Gestational Diabetes

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Overview

Gestational diabetes is diabetes occurred in case of some women during pregnancy because of insufficiency of the body to secrete insulin in quantities needed to maintain blood glucose (blood sugar amount) in the normal range. Blood glucose usually increases between weeks 24 and 28 of pregnancy.

Gestational diabetes is different from other types of diabetes, due to the fact that it occurs during pregnancy and disappears after birth. Other types of diabetes, type I and type II, may occur anytime throughout the life.
This type of diabetes is a risk factor for the emerge of hypertension during pregnancy. The child may have increased birth weight, which complicates natural birth. Women who had gestational diabetes during pregnancy have increased risk of developing diabetes during the next pregnancies too, and are at risk of developing type II diabetes less than five years after birth.
 


Causes

Gestational diabetes occurs because the pancreas does not secrete optimal amounts of insulin. During pregnancy the placenta secretes hormones that block insulin activity. This causes an increased need of insulin to keep blood sugar normal. As the pregnancy ages, more hormones that block the insulin are produced, so the body becomes insulin resistant.


Risk Factors

Women at high risk of developing gestational diabetes are:
- Those who have had gestational diabetes in previous pregnancy: 30% to 60% of women who had gestational diabetes develop diabetes again during the next pregnancy; the overweight women, the ones who had a baby with excessive birth weight or have needed insulin during a previous pregnancy are at greater risk of developing diabetes
- Women who have a family parent or brother or sister with type II diabetes
- Women from high risk ethnic groups: Latin Americans, Africans, Asians
- Women who have more than 25 years when they become pregnant: risk increases by 4% per year, every year after 25 years
- Those that are under the age of 25 years but are overweight
- Women who had a baby weighing more than 8.8 pounds or less than 4.4 pounds at birth
- Women with polycystic ovary syndrome: although it is difficult for a woman to become pregnant with this disease, the risk of developing diabetes during pregnancy is higher than in the case any other women
- Women who smoke
 
Other factors that indicate an undiagnosed gestational diabetes are:
- High birth weight baby (less than 8.8 pounds)
- Mother with hypertension
- History of multiple miscarriages
- Child dead at birth without a specific cause

Symptoms

The most common gestational diabetes symptoms are thirst, frequent urination, hunger, blurred vision. Still, the most patients do not present any symptoms. Sometimes symptoms can go unnoticed, as frequent urination and increased hunger frequently occur during normal pregnancy. If symptoms are present, may be an indication that diabetes was present even before pregnancy.


Pathophysiological mechanism

Gestational diabetes is diagnosed most often between 24 and 28 weeks of pregnancy. If glucose levels are maintained within normal limits and the weight is normal at birth, the fetal risks of complications are similar to those of a fetus in non-diabetic mother.
It is important to keep blood sugar within normal limits to prevent complications in the fetus, newborn and mother:
- The fetus: problems with high weight of the fetus
- Newborn: child’s low blood sugar level
- Mother: high blood pressure


Consult a specialist

For a pregnant woman treated with insulin for gestational diabetes, call the doctor when:
- It loses consciousness and can not know for sure the blood sugar level
- When evaluating the blood sugar level and it is more than 50 milligrams per deciliter, or when symptoms of hypoglycemia do not improve after the sugar administration
- When pregnant is lethargic or sleepy, and blood sugar is below 60 milligrams per deciliter after the administration of sugar
- When the mother noticed a change in fetal movements or they end
- When blood sugar is less than 55 milligram to deciliter, and pregnant does not know how to raise blood sugar
- When blood sugar levels are within acceptable limits but the pregnant woman does not know how to act in a crisis
- When after the administration of a higher dose of insulin or insulin administration delayed, the glucose level does not return to normal
- When it is not controlled the blood sugar level, even with treatment: in this case may be need to change treatment or if treatment is insulin, the dose
- When there is a malaise that lasts more than two days (without the case of a cold or flu) and which is accompanied by:
- Vomiting or diarrhea for more than 6 hours
- Symptoms of extreme thirst or dizziness that could be caused by diabetes
- Administration of medical treatment that showed no symptoms diminish
- High levels of glucose, more than 250 milligrams to deciliter and urine tests indicate ketoacidosis (elimination of ketones in the urine) with more than 2 +.
You go to the doctor in the case of suspecting the presence of gestational diabetes. For example, when are present the symptoms: thirst, frequent urination, hunger and vision impaired.


Recommended medical specialists

Doctor that diagnose and treat gestational diabetes can be:
- Obstetrician
- General Practitioner
For pregnant women who require treatment with insulin is needed the consultation of:
- Endocrinologist
- Medical disease and diabetes nutrition
- Obstetrician who specializes in treating high-risk pregnancies.


Diagnosis

Diagnosis of gestational diabetes is placed in the results of several tests:
- Fasting glucose level (harvested in the morning, without the patient eating before): if the fasting glucose level is greater than 129 milligrams to deciliter or two random blood glucose taken at any time of day are over 200 mg deciliter, diabetes is diagnosed without doing other tests; for fasting glucose, do not eat and drink anything but water with 8-12 hours before harvest
- Oral glucose tolerance test: is given a glass of water with 50 grams of glucose and after an hour the blood is harvested and glucose level is investigated; if the glucose levels within one hour after administration of glucose is higher than 140 milligrams per deciliter (sometimes 130 or 135),is considered the diagnosis of diabetes
Usually, the tests for diabetes are made at 24-28 weeks of pregnancy, but in the case of pregnant women with high risk, such tests are earlier.
 
Early diagnosis

The risk of developing gestational diabetes is estimated at a woman’s first visit to the doctor. We recommend testing for diabetes in weeks 24-28 of pregnancy in women at high risk:
- Older than 25 years when pregnancy
- Diagnosis of gestational diabetes in previous pregnancies
- Birth of a baby weighing more than 8.8 pounds
- One of the parents or relatives have type II diabetes
- Overweight mother
- The mother is a member of a high risk of diabetes ethnic group
- Pregnant with polycystic ovary
- Pregnant with acanthosis nigricans (black skin disease in folds)
- Pregnant is corticosteroidian treatment


Investigations

During the pregnancy of a woman diagnosed with diabetes, a series of tests are necessary to monitor blood glucose levels and the evolution of pregnancy:
- Home blood glucose monitoring is done 1-2 hours after meals
- Ultrasound is used to estimate gestational age fetus’s weight, health assessment and possible fetal abnormalities; ultrasound does not accurately estimated her weight in the last months
- Blood pressure and urinary protein are tests that are routine in any pregnant woman visit to the doctor
- In some cases is dosed an amount of glycosylated hemoglobin; sometimes dosed every month in women with gestational diabetes; glycosylated hemoglobin is an indicator of the average blood glucose level over the past 2-3 months; this test is sometimes made for women who are suspected of having diabetes before they become pregnant
Tests in the time of labor – during labor and after birth babies born to mothers with diabetes are monitored closely:
- Monitoring of fetal heart rate
- Mother glucose is monitored every hour because higher limits may fluctuate and may be higher than the accepted values.
 
Investigation after birth

After birth, blood glucose is measured several times. It also evaluates the newborn blood sugar several times in the first hours after birth, to avoid the marked decrease in blood glucose.
Although gestational diabetes disappears after delivery, the mother is in high risk of developing type II diabetes, so it is recommended a glucose tolerance test 6 weeks after childbirth or after breast feeding is stopped:
- If the test is negative, glucose evaluation is recommended at least every 3 years; the women with risk factors should be evaluated once a year
- If the result of blood sugar, after performing random tests is higher than normal, is recommended a glucose tolerance test to determine whether or not is type II diabetes


Treatment

Treatment – Overview

Watchful waiting – Watchful waiting is the clinical evaluation over a period of time without being treated. This is not recommended for pregnant women with risk factors for gestational diabetes. Watchful waiting also is not indicated if the pregnant woman is treated with insulin and hypoglycemia symptoms do not resolve despite therapy. It is necessary in this case, tjat the pregnant woman to go to the emergency room.
Exercise – Regular physical activity, moderate during pregnancy result in efficient use of insulin to maintain normal blood sugar. In most cases regular physical activity and diet are the only measures for gestational diabetes. If exercise and diet maintain normal blood sugar level, insulin therapy is required. In case of insulin administration it is necessary that the pregnant woman always have something sweet available to prevent symptoms of hypoglycemia that can occur during physical activity.
Glucose monitoring – home blood glucose monitoring is done 4 times per day in the case of women with gestational diabetes without insulin treatment – before breakfast and 1-2 hours after meals and 6 times per day for pregnant women treated with insulin – before each meal and 1-2 hours after. Monitoring is recommended to be done with a devices that measure blood sugar level, not paper testers because they are less sensitive. Higher levels of blood glucose than those indicated increase the risk of complications to both mother and child.
 

General principles:
- It is indicated insulin therapy if the diet and physical activity do not maintain optimal blood sugar level in range
- Overweight pregnant women should not diet during pregnancy: if the mother’s weight is 20% higher than indicated for age and height, the recommendation will be that the weight gained during pregnancy will not be more than 7 kg; proper diet and exercise will help to gain an acceptable and indicated weight depending on the stage of pregnancy.
- The pregnant woman needs to monitor fetal movements and to notify any changes in movement or the possibly the stopping of the movement; normally the fetus move several times during the day; if not perceived movement is indicated to settle the pregnant woman in lying position, on the left side for 2 hours; at this time if not perceived fetal movements it is indicated to seek medical advice
- Administration of insulin can cause hypoglycemia: very low blood glucose levels are rare in women with diabetes, but they must be educated about possible symptoms of hypoglycemia
 
Medications

For most pregnant women with gestational diabetes, diet and exercise keep blood sugar normal. If blood sugar is not maintained within limits is required insulin therapy. Pregnant women should be instructed on how insulin is administrated.
Complications of gestational diabetes have a higher frequency of occurrence when the baby grows more in weight than usual. Fetal weight is assessed by ultrasound. If the ultrasound indicates an increased weight of the fetus may be required insulin therapy.
 
Insulin – therapeutic substance indicated

Insulin is the only substance indicated for the treatment of gestational diabetes, where the diet and physical activity does not keep the blood sugar level normal.
Another substance: glyburide (a drug used in treatment of diabetes type II) was studied for the treatment of gestational diabetes, but is not currently indicated treatment with this substance.
Insulin dose may be adjusted during pregnancy. It can be increased as gestation ages, because the placenta secretes large amounts of hormones that it blocks the activity of insulin. The increased weight of the pregnant woman is accompanied by a greater need for insulin. Sometimes hospitalization is necessary to regulate blood sugar level in the first days of insulin therapy.
Other medications, such as sulphonylureas or metformin therapy used in type II diabetes, are not indicated in pregnancy because of the detrimental effects on the fetus.
 
Alternative therapies

Seeing a nutritionist may be necessary for a pregnant women with gestational diabetes to achieve a proper diet. All pregnant women are prescribed vitamins. It is not recommended to take all other vitamins than those indicated by your doctor.


Attitude after birth

Gestational diabetes usually resolves after delivery. The risk of developing gestational diabetes in the pregnancies following, or develop type II diabetes is present. We recommend:
- Glucose tolerance test with 75 g glucose dissolved in water, 6 weeks after birth
- If blood sugar level is slightly elevated at 6 weeks after pregnancy, the risk of developing type II diabetes, you need a healthy diet, regular exercise and testing for diabetes each year
- In the following pregnancies testing for diabetes is required, before pregnancy and during early pregnancy, at 24-28 weeks
Women taking progesterone pills who had gestational diabetes have a higher risk of diabetes type II.

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