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Gestational diabetes
Classification and external resources
ICD-10 O24.
ICD-9 648.8
MedlinePlus 000896

Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings O00-O99 - Pregnancy, Childbirth and the Puerperium (O00-O08 Pregnancy with Abortive outcome ( Ectopic The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Hyperglycemia, hyperglycaemia, or high blood sugar is a condition in which an excessive amount of Glucose circulates in the Blood plasma Gestational diabetes affects 3-10% of pregnancies, depending on the population studied. [1] No specific cause has been identified, but it is believed that the hormones produced during pregnancy reduce a woman's sensitivity to insulin, resulting in high blood sugar levels. Insulin is a Hormone with intensive effects on both metabolism and several other body systems (eg vascular compliance

Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. A symptom' (from Greek σύμπτωμα, "accident misfortune that which befalls" from συμπίπτω, "I befall" from Diagnostic tests detect high levels of glucose in blood samples. Glucose (Glc a Monosaccharide (or simple Sugar) also known as grape sugar, is an important Carbohydrate in Biology.

Babies born to mothers with gestational diabetes are at increased risk of complications, primarily growth abnormalities and chemical imbalances such as low blood sugar. Hypoglycemia or hypoglycaemia is the medical term for a pathologic state produced by a lower than normal level of Glucose ( sugar) in the blood Gestational diabetes is a reversible condition and women who have adequate control of glucose levels can effectively decrease the associated risks and give birth to healthy babies. Diabetes is a Chronic disease with no cure As of 2008. It is associated with an impaired Glucose cycle, altering Metabolism.

Women with gestational diabetes are at increased risk of developing type 2 diabetes mellitus after pregnancy, while their offspring are prone to developing childhood obesity, with type 2 diabetes later in life. Diabetes mellitus type 2 or Type 2 Diabetes (formerly called non - Insulin -dependent Diabetes mellitus (NIDDM or adult-onset diabetes is a metabolic Childhood Obesity is a condition where excess body fat negatively affects a child's health or wellbeing Diabetes mellitus type 2 or Type 2 Diabetes (formerly called non - Insulin -dependent Diabetes mellitus (NIDDM or adult-onset diabetes is a metabolic Most patients are treated only with diet modification and moderate exercise but some take anti-diabetic drugs, including insulin. Anti-diabetic drugs treat Diabetes mellitus by lowering Glucose levels in the blood Insulin is a Hormone with intensive effects on both metabolism and several other body systems (eg vascular compliance

Diabetes mellitus
Types of Diabetes
Diabetes mellitus type 1
Diabetes mellitus type 2
Gestational diabetes

Pre-diabetes:
Impaired fasting glycaemia
Impaired glucose tolerance
Disease Management
Diabetes management:
•Diabetic diet
•Anti-diabetic drugs
•Conventional insulinotherapy
•Intensive insulinotherapy
Other Concerns
Cardiovascular disease

Diabetic comas:
•Diabetic hypoglycemia
•Diabetic ketoacidosis
•Nonketotic hyperosmolar

Diabetic myonecrosis
Diabetic nephropathy
Diabetic neuropathy
Diabetic retinopathy

Diabetes and pregnancy
Blood tests
Blood sugar
Fructosamine
Glucose tolerance test
Glycosylated hemoglobin

Contents

Definition

Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy". Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Diabetes mellitus type 1 (Type 1 diabetes Type I diabetes T1D T1DM IDDM juvenile diabetes is a form of Diabetes mellitus. Diabetes mellitus type 2 or Type 2 Diabetes (formerly called non - Insulin -dependent Diabetes mellitus (NIDDM or adult-onset diabetes is a metabolic Impaired fasting glycaemia (IFG is a pre-diabetic state of dysglycemia associated with insulin resistance and increased risk of cardiovascular pathology although of lesser risk than Impaired Glucose Tolerance (IGT is a pre- Diabetic state of dysglycemia that is associated with Insulin resistance and increased risk of cardiovascular pathology Diabetes is a Chronic disease with no cure As of 2008. It is associated with an impaired Glucose cycle, altering Metabolism. The diet most often recommended for people who suffer from Diabetes mellitus is high in Dietary fiber, especially soluble fiber but low in fat (especially Saturated fat Anti-diabetic drugs treat Diabetes mellitus by lowering Glucose levels in the blood Conventional insulinotherapy is a therapeutic regimen for treatment of Diabetes mellitus which contrasts with the newer Intensive insulinotherapy. Intensive insulinotherapy is a therapeutic regimen for Diabetes mellitus treatment Cardiovascular disease or cardiovascular diseases refers to the class of diseases that involve the Heart or Blood vessels ( arteries and Diabetic coma is a Medical emergency in which a person with Diabetes mellitus is Comatose (unconscious because of one of the acute complications Diabetic hypoglycemia describes a low blood glucose level occurring in a person with Diabetes mellitus. Diabetic ketoacidosis (DKA is a life-threatening complication in patients with diabetes mellitus Nonketotic hyperosmolar coma (nonketotic Hyperglycaemia) is a type of Diabetic coma associated with a high mortality seen in Diabetes mellitus type 2. Diabetic myonecrosis is a rare complication of Diabetes. It is caused by Infarcted Muscle tissue usually in the thigh Diabetic nephropathy ( nephropatia diabetica) also known as Kimmelstiel-Wilson syndrome and intercapillary glomerulonephritis, is a progressive Kidney Diabetic neuropathies are neuropathic disorders that are associated with Diabetes mellitus. Diabetic retinopathy is Retinopathy (damage to the Retina) caused by complications of Diabetes mellitus, which can eventually lead to Blindness For women with Diabetes mellitus, Pregnancy can present some particular challenges for both mother and child Blood sugar, used in a physiological context is a misnomer and misleading Fructosamine is a compound that can be considered the result of a reaction between Fructose and Ammonia or an Amine (with a molecule of water being released A glucose tolerance test in medical practice is the administration of Glucose to determine how quickly it is cleared from the blood Glycosylated (or glycated hemoglobin ( hemoglobin A1c Hb1c, or HbA1c) is a form of Hemoglobin used primarily to identify the average Impaired Glucose Tolerance (IGT is a pre- Diabetic state of dysglycemia that is associated with Insulin resistance and increased risk of cardiovascular pathology [2] This definition acknowledges the possibility that patients may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether symptoms subside after pregnancy is also irrelevant to the diagnosis . [3]

Epidemiology

The frequency of gestational diabetes varies widely by study depending on the population studied and the study design. A study design is an analytic approach to conduct an Epidemiological investigation such as a Clinical trial. It occurs in between 5 and 10% of all pregnancies (between 1-14% in various studies). [3]

Pathophysiology

Effect of insulin on glucose uptake and metabolism. Insulin binds to its receptor (1) on the cell membrane which in turn starts many protein activation cascades (2). These include: translocation of Glut-4 transporter to the plasma membrane and influx of glucose (3), glycogen synthesis (4), glycolysis (5) and fatty acid synthesis (6).
Effect of insulin on glucose uptake and metabolism. Insulin binds to its receptor (1) on the cell membrane which in turn starts many protein activation cascades (2). These include: translocation of Glut-4 transporter to the plasma membrane and influx of glucose (3), glycogen synthesis (4), glycolysis (5) and fatty acid synthesis (6). The cell membrane (also called the plasma membrane, plasmalemma, or "phospholipid bilayer" is a Selectively permeable Lipid bilayer Glycogen is a Polysaccharide of Glucose (Glc which functions as the secondary short term energy storage in Animal cells See also Gluconeogenesis, which carries out a process wherein glucose is synthesized rather than catabolized In Chemistry, especially Biochemistry, a fatty acid is a Carboxylic acid often with a long unbranched Aliphatic tail ( chain) which

The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is increased insulin resistance. Insulin resistance is the condition in which normal amounts of Insulin are inadequate to produce a normal Insulin response from Fat, Muscle Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to the insulin receptor. In Molecular biology, the insulin receptor is a transmembrane receptor that is activated by Insulin. The interference probably occurs at the level of the cell signaling pathway behind the insulin receptor. Cell signaling is part of a Complex system of Communication that governs basic cellular activities and coordinates cell actions [4]. Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin is needed to overcome this resistance; about 1. 5-2. 5 times more insulin is produced in a normal pregnancy. [4]

Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which progresses thereafter to levels seen in non-pregnant patients with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance they cannot compensate with increased production in the β-cells of the pancreas. Placental hormones, and to a lesser extent increased fat deposits during pregnancy, seem to mediate insulin resistance during pregnancy. The placenta is an Ephemeral organ present in placental Vertebrates, such as Eutherial Mammals and Sharks during Gestation Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body Fats consist of a wide group of compounds that are generally soluble in organic solvents and largely insoluble in water Cortisol and progesterone are the main culprits, but human chorionic somatomammotropin, prolactin and estradiol contribute too. Cortisol is a Corticosteroid Hormone produced by the Adrenal gland (in the Zona fasciculata of the Adrenal cortex) Progesterone is a C-21 Steroid Hormone involved in the Female Menstrual cycle, Pregnancy (supports Gestation Prolactin ( PRL) or Luteotropic hormone ( LTH) is a Peptide hormone primarily associated with Lactation. Estradiol (17β-estradiol (also oestradiol) is a Sex hormone. [4]

How this imbalance between insulin needs and production develops in GDM, remains unclear. Suggested mechanisms are similar to those in type 2 diabetes: autoimmunity, single gene mutations, and other mechanisms. Autoimmunity is the failure of an organism to recognize its own constituent parts as self, which results in an immune response against its own cells and tissues In biology mutations are changes to the Nucleotide sequence of the Genetic material of an organism [5]

Because glucose travels across the placenta (through diffusion facilitated by GLUT3 carriers), the fetus is exposed to higher glucose levels. Facilitated diffusion (or facilitated transport) is a process of Diffusion, a form of Passive transport facilitated by Transport proteins The GLUT3 is a high-affinity isoform of Type I Glucose transporter expressed mostly in Neurons where it is believed to be the main glucose transporter isoform and in This leads to increased fetal levels of insulin (insulin itself cannot cross the placenta). Insulin is a Hormone with intensive effects on both metabolism and several other body systems (eg vascular compliance The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia). Large for gestational age (LGA babies are those whose Birth weight lies above the 90th percentile for that Gestational age. After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia). Hypoglycemia or hypoglycaemia is the medical term for a pathologic state produced by a lower than normal level of Glucose ( sugar) in the blood [6]

Risk factors and symptoms

Classical risk factors for developing gestational diabetes are the following:[7]

In addition to this, statistics show a double risk of GDM in smokers. Smoking is a practice where a substance most commonly Tobacco, is burned and the Smoke tasted or inhaled [9] Polycystic ovarian syndrome is also a risk factor. Polycystic ovary syndrome abbreviated PCOS or PCO (also known clinically as Stein-Leventhal syndrome, Sclerocystic ovary syndrome, Hyperthecosis [7] Some studies have looked at more controversial potential risk factors, such as short stature. Short stature refers to a height of a human being which is below expected [10]

Frequently women with gestational diabetes exhibit no symptoms (which is an argument in favour of screening during pregnancy). However, possible symptoms include increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision. Thirst is the craving for liquids resulting in the basic Instinct of humans or animals to Drink. Urination, also known as micturition, voiding, and more rarely emiction, is the process of disposing Urine from the Urinary bladder Nausea ( Latin: Nausea, Greek:, " Sea-sickness " also called wamble) is the sensation of unease and discomfort Vomiting (also called throwing up, emesis) is the forceful expulsion of the contents of one's Stomach through the Mouth and sometimes the Cystitis is Inflammation of the Urinary bladder. The condition more often affects women but can affect either sex and all age groups Candidiasis, commonly called yeast infection or thrush, is a Fungal infection (mycosis of any of the Candida species of which Blurred vision is an Ocular Symptom. Causes There are many causes of blurred vision including use of Atropine.

Diagnosis and screening

Because GDM is asymptomatic in most cases, the diagnosis of gestational diabetes is a process that takes into account a clinical assessment of risk factors, screening tests and diagnostic tests. Screening, in medicine is a strategy used in a Population to detect a Disease in individuals without signs or Symptoms of that disease These tests look for high levels of glucose in plasma or serum. Glucose (Glc a Monosaccharide (or simple Sugar) also known as grape sugar, is an important Carbohydrate in Biology. This can be done in a stepwise approach where a suspicious result on a screening test is followed by diagnosic test. Alternatively, a more complicated diagnostic test can be used directly at the first antenatal visit in high-risk patients (for example in those with polycystic ovarian syndrome or acanthosis nigricans). Polycystic ovary syndrome abbreviated PCOS or PCO (also known clinically as Stein-Leventhal syndrome, Sclerocystic ovary syndrome, Hyperthecosis Acanthosis nigricans is a brown to black poorly defined velvety Hyperpigmentation of the Skin, usually present in the posterior and lateral folds of the Neck [6]

Tests for gestational diabetes
Non-challenge blood glucose tests
  • Fasting glucose test
  • 2-hour postprandial (after a meal) glucose test
  • Random glucose test
Screening glucose challenge test
Oral glucose tolerance test (OGTT)

Non-challenge blood glucose tests involve measuring glucose levels in blood samples without challenging the subject with glucose solutions. Postprandial means after eating a meal This term is often used in the context of blood sugar (or blood Glucose) levels which are normally measured 2 hours after eating A glucose tolerance test in medical practice is the administration of Glucose to determine how quickly it is cleared from the blood A blood glucose levels can be determined when fasting, 2 hours after a meal, or simply at any random time. Both screening glucose challenge tests and oral glucose tolerance tests involve drinking a glucose solution, to check how the body handles this glucose challenge.

The screening glucose challenge test and oral glucose tolerance test involve drinking a standard solution with a high concentration of glucose, which has a very sweet taste some women find unpleasant. Sometimes, artificial flavours are added for this reason. Some women may experience nausea during the test, and more so with higher glucose levels. [11][12]

Screening pathways

Screening and diagnostic measures are controversial and differ between countries, in part due to differences in population risks, cost-effectiveness considerations, and lack of an evidence base to support large national screening programs. Evidence-based medicine (EBM aims to apply Evidence gained from the Scientific method to certain parts of medical practice [13] The most elaborate regime entails a random blood glucose test during a booking visit, a screening glucose challenge test around 24-28 weeks' gestation, followed by an OGTT if the tests are outside normal limits. If there is a high suspicion, women may be tested earlier. [3]

In the United States, most obstetricians prefer universal screening of all women with a screening glucose tolerance test. The United States of America —commonly referred to as the [14] In the United Kingdom, obstetric units often rely on risk factors and a random blood glucose test. The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom, the UK or Britain,is a Sovereign state located [15][6] The American Diabetes Association and the Society of Obstetricians and Gynecologists of Canada recommend routine screening unless the patient is low risk (this means the woman must be younger than 25 years and have a body mass index less than 27, with no personal, ethnic or family risk factors)[3][13] The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening. The American Diabetes Association, or the ADA is an American health organization providing Diabetes research information and advocacy The body mass index ( BMI) or Quetelet index, is a statistical measurement which compares a person's weight and height The Canadian Diabetes Association is an organization whose mission is to promote the health of Canadians through Diabetes research education service and advocacy The American College of Obstetricians and Gynecologists ( ACOG) is a Professional association of Medical doctors specializing in Obstetrics and [16][17]

Urinary glucose testing

Women with GDM may have high glucose levels in their urine (glucosuria). Glycosuria or glucosuria is an abnormal condition of Osmotic Diuresis due to excretion of Glucose by the kidneys Although dipstick testing is widely practiced, it performs poorly, and discontinuing routine dipstick testing has not been shown to cause underdiagnosis where universal screening is performed. A dipstick is one of several devices dipped into a liquid to perform a chemical test or to provide a measure of quantity of the liquid [18] Increased glomerular filtration rates during pregnancy contribute to some 50% of women having glucose in their urine on dipstick tests at some point during their pregnancy. Renal function, in Nephrology, is an indication of the state of the Kidney and its role in Renal physiology. The sensitivity of glucosuria for GDM in the first 2 trimesters is only around 10% and the positive predictive value is around 20%. The positive predictive value, or precision rate, or post-test probability of disease, is the proportion of patients with positive test results who are correctly diagnosed [19][20]

Non-challenge blood glucose tests

When a plasma glucose level is found to be higher than 126 mg/dl (7. 0 mmol/l) after fasting, or over 200 mg/dl (11. 1 mmol/l) on any occasion, and if this is confirmed on a subsequent day, the diagnosis of GDM is made, and no further testing is required. [3] These tests are typically performed at the first antenatal visit. They are patient-friendly and inexpensive, but have a lower test performance compared to the other tests, with moderate sensitivity, low specificity and high false positive rates. In Statistics, the terms Type I error (also α error, or false positive) and type II error ( β error, or a false negative [21][22][23]

Screening glucose challenge test

The screening glucose challenge test is performed between 24-28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). It involves drinking a solution containing 50 grams of glucose, and measuring blood levels 1 hour later. [24]

If the cut-off point is set at 140 mg/dl (7. 8 mmol/l), 80% of women with GDM will be detected. [3] If this threshold for further testing is lowered to 130 mg/dl, 90% of GDM cases will be detected, but there will also be more women who will be subjected to a consequent OGTT unnecessarily.

Oral glucose tolerance test

The oral glucose tolerance test (OGTT)[25] should be done in the morning after an overnight fast of between 8 and 14 hours. A glucose tolerance test in medical practice is the administration of Glucose to determine how quickly it is cleared from the blood During the three previous days the subject must have an unrestricted diet (containing at least 150 g carbohydrate per day) and unlimited physical activity. Carbohydrates (from ' Hydrates of Carbon ' or saccharides ( Greek σάκχαρον meaning " Sugar " are the most The subject should remain seated during the test and should not smoke throughout the test.

The test involves drinking a solution containing a certain amount of glucose, and drawing blood to measure glucose levels at the start and on set time intervals thereafter.

The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes. [26]

The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:

An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify less women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test. [27]

The glucose values used to detect gestational diabetes were first determined by O'Sullivan and Mahan (1964) in a retrospective study (using a 100 grams of glucose OGTT) designed to detect risk of developing type 2 diabetes in the future. The values were set using whole blood and required two values reaching or exceeding the value to be positive. [28] Subsequent information led to alterations in O'Sullivan's criteria. When methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed.

Complications

GDM poses a risk to mother and child. This risk is largely related to high blood glucose levels and its consequences. The risk increases with higher blood glucose levels. [29] Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably. [30]

The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit. A neonatal intensive care unit, usually shortened NICU (pronounced "Nickyou" and also called a newborn intensive care unit intensive care nursery (ICN and special Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic)[29] and small for gestational age. Large for gestational age (LGA babies are those whose Birth weight lies above the 90th percentile for that Gestational age. Small for gestational age (SGA babies are those whose Birth weight lies below the 10th percentile for that gestational age Macrosomia in turn increases the risk of instrumental deliveries (e. g. forceps, ventouse and caesarean section) or problems during vaginal delivery (such as shoulder dystocia). Forceps are a handheld hinged instrument used for grasping and holding objects Ventouse is a Vacuum device used to assist the delivery of a Baby when labour has not progressed adequately A Caesarean section (or Cesarean section in American English) also known as C-section, is a form of Childbirth in which a surgical Shoulder dystocia is a specific case of Dystocia whereby after the delivery of the head the anterior Shoulder of the Infant cannot pass below the pubic Macrosomia may affect 12% of normal women compared to 20% of patients with GDM. [6] However, the evidence for each of these complications is not equally strong; in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study for example, there was an increased risk for babies to be large but not small for gestational age. [29] Research into complications for GDM is difficult because of the many confounding factors (such as obesity). Labelling a woman as having GDM may in itself increase the risk of having a caesarean section. [31][32]

Neonates are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia). Hypoglycemia or hypoglycaemia is the medical term for a pathologic state produced by a lower than normal level of Glucose ( sugar) in the blood Jaundice, also known as icterus (attributive adjective "icteric" is yellowish discoloration of the Skin, sclerae (whites of the eyes Red blood cells are the most common type of Blood cell and the Vertebrate body's principal means of delivering Oxygen to the body tissues via the Blood Polycythemia (or polycythaemia or erythrocytosis) is a condition in which there is a net increase in the total number of Blood cells, primarily Red In Medicine, hypocalcaemia is the presence of low serum Calcium levels in the Blood, usually taken as less than 2 The prefix hypo- means low (contrast with hyper- meaning high [33] GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis. Surfactants are wetting agents that lower the Surface tension of a liquid allowing easier spreading and lower the Interfacial tension between two liquids [33]

Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown to be an independent risk factor for birth defects. A congenital disorder is a disease or disorder that is present at birth Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy, whereas GDM gradually develops and is least pronounced during the first trimester. Pregnancy ( Latin graviditas) is the carrying of one or more offspring known as a Fetus or Embryo, inside the Uterus of a Female Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations; this is thought to be due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy. [34][35][36]

Because of conflicting studies, it is unclear at the moment whether women with GDM have a higher risk of preeclampsia. Pre-eclampsia (US preeclampsia) is a Medical condition where Hypertension arises in pregnancy ( Pregnancy-induced hypertension) in association [37] In the HAPO study, the risk of preeclampsia was between 13% and 37% higher, although not all possible confounding factors were corrected. [29]

Prognosis

Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence. [38]

If a woman develops gestational diabetes, it implies her body processes glucose differently. Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women who needed insulin treatment, had antibodies associated with diabetes (such as antibodies against glutamate decarboxylase, islet cell antibodies and/or insulinoma antigen-2), women with more than two previous pregnancies, and women who were obese (in order of importance). Antibodies (also known as immunoglobulins, abbreviated Ig) are Gamma globulin Proteins that are found in Blood or other Bodily Glutamate decarboxylase (GAD is an Enzyme that catalyzes the decarboxylation of Glutamate to GABA and CO2 [39][40] Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years. [28] Depending on the population studied, the diagnostic criteria and the length of follow-up, the risk can vary enormously. [41] The risk appears to be highest in the first 5 years, reaching a plateau thereafter. [41] One of the longest studies followed a group of women from Boston, Massachusetts; half of them developed diabetes after 6 years, and more than 70% had diabetes after 28 years. [41] In a retrospective study in Navajo woman, the risk of diabetes after GDM was estimated to be 50 to 70% after 11 years. The Navajo or Diné people (also spelled Navaho) of the Southwestern United States [42] Another study found a risk of diabetes after GDM of more than 25% after 15 years. [43] In populations with a low risk for type 2 diabetes, in lean subjects and in patients with auto-antibodies, there is a higher rate of women developing type 1 diabetes. Diabetes mellitus type 2 or Type 2 Diabetes (formerly called non - Insulin -dependent Diabetes mellitus (NIDDM or adult-onset diabetes is a metabolic Autoimmunity is the failure of an organism to recognize its own constituent parts as self, which results in an immune response against its own cells and tissues Diabetes mellitus type 1 (Type 1 diabetes Type I diabetes T1D T1DM IDDM juvenile diabetes is a form of Diabetes mellitus. [40]

Children of women with GDM have an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life. [44] This risk relates to increased maternal glucose values. [45] It is currently unclear how much genetic susceptibility and environmental factors each contribute to this risk, and if treatment of GDM can influence this outcome. [46]

There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37962 patients were reported to have GDM, and there was a tendency towards more breast and pancreatic cancer, but more research is needed to confirm this finding. [47][48]

Classification

The White classification, named after Priscilla White[49] who pioneered in research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. Priscilla White MD ( March 17, 1900 - December 16, 1989) was a pioneer in the treatment of diabetes during pregnancy and Type It distinguishes between gestational diabetes (type A) and diabetes that existed prior to pregnancy (pregestational diabetes). These two groups are further subdivided according to their associated risks and management. [50]

There are 2 subtypes of gestational diabetes (diabetes which began during pregnancy):

The second group of diabetes which existed prior to pregnancy is also split up into several subtypes. For women with Diabetes mellitus, Pregnancy can present some particular challenges for both mother and child

Treatment

The goal of treatment is to reduce the risks of GDM for mother and child. Scientific evidence is beginning to show that controlling glucose levels can result in less serious fetal complications (such as macrosomia) and increased maternal quality of life. Large for gestational age (LGA babies are those whose Birth weight lies above the 90th percentile for that Gestational age. Quality of life is the degree of well-being felt by an individual or group of people Unfortunately, treatment of GDM is also accompanied by more infants admitted to neonatal wards and more inductions of labour, with no proven decrease in cesarean section rates or perinatal mortality. Induction is a method of artificially or prematurely stimulating labour in a woman A Caesarean section (or Cesarean section in American English) also known as C-section, is a form of Childbirth in which a surgical Perinatal mortality (PNM also perinatal death, refers to the death of a Fetus or Neonate and is the basis to calculate the perinatal Mortality [51][52] These findings are still recent and controversial. [53]

Counselling before pregnancy (for example, about preventive folic acid supplements) and multidisciplinary management are important for good pregnancy outcomes. Folic acid (also known as Vitamin M and Folacin) and Folate (the Anionic form are forms of the water-soluble Vitamin B9 [54] Most women can be managed with dietary changes and exercise. Self monitoring of blood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy. Anti-diabetic drugs treat Diabetes mellitus by lowering Glucose levels in the blood Insulin is a Hormone with intensive effects on both metabolism and several other body systems (eg vascular compliance

Any diet needs to provide sufficient calories for pregnancy. The main goal of dietary modifications is to avoid peaks in blood sugar levels. This can be done by spreading carbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more. [7]

Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM. [7][55]

A kit with a glucose meter and diary used by a woman with gestational diabetes.
A kit with a glucose meter and diary used by a woman with gestational diabetes.

Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low. [30][56]

There is some evidence that certain oral glycemic agents might be safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes. However, few studies have been performed as of this time and this is not a generally accepted treatment. These agents may be used in research settings, or if the patient needs intervention but refuses insulin therapy, and is aware of the risks. [7] Glyburide, a second generation sulfonylurea, has been shown to be an effective alternative to insulin therapy. Glibenclamide ( INN) also known as glyburide ( USAN) is an Anti-diabetic drug in a class of medications known as Sulfonylureas used Sulfonylurea (UK Sulphonylurea derivatives are a class of Antidiabetic drugs that are used in the management of Diabetes mellitus type 2 ("adult-onset" [57][58] In one study, 4% of women needed supplemental insulin to reach blood sugar targets. [58]

Metformin has shown promising results. Metformin ( INN; trade names Glucophage, Riomet, Fortamet, Glumetza, Obimet, Dianben, Diabex, Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels. [59] A recent randomized controlled trial of metformin versus insulin showed that women preferred metformin tablets to insulin injections, and that metformin is safe and equally effective as insulin. A randomized controlled trial (RCT is a type of scientific Experiment most commonly used in testing the Efficacy or Effectiveness of Healthcare [60] Severe neonatal hypoglycemia was less common in insulin-treated women, but preterm delivery was more common. Almost half of patients did not reach sufficient control with metformin alone and needed supplemental therapy with insulin; compared to those treated with insulin alone, they required less insulin, and they gained less weight. [60] There remains a possibility of long-term complications from metformin therapy, although follow-up at the age of 18 months of children born to women with polycystic ovarian syndrome and treated with metformin revealed no developmental abnormalities. Polycystic ovary syndrome abbreviated PCOS or PCO (also known clinically as Stein-Leventhal syndrome, Sclerocystic ovary syndrome, Hyperthecosis [61]

Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child. [62]

A repeat OGTT should be carried out 2-4 months after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised. [7]

Controversy

Gestational diabetes is a controversial subject. Some critics question whether GDM is a disease in its own right. Labelling women as 'suffering from GDM' seems to predispose them to more interventions (like cesarean sections) for perceived increased risks,[31][32] while treatment of GDM has not been proven to affect perinatal mortality or caesarean section rates. [51] Lack of reproduceability of glucose tolerance testing is another problematic area. [63]

See also

Footnotes

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