Article by Dr Manasa S, B.A.M.S
Gestational Diabetes Mellitus (GDM)
Gestational Diabetes Mellitus is a form of diabetes identified for the first-time during pregnancy, typically manifesting between the 24th and 28th weeks of gestation. Similar to other diabetes types, GDM impairs the body’s ability to regulate blood sugar, leading to elevated glucose levels that can impact both maternal and foetal health. While a balanced diet and healthy lifestyle can often manage GDM, medication may be required in some cases. Prompt diagnosis and treatment are crucial, as unmanaged GDM can result in significant health complications for both the mother and the baby. Fortunately, blood sugar levels generally normalize postpartum, highlighting the importance of monitoring and managing this condition throughout pregnancy.
Normal Blood sugar levels during pregnancy
– Before a meal – 95 mg/dl or less
– 1 hour after a meal – 140 mg/dl or less
– 2 hours after a meal – 120 mg/dl or less
Causes of gestational diabetes
The aetiology of gestational diabetes mellitus (GDM) primarily involves pancreatic beta-cell dysfunction and significant insulin resistance caused by hormonal changes during pregnancy.
Pancreatic Beta-Cell Dysfunction – This refers to the inability of pancreatic beta cells to respond adequately or promptly to rising blood glucose levels. The delayed or insufficient insulin secretion contributes to elevated blood glucose levels.
Insulin Resistance – During pregnancy, the placenta releases several hormones that interfere with insulin’s effectiveness, leading to increased insulin resistance. The primary hormone responsible for this is human placental lactogen. Additionally, other hormones such as growth hormone, prolactin, corticotropin-releasing hormone, and progesterone also contribute to insulin resistance and subsequent hyperglycaemia.
These combined effects of impaired beta-cell function and heightened insulin resistance due to hormonal influences are central to the development of gestational diabetes.
Symptoms of gestational diabetes
– Excessive thirst
– Blurred vision
– Fatigue
– Excessive urge to urination
– Yeast infections
Pathophysiology
During pregnancy, the placenta releases a hormone called human placental lactogen, which is similar in composition to growth hormone. This hormone induces significant metabolic changes to ensure the foetus receives adequate nutrition. One of its effects is altering insulin receptors, which can lead to decreased glucose uptake in peripheral tissues. Specific molecular changes associated with this process include –
– Alteration of the beta-subunit of the insulin receptor
– Reduced phosphorylation of tyrosine kinase
– Remodeling of the insulin receptor substrate-1 and phosphatidylinositol 3-kinase
These changes can result in higher maternal blood glucose levels, which cross the placenta and cause foetal hyperglycaemia. In response, the foetal pancreas is stimulated to produce more insulin. The anabolic properties of insulin then promote accelerated growth of foetal tissues.
Types of gestational diabetes
Gestational diabetes is divided into two types –
– Class A1 is a type used to describe gestational diabetes which can be managed with the help of diet alone.
– Class A2 is a type used to describe gestational diabetes where insulin or oral medications are needed to manage the condition.
Risk factors
Gestational diabetes is linked to various genetic and environmental risk factors. These include –
– Being over age 25
– Having a body mass index (BMI) between 25.0 and 29.9
– Decreased physical activity
– Triglycerides greater than 250
– Low LDL
– Having close relatives with type 2 diabetes
– Haemoglobin A1C greater than 5.7
– Abnormal oral glucose tolerance test
– Conditions that cause insulin resistance, such as polycystic ovarian syndrome and the skin disorder acanthosis nigricans
– High blood pressure prior to pregnancy
– Past medical history of cardiovascular diseases
– A history of gestational diabetes in a previous pregnancy
– Significant weight gain during a current or previous pregnancy
– Taking corticosteroids
– Being pregnant with multiples (such as twins or triplets)
– Having hypothyroidism
Certain ethnic groups are also at a higher risk for developing gestational diabetes. These groups include –
– African Americans
– Asian Americans
– Hispanics
– Native Americans
– Pacific Islanders
Complications of gestational diabetes
Complications arise when gestational diabetes is not carefully managed, leading to elevated blood sugar levels. High blood sugar can cause several issues for both the mother and the baby, including an increased likelihood of requiring a C-section for delivery.
For the baby
– Excessive birth weight, making it more likely for the baby to grow too large. Babies weighing 9 pounds or more may become wedged in the birth canal, suffer birth injuries, or necessitate a C-section birth.
– Early (preterm) birth, either due to increased risk of early labour or the recommendation for early delivery because of the baby’s size.
– Serious breathing difficulties such as respiratory distress syndrome, which makes breathing challenging for babies born prematurely.
– Low blood sugar (hypoglycaemia), with severe episodes potentially causing seizures. Prompt feedings and intravenous glucose solutions can stabilize the baby’s blood sugar levels.
– Higher risk of developing obesity and type 2 diabetes later in life.
– In severe cases, untreated gestational diabetes can result in stillbirth, with the baby dying either before or shortly after birth.
For the mother
– Increased risk of high blood pressure and preeclampsia, a serious pregnancy complication characterized by high blood pressure and other symptoms that can threaten both the mother’s and the baby’s lives.
– Higher likelihood of requiring a C-section for delivery.
– Increased likelihood of experiencing gestational diabetes again in future pregnancies.
– Higher risk of developing type 2 diabetes as the mother ages.
Diagnosis Timing of Testing for Gestational Diabetes
Doctors typically check for gestational diabetes between weeks 24 and 28 of pregnancy. However, if you are at high risk, testing may occur earlier.
Gestational Diabetes Testing Procedure
Initial Glucose Tolerance Test
Glucose Intake – You will drink a sweet beverage containing 50 grams of glucose.
Blood Glucose Test – An hour after consuming the drink, a blood sample will be taken to measure your blood sugar levels.
If Initial Test Results are High
3-Hour Oral Glucose Tolerance Test:
– Fasting: You must fast for at least 8 hours.
– Glucose Intake: After fasting, you will consume a drink with 100 grams of glucose.
– Blood Glucose Testing: Blood samples will be taken at one-hour intervals over the next three hours.
Alternative Testing Method:
– Fasting: Fast for at least 8 hours.
– Glucose Intake: Drink a beverage containing 75 grams of glucose.
– Blood Glucose Testing: Blood samples will be taken every hour for the next two hours.
Blood Sugar Levels and Gestational Diabetes
– Normal Range – Blood sugar levels below 130-140 mg/dL (7.2-7.7 mmol/L) are considered normal.
– High Blood Sugar Level – If your blood sugar level is above 130-140 mg/dL, further testing is required.
– Diagnosis Threshold – Levels above 200 mg/dL (11.1 mmol/L) strongly indicate gestational diabetes.
Follow-Up Testing
If you are at high risk for gestational diabetes but initial test results are normal, your doctor may recommend retesting later in the pregnancy to ensure you remain free of the condition.
General preventive measures
While there are no guarantees for preventing gestational diabetes, adopting healthy habits before pregnancy can improve your chances. If you’ve had gestational diabetes, these habits may also reduce the risk of recurrence in future pregnancies and the development of type 2 diabetes.
Eat healthy foods: Focus on foods high in fibre and low in fat and calories, such as fruits, vegetables, and whole grains. Aim for variety to achieve nutritional goals without compromising taste. Be mindful of portion sizes.
Keep active: Regular exercise before and during pregnancy can help protect against gestational diabetes. Aim for 30 minutes of moderate activity most days of the week. This can include brisk walking, cycling, swimming, or incorporating short bursts of activity, like parking further away or taking short walk breaks.
Start pregnancy at a healthy weight: If you’re planning to get pregnant, losing extra weight beforehand can contribute to a healthier pregnancy. Focus on lasting dietary changes, like increasing your intake of vegetables and fruits.
Don’t gain more weight than recommended: Gaining some weight during pregnancy is normal and healthy, but gaining too much too quickly can increase the risk of gestational diabetes. Consult your healthcare provider to determine a reasonable amount of weight gain for you.
Treatment and management
Frequent Checkups:
Increased number of prenatal visits for monitoring.
Regular blood sugar level checks by healthcare provider
Blood Sugar Monitoring:
Self-monitoring at home using a glucose meter.
Keeping detailed records of blood sugar levels.
Dietary Changes:
Following a balanced diet plan as advised by a healthcare provider or dietitian.
Emphasis on foods that help regulate blood sugar levels.
Exercise:
Incorporating regular physical activity into daily routine
Engaging in exercises suitable for pregnancy, such as walking or swimming
Medication:
Use of insulin or other medications if diet and exercise are insufficient.
Adherence to prescribed medication regimen is crucial.
Insulin Administration:
Strictly following the prescribed insulin dosage and schedule if required.
Proper technique for insulin injection and storage.
By managing gestational diabetes effectively, you can help ensure a healthier pregnancy for both you and your baby.
Gestational Diabetes Diet
To maintain optimal health with gestational diabetes, it is crucial to adhere to a healthy, low-sugar diet tailored for individuals with diabetes. Consulting with your doctor ensures that you are meeting your nutritional needs and following an appropriate meal plan.
Substitute sugary snacks like cookies, candy, and ice cream with natural sugars found in fruits, carrots, and raisins. Incorporate vegetables and whole grains into your diet while being mindful of portion sizes. Regular meals are essential; aim for three small meals and two or three snacks at consistent times daily.
Your daily caloric intake should consist of 40% carbohydrates, 20% protein, and 25-40% fats, with an emphasis on complex, fibre-rich carbohydrates. Strive for 20-35 grams of fibre per day through whole-grain breads, cereals, pasta, brown or wild rice, oatmeal, vegetables, and fruits. Keep total fat intake below 40% of daily calories, ensuring saturated fats are less than 10%. A varied diet helps secure adequate vitamins and minerals, and a supplement may be necessary; consult your doctor for recommendations. Individuals with gestational diabetes needs to avoid certain foods to control the condition
Carbohydrates
According to the American Academy of Nutrition and Diabetes recommends a minimum of 157g of carbohydrates and 28g of fibre per day to all pregnant women. But, for women with gestational diabetes eating complex carbohydrates is recommended over the simple carbohydrates. Complex carbohydrates take a longer time to get digested and thus it is less likely to produce a spike of blood sugar, and this helps to reduce insulin resistance. Healthy carbohydrate choices are as under:
– Brown rice
– Whole grains
– Beans, peas, lentils, and other legumes
– Low sugar fruits
– Protein
The recommended dietary allowance of protein during pregnancy is based on the trimester and based on the individual requirement. The general recommended protein requirement during the first trimester is 46g per day and it is about 71 grams per day during the second and third trimester. The good sources of protein are as under:
– Poultry
– Lean meats
– Fish, however certain types of fishes like tuna and swordfish to be avoided during pregnancy
– Tofu
– Fat
Fat which has nutrients such as vitamins and minerals are essential during pregnancy. These healthier fasts help in reducing insulin resistance. Healthy fats include:
– Olive oil
– Avocado
– Seeds
– Unsalted nuts
Gestational Diabetes Breakfast Ideas
Consider these breakfast options:
– A bowl of oatmeal made with water or skim milk
– Two slices of whole-grain toast with unsaturated low-fat spread or cream cheese
– A boiled or poached egg
– Yogurt with nuts
Gestational Diabetes Snacks
Snack ideas include:
– Greek yogurt with nuts, seeds, or fruit
– Unsalted nuts or seeds
Prenatal Care and Managing Gestational Diabetes
Prenatal care is vital for diagnosing and managing gestational diabetes. Your doctor can provide dietary, activity, and weight management advice, and may refer you to nutritionists or other health professionals for additional support.
For morning sickness, small snacks like crackers, cereal, or pretzels can be helpful, particularly before getting out of bed. Throughout the day, opt for frequent small meals and avoid fatty, fried, and greasy foods. If you use insulin, have a plan for managing low blood sugar, especially if vomiting occurs, and consult your doctor for guidance.
Gestational Diabetes Exercise
Exercise is beneficial during pregnancy and helps to regulate and manage blood sugar levels and reduce the risk of complications during pregnancy while preventing excessive weight gain. Staying active supports good posture and alleviates common pregnancy discomforts such as backaches and fatigue. With your doctor’s approval, aim for 30 minutes of moderate activity most days. The good options and suitable activities for pregnant women with gestational diabetes mellitus include low intensity exercises such as walking, swimming, stationary cycling (biking) and modified Yoga. Running is also included. If you’re new to exercise, start slowly and gradually increase to 30 minutes daily.
It is very important that the pregnant woman should consult the doctor / Yoga or exercise trainer or experts before starting or changing their exercise routines.
Continue any pre-pregnancy workouts if approved by your doctor, who can advise on necessary adjustments or recommend alternative activities. Always carry a quick source of sugar, like glucose tablets or hard candy, during workouts to address potential low blood sugar.
Study – According to a study published in Science Direct, it is said that in the 21st century GDM imposes a major challenge for healthcare professions. It is more widespread in the Indian population than in Asian countries. The increased occurrence of GDM in pregnant women is due to changes in lifestyle and dietary patterns and also lack of understanding of pregnancy complications. WHO emphasizes on patient centred education since GDM diagnostic technique is not universally accepted. This is a promising strategy for minimizing the burden of diabetes. It was found that the women in poor locations have a higher chance of acquiring GDM and even small expenses are likely to impair their participation in screening the condition. Therefore, free-of-cost screening for GDM and proper treatment for maternal health care can be a significant step towards diabetes care as well as social prosperity. GDM is also said to be a metabolic and reproductive disorder.
Study – Foetal Heart Rate – FHR was found to be higher in diabetic pregnancies than in non-diabetic pregnancies.
Study – One study showed an association between high pre-pregnancy hemoglobin levels and GDM risk.
Study – Another study showed that GDM was associated with greater increment in BMI but not with increased GWG (gestational weight gain) in kilograms.
Ayurveda Understanding of Gestational Diabetes
There is no direct description of any disease condition in Ayurveda which resembles gestational diabetes mellitus. So, we can understand gestational diabetes from the viewpoint of Prameha / Madhumeha – in terms of all aspects i.e. etiological factors, pathogenesis, symptoms, prognosis and treatment principles – which include dietetic and lifestyle modifications, therapies and medicines.
Treatment principles of medovaha sroto dushti, sthoulya, medoroga, imbalances and variations of agni, ama and kapha aggravation. Gestational diabetes vis-à-vis prameha in garbhini can be due to any chronic or long-standing illness. The primary diseases should be promptly treated.
Before conceiving or during the planning of the same, the woman can undergo Panchakarma therapies like vamana, virechana and vasti. This helps especially in those having history of gestational diabetes in their previous pregnancy or have family history of diabetes. This is basically a preventive strategy.
External therapies like Abhyanga, Swedana, Udwarthana, Shirodhara, and Sarvanga Dhara helps in dealing with stress and mental imbalances and can be planned in pre-conception time period.
The rules and regulations laid down in Garbhini Paricharya – Ayurveda antenatal care shall be promptly followed as and when needed.
Counselling, psychotherapy, regular exercises, good quality and quantity of sleep, religious and divine therapies, meditation and modified Yoga postures are also helpful in this direction.
Related Reading – ‘Ayurveda Understanding and Management of Gestational Diabetes’
