Diabetes in Pregnancy

What Is Diabetes Melitus?

Diabetes Mellitus is a disorder which prevents the body from effectively utilising
glucose. Simple carbohydrates (e.g. sugar in soft drinks or jam) and complex
carbohydrates (rice or noodles) are broken down by the body to form glucose.
The glucose in the bloodstream is subsequently metabolised by various tissues

in the body and this process is regulated by insulin. Insulin is a hormone

produced by the pancreas, a small organ located behind the stomach. Insulin
deficiency and/or insulin resistance prevents glucose from entering cells to be

used as a source of energy. This causes glucose to accumulate in the blood

stream, resulting in diabetes mellitus.

What Is Meant By Gestational Diabetes Mellitus (GDM)?

Diabetes that developed only in pregnancy, is called Gestational Diabetes Mellitus (GDM). This is a serious

condition affecting pregnant women who were previously healthy but detected to have elevated blood
glucose levels during pregnancy .

What Is The Different Between GDM and Type I or II Diabetes?

1. Patient already has diabetes before they get pregnant

Diabetes can be divided into Type 1 Diabetes Mellitus or Type 2 Diabetes Mellitus. Previously, Type 1

Diabetes was termed “Insulin Dependent Diabetes Mellitus” (IDDM) and Type 2 Diabetes was termed
“Non-Insulin Dependent Diabetes Mellitus” (NIDDM). Over 90% of diabetes patients suffer from Type 2

Diabetes. For Type 1 Diabetes patients, the beta cells in the pancreas produce very litte insulin or none

at all. For Type 2 Diabetes patients, the main pathology is insensitivity of the insulin receptors (or insulin

resistance) and these patients are usually over-weight or obese.

2. GDM

During pregnancy, the various hormones produced by the placenta interferes with the action of insulin,

causing insulin resistance. Hormones such as oestrogen, cortisol and human placental lactogen, disrupts

insulin action. As the placenta continues to grow during the second and third trimester, more of these

hormones are produced, resulting in an increase in insulin resistance. The pancreas responds by
producing even more insulin to overcome the resistance. Failure to compensate results in GDM. The

patient will usually recover following childbirth, however she remains at high risk of developing diabetes

later on in life.

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How Common Is GDM?

GDM is usually detected after the 24th week of pregnancy, and occurs in about 1-14% of pregnancies each

year. If left undetected and untreated, GDM can cause many serious complications for the pregnant

women and the fetus/baby.

Who Is At Risk Of Getting GDM?

DM can happen to anyone during pregnancy. However, there are certain risk factors associated with

getting GDM, which includes:

Family history of diabetes

– Women age > 25 years

– Being overweight or obese prior to pregnancy

– History of previous GDM

– Current obstetric problems (e.g. hypertension in pregnancy, polyhydramnios)

– History of big baby (> 4 kg), still birth or birth deformities

– Recurrent vaginal candidiasis or fungal skin infection

SIGNS AND SYMPTOMS

Typically women with GDM have no signs or symptoms, although some women may suffer from excessive

thirst, urinary frequency and lethargy. Most women with GDM do not have any risk factors. Your doctor
should conduct the Modified Oral Glucose Tolerance Test (MOGTT) to detect GDM during your first

antenatal visit if you have any risk factors, or in between week 24th and 28th of your pregnancy if you are
at low risk. However, if your risk is high and the first test performed early during the pregnancy is negative

then a second test is usually performed between 24th and 28th weeks of your pregnancy.

What Is An MOGTT?

This is a test conducted after the patient has fasted overnight, typically starting at 10 p.m. the night before.
A blood sample will be taken in the morning. The patient is then required to drink a sugary drink (75 gm of

glucose diluted in 250 ml of water), and another blood sample will be taken 2 hours later.


Results Interpretation

Venous plasma glucose (mmol/l Fasting 2 hours post glucose load

Normal < 5.1 < 7.8

GDM >= 5.1 >= 7.8

TREATMENT

Treatment for GDM includes taking appropriate and adequate steps to ensure that your blood glucose

levels are always within normal limits during the pregnancy. Your doctor will advise you to follow a
suitable meal plan and to increase your level of physical activity to control your blood glucose level. You

will also have to regularly monitor your blood glucose (ideally 4 to 6 times a day) to ensure that your blood
glucose is well controlled. Some women with GDM will require insulin injections, in addition to practicing a
healthy diet and being physically active, to achieve the desired glycaemic targets.

Oral anti-diabetic (OAD) medications are generally not recommended during pregnancy. However, several
current research have shown that some OADs are safe for use during pregnancy. Your doctor may
prescribe you an OAD if your blood glucose levels are not that high.

The good news is that regular blood glucose monitoring in addition to practicing a healthy diet and being
physically active is enough to control your GDM whilst reducing the risk of adverse events for you and
your baby.

After you have delivered your baby and the placental hormone no longer circulates in the body, your

blood glucose levels will return back to normal (except if you already have diabetes before being pregnant,
but was not diagnosed earlier). Therefore, you don’t have to be overly concerned about your condition.

However, you still need to take good care of yourself and enjoy the pregnancy.

If you already have diabetes and plan to become pregnant, you have to work hard to control your blood

glucose levels several months before conception, because research has shown that a high blood

glucose during the first trimester increases the risk of congenital abnormalities.You are advised to attend a

‘pre-pregnancy care’ clinic before you try to get pregnant to ensure that your blood sugar control is
excellent.

Why Is A Specific Diet Recommended?

A balanced and nutritious diet is essential to maintain good health in the pregnant women and a

successful pregnancy. For women with GDM, a good diet will ensure that the blood glucose levels remain

normal and generally this is the first step taken before initiating insulin injections. Attention should be
given to total daily calorie intake and the choice of food consumed to ensure glycaemic control. The daily

calorie requirement will increase by 300 calories during the second and third trimester. For example, if the

total daily calorie requirement is 1,800 kcal normally (not pregnant) and the body weight remains stable, 
the total daily calorie requirement of 2,100 kcal will be required from 14 weeks gestation onwards till

delivery.

Below are some suggestions for healthy eating that will help will glycaemic control:

Avoid sweets and food with high sugar content (e.g. cakes, ice creams, junk foods, soft drinks, canned

fruits, jams, chocolates)

Take complex carbohydrates (e.g. cereals, nuts, peas, vegetables and starchy food)

Take high fibre food (e.g. fruits, vegetables, legumes, wholemeal breads)

Ensure a low fat diet, especially saturated fats (butter, fatty meat, cream). Choose thin slices of beef or

skinless chicken

Avoid oily and deep fried food

Do You Have To Exercise?

Frequent physical activity of moderate intensity can reduce the risk caused by GDM by increasing insulin

sensitivity in the cells, resulting in better glycaemic control. It also helps in preventing other discomforts
associated with pregnancy such as constipation, back ache and muscle cramps.

Walking, stretching and light weight lifting will help you sweat during pregnany. Start with 15 minute

sessions three times a week, then slowly increase the frequency and duration of exercise at your own pace
and comfort. Take plenty of fluids to prevent dehydration and be alert when exercising during pregnancy.

The extra weight in your abdomen will shift your centre of gravity, increasing your risk of falling.

Therefore, avoid any activity which results in body instability. Stop exercising if you suffer from any

headaches, dizziness, shortness of breath, feeling light-headed, palpitations, back pain, pelvic pain or
vaginal bleeding. 3

What Happens If Diet Control And Exercise Fails To Control The Blood Glucose Levels?

In some cases, although you are already strictly controlling your diet and performing regular exercise,

your blood glucose levels remain elevated. In this situation, your doctor may prescribe insulin injections.

Insulin cannot be taken orally since it will be destroyed by gastric juices. Insulin is safe to use during
pregnancy and is only a temporary measure since your blood glucose will return back to normal after

delivery.

Insulin is given via an injection just under the skin using a very fine needle, resulting in just minor
discomfort during the injection. It can be self-administered and you will be taught by your doctor or nurse

on the injection techniques. The amount of insulin required to maintain glycaemic control will increase as

the pregnancy progresses. This does not mean that your GDM is getting worse. The increase in the size of

your placenta as pregnancy progresses results in increasing amount of hormones which counters the
effects of insulin. Therefore, more insulin is required to overcome the effects.

How Do You Inject Insulin? 

Your doctor or trained nurse will teach you the right insulin injection technique. It is a subcutaneous

injection usually administered at the abdomen or thighs.

Insulin And Needle Care

Insulin must be kept in the dry area inside the refridgerator (e.g. the dairy produce section). You are

encouraged to use a new needle for each injection. Repeated use of the same needle will cause it to

become blunt, causing pain during injection.

Regular Blood Glucose Monitoring

Regular blood glucose monitoring is essential because the results indicate whether or not you are

responding to treatment. It also helps you to determine if you require any changes in your dietary and

physical activity program, and the doses of your medications. Ideally, you should check your blood glucose
levels 4-7 times a day. You should take a fasting blood sample together with a one- or two-hour post-meal

blood sample. Blood glucose measurements pre-meal and post-meal are encouraged since the results will

help you adjust the amount of insulin required. There is also scientific evidence that controlling post-meal
glucose levels results in better outcome for mother and baby as compared to controlling fasting blood

glucose levels only. Your doctor may also advise you to check your blood glucose levels before and after

exercising to avoid a hypoglycaemic attack during exercise.

During pregnancy, the recommended glycaemic targets will be tighter compared to a diabetes patient who

is not pregnant. This is very important since abnormal blood glucose levels are associated with higher

rates of complications for the pregnant mother and the fetus/baby. To reduce the risk for women with
GDM, the recommended glucose level is ? 5.3 mmol/L (fasting and premeal) or ? 6.7 mmol/L (post-meal).

Your doctor should discuss with you about your recommended targets for glycaemic control. Checking for

glucose in the urine is not recommended as it is inaccurate particularly during pregnancy.

Alcohol Abstinence And Smoking Cessation

You are advised not to take alcohol throughout your pregnancy as this might adversely affect your

pregnancy. Smoking cessation is also important as research has shown that exposure to cigarette smoke,
even as a passive smoker, have a negative effect on the fetal development. 
What Happens If You Experience Hypoglycaemia?

Low blood glucose (or hypoglycaemia) is a complication only associated with an individual on insulin

injection. It may occur if you delay your breakfast or exercise more intensely than usual. It is a medical

emergency and requires immediate intervention. If you experience any hypoglycaemic symptoms (e.g.
confusion, dizziness, blurring of vision, sweating, tremors, extreme hunger), you have to immediately

consume any form of sugar. When you are using insulin, you will have to bring along some sweets or

food/drinks (e.g. sweet candy, glucose drinks) as a precautionary measure. Tell your doctor about any

hypoglycaemic attacks that you may have experienced. Your doctor may want to change the dose or type
of insulin used.

COMPLICATIONS

The rates of complications depends on your level of self-care. If your blood glucose levels are well

controlled throughout your pregnancy, you can prevent the complications. If your blood glucose levels are
high, it will be transferred to the fetus via the placenta, exposing the fetus to high levels of blood glucose.

This will cause the fetal pancrease to react by producing more insulin to lower the blood glucose level. In

addition, the fetus will also get excess energy (in the form of glucose) more than is required, and the

excess energy will be stored as fat, resulting in macrosomia (defined as a baby born with body weight ? 4.0

kg).

The rates of complications depends on your level of self-care. If your blood glucose levels are well

controlled throughout your pregnancy, you can prevent the complications. 8 If your blood glucose levels

are high, it will be transferred to the fetus via the placenta, exposing the fetus to high levels of blood

glucose. This will cause the fetal pancrease to react by producing more insulin to lower the blood glucose

level. In addition, the fetus will also get excess energy (in the form of glucose) more than is required, and
the excess energy will be stored as fat, resulting in macrosomia (defined as a baby born with body weight

? 4.0 kg).

The baby’s blood glucose levels will be closely monitored following delivery, and he/she may require

intravenous glucose if the blood level is too low. The baby is also at risk of prolonged jaundice, electrolyte

imbalances (e.g. low calcium and magnesium levels), breathing difficulties and congenital abnormalities.

Macrosomic babies tend to develop into obese adults in the future, with the attendant increased risk of

developing Type 2 Diabetes.

Ultrasound examination antenatally is useful to monitor the size of the growing fetus and to detect the

presence of polyhydramnios. Like other diabetes patients, women with GDM is at high risk of experiencing

complications such as urinary tract infections, diabetic ketoacidosis, and fungal skin infection. They are

also susceptable for pre-term deliveries due to polyhydramnios and big baby.

GDM also causes complications during delivery, resulting in a difficult delivery and higher rates of

Caesarean sections. You are also at higher risk of getting pre-eclampsia (high blood pressure which may
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be life-threatening) during the pregnancy. You are also at higher risk of getting GDM in future subsequent

pregnancies. According to the National Institute of Health, USA, women with GDM has a 20-50% risk of

getting Type 2 Diabetes in 5-10 years after delivery. This however, can be prevented – as shown in various
landmark studies which demonstrated that lifestyle modification with or without pharmacological

interventions for individuals at high risk (including women with GDM), reduced the risk of developing

diabetes by 2-58%.

Will GDM Affect The Delivery Process?

GDM by itself is not an indication for a Caesarean section. However, if the baby is too big for a normal
vaginal delivery, or if the baby cannot be delivered normally, a Caesarean section is then required. If the

baby is too big, there is a risk of experiencing trauma during delivery, particularly bone fractures and

nerve injuries at the shoulder region.

Keep Your Doctor’s Appointments

This is very important as your doctor will be able to detect early any complications for both the mother

and the fetus, and intervene early before the condition worsens. When you are diagnosed with GDM, you
may be advised to come for regular antenatal check-ups every two weeks until 32 weeks gestation,

thereafter weekly visits to the clinic. During the visits, ultrasound examinations will be conducted to detect

any congenital abnormalities, other complications, and monitoring the growth fo the fetus. Blood glucose

monitoring will be conducted at least every two weeks to assess the effectiveness of treatment.

Close to delivery, you will be advised to monitor closely fetal movement, by for example, counting the

number of ‘kicks’ that you experience.

There is a high possibility that your doctor will set a delivery date between the 38th to the 40th week of

gestation because for women with GDM, the risk of complications increases after the 38th week If you

require insulin therapy, you will be given an insulin injection in the morning before delivery, or the insulin

may be given intravenously throughout the delivery process. After your baby is born, the blood glucose

levels will return to normal and insulin will no longer be required.

An OGTT test is recommended 6-12 weeks post-delivery to ensure that the glucose levels have returned to

normal. Following this, screening for Type 2 Diabetes should be done annually.

The good news is that although GDM can be a serious and dangerous condition, you can see that a well

controlled diet together with regular exercise can help control your blood glucose levels and reduce the

risk of complications for you and your baby. By following all of the guidelines above, you have a very good

chance to deliver normally, giving birth to a healthy baby, even with GDM. More importantly, always

discuss with the team managing your pregnancy how best to achieve all of the treatment targets.

Reference

1. Malaysian CPG on Management of Diabetes in Pregnancy 

Last Reviewed : 23 August 2019

Writer : Dr. Mastura Ismail

Accreditor : Dr. Zanariah Hussein

Reviewer : Dr. Rafaie bin Amin