dr. Sarah Buckley: Gestacijski dijabetes

[Saradadevii]

Q: I have been diagnosed with gestational diabetes. I am so heartbroken as I truly want a natural birth. Is there any chance I can still birth naturally?


A: Firstly, I can understand your concern at being diagnosed with what sounds like a serious condition. However, as I will explain, this is not something to be dramatically concerned about, except for the influence it will have on your carers.

Gestational Diabetes Mellitis (GDM) refers to an elevation of glucose (a simple sugar) in the blood of a pregnant woman, whose blood glucose level is normal outside of pregnancy.

GDM is mostly caused by the woman's normal pregnancy hormones (made by the baby's placenta), which make her body somewhat resistant to the effects of insulin. Insulin is the hormone (the body' schemical messenger) that lowers the levels of glucose in the blood by transporting it into the cells. You could imagine insulin as opening the door of the cell and allowing in glucose, which used as the primary energy source for most of the body tissues.

Insulin resistance means that the body is responding less to insulin (the door is not open as wide), and so less glucose enters the cell and more stays in the bloodstream, giving higher levels than usual. In pregnancy this is beneficial, as it leaves more glucose in the mother's bloodstream,which makes more glucose available to the baby, who gets all the glucose needed for growth and development from the mother's bloodstream, via the placenta. This transfer of glucose is dependent on the mother's levels being higher than the baby's.

The level of insulin resistance that an individual pregnant woman has depends on her own biochemistry and genetics, as well as her diet and activity levels. Some women, and some families, seem to get more insulin resistance than others in pregnancy, and this may reflect a slightly increased susceptibility to diabetes in later life. The baby also plays a part, because he/she can signal the mother's body to increase glucose levels by producing more pregnancy hormones, giving more insulin resistance. As above, this is more likely to happen when the baby is big.

If the mother has a diet that includes a lot of carbohydrates with a high glycemic-index (ie foods that cause a rapid rise in blood glucose) and/or low levels of activity, her blood glucose may be higher and she may be more likely to be given this diagnosis.

So you can see that it is normal and healthy to have higher levels of glucose in pregnancy. However, when levels reach a certain point, a woman is at risk of being labeled with 'impaired glucose tolerance' (IGT, also called 'pre diabetes')and at even higher levels, with GDM.

GDM is a very controversial diagnosis. Some experts in the area have called it 'a diagnosis still looking for a disease', a 'non-entity' and a 'useless diagnosis', while others think it is so important that every pregnant woman should be tested for it. Michel Odent believes that the diagnosis of GDM causes more harm than good by labeling the pregnant woman 'high risk' which increases her anxiety but has no benefits for her or her baby, as below.

The US Preventative Services has not recommended routine screening and a Canadian committee of experts also concluded, 'Until evidence is available from large randomised controlled trials that show a clear benefit from screening for glucose intolerance in pregnancy, the option of not screening for GDM is considered acceptable.' The UK-based Cochrane database, which has analyzed the best medical evidence, also concludes that there are no benefits to treating GDM, in terms of outcome for mother and baby, which makes the diagnosis also very questionable.

Some doctors are concerned that women with GDM are more likely to have a very large ('macrosomic') baby, and it is true that there is an association between GDM and large babies. However, these large babies can be explained by other factors,such as the mother being overweight. Medical treatment does not seem to change this significantly, and it seems more likely that the size of the baby is causing the GDM, (because a big baby needs more glucose and so makes more hormones to increase insulin resistance) rather than GDM causing a big baby.

International studies show that the only major outcome from making this diagnosis is to increase the risk of a caesarean. This is unfortunate, but makes your concerns very valid.

My advice to you is the same as I would give to any pregnant woman- ensure that your diet is balanced, with adequate levels of protein, high-quality fats and low-GI carbohydrates.(See website below for more about GI index of foods) Keep a good balance between rest and exercise- walking and/or swimming regularly (at least 3 to 4 times per week) are beneficial. Unless your blood glucose is very high and/or causing symptoms such a thirst and passing lots of urine (this is uncommon for GDM), I would not recommend that you take any medication. If you need to control your blood sugars, consider exercising more and/or changing your diet.

You may also want to ask around and ensure that you have a carer who has a reasonably relaxed attitude to GDM. Your chances of a normal birth are much more related to your carers attitudes to GDM than to your condition. In particular, you need to consider that the extra tests and scans that are often used to check the baby's condition and weight are more likely to cause more interventions (especially caesareans) and unlikely to improve the outcome for you or your baby. Henci Goer's paper, as below, is an excellent resource.

After the birth, there are sometimes concerns about the baby having a low blood sugar. This is less likely if your blood sugars have been stable and you have not received iv glucose in labour. It is wise to ensure that your baby has free access to your breasts after birth, and is kept warm and dry.
La Leche League advise
"The best way to stabilize blood sugar and prevent hypoglycemia (low blood sugar) in all infants is prompt and frequent feedings of colostrum and human milk."

There is a lot more information about gestational diabetes and whether to test for it in the new edition of my book Gentle Birth., Gentle Mothering.

Blessings for a gentle and straightforward birth.

Resources:
Guide to low GI foods
http://www. glycemicindex.com

Comments by Michel Odent
http://www.birthpsychology.com/primalhealth/#anchor336050< /p>

Comments by Henci Goer
http://parenting.ivillage.com/pregnancy/ pcomplications/0,,9cgc,00.html

Low Blood sugar in newborn babies
http://www.lalecheleague.org/NB/NBJulAug97p107.html

Tuffnell DJ, West J, Walkinshaw SA. Treatments forgestational diabetes and impaired glucose tolerance in pregnancy.The Cochrane Database of Systematic Reviews 2003, Issue 1. Art.No.: CD003395. DOI: 10.1002/14651858.CD003395.

Canadian TaskForce on the Periodic Health Examination. Periodic health examination,1992 update: 1. Screening for gestational diabetes mellitus.Can Med Assoc J 1992;147(4):435-43.

ACOG. Diabetes and pregnancy. Technical Bulletin No. 200, 1994.

[kailash]

Hvala za ovo! Upravo mi je trudnoj prijateljici dijagnosticiran gestacijski dijabetes i ovo će joj svakako koristiti!

[Danci_Krmed]

super tekst saradadevii, dobro će doći velik broj trudnicama

[krumpiric]

ja sam odbila onaj regularni ogtt i sad ipak moram ići, naglo sam dobila 4kg(u mj dana isto ko i u ostalih 5,5mj zajedno), baka mi je dijabetičar na inzulinu, a M se rodio s 4030g.
Hvala na tekstu, nadam se da mi neće trebati...al opet... :/

[stellita]

Ja sam radila OGTT i kao inace pobornik zdravog nacina zivota pa time i prehrane ( osobno ne jedem meso- ribu jedem, secer, te bijele smrti isto nema, kao ni salama, aditiva i sl. gluposti) jako sam se zacudila kada mi je na testu nadjena blago povisena razina GUK nakon 120min. Savjetovali su mi dijetu od 2200 kcal jer se ipak puno krecem i evo sada ja opet si mislim a sto da mijenjam?? Do sada sam se tako hranila, 5 obroka (dobro ovdje su ukljucili i taj nocni u 22 sata) a ipak nosim blizance.
Zaista a sto bi samo bilo da sam startala s 100 kg u trudnocu i da sam opalila po cvarcima i kulenu? Znam da intolerancija na guk je prolazna stvar ali s druge strane ja sam u 18tj trudnoce dobila samo 3 kg.
Odlucila sam se jos vise disciplinirati (ako je to ikako moguce ) pa sljedeci tjedan radim mali profil i bas me zanima kako ce to ispasti. Inace mi je HgbA1c bio 4!

eh...

[kailash]

stellita meni su savjetovali dijetu od 1800 kcal jer sam dobivala puno kila (ukupno 30). međutim, nisam se držala nikakve dijete jer sam zaista, kao i ti, pazila što jedem. pogotovo što je na listi bilo 90% meni nejestivih stvari (meso, riba, jaja,...).

[laky]

nazalost neznam engleski toliko dobro da prevedem teksta isto mi je dijagnosticiran gestacijski dijabetes a udebljala sam se 4 kg u 21 tt.
uglavnom jedem povrće,voće jabuke i sir nemasni posni ,kruh isključivo crni..

[stellita]

ja sam učinila taj mali profil kod kuće i rezultati dakle sva 4 su bila oko 4.00!! Dakle savršeno....i sada će me maltretirati da to radim svaka 3 tjedna. Uzas jednom kada te uhvate u kolo onda te masakriraju do temelja.....

[Poslid]

Fora je u tome što za gestacijski dijabetes u trudnoći nema nikave terapije i on nestaje nakon trudnoće.
Dakle sve što ostaje je pravilna i zdrava prehrana - a toga bi se morali držati svi (ne samo trudnice).
Restriktivne diejte kod trudnica su opasne i stresne i nikao mi nije jasno zašto ih i dalje prepisuju.

[kailash]

Obrisala sam postove koji su se više ticali patoloških stanja. usmjerimo se ovdje ipak na ono o čemu tekst i govori.
Hvala .

[Danka_]

Treba samo imati na umu da gestacijski dijabetes moze biti patolosko stanje, i onda donositi odluke s obzirom na konkretni slucaj.
Problem je sto je tesko znati radi li se o patologiji ili ne dok se ne napravi test. Ako ne OGTT, onda mozda profil, ili samo skrining test.
Naravno, svaka zena moze i treba odluciti sama za sebe, uvazavajuci realnost i razum. Dakle, bez zastrasivanja, ali i bez uljuljkivanja, nego na osnovu objektivnih pokazatelja. Pri cemu treba imati na umu da simptomi hiperglikemije u trudnoci mogu proci neopazeno.

Evo, necu vise.

[kailash]

Danka .

Nadovezat ću se jednim citatom, kad već govorimo da prehrana može pomoći u prevenciji GD, ali i utjecati na već postojeći GD.

"Exercise is also important, as it promotes insulin sensitivity as well as helping burn calories. Diet and exercise during pregnancy have been shown to reduce the chances of developing GD and also of having an overly large baby. Even fifteen to thirty minutes of light exercise such as walking three times weekly can be beneficial.

Dietary changes that may benefit GD, or even prevent its development, include:
-replacing food with a high glycemic index (GI) with low GI carbohydrates
-decreasing fat and increasing carbohydrates in the diet
-increasing essential fatty acids in the diet.

It is also sensible to ensure adequate levels of chromium, magnesium, vitamin E, selenium, vitamin B6, and zinc in diet, which may help with glucose metabolism.
Other food and herbs that may be helpful include onions and garlic, aloe vera, ginseng, fenugreek.