According to various studies, pregnancy is a diabetogenic state. The hormones that lead to fetal growth and development, mobilizes the woman’s nutritional resources, primarily glucose, making them available to the fetus. Out of the 40 weeks of pregnancy, hormonal activity shifts into high gear during the last 20 weeks. Food and nutrition play a crucial part. Due to the increased requirements of the fetus, there is marked increase in glucose in the blood.
In some women, the secretion of insulin which helps in the absorption of food, leads to gestational diabetes mellitus (GDM). Women, who have babies later in life, as is common these days, are at increased risk.
A family history of diabetes, difficulties or complications in conceiving and previous miscarriages are all risk factors. However, there are instances when women with all three do not get GDM. And conversely, it could happen that even without a single risk factor a woman could develop GDM.
A manageable condition
“GDM is a manageable condition in pregnancy,” says Kumar, a diabetologist at Sitaram Bharti Institute of Research and Medical Sciences, New Delhi. Despite a family history, women are often surprised when they develop GDM. And very few are mentally prepared for the changes which are needed. “In India, especially in the more traditional families, pregnancy is a time when women are indulged and food plays a major role,” says Arvinder Parmar, a freelance nutritionist based in Chandigarh, who has treated women with pregnancy related complications.
According to her, this should ideally be the time to maintain a healthy diet because in most cases food habits change for the requirements of the fetus. Food habits, thus developed during pregnancy, will more or less be a pattern for life. According to Parmar, women who altered their food habits not only had a healthy pregnancy, they also recovered from childbirth much faster.
How to diagnose
Initial monitoring tests includes a level II ultrasound, genetic counselling and certain lab tests which include measuring serum creatinine, haemoglobin A1c (HgAlc), and thyroid-stimulating hormone (TSH) levels, as well as a triple screen test (serum human chorionic gonadotropin (hCG). The triple screening is used for detecting Downs Syndrome in the second trimester of pregnancy). The TSH level needs to be obtained because of the association of diabetes with hypothyroidism.
The HgAlc, which reflects the level of glucose control in the preceding six to eight weeks, should be normal. A high value of HgAlc may indicate a higher risk of congenital malformations in a woman with GDM and may also lead to miscarriage. Monitoring through an ultrasound provides a measure of fetal weight and amniotic fluid volume. The size of the baby’s head is checked for abnormal growth since mothers with GDM tend to have babies with large heads.
There are birth-related complications in women with GDM and the most common is pregnancy-induced hypertension (PIH) or eclampsia and pre-term labour (PTL). Weekly blood pressure and urine protein measurements, as part of routine prenatal care, should provide early indications suggestive of PIH and pre-eclampsia.
In many cases, babies of GDM mothers show hyperinsulinemia (high levels of insulin in the body), which may in turn retard lung development and may delay lung maturity, often until 38 weeks gestation. This would lead to respiratory distress in the baby. The baby may also have hypoglycemia which is resolved by giving either milk or glucose solution. Blood sugar monitoring has to be done every hour till the level stabilizes.
Another complication is Erb’s palsy, a stretch injury to the brachial plexus, which could lead to seizures at birth, and intra partum fetal hypoxia (lack of oxygen in the fetal brain). The flaccid paralysis of Erb’s palsy is usually resolved in the first few days to weeks of the baby’s life, but occasionally is lifelong.
Says Dr Rinku Sengupta, obstetrician and gynaecologist at the Sitaram Bhartia Institute of Science and Research: “The risks of uncontrolled GDM are macrosomia (oversized fetus), pregnancy induced hypertension, pre-term labour and even cases of intra-uterine fetal death.”
How to treat it
For those who are diagnosed with GDM, insulin levels have to be monitored strictly. Since there is a very short time to ensure that the outcome is healthy, doctors normally advise administering insulin immediately. Blood sugar also needs to be monitored at all three mealtimes.
The amount of insulin to be taken is recommended by the endocrinologist/ diabetologist. In most cases, the mother is put on a 1800-calories-a-day diet. There should be no direct intake of sugar. That means no sweets, chocolates or desserts. Fruits with high fibre like sweet lime and oranges are excellent. These slow the breakdown of food so that glucose release in the blood happens in a manner that is in tandem with the rate of insulin release.
“Healthy snacks like roasted chana (gram) or fruits like sweet lime was all I could have,” says Oberoi. In the last few weeks of the pregnancy, she lost weight even as the baby gained 250gms per week. All this was strictly monitored by doctors.
According to studies conducted in the US, by following a slightly modified American Diabetic Association diet and engaging in regular exercise, approximately 85% of women who suffer from GDM will achieve adequate glucose control. Exercise is the second most important part of the therapy. It promotes fitness and also increases insulin sensitivity.
Three-point care programme
• This includes control of the diabetes, continuous monitoring of the mother for complications, and the prevention of complications to the fetus. Diabetes care continues with diet control, monitoring of blood glucose levels, and insulin therapy. Dr Sengupta says “We don’t give drugs in GDM to control blood sugar but prescribe insulin, which is safer.”
• For the mother, GDM usually goes away after the delivery although it may take some time before glucose intolerance in the body is resolved. Slowly, the insulin requirement of the body drops by 60% of that needed before delivery. Through careful monitoring, the doctor decides if insulin treatment needs to be continued. “Very rarely does a woman need insulin on a long-term basis,” says Kumar. “Low-dose oral medicines are normally enough.”
• But chances of women developing Type II diabetes do remain high, and in most instances doctors advise a routine of healthy eating habits, regular exercise and periodic check-ups. “If the patient is aware and disciplined, GDM can be managed very well and it can actually turn out to be a blessing since it makes the patient switch to a healthier lifestyle, which obviously has benefits in the long run” says Kumar. In Soma Oberoi’s case, this is exactly what has happened.
Chitra Narayanan also contributed to this story.