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November 16, 2015

The challenge of gestational diabetes: "Why me?"

My pregnancy had been going well, and I was feeling great. Then my doctor told me I had gestational diabetes, and everything changed.

When I found out I was pregnant, I wasn’t just ecstatic at the thought of the new addition. I was also excited at getting a free pass to eat for two! So it was an unhappy shock to discover at the four-month mark that I had gestational diabetes. As the doctor talked about next steps, all I could focus on was the mac ‘n’ cheese burger and chocolate cake I’d had the night before, not to mention the visions of 15-pound babies in my head!

The early months of my pregnancy had been blissful. Luckily, I didn't suffer from morning sickness or any of the usual complaints. That all changed with my frightening diagnosis. I decided to do everything I could to control my gestational diabetes and have the healthiest pregnancy and baby possible.

A diagnosis of gestational diabetes can be unnerving, even for a health professional. Marlena Isaacs, unit co-ordinator of the emergency department at Rouge Valley Health System - Centenary Site, Toronto, was caught off-guard by her diagnosis. A registered nurse for 13 years, Isaacs was not anticipating any health issues during her pregnancy. She felt great and the baby was developing well.

Once diagnosed, she had to follow a strict meal plan, counting her carbohydrates and using measuring cups to control servings. When told she would need insulin, she was devastated. A diabetes educator reassured her that she hadn’t done anything wrong; her body had just become insulin-resistant due to increased hormones.

“She told me not to worry, I did everything right,” Isaacs says. “I think I was in denial that this was really happening to me, until they sent me home with insulin to inject myself.”

What is gestational diabetes?

As food is digested, the carbohydrates in it become simple sugar, or glucose. The pancreas releases insulin to convert that glucose to energy. But between 20 and 24 weeks of pregnancy, placental hormones are produced that elevate blood sugar levels, and women with gestational diabetes mellitus (GDM) can’t make enough insulin to handle the excess glucose. With the exposure to higher levels of glucose, the baby may grow dangerously large. According to the Canadian Diabetes Association’s Clinical Practice Guidelines, risk factors for GDM include maternal age, excess maternal weight, a previous history of prediabetes and GDM or delivering large babies. A family history of diabetes is also a factor, as well as taking certain medications or steroids. Certain ethnicities, especially Aboriginal, Hispanic, South Asian, Asian and African are at larger risk of GDM.

But GDM exhibits few clear symptoms and often affects women without any risk factors at all, so pregnant women are routinely tested between 24 and 28 weeks’ gestation. As I had multiple risk factors, my doctor suggested I get tested early, and the head start allowed me to begin treatment months earlier than I would have done otherwise.

How gestational diabetes affects mother and child

Untreated gestational diabetes can lead to complications relating to delivering a large baby, including an increased likelihood of preeclampsia and caesarean section. That’s why once a diagnosis has been made, the baby’s size is monitored frequently for the remainder of the pregnancy. Doctors will routinely schedule induction between 38 to 39 weeks to ensure a safe delivery.

The good news is that in most cases, the mother’s blood sugar returns to normal after delivery. However according to a 2008 study published in the Canadian Medical Association Journal, women who have had GDM have a known risk of recurrence with subsequent pregnancies, and are at a significantly increased risk of developing type 2 diabetes later in life.

With treatment, the associated risks for the child are generally not serious. While the delivery itself may be hard on the baby (if large for gestational age), in most cases, children do not suffer any long-term effects due to gestational diabetes. In rare cases, babies may suffer low blood sugar after delivery, which could irritate the brain. There is also an increased risk of jaundice, which is typically treated with phototherapy.

Treating gestational diabetes

After diagnosis, the patient is scheduled for appointments at a diabetes education centre. These sessions provide detailed information about GDM, what foods to avoid, how to measure blood sugar levels, create and keep to schedules, how to track food intake, and if necessary, how to inject insulin several times a day. That becomes necessary if the first treatment option of a restricted diet and moderate exercise fails to maintain blood glucose levels at target values. Oral diabetes medication is not approved for pregnant women.

Controlling GDM through diet requires a lot of discipline. Meals need to be scheduled, and the serving size and composition of each meal need to be measured. One of the low points in my pregnancy was going to a family celebration at an all-you-can-eat restaurant. Over the course of three hours, I watched my family devour a feast of high-carb/high-calorie delights while I miserably ate steamed vegetables and a salad.

Preventing gestational diabetes

According to Isaacs, “Diet and exercise are the key to any healthy lifestyle.” The Canadian Diabetes Association’s Guide for a healthy lifestyle after gestational diabetes recommends maintaining a healthy weight through eating well and exercising in moderation can both reduce the likelihood of gestational diabetes while pregnant, and reduce the risk of developing type 2 diabetes later. After pregnancy, women should periodically check their blood sugar levels. In addition, breastfeeding can reduce the risk of diabetes for both mother and baby.

Although it was a challenge, I was lucky to not need insulin. According to Isaacs, it was a psychological struggle to inject herself with her first needle: “I didn't know if I was going to cry or be sick,” she says. “But I knew I had to do it. I had to do it for my baby. I had no other option. I've been an emergency room nurse for 13 years and I've seen it all. Surely I could conquer a tiny needle four times a day!”

But in the end, we both knew that we would do whatever it took to ensure the health of our children, and we both safely delivered healthy, beautiful babies. Says Isaacs: “All of this is worth it, with the goal to have a healthy baby at the end of this journey.”

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