Gestational diabetes
Gestational diabetes | |
---|---|
Other names | Gestational diabetes mellitus (GDM) |
Frequency | ~6% of pregnancies[3] |
Gestational diabetes is a condition in which a person without
Gestational diabetes can occur during pregnancy because of
Maintenance of healthy weight and exercising before pregnancy assist in prevention.
Gestational diabetes affects 3–9% of pregnancies, depending on the population studied.
Classification
Gestational diabetes is formally defined as "any degree of
The White classification, named after Priscilla White,[6] who pioneered research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk.[7] It distinguishes between gestational diabetes (type A) and pregestational diabetes (diabetes that existed prior to pregnancy). These two groups are further subdivided according to their associated risks and management.[8]
The two subtypes of gestational diabetes under this classification system are:
- Type A1: abnormal oral glucose tolerance test (OGTT), but normal blood glucose levels during fasting and two 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
- Type B: onset at age 20 or older and duration of less than 10 years.
- Type C: onset at age 10–19 or duration of 10–19 years.
- Type D: onset before age 10 or duration greater than 20 years.
- Type E: overt diabetes mellitus with calcified pelvic vessels.
- Type F: diabetic nephropathy.
- Type R: proliferative retinopathy.
- Type RF: nephropathy.
- Type H: ischemic heart disease.
- Type T: prior kidney transplant.
An early age of onset or long-standing disease comes with greater risks, hence the first three subtypes.[medical citation needed]
Two other sets of criteria are available for diagnosis of gestational diabetes, both based on blood-sugar levels.[9]
Criteria for diagnosis of gestational diabetes, using the 100 gram
- Fasting 95 mg/dl
- 1 hour 180 mg/dl
- 2 hours 155 mg/dl
- 3 hours 140 mg/dl
Criteria for diagnosis of gestational diabetes according to National Diabetes Data Group:[9][11]
- Fasting 105 mg/dl
- 1 hour 190 mg/dl
- 2 hours 165 mg/dl
- 3 hours 145 mg/dl
Risk factors
Classical risk factors for developing gestational diabetes are:[12]
- Polycystic ovary syndrome[13]
- A previous diagnosis of gestational diabetes or impaired fasting glycaemia
- A type 2 diabetes
- Maternal age – a woman's risk factor increases as she gets older (especially for women over 35 years of age).
- Paternal age – one study found that a father's age over 55 years was associated with GD[14]
- Ethnicity (those with higher risk factors include 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.[15]
- A previous pregnancy which resulted in a child with a macrosomia (high birth weight: >90th centile or >4000 g (8 lbs 12.8 oz))
- Previous poor obstetric history
- Other genetic risk factors: There are at least 10 genes where certain polymorphism are associated with an increased risk of gestational diabetes, most notably TCF7L2.[16] The MTNR1B gene is a common gene that is associated with how the body handles insulin and glucose. When this gene is not working properly, it can lead to less insulin production and higher blood glucose levels.[17]
In addition to this, statistics show a double risk of GDM in smokers.[18] Some studies have looked at more controversial potential risk factors, such as short stature.[19]
About 40–60% of women with GDM have no demonstrable risk factor; for this reason many advocate to screen all women.
Pathophysiology
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 beyond the insulin receptor.[22] 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.[22]
Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which in cases of GDM progresses thereafter to levels seen in a non-pregnant woman with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance that they cannot compensate for with increased production in the β-cells of the pancreas.
It is unclear why some women are unable to balance insulin needs and develop GDM; however, a number of explanations have been given, similar to those in type 2 diabetes:
Though the clinical presentation of gestational diabetes is well characterized, the biochemical mechanism behind the disease is not well known. One proposed biochemical mechanism involves insulin-producing β-cell adaptation controlled by the HGF/c-MET signaling pathway. β-cell adaption refers to the change that pancreatic islet cells undergo during pregnancy in response to maternal hormones in order to compensate for the increased physiological needs of mother and baby. These changes in the β-cells cause increased insulin secretion as a result of increased β-cell proliferation.[26] HGF/
c-MET is a receptor tyrosine kinase (RTK) that is activated by its ligand, hepatocyte growth factor (HGF), and is involved in the activation of several cellular processes. When HGF binds c-MET, the receptor homodimerizes and self-phosphorylates to form an SH2 recognition domain. The downstream pathways activated include common signaling molecules such as RAS and MAPK, which affect cell motility, and cell cycle progression.[29]
Studies have shown that HGF is an important signaling molecule in stress related situations where more insulin is needed. Pregnancy causes increased insulin resistance and so a higher insulin demand. The β-cells must compensate for this by either increasing insulin production or proliferating. If neither of the processes occur, then markers for gestational diabetes are observed. It has been observed that pregnancy increases HGF levels, showing a correlation that suggests a connection between the signaling pathway and increased insulin needs. In fact, when no signaling is present, gestational diabetes is more likely to occur.[27]
The exact mechanism of HGF/c-MET regulated β-cell adaptation is not yet known but there are several hypotheses about how the signaling molecules contribute to insulin levels during pregnancy. c-MET may interact with FoxM1, a molecule important in the cell cycle, as
Although the mechanism of HGF/c-MET control of gestational diabetes is not yet well understood, there is a strong correlation between the signaling pathway and the inability to produce an adequate amount of insulin during pregnancy and thus it may be the target for future diabetic therapies.[27][28]
Because glucose travels across the placenta (through
Screening
Non-challenge blood glucose test
|
Screening glucose challenge test |
Oral glucose tolerance test (OGTT)
|
A number of screening and diagnostic tests have been used to look for high levels of
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, two 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.[31][32]
There is currently not enough research to show which way is best at diagnosing gestational diabetes.[33] Routine screening of women with a glucose challenge test may find more women with gestational diabetes than only screening women with risk factors.[34] Hemoglobin A1c (HbA1c) is not recommended for diagnosing gestational diabetes, as it's a less reliable marker of glycemia during pregnancy than oral glucose tolerance testing (OGTT).[35]
Because women diagnosed with Gestational Diabetes (GDM) during pregnancy are at an increased risk for developing Type 2 Diabetes Mellitus after pregnancy, post pregnancy glucose tolerance testing is needed.[36] Based on the recent meta-analysis conducted by the Patient-Centered Outcomes Research Institute, research has shown that post pregnancy testing reminders are associated with greater adherence to oral glucose tolerance testing up to 1 year postpartum. [37]
Pathways
Opinions differ about optimal screening and diagnostic measures, in part due to differences in population risks, cost-effectiveness considerations, and lack of an
In the
Some pregnant women and careproviders choose to forgo routine screening due to the absence of risk factors, however this is not advised due to the large proportion of women who develop gestational diabetes despite having no risk factors present and the dangers to the mother and baby if gestational diabetes remains untreated.[20]
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.
Screening glucose challenge test
The screening glucose challenge test (sometimes called the O'Sullivan test) is performed between 24 and 28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). No previous fasting is required for this screening test,[47] in contrast to the OGTT. The O'Sullivan test involves drinking a solution containing 50 grams of glucose, and measuring blood levels one hour later.[48]
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
A standardized
IADPSG (International Association of Diabetes and Pregnancy Study Groups) has developed diagnostic criteria for GDM, based on the results of adverse pregnancy outcomes in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study.[50] These were recommended by WHO 2013.[51]
According to these gestational diabetes mellitus should be diagnosed at any time in pregnancy if one of the following criteria are met, using a 75 g glucose OGTT:
- Fasting blood glucose level ≥92 mg/dL (5.1 mmol/L)
- 1 hour blood glucose level ≥180 mg/dL (10 mmol/L)
- 2 hour blood glucose level ≥153 mg/dL (8.5 mmol/L)
Urinary glucose testing
Women with GDM may have high glucose levels in their urine (
Prevention
Vitamin D supplementation during pregnancy may help to prevent gestational diabetes.[55] A 2015 review found that when done during pregnancy moderate physical exercise is effective for the prevention of gestational diabetes.[56] A 2014 review however did not find a significant effect.[57] It is uncertain if additional dietary advice interventions help to reduce the risk of gestational diabetes.[58] However, data from the Nurses' Health Study shows that adherence to a healthy plant-based diet is associated with lower risk for GDM.[59] Diet and physical activity interventions designed to prevent excessive gestational weight gain reduce the rates of gestational diabetes. However, the impact of these interventions varies with the body-mass index of the person as well as with the region in which the studies were performed.[60]
Moderate-quality evidence suggest that there is a reduced risk of gestational diabetes mellitus and caesarean section with combined diet and exercise interventions during pregnancy as well as reductions in gestational weight gain, compared with standard care.[61]
A 2023 review found that a plant-based diet (including fruits, vegetables, whole grains, nuts and seeds, and tea) rich in phytochemicals lowers the risk of GDM.[62] A Cochrane review, updated 2023, stated that myo‐inositol has a potential beneficial effect of improving insulin sensitivity, which suggested that it may be useful for women in preventing gestational diabetes″.[63]
It has been suggested that for women who have had gestational diabetes, diet, exercise, education, and lifestyle changes between pregnancies may lower their chances of having gestational diabetes again in future pregnancies.[64] However, there is no research to show whether interventions between pregnancies lower the number of women who develop gestational diabetes again.[64]
Management
Treatment of GDM with diet and insulin reduces health problems mother and child.
A repeat OGTT should be carried out 6 weeks after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised.[12]
Lifestyle interventions include exercise, diet advice, behavioural interventions, relaxation, self-monitoring glucose, and combined interventions.
If a
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.[20]
Lifestyle
Counselling before pregnancy (for example, about preventive
Any diet needs to provide sufficient calories for pregnancy, typically 2,000–2,500 kcal with the exclusion of simple carbohydrates.
The Mediterranean diet may be associated with reduced incidence of gestational diabetes.[69] However, there is not enough evidence to indicate if one type of dietary advice is better than another.[70]
Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM.[12][71] Pregnant women who exercise have lower blood sugar levels when fasting and after meals compared to those who do not exercise.[72] It is not clear which form of exercise is best when pregnant.[72]
Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low.[73] There is not a lot of research into what target blood sugar levels should be for women with gestational diabetes and targets recommended to women vary around the world.[74] Target ranges advised by the Australasian Diabetes in Pregnancy Society are as follows:[12]
- 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
Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child.[75]
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 be necessary. This is most commonly fast-acting insulin given just before eating to blunt glucose rises after meals.
There is some evidence that certain medications by mouth might be safe in pregnancy, or at least, are less dangerous to the developing fetus than poorly controlled diabetes. When comparing which diabetes tablets (medication by mouth) work best and are safest, there is not enough quality research to support one medication over another.
People may prefer metformin by mouth to insulin injections.[3] Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels.[80]
Almost half of the women 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.[81] With no long-term studies into children of women treated with the drug, there remains a possibility of long-term complications from metformin therapy.[3] Babies born to women treated with metformin have been found to develop less visceral fat, making them less prone to insulin resistance in later life.[81]
Prognosis
Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy, if a woman had GDM in her first pregnancy, are between 30 and 84%, depending on ethnic background. A second pregnancy within one year of the previous pregnancy has a large likelihood of GDM recurrence.[82]
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
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.[89] This risk relates to increased maternal glucose values.[90] It is currently unclear how much genetic susceptibility and environmental factors contribute to this risk, and whether treatment of GDM can influence this outcome.[91]
Relative benefits and harms of different oral anti-diabetic medications are not yet well understood as of 2017.[77]
There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37,962 women 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.[92][93]
Research is being conducted to develop a web-based clinical decision support system for GDM prediction using machine learning techniques. Results so far demonstrated great potential in clinical practicality for automatic GDM prognosis.[94]
Complications
GDM poses a risk to mother and child. This risk is largely related to uncontrolled blood glucose levels and its consequences. The risk increases with higher blood glucose levels.[95] Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably.[73]
The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a
Another finding was that gestational diabetes increased the susceptibility of the fetus to intrapartal hypoxia, regardless of the size of the fetus.[citation needed]
"The risk of hypoxia and the resulting risk of poor condition in newborn infants was nearly seven-fold in the fetuses of mothers with gestational diabetes compared to the fetuses of non-diabetic mothers," says researcher Mikko Tarvonen. According to the findings, the risk of needing to perform resuscitation on the newborn was ten-fold.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 an unnecessary caesarean section.[98][99]
Neonates born from women with consistently high blood sugar levels are also at an increased risk of low blood glucose (
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 and early second trimester. Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations.[101][102][103] 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).[104] 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
Epidemiology
Gestational diabetes affects 3–10% of pregnancies, depending on the population studied.[3][106]
References
- ^ "Diabetes Blue Circle Symbol". International Diabetes Federation. 17 March 2006. Archived from the original on 5 August 2007.
- ^ a b c d e f g h i j k l m n o p q r s t u v w x y "Gestational Diabetes". NIDDK. September 2014. Archived from the original on 16 August 2016. Retrieved 31 July 2016.
- ^ .
- PMID 9704245. And the rest of the issue B1–B167.
- ^ PMID 14693936.
- PMID 15396063.
- ^ "Priscilla White - White Classification, Diabetes in Pregnancy". Archived from the original on 2017-03-02. Retrieved 2017-02-20.
- ISBN 978-0-443-06572-9.
- ^ PMID 27979889.
- PMID 7148898.
- S2CID 3395229.
- ^ PMID 16751853.
- PMID 18710713.
- PMID 30381468.
- PMID 17416786.
- PMID 23690305.
- ISSN 2090-2441.
- PMID 15583369.
- PMID 17666468.
- ^ ISBN 978-0-915473-22-9.
- ^ "Gestational Diabetes". American Pregnancy Association. 27 April 2020. Retrieved 14 October 2020.
- ^ a b Carr DB, Gabbe S (1998). "Gestational Diabetes: Detection, Management, and Implications". Clin Diabetes. 16 (1): 4. Archived from the original on 2007-10-10.
- PMID 25202741.
- ISBN 978-1-4557-3395-8.
- PMID 15765129.
- S2CID 46710474.
- ^ PMID 24089510.
- ^ PMID 22427375.
- PMID 22128289.
- ^ PMID 15934273.
- PMID 11165688.
- PMID 3799747.
- PMID 28832911.
- ^ PMID 28771289.
- ^ Powe CE, Edelson PK (2020-05-27). "HbA1c Can Underestimate Maternal Glycemia During Pregnancy". Massachusetts General Hospital.
- ^ Noctor, E., & Dunne, F. P. (2015). Type 2 diabetes after gestational diabetes: The influence of changing diagnostic criteria. World journal of diabetes, 6(2), 234–244. https://doi.org/10.4239/wjd.v6.i2.234.
- ^ Saldanha IJ, Adam GP, Kanaan G, Zahradnik ML, Steele DW, Danilack VA, Peahl AF, Chen KK, Stuebe AM, Balk EM. Postpartum Care up to 1 Year After Pregnancy: A Systematic Review and Meta-Analysis. Comparative Effectiveness Review No. 261. (Prepared by the Brown Evidence-based Practice Center under Contract No. 75Q80120D00001.) AHRQ Publication No. 23-EHC010. PCORI Publication No. 2023-SR-01. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. DOI: https://doi.org/10.23970/AHRQEPCCER261.
- ^ PMID 12417905.
- S2CID 28960551.
- S2CID 32186114.
- ^ Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2003; 27 (Suppl 2): 1–140.
- PMID 14551019.
- PMID 18490689.
- S2CID 32300456.
- S2CID 12056832.
- PMID 17506370.
- ^ GLUCOSE TOLERANCE TEST Archived 2012-12-12 at archive.today at the Dwight D. Eisenhower Army Medical Center. Last Modified November 25, 2009
- ^ Metzger BE, Biastre SA, Gardner B (2006). "What I need to know about Gestational Diabetes". National Diabetes Information Clearinghouse. Archived from the original on 2006-11-26. Retrieved 2006-11-27.
- ^ "Glucose screening tests during pregnancy". Medline Plus. U.S. National Library of Medicine. Retrieved 8 November 2018.
- PMID 18463375.
- hdl:10665/85975.
- PMID 17465289.
- PMID 16266604.
- S2CID 7177148.
- PMID 31581312.
- S2CID 36297578.
- S2CID 13168801.
- PMID 28046205.
- PMID 34510175.
- S2CID 13660089.
- PMID 29129039.
- PMID 36901197.
- PMID 36790138.)
{{cite journal}}
: CS1 maint: multiple names: authors list (link - ^ PMID 28836274.
- ^ PMID 19588341.
- ^ PMID 28472859.
- PMID 32575163.
- S2CID 19468297.
- S2CID 232058447.
- PMID 28236296.
- S2CID 220572575.
- ^ PMID 28639706.
- ^ PMID 8166187.
- ^ PMID 37815094.
- S2CID 24794632.
- PMID 10550081.
- ^ PMID 28120427.
- ^ PMID 25609400.
- S2CID 3418227.
- S2CID 43358857.
- ^ PMID 25013215.
- PMID 17290037.
- PMID 16505245.
- ^ PMID 16505514.
- ^ Janzen C, Greenspoon JS (2006). "Gestational Diabetes". Diabetes Mellitus & Pregnancy – Gestational Diabetes. Armenian Medical Network. Archived from the original on 2007-01-05. Retrieved 2006-11-27.
- ^ PMID 12351492.
- PMID 17392549.
- PMID 15741354.
- PMID 17519427.
- PMID 17982340.
- S2CID 2373773.
- PMID 17705823.
- PMID 35064173.
- ^ PMID 18463375.
- .
- ^ PMID 34151398.
- PMID 9371855.
- S2CID 23520352.
- ^ S2CID 34954951.
- PMID 17977497.
- S2CID 13356040.
- PMID 15449398.
- PMID 18674752.
- S2CID 2430661.
- ^ Schneider C. "Diabetes and the Risk to Your Family Tree". www.diabetescare.net. Diabetescare.net. Archived from the original on 10 December 2014. Retrieved 5 December 2014.
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
- Diabetes.co.uk: Gestational Diabetes