Gestational Diabetes: Watching Your Baby

Close observation of your baby is very important when you have gestational diabetes. Working closely with your health care team will help you give birth to a healthy baby. Your health care provider should closely check both you and your baby throughout the pregnancy.

Fetal monitoring to check the size and health of the fetus often includes ultrasound and non stress tests.When you have gestational diabetes, your health care team may recommend some extra tests to check on your baby, extra ultrasound scans to check how your baby is growing and how much amniotic fluid you have. You’ll probably be advised extra ultrasound scans every four weeks from week 28 to week 36 week of your pregnancy.

Tests that will be conducted to monitor your baby’s well being:

Non  stress test:

A non stress test is a very simple, painless test for you and your baby. A machine called electronic fetal monitor that hears and displays your baby’s heartbeat is used to perform this test. Sensors are placed on your stomach and connected to a monitor to measure your baby’s heart rate. Your baby’s heart beat should increase when the baby moves. If your baby’s heart doesn’t beat faster during movement, the baby may not be getting enough oxygen. When the baby moves, the baby’s heart rate normally increases 15 – 20 beats above its regular rate. Your health care provider can compare the pattern of your baby’s heartbeat to movements and find out whether the baby is doing well. Your health care provider will look for increases in the baby’s normal heart rate occurring within a certain period of time.

Biophysical profile (BPP):

To see how your baby is growing your doctor will perform repeated ultrasound exams. This test combines a non stress test with an ultrasound study of your baby. There’s a scoring system that enables your doctor to evaluate your baby’s heartbeat, movements, breathing and overall muscle tone, and determine whether your baby is surrounded by a normal amount of amniotic fluid. Your baby’s scores on heartbeat, breathing and movement help your doctor tell if the baby’s getting enough oxygen. When the amniotic fluid is low, it may mean that your baby hasn’t been urinating enough. This could indicate that over time the placenta has not been working as well as it should.

Fetal movement counting:

Your doctor may perform this simple test at the same time as the non stress test or the biophysical profile. You simply count how often your baby kicks over a set time. Kick counts is done to check your baby’s activity. The time between the baby’s movements is checked. Infrequent movement may mean your baby isn’t getting enough oxygen.

If you don’t go into labor by your due date or sometimes your doctor may induce labor earlier .

Delivering after your due date may increase the risk of complications for you and your baby.

Who is at high risk for gestational diabetes?

The following factors increase your risk of developing gestational diabetes during pregnancy:

• Being overweight prior to becoming pregnant. Even if you are 20% or more over your ideal body weight you are at risk for gestational diabetes.
• Family history of diabetes. If your parents or siblings have diabetes.
• Your risk of developing gestational diabetes increases if you have prediabetes. It is a condition were you have slightly elevated blood sugar levels, higher than normal but not high enough to make you diabetic. Other names for it are “impaired glucose tolerance” and “impaired fasting glucose.”
• Excessive weight gain during pregnancy, particularly in the first trimester increase the risk of gestational diabetes.
• If you have had gestational diabetes during a previous pregnancy.
• Having glucose in your urine.
• If you have given birth to a baby over 9 pounds.
• If you have given birth to a stillborn baby.
• You’ve had a baby with a birth defect.
• Having too much amniotic fluid, a condition called polyhydramnios.
• You have high blood pressure.
• You’re over 35.
• Being a member of nonwhite race. Reason for this is still not clear, women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.

Who is at low risk for Gestational Diabetes?

Your at low risk if you meet all of the following criteria:

• Your younger than 25.
• Your weight is in a healthy range.
• Your not a member of any racial or ethnic group with a high prevalence of diabetes, including people of Hispanic, African, Native American, South or East Asian and indigenous Australian ancestry.
• None of your close relatives have diabetes.
• You’ve never had a high result on a blood sugar test.
• You’ve never had an overly large baby or any other pregnancy complication usually associated
with gestational diabetes.

Many women who develop gestational diabetes have no known risk factors.

If you are having gestational diabetes and are able to control your blood sugar levels within the normal range then you are avoiding harm to yourself and your baby and can deliver a healthy baby. It’s important to keep your blood sugar levels in check because poorly controlled GDM can cause serious short-term and long-term complications for you and your baby. Complications are particularly more in those whose blood sugar levels are not well controlled and who are obese before pregnancy.

The main problem with having too much sugar in your blood is that it crosses the placenta to your baby.

How gestational diabetes affects your baby

Untreated or uncontrolled high blood sugar levels means problems for your baby, your baby may be at increased risk of:

• Excessive birth weight, Macrosomia:

Infants born to mothers with GDM are at risk of being large for gestational age. This condition is called as macrosomia.

When you have gestational diabetes, your pancreas works overtime to produce insulin, but the insulin does not lower your blood glucose levels. Insulin does not cross placenta although glucose and other nutrients do. So extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby’s pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat, causing your baby to put on extra weight, particularly in the upper body. This can lead to macrosomia, or a “fat baby”.

A macrosomic baby may be too large to enter the birth canal. This in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section). Or the baby’s head may enter the canal but then his shoulders may get stuck. This situation is called shoulder dystocia, and your practitioner will have to use special maneuvers to deliver your baby.

The development of macrosomia can be evaluated during pregnancy by using sonography. When you are having gestational diabetes your doctor will advice more frequent visits to the hospital to monitor you and your baby.

• Delivery-related complications due to the infant’s large size include:

Birth injury (trauma) because of the baby’s large size : It leads to an increased risk of shoulder dystocia. This is when your baby’s head has been born but one of his or her shoulders is stuck behind your pelvic bone, preventing his or her body being delivered. This in turn can damage nerves in your baby’s neck or result in a fracture of one of his or her arms or shoulders. Very rarely, it can cause brain damage if the blood supply to your baby’s brain is blocked off for too long.
Delivery by c-section: To prevent the risks involved in delivery through vagina delivery by cesarean section is recommended for women with gestational diabetes.

• Early (preterm) birth and respiratory distress syndrome:

A mother’s high blood sugar may increase her risk of going into labor early and delivering her baby before its due date. Or her doctor may recommend early delivery because the baby is growing large. Babies born early may experience respiratory distress syndrome; a condition that makes breathing difficult. The baby’s lungs haven’t developed as they should hence the baby has problem in breathing. Babies with this syndrome may need help breathing until their lungs mature and become stronger. Babies of mothers with gestational diabetes may experience respiratory distress syndrome even if they’re not born early. As GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis.

• Your baby is more likely to have periods of low blood sugar (hypoglycemia):

After birth during the first few days of life your baby may have low blood sugar. As the high glucose environment disappears, your baby may continue to make extra insulin causing his or her blood glucose levels to drop, condition called as hypoglycemia.

Severe episodes of hypoglycemia may provoke seizures in the baby. Hence, it’s recommended that you breastfeed your baby within 30 minutes of delivery to return the baby’s blood sugar level to normal. Otherwise, your baby may be given a sugar solution orally or through a drip directly into a vein. Midwives will check your baby’s blood sugar level regularly.

• Jaundice

If you have gestational diabetes there is an increased risk of your new born developing jaundice. Jaundice is yellowish discoloration of the skin and the whites of the eyes. Jaundice occurs when bilirubin is present in your baby’s blood. Bilirubin normally forms when the body recycles old or damaged red blood cells. If a baby’s liver isn’t mature enough to break down bilirubin then it stays in blood. Although jaundice usually isn’t a cause for concern, however careful monitoring is important. This usually fades without the need for medical treatment. depending on the severity your baby may need
treatment with a special ultraviolet light after being born.

• Development of diabetes later in life :

Babies have excessive fat stores as a result of high maternal sugar levels during pregnancy. They often continue to be overweight in childhood and adulthood. Babies are at a higher risk of developing obesity and type 2 diabetes later in life.

• Gestational diabetes and birth defects:

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. Gestational diabetes affects the mother in late pregnancy, after the baby’s body has been formed. Because of this, gestational diabetes does not cause the kinds of birth defects sometimes seen in babies whose mothers had diabetes before pregnancy. Gestational diabetes has not clearly shown to be an independent risk factor for birth defects. But studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations.

• Chemical imbalances after birth:

Chemical imbalances which may require admission to a neonatal intensive care unit. If your blood sugar control is especially poor, your baby is at risk for polycythemia (an increase in the number of red cells in the blood) and hypocalcemia (low calcium in the blood), and your baby’s heart function could be affected as well. Neonates are also at an increased risk of low
magnesium (hypomagnesemia).

• Still birth

Untreated gestational diabetes can result in a baby’s death either before (still birth) or shortly after birth. Controlling blood sugar levels reduces this risk.

Complications that may effect you

Gestational diabetes isn’t an immediate threat to your health. However, poorly controlled diabetes in pregnancy puts you at a higher risk of various problems.

• High blood pressure, preeclampsia and eclampsia.

Gestational diabetes increases your risk of developing two serious complications of pregnancy: preeclampsia and eclampsia.

Preeclampsia is a toxic condition that develops in late pregnancy and causes a sudden rise in blood pressure, excessive weight gain, fluid build-up, albumin in your urine, severe headache, and visual disturbances. Mothers with gestational diabetes have an increased risk for high blood pressure during pregnancy.

Eclampsia is a toxic condition characterized by convulsions and possibly coma during or immediately after pregnancy.

• Future diabetes, diabetes during subsequent pregnancy and later in life.

If you have gestational diabetes, it’s more likely that you will have gestational diabetes during a future pregnancy too. You’re also more likely to develop type 2 diabetes as you get older. However, making healthy lifestyle choices such as eating healthy foods and exercising can help reduce the risk of future type 2 diabetes. If women with a history of gestational diabetes reach their ideal body weight after delivery, then their chances of developing type 2 diabetes is less.

The punch line is if your diagnosed with gestational diabetes take care that your blood glucose levels are maintained within the normal range through out your pregnancy for your baby’s and your good health.

When using insulin, a low blood sugar level condition can occur which is called as hypoglycemia. Hypoglycemia occurs if you do not eat enough food, skip a meal, do not eat at the right time of day or if you exercise more than usual or if the dosage of insulin taken was more.

Symptoms of hypoglycemia include: Feeling weak, shaky, you might also feel dizzy and sudden hunger. There may be sweating and confusion and you might as well have headaches.

If you think you are having a low blood sugar reaction, check your blood sugar. Hypoglycemia is a serious problem that needs to be treated right away. If your blood sugar is less than 60 mg/dL, eat a sugar-containing food, such as 1/2 cup of orange or apple juice; 1 cup of skim milk; 4-6 pieces of hard candy (not sugar-free); 1/2 cup regular soft drink; or 1 tablespoon of honey, brown sugar, or corn syrup. Fifteen minutes after eating one of the foods listed above, check your blood sugar. If it is still less than 60 mg/dL, eat another one of the food choices above. If it is more than 45 minutes until your next meal, eat a bread and protein source to
prevent another reaction.

Record all low blood sugar reactions in your log book, including the date, time of day the reaction occurred and how you treated it.

The aim of treatment for gestational diabetes is to keep blood sugar (glucose) levels within normal limits during the pregnancy so as to make sure that the growing baby is healthy.

Most women can manage their gestational diabetes mellitus with dietary changes and exercise. If managing your diet and exercising cannot control glucose levels then you may be prescribed antidiabetic drugs or insulin therapy, most commonly insulin therapy will be given.

Insulin therapy:

Insulin is a hormone that controls blood sugar by helping move sugar from the blood into other body tissues where it is used for energy. It also stops the liver from producing more sugar. Insulin is not harmful to your baby. It cannot move from your bloodstream to the baby’s.

Insulin therapy is necessary and recommended when blood glucose levels cannot be controlled by diet and exercise and if complications like excessive fetal growth are observed.

Do I Need to Take Insulin for Gestational Diabetes?

Based on your blood sugar monitoring results, your health care provider will tell you if you need to take insulin in the form of injections during pregnancy. If insulin is prescribed for you, you will be taught to give yourself insulin.

Doctor will prescribe fast-acting insulin before meals to control the sharp rise in glucose soon after meals. All types of insulin that are available in market work in this way. The types of insulin differ only in how quickly they begin to work and how long they continue to control blood sugar.

Care needs to be taken to avoid low blood sugar level condition called as hypoglycemia due to excessive insulin injection.

Studies have shown that in insulin-treated women preterm delivery was more common.

As pregnancy progresses, the placenta will make more pregnancy hormones that block action of insulin and larger doses of insulin may be needed to control your blood sugar. Your health care provider will adjust insulin dosage based on your blood sugar log.

Antidiabetic Drugs

There is evidence that certain oral glycemic agents are safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes.

• Metformin

Metformin is safe and equally effective as insulin. Women prefer metformin tablets to insulin injections. Metformin in its oral format is used alone or with other medications, including insulin if patients do not reach sufficient control with metformin alone. But compared to those treated with insulin alone, they gained less weight and patients required less insulin dosage.

Metformin helps to control the amount of glucose (sugar) in your blood by decreasing the amount of glucose you absorb from your food and the amount of glucose made by your liver. Metformin also increases your body’s response to insulin.

• Glyburide

Glyburide, a second generation sulfonylurea, has been shown to be an effective alternative to insulin therapy. Glyburide lowers blood sugar by stimulating the pancreas to secrete insulin and helping the body use insulin efficiently.

Some doctors feel more research is needed to confirm that oral drugs are as safe and as effective as injectable insulin to control gestational diabetes.

How will I know whether my blood glucose levels are on target?

Once diagnosed with gestational diabetes melitus during pregnancy, testing your blood sugar at certain times of the day will help determine if your eating patterns and exercise during pregnancy are keeping your blood sugar levels in control, or if you need extra insulin to protect your developing baby.

How Do I Monitor My Blood Sugar Levels?

You can use a small device called a blood glucose meter to check your blood glucose levels on your own. Your health care provider will demonstrate how to use a glucometer. You can prick your finger with a lancet; a small, sharp needle. Put a drop of blood on a test strip and insert it into the slot in the glucometer to display your results. Record the results in a log book and then dispose the lancet and strips properly.

Your health care provider will ask you to maintain a daily food record and your home sugar levels. You have to take your blood sugar readings with you to your doctor during your appointments so that your doctor can evaluate how well your blood sugar levels are controlled and determine if changes need to be made to your treatment plan. If your results are often out of range, your health care provider will suggest ways you can reach your targets.

The goal of monitoring is to keep your blood sugar as close to normal as possible. The blood glucose ranges for women with gestational diabetes include:

Time of Test                          Target Blood Sugar Reading

Before breakfast                      below 95

1 Hour after a meal                 not above 140

2 Hours after meals                whole blood below 120

Insulin treatment is started if above levels are not maintained.

Gestational diabetes is better understood by first understanding the body’s glucose metabolism.

Glucose Metabolism:

Glucose is the body’s fuel. Without glucose, or without being able to convert it into energy rapidly and efficiently, we cannot survive in good health. So it’s very important that our energy-metabolism system works efficiently. Here is a very simple explanation of how our body converts glucose into energy.

When you eat food, Your digestive system breaks down most of the food into glucose. This glucose is absorbed into the bloodstream through the small intestine. In response to the rise in blood-glucose levels after a meal, β-cells in the pancreas releases insulin. Insulin is a hormone that helps glucose move from your bloodstream into your body’s cells, where it’s used as energy. This is how the food you eat gets converted into energy which lets you go by your daily activity.

What happens during pregnancy:

The placenta is an organ that connects the baby by the umbilical cord to the uterus. The placenta helps shift nutrients from the mother to the developing fetus. The placenta also produces several hormones which block the usual action of insulin to make sure your growing baby gets enough sugar. They work by stopping the action of insulin. This condition is called Insulin resistance. Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy to ensure glucose supply to the growing fetus. This means that too much glucose remains in your blood instead of moving into the cells and getting converted to energy, raising your blood sugar. Modest elevation of blood sugar after meals is normal during pregnancy, but it should not be too high enough to cause diabetes.

Due to this almost all women have some degree of impaired glucose intolerance. Due to Insulin resistance your body has to produce more insulin, upto three times the normal amount in order to keep the blood sugar levels normal. If your body is not able to produce the required amount of insulin. The blood sugar levels rise and this condition is called Gestational Diabetes Mellitus (GDM). It is still unclear why some women are not able to produce enough insulin needed to keep the blood-glucose levels in check.

Gestational Diabetes usually sets in during the third trimester of pregnancy. Hence all women are usually screened for GDM during the 24th and 28th week. For some women GDM sets in as early as 20th week, But not always. For most women with gestational diabetes, the blood sugar returns to normal levels after the baby is born.