By: Fatima Choudary

GESTATIONAL
DIABETES
Gestational Diabetes
A condition in which pregnant women, who do not previously have
Diabetes exhibit high blood sugar levels.
Usually occurs during the third trimester
It is caused when the insulin receptors do not function properly
most likely due to pregnancy related hormones


Risk Factors


Previous diagnosis of gestational diabetes prediabetes, impaired
glucose tolerance or impaired fasting glycaemia
Family history with a first degree relative with Type 2 Diabetes
Maternal age: a womans risk increases as her age increases
(especially in women >35 years of age)
Previous pregnancy that resulted in a child with macrosomia
Ethnic background
Being overweight or obese
Studies show twice the risk in smokers vs. nonsmokers
About 40-60% of women with GDM have no Risk factor therefore it
is beneficial to screen all pregnant women.

Symptoms
Usually there are no symptoms
And if any they are mild and not life threatening
May include:
Blurred vision
Fatigue
Increased thirst
Increased urination
Nausea
Vomiting
Weight loss despite increased appetite



Insulin
Is produced by the beta cells of the pancreas
It is produced in response to ATP from glucose metabolism closing
Potassium channels and depolarizing the cell
Regulates carbohydrate and fat metabolism in the body
Promotes the entry of glucose into most cells (ex. Liver, skeletal
muscle and fat)
In the liver the glucose is converted and stored as glycogen
In adipocytes it is stored as triglycerides
It is provided within the body in a constant proportion to remove
the excess glucose from the blood, which would otherwise be toxic
It stops the use of fat as an energy source by inhibiting the release
of glucagon from the alpha cells of the pancreas
It does not however cross the placenta


Insulin Regulation
Hyperglycemia, GH and Cortisol: Increase insulin secretion
Hypoglycemia and somatostatin: Decrease insulin secretion
Beta agonists (ex. Isoproterenol, terbutaline etc.): Stimulate Insulin
secretion
Alpha agonists (ex. Phenylephrine, clonidine etc.): Inhibit Insulin
secretion
Anabolic effects of Insulin
Increase glucose transport in skeletal muscle and adipose
Increase glycogen synthesis and storage
Increase triglyceride synthesis and storage
Increase sodium retention (in the kidneys)
Increase protein synthesis (in muscles)
Increase cellular uptake of potassium and amino acids
Inhibits ketoacidosis formation and lipolysis
Insulin deficiency
Type 1 Diabetes Mellitus: It is due to an autoimmune destruction of
beta cells of the pancreas. Usually see islet leukocytic infiltration.
Occurs in patients <30 years of age
Type 2 Diabetes Mellitus: It is due to Insulin resistance. Usually see
Islet amyloid deposition. Occurs in patients >40 years of age
Diabetic Ketoacidosis: Which is a complication of Type 1 Diabetes
Mellitus
Gestational Diabetes: Also a mechanism of insulin resistance
Pathophysiology
The mechanism underlying the etiology is unknown
The main cause is insulin resistance
Pregnancy hormones (such as: Progesterone, Cortisol, human
placental lactogen, prolactin and estradiol) are thought to interfere
with the action of Insulin as it binds to its insulin receptors
The interference probably occurs at the level of the cell signaling
pathway
Insulin resistance is a normal phenomenon occurring in the second
trimester of pregnancy, which can progress to levels seen in non
pregnant type 2 diabetic patients
Placental hormones and increased fat deposit during pregnancy
seem to mediate the insulin resistance
Glucose travels across the placenta via diffusion facilitated by GLUT-
3 carriers
In untreated gestational Diabetes the fetus is exposed to
consistently high levels of glucose
This leads to increased fetal level of insulin
The growth stimulating effects of insulin can lead to excessive
growth and large body (Macrosomia)
After birth the high levels of glucose disappears leaving the babies
with ongoing increased insulin production leading to decreasing
amounts of glucose eventually causing hypoglycemia
Diagnosis

Fasting glucose test
2 hour postprandial glucose test
Random glucose test
Screening glucose challenge test
Oral glucose tolerance test
Urinary glucose test


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
Screening glucose challenge test
Aka O'Sullivan test is performed between 24-28 weeks
No previous fasting required
Involves drinking a solution containing 50 grams of glucose and
measuring blood levels one hour later
If that comes back positive, you do a diagnostic test which involves
measuring blood levels 3 hours after drinking a solution containing
50 grams of glucose.


Oral glucose tolerance test
Done in the morning after an overnight fast of 8-14 hours
During previous 3 days patient must have unrestricted diet (150g of
carbohydrate and unlimited physical activity)
Involves drinking a solution containing a certain amount of glucose
(75-100g) and drawing blood to measure glucose levels at the start
and on set time intervals
The following values during the 100g of glucose OGTT are
considered to be abnormal according to American Diabetes
Association:
Fasting blood glucose level 95 mg/dl (5.33 mmol/L)
1 hour blood glucose level 180 mg/dl (10 mmol/L)
2 hour blood glucose level 155 mg/dl (8.6 mmol/L)
3 hour blood glucose level 140 mg/dl (7.8 mmol/L)

Urinary Glucose test
Women with GDM have high glucose levels in their urine glucosuria
Dipstick testing is widely performed, although it performs poorly
However discontinuing routine dipstick testing has not been shown
to cause under diagnosis
Increased GFR during pregnancy contributes to 50% of women
having glucose in their urine
How GDM affects the Baby
Affects the mother in late pregnancy, after the babys body has
been formed but while it is still growing
Gestational Diabetes does not cause the type of birth defects
sometimes seen in babies whose mothers had diabetes before
pregnancy
If untreated or poorly controlled it can hurt the baby
Although insulin doesnt cross the placenta, glucose and other
nutrients do.
Extra blood glucose crosses the placenta causing high blood
glucose levels in the baby
This causes the babys pancreas to make extra insulin to get rid of
the extra glucose. The extra energy is stored as fat and can lead to
macrosomia


















19.2 pound baby

Macrosomia
These babies health problems of their own
Damage to shoulder during birth
Newborns may have low glucose levels, because even after birth
the babys pancreas is producing large amounts of Insulin, which
takes up the remaining glucose and leading to Hypoglycemia
They are also at risk of breathing problems
Babies with excess insulin become children who are at risk of
developing obesity and adults who are at risk of developing type 2
Diabetes
Macrosomia leads to problems during vaginal deliveries and risk of
instrumental deliveries
The development of macrosomia can be evaluated during
pregnancy using sonography


Jaundice
High red blood cell mass (polycythemia)
Low calcium (hypocalcaemia)
Low magnesium (hypomagnesaemia)
Untreated GDM interferes with maturation
Respiratory Distress Syndrome due to incomplete lung maturation
and impaired surfactant synthesis

How GDM affects the mother
Women diagnosed with GDM have a high risk of developing DM in
the future
Risk is highest in women that required Insulin treatment
antibodies associated with diabetes ex. Antibodies against
glutamate decarboxylase, islet cells and/or insulinoma antigen 2


Management
Controlling glucose levels
Diabetic diet
G.I diet
Oral medications
But if the above do not work then Insulin therapy may become
necessary
Unfortunately treatment of GDM is also accompanied by more
infants admitted to the neonatal wards and more inductions of
labor
Oral Medications like:
Glyburide (second generation sulfonylurea) has been shown as an
effective alternative to insulin therapy
Metformin
Prognosis
GDM generally resolves once the baby is born
Chances of developing GDM in your second pregnancy after having
it in your first are between 30-84% (depending on ethnic
background)

In the words of Beyonce Knowles Strong enough to bare the
children, then get back to business