Gestational diabetes

Gestational diabetes
Classification and external resources
Universal blue circle symbol for diabetes.[1]
ICD-10	O24
ICD-9	648.8
MedlinePlus	000896
MeSH	D016640

Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy (especially during third trimester of pregnancy). It is widely accepted as a disease only in the United States, there is some question whether the condition is natural during pregnancy . Gestational diabetes is caused when the body of a pregnant woman does not secrete excess insulin required during pregnancy leading to increased blood sugar levels.

Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied,^[2] so may be a natural phenomenon.

As with diabetes mellitus in pregnancy in general, babies born to mothers with gestational diabetes are typically at increased risk of problems such as being large for gestational age (which may lead to delivery complications), low blood sugar, and jaundice. Gestational diabetes is a treatable condition and women who have adequate control of glucose levels can effectively decrease these risks.

Women with gestational diabetes are at increased risk of developing type 2 diabetes mellitus (or, very rarely, latent autoimmune diabetes or Type 1)^{[citation needed]} after pregnancy, as well as having a higher incidence of pre-eclampsia and Caesarean section;^[3] their offspring are prone to developing childhood obesity^{[citation needed]}, with type 2 diabetes later in life^{[citation needed]}. Most patients are treated only with diet modification and moderate exercise but some take anti-diabetic drugs, including insulin.^[3]

Women treated for gestational diabetes, generally have smaller birthweight babies, leading to other problems, such as survival rate of premature and early births, particularly male babies.

Classification

Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy".^[4] This definition acknowledges the possibility that patients may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether symptoms subside after pregnancy is also irrelevant to the diagnosis.^[5]

The White classification, named after Priscilla White^[6] who pioneered in research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and diabetes that existed prior to pregnancy (pregestational diabetes). These two groups are further subdivided according to their associated risks and management.^[7]

There are 2 subtypes of gestational diabetes (diabetes which began during pregnancy):

• Type A1: abnormal oral glucose tolerance test (OGTT) but normal blood glucose levels during fasting and 2 hours after meals; diet modification is sufficient to control glucose levels
• Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required

The second group of diabetes which existed prior to pregnancy is also split up into several subtypes.

Risk Factors

Classical risk factors for developing gestational diabetes are the following:^[8]

• a previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia
• a family history revealing a first degree relative with type 2 diabetes
• maternal age - a woman's risk factor increases as she gets older (especially for women over 35 years of age)
• ethnic background (those with higher risk factors include African-Americans, Afro-Caribbeans, Native Americans, Hispanics, Pacific Islanders, and people originating from South Asia)
• being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively.^[9]
• a previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000 g (8 lbs 12.8 oz))
• previous poor obstetric history

In addition to this, statistics show a double risk of GDM in smokers.^[10] Polycystic ovarian syndrome is also a risk factor,^[8] although relevant evidence remains controversial.^[11] Some studies have looked at more controversial potential risk factors, such as short stature.^[12]

About 40-60% of women with GDM have no demonstrable risk factor; for this reason many advocate to screen all women.^[13] Typically women with gestational diabetes exhibit no symptoms (another reason for universal screening), but some women may demonstrate increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision.

Pathophysiology

Effect of insulin on glucose uptake and metabolism. Insulin binds to its receptor (1) on the cell membrane which in turn starts many protein activation cascades (2). These include: translocation of Glut-4 transporter to the plasma membrane and influx of glucose (3), glycogen synthesis (4), glycolysis (5) and fatty acid synthesis (6).

The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is increased insulin resistance. Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to the insulin receptor. The interference probably occurs at the level of the cell signaling pathway behind the insulin receptor.^[14] Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin is needed to overcome this resistance; about 1.5-2.5 times more insulin is produced than in a normal pregnancy.^[14]

Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which progresses thereafter to levels seen in non-pregnant patients with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance they cannot compensate with increased production in the β-cells of the pancreas. Placental hormones, and to a lesser extent increased fat deposits during pregnancy, seem to mediate insulin resistance during pregnancy. Cortisol and progesterone are the main culprits, but human placental lactogen, prolactin and estradiol contribute too.^[14]

It is unclear why some patients are unable to balance insulin needs and develop GDM, however a number of explanations have been given, similar to those in type 2 diabetes: autoimmunity, single gene mutations, obesity, and other mechanisms.^[15]

Because glucose travels across the placenta (through diffusion facilitated by GLUT3 carriers), the fetus is exposed to higher glucose levels. This leads to increased fetal levels of insulin (insulin itself cannot cross the placenta). The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia). After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia).^[16]

Screening

2006 WHO Diabetes criteria^[17]  edit

Condition	2 hour glucose	Fasting glucose
	mmol/l(mg/dl)	mmol/l(mg/dl)
Normal	<7.8 (<140)	<6.1 (<110)
Impaired fasting glycaemia	<7.8 (<140)	≥ 6.1(≥110) & <7.0(<126)
Impaired glucose tolerance	≥7.8 (≥140)	<7.0 (<126)
Diabetes mellitus	≥11.1 (≥200)	≥7.0 (≥126)

A number of screening and diagnostic tests have been used to look for high levels of glucose in plasma or serum in defined circumstances. One method is a stepwise approach where a suspicious result on a screening test is followed by diagnostic test. Alternatively, a more involved diagnostic test can be used directly at the first antenatal visit in high-risk patients (for example in those with polycystic ovarian syndrome or acanthosis nigricans).^[16]

Tests for gestational diabetes

Non-challenge blood glucose tests Fasting glucose test 2-hour postprandial (after a meal) glucose test Random glucose test

Screening glucose challenge test

Oral glucose tolerance test (OGTT)

Non-challenge blood glucose tests involve measuring glucose levels in blood samples without challenging the subject with glucose solutions. A blood glucose level is determined when fasting, 2 hours after a meal, or simply at any random time. In contrast, challenge tests involve drinking a glucose solution and measuring glucose concentration thereafter in the blood; in diabetes, they tend to remain high. The glucose solution has a very sweet taste which some women find unpleasant; sometimes, therefore, artificial flavours are added. Some women may experience nausea during the test, and more so with higher glucose levels.^[18][19]

Pathways

There are different opinions about optimal screening and diagnostic measures, in part due to differences in population risks, cost-effectiveness considerations, and lack of an evidence base to support large national screening programs.^[20] The most elaborate regime entails a random blood glucose test during a booking visit, a screening glucose challenge test around 24–28 weeks' gestation, followed by an OGTT if the tests are outside normal limits. If there is a high suspicion, women may be tested earlier.^[5]

In the United States, most obstetricians prefer universal screening with a screening glucose challenge test.^[21] In the United Kingdom, obstetric units often rely on risk factors and a random blood glucose test.^[16][22] The American Diabetes Association and the Society of Obstetricians and Gynaecologists of Canada recommend routine screening unless the patient is low risk (this means the woman must be younger than 25 years and have a body mass index less than 27, with no personal, ethnic or family risk factors)^[5][20] The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening.^[23][24] The U.S. Preventive Services Task Force found that there is insufficient evidence to recommend for or against routine screening.^[25]

Non-challenge blood glucose tests

When a plasma glucose level is found to be higher than 126 mg/dl (7.0 mmol/l) after fasting, or over 200 mg/dl (11.1 mmol/l) on any occasion, and if this is confirmed on a subsequent day, the diagnosis of GDM is made, and no further testing is required.^[5] These tests are typically performed at the first antenatal visit. They are patient-friendly and inexpensive, but have a lower test performance compared to the other tests, with moderate sensitivity, low specificity and high false positive rates.^[26][27][28]

Screening glucose challenge test

The screening glucose challenge test (sometimes called the O'Sullivan test) is performed between 24–28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). It involves drinking a solution containing 50 grams of glucose, and measuring blood levels 1 hour later.^[29]

If the cut-off point is set at 140 mg/dl (7.8 mmol/l), 80% of women with GDM will be detected.^[5] If this threshold for further testing is lowered to 130 mg/dl, 90% of GDM cases will be detected, but there will also be more women who will be subjected to a consequent OGTT unnecessarily.

Oral glucose tolerance test

Main article: Oral glucose tolerance test

The OGTT^[30] should be done in the morning after an overnight fast of between 8 and 14 hours. During the three previous days the subject must have an unrestricted diet (containing at least 150 g carbohydrate per day) and unlimited physical activity. The subject should remain seated during the test and should not smoke throughout the test.

The test involves drinking a solution containing a certain amount of glucose, and drawing blood to measure glucose levels at the start and on set time intervals thereafter.

The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes.^[31]

The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:

• Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
• 1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
• 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
• 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)

An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify fewer women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test.^[32]

The glucose values used to detect gestational diabetes were first determined by O'Sullivan and Mahan (1964) in a retrospective cohort study (using a 100 grams of glucose OGTT) designed to detect risk of developing type 2 diabetes in the future. The values were set using whole blood and required two values reaching or exceeding the value to be positive.^[33] Subsequent information led to alterations in O'Sullivan's criteria. When methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed.

Urinary glucose testing

Women with GDM may have high glucose levels in their urine (glucosuria). Although dipstick testing is widely practiced, it performs poorly, and discontinuing routine dipstick testing has not been shown to cause underdiagnosis where universal screening is performed.^[34] Increased glomerular filtration rates during pregnancy contribute to some 50% of women having glucose in their urine on dipstick tests at some point during their pregnancy. The sensitivity of glucosuria for GDM in the first 2 trimesters is only around 10% and the positive predictive value is around 20%.^[35][36]

Management

Main article: Diabetes management

A kit with a glucose meter and diary used by a woman with gestational diabetes.

The goal of treatment is to reduce the risks of GDM for mother and child. Scientific evidence is beginning to show that controlling glucose levels can result in less serious fetal complications (such as macrosomia) and increased maternal quality of life. Unfortunately, treatment of GDM is also accompanied by more infants admitted to neonatal wards and more inductions of labour, with no proven decrease in cesarean section rates or perinatal mortality.^[37][38] These findings are still recent and controversial.^[39]

A repeat OGTT should be carried out 2–4 months after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised.^[8]

If a diabetic diet or G.I. Diet, exercise, and oral medication are inadequate to control glucose levels, insulin therapy may become necessary.

The development of macrosomia can be evaluated during pregnancy by using sonography. Women who use insulin, with a history of stillbirth, or with hypertension are managed like women with overt diabetes.^[13]

Lifestyle

Counselling before pregnancy (for example, about preventive folic acid supplements) and multidisciplinary management are important for good pregnancy outcomes.^[40] Most women can manage their GDM with dietary changes and exercise. Self monitoring of blood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy.

Any diet needs to provide sufficient calories for pregnancy, typically 2,000 - 2,500 kcal with the exclusion of simple carbohydrates.^[13] The main goal of dietary modifications is to avoid peaks in blood sugar levels. This can be done by spreading carbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources—known as the G.I. Diet. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more.^[8] Ingesting more fiber in foods with whole grains, or fruit and vegetables can also reduce the risk of gestational diabetes. ^[41]

Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM.^[8][42]

Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low.^[43] Target ranges advised by the Australasian Diabetes in Pregnancy Society are as follows:^[8]

• fasting capillary blood glucose levels <5.5 mmol/L
• 1 hour postprandial capillary blood glucose levels <8.0 mmol/L
• 2 hour postprandial blood glucose levels <6.7 mmol/L

Regular blood samples can be used to determine HbA1c levels, which give an idea of glucose control over a longer time period.^[8]

Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child.^[44]

Medication

If monitoring reveals failing control of glucose levels with these measures, or if there is evidence of complications like excessive fetal growth, treatment with insulin might become necessary. The most common therapeutic regime involves premeal fast-acting insulin to blunt sharp glucose rises after meals.^[8] Care needs to be taken to avoid low blood sugar levels (hypoglycemia) due to excessive insulin injections. Insulin therapy can be normal or very tight; more injections can result in better control but requires more effort, and there is no consensus that it has large benefits.^[16][45][46]

There is some evidence that certain oral glycemic agents might be safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes. Glyburide, a second generation sulfonylurea, has been shown to be an effective alternative to insulin therapy.^[47][48] In one study, 4% of women needed supplemental insulin to reach blood sugar targets.^[48] Metformin has shown promising results, with its oral format being much more popular than insulin injections.^[3] Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels.^[49] A recent randomized controlled trial of metformin versus insulin showed that women preferred metformin tablets to insulin injections, and that metformin is safe and equally effective as insulin.^[50] Severe neonatal hypoglycemia was less common in insulin-treated women, but preterm delivery was more common. Almost half of patients did not reach sufficient control with metformin alone and needed supplemental therapy with insulin; compared to those treated with insulin alone, they required less insulin, and they gained less weight.^[50] With no long-term studies into children of women treated with the drug, here remains a possibility of long-term complications from metformin therapy,^[3] although follow-up at the age of 18 months of children born to women with polycystic ovarian syndrome and treated with metformin revealed no developmental abnormalities.^[51]

Prognosis

Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence.^[52]

Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women who needed insulin treatment, had antibodies associated with diabetes (such as antibodies against glutamate decarboxylase, islet cell antibodies and/or insulinoma antigen-2), women with more than two previous pregnancies, and women who were obese (in order of importance).^[53][54] Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years.^[33] Depending on the population studied, the diagnostic criteria and the length of follow-up, the risk can vary enormously.^[55] The risk appears to be highest in the first 5 years, reaching a plateau thereafter.^[55] One of the longest studies followed a group of women from Boston, Massachusetts; half of them developed diabetes after 6 years, and more than 70% had diabetes after 28 years.^[55] In a retrospective study in Navajo women, the risk of diabetes after GDM was estimated to be 50 to 70% after 11 years.^[56] Another study found a risk of diabetes after GDM of more than 25% after 15 years.^[57] In populations with a low risk for type 2 diabetes, in lean subjects and in patients with auto-antibodies, there is a higher rate of women developing type 1 diabetes.^[54]

Children of women with GDM have an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life.^[58] This risk relates to increased maternal glucose values.^[59] It is currently unclear how much genetic susceptibility and environmental factors each contribute to this risk, and if treatment of GDM can influence this outcome.^[60]

There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37962 patients were reported to have GDM, and there was a tendency towards more breast and pancreatic cancer, but more research is needed to confirm this finding.^[61][62]

Complications

GDM poses a risk to mother and child. This risk is largely related to high blood glucose levels and its consequences. The risk increases with higher blood glucose levels.^[63] Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably.^[43]

The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit. Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic)^[63] and small for gestational age. Macrosomia in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section) or problems during vaginal delivery (such as shoulder dystocia). Macrosomia may affect 12% of normal women compared to 20% of patients with GDM.^[16] However, the evidence for each of these complications is not equally strong; in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study for example, there was an increased risk for babies to be large but not small for gestational age.^[63] Research into complications for GDM is difficult because of the many confounding factors (such as obesity). Labelling a woman as having GDM may in itself increase the risk of having a caesarean section.^[64][65]

Neonates are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia).^[66] GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis.^[66]

Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown to be an independent risk factor for birth defects. Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy, whereas GDM gradually develops and is least pronounced during the first trimester. Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations.^[67][68][69] A large case-control study found that gestational diabetes was linked with a limited group of birth defects, and that this association was generally limited to women with a higher body mass index (≥ 25 kg/m²).^[70] It is difficult to make sure that this is not partially due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy.

Because of conflicting studies, it is unclear at the moment whether women with GDM have a higher risk of preeclampsia.^[71] In the HAPO study, the risk of preeclampsia was between 13% and 37% higher, although not all possible confounding factors were corrected.^[63]

Epidemiology

Gestational diabetes affects 3-10% of pregnancies, depending on the population studied.^[2]

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External links

• IDF Diabetes Atlas
• International Diabetes Federation
• National Institute of Child Health and Human Development - Am I at Risk for Gestational Diabetes?
• National Institute of Child Health and Human Development - Managing Gestational Diabetes: A Patient's Guide to a Healthy Pregnancy
• Gestational Diabetes Resource Guide - American Diabetes Association
• World Diabetes Day
• Diabetes.co.uk: Gestational Diabetes