Diabetes In Pregnancy(Gestational Diabetes)
Gestational diabetes is a type of diabetes that occurs only in pregnancy and usually disappears after the birth of the baby. It is present in less than 15% of all pregnancies and is usually detected at 24-28 weeks of pregnancy. Scientifically, gestational diabetes mellitus (GDM ) is defined as ‘carbohydrate intolerance with recognition or onset during pregnancy’, irrespective of the treatment with diet or insulin. The importance of GDM is that two generations are at risk of developing diabetes later. Women with a history of GDM are at increased risk of future diabetes, predominately type 2 diabetes, while their offspring are prone to developing childhood obesity, with type 2 diabetes later in life.
The Diabetes in Pregnancy Study group India (DIPSI) has come out with report containing practice guidelines for GDM in the Indian environment. Due to high prevalence of GDM, the DPISI report strongly recommends essential screening of all pregnant women in India.
Symptoms: Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples. No specific cause has been defined so far, but it is believed that the hormones produced during pregnancy increase a women’s resistance to insulin, resulting in impaired glucose tolerance.
Classification: Broadly, there are two subtypes of GDM:
1. Type A1: Abnormal oral glucose tolerance test, but normal blood glucose levels during fasting and two hours after meals. For this group diet modification is sufficient to control glucose levels.
2. Type2: Abnormal OGTT (Oral glucose tolerance test), compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required.
Management:The goal of treatment is to reduce the risk of GDM for mother and child. The control of glucose levels can be beneficial in terms of less serious foetal complications (such as macrosomia, i.e., larger foetus size for gestational age) and enhanced maternal quality of life. Counselling before pregnancy and multidisciplinary management are important for good pregnancy outcomes.
The compliance with the treatment plan depends on several factors including the patient’s understanding of the implications of GDM for her baby and herself; dietary and exercise recommendations; self-monitoring of blood glucose; self-administration of insulin and adjustments of insulin doses; identification and treatment of hypoglycemia(patient and family members); safe physical activity; and development of techniques to reduce stress. Care has to be taken to minimize the anxiety of the women.
A team approach is ideal for managing GDM in women. The team would usually comprise an obstetrician, a diabetes physician, a diabetes educator, a dietitian, a midwife and a pediatrician. In practice, however, the team approach is not always possible due to limited resources. Self-monitoring of blood glucose levels can guide therapy. Some women will need anti-diabetic drugs- most commonly insulin therapy. Any diet needs to provide sufficient calories for pregnancy, typically 2,000-2,500 kcl with the exclusion of simple carbohydrates. The main goal of dietary modification is to avoid peaks in blood sugar levels. This can be achieved by spreading carbohydrate intake over meals and snacks throughout the day, and using slow release carbohydrate sources. Since insulin resistance is highest in morning, breakfast carbohydrates need to be restricted more. Regular moderately intense physical exercise is beneficial. Regular blood samples can be tested for HbA1c levels, which give an idea of glucose control over a longer period of time. The anti-diabetic drugs Glyburide and Metformin have shown promising results in GDM cases and found to be as effective as insulin.
There is need to create awareness about the GDM among the public, especially among rural women, in order to make a stronger and healthier India by saving the mother today and saving the babies of tomorrow.