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GESTATIONAL DIABETES

What is Gestational Diabetes ?

The main cause of diabetes is a shortage of a chemical called insulin. Sometimes, diabetes is triggered by being overweight or by other substances and hormones which stop insulin from working properly. Without proper amounts of insulin in the body tissues, glucose cannot be turned into the energy the body needs. The level of sugar will then rise in the blood, and sugar can overflow into the urine, where it may have been picked up by testing. Gestational diabetes means diabetes which appears for the first time during pregnancy and (usually) goes away after childbirth. It can affect the size and wellbeing of your baby, and increases the chance of your baby getting a low blood glucose level in the first few days of life (neonatal hypoglycaemia).

How does Gestational Diabetes occur ?

During pregnancy, hormones are produced which prevent your insulin from working properly. This is why diabetes has appeared for the first time now that you are pregnant. The effects of the pregnancy hormones are mainly seen only from about the 24th week of pregnancy onwards. This is why you were probably tested at about this time. You may also have been tested because of glucose in your urine, previous pregnancies with a large baby, or other problems which we know to be more common in people with diabetes.

Why does Gestational Diabetes occur ?

Diabetes is a common condition which is partly inherited. Without having one or more such genes, your gestational diabetes would probably not have occurred. Being overweight may also have been a factor in your developing it. Gestational diabetes occurs in betwee 1 in 50 and one in 20 pregnancies, and is more likely to occur if your mother had diabetes, at some stage of her life.

How is Gestational Diabetes diagnosed ?

More and more antenatal clinics are now testing routinely for diabetes at 26 to 28 weeks by giving a drink of a standard amount of dextrose (usually 75 grams). A blood glucose test is taken an hour later. If your blood glucose is raised, you will have a procedure called a glucose tolerance test. Another dextrose drink will be given, and half-hourly blood tests taken to see how your blood level of glucose behaves. In the future, we expect the diagnosis to be easier: a test which will directly identify the gene(s) which is (are) the cause of your diabetes, and which will be performed at your first antenatal visit.

What does treatment for Gestational Diabetes involve ?

You will need to be seen regularly in a special antenatal clinic, by a team usually consisting of obstetrician, diabetes nurse, midwife, and a diabetes specialist. The nurse will show you how to check your own blood glucose level, using a finger prick sample. You will need to check your own blood glucose at least once or twice each day for at least 2 days each week, to see that your treatment is bringing the tests down to normal. The usual treatment is diet, although there is some doubt about how effective dieting actually is in affecting the outcome. You will meet a dietitian who will outline the main principles of healthy eating. He or she will also outline the importance of regular exercise, which is known to lower blood glucose. You will also need to watch your weight and may possibly need to lose some. In many women, diet alone is not enough to bring the blood glucose levels down to normal. You will then need to learn to give yourself insulin injections. This is not as bad as it sounds, and will usually only need to be done during the remaining weeks of your pregnancy. Special pens are now mostly used for the injections. The jabs are not really painful at all. You will still have to stick to your diet, though!

During treatment for Gestational Diabetes

Keeping to a regular diet with three meals each day is important. If you do need injections, doses of a short-acting insulin are usually given 15 to 30 minutes before each meal to deal with the food you eat. A longer acting insulin type is given at bedtime with a snack to look after your overnight sugar levels (and occasionally also before breakfast). Other routines are used by some hospitals. Whatever your treatment, the aim is to keep the blood glucose between 4 and 7 mmol/l (70 to 120 mg/dl) before meals and no more than 10 mmol/l (180 mg/dl) after meals. Your care team may however give you a different routine and different targets. To achieve these, you will need to alter amounts of food and insulin. Your doctor or nurse will also check a blood test sample for haemoglobin A1c or fructosamine: these tests give the doctor an additional idea of how well your diabetes has been controlled over the previous weeks. Find out whom to keep in touch with: your doctor or your nurse need to be available to give you advice should things go wrong in any way. Your blood glucose can drop too low: this is called an insulin reaction or "hypo": the symptoms are sweating, palpitations, acute hunger and faintness. You can actually pass out. For this reason, have lump sugar or Dextrosol handy to take for such symptoms. Follow up by some food as soon as possible. Your obstetrician or midwife will check you regularly: ultrasound will be used at 18 to 20 weeks to check for birth defects. It will be repeated later in the pregnancy to check how well your baby is growing (babies can get rather big in people with diabetes). A very big baby may mean having a Caesarean delivery, but delivery will usually be vaginal unless there are other complications. It is not routine to induce labour before the baby is actually due, but may be necessary if the baby is large or there are other complications. When you go into labour, you will need a glucose solution dripped into a vein, and a special insulin pump to keep the glucose levels normal. Your blood will be checked every 30 to 60 minutes and the insulin dose rate changed by the nurse.

After treatment for Gestational Diabetes

Once the baby is born, it may have low blood glucose levels (neonatal hypoglycaemia) . This can happen as a brief reaction to your own high glucose levels. Such a baby will then need early feeding, and may need to be cared for in the neonatal (baby) unit You will soon be able to visit, hold and feed your baby. Your glucose drip will be stopped and insulin is not usually then needed any longer. Your glucose tolerance test will however be repeated a month or so later, to check that it has returned to normal. You should have a blood glucose test taken after a big meal or a standard dextrose drink every year from now on. About 50% of people with gestational diabetes will develop permanent diabetes later in life. It is better to diagnose diabetes early to prevent later complications. Keeping your weight down reduces the risk. Gestational diabetes is likely to recur with your next pregnancy: your doctor needs to know as soon as you become pregnant next time. Your baby has only a 4% chance of having diabetes at some stage of his or her life, increasing to 10% if your partner also has diabetes. It is not worthwhile checking your child for diabetes in its early years: when they occur, the symptoms of diabetes are usually fairly clearcut. Research is being carried out to find out how often your child should be checked for diabetes in later (adult) life.

What if you were not treated for Gestational Diabetes?

Without good control of your diabetes and supervision of the pregnancy, the risks of extra fluid in the womb (hydramnios), stillbirth, pre-eclampsia, premature labour and a large baby are much higher.