Reasons for diabetes during pregnancy

Diabetes is an acute issue prevalent worldwide. There are three major types of diabetes including type-1, type-2 and Gestational Diabetes.  Among them, gestational diabetes takes prominent place and develops during any stage of the pregnancy. In 2017, global diabetic women (20-79 years) were 204 million and this number predicted to increased up to 308 million by 2045. 16.2% of pregnant mothers had some form of high blood sugar during pregnancy and according to studies done, the prevalence of high blood glucose during pregnancy increases rapidly with age. It is the highest in women over the age of 45.  Most of the incidences of high blood sugar during pregnancy were prominent in low and middle-income countries where maternal care is limited. 

In the past the occurrence of gestational diabetes was a rare due to healthy lifestyles and the feeding style. However, nowadays, most of pregnant mothers are suffering from diabetes in the initial step of their pregnancies. That is the main reason to select this topic and creating awareness regarding gestational diabetes. This attempt would significantly contribute to prevent or manage this condition. 

Pathophysiology of gestational diabetes
Pregnancy is combined with a number of changes in glucose metabolism and as a result insulin action reduces as pregnancy progresses due to the insulin resistance. This resistance is created by certain hormones which are produced by human placenta during pregnancy including human placental lactogen and placental production of tumour necrosis alpha (TNF-alpha). They play a key role in the development of insulin resistance. Pregnancy as an insulin resistant state may reveal even the smallest pre-existing defects in insulin secretion or insulin sensitivity and as a consequence, relative β-cell failure. The pathophysiological changes of gestational diabetes are similar to those observed in type-2 diabetes mellitus, which is also characterised by peripheral insulin resistance accompanied by an insulin secretory defect. At the same time, there are changes in fasting glucose likely reflecting an increased uptake of glucose by the fetoplacental unit in healthy normal glucose tolerant women in the third trimester of pregnancy.

Health consequences of gestational diabetes

New born with high body weight 
Neonatal hypoglycaemia; Lower glucose level in newborn and is a major cause of brain injury  Shoulder dystocia; is a delivery that requires additional systematic arrangement to release the shoulders after gentle downward traction has failed.

Preeclampsia; is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system mainly liver and kidneys.

Premature birth
Infant jaundice; is yellow discoloration of a newborn baby’s skin and eyes due to baby’s blood contains an excess of bilirubin, a yellow pigment of red blood cells.

Maternal morbidity; Illness occurs in pregnant mothers Maternal mortality; Death of women during pregnancy
Increased risk of developing type-2 diabetes in mothers after delivery

Long-term effects in offspring of women with GDM
The offspring of women with a history of gestational diabetes has increased long-term risk of developing metabolic diseases such as obesity, type-2 diabetes and the metabolic syndrome.In recent years studies have been made on the phenomenon of epigenetic transmission of acquired characteristics from mother to child due to perinatal programming of the fetus.

 Maternal glucose easily crosses the placenta and as a consequence maternal hyperglycemia leads to offspring hyperglycemia, which induces excess levels of insulin in fetal and possible modification of growth and future metabolism of the fetus.  Furthermore, some studies have discovered that the children of diabetic mothers are exposed to an increased risk of developing type-2 diabetes compared to children born to non-diabetic mothers.

Diagnosis of gestational diabetes
OGTT- Oral Glucose Tolerance Test
PPBS- Postparandial Blood Sugar Test

 Risk factors associated with gestational diabetes

• Being older than 35 years old
• Obesity 
• Family history of diabetes
• Polycystic ovarian syndrome; is a hormonal disorder common among women who have infrequent or prolonged menstrual periods. 
• Use of corticosteroid (Artificial steroid hormone use to maintain pregnancy and other inflammatory diseases) during pregnancy
• Previous pregnancy with gestational diabetes
• Previous delivery of a baby large than 4000gs

Management of Gestational diabetes
Weight loss before conception through dietary modification
According to research studies, 4.5 kg of weight loss between pregnancies have been shown to reduce the risk of developing gestational diabetes in a subsequent pregnancy by up to 40%.

Regular physical activity
Doing an exercise regularly has been found to be helpful in improving glycemic control in women with gestational diabetes since it improves insulin sensitivity. 

Healthy diet
Pregnant mothers need to pay more attention to their diets since mothers must get all the vitamins and minerals that are needed by themselves and their babies. 
Therefore, pregnant women should try to eat food rich in vitamins and other micro and macro nutrients from different sources daily in order to have a balanced diet with the right proportions of nutrients such as carbohydrates, protein, vitamins, minerals and water. Getting nutritional advice, preferably from an appropriately skilled dietitian is helpful to maintain appropriate weight gain and normal blood sugar level without ketonuria (excretion of abnormally large amounts of ketone bodies in the urine due to keitosis), and moderate energy restriction for obese women.

Insulin therapy
Human insulin crosses the placenta in insignificant amounts and is considered safe for use during pregnancy while insulin analogues such as insulin lispro, aspart insulin and glargine can be used for women with gestational diabetes after getting advice from a doctor. 

The doses may be higher than those required in non-pregnant subjects and should be reviewed frequently so that adequate glycemic control is achieved rapidly. 

Conclusion 
As gestational diabetes has dramatically increased worldwide pregnant mothers need to pay more attention to their health during pregnancy in order to prevent long-term health consequences from the perspective of both the mother and the newborn.  

(The writer is a medical laboratory technologist at a private hospital and holds a MSc. Degree in Industrial and Environmental Chemistry from the University of Kelaniya, a BSc in Food Production and a Technology Management degree from the Wayamba University of Sri Lanka)