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Gestational Diabetes


OVERVIEW OF Gestational Diabetes :

During pregnancy, some women develop high blood sugar levels. This condition is known as gestational diabetes mellitus (GDM) or gestational diabetes. Gestational diabetes typically develops between the 24th and 28th weeks of pregnancy.


CAUSES :

The hormonal changes can leads to gestational diabetes and the way our body convert those food into energy.

A hormone called insulin breaks down the glucose (sugar) from food and delivers it to our cells. Insulin keeps the level of glucose in our blood at healthy level. But if insulin doesn’t work right or we don’t have enough of it, sugar build up in the blood and leads to diabetes.

The following factors increases the chances of GD include:

Heart disease

High blood pressure

Inactivity

Obesity

Personal or family history of gestational diabetes

Poly cystic ovarian syndrome

Previous birth of a baby weighing nine pounds or more.

Frequent urination.


PATHOPHYSIOLOGY :

Advanced maternal age , overweight / obesity and ethnicity ,hypertension, type 2 diabetes mellitus, polycystic ovarian syndrome, polymorphisms of susceptible genes, increase low grade inflammation, increase insulin receptor phosphorylation defects, decrease adiponectin, Increase in adipocyte fatty acid binding protein results  in beta cell dysfunction   insufficient insulin production and insulin resistance. There is increase in glucose and increase free fatty acids resulting in gestational diabetes .

During pregnancy oestrogen, progesterone, cortisol and prolactin, increase in human placental lactogen

                

 Defective insulin receptor phosphorylation IRS 1 expression p58 subunit of P13K expression

 

Decrease in pancreatic beta cell and increase in insulin secreation

 

It leads to hyperinsulemia and causes INSULIN RESISTANCE

 

Increase in glucose and increase and increase free fatty acids leads to Insulin resistance


COMMON CLINICAL SIGNS AND SYMPTOMS :

Fatigue

Excessive thrist

Frequent urination

Snoring

Blurred vision

Nausea.


DIAGNOSTIC :

The American diabetes association also advises that you to be tested for type 2 diabetes if you have the risk factors forthis condition. This testing should be done at your first prenatal visit.

Screening is done by these tests:

One hour glucose tolerance test:

The person is aske to drink a special beverages which is high in sugar. One hour later the healthcare provider measures your blood sugar (glucose) levels. If the levels are hogher than a certain level, this is considered an abnormal result.

 

Three-hour glucose tolerance test:

If the 1-hour test is abnormal, you will have a second glucose tolerance test done to confirm the diagnosis. You will drink another special beverage, but with more sugar. Your healthcare provider will measure your blood sugar levels 1 hour, 2 hours, and 3 hours later. You have gestational diabetes if at least two of the glucose measurements are higher than normal.

If you are diagnosed with gestational diabetes, you should get tested for diabetes 4 to 12 weeks after your baby is born. You should also get this screening at least every 3 years for the rest of your life.

First-trimester laboratory studies

  • HbA1C :  4-5.6 % is the normal range of HbA1C
  • Blood urea nitrogen (BUN): 5-20mg/dl is the normal range.
  • Serum creatinine: Adult men, 0.74 to 1.35 mg/dL (65.4 to 119.3 micromoles/L) For Adult women, 0.59 to 1.04 mg/dL (52.2 to 91.9 micromoles/L)
  • Thyroid-stimulating hormone: 0.9 – 2.3 nanograms per deciliter
  • Free thyroxine levels
  • Spot urine protein-to-creatinine ratio: less than 3.5(mg/mg)
  • Capillary blood sugar levels

Second-trimester laboratory studies

  • Spot urine protein-to-creatinine study in women with elevated value in first trimester
  • Repeat HbA1C
  • Capillary blood sugar levels

Ultrasonography

  • First trimester - Ultrasonographic assessment for pregnancy dating and viability
  • Second trimester - Detailed anatomic ultrasonogram at 18-20 weeks and a faetal echocardiogram if the maternal glycohemoglobin value was elevated in the first trimester
  • Third trimester - Growth ultrasonogram to assess fetal size every 4-6 weeks from 26-36 weeks in women with overt preexisting diabetes; perform a growth ultrasonogram for fetal size at least once at 36-37 weeks for women with gestational diabetes mellitus

Electrocardiography

If maternal diabetes is longstanding or associated with known microvascular disease, obtain a baseline maternal electrocardiogram (ECG) and echocardiogram.

 

Normal range:

  • Before a meal (preprandial): 95 mg/dl or less
  • One hour after a meal (postprandial): 140 mg/dl or less
  • Two hours after a meal (postprandial): 120 mg/dl or less

 


TREATMENT AND PROGNOSIS :

Diet therapy:

The main aim of the dietary therapy is to avoid single large meals and foods with  a large percentage of simple carbohydrates.  The diet should include food with complex carbohydrate and cellulose such as whole grain breads and legumes. The diet plays a important role in controlling the diabetes.

Insulin:

The main aim of insulin therapy in preganant women is to achieve glucose profiles similar to those of nondiabetic pregnant women. In gestational diabetes early intervention of insulin or an oral agent is key to achieving a good outcome when diet thrapy fails to provide adequate glycemic control.

Glyburide and metformin

The efficacy and safety of insulin have made it the standard for treatment of diabetes during pregnancy. Diabetic therapy with the oral agents glyburide and metformin, however, has been gaining in popularity. Trials have shown these 2 drugs to be effective, and no evidence of harm to the fetus has been found, although the potential for long-term adverse effects remains a concern. 

 

Prenatal Obstetric Management:

This include biophysical tets can ensure that the fetus is well oxygenated, including fetal heart rate testing, fetal movement assessment, ultrasonographic biophysical scoring and fetal umbilical doppler ultrasonographic studies.

Management of the neonate

Current recommendations for infants of diabetic mothers—the most critical metabolic problem for whom is hypoglycemia—include the employment of frequent blood glucose checks and early oral feeding (ideally from the breast) when possible, with infusion of intravenous glucose if oral measures prove insufficient.


PROGNOSIS :

The gestational diabetes can lead to diabetes in later stages of life and and also it predicts whether the diabetes is present before the pregnancy. The appropriate treatment at the time might leads to the deterioration in the diabetes of the pregnant women.


PREVENTION :

Spend atleast 150 minutes per week of anaerobic exercises such as walking or cycling .

Avoid saturated and trans fats along with refined carbohydrates out of your diet.

Take large amounts of fruits, vegetables and grains.

Eat smaller portions and don’t take large amount of food at a time.

 

 


Medicines used in the Treatment :

Glyburide and metformin

The efficacy and safety of insulin have made it the standard for treatment of diabetes during pregnancy. Diabetic therapy with the oral agents glyburide and metformin, however, has been gaining in popularity. Trials have shown these 2 drugs to be effective, and no evidence of harm to the fetus has been found, although the potential for long-term adverse effects remains a concern. 

Insulin