QuoteReplyTopic: Gestational Diabetes Posted: 11 February 2011 at 12:15pm
I was 19 weeks pregnant when I was diagnosed with GD, which was a complete surprise. I had done the POAS test with my MW at 18+1 and she then sent me for a GTT, but I had no other symptoms, and didn’t fit the classic risk profile – I was slightly older (at 35) and somewhat overweight, but not really obese. After my diagnosis I immediately started looking for information on GD, but found it really hard to sort out. I am lucky that the GD team at Chch Womens Hospital are fantastic, and have been incredibly supportive, and I also have a fantastic MW.
However, in talking with other women on this site it seems like not everyone is as lucky. Although 3-5% of pregnant women (maybe more) will develop GD, there is relatively little practical information out there. So I thought I would share some of the information that I have learned, and we can support each other and rant about the stuff that doesn’t work. Note that I am not a doctor or a medical person (just a pregnant scientist) so I may be wrong on some points and if you are a medical person, please add your 10c worth!
Also, I apologise if it seems like some of my information has a 'lecturing' tone - I'm a uni lecturer by trade, so I can't help myself!
So, here are some of the factors that might increase your risk of developing GD. Note that depending on where you look, different information will be found. Factors include:
• Age (older women tend to be more prone, some sites say over 35, some over 40)
• Weight (obese women are at greater risk, but again, at exactly what point your risk increases is unclear – some sites refer to a BMI of over 30 or 35, some indicate a total weight over 100kg)
• Family history (this is one of the key factors – if your mum, sister or auntie has diabetes or has had GD you are at increased risk)
• Lifestyle factors – poor diet and/or lack of exercise can increase risk
• Certain medical conditions, particularly PCOS can increase the risk of GD
• Ethnicity – Asian women are more at risk of developing GD than women from other ethnic backgrounds
So diabetes is caused when your body either stops producing enough insulin (typically Type 1 diabetes, which develops in childhood) or develops a resistance to insulin (Type 2 diabetes). Both things can happen during pregnancy. When you are pregnant, you need about twice as much insulin as a non-pregnant person, so for some people, our bodies just don’t produce enough. Added onto that, the placenta releases a number of hormones some of which can block the effects of insulin. When you have GD one or both of these things may happen. Understanding GD means understanding the roles of glucose and insulin in our bodies.
Glucose is a type of saccharide molecule, and it is found in many types of food. Glucose molecules are found in table sugar (sucrose), milk sugar (lactose) and starchy foods (where it is known as amylose and amylopectin). Sugars are also found in fruit and honey. When you eat any of these types of food, your body takes the different sugars or starches and breaks them down to form glucose which is released into your blood stream. Some foods break down to form glucose rapidly releasing a fast hit of glucose into your bloods stream. These are often referred to as ‘high GI’ foods, and include things like table sugar and white bread. Other foods, known as ‘low GI’ break down more slowly and release the glucose gradually. Low GI foods include basmati rice, whole grain breads and fruit.
Insulin is a protein that is produced in your pancreas. It does two important things – it takes glucose out of your blood and shoves it into your cells, which gives you energy, and it takes any un-needed glucose and stores it in your liver as a chemical called glycogen. (When your blood sugar levels drop low, another protein takes the glycogen out of your liver, converts it back to glucose and releases it into your blood stream.) So when you suffer from diabetes, the lack of insulin means that glucose builds up in your blood, but isn’t transferred into your cells where it gives you energy (meaning that you can feel really tired), and isn’t stored in your liver efficiently either. Instead, the glucose is excreted in your urine (apparently this starts to taste sweet, which is where the name for diabetes came from originally).
Unfortunately, avoiding glucose containing foods is not an option, as glucose provides the primary energy for your cells, and without that energy you will eventually get sick, and die.
For most people with GD, it will disappear within a few days of giving birth – you no longer need all that extra insulin, and the placenta is no longer producing hormones that block the effect of insulin. However, it can have some risks both to the pregnant woman, and also to the baby.
The biggest risks to the baby are that baby could be abnormally large, and could have low blood sugar (hypoglycaemia) at birth. There are two reasons why the baby may grow very large – firstly, if there are high levels of glucose in your blood this will be transferred to baby, and baby will put on an extra layer of fat around his/her torso. Secondly, baby will produce insulin to deal with the extra glucose that he/she is getting from you, and this insulin can act as a growth hormone. The main problem with a big baby is potential shoulder dystocia (shoulders getting stuck).
As baby may be getting high loads of glucose in your blood stream, and then producing extra insulin, this can lead to baby becoming hypoglycaemic after birth because they have all this insulin, but suddenly there is no more sugar. Other complications that commonly affect babies of GD mums include jaundice and breathing problems. Apparently around 30-35% of babies have one or more of these conditions, but remember, that also means that 65-70% of babies are completely healthy!
For the mum, the risks of GD are much the same as the risks associated with Type 1 and Type 2 diabetes. These are covered in detail on the Diabetes NZ website (www.diabetes.org.nz). However, because most women only have GD for a few weeks/months the effects are unlikely to be major unless the GD has been poorly controlled. GD can lead to increased risks of other pregnancy related conditions such as pre-eclampsia, and may lead to early placental deterioration.
The other major risk is that 50% of women with GD will go on to develop Type 2 diabetes within 20 years of their GD pregnancy.
The management of GD during pregnancy begins with regular monitoring of blood glucose levels, and diet control. If the diet control is not keeping the blood sugar levels low enough, then medication is also used. You may also be asked to keep a food diary for the first week or two. Different DHB’s around New Zealand target different levels for blood sugar management, and all dieticians will give slightly varying advice. In some DHB’s, your primary maternity care will remain with your LMC or midwife, but in other DHB’s, your primary maternity care will be transferred to the diabetes unit at the hospital. In all cases, you will probably see a dietician, diabetes physician and obstetrician. You will probably also see a diabetes midwife.
For blood sugar management, you will be asked to do regular finger prick tests (the hospital will set you up with the appropriate kit), at least 3 or 4 times a day, possibly as much as 6 times a day. You may test before meals (especially first thing in the morning), and will probably be testing either 1 hour or 2 hours after meals. The diabetes team will probably suggest that you aim for blood sugar levels below 5 or 5.5 mmol/L before meals, and blood sugar levels below 7 mmol/L after meals (some DHBs may have higher targets). Be aware, that if you haven’t eaten for a couple of hours, there is NOTHING you can do to control the before meal readings, so if they are high, it’s not your fault!
The purpose of the finger prick tests is to identify when and how your blood sugar levels respond to food, so if you are eating healthily and still getting high levels, then that is an indication that your body is not producing enough insulin and/or the insulin is not working effectively. I believe that there is a study currently underway (but not yet published) to evaluate the outcomes associated with different blood sugar target levels.
For the diet, everyone will receive slightly different advice, and everyone’s bodies will react to glucose slightly differently. In many cases you simply have to try something and see how your blood sugar levels respond, then you will know whether you can eat that food again, or not. The general advice I received was to try and have about 50g of carbohydrate with each meal, and snacks with 10-20g carbohydrate between meals (and before bed if necessary). If possible, try and have something containing protein (meat, eggs, nuts, dairy) with your meals, and try to avoid fat, especially saturated fats. You also want to try and ensure that the carbohydrate is low GI. This means that the ingredient and nutrition panels on food will become your best friend. It can be very difficult trying to balance the needs of a GD diet with the needs of a pregnancy diet and avoiding listeria risk foods.
If the diet doesn’t work on its own (and especially if you are consistently high before meals), medication will be recommended. There are two medications that are currently used for GD – an anti-diabetic pill called ‘Metformin’ and self-injections of insulin. Both have pros and cons, as described below.
Metformin is an anti-diabetic drug. It does two things, reduces insulin resistance, and also inhibits the release of glycogen from the liver. It is often recommended if you are in the earlier stages of pregnancy (so lots of insulin resistance to go) and if the main problem is your fasting/before meals glucose levels. The major side effects are stomach upsets, and particularly diarrhoea and nausea (this can be a bonus if you have constipation from iron tablets!) The other disadvantage is that metformin does cross the placenta to baby. A recent study has been completed in NZ and Australia showing that babies whose mums took metformin had similar outcomes to those who were on insulin. A follow up study is currently underway following those children for the first few years to confirm that there are no adverse effects. A benefit to the mother of taking metformin is that it limits weight gain, and in fact, some women will lose weight after starting with metformin. If you want to find out more, check out this report of the Metformin in Pregnancy Study: http://www.nejm.org/doi/full/10.1056/NEJMoa0707193#t=article
Insulin is the other major treatment for diabetes. You may end up taking insulin on its own or in combination with metformin. Insulin must be taken by self-injection, and depending on need, could be used up to 4 times per day (before each meal, and before bed). Unlike the finger prick tests, the insulin injections don’t hurt. There are two types of insulin – fast acting (used before meals, usually either Humalog or NovoRapid) and intermediate acting (used before bed, Humalin or protophane). However, you need to manage what you eat much more closely, as there is a risk of hypoglycaemia (low blood sugar) if you haven’t eaten enough carbohydrate to ‘use up’ the insulin. Hypos are quite unpleasant, and can be dangerous if not identified and treated.
During your pregnancy, you are likely to have a number of ultrasound growth scans to evaluate how your baby is growing, and whether they are likely to be particularly large. The outcome of those growth scans may affect the management of your labour and delivery.
I had GD last pregnancy,so I really don't want it again. I found finger pricking and diary useful and in 10 weeks of monitoring only went over the limit once. I don't eat the foods (except perhaps bread) that spike it, even though I failed the test. My baby was born little and has remained on the 5th percentile ever since, not the big baby I was told!
I really want to get on to this early this time. Have you found any good links to websites or something with good diet ideas? I'm pretty good but its always good to have reminders and ideas.
Diet has been one of the biggest problems for me. I found some regular diabetes cookbooks (which are good cos they have nutritional information) but these are all aimed at Type 1/2 rather than GD.
I think the best thing you can do to prevent GD (and it doesn't always work) is to ensure a healthy weight and good fitness level before pregnancy. If you have that, all the other things are basically out of your control, other than avoiding high GI foods. Ultimately, there's very little way to control the hormones released by your placenta, or the way your body responds to those hormones.
The final bit of information is about management of GD during labour and the post natal period. At the moment this is all based on information received from my LMC and OB, so if anyone has actual experiences to relate, I would love to hear how it went ...
The management of labour for women with GD is very dependent on where you are located within NZ, and how well your GD has been managed during pregnancy. Much of what I will discuss here is how things are done in Canterbury, but I would welcome feedback from GD mums in other parts of NZ.
Because a GD pregnancy is considered to be high-risk, your LMC will generally require you to deliver at a major hospital (one with secondary care facilities) such as NZ womens, Chch womens, Wellington or Hutt hospitals. You may also be required to stay at that hospital (rather than transferring to a birthing unit or local maternity hospital) for at least 24 hours following the birth so that your baby’s health can be monitored. Due to the increased risks associated with GD, particularly with respect to placental deterioration, very few DHB’s are willing to allow a GD mum to go post-term. Some DHBs (such as Auckland) have a blanket policy of induction at around 38 weeks, while others (such as Canterbury) will assess patients on a more individual basis, but will induce at around 40 weeks unless an earlier induction is indicated.
In most cases, either continuous or intermittent electronic fetal monitoring will be required. Your blood sugar levels will be tested regularly (hourly in Canterbury) during labour. If your levels drop low, you will be put on a glucose drip, with insulin piggy-backed into the drip. The amount of glucose is kept constant, while the insulin is adjusted depending on your blood sugar results.
After your baby is born his/her blood sugar will tested several times to ensure that he/she is not hypoglycaemic. If low blood sugars are detected, this will be treated first, by breastfeeding, and then by supplemental feeding if necessary. Some DHBs suggest that women with GD express and store colostrums prior to delivery so that it can be fed to their baby if supplemental feeding is required, otherwise, formula or glucose may be used to supplement feed the baby.
Great info on GD. I developed it at 31 wks. I was able to control it with diet and exercise so I was very lucky. I have pcos so that was probably why I got it.
Anyway, I had a very healthy baby girl, delivered naturally and 7lb1oz so def not a big baby!! I did have to have her in the hospital but just my mw and an hospital mw there. My bs were monitored during labour and they did go up, but only got over 7 just before I gave birth.
We had to stay at the hospital for about 8 hours while they monitored my baby's blood sugars. They were fine and we were able to go.
I had great support and help down here on diet and being seen by an o.b. Also had a late scan to check baby size. In the end I kind of think it was a good thing as I was really strict with my diet and only put on 12kgs and 10kgs of that fell off in about 2 weeks!!!
GL Karen with the rest of your pregnancy and birth.
Hi Karen,
Great thread - I wish I had something like this to read through.
I, like Maisey (who is from the same due date thread as me! *waves to maisey*), was diagnosed at 30ish weeks.
I am NZ European, not overweight, mid 20s, good diet, exercise regularly, no pre existing conditions BUT have a family history of Type 1 and 2 diabetes so after my GTT was high, I was diagnosed with GD (albeit quite a mild case).
Lucky for me, I also managed to keep my bs down with slight modification to my diet (carbs and the fact that I ate three good sized meals a day instead of say 6 smaller meals was my downfall).
My DD was born 7 pd 10 oz, healthy as. Again like maisey, I had to deliver in hospital but would have likely done that anyway. They monitored her bs levels for the first 24 hours and all was 100% fine. To date, there is no effect to either of us from the GD - wouldnt even know I had it.
The other thing that was good (again like Maisey) was that the control on my diet helped me not gain a huge amount - 10kg roughly i think.
They usually induce you at 38 weeks if you have to have insulin, or at 40 weeks if you are diet controlled.
I was induced at 39+4 since I had been diet controlled and delivered 39+6 (yea it took a while). I was later told because my GD was mild, I could have continued on another week or so before being induced . In hindsight, I wished I had but the diabetes team up here were pretty good so I just went with their recommendations at the time.
Hope all goes well with the rest of your pregnancy and birth
Great Thread Karen, Full of awesome information and I think is going to be a great place for us all to share our GD stories, especially how it was managed during pregnancy and then birth and what happened after etc.
My LMC reffered me to have a 2 hour GTT at 26 weeks due to PCOS. There is a huge link between PCOS and GD as insulin resistance has often already developed prior to pregnancy as a result of the PCOS.
In the words of my LMC I failed the GTT "spectacularly", in other words I had very severe GD. In hind sight I think I might have requested a 2nd GTT in 1-2 weeks time, I still to this day think I only have borderline GD.
I transfered from my LMC to the hospital MW system at NWH in auckland city. My new MW turned out to be great so I quickly got over being upset about having a new one.
I started off managing the GD with diet only from 26-29 weeks. IMO my sugars werent that bad, I rarely went "over" perhaps 1 out of 10. We decided we would try Metformin medication to help generally lower my sugars. The metformin worked really well, I was on a low dose of 3 tablets a day from 29-32 weeks, then up to 5 a day from 32-34 weeks. At 34 weeks I however had "had enough" of the nasty side effect of the metformin (severe # 3's as I describe them, sorry TMI!)
so we decided we would try a week without metformin to see how I went. I did well for the 1st week, then totally unrelated I was admitted with early labour at 35 weeks. This all settled btw. I went back on them for a week at 35 weeks, then moved to Insulin at 36 weeks.
Im now being induced at 38+1 (next thursday hehe) as is Auckland Hospital's protocol for Insulin Managed GD. I think I could have if I wanted argued a case to continue to 39 or even 40 weeks however I now seem to be developing Pre-Eclampsia so is better to deliver naturally with induction at 38 weeks than have an emergency c-section later on. Plus to be honest Im happy to get my baby out!
Ask me again once its all over and I might say GD is no big deal. Ask me today and I will tell you I am 100% OVER IT! Finger pricking 4 times a day hurts. Metformin messes up your bowels something wicked and insulin injections while they dont hurt arent the most pleasant things.
In the end its all about having a healthy baby! Will let you know next week how it goes hehe
Jade, interesting that you've had to transfer from independant to hospital mw. The GD mw who took the group session said several times that if you're with an independant, you can stay with her, and just see specialist at scheduled times, but if you're with a hospital mw or shared care with hospital (which I was), then they transfer you to the GD team as it all falls under the same health board in the end, so its easier for them to keep track if they take on all 'public' GD patients.
I'm still early days (wasn't diagnosed until 2 weeks ago when I finally went for my 2hr GTT after JUST failing my 1hr test in Dec) so nothing to add just yet (apart from agreeing that yes, finger pricks bloody well hurt!! I'm sure I must be doing it wrong as one hand is now covered in tiny scabs from all the finger pricking 5x daily!) but I find out on Monday whether they will take baby out (I'm already having an elective for other reasons) closer to 38 weeks, or leave me til 39+ as is standard with electives. Havent had a scan since my 3D one at 26 weeks, so I have no idea if baby is small or large for dates, but I have been measuring a few weeks ahead for the majority of the pregnancy, I guess next weeks appt wmay possibly include a scan to check?
I went into labour naturally and kept my MW etc, total drug free easy birth. Although it did all happen a month early. They were going to induce at due date possibily it certainly wasn't a given and I was very opposed to it as I was controlling it all so well.
BTW - I wasn't overweight or unfit either - I was the fitest I've ever been before getting PG! I was 36, but was the only risk factor I had!
Well, after dumping all that information, my GD turned out to be reasonably severe.
Within a week of finger pricks and diet control, I was put on metformin, gradually increasing from two tablets per day to five per day. My main issue has always been fasting bs levels (before and after breakfast). At about 24 weeks, I added rapid acting insulin before breakfast, and at about 28 weeks, intermediate acting insulin (before bed) was also added. With all that medication, I have actually achieved very good blood sugar control, and my growth scans at 28 and 32 weeks showed growth in the 45th and 36th percentile respectively.
At the moment, the plan is for me to be induced at my due date, if I don't go into labour before, but this will be dependent on my 36 week growth scan (at the moment, baby is still breech so that will also have an effect ...)
In terms of treatment, I would say the finger pricks and diet control are the most difficult things (especially at Xmas time). The insulin and metformin are actually easier to deal with ...
hey guys
i've just been diagnosed with GD, this is an awesome thread!! thanks for starting it Karen.
i'm totally not in any risk factors (aside from diet/exercise i guess), i'm 25, not overweight (im pretty little actually), no family history aside from a male cousin, etc. my GTT result was 9.7.
so i just saw a lady at the diabetes clinic yesterday and am yet to see the dietician and obstetrician. i'm on finger pricks 4 times a day. think i managed to bruise my finger with last nights one! my results yesterday were fine and the lady from the clinic was happy with them, however i forgot to do the morning one today and my after breakfast one i failed - 8.4. so will see how things go, but if my levels later on today are like yesterdays i might be like you karen and just have a problem in the mornings.
anyway, good to hear some good stories in here (and people going into labour naturally!)
Heaf I was the same, GTT was 9.6 at 2 hours! I'm still on diet management rather than medication, I found restricting carbs,(esp in the mornings) to small amounts but not cutting them out completely kept my glucose levels down, have you tried UpnGo's? Theres a low GI version called vibe (usually on supermarket shelf with cereal like special K, sultana bran etc) that comes in banana or wildberry, it takes very little to cause my levels to spike in the mornings, but one of those and either a piece of fruit, or a non-baked muesli bar (nut/fruit ones, but then that could just be me and how my body processes it!) kept my levels inside the acceptable range.
Had to cut out snacks as well as they'd spike my levels, and no fried/baked foods either, I made the mistake of adding ONE small triangle hash brown to my normal dinner one night, and my levels came back at 9.1! I'm allowed to have something for afternoon tea if dinner is going to be delayed for any reason, if I leave it too long to eat, then the body pulls out the 'stored' glucose (glycogen) and then if you eat after that, can cause a high reading
I assume you've been asked to keep a food diary? Make a note if you can of what the total carb amount was (nutritional charts will have per serving, and per 100gm) for anything you eat and that will help them figure out how much you can have per meal/day etc, for eg, I can only have 30gm of carb in the mornings, but my body can cope with up to 50 in the evenings, and my total for the day is not to exceed 140gm. Its much easier to work out what you can/cant have once they give you some numbers to work with, rather than constant trial and error!
I had a lovely bruise the first time i did it too, and since I am shocking with needles to begin with, that seriously didnt help my confidence any! Managed to figure out how to hold the pricker so it JUST pierces the skin, rather than a large jab that keeps bleeding after I'm done, takes a few goes to get it 'right'
The great news is once the placenta is out, you are no longer considered diabetic, but you'll have to do another 2hr GTT 6 weeks post-partum, and every 12 months after that...
aw really, i hated the 2 hour test, i felt like i was going to be sick
haven't been asked about the food diary yet, i guess the dietician might tell me to do one? but I might start writing down what i'm eating anyway in case they want to know.
will have a look at those Up&Go's...i'm not usually a big breakfast fan anyway so that might do the trick well.
I guess it will be a bit of trial and error to see what i can and can't eat! at least its only for a few weeks i guess...
They'll ask you to do one, so it will def help if you get started on one pre-emptively, saves time and not knowing what you can/cant have in the meantime.
You have to eat regularly, no skipping meals, esp breakfast! They recommend no more than 4 hours between meals (any more than that and the glycogen starts being released, which, as I mentioned before, will elevate your glucose levels without having eaten a thing). I was never a big breakfast eater either, so up'n'go's have been awesome! The usual ones I can still have, but they have a higher carb content, so it would mean I could only have that til lunchtime, whereas the vibe ones mean I can have something else with it, or leaves a 'carb allowance' for morning tea.
Yeah I hated the 2 hour one too, felt like I was going to keel over (although that may have been more to do with having GD and my body couldnt handle it as well as it should have, may be diff next time once the GD is gone...?)
Most veges you can eat as much as you like (except high starch ones like potatoes, corn etc) and if you're stuck for snacks, the dietician i saw said kiddy packs are JUST the right size to allow for an adult low-carb snack, I found vege chips in the supermarket (signature range, so pretty cheap too) that are only 8gm of carb per bag, so I usually have a couple of them in the bag while I'm out
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Gestational Diabetes
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