Stressful. That was the word that best captured Jessica’s diagnosis with Gestational Diabetes Mellitus (GDM).
The 35-year-old’s first pregnancy had proceeded uneventfully until her glucose tolerance test. When, at 28 weeks, her test results came back positive.
The positive result came on a Friday. She could not see her doctor until after the weekend. The advice nurse gave her quick advise to limit her calorie intake, so Jessica starved and fretted the whole weekend. Only after meeting with a dietician and her doctor did she understand that she could eat a reasonable amount for a hungry pregnant woman, but would need to limit carbohydrates, space out her meals, and check her blood sugar throughout the day.
Still the constant monitoring and constant feeling of guilt took a toll:
The worst part was feeling like I was ‘ruining’ my baby just because I decided to eat a cookie or whatever. It led to a ton of stress and guilt. And anxiety. So much anxiety.”
What is Gestational Diabetes (GDM)?
Gestational Diabetes Mellitus (GDM) is diabetes that begins or is first recognized during pregnancy. It affects 6-9% of all pregnancies in the United States. Its incidence has risen nearly 20-fold since 1980, and continues to climb.
Like other type of diabetes, gestational diabetes stems from difficulty managing your blood sugar (glucose).
When your blood sugar rises, your pancreas, an organ situated behind your stomach, secretes insulin. Insulin is a hormone that allows glucose (sugar) to move into your body’s cells for energy.
Starting around 20 to 24 weeks of pregnancy, your baby’s placenta begins producing hormones that make your cells resistant to insulin. You need more insulin to let glucose (sugar) into your cells. In response, your body increases insulin production. But, if your body cannot produce enough insulin, you develop gestational diabetes.
GDM typically has no symptoms. But some women may notice nausea, fatigue, an increased need to pee, and increased thirst.
Of course, these are also classic symptoms of… pregnancy.
All major medical organizations therefore recommend screening pregnant women for GDM between 24 and 28 weeks.
That Monday, her doctor and a dietician quickly got Jessica up to speed on management. She would need to limit her carbohydrate intake, try to eat small meals throughout the day, and engage in regular exercise. She should try to walk for 10-15 minutes after eating to prevent post-meal spikes in blood sugar. Her blood sugar would need to be checked through the day, once upon waking and 1-2 hours after every meal to ensure it stayed within her target range.
“It was pretty standard diet stuff… just carb restrictions so once I understood the basics it was easy enough to know what to eat. But combining it with pregnancy cravings and figuring out what to eat on a busy weeknight after work took a lot of time to figure out. Ended up eating mostly the same thing every day for breakfast and lunch, which I hear is fairly typical.”
(Note: Newer tools like the Freestyle Libre can ease the burden of repeat blood sugar checks. The Libre reports your blood sugar to a separate bluetoothed reader. And after a insertion, it can be worn for up to 14 days, obviating the need for finger pricks.)
For Jessica, if she could not keep herself in range with diet and exercise alone, her doctor told her, she would need to inject herself with insulin.
Women whose blood sugar cannot be controlled with diet and exercise will need to take medications to lower their blood sugar. Insulin—which requires injection—is the recommended choice, because insulin does not pass through the placenta to the baby, according to the American College of Obstetricians and Gynecologists (ACOG).
For women who are unable or unwilling to inject insulin, oral medications like glyburide and metformin are alternatives. However, these medications do pass through the placenta, and we have only limited information on their safety.
Risks for Mom and Baby
If you have been diagnosed with GDM, do not stress. Most women with well-managed gestational diabetes go on to have normal, healthy pregnancies and births. Poorly controlled gestational diabetes does have some risks, however. So it’s important to follow your doctors’ directions on diet, exercise, and medications.
The biggest risk of GDM is having an overly large baby. When your blood sugar rises, the excess sugar passes through the placenta to your baby. In response, your baby secretes more insulin. In turn, high insulin levels in your baby promotes growth and weight gain.
Of course, genetics also plays a role in baby size. Some babies are just large. But babies affected by poorly controlled GDM tend to be disproportionately large: large body relative to their head. The extra insulin promotes weight gain. A too-large baby underlies most of other risks associated with GDM.
Risks associated with a too-large baby:
- Baby getting stuck in the birth canal (Most often the shoulders become stuck, so this is sometimes called shoulder dystocia.)
- Baby experiencing shoulder and neck injuries from being stuck in the birth canal.
- Birth complications, such as the need for a C-section or assisted delivery and severe tearing of the vagina and the perineum (the area between the vagina and the anus).
- Elevated risk of severe bleeding after birth.
Risks associated with baby’s high insulin levels:
A few risks, not from your baby’s size, but directly from the baby’s high insulin levels
- Breathing problems after birth. Insulin interferes with the production of surfactant, a fluid that your baby’s lungs secrete to help prepare for life outside the womb. A lack of surfactant can cause breathing problems (respiratory distress).
- Low blood sugar after birth (hypoglycemia). During pregnancy, your baby’s placenta supplies it with your glucose (sugar) from your blood. When their umbilical cord is clamped, your baby loses access to your blood supply and with it, access to a steady supply of energy. Babies normally handle this transition with a burst of hormones that raise their blood sugar. Excess insulin can interfere with the production of these hormones, placing your baby at risk of low blood sugar. Low blood sugar happens more often when mom’s diabetes was poorly controlled or if the baby is large, weighing over 4000g (8 lbs, 13 oz). If your baby is at risk for low blood sugar, your doctor will likely check his blood sugar 3-6 hours after birth. Breastfeeding or formula feeding shortly after birth can also help prevent low blood sugar.
These risks can sound scary. But again, most of them are unlikely, especially if your diabetes is well-managed.
Other Pregnancy and Birth Risks
GDM also raises the risk of preterm birth, stillbirth, and preeclampsia, a pregnancy complication characterized by high blood pressure and other signs of organ dysfunction, such as severe swelling and protein in your urine. Most of these risks are only slightly higher than in pregnancies not affected by gestational diabetes.
For example, women with GDM generally face a slightly elevated risk of stillbirth. The risk of stillbirth rises past 39 weeks, for all pregnancies. It rises more steeply, however, for pregnancies complicated by gestational diabetes. Although the difference is small–and the overall rate of stillbirth for women with gestational diabetes is still very low, less than 1 in 1,000–doctors often induce GDM pregnancies by 39 or 40 weeks to be on the safe side.
The increased risk for preeclampsia, however, is fairly high. Preeclampsia affects between 2-8% of all pregnancies in the U.S. But preeclampsia affects 9.8% of pregnancies of women with GDM who have a fasting glucose level under 115 mg/dL, according to the ACOG. This rises to 18% for women with a fasting level above 118 mg/dL.
Women with GDM face an elevated risk of developing Type 2 Diabetes: anywhere from 15 to 70% will develop Type 2 Diabetes. As a precaution, even after delivery, your doctor should keep a close eye on your blood sugar, checking it right after birth and again 6-12 weeks later, to make sure your blood sugar has returned to normal. After that, ACOG recommends rechecking every 1-3 years.
Despite their high risk, less than 1 in 5 women may receive follow-up testing for Type 2 Diabetes after pregnancy, so make sure your primary care doctor is aware of your elevated risk. The risk for Type 2 Diabetes is high—but it’s not inevitable. Weight loss, eating well, and exercising help lower your risk of Type 2 Diabetes. Breastfeeding, especially exclusively and for at least three months, may also lower your risk.
Women who have had gestational diabetes are also at moderately higher risk of developing chronic high blood pressure and heart disease. So it’s important to be aware, and make your doctor aware, of your elevated risk for that too.
Back to Jessica…
After months of snacking on cheese and nuts, and staying in range for meals, Jessica’s morning blood sugar began to rise above her ideal range. She tried “cheating” by snacking in the middle of the night to stimulate insulin production drop her morning blood sugar. But she eventually had to go on insulin.
Because she was on insulin, her doctor wanted to induce her at 40 weeks. This is what ACOG recommends. Jessica, however, held out to a few more days, feeling that her body was just not ready.
Perhaps she was onto something, because her induction took over 48 hours. It felt “medicalized and depersonalized”, with someone pricking her finger to check her blood sugar every few hours. After two days, she developed a fever and had to have an emergency C-section. While she felt it was “stressful and disappointing labor, for sure”, the outcome was good: Her baby girl arrived perfectly healthy and weighing a very normal 7 lbs 11 oz.
She also credits her greater carb-consciousness with helping her shed the baby weight.
“After the birth, I was glad to have the sugar testing data. I had learned which foods my body processed as sugar–not obvious things like potatoes more than pasta… I did a pretty serious carb restriction, but not keto, to finally lose the 25-30 lbs of baby weight I had”
She has not had any problems with her blood sugar since, and her second pregnancy proceeded uneventfully, with no sign of gestational diabetes.
She now has a second healthy and thriving baby girl.