A diagnosis of gestational diabetes shocked MICHELLE D SOUZA to the core. She explains the implications of the silent, often misunderstood, disease she has overcome – lifting the lid on some myths along the way
We look at the diagnosis and consequences of this oftensilent condition
Your test results are out,” my midwife said. “You have gestational diabetes.” I clutched the sides of my seat and tried not to fidget nervously. My husband started asking questions which my midwife graciously answered. I suddenly seemed to have a lot of information thrown my way. Or at least that’s what I assumed since I had already started to zone out. ‘Is this something I did?’ my mind wandered. ‘I thought pregnancy was the time I could eat whatever I wanted. Satisfy those cravings, they said.’ I tried hard to pay attention to what my midwife was saying. I clearly failed. ‘I don’t need this right now,’ I thought. ‘Maybe the test results are wrong? But I wouldn’t want to repeat that glucose test again!’ In my family, I am generally known to be a ‘strong’ person, yet somehow at this moment, I was far from being one. Blame it on those pregnancy hormones. Tears followed. Uncontrolled sobs, actually. It took me quite a while to get myself back together. A couple of weeks passed by before I was able to accept what was happening. And the journey? It was one I couldn’t wait to get over with; one I would wrestle with almost all the way up to my delivery. But more importantly – it was one I would overcome.
So what exactly is gestational diabetes?
Gestational diabetes mellitus (GDM) is a temporary condition where your body is not able to produce enough insulin to regulate blood sugar efficiently. This, in turn, can have adverse effects on your baby depending on the severity of the issue. According to research done by the Auckland District Health Board, GDM affects roughly 6.6 per cent of pregnant women in New Zealand. Women with a family history of diabetes or those who are overweight are more prone to developing gestational diabetes during their pregnancy. Researcher Dr Chris Mckinlay of the Liggins Institute, who also works as a neonatologist at Middlemore Hospital, said, “I think it’s important to emphasise that GDM can affect all women, not just those who are overweight, though there is certainly ethnic predisposition towards Asian and Pacific people.” Irrespective of your ethnicity, finding out that you have gestational diabetes during your pregnancy can be quite unsettling. Judy Graham, clinical midwife specialist for diabetes in pregnancy at the Counties Manukau District Health Board, said that for some women it is the first time they have ever heard of diabetes so have no prior knowledge about the condition. “Being told you have diabetes in pregnancy is the last thing many women want to hear. It can be quite frightening for them,” she said. “They often do not understand the condition or the effects that it can have on their health or that of their unborn baby. This along with different cultural attitudes towards food makes it difficult for us to ensure that we are getting the correct message across to women.” Developing a medical condition during pregnancy can also often mean additional financial commitments for some families, which can be a struggle for women to meet. “In spite of the advice and information that we provide to our women, they are not always able to buy the healthiest foods,” Judy explains. “Also, because diabetes is a somewhat silent disease – you can’t see or feel anything – it can be hard to comprehend it as a real threat,” Judy said. “It’s not until the importance of monitoring their sugar levels in their pregnancy are explained to them or that they see concerns in their baby’s growth scans, that GDM mums become more committed. So the challenge is not just for the midwife. The woman faces the greatest challenge. We try to hold her hand and help her along the journey if she’ll let us.”
How do you find out if you have gestational diabetes?
To start with, you will be asked to do a glucose challenge test in your 24th to 28th weeks of pregnancy. If you have a family history of diabetes, a higher gestational weight, previous signs of Polycystic Ovary Syndrome, or a routine Hba1c blood test result with 41 mmol or higher, you will have to do a two-hour glucose test as opposed to the one-hour glucose test. Both these tests require you to have a sweet glucose drink on an empty stomach and then have your blood tested an hour or two later, respectively. If your results show that you have diabetes, your LMC will then refer you to a diabetes midwife specialist and a nutritionist, who will follow up with you throughout your pregnancy. Additionally, you will also be asked to see an obstetrician in the weeks closer to your delivery. Many women, initially, can feel a sense of shock or even guilt when they first find out they have gestational diabetes. Kate Adams, who discovered she had it much later on in her pregnancy had such a reaction. “At first I was shocked,” Kate says. “I was also upset. I felt like it was something I had caused, and that I had put my baby at risk.” “Later on, after talking to a few people, I realised that this was something I could not control, and it was just something I had to deal with for a short time. So I kind of got on with it – I had to really.” Vicky Fletcher, a mum with GDM in her second pregnancy, had a different experience. “Well, the first thing I asked my obstetrician was, ‘Is it manageable?’ and she said, ‘Yes, it’s totally manageable.’ So then I just thought, that’s fine. I can just deal with it.” “What was really nice is that my diabetes midwife said, you can’t give it to yourself, it just sort of happens,” Vicky recalls. As a pregnant mum with gestational diabetes, you then get access to all kinds of support or advice you need.
Upon diagnosis, if not controlled effectively, gestational diabetes can affect both mum and baby. Pregnant women are then at a higher risk of pre-eclampsia, going into pre-term labour and needing to deliver a large baby. The major concerns, however, are the effects that GDM can have on the baby. Issues start to arise when baby grows too large for their gestational age. This can lead to complications during and post-delivery, including shoulder dystocia
or birth trauma, respiratory distress (particularly in caesarean births) and hypoglycaemia (low blood sugar). “The risk of hypoglycaemia is reduced by good maternal control but all babies of diabetic mothers are at risk and need initial blood glucose monitoring,” Dr Mckinlay said. If the baby is seen to have any risks, they will spend a few hours or a couple of days in NICU until they’re ready to go home. Scary thoughts aside, it is important to remember that gestational diabetes can be kept in check by monitoring your diet, including some exercise in your day, and taking some medication (if required). “An important message is that gestational diabetes can be treated, which for most women just means changing how they eat in pregnancy,” Dr Mckinlay said. A nutritionist can assist you in coming up with a proper meal plan to help control your blood sugars. The meal plan will include portion sizes, snack ideas and carbcounting. Good eating habits should be complemented with some form of exercise for at least 20-30 minutes a day. You will also be asked to keep a food diary. To test your blood sugar levels you will be given a home glucose testing kit which will include a digital meter, test strips and a finger pricker. As part of your daily routine, you will be asked to test your blood at least four times a day; once in the morning before you eat anything, and then once two hours after breakfast, lunch and dinner. This process can be frustrating, and can even make you anxious about how what you eat affects you. “Sugar monitoring was hard,” Kate said. “I found it frustrating that my levels were all over the show no matter how well I ate or exercised. It was frustrating to have no control.” During my own journey with gestational diabetes, after trying a few meal options, I was successfully able to keep my blood sugars down with a change in diet and half-hour walks daily. Nonetheless, this may not suffice for all women, and subsequently, a bit of medication may be required. Remember that needing to take medication is in no way an indication that you have failed. Sometimes what works for you one week may not work the next week. It often happens that most women are able to manage their sugar levels in the first few weeks but find it harder later in their pregnancy. While taking medication can make some pregnant mums feel secure that their blood sugars are in control, other mums tend to feel anxious and sceptical. Kate had similar anxieties. “At first I was scared about how it would affect my baby. The injections didn’t faze me. It was more about what I am putting into my body and what effects that’s going to have on the baby. After seeing the effect taking insulin had on the growth of my baby via the growth scans, I was more relaxed about it all.” Another pregnant mum, Nita Yu, who had gestational diabetes in both her pregnancies, struggled to come to terms with taking medication. After she got her glucose challenge test results, she was prescribed to take Metformin tablets and insulin. Looking for a cause, Nita found that it could’ve been due to a recent overseas trip and a needed change of diet; and went to talk to her doctors again about reconsidering the medication route. Nita felt that the change in her diet made a big difference, and perhaps she did not need medication anymore. “I would often think to myself, can I avoid taking insulin? But [the doctors] did explain to me why they are giving you medicine, because they’re looking more at the baby’s living environment inside and trying to reduce all the risk factors when the baby comes out. I understand that. But I was still struggling.” After a few concerns in the baby’s growth scans, Nita realised that she may be better off having the medication and has since taken her recommended dose.
How does this affect my delivery?
As a GDM mum, your birth plan is going to look a little different and will include less control from your side. Your obstetrician will decide when the baby needs to come out – roughly in the 38th-40th week of your pregnancy depending on how well you are progressing. In most cases, you may have a date set to be induced. However, it is possible for you to go into labour normally and have a natural birth, which is what I had experienced. Baby will then need to be checked for hypoglycaemia and ensure that they don’t need any extra glucose. Almost all mums go back to their pre-pregnancy glucose levels after delivery of the baby. You will, however, need to do routine checks once a year from then on to check for type 2 diabetes. When I delivered, I remember being ecstatic about finally getting to eat whatever I wanted. Looking back on those months, the journey was hard. But one line that my midwife told me on that very first day still sticks with me, and that is: “This too shall pass.” And she was right.
If not controlled effectively, gestational diabetes can affect both mum and baby