About Gestational Diabetes

Gestational Diabetes Mellitus (GDM) is a form of diabetes that begins during pregnancy. It usually starts after about 20 weeks of pregnancy and may be asymptomatic. Gestational diabetes affects 12% of women, with the numbers developing this condition increasing alongside obesity levels. It is diagnosed by means of a test called an Oral Glucose Tolerance Test.

Of the women who develop GDM during pregnancy, about 70% can control their blood glucose by making changes to their diet and increasing their exercise, about 30% of women with GDM will require insulin.

After pregnancy GDM goes away in about 80% of women, the other 20% of women will continue to have diabetes or pre-diabetes. Women who develop GDM have a very high risk of developing permanent diabetes in their lifetime.

Women who develop GDM have a very high risk of developing permanent diabetes in their lifetime.

Risk factors for developing gestational diabetes during pregnancy

Over 30 years of age
Overweight and obesity
Polycystic ovarian syndrome(PCOS)
Multiple pregnancies (twins/triplets)
Family history of diabetes
Non-Caucasian ethnicity
History of miscarriages, stillbirth, neonatal death or a baby born with a congenital abnormality
Previous gestational diabetes
Delivery of a large baby previously (over 4kg)

In this section:

Pre Pregnancy Care

Checklist for planning a pregnancy:

If you previously had GDM you may have developed diabetes before your next pregnancy so have your blood glucose levels checked and plan a visit with your GP or your local diabetes team to discuss this before becoming pregnant.
Take folic acid in preparation for pregnancy
Try to achieve your ideal body weight prior to conception, this will reduce your chances of developing GDM again
Stop smoking and drinking alcohol
Have a healthy diet
Continue to use reliable contraception until it is safe for you to conceive

Diet

Nutrition before Pregnancy
A healthy and balanced diet helps ensure that in the event of pregnancy, a woman of childbearing age will be in good health throughout the pregnancy and will be able to provide the unborn infant with the nutrition needed to develop properly.

Cut out alcohol.
All women with diabetes are advised to take 5mg of folic acid before conception.

Women of childbearing age should aim to consume a nutritionally adequate diet. Such a diet should contain food from the five main food groups every day.

Healthy eating guidelines for women of childbearing age:

Enjoy a wide variety of foods from the five food groups.
Pay attention to serving sizes - choose smaller portions and add plenty of vegetables, salad and fruit.
Include wholemeal breads, cereals, potatoes, pasta and rice to provide energy.
Eat at least five servings of different coloured fruit and vegetables every day.
Use low-fat varieties of milk, yoghurt and cheese - choose milk and yoghurt more often than cheese.
Include lean meat, poultry and fish (oily is best) daily, and remember that peas, beans and lentils are good alternatives.
Use polyunsaturated and monounsaturated spreads and oils sparingly - reduced-fat spreads are best.
Healthy eating can be enjoyed without foods like confectionery, savoury snacks, and biscuits - these foods are rich in calories, fat, sugar and salt and need to be limited.
Drink plenty of water.

Healthy cooking practices:

Grill, bake, steam or boil food instead of frying or deep frying.
Prepare and store food safely.
Limit salt intake.

Vitamin D
Vitamin D is needed for strong healthy bones and may protect against heart disease and cancer. Most people do not get enough vitamin D. Eating oily fish once or twice a week is the best way to get vitamin D. A vitamin D supplement of 200 IU per day is recommended.

Exercise

Physical activity is an important part of preparing for your pregnancy. Discuss exercise and an exercise plan that may best suit you with your doctor. Choose activities that you enjoy such as walking or swimming that you can make part of your daily routine.
If you have not been active for a while, start slowly and build up gradually. Gentle exercise is important especially if you have problems with high blood pressure, with your eyes, kidneys or heart or nerve damage.

Pre Pregnancy Care

Pregnancy

In this section:

Ante Natal Care

Gestational Diabetes Mellitus(GDM) is diabetes occurring for the first time in pregnancy. It usually develops after 20 weeks of pregnancy. Good control of diabetes during pregnancy combined with good antenatal care is known to reduce the risks for babies born to mothers with GDM and also reduce the risks for mothers. With GDM you will need to have hospital antenatal care to meet the needs of your pregnancy and diabetes.

Your visits to the clinic will be every 2 -4 weeks until 36 weeks gestation and from then on every week until delivery.
There may be more frequent ultra sound scans required for examination of fetal growth, in case your baby is growing too large or not growing enough or if you have high blood pressure.
You will be reviewed by your obstetric and diabetes teams as required. Your weight and blood pressure will be checked regularly. A specialised blood test known as HbA1c, which can assess how well blood glucose levels are being controlled in a person with diabetes, will be taken periodically to monitor your blood glucose control. Urine tests will be done at each visit to check for any kidney problems .

Almost 70% of women with GDM will be able to control their blood glucose by diet and exercise only. The other 30% of women with GDM will need additional treatment with insulin.
If you require insulin treatment, the dose of insulin increases as your pregnancy progresses and insulin adjustments will be made frequently in conjunction with your diabetes team, to maintain your blood glucose strictly within target.

Your Goals:

Your doctor and diabetes nurse may ask you to check your blood glucose levels at home with a testing meter called a glucometer. They will discuss with you when and how often to check your glucose levels. It is recommended to aim for fasting blood glucose below 5.3 mmol/l and an after meals blood glucose level below 7.8 mmol/l.
Follow diet and exercise guidelines
Attend all clinic appointments
Record baby movements and inform your doctor/nurse of any changes or concerns you may have
If you have nausea and vomiting, always phone your Diabetes Team for advice.

Diet

Foods to help your baby grow

Take a supplement 10micrograms of Vitamin D daily during pregnancy
Take folic acid for 12 weeks before pregnancy and during the first 12 weeks of pregnancy
Iron is important to make the extra blood needed by you and your baby. Good sources red meat, chicken, fish, eggs, cereals fortified with iron, beans ,peas and lentils and green vegetables
Vitamin C aids the absorption of non meat iron. Sources include oranges, kiwis berries, tomatoes, potatoes, peppers and green vegetables
Calcium is important for healthy teeth and bones. Good sources include milk, hard cheese and yogurt
Eat oily fish once a week, Omega 3 fats are derived from fish oils. Sources include sardines, salmon, trout, herring and mackerel. These are important for your baby's brain and nerve development.

Breastfeeding can protect you and baby against diabetes, obesity and other illnesses. Ask your doctor, midwife or dietician for more information.

A diabetic diet is a healthy diet. The following are the guidelines you should follow:

Follow a healthy balanced diet.
Eat regular meals with small amounts of high fibre carbohydrate food at each meal.
Eat plenty of vegetables
Avoid added sugars in your diet.
Include a small breakfast everyday.

1. Follow a healthy balanced diet

What is a healthy diet?

A healthy diet is a balance of foods from all the food groups. Your diet should be low in fat, low in sugar and salt, rich in wholegrains, fruits, vegetables and calcium. You should eat a well balanced diet to stay healthy and support baby's growth. Be sure to follow guidelines for food safety during pregnancy.

Balance

The pyramid below shows how much of each food you need every day. The dietician can make a meal plan that suits your own needs.

2. Eat regular meals with small amounts of high fibre carbohydrate food at each meal.

There are three basic nutrients in food: carbohydrate, protein and fat.

Carbohydrates provide us with most of our energy. Carbohydrate foods turn into sugar (glucose) after you eat them. It is important that these foods are eaten in the same quantity and at regular times throughout the day. This will help you keep the amount of sugar in your blood steady and energy levels up. Choose high fibre, whole grain options as they release the energy (sugar) more slowly. High fibre, whole grains also contain more vitamins and minerals, can help prevent constipation and keep hunger at bay.

Protein is essential for your baby's development and can help keep hunger at bay. Protein is found in meat, chicken, fish, eggs, peas, beans, lentils, tofu, nuts and cheese and will not turn to sugar when you eat them. Speak with your dietitian about the right amount for you.

Fats do not turn to sugar but should be limited in your diet. One special fat (omega-3) should be increased in your diet. Omega-3 fats have been shown to improve baby's brain development and are important to heart health. The best source is oily fish e.g. salmon, trout, mackerel, sardines, kippers and herring. Aim for 1 to 2 portions of oily fish per week. Vegetarian sources of omega-3s include soya, walnuts and rapeseed oil.

The following are types of carbohydrates foods:

a. Starches: bread, cereal, grains, rice, potatoes, yams, corn, peas, beans (baked beans, kidney beans, chickpeas).
b. Milk and yogurt: contain lactose, a natural sugar.
c. Fruit contains fructose, a natural sugar

a. Starches

Examples of high fibre starchy foods are:

Breakfast cereals: porridge oats, All-Bran®, Shredded Wheat®
Breads, baps, rolls, pitta: wholegrain, granary, wholemeal, rye, oat bran, chapatti.
Grains: brown rice, basmati rice, millet, whole barley, quinoa.
Pasta: macaroni, spaghetti, couscous, semolina or noodles - try whole wheat versions.
Crisp breads: rye crisp bread, wholegrain crackers, oatcakes.
Potatoes: new potatoes, sweet potatoes or yams.

b. Milk and Yogurt

Milk and yogurt are good sources of calcium for strong bones and teeth. Choose yogurts with no added sugar (diet or sugar free). Limit your milk to no more than 3 glasses of 200ml each daily as too much milk can make your blood glucose levels too high. Your dietician will advise you on the best type of milk for you.

c. Fruit

Fruit is a healthy food, but it is high in natural sugars. A portion of fruit is either one very small piece of fruit or half of a large piece of fruit. Try to eat fruit that is not ripe. Good options are small green banana, green apple or pear, kiwi, Satsuma, grapefruit. Do not eat fruit that has been canned in syrup. Avoid fruit juices. Avoid dried fruits such as raisins, sultanas, dates and apricots. Discuss recommended portions with your Dietician or Diabetes Nurse Specialist.

3. Eat plenty of vegetables

4. Avoid added sugars in your diet:

Sugar & sugary foods (e.g. chocolates, sweets, toffees, cakes, honey, jam, marmalade, normal fizzy drinks, sugar/chocolate coated breakfast cereals etc)are absorbed quickly by the body, which can cause your blood sugar level to rise rapidly. It is therefore best to avoid these foods and to choose low sugar alternatives.

TIP:
Avoid foods labelled "diabetic" (chocolates, sweets and jams) or made with sugar alcohols like sorbitol, malitol, xylitol. They are often high in fat and can cause wind, bloating and diarrhoea if you eat a lot of them.

Sugar in Medication: Some medicines like those for heartburn and constipation contain sugar. Make sure all the medications you are taking are sugar free. Speak with your doctor or pharmacist about sugar-free options that are safe in pregnancy.

5. Include a small breakfast every day

Blood glucose levels tend to be higher in the morning time. You may need to limit the amount of carbohydrate you take at breakfast and you must avoid added sugars.

Sample breakfasts:

Remember... NO JUICE!

1 Shredded Wheat® biscuit or 40g All-Bran® sticks and 200 ml low-fat milk.
30g dry porridge made on water.
1 slice wholegrain or granary toast and 125g diet yogurt.
2 thin slices wholegrain or granary toast and 30g light cheddar cheese and tomato slices.
1 slice wholegrain or granary toast and 1 poached egg and 2 dessert spoons reduced-sugar baked beans and a half of grilled tomato/mushrooms and 1 grilled rasher (fat trimmed)

Summary: Putting it all together

To keep your blood glucose levels under control and meet your needs for pregnancy you should:

Eat three meals and some snacks spaced evenly over the day. Smaller portions of carbohydrates eaten more often can keep your blood glucose levels steady and prevent over-eating.
Avoid added sugars and sugary foods.
Include a small portion of starchy carbohydrate at each meal (wholegrain bread, brown rice, pasta, new potatoes, sweet potatoes, high fibre cereals)
Limit fatty or fried foods and take-aways.
Do not skip meals. You may find yourself eating too much at the next meal because you are overly hungry.

Foods and Drinks to avoid or limit in Pregnancy

Avoid alcohol
Avoid excess amounts of vitamin A
Avoid cod liver oil supplements, and vitamin and mineral supplements which contain vitamin A.
Avoid liver, liver pate, and liver sausage.
It is recommended that pregnant women should limit their caffeine intake to less than 200mg a day. There may be a slight risk that too much caffeine will affect your baby's birth weight and in some cases cause miscarriage.
Caffeine is found naturally in a range of foods such as coffee, tea and chocolate. It is also added to some drinks especially to so called energy drinks.

Caffeine content of some foods and drinks:

1 average mug of instant coffee 100mg
1 mug of filtered coffee 140mg
1 mug of tea 75mg
1 can of regular/diet cola drinks up to 40mg
1 can of energy drink up to 80mg
1 bar of chocolate (50mg) up to 50mg.

Avoid shark, swordfish, marlin, tilefish, ray and King mackerel as they may contain high levels of mercury. Limit tuna to 2 small cans or 1 fresh tuna steak per week.
Avoid raw or lightly cooked eggs and foods that contain them e.g. home-made mayonnaise and mousse.
Avoid unpasteurised milk and dairy products, including soft, mould-ripened cheese e.g. Camembert and brie.
Avoid raw or undercooked meat, poultry, fish and shellfish.
Avoid pre-cooked or ready prepared foods that do not require reheating
Do not eat pate
Do not eat unwashed fruit and vegetables
Avoid herbal remedies.

FOOD SAFETY TIPS:

Food should always be handled, stored and cooked in a hygienic manner.
Keep raw and cooked foods separate to avoid contamination.
Eat all foods before their use-by date.
Follow manufacturers instructions for storage and preparation/
Wash all fruit and vegetables before eating.
Defrost frozen meat thoroughly before cooking.
Never re-heat foods more than once.
Always wear gloves when gardening or handling cat litter.

Exercise

Exercise (30 minutes a day) is an important way to keep healthy during your pregnancy. Pregnancy will put extra stress on your heart and lungs so it is best not to begin with a hard exercise programme. Choose exercises that you will enjoy such as walking or swimming and always discuss your exercise plan with your doctor who will advise you the type of exercise plan best suited for you. If you haven't been active for a while start slowly and build it up gradually. Remember physical activity affects blood glucose levels so always check your blood glucose after any activity.

Treatment (Targets, Hypos)

During your pregnancy your insulin dose (if insulin was needed) will change considerably. You will be encouraged to be involved with the changing of your insulin dose as pregnancy proceeds. Insulin type and doses to achieve the best possible glucose control will be discussed with you and closely monitored by your physician and diabetes nurse specialist. The most usual way is to take 3 injections of rapid acting insulin given by a pen before breakfast, lunch and evening meal, combined with an injection of long lasting insulin taken at bedtime.

If you are ill, particularly if you have a temperature, your blood glucose level will rise even if you do not eat. Contact your doctor or diabetes nurse for help. Your blood glucose level is more difficult to control when you are ill and the staff will be able to advise you.

Hypoglycaemia and Pregnancy

Hypoglycaemia can occur if your blood sugar drops too low. Although it can happen if your GDM is being treated with insulin, it is uncommon.

Common symptoms of low sugar include:

Confusion or difficulty paying attention
Dizziness or light headedness
Shakiness
Clumsy movements
Sweating
Hunger
Difficulty speaking

To avoid episodes of hypoglycaemia you will need to:

Eat meals regularly
Test your blood glucose level regularly as directed by your doctor and diabetes nurse specialist and adjust your food intake and insulin levels as advised.
Make sure family and friends close to you recognise an episode of hypoglycaemia and know how to help you.
Carry dextro-energy tablets with you.
You should take care before driving, checking your blood glucose before you set off.

Possible problems during pregnancy

Morning Sickness
Morning sickness is very common in pregnancy, usually improving after about 16 weeks. Some women find eating a dry biscuit or a glass of milk before getting up in the morning can help to prevent the nausea.

Pre-eclampsia is a condition where the mother develops very high blood pressure, protein in the urine and fluid retention. This occurs usually in the last trimester of pregnancy. If this occurs you will be admitted to hospital and given drugs to control your blood pressure. If severe, it may warrant early delivery of your baby.

Polyhydramnios occurs when you retain more amniotic fluid (the liquid in which your baby floats throughout pregnancy) than normal. This can happen when your diabetes control is not good and can cause pre mature labour (onset of labour before the baby is fully developed).This condition can be improved by tighter blood glucose control in the mother.

Labour and Delivery

Your labour and delivery will be closely monitored due to your gestational diabetes.The best time and way to deliver your baby will be discussed with you close to the time, with the decision being based on aspects of your baby's health, your diabetes control, blood pressure and any previous deliveries. If you have required insulin in your pregnancy, you will need insulin support throughout active labour and delivery to ensure stable blood glucose levels.
If it is recommended that your labour is induced you will be allowed eat and drink as normal with close monitoring of your blood glucose levels. Insulin will be given as required and once labour is established a glucose and an insulin drip will be started with your blood glucose being measured frequently.
If your delivery is to be a planned caesarean section you will be asked to fast from the night before and a glucose and insulin drip will be started before you go in to theatre. When your baby is born, his/her blood glucose will be tested frequently. Sometimes babies of mothers with diabetes will have low blood glucose and it is recommended to breastfeed them as soon as possible after the birth and to feed frequently.

After delivery of your placenta, gestational diabetes will generally go away. Insulin is stopped and you can eat and drink as normal. Your blood glucose will be checked after delivery until your levels stabilise.

Babies born to mothers with well controlled GDM should have no more problems then those born to mothers without diabetes. Sometimes babies need to be admitted to the special care baby unit for blood glucose control because they can develop low blood glucose in the first few days. This will be managed, if possible, by increasing the feeds the baby receives but sometimes a glucose drip is needed for a short period. Within the first 24 hours after birth, doctors will check that your baby is healthy. Some babies develop jaundice after birth and may require phototherapy (light treatment).

Infant Feeding

Breast feeding provides the best nutrition for your baby; giving him/her extra protection against infection and helps you to develop a deep bond with your baby. Breast feeding is recommended in women with Gestational Diabetes, with research showing that breastfed babies are less likely to develop diabetes and obesity in the future. Breastfeeding may also help to reduce the onset of Type 2 diabetes in mothers in the future. It allows your body to use up some extra calories that were stored during pregnancy

Points to remember when breastfeeding

Early breastfeeding, within the first hour of delivery is recommended to help prevent low blood glucose levels in the baby.
Your diet may need to be altered as your energy requirements will increase when you are breastfeeding.
You should eat before breastfeeding, and keep a snack close by in case the feeding is prolonged.
Drink according to your thirst.
If your baby is found to have low blood glucose levels, it may be necessary to supplement breast feeds with expressed breast milk and formula milk if recommended by your paediatrician; this may only be for a short time.

Post Pregnancy

In this section:

After Delivery

Generally your experience of childbirth will be the same as for any new mother, however the doctors will take some extra steps in monitoring both you and baby due to your diabetes.

After the delivery of your placenta, your insulin will be stopped and in most cases the problem of GDM will go away following delivery.
Your blood glucose will be checked regularly after delivery for the first 24 hours and you will resume a normal diet.

Babies born to mothers with well controlled GDM during their pregnancy should have no more problems then those born to mothers without diabetes. Sometimes babies will need to be admitted to the Special Care Baby Unit, usually for help with blood glucose control because babies can develop low blood glucose levels in the first few days of life. Where possible this is managed by increasing the feeds your baby receives, but sometimes a glucose drip is needed. Early feeding of your baby (within the first hour) is encouraged. Within the first 24 hours after birth, doctors will check that your baby is healthy. Some babies develop jaundice after birth, so your baby may require treatment. Phototherapy (light treatment) is usually enough depending on the condition of your baby.

Infant Feeding

Breast feeding provides the best nutrition for your baby; giving him/her extra protection against infection and helps you develop a deep bond with your baby. Breast feeding is recommended in women with GDM, with research showing that breastfed babies are less likely to develop diabetes and obesity in the future. It also helps keep the mothers glucose levels under control, and it allows your body use up some extra calories that were stored during pregnancy.

Points to remember when breastfeeding:

Early breastfeeding, within the first hour of delivery is recommended to help prevent low blood glucose levels in your baby.
Your diet may need to be altered as energy requirements will increase when breastfeeding.
You should eat before breastfeeding, and keep a snack close by in case the feeding is prolonged.
Drink according to your thirst
If your baby is found to have low blood glucose levels, it may be necessary to supplement breast feeds with expressed breast milk and formula milk if recommended by your paediatrician; this may only be for a short time.

The chance of your baby developing diabetes in the future is relatively low. To further minimise this risk, it is very important to ensure he/she has a well balanced diet and is kept physically active during childhood. Vitamin D is essential for good bone health. Evidence in Ireland suggests that children and adults have low levels of vitamin D; all babies are advised to be given a D3 supplement with no other vitamins added to it.

Post Natal Check-up

Contraceptive advice can be provided prior to discharge. Make sure your cervical screen is up to date. Follow up should be arranged at 6-12 weeks following delivery for a postnatal examination with the Obstetrician.

Because you had gestational diabetes, you are at an increased risk of this occurring again in any future pregnancy. You are also at an increased risk of developing pre-diabetes or type 2 diabetes in your lifetime. It is therefore important that you have your blood checked postnatally to ensure everything is back to normal.
Arrangements will be made for you to have a postnatal oral glucose test at approximately 6-12 weeks after delivery to determine whether you do or do not have diabetes outside of pregnancy. If this is positive an appointment will be made for you to attend the Diabetes Service. Diabetes Service. If your postnatal oral glucose test is normal, you should make sure to always have an annual check of your blood glucose levels with your GP.