Introduction
In our 18th episode of the Empowering NICU Parents Podcast, we focus on gestational diabetes. We review the pathophysiology of diabetes in general and how the different types vary, but in a way that everyone will understand. We then discuss how gestational diabetes is diagnosed, at what point your provider will typically test for it, what the test entails, which women are at more of a risk for developing gestational diabetes and the general management to follow if you are diagnosed with it.
We touch on any additional risks gestational diabetes may pose to the mother’s health followed by a review of the risks for the fetus and while in utero. To close out this episode, I review some common feelings women with gestational diabetes endure and what we as providers and members of the care team can do to ease those feelings all while optimizing outcomes for the mother and infant!
Gestational diabetes is quite common and infants of diabetic mothers are often admitted to the NICU for several different reasons, so we felt it was an important subject to touch upon. In our next episode, we will discuss infants of diabetic mothers in much more detail, some of the common diagnoses, why they may be admitted to the NICU as well as common treatment plans.
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Episode 18
What is diabetes mellitus?
Chances are either you personally have been affected by or you know someone who was diagnosed with gestational diabetes. In general, diabetes is a condition where the body cannot make enough insulin or does not use insulin normally. When we eat, our body breaks down sugar and starches from food and converts glucose to use for energy. Our pancreas makes the hormone insulin that helps to regulate the right amount of glucose in our blood. Insulin helps the sugar or glucose in the blood move into cells so it can be used as fuel. It acts like a key to let the sugar in our bloodstream enter into the cells so it can be used for energy.
As I mentioned, with diabetes, there is either not enough insulin or the body does not use it effectively which prevents the glucose from moving into the cells and it leads to a build-up of too much sugar in the bloodstream otherwise known as hyperglycemia. High blood sugars in the body can cause damage to blood vessels, the nerves, eyes, kidneys, and heart. Close management of blood sugars with medications, and/or diet, and exercise reduces the risk for complications.
Different types of diabetes
There are 3 types of diabetes, Type 1 diabetes is an autoimmune disorder. The body’s immune system damages the cells in the pancreas that make insulin so there is not enough insulin in the body to move the glucose into the cells therefore leaving too much glucose in the bloodstream. Type 1 diabetes is often diagnosed in childhood or young adults, but it can start at any age. People with Type 1 diabetes need to take insulin on a regular basis to control their blood sugars.
Type 2 diabetes is characterized by the inability to use the insulin the body makes or they do not make enough insulin. It is not considered an autoimmune disease and is often due to being overweight and/or a family history. To treat the hyperglycemia with Type 2 diabetes, people need to take an oral medication or possibly insulin.
But today we are going to specifically focus on gestational diabetes which is a kind of diabetes women develop during their pregnancy. The prevalence of diabetes mellitus and gestational diabetes is increasing worldwide.
How pregnancy hormones affect insulin and blood sugars
Pregnancy changes many things in the woman’s body including how her body uses glucose. The placenta not only provides the fetus with nutrients, oxygen, and water, but it also makes hormones necessary to maintain a healthy pregnancy. Later in the pregnancy, the hormones estrogen, cortisol, and human placental lactogen can actually block insulin. With the insulin blocked, it is called insulin resistance and it prevents glucose from going into the body’s cells and therefore causes the blood sugar levels to increase. All pregnant women have some degree of insulin resistance during late pregnancy.
Now as the placenta grows, it makes more of these hormones which means that the pancreas must make more insulin. If the pancreas is not able to keep up and make enough insulin, it results in gestational diabetes. Pregnancy can also affect the insulin needed by a woman who already had diabetes before the pregnancy. With Type 1 diabetes, she may need more insulin and with Type 2 diabetes, she may need to start using insulin or require more than before.
Who is at risk for gestational diabetes?
According to the CDC, each year gestational diabetes affects 2 to 10% of pregnancies in the United States. Women are at an increased risk of developing gestational diabetes if they are older than 25, had gestational diabetes with a previous pregnancy, had a larger infant in a previous pregnancy, are overweight, have high blood pressure or a history of heart disease. Women with polycystic ovarian syndrome or PCOS, those that are pregnant with twins or multiples, have a history of stillbirth, or if there is a family history with either a parent or sibling who has diabetes are also at an increased risk. Additionally, African American, American Indian, Asian American, Hispanic, Latina, or Pacific Islander women are also at an increased risk of developing gestational diabetes.
How is gestational diabetes diagnosed?
Since women without any known risk factors can also develop gestational diabetes, healthcare providers test all pregnant women between 24-28 weeks. Initially, a glucose challenge screening test is done to monitor a blood glucose level one hour after a glucose drink is consumed. The test evaluates how the body processes sugar. A high level of glucose in the blood may indicate that her body is not processing sugar effectively, resulting in a positive test. If the initial glucose screening is positive, a 3-hr glucose tolerance test will be performed.
For the glucose tolerance test, fasting is required and additional instructions will be given prior to the test. Initially, a baseline “fasting glucose level” will be drawn, followed by consumption of a larger glucose drink. Blood glucose levels will be drawn every hour for the next three hours. According to the American Diabetes Association, abnormal values for the Glucose Tolerance Test are as follows: for fasting 95 mg/dL or higher; one hour post the glucose drink, 180 mg/dL or higher; two hours post glucose drink, 155 mg/dL or higher; three hours post glucose drink, 140 mg/dL. If only one level is abnormal, some changes in diet may be recommended with some additional testing later in the pregnancy. If two or more levels are elevated, a diagnosis of gestational diabetes will be made.
What occurs next if you are diagnosed with gestational diabetes?
Once the diagnosis of gestational diabetes is made, a more thorough treatment plan will be advised by the provider. The treatment plan will typically include more regular prenatal check-ups to closely monitor the mother and fetus. Additional testing may be done on a regular basis including non-stress tests and biophysical profiles. Kick counts may also be recommended to closely monitor fetal movement. The provider will also give recommendations for how often to check blood sugars, the goal for glucose levels to be maintained, and how best to manage the blood glucose levels during the pregnancy. Blood sugar levels are affected by physical activity as well as diet.
Overall, treatment for gestational diabetes will typically include a monitored, healthy diet with foods and drinks low in carbohydrates, exercise, and blood glucose monitoring. Some women may need to start oral medications and/or insulin injections to help normalize blood sugars. Insulin in safe to use during the pregnancy. A referral to a dietician is common as well to help get recommendations of the best foods to eat during the pregnancy.
It is essential for mothers to attend every prenatal care check-up and to monitor their blood glucose levels closely. Detailed instructions will be provided if the blood sugars are too high. A log should be kept with all of the blood sugar values and taken to each appointment to share with the provider.
Women with gestational diabetes should try and stay active with a goal of 30 minutes of activity with a moderate amount of intensity 5 days a week if possible. It is recommended for pregnant women to speak with their provider about exercises that are recommended and safe during the pregnancy.
And as with every pregnancy, close monitoring of weight gained during the pregnancy is important to follow. If weight is gained too quickly, it can make it more difficult to manage blood sugars.
How does gestational diabetes affect the mother’s health?
Gestational diabetes can cause other complications in the mother including high blood pressure and/or preeclampsia. Women with gestational diabetes are also at an increased risk for premature delivery if there are complications during the pregnancy and the potential need to induce labor early. Due to the increased risk of infants of diabetic mothers being larger than average, there is an increased risk of shoulder dystocia during delivery which may cause additional injury to the infant and/or mother. For the mother, a delivery with shoulder dystocia increases her risk for postpartum hemorrhage.
While gestational diabetes and elevated blood sugars usually resolves after delivery, women with gestational diabetes have an increased risk of developing gestational diabetes in future pregnancies and about 50% of women go on to develop Type 2 diabetes later in life.
How does gestational diabetes affect the fetus?
Close monitoring and control of blood sugars during the pregnancy is not only important for the mother, but the fetus as well. The physiologic changes that accompany pregnancy coupled with either Type 1, Type 2, or gestational diabetes, alter the fetal environment due to the increased level of maternal glucose, episodic hypoglycemia, and ketone exposure. Unfortunately, even early in the pregnancy, this environment can have a teratogenic effect or disturb the development of the embryo or fetus and may lead to miscarriages or congenital malformations especially if there is poor control of blood sugars.
In the second and third trimester, the placental transport dictates the fetus’ blood sugars. Fetal blood sugars have been found to be on average slightly less than the maternal blood sugar. Therefore, elevations in maternal glucose result in higher glucoses in the fetus and increased fetal insulin production. Repetitive or continuous elevations in blood glucose lead to fetal hyperinsulinism and affect the patterns of growth and development.
Although more common in women with preexisting diabetes, birth defects are common in infants of diabetic mothers and can involve the heart and blood vessels, brain and spine, urinary system and/or kidneys, and digestive system. The fetus may grow at a slower rate due to poor circulation or other complications.
What causes fetal macrosomia?
Fetal macrosomia or larger than normal infants with a birthweight greater than 4000 grams are common with diabetic pregnancies due to the hyperinsulinemia. The fetus receives all of its nutrients from the placenta. If the mother’s blood sugar is too high, the infant’s blood sugar will rise as well. The fetus’ pancreas will then make more insulin in response to the high blood sugar and cause fat to form and the fetus will grow larger.
Macrosomic infants have an increased risk of morbidity and mortality due to unexplained death in utero, birth trauma, hypertrophic cardiomyopathy – where the heart muscle becomes abnormally thick, vascular thrombosis, neonatal hypoglycemia, elevated bilirubin levels, an elevated number of red blood cells, and respiratory distress. Macrosomic infants have double the risk for shoulder dystocia during delivery which may lead to clavicle fractures and/or a brachial plexus injury. The brachial plexus is the network of nerves that sends signals for feeling and movement from your spinal cord down to the shoulder, arm and hand. Macrosomia also increases the risk of stillbirth during the last 4-6 weeks of the pregnancy. The risk of stillbirth is directly correlated with poor maternal blood glucose control.
The fetus while in utero and their future treatment required post delivery are correlated to how well blood sugars are managed during the pregnancy. I do not say this to make any mother who previoulsy or currently has a pregnancy with Type 1, Type 2, or gestational diabetes feel bad. But after listening to and speaking with many mothers of infants with diabetes after the baby has been born, many have not been fully educated on how their diabetes affects their health, but also increases the risk of complications to their infant.
Common feelings of women with gestational diabetes
We created this episode was to educate and help mothers and families understand a little more about gestational diabetes. During my research for this episode, I found an article that reviewed some of the common feelings and experiences of a focus group of women with gestational diabetes that I wanted to touch on. Not only is it important for healthcare providers to hear and understand the common feelings of women with gestational diabetes, but also for mothers who have previously or are currently experiencing a pregnancy with diabetes to know that some of their feelings are very normal.
Many women reported in the study that they found the diagnosis of gestational diabetes with the immediate need for dietary restrictions, pharmacologic treatment, additional visits, and self-glucose monitoring overwhelming and frightening. The women felt that an earlier warning about the potential risk of a diagnosis of gestational diabetes would have minimized the shock. And while some women found the education and information they were given about the risks to the mother and their fetus helpful, others found it threatening and did not want to hear all of the risks.
Many of the women reported feeling that the expectations from their healthcare provider were stressful and they often felt chastised if they weren’t compliant with their recommended diet and/or monitoring of their blood sugars. And sadly many women not only felt extreme pressure to follow their recommended diet but then experienced feelings of failure if their blood sugars were still not in the recommended range. Oftentimes women felt that their healthcare provider threatened them with the safety and health of their baby and that all of the burden of responsibility fell on them.
Women also felt stigmatized or judged for having gestational diabetes. Many reported that they felt the healthcare providers were mostly focused on the fetus’ health, not the mother’s health. In the postpartum period, many women felt that there was very little follow-up which concerned them since they were told they were at an increased risk of developing gestational diabetes in future pregnancies and/or Type 2 diabetes. Women often reported a sense of abandonment in the postpartum period after a period of such intense intervention that left them feeling uncertain about their future risks.
The diagnosis of gestational diabetes can be emotionally distressing for many women but with education, guidance, and support, my hope is that we can ensure that the mothers feel supported and it ultimately optimizes the outcomes for them and their baby.
Closing
I hope this review of gestational diabetes has been helpful for you whether you are a parent or part of the healthcare team. As I stated, the diagnosis of gestational diabetes can leave mothers feeling shocked, scared, and uncertain. I put this episode together to serve as an adjunctive educational piece to summarize how gestational diabetes is diagnosed and how appropriate management does ultimately affect the mother’s health and that of her fetus. But, with a healthy collaboration between the healthcare provider and patient, mothers can feel supported and empowered as opposed to frightened and stigmatized leading to the most optimal outcomes for the fetus and mother. Tune in to our next episode in 2 weeks to hear some of the common potential complications for infants of diabetic mothers and how they are typically treated in the nursery and NICU.
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Remember, once empowered with knowledge, you have the ability to change the course.
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