Wednesday, April 3, 2013

Predicting Diabetes - Pregnancy As a Crystal Ball

At this point in my life, I have had the honor of helping many women have happy, healthy pregnancies. Good maternity care is essential, but sometimes pregnancy itself acts like a crystal ball.

Okay. This may sound a bit like voodoo, but please hear me out.

Scientists have known for some time that high blood pressure in some pregnancies can be a predictor of future heart issues in certain women. Now it seems that gestational diabetes can also be an indicator of who will get the full blown diabetes disease later in life.

Best of all, if it can be predicted... we may be able to avert the onset of this terrible disease.

Is it possible that those unique nine months of unprecedented nausea, hormonal changes, and emotional roller coaster rides, will hold even more clues to help save women's lives? Think about this as you kiss and hug your newborn as a new mother... or as you watch your own mother play with her grandchildren, hopefully as a still-vibrant and healthy senior. It goes without saying that the health of mothers is incredibly vital to the health and well being of their offspring.

What is Gestational diabetes?

Gestational diabetes is defined as any type of glucose impairment that is initially detected during pregnancy. The incidence of Gestational Diabetes in the United States is about 4% and rates are increasing over the last few years. High risk factors for the development of the condition include:

What are the risk factors for Gestational diabetes?

  • Age over 25 years

  • Obesity

  • Family history of diabetes

  • Previous history of gestational diabetes

  • Certain ethnic groups (Hispanic, American Indian, Asian, African-American)

What are the screening recommendations for Gestational diabetes?

The American College of Obstetrics and Gynecology recommends that all pregnant women be screened for gestational diabetes. The most common diagnostic test is the 50 gram 1-hour glucose challenge test that is given between 24 and 28 weeks of gestation. An abnormal result is defined as blood glucose of 130 mg/dl or greater or 140 mg/dl or greater, depending upon the criteria used. If abnormal, the patient then undergoes a 100 g 3-hour oral glucose tolerance test in which 2 or more abnormal values confirm the diagnoses.

What are the treatment options for Gestational diabetes?

Various treatments during pregnancy including dietary modifications directed by a certified nutritionist who specializes in diabetes, physical activity and possibly medications, depending upon the level of severity. The medications may include oral hypoglycemic agents or insulin, depending upon the glucose values obtained as the pregnancy progresses. Increased resistance to insulin occurs as pregnancy progresses, stressing the pancreas and making more demands on the pancreas to manufacture insulin.

Why is it advisable to treat gestational diabetics?

Controlling glucose levels in pregnancy reduces the risk of congenital anomalies, miscarriage, preeclampsia, preterm delivery, macrosomia (large babies), polyhydramnios (excessive amniotic fluid), stillbirth, Cesarean sections, difficult or traumatic delivery, and infections postpartum.

Immediately after delivery, miraculously the diabetes disappears!!! Resistance to insulin resolves within hours and patients often return to their pre-pregnancy normal state.

Does the end of pregnancy close the chapter on Gestational diabetes?

Some women, whose diabetes was not diagnosed prior to the pregnancy, have been found to have long standing diabetes that was uncovered with the routine screening that is performed during pregnancy. Even if it is a new onset of disease, detected during pregnancy, it is a known fact that women who have had gestational diabetes are at major risk for developing Type II diabetes later on in life. Some articles (Callaghan, 4/10) report that approximately one-third of women with gestational diabetes continue to have evidence of diabetes immediately postpartum. Other estimates range at about 50% chance of developing diabetes in the ten years following the pregnancy.

How should these women be followed after their pregnancy ends?

  1. All women who have had gestational diabetes should have a repeat oral glucose tolerance test (75 gm 2 hour test) at their 6 to 12 week postpartum visit or after breast feeding has been discontinued.

  2. Even if the values are normal, annual screening with a fasting glucose and/or HbA1C blood test has been suggested. However, at minimum, screening at least every 3 years is advisable.

  3. Encourage diabetes prevention education by encouraging exercise, weight loss, and proper diet.

  4. Women with pre-diabetes should consider medication regimens and lifestyle changes that prevent the chances of progression of their disease.

In Summary

Women have a distinct advantage of having a unique "window in time" in their life during pregnancy when potentially later in life disease complications might appear which the stress of pregnancy can unmask. If taken seriously, this can serve as an early marker of future disease and with proper monitoring and intervention can allow for possible opportunities for reversal.

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