1. Gestational Diabetes Amanda Manresa Maria Nunes-Quijano

2. What is Gestational Diabetes?  Pregnant women who have never had diabetes before but who have high blood glucose levels during pregnancy  Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy

3. What causes Gestational Diabetes?  Hormones from the placenta help the baby develop. But these hormones also block the action of the mother's insulin in her body. This problem is called insulin resistance. Insulin resistance makes it hard for the mother's body to use insulin.  During pregnancy, the placenta makes hormones that can lead to a buildup of sugar in your blood. Usually, your pancreas can make enough insulin to handle that. If not, your blood sugar levels will rise and can cause gestational diabetes.

4. Risk Factors You are more likely to get gestational diabetes if:  You were overweight before you got pregnant.  You are African-American, Asian, Hispanic, or Native American.  Your blood sugar levels are high, but not high enough to be diabetes.  Diabetes runs in your family.  You’ve had gestational diabetes before.

5. Signs & Symptoms  Sugar in urine  Unusual thirst  Frequent urination  Fatigue  Nausea  Frequent vaginal, bladder, and skin infections  Blurred vision

6. Diagnosis  Approximately 2-5% of pregnant women develop gestational diabetes; this number may increase to 7-9% of mothers who are more likely to have risk factors. The screening for this disease usually takes place between your 24th and 28th week of pregnancy.  If the patient is at high risk for developing gestational diabetes, you may test for diabetes at the first prenatal visit. If the patient is at average risk for developing gestational diabetes, you'll likely have the screening test during the second trimester — between 24 and 28 weeks of pregnancy. Doctors test for gestational diabetes during this time because the placenta is producing large amounts of hormones that may cause insulin resistance. If the results indicate elevated levels, further testing would be done to confirm a gestational diabetes diagnosis.  There are two tests done to diagnose gestational diabetes: Glucose Challenge Test and the Glucose Tolerance Test. If the Glucose Challenge Test comes back negative, no further testing is required. However, if the test comes back positive the patient must have the follow up three hour Glucose Tolerance Test done.  Once the Glucose Tolerance Test is completed, if only one of your readings comes back abnormal, your doctor may suggest some changes to your diet and/or test you again later in the pregnancy. If two or more of your readings come back abnormal, you’ll be diagnosed with Gestational Diabetes.

7. Glucose Challenge Test  No preparation is required prior to the test. During the test, the mother is asked to drink a sweet liquid (glucose) and then will have blood drawn one hour from having the drink, as blood glucose levels normally peak within one hour. No fasting is required prior to this test.  The test evaluates how your body processes sugar. A high level in your blood may indicate your body is not processing sugar effectively (positive test). If the results of this screen are positive, the woman may have the Glucose Tolerance Test performed. It is important to note that not all women who test positive for the Glucose Challenge Screening test are found to have diabetes upon further diagnosis.  If the blood glucose level is higher than 140 mg/dL after the one- hour test, the Glucose Tolerance Test is recommend (three-hour test.

8. Prepping for the Glucose Tolerance Test  Eat a balanced diet that contains at least 150 grams of carbohydrate per day for 3 days before the test. Fruits, breads, cereals, grains, rice, crackers, and starchy vegetables such as potatoes, beans, and corn are good sources of carbohydrate.  Do not eat, drink, smoke, or exercise strenuously for at least 8 hours before your first blood sample is taken.  You will not be permitted to eat or drink anything but sips of water for 14 hours prior to the test, so it is best to schedule the test for first thing in the morning.  Assess all prescriptions and non-prescription medicines the patient is taking. Certain medications may need to be stopped before the test.

9. Glucose Tolerance Test  A blood sample will be collected when the patient arrives. This is the fasting blood glucose value. It provides a baseline for comparing other glucose values.  The patient then will be asked to drink a sweet liquid containing a measured amount of glucose. It is best to drink the liquid quickly. For the standard glucose tolerance test, they will drink 75 grams or 100 grams.  Blood samples will be collected at timed intervals of 1, 2, and sometimes 3 hours after they drink the glucose. Blood samples may also be taken as soon as 30 minutes to more than 3 hours after they drink the glucose.

10. Oral Glucose Tolerance Test Cont. The following are the values that the American Diabetes Association considers to be abnormal during the Glucose Tolerance Test:  Fasting: 95 mg/dl or higher  One hour: 180 mg/dl or higher  Two hours: 155 mg/dl or higher  Three hours: 140 mg/dl or higher

11. Treatment  Diet is the mainstay of treatment in Gestational Diabetes whether or not pharmacologic therapy is introduced. Dietary control with a reduction in fat intake and the substitution of complex carbohydrates for refined carbohydrates seeks to achieve and maintain the maternal blood glucose profile essential during gestation.  The ADA also recommends nutritional counseling, if possible by a registered dietitian, with individualization of the nutrition plan based on height and weight.  When diet and exercise fail, insulin can be used. Insulin is required when the fasting plasma glucose is more than 95 mg/dl or when 1-h postprandial values are over the 130 to 140 mg/dl range and when 2-h postprandial values exceed 120 mg/dl.  If you're testing your blood glucose, the American Diabetes Association suggests the following targets for women who develop gestational diabetes during pregnancy:  Before a meal (preprandial): 95 mg/dl or less  1-hour after a meal (postprandial): 140 mg/dl or less  2-hours after a meal (postprandial): 120 mg/dl or less

12. How Gestational Diabetes affects the pregnancy  Mothers have a higher chance for a premature delivery  Increased chance of cesarean delivery  Slightly increased risk of fetal and neonatal death  When you have gestational diabetes, your pancreas works overtime to produce insulin, but the insulin does not lower your blood glucose levels  Extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This can lead to macrosomia, or an overweight baby.  Babies with macrosomia face health problems of their own, including damage to their shoulders during birth.  Because of the extra insulin made by the baby's pancreas, newborns may have very low blood glucose levels at birth and are also at higher risk for breathing problems.  Babies with excess insulin become children who are at risk for obesity and adults who are at risk for type 2 diabetes.

13. After the pregnancy…  Gestational diabetes usually goes away after pregnancy. But once you've had gestational diabetes, your chances are 2 in 3 that it will return in future pregnancies. In a few women, however, pregnancy uncovers type 1 or type 2 diabetes. It is hard to tell whether these women have gestational diabetes or have just started showing their diabetes during pregnancy. These women will need to continue diabetes treatment after pregnancy.  Many women who have gestational diabetes go on to develop type 2 diabetes years later. There seems to be a link between the tendency to have gestational diabetes and type 2 diabetes. Gestational diabetes and type 2 diabetes both involve insulin resistance. Certain basic lifestyle changes may help prevent diabetes after gestational diabetes.

14. References  Gestational Diabetes. (n.d.).http://www.diabetes.org/diabetes-basics/gestational/http://www.diabetes.org/diabetes-basics/gestational/  Gestational Diabetes Causes, Diagnosis, and Treatment. (n.d.).http://www.webmd.com/diabetes/gestational-diabetes-guide/gestational_diabeteshttp://www.webmd.com/diabetes/gestational-diabetes-guide/gestational_diabetes  Gestational Diabetes: Testing and Treatment. (2012). http://americanpregnancy.org/pregnancy-complications/gestational-diabetes/ http://americanpregnancy.org/pregnancy-complications/gestational-diabetes/  Guillemette, L., Lacroix, M., Battista, M. C., Doyon, M., Moreau, J., Ménard, J.,... & Hivert, M. F. (2014). TNFα dynamics during the oral glucose tolerance test vary according to the level of insulin resistance in pregnant women. The Journal of Clinical Endocrinology & Metabolism, 99(5), 1862-1869.  Hartling, L., Dryden, D. M., Guthrie, A., Muise, M., Vandermeer, B., & Donovan, L. (2013). Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the US Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research. Annals of internal medicine, 159(2), 123-129.