Worldwide the prevalence of diabetes has increased over the years. In Jamaica, approximately 11.9 per cent of the population 15 years and older have diabetes. Women with gestational diabetes have a three-to-seven-fold increased risk for developing type 2 diabetes in the future. The good news is early diagnosis and treatment can result in a successful pregnancy, and subsequent lifestyle changes can reduce your risk of developing type 2 diabetes in the future.

What is gestational diabetes?

When blood glucose is elevated during pregnancy or recognised for the first time in pregnancy, this is termed gestational diabetes. It can develop early (likely pre-existing) but in most cases it occurs in middle of the pregnancy. When you consume a meal, it is broken down and glucose is absorbed from your stomach into the blood. Insulin is a hormone produced by the pancreas to help control the blood sugar levels. Some women are unable to produce enough insulin or utilise the insulin to meet the demands of the body during pregnancy and consequently the blood sugar level rises.

What are the risk factors for developing gestational diabetes?

It is important to note that anyone can develop gestational diabetes and you may not have any risk factor prior to developing this condition. However, if you have any of the following, you are at increased risk of developing gestational diabetes:

•African/Caribbean, Asian, Hispanic, native American and Pacific Island descent

•Gestational diabetes in a previous pregnancy

•Baby weighing more than 4.5kg in a previous pregnancy

•Obesity (BMI greater than 30 kg/m2)

•Sedentary lifestyle

•History of polycystic ovarian syndrome

•Age greater than 40 years

•History of hypertension (high blood pressure)

•Family history of diabetes – parents or siblings

How is gestational diabetes diagnosed?

In Jamaica, it is recommended that all pregnant women get screened for gestational diabetes. At your first pregnancy visit, your doctor will take a detail history to assess your risk of developing gestational diabetes. If your risk is considered high, an oral glucose tolerance test (OGTT) will be performed early in the pregnancy. If your risk is low at booking or the early OGTT was negative for gestational diabetes, a screening test is performed between 24 to 28 weeks called the O’Sullivan’s Test (OST). If the OST is positive, the diagnostic OGTT is performed. Your doctor will inform you of your results and if you meet the criteria for gestational diabetes.

How does gestational diabetes affect me and my baby?

The effects of poorly controlled diabetes on the woman and her baby are numerous and its sequel can have a lifelong impact. The baby of a woman with uncontrolled diabetes can become macrosomic (baby weighing over 4.5 kg). In this situation, a vaginal delivery may be complicated by shoulder dystocia (baby shoulder become entrapped during delivery) and may result in nerve injury to the baby. In extremely rare circumstances, stillbirth or the baby passing away close to term may occur. After delivery, the baby may be admitted to the nursery for blood glucose monitoring as they may have low blood sugars due to the presence of increased insulin at birth. Breathing problems and jaundice may also occur. The good news is, most cases, once the complications are detected early, it can be treated and reversed. Women with gestational diabetes are at increased risk for induction of labour prior to your due to date. It is important to note that most women will have a successful vaginal delivery with gestational diabetes. If your obstetrician thinks the baby is too big for a safe vaginal delivery, the risk and benefit of a caesarean delivery will be discussed with you. Women with large babies are also at risk of severe tears to the vagina and perineum, and excess bleeding after delivery. Some women with gestational diabetes may be at increased risk of developing pre-eclampsia (high blood pressure and protein in urine) during the pregnancy. Though these complications are uncommon, controlling your blood glucose during pregnancy, labour and delivery will reduce the chances of developing these risks.

How do I achieve a successful pregnancy with gestational diabetes?

1.) Experienced team of health-care providers

If you are diagnosed with gestational diabetes a special team of health care providers should be involved in your care. This team should ideally include an obstetrician and gynaecologist (ObGyn), senior midwife, dietician, and you should be delivered in a tertiary hospital with a neonatologist/paediatrician and a neonatal unit.

2.) Blood sugar monitoring and maintenance

After diagnosis your doctor will order frequent blood glucose monitoring. This is performed using a glucometer, using a small drop of blood acquired by a finger prick. You will be taught how to test your blood sugar levels and you will be required to log the glucose values for review by your doctor. You will also be advised on frequency in which you perform this simple test. There are several guidelines which exist for the target blood sugar levels, your doctor will advise you of the values suitable for you. Generally, a fasting blood glucose of 5.3 mmol/L, one hour 7.8mmol/l and two hour 6.4 mol/L post meal is acceptable.

3.) Healthy diet and exercise

A healthy lifestyle, which includes a diabetic diet and exercise is the most important step in achieving a successful pregnancy. You may be asked to see a dietician who will advise you on what foods you should eat and avoid. The aim is to have a balanced diet having three meals each day and two snacks to prevent your blood sugars from going too low or too high. Eating healthy can be hard but it is possible, and you should focus on eating what your body needs. In general, stay away from foods that are high in sugar (carbohydrates) and fat, and eat plenty of fruits, vegetable, and whole grains (eat the rainbow!). Select non-fat dairy and lean meat (chicken and fish) and steer clear of red meat. Walking for 30 minutes after a meal is considered safe for most pregnant women. An exercise plan should be made on an individual basis and with your obstetrician’s approval. Finally, discuss with your doctor how much weight gain is appropriate for you during your pregnancy as rapid weight gain can impact your glucose control.

4.) Medications

In addition to diet and exercise some women may require medications such as metformin or insulin to help maintain normal blood sugar levels. In this case, diet and exercise would have failed or the blood glucose level were too high at the time of diagnosis. In addition, if your baby is found to be too large with a confirmed diagnosis you will require insulin. Again, do not worry you will be thought how to safely administer the insulin and your required dose. This may be scary to some individuals, however, the results will be worth it for you and your baby in the long run.

5.) Monitoring the pregnancy and baby

Once you are diagnosed with gestational diabetes the frequency of your antenatal visits will increase. You will be required to do additional ultrasounds to check the baby’s growth and well-being. Your doctor may also request that you monitor your baby’s movements closely. For some women, the diagnosis can be stressful emotionally and physically, speak with your health-care provider about your feelings and ask for help.

6.) How will gestational diabetes affect me and my baby in the future?

Gestational diabetes usually resolves after delivery of your baby. All medications commenced during the pregnancy will be discontinued and your blood sugar levels measured prior to discharge from hospital. Women with gestational diabetes have an increased risk of developing type 2 diabetes in the future. Therefore, a fasting blood sugar test for diabetes should be performed approximately six to 12 weeks after delivery and every one to three years subsequently. It is recommended that you maintain a normal weight, consume a healthy diet and exercise to reduce your risk of being diagnosed with type 2 diabetes and gestational diabetes in the future. Children born to women with gestational diabetes are also at increased risk of childhood obesity and type 2 diabetes in adulthood. Therefore, your child’s paediatrician should be aware of your diagnosis in pregnancy to monitor the child as he/she develops.

Speak with your ObGyn about your risk of developing diabetes in pregnancy and how you can prevent it from occurring prior to becoming pregnant. The control of gestational diabetes can reduce the overall burden of diabetes in our population.

Dr Kimberlee Lewis Patten is a consultant Obstetrician and Gynaecologist. She can be found at Charis Women’s Wellness and Maternity Care Centre, Unit 22, Seymore Park Business Centre, 2 Seymore Avenue, Kingston 6, Tel. 876-665-6251. She has other locations in Kingston and St. Andrew and St. Catherine. She may be contacted by email: drlewispatten@gmail.com, or on Instagram @drlewispattenobgyn.