose tolerance test should be performed.

Diagnosis of gestational diabetes is therefore based on the blood glucose levels measured during the OGTT as shown in the table below:

Time of Testing	Gestational Diabetes Plasma glucose levels
Fasting	≥5.2 mmol/l (≥95 mg/dl)
At 1 hour	≥10 mmol/l (≥180 mg/dl)
At 2 hours	≥8.5 mmol/l (≥155 mg/dl)
At 3 hours	≥7.8 mmol/l (≥140 mg/dl)

How is gestational diabetes managed?

The main aims of treating gestational diabetes are to normalise the maternal blood glucose level, to detect high blood glucose in the mothers and to monitor fetal growth and well-being.

Eating a healthy diet is the cornerstone of therapy for gestational diabetes. Regular physical activity should be encouraged. Blood sugar levels should be checked both fasting and 1-hr or 2-hrs post meals. The following table shows target blood glucose levels for most women with gestational diabetes:

Target blood glucose levels
Fasting	5.2 mmol/l (<95 mg/dl)
1 hour after neal	7.8 mmol/dl (<140 mg/dl)
2 hours after meal	6.6 mmol/l (<120 mg/dl)

Some women with gestational diabetes may need insulin in order to have an adequate blood glucose control. A healthcare professional should be consulted for a suitable insulin regimen. Oral anti-diabetic drugs are not recommended.

How to manage pre-existing diabetes in pregnancy?

Pregnancy in individual with pre-existing diabetes, either type 1 or type 2 diabetes, should be planned. Good glycemic control with HbA1c <6.5% should be achieved before conception. Insulin therapy may be required in some type 2 individuals to achieve good glycemic control before conception.

Glycemic control may deteriorate especially during the last 6 months of pregnancy. In type 1 diabetes, higher insulin doses may be required. Whereas in individuals with type 2 diabetes, previously managed by diet and/or oral anti-diabetic drugs, usually require insulin therapy. Blood glucose should be monitored regularly and insulin dosage adjustment may be needed in order to achieve the target blood glucose levels (see above).

Insulin requirement drops by 60-75% immediately after delivery. During breast feeding, the insulin therapy may need to be continued at a lower dosage in type 2 diabetes if the glycemic control is not satisfactory with diet alone. In type 1 diabetes, insulin doses should be reduced accordingly.

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