The unspoken side of pregnancy
While there are many challenges women living with diabetes may face during pregnancy, gestational diabetes (GDM) is of growing concern. The NDSS reports out of every seven women who are pregnant, at least one will develop GDM; and a further 22 per cent of women who had GDM report having it in subsequent pregnancies.¹ While GDM is a very common complication of pregnancy, it is also the fastest growing type of diabetes in Western Australia.
“Our colleagues at Fiona Stanley Hospital indicate that of the 4000 pregnant women they support annually, 27 per cent are diagnosed with gestational diabetes,” stresses Sophie McGough, general manager at Diabetes WA.
Experts have identified that some of the leading factors behind seeing this increase is due to a revised diagnostic criteria for GDM, combined with women falling pregnant at later ages, and the Australian population being heavier – more people of child-bearing ages living with obesity – and more ethnically diverse than previous generations. However, many of the factors associated with GDM can be modified to reduce the risks towards both you and your baby’s health.
What is GDM?
“From around week 16-20 of pregnancy, the placenta starts making additional hormones that can cause a woman to become more resistant to the insulin her body is making,” explains Dr Emily Gianatti, endocrinology lead for Diabetes in Pregnancy Services at Fiona Stanley Hospital.
“As a result, unfortunately, the woman’s pancreas isn’t able to make enough insulin to compensate for this greater resistance in the body.”
When the pancreas is unable to produce enough insulin, your blood glucose levels (BGLs) will rise; and without treatment can cause harm to both mother and baby.
Previously only women who were at risk of GDM were tested, however, today, all women are encouraged to undergo the oral glucose tolerance test (OGTT) between weeks 24-28 of pregnancy, explains Marina Mickleson, nurse practitioner and midwife at King Edward Memorial Hospital (KEMH).
While you may still choose not to undergo the test, the majority will do the screening; and as a result, more women are being successfully diagnosed and making changes to their lifestyle for a healthier pregnancy.
“And for women who previously tested negative but show signs of a bigger baby, some doctors may repeat the OGTT test or then treat the pregnancy as GDM to ensure extra monitoring is in place and there is no harm to mum or bub,” says Mickleson.
Factors that put you at a greater risk of developing GDM include living with obesity, being of advanced maternal age (older than 35 years), certain ethnic backgrounds (including Aboriginal, Melanesian, Middle Eastern, Asian, Polynesian and Indian subcontinent), having elevated BGLs in the past, have PCOS, and someone who has a family history of type 2 or a first-degree relative – such as mother or sister – who had GDM in a pregnancy.
This condition usually goes away after a baby is born, however, the mother – particularly someone who has poorly controlled GDM – is at a higher risk of then developing type 2 diabetes within 10-20 years.
Management of GDM
After being diagnosed with GDM, it is critical to monitor your BGLs up to four times a day, adjust your diet, and undertake gentle physical activity every day; and as a result over half of all women with GDM can manage it through these modifiable changes.
“Whilst diet is the main treatment for GDM, it doesn’t necessarily mean their diet is unhealthy,” explains Dr Gianatti. “It’s about distributing the spread of carbohydrates, ensuring the right type of carbohydrates are eaten, as well as having a well-balanced diet to meet the nutritional requirements of the mother and baby.”
This specific way of eating involves spreading the intake of a certain type and amount of carbohydrates across three main meals and three snacks; and this can help you achieve healthy pregnancy weight gain, keep your BGLs within the normal range and ensure optimal growth of your baby.
“It’s also important for a multidisciplinary clinic providing care to a woman with GDM, that they’re not providing a one size fits all dietary approach to women,” adds Dr Gianatti.
“For example, in our clinic we have a lot of women who are from a CaLD group, and we provide dietary education to them that’s more appropriate to their cultural or ethnic groups.”
Similarly physical activity helps to manage BGLs and pregnancy weight gain, as well as pregnancy symptoms like heartburn, constipation and lower back pain. However, it is important to note that you should talk to your healthcare team about starting or continuing any form of physical activity to ensure it doesn’t put either of you at any risk.
“Unfortunately, we are seeing up to 40 per cent of women diagnosed with GDM requiring insulin therapy during their pregnancy,” adds Mickleson. This medication will not harm you or your baby, but it is vital to learn how much and how to inject insulin by a diabetes educator; and your dose will need to be reviewed regularly.
Mickleson also recommends building a rapport with your healthcare professionals and to seek help from them if you’re struggling with BGLs or mental wellbeing; to attend education sessions offered by hospitals and diabetes educators to learn more about your diagnosis; and to communicate your diagnosis with your partner and family members to help support you.
“And above all, avoid Dr Google for answers,” says Mickleson who explains that every pregnancy is different, so your management and care should be unique to you and your baby and directed by your pregnancy care provider.
The risks associated
“Diagnosed GDM that is well treated is associated with low risks for mother and baby,” emphasises Dr Gianatti. However, undiagnosed GDM – or diagnosed GDM that is not well controlled – poses significant risks and challenges to both mother and baby.
“If you have uncontrolled hyperglycaemia (high BGLs), this can cause significant problems for the baby,” adds Dr Sarah Straw, consultant physician for the Kimberley Regional Physician Team at WA Country Health Service Kimberley.
“Sustained high BGLs can lead to fetal macrosomia (large for gestational age), which can then lead to problems with delivery and birth, and can increase the risk of needing an emergency cesarean.
“Further uncontrolled hyperglycaemia can lead to developing diabetic ketoacidosis (DKA) which can be life threatening for both mum and baby, so it’s very important to try to avoid that by managing and optimising treatment as soon as possible.”
“On the other side are episodes of hypoglycaemia (low BGLs), so if you’re overtreating with insulin, you’ve done a lot of exercise or you haven’t eaten as much and you have low BGLs, similarly to DKA this can lead to a loss of consciousness – which both may cause the need for an emergency delivery and risk to mum and baby.”
Further, the infant is at increased risks of jaundice or respiratory distress post-birth, requiring special care nursery or neonatal ICU admission, abnormalities in BGLs, and developing obesity and type 2 diabetes.
Additionally, mothers are also at risk of preeclampsia, pregnancy-induced hypertension, postnatal depression, subsequent GDM pregnancies, and developing type 2 diabetes post-birth; and some women may even experience high levels of emotional distress after being diagnosed with GDM or during their treatment.
“There’s a lot of misinformation about GDM in the community and a lot of stigma attached to the diagnosis,” explains Dr Gianatti. “People might believe it’s a disease they’ve caused themselves because they’re overweight or they’ve gained too much weight in pregnancy, and they may believe others think the same.”
This is why it’s really important for your healthcare team to encourage you to learn about the environmental factors associated with GDM and how some can be modified to reduce your risks, as well as how your genetics – that cannot be modified – may contribute to your risk of GDM.
“However, if a patient has good preconception health and maintains this during pregnancy – and if diagnosed maintains very well controlled GDM or type 2 diabetes – then the risks of complications drop significantly,” says Dr Straw. “They would still be at a higher risk than a pregnancy without diabetes or other chronic medical conditions; but if they can control their BGLs then they can definitely reduce the risks.”
As a result, the Diabetes Telehealth Service* by Diabetes WA recognised the service gaps in local antenatal care pathways for women with GDM.
“This service offers access to a credentialled diabetes educator via video conference and provides skilled, timely and effective intervention when local specialised service is limited or overburdened,” explains Gill Denny, tele-services manager at Diabetes WA. “The goal of this service is to provide a gold standard of care in the right place at the right time, giving the woman the opportunity to receive care close to home; resulting in positive outcomes for both mum and bub.”
The Telehealth GDM Service works closely with KEMH, and a cross referral pathway for KEMH regional GDM patients has been developed.
Reduce the rates
“After a GDM pregnancy, we encourage the mother – who is overweight or living with obesity – to seek assistance to return to a healthy body mass index (BMI) to decrease the risk of GDM in future pregnancies, as well as to decrease the risk or delay the onset of type 2 diabetes in her future,” says Mickleson.
However, before falling pregnant it is important to consider your preconception health (Refer to preconception story).
Dr Gianatti explains that GP’s play an important role in ensuring a diagnosis of diabetes is made early, in educating you about any underlying health conditions that may increase your risk of GDM or other complications, as well as ensuring you receive adequate help and support throughout your pregnancy.
Considering the treatment for the majority of women is to adjust your diet and lifestyle, it is important to also reduce the stigma associated with GDM through educating everyone about both genetic and environmental factors – some of which can be modified – that contribute to a woman’s risk of developing GDM.
“Being that so many of our members have experienced diabetes in pregnancy, Diabetes WA wants to provide a voice for these women and their children,” says McGough. Raising awareness today not only speaks volumes, but can help save someone’s life.
*Diabetes Telehealth Service is available for Regional WA, 8:30am – 4.30pm Monday to Friday, at 1300 001 880.
This article is taken from our member magazine Diabetes Matters, Winter 2021 issue
References ¹ NDSS. 2020. Gestational diabetes. https://www.ndss.com.au/wp-content/uploads/ndss-data-snapshot-202012-gestational-diabetes.pdf ² NDSS. 2020. Life after gestational diabetes. https://www.ndss.com.au/wp-content/uploads/resources/booklet-gestational-diabetes-life-after.pdf