How to manage gestational diabetes —Expert

Obstetrics/gynaecology resident, Dr. ’Kemi Windapo, who is also the President, Association of Resident Doctors, Federal Medical Centre, Ebute-Metta, speaks to TOBI AWORINDE about gestational diabetes

What is gestational diabetes?

In simple terms, gestational diabetes is any degree of high blood glucose (sugar) that is first diagnosed during pregnancy and usually disappears following delivery. It affects how the cells in the body use glucose and it can lead to significant complications in both the mother and the baby. Therefore, it needs to be detected early and managed appropriately.

What causes gestational diabetes?

Gestational diabetes results from a combination of factors, including a woman’s inability to produce enough insulin (the hormone that reduces blood glucose levels) to compensate for the increased nutritional demands of pregnancy as well as high levels of some hormones produced by the placenta during pregnancy; these are known as the diabetogenic hormones of pregnancy. They make it more difficult for the body to process glucose efficiently, thus, resulting in high blood glucose levels.

How is gestational diabetes diagnosed?

Women with risk factors for gestational diabetes or women with symptoms such as increased thirst, increased urination, weight loss and tiredness, which are suggestive of high glucose levels, are sent for an oral glucose tolerance test. This involves testing for the fasting blood sugar, following which a 75g glucose load is ingested. The blood glucose values an hour and two hours after the glucose load is ingested are tested. If any of the values are higher than expected, a diagnosis of gestational diabetes can then be made.

How common is gestational diabetes?

Gestational diabetes varies from region to region and also depends on the criteria used for its diagnosis. The prevalence is therefore broad. Worldwide, it affects about one to 45 in every 100 pregnant women. A large study done in Africa suggested that gestational diabetes affects 13 in every 100 pregnant women.

Can a woman be treated for gestational diabetes during pregnancy?

Yes. Treatment is actually necessary in order to prevent the complications associated with gestational diabetes in both the mother and the baby. Treatment depends on the severity of the condition and the presence or absence of complications.

Is there any medication needed for treatment?

Yes. Oral anti-diabetic medications, like Metformin, may be employed in the management of gestational diabetes. Insulin therapy may also be necessary. These have been found to be safe with no adverse effects on the growing foetus.

Should a woman with gestational diabetes change her diet?

Dietary modification is usually the first line of action in the management of gestational diabetes. Frequent small meals high in fibre and low in calories are recommended. Emphasis should be on meals with lots of vegetables and fruits.

Will gestational diabetes affect the delivery of the baby?

Barring any contraindications, a vaginal delivery can be conducted. The presence of gestational diabetes increases the chances of shoulder dystocia, a condition where there is difficult delivery of the baby’s shoulder following the delivery of the baby’s head, which occurs as a result of abnormal accumulation of fat in the baby’s shoulders. This condition can lead to an injury to the baby such as an injury to the nerves controlling the upper limbs or even death, if not immediately identified and resolved. It can also result in severe tears in the vagina and perineum of the mother. Caesarean delivery is reserved for conditions where vaginal delivery is not advisable, such as when gestational diabetes exists with other medical conditions in pregnancy or if the baby is suspected to be bigger than usual.

If a woman has gestational diabetes, will the condition disappear after she is delivered of the baby?

In actual gestational diabetes, it usually resolves following delivery because there is a withdrawal of the diabetogenic hormones, which are produced by the placenta. The actual diagnosis of gestational diabetes can only be made six weeks after delivery because, at this time, a repeat OGTT done is expected to be normal. If the OGTT done at this time is positive, there is a possibility that the diabetes predated the pregnancy (pre-gestational).

It is, however, important to note that because gestational diabetes increases the risk of developing overt diabetes in future, routine yearly testing for diabetes is recommended.

What are the risk factors?

Risk factors for gestational diabetes include previous history of gestational diabetes or pre-diabetes, first-degree relative with diabetes mellitus, history of a big baby (weighing more than 4kg); history of a malformed baby, history of an unexplained stillbirth, being overweight and obese (over 90kg), pre-pregnancy history of Polycystic Ovarian Syndrome, women who are of African descent; and lack of physical activity.

How can one reduce the risk of having gestational diabetes?

When it comes to preventing gestational diabetes, there are no guarantees. One can, however, reduce the risk of having gestational diabetes by ensuring a healthy lifestyle prior to conception. Consume a high-fibre and low-calorie diet; lots of vegetables and fruits are highly recommended. Portion control is a very important factor to consider. Exercising before and during pregnancy may help prevent gestational diabetes. Exercising for 30 minutes per day, at least five times a week, is recommended. Exercising can include a brisk walk, yoga, cycling, swimming and so on. Starting pregnancy at a healthy weight can also help reduce the risk. Changes to diet and taking up routine exercise can help one lose extra weight beforehand. It is also important to undergo preconception care and counselling with a qualified medical practitioner so that occult pre-existing conditions and risk factors can be identified and mitigated prior to attempting conception.

What other conditions can a woman with gestational diabetes develop?

Women with gestational diabetes are at increased risk of developing high blood pressure and preeclampsia – high blood pressure associated with significant amount of protein in the urine – which can threaten the lives of both the mother and the baby. Women with gestational diabetes are also at an increased risk of having a delivery by caesarean section, especially if the baby grows bigger than usual. There is an increased likelihood of developing gestational diabetes in subsequent pregnancies and in future, about 20 out of 100 women who had gestational diabetes will develop frank Type 2 diabetes within five years of delivery.

Does gestational diabetes have any effect on the baby?

Gestational diabetes can have effects on the baby both during pregnancy and after delivery. During pregnancy, it increases the risk of the baby growing bigger than usual –  macrosomia – which can lead to complications at birth and also increase the need for delivery by caesarean section. It also increases the risk of the baby being born before term. Babies born early to mothers with gestational diabetes have an increased risk of having breathing problems at birth which is known as Respiratory Distress Syndrome. In untreated or poorly managed gestational diabetes, there is a risk of having a baby with major abnormalities or birth defects. Though uncommon, there can be a sudden unexplained stillbirth, which is a catastrophic complication. Later in life, children of women who have gestational diabetes will have a higher chance of developing obesity and Type 2 diabetes.

Will the baby of a woman with gestational diabetes be born with diabetes?

No. Quite paradoxically, the baby will be born with an increased risk of low glucose levels (hypoglycaemia) shortly after birth due to a withdrawal from the maternal environment of high glucose and the adaptive high insulin levels in the baby. This hypoglycemia may present as seizures in severe cases. It is, therefore, important to routinely monitor blood glucose levels in infants of diabetic mothers. Frequent feeding and sometimes, intravenous administration of glucose can help to return the baby’s glucose levels to normal.

Can a woman with gestational diabetes breastfeed her baby?

Yes. Breastfeeding is not contraindicated in gestational diabetes.

What are the financial implications of managing gestational diabetes?

The financial implications will usually depend on the management modality. Some women with gestational diabetes can be managed with a simple dietary modification while some others will require oral anti-diabetic medication or insulin therapy and in some cases both oral anti-diabetic medication and insulin therapy may be necessary. Metformin is the commonest oral anti-diabetic medication in use and costs about N300 for a sachet of 10 tablets and can cost more depending on the brand. A vial of insulin on the other hand costs about N3,000 and can also vary in price, depending on the brand. We also have to note that self-monitoring of blood glucose levels is an important aspect in the management of gestational diabetes. A home self-monitoring kit can cost between N8,000 and N15,000 also depending on the brand. The cost of consulting with a maternal medicine consultant, endocrinologist, dietician, diabetic nurses and so on will have to be put into consideration as the care required in the management of gestational diabetes is multidisciplinary.