Gestational diabetes is a type of diabetes that develops during pregnancy and usually disappears after giving birth. It occurs in 2-10% of pregnancies due to hormonal changes reducing the body's ability to use insulin. While most women have no symptoms, screening tests are done between 24-28 weeks of pregnancy to check blood sugar levels. Eating a healthy diet and exercise can help manage gestational diabetes and reduce risks to both mother and baby like high birth weight or developing diabetes later in life.

2. About
This is a type of diabetes (also called Gestational Diabetes) that
some women get during pregnancy (especially during 3rd trimester).
Between 2 and 10 percent of expectant mothers develop this
condition characterized by high blood sugar, making it one of the
most common health problems of pregnancy.
It usually disappears after the birth, and does not mean that
the baby will be born with diabetes

3. Causes
Gestational diabetes is caused by hormonal changes in pregnancy
which can change the body’s ability to use a substance called
insulin. Insulin is important because it helps keep blood sugar at a
healthy level. Whilst all women undergo hormonal changes, only
some women develop gestational diabetes.
This is likely due to pregnancy related factors such as the
presence of human placental lactogen that interferes with
susceptible insulin receptors.

4. Symptoms & Risks
Gestational diabetes usually has no symptoms. That's why
almost all pregnant women have a glucose-screening test
between 24 and 28 weeks.
Risks:
1. Being overweight prior to becoming pregnant (if you are
20% or more over your ideal body weight)
2. Being a member of a high risk ethnic group (Hispanic,
Black, Native American, or Asian)
3. Having sugar in your urine

5. 4. Impaired glucose tolerance or impaired fasting glucose (blood
sugar levels are high, but not high enough to be diabetes)
5. Family history of diabetes (if your parents or siblings have
diabetes
6. Previously giving birth to a baby over 9 pounds
7. Previously giving birth to a stillborn baby
8. Having gestational diabetes with a previous pregnancy
9. Having too much amniotic fluid (a condition called
polyhydramnios)

6. Diagnosis
High risk women should be screened for gestational diabetes as
early as possible during their pregnancies. All other women will be
screened between the 24th and 28th week of pregnancy.
To screen for gestational diabetes, an oral glucose tolerance test is
done. This test involves quickly drinking a sweetened liquid, which
contains 50g of sugar. The body absorbs this sugar rapidly, causing
blood sugar levels to rise within 30-60 minutes. A blood sample will
be taken from a vein in the arm 1 hour after drinking the solution.
The blood test measures how the sugar solution was metabolized.

7. A blood sugar level greater than or equal to 140mg/dL is
recognized as abnormal. If your results are abnormal based on the
oral glucose tolerance test, another test will be given after fasting
for several hours.
In women at high risk of developing gestational diabetes, a normal
screening test result is followed up with another screening test at
24-28 weeks for confirmation of the diagnosis.

9. Pathophysiology
The precise mechanisms remain unknown. There is increased
insulin resistance. Pregnancy hormones and other factors interfere
with the action of insulin as it binds to the insulin receptor. The
interference probably occurs at the level of the cell signaling
pathway behind the insulin receptor. Since insulin promotes the
entry of glucose into most cells, insulin resistance prevents glucose
from entering the cells properly. As a result, glucose remains in the
bloodstream, where glucose levels rise. More insulin is needed to
overcome this resistance; about 1.5-2.5 times more insulin is
produced than in a normal pregnancy.

10. Diabetic Diagnostic
Criteria
Condition 2 hour glucose Fasting glucose
HbA1c
mmol/l(mg/dl) mmol/l(mg/dl) %
Normal <7.8(<140) <6.1(<110) <6.0
Impaired fasting glycaemia <7.8(<140) >6.1(>110) & <7.0(<126) 6.0 - 6.4
Impaired Glucose Tolerance >7.8(>140) <7.0 (<126) 6.0 – 6.4
Diabetes mellitus >11.1(>200) >7.0 (>126) >6.5

11. Management
The goal of treatment is to reduce the risks of GDM for mother and
child. Scientific evidence is beginning to show that controlling
glucose levels can lessen serious fetal complications and increase
maternal quality of life.
Lifestyle:
1. Eating a balanced diet of wholegrain carbohydrates, lean
proteins and healthy fats.
2. Regular moderately intense physical exercise is advised

12. 3. Any diet needs to provide sufficient calories for pregnancy,
typically 2,000 - 2,500 kcal with the exclusion of simple
carbohydrates.
4. The main goal of dietary modifications is to avoid peaks in blood
sugar levels. This can be done by spreading carbohydrate intake
over meals and snacks throughout the day, and using slow-release
carbohydrate sources—known as the G.I. Diet.
5. Since insulin resistance is highest in mornings, breakfast
carbohydrates need to be restricted more. Ingesting more fiber in
foods with whole grains, or fruit and vegetables can also reduce the
risk of gestational diabetes.

13. Self monitoring can be accomplished using a handheld capillary
glucose dosage system. Compliance with these glucometer
systems can be low.
Target ranges advised are:
 Fasting capillary blood glucose levels <5.5 mmol/L
 1 hour postprandial capillary blood glucose levels <8.0 mmol/L
 2 hour postprandial blood glucose levels <6.7 mmol/L

14. Medication:
Taking insulin, if necessary. Insulin is currently the only diabetes
medication used during pregnancy.
Care needs to be taken to avoid low blood sugar levels
(hypoglycemia) due to excessive insulin injections. Insulin therapy
can be normal or very tight; more injections can result in better
control but requires more effort.

15. Glyburide, a second generation sulfonylurea, has been shown to
be an effective alternative to insulin therapy.
Metformin has shown promising results, with its oral format being
much more popular than insulin injections.
But half of patients did not reach sufficient control with metformin
alone and needed supplemental therapy with insulin; compared to
those treated with insulin alone, they required less insulin, and they
gained less weight. There is a possibility of long-term complications
from metformin therapy, although follow-up at the age of 18 months
of children born to women with POS and treated with metformin
revealed no developmental abnormalities.

16. Complications
Most women who have gestational diabetes deliver healthy babies.
However, gestational diabetes that's not carefully managed can
lead to uncontrolled blood sugar levels and cause problems for you
and your baby, including an increased likelihood of needing
delivery by C-section.
Complications that may affect the baby :
1. Excessive birth weight:
Extra glucose in your bloodstream crosses
the placenta, which triggers your baby's pancreas to make extra
insulin. This can cause your baby to grow too large (macrosomia).

17. 2. Preterm birth and respiratory distress syndrome:
Maternal high blood sugar may increase
her risk of going into labor early and delivering her baby before its
due date. Or the doctor may recommend early delivery because the
baby is growing so large. Babies born early may experience
respiratory distress syndrome. Babies with this syndrome may
need help breathing until their lungs mature and become stronger.
Babies of mothers with gestational diabetes may experience
respiratory distress syndrome even if they're not born early.

18. 3. Low blood sugar (hypoglycemia):
Sometimes babies develop low blood
sugar (hypoglycemia) shortly after birth because their own insulin
production is high. Severe episodes of hypoglycemia may provoke
seizures in the baby. Prompt feedings and sometimes an
intravenous glucose solution can return the baby's blood sugar
level to normal.
4. Jaundice:
This yellowish discoloration of the skin
and the whites of the eyes may occur if a baby's liver isn't mature
enough to break down a substance called bilirubin. Although
jaundice usually isn't a cause for concern, careful monitoring is
important.

19. 5. Type 2 diabetes later in life: Babies of mothers who have
gestational diabetes have a higher risk of developing obesity and
type 2 diabetes later in life.
Untreated gestational diabetes can result in a baby's death either
before or shortly after birth.
Complications that may affect the mother:
1. High blood pressure, preeclampsia and eclampsia:
Increases the risk of developing high
blood pressure during pregnancy & risk of preeclampsia and
eclampsia — two serious complications of pregnancy that cause
high blood pressure and other symptoms that can threaten the lives
of both mother and baby.

20. 2. Future diabetes:
Risks to develop gestational diabetes in a
future pregnancy. More likely to develop type 2 diabetes later.
However, making healthy lifestyle choices such as eating healthy
foods and exercising can help reduce the risk of future type 2
diabetes. Of those women with a history of gestational diabetes
who reach their ideal body weight after delivery, fewer than one in
four develop type 2 diabetes.

21. Prognosis
Gestational diabetes generally resolves once the baby is born. The
risk is highest in women who needed insulin treatment, had antibodies
associated with diabetes, women with more than two previous
pregnancies, and women who were obese (in order of importance).
Women requiring insulin to manage gestational diabetes have a 50%
risk of developing diabetes within the next five years.
Children of women with GDM have an increased risk for childhood
and adult obesity and an increased risk of glucose intolerance and
type 2 diabetes later in life.