Ep 56: Everything You Need to Know About Gestational Diabetes (GDM)

I get a lot of questions about gestational diabetes (also known as gestational diabetes mellitus or GDM). I think it scares a lot of women to know that their blood sugar could affect their pregnancy, baby, and delivery, so I wanted to share everything I know about GDM in today’s episode. 

We’re talking about what exactly gestational diabetes is, how common it is, how it's diagnosed, and how it's treated. I’ll also cover some of the side effects GDM can have on you and your baby and why you need to pay extra attention to your own health in the postpartum period. 

All pregnant women get tested for gestational diabetes, but it’s important to remember that the test is for the best for you and baby alike. Don’t try to cheat the test or worry about the results!

If you have any other questions about GDM after listening to this episode, come on over to the All About Pregnancy and Birth Facebook Group - I’d love to answer your questions there.

In this Episode, You’ll Learn About:

  • What exactly gestational diabetes is.
  • How we test for and diagnose GDM.
  • Some of the side effects gestational diabetes can have on you and your baby.
  • The recommended nutritional breakdown of the food you eat during pregnancy.
  • Why insulin is the first-line medication recommended for treating GDM. 
  • How gestational diabetes can affect the postpartum period.
  • Why consent absolutely must be received before a provider conducts an episiotomy



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Transcript

Speaker 1: In today's episode, I am covering a topic that I get lots of questions about-gestational diabetes.

Speaker 2: Welcome to the All About Pregnancy & Birth podcast. I'm your host, Dr. Nicole Calloway Rankins, a board certified Ob Gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, confident, and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. You can see the full disclaimer at www.ncrcoaching.com/disclaimer.

Speaker 1: Hello and welcome to another episode of the podcast. This is episode number 56 and of course I am so glad that you're spending a bit of your time with me today. So in today's episode of the podcast I am talking about gestational diabetes. I get a fair number of questions on this. So I decided I finally need to go ahead and tackle this on a podcast episode. So in today's episode you are going to learn what gestational diabetes is, how common it is, what are some of the complications that can arise from gestational diabetes issues both for moms and babies, and how we diagnose gestational diabetes. That's probably what I get the most questions about, how gestational diabetes is treated. Also how it affects your pregnancy management in terms of testing and delivery and your labor, and then finally how gestational diabetes impacts you after you give birth. So I'm covering a ton of information in this episode, but I think afterwards you're going to really appreciate everything that you've learned.

: Now before we get into the episode, let me do a couple of quick reminders. I have some awesome resources to help you as you get ready for your pregnancy and birth. In addition to the All About Pregnancy & Birth podcast, I have a free online class on how to make a birth plan that works. And I get more and more stories and messages about how it was so important that women were prepared and educated and ready to advocate for themselves in situations during their pregnancy and birth and where that really made a difference for them. I just think more and more strongly that you really need to take the time to educate so you're ready to advocate for yourself. Obviously this podcast is part of that, but with my free online class on how to make a birth plan, I take it to another level.

Speaker 1: I talk about what to include in your birth wishes, how to approach the process. Some specific you need to ask and understand about your healthcare provider, your doctor, your midwife, about the hospital where you give birth so that you can have your best experience giving birth. The class is totally free. You can register for it at www.ncrcoaching.com/register. It's an on demand class offered several times a day. So go ahead and check that out. And if you want to take it to the next level, then check out my online childbirth education class, The Birth Preparation Course. This course will ensure you are knowledgeable, prepared, confident, and empowered going into your birth. Very comprehensive, eight hours of content covers everything from mindset, the details of labor, the postpartum period, pain management, how to push, how to avoid tears. It covers a ton. You will be so ready after you go through this course and if you kind of want to take a test drive or get a feel for it, then check out the free class first.

Speaker 1: And the other thing is that in the free class you get access to a big discount on The Birth Preparation Course. So definitely check that out. The free class on how to make your birth plan is www.ncrcoaching.com/register. The Birth Preparation Course is www.ncrcoaching.com/enroll. And of course those links will be in the show notes.

: All right, so let's talk about gestational diabetes. So what is gestational diabetes? And the full name for it is gestational diabetes mellitus. So gestational diabetes mellitus is a condition where you're not able to process carbohydrates properly and it develops during pregnancy. We don't have super good estimates on how prevalent it is. The last data where we really checked for it is a bit old. It's a few years old, but roughly about 7% of pregnancies are complicated by any type of diabetes and most of those are that diabetes that develops during pregnancy.

Speaker 1: Now the prevalence of diabetes does vary in relationship to the prevalence of type two diabetes. And type two diabetes is the sort of garden variety diabetes that adults develop. So it varies based on populations or specific racial and ethnic groups. So white women generally have a lower rate of gestational diabetes and there's an increased prevalence of gestational diabetes in Hispanic women, African American women, Native American women, and Asian women. Also other risk factors that will increase your chances of having to gestational diabetes are the same risk factors that we see for type two diabetes. So obesity or being overweight, not exercising, increased age, those things will also increase your chances of having gestational diabetes.

: Now why do we even get worried or concerned about that developing during pregnancy? Well, it's because it can cause some issues. So women who have GDM and I may go back and forth between GDM and gestational diabetes because it gets tiring to say gestational diabetes all the time. But women who have GDM have a higher risk of developing preeclampsia. For women who have good blood sugar control, the risk of developing preeclampsia is about 10% whereas it is about 18% if you have issues with your blood sugar control. Women with GDM also have a higher chance of having cesarean birth. So 25% of women with GDM who are being treated with medication will require or have a cesarean birth. That number is lower if you don't need medication. If your diabetes is just controlled with diet during your pregnancy, then that's 17% and that's versus 9% for women who don't have any diabetes during pregnancy. And I'll talk about how gestational diabetes is treated in a bit.

: The other big issue that's important is that women with GDM have an increased risk of developing diabetes later in life, anywhere from 15 studies say all the way up to 70% of women who have gestational diabetes will go on to develop diabetes within the next 20 years or so. That number is going to be higher for certain racial and ethnic groups. So, Hispanic women, African American women, they have a higher chance of developing diabetes if they had to gestational diabetes and they are also more likely to develop it sooner after pregnancy then white women. Now for babies, the issue with gestational diabetes is that babies are at an increased risk of macrosomia, which is being a big baby, having low blood sugar at birth. And the reason that that happens is because sugar in your blood crosses the placenta and gets to the baby. So if you have high levels of blood sugar, then that extra sugar, that sugar is going to cross the placenta and that extra sugar is going to be in your baby's system.

: Now your baby has a pancreas, the pancreas is the organ that we all have that creates insulin in our bodies. So your baby's pancreas will make more insulin in order to take care of that elevated blood sugar. So what happens is when your baby is born and is cut off from the placenta, then that extra blood sugar that had been floating around is now gone. But your baby had been getting used to making that extra insulin. So your baby has higher levels of insulin in its blood because it's been trying to control its own blood sugar levels from that extra blood sugar from you. So it gets cut off from the extra blood sugar after birth and then that extra high levels of insulin are still there. And what happens is the baby's blood sugar can drop very, very low after birth, like as low as forties, like really, really low. So I know that was kind of a long way to explain it, but again, babies of women who have gestational diabetes, their babies are at risk for having that low blood sugar because of that issue.

Speaker 1: The babies get used to having high blood sugar and having to take care of it and then they get cut off from it and then that extra insulin in their system makes their blood sugar low. I hope that makes sense. That was a little bit of a long explanation. Some other things that can happen is babies have a higher risk of something called hyperbilirubinemia, which is when there are elevated levels of bilirubin in the blood that can lead to jaundice, so babies have to have treatment for that. Also, an increased risk of shoulder dystocia where the shoulder gets stuck on the way out after birth, during birth, rather during a vaginal delivery, the shoulder gets stuck under the pubic bone and that can be a true, that is a true obstetric emergency and can cause some longterm issues. And then other issues with birth trauma where the baby has some sort of trauma, whether it's a broken bone or a bruised face, those kinds of things just because of the size.

: And then the bad, big, bad thing. Of course, all of those things are bad, but there's also an increased risk of stillbirth for women with gestational diabetes. The other thing that we've come to find is that there are studies that show that babies whose moms have gestational diabetes, those babies as they get older into childhood and as adults they have an increased risk of being obese and developing diabetes themselves. So that risk from mom having diabetes carries through to the child potentially having issues with weight or diabetes as a child and an adult.

: All right, so how do we diagnose gestational diabetes? I'm going to be talking about the approach that is used in the US, there are different approaches in different places, but I'm going to talk about the approach that is most commonly used in the US. So it's recommended in the US that all pregnant women are screened for gestational diabetes using a laboratory based screening test that includes checking blood glucose levels. It used to be back in the day, and I think in some other places they screen for diabetes based on like just your weight and if anybody in your family has diabetes. But unfortunately in the US pretty much everybody has a risk factor. Most people do. Something like 90% of people have a risk factor for diabetes, whether they're overweight or they have a family member who has diabetes.

: So every pregnant woman gets screened for it. Generally screening is performed between 24 and 28 weeks. Now for some women, early pregnancy screening is recommended. And really what that is looking for when you get early pregnancy screening, it's done at the initial prenatal visit and it's actually looking for undiagnosed type two diabetes. So diabetes that actually was there before you got pregnant, but you hadn't been tested for it for some reason. So we're looking for it in that first visit for a select group of women who have higher risk factors.

Speaker 1: So if you are overweight or obese and you have another risk factor, so if you're overweight and obese and you have a first degree relative with diabetes, so your mom, your dad, your sister, your brother had diabetes. If you are in a high risk race or ethnicity, so African American, Latina and Native American, Asian-American. If you have previously given birth to a baby that weighs more than nine pounds and again you're also overweight and obese, so you're overweight and obese and have one of these risk factors. If you previously had gestational diabetes, if you have hypertension where your blood pressure is high, 140 over 90 or you are on medication for high blood pressure, then you should get tested early in pregnancy at that initial visit. Women with PCOS, polycystic ovarian syndrome should get tested at that initial visit for diabetes as well. We don't always do a great job of catching women who we should look for at that early visit to see if they may have some underlying diabetes or impaired glucose tolerance where they're on the border and we may need to be a little bit more careful.

Speaker 1: So just keep those risk factors, those things in mind. And if you fall into one of those categories and you haven't been tested and you're before 24-28 weeks, then ask maybe if you want to get tested, just to be sure because we can actually improve outcomes if you have better blood sugar control, if you get tested early. So at that initial visit we usually do it with something called hemoglobin A1C. It's a simple blood test and that gives us an indication of what your blood sugar was over the past two to three months. So that test is great for telling us sort of a longterm measure of your blood sugar and if that's elevated, then it's likely that your blood sugar was elevated before pregnancy. And you probably had diabetes before pregnancy and it's really important to know this because if you have high blood sugars during that early part of pregnancy, then the risk of miscarriage goes way up and also the risk of congenital anomalies.

Speaker 1: So having issues with the way your baby develops, having problems with the way your baby develops are definitely increased. If you have poor blood sugar control in that early part of pregnancy in the first trimester. So we definitely want to look and check for women who have those increased factors, overweight or obese. And then one of the other factors that I mentioned, now even if the results of their early test are negative, we still recommend repeating it at 24 to 28 weeks for everybody. So even if you're good with the early tests, you've got to have another test again at 24 to 28 weeks because some women will go on to still develop diabetes during pregnancy and in the US the most common approach that we use to test for gestational diabetes is a two step approach. Some places use or countries use a one step approach.

Speaker 1: The most common approach in the US is a two step approach and the way that that works, is the first step is that you get a 50 gram oral glucose solution. It is this sugary sweet drink and although you think it would sound quite lovely to have a sugary sweet drink, it does for me because I like sweets, but I find that that drink is disgusting. That's also called glucola. It comes in different flavors. Cola, orange, I think orange is probably the best one, but it really is a lot of concentrated sweets. And then you get your blood sugar checked one hour after you drink that sweet drink. You do not need to fast before this test, despite what anybody says, you do not need to fast, you don't need to change your diet or anything like that. And another thing I would say is that sometimes I see women trying to quote unquote beat the test or get around this test and you really don't want to do that.

Speaker 1: If you have gestational diabetes, then you want to know, you want to be able to treat it and look out for things appropriately. So don't try to beat the test or you know, alter your results. Just eat what you normally eat, take the test and see what your results are so you can get treated appropriately. Now the one thing that is very confusing about the one hour test is that there are different cutoff values for what's considered abnormal. Some institutions say a number of 130 or greater is abnormal and you need to go onto the second step. Some say 135 or greater is abnormal and you need to go onto the second step, and some say a number of 140 or greater is abnormal. So different institutions will have different values. And the reason that different institutions have different values is because studies show that not one cutoff is better than another. So really each individual place decides what value they're going to use in that, what they are going to stick with.

: Okay. Now if you have an elevated level, then you need to go to the second step of the test. So the first one is a screening test. It tells you whether or not you're at increased risk. If you are at increased risk, then the second step is what is called a diagnostic test. Now most women have to go through the diagnostic test. If the first one is abnormal, but some doctors will skip the second part. If your first value for the first test is greater than 200, so if your glucose value for the first test is greater than 200, so if it is really high, then some folks will just skip the second part, but most of the time if you have an elevated one hour glucola or one hour glucose test greater than 130, 135 or 140 depending on your institution, then you're going to go to that second step.

Speaker 1: This one is a 100 gram, three hour diagnostic oral glucose tolerance test, so you drink an even bigger load of glucose and get your blood checked and this one is different. It is fasting, so you get a fasting blood sugar than a blood sugar at one hour after you drink the drink, blood sugar at two hours and blood sugar at three hours. And you are considered to have gestational diabetes if you have two or more values that are abnormal on that three hour test, so of those four values of the fasting one, two and three hour values, if two or more or the of those are abnormal, then you are considered to have gestational diabetes. The other thing is that the cutoff for that test is also different based on the institution. There's actually a lot about gestational diabetes that is sort of what we do by convention or studies aren't clear.

Speaker 1: We're obviously doing the best we can, but it can feel confusing when you talk to your friend and they're like, well my number was this and my value is that, but my doctor didn't do this. So know that there can be a lot of variety in how things are treated and approached and managed in gestational diabetes because there's not a lot of research to support one particular method is better than another. Okay. All right, so some folks are not able to tolerate that sweet drink. I can tell you it is really, it is a lot. I can't stand it. I hope I'm not biased and I'm not scaring you. That drink is like, eh. So for some people it will cause nausea and for a small percentage of people it will cause vomiting or it may just just makes you feel like wow, you know, it just kind of leaves a bad taste in your mouth.

Speaker 1: You can try and do it over ice. So a lot of places keep it in the refrigerator and keep it cold because it's a little bit more tolerable over ice. But for some people, even with ice, they still can't, you know, finish the whole thing. It's just a lot. So if you find that you can't, you know, slug it down and take the drink. And I will say most women do, most women do find with the glucose test, it's not an issue. You'll most likely, you'll be just fine with it. But if you can't, then there are a couple other options. One is that you may be able to take some nausea medicine beforehand and then come back and do the test on another day. So take some nausea medicine and then come back and do the test another day. Another option is using candy or a soft drink to get that 50 gram glucose load.

Speaker 1: Those are tolerated, but there's not a lot of data or studies to show that those methods work. A common thing, or I should say a study that was done was using jellybeans instead of the glucose strength, the glucola drink, and it was 28 jelly beans and that actually worked pretty well in terms of the sensitivity and how well the test work. But again, it's 28 jellybeans. That's still quite a few jelly beans, so that is an option as well. And then the third option is that you can just check your blood sugar. So we just check your blood sugar for a couple of weeks in order to see what your blood sugar looks like and it's going to be blood sugars four times a day. I'll talk about monitoring in a minute. So blood sugars four times a day, check those for a couple weeks between 24 to 28 weeks. And if those look okay, then you probably do not have gestational diabetes.

: All right. Now why do we even treat gestational diabetes, right? Cause there's no point in looking for a condition if treating it doesn't help. So treating diabetes actually improves outcomes. Studies have shown that it improves perinatal death, it improves shoulder dystocia rates, it reduces birth trauma, reduces fractures, reduces nerve palsy, it reduces the risk of moms developing preeclampsia, reduces the chances of baby being big. So treating diabetes helps prevent or reduce the chances of those bad things happening. So how exactly do we treat gestational diabetes or GDM? Now what everybody should start with, or what we always start with is non pharmacologic approaches. So approaches that do not involve medications and that typically means dietary modifications, exercise and checking your blood sugars on a regular basis. And the goal of that of course, is to get normal blood sugar levels, make sure you're gaining adequate weight, but not too much weight. And then make sure baby is growing and developing.

: Now it is recommended that women with gestational diabetes, every woman has nutritional counseling by a registered dietician. And you get a personalized nutrition plan based on your body mass index. So if you are starting off with a lower body mass index, because I will say there are plenty of women who are normal weight and still developed gestational diabetes, so you would get a plan based on your weight, whereas someone who is overweight will probably have a different plan for their nutrition plan in managing their gestational diabetes. And the thing that they are that we're trying to look at, the thing that we're trying to balance is how many calories you're taking in, specifically what amount of that is carbohydrates. So it's those carbohydrates that you have trouble processing when you have gestational diabetes or diabetes in general.

Speaker 1: And a lot of people think of carbohydrates as just like sweets and sugar and that kind of thing. But carbohydrates are actually more than that. Fruits are carbohydrates, complex carbohydrates are like vegetables, those kind of things. So it's really how you metabolize all carbohydrates. So what we recommend in terms of the distribution, if you have gestational diabetes that your carbohydrates are limited to about 40% of your calories and then 20% of your calories are protein and the other 40% of your calories are fat. There's not a whole lot of science behind that and not a whole lot of studies, just a couple of small studies, but that has tended to be a recommended distribution for what you eat. So that usually ends up being three meals a day and then three or four snacks in order to distribute carbohydrates and then make sure your blood sugars don't go up and down.

Speaker 1: So three meals a day and three to four snacks. There are also a few small studies that show that exercise will help as well. So women should aim for about 30 minutes of exercise five days a week. Actually, we should all aim for exercise during pregnancy and outside of pregnancy. It doesn't have to be anything major. It can be just 10 to 15 minutes after each meal. Nothing that's super duper intense or strenuous. You shouldn't be starting a new exercise routine during pregnancy. And while I'm thinking about it, I did a podcast episode recently on nutrition and pregnancy and that will be very helpful for you whether you have diabetes or not. Just to kind of give you an overview of nutrition and pregnancy. So I'll link to that in the show notes.

: So after you have seen the nutritionist and you have a diet plan, then we need to start checking your blood sugars to make sure that you have good blood sugar control. And here again is another gray area of how frequently your blood sugar should be checked. We typically recommend based on the evidence that we have, just not a lot of evidence there, four times a day. So once fasting in the morning and then once again after each meal, you can check your blood sugars after your meals, either one hour after your meal or two hours after your meal. There is no study that shows that one is better than the other. So again, you'll do fasting blood sugar and then a blood sugar either one hour after each meal or two hours after each meal. Studies have shown that we get better blood sugar control if we check blood sugars after meals, than before meals. For diabetes outside of pregnancy, you often check before meals, but during pregnancy it's better to check your blood sugar after your meals.

Speaker 1: Now if we see that your blood sugar looks good on diet, then we can decrease it so you don't necessarily have to do it four times a day. It can go down to three times a day or two times a day, but it should be at least two times a day. And the fasting blood sugar is usually the most useful one in terms of like how it correlates with outcomes. So usually we can say if everything looks good for a couple of weeks or you can back it down to fasting and then another meal. So a minimum of two times a day. As far as the values that we're looking for. Those two can also vary, but most of us say a fasting blood sugar below 95 is acceptable and then a one hour blood sugar below one 40 or a two hour blood sugar below one 20 are acceptable and again, we look at those every single week.

Speaker 1: All right. Now if diet alone is not controlling your blood sugars, then you need to go to medications. Now the first line medication that is recommended to treat gestational diabetes is insulin. Insulin? Yes, I know people are like what, I have to go straight to insulin? But yes, if you need medication for gestational diabetes, the first line treatment is insulin and it's recommended for a couple of reasons. One, it does not cross the placenta, so we know that it will not affect your baby in any way. The second one is that insulin is the best at getting that really tight control of your blood sugars and keeping them in that normal range most effectively. Now, I will say however, that for a time we kind of got away from insulin and we tried to do more oral medications and part of that is because insulin is injecting, you know it's needles and some people have a problem with that and it's easier to do a pill.

Speaker 1: So we tried pills for a time. However, these medications and the ones that are used are Metformin and Glyburide. These medications have not been approved by the FDA for gestational diabetes treatment and they also cross the placenta. And then there's also not much data on the long term use of these medications in pregnancy and how they affect pregnancy and how they affect babies. So again, the recommended first line treatment for medication if you have GDM is insulin. However, we do realize that some women can't afford insulin, some types of insulin can be rather expensive and some women just don't want to administer themselves insulin. Some women don't want to do needles. And if that's the case, then the next recommended one and by recommended, when I say recommended, I'm saying ACOG. So ACOG is the American College of Obstetricians and Gynecologists.

Speaker 1: It sets standards for practice for OB care in the US. So the next recommended medication is Metformin. And then if you can't for some reason take Metformin, then Glyburide is the next alternative. So insulin is the best then followed by Metformin and Glyburide. All right, so when you have GDM during pregnancy, we recommend for most women that you have increased what's called antenatal testing or antenatal surveillance where we check on your baby and make sure your baby is doing okay. That usually comes in the form of twice weekly NSTs. Those are non-stress tests where you are put on the monitor. We check the baby's heart rate for 20 minutes and then also check the level of amniotic fluid around the baby. And we usually start those at about 32 weeks. So twice a week you come in, you get put on the monitor, check the fluid around the baby, and that is started at 30 weeks.

Speaker 1: And that's always done for women who are on medication. So if you're on insulin or Metformin, then for sure you need to have twice weekly testing. If your blood sugar is not very well controlled, we're having a hard time controlling it, then we definitely want to do testing there. It's kind of iffy whether or not women who have well controlled diet control diabetes, if you're not taking any medications, if you're controlling your blood sugars just with changes in your diet alone, it's not necessarily been proven that having that twice weekly testing is necessary, but a lot of folks will do it or they may start it later in the pregnancy. So it may be at 34 weeks or 36 weeks if your blood sugar is controlled just by diet alone that you start that antenatal testing.

: Okay, so when do we recommend delivery for women that have GDM? Now if you have GDM and you have good blood sugar control, then there's no reason that you cannot go all the way to full term, even up to 41 weeks if your diabetes is only controlled with diet and exercise. So definitely do not need to be induced before 39 weeks unless there's another reason for induction and studies have shown that going up to 40 weeks and 6 days or 41 weeks is perfectly safe and appropriate if you have just diet controlled GDM. Then if you have GDM that is well controlled with medication, whether it's insulin or it's oral medication, then we recommend delivery somewhere between 39 weeks and 39 weeks and 6 days, so between 39 weeks and your due date. So induction by your due date. And the reason for that is a couple of studies have shown a lower infant mortality rate if we induce in that 39th week of pregnancy for women that have well controlled diabetes with medication.

Speaker 1: Now if your blood sugar is not well controlled, then we typically tend to induce earlier because the increased risk of stillbirth starts to go up if your blood sugar is poorly controlled. So in that case it may be recommended that you get delivered as early as even 37 weeks or 38 weeks, never usually before 37 weeks. But for some women, if your blood sugar is not under good control, then it may be recommended that you get delivered at 37 or 38 weeks. Another thing that often happens with women that have gestational diabetes is they get an ultrasound towards the end of pregnancy to kind of get a guess for how big the baby is. We know that macrosomia or big babies is associated gestational diabetes. So doctors order ultrasounds to look for it. The issue with that is that ultrasound is notoriously inaccurate in the third trimester at actually predicting the size of a baby, it can be very, very, very off.

Speaker 1: I talked about this in another podcast episode. But what happens when we think your baby is big? So I will link to that in the show notes. I think it's the truth about, you know, having a big baby and again, ultrasound is really inaccurate in the third trimester, but it's the best thing that we have now. It looks like on ultrasound your baby is greater than 4,500 grams, which is 9 pounds, 14 ounces or so roughly. Then we at least have a discussion about the possibility of a scheduled cesarean section. Babies with diabetes have a fat distribution that's different. That increases the risk of shoulder dystocia in birth trauma and the bigger the baby is, the more higher the risk for those issues happening. So if your baby is suspected to be greater than 4,500 grams, then there is a recommendation of at least discussing or offering the option of a scheduled cesarean section in that instance.

Speaker 1: And then if you don't want to have a cesarean birth, then as far as labor, you know, it'll probably recommend induction, don't use a lot of Pitocin, those kinds of things. So really a discussion around what happens if your baby is over 4,500 grams. Now during labor, women with gestational diabetes, you don't have to do much of anything different. Women who have pre gestational diabetes, women who have diabetes that was diagnosed before pregnancy, they have a higher risk of developing issues with blood sugar during labor. But just gestational diabetes usually blood sugars are fine during labor, they don't go too high, too low, so we usually check a blood sugar when you get admitted to the hospital during the early part of labor, it may be measured two or three times in the active phase of labor. It may be measured every four hours or so. So it doesn't require much difference in terms of checking your blood sugars during your labor.

: In the postpartum period there are a couple of important things that happen afterwards or that you need to pay attention to. If you have GDM. And let me back up and say first that if you have GDM gestational diabetes, whether it is treated with medications or diet, you can stop your medications immediately after birth and resume a normal diet. The placenta and hormones from the placenta can interfere or make gestational diabetes worse, particularly towards the end of pregnancy. That's why we don't even test for it until closer to the end of pregnancy, but once that placenta is gone, then the effects of the placenta, hormones on blood sugar metabolism go away right away. So you can stop all your medications and resume whatever your normal diet is because you will go back to your regular pre pregnancy, the way you manage the blood sugar almost immediately. Now, even though it typically resolves after delivery and you get back to metabolizing blood sugar, normally a good percentage of women will actually go on to develop diabetes later in life. And as I said earlier, anywhere from 15 to 70% of women who have GDM will go on to develop type two diabetes as an adult.

: Studies have shown that women who have a history of GDM have a seven fold increased risk of developing type two diabetes compared to women who don't have a history of GDM. So what we recommend is that anywhere between 4 to 12 weeks postpartum, if you've had gestational diabetes, then you need to be checked for diabetes outside of pregnancy and it is yet another different test. This one is a two hour oral glucose tolerance test that we use to diagnose diabetes in the postpartum period. And the thing about this one is that it is fasting also. And I mentioned that because this test often does not get ordered or does not get done.

: Number one, a lot of physicians and providers studies have shown that we do a really bad job of recommending that women get this test if they have gestational diabetes, we forget to tell them that they need this test. Or the other thing that happens is that we tell women that they need the test, but because it requires some scheduling, like it requires, you know, two hours of your time and you have to be fasting, a lot of women don't go back and get it done to be honest with you. So they come for their six week checkup and it's like, Oh, you need to schedule this test within the next few weeks where you need to be fasting but you've got this new baby.

Speaker 1: But again, it is important that you get this test done because a good percentage of women will go on to develop some impaired glucose tolerance later. Now, if you do, I should say, when you do get that test within the first 4 to 12 weeks and it turns out being negative, which is good, then you still need to get repeat testing. So every one to three years, ACOG recommends that you get tested for diabetes. If you had a pregnancy that was affected by gestational diabetes. Okay, so just because that normal postpartum screen is there in that 4 to 12 weeks, you still need to get tested every one to three years because you had that increased risk.

: The other thing to be aware of is that actually depression is more common in women who have gestational diabetes. So if you have GDM then be on the lookout for postpartum depression because it is more likely, unfortunately for that to happen for you. So I know there was a lot of information. But I hope that you understand and got a good grasp of gestational diabetes. So just to recap, gestational diabetes is when you develop an inability to really process carbohydrates during pregnancy. It affects about 6%, 7% of pregnancies. All women are tested for gestational diabetes between 24 and 28 weeks. That's the peak time of when it's going to show up. If you are in a high risk category, then you should be tested at your initial visit to see if you actually had diabetes before pregnancy. We use a two step approach in the US to screen for diabetes between 24 and 28 weeks, so that screening test is that one hour 50 gram glucose load.

Speaker 1: If that is abnormal, then you go onto the second step, which is the three hour test. You do not need to fast for step one. You do need to fast for step two. As far as treating gestational diabetes it involves dietary changes. First checking your blood sugars, exercising. If that doesn't work, then the first line medication treatment is insulin followed by Metformin and then Glyburide. For a small segment of women for delivery, if you have well controlled diet controlled diabetes, perfectly okay to go up to 41 weeks. If you are on medication, whether it is insulin or the oral medication, then we know the best outcomes happen if you are induced between 39 and 40 weeks. If you have poor blood sugar control, we're having trouble controlling it or you haven't been taking your medicine for some reason then induction earlier may be recommended, 37 or 38 weeks and if your baby is suspected to be greater than 4,500 grams, then there may be a recommendation for a C-section.

Speaker 1: There at least should be a discussion about it. And then finally, if you have GDM, you need to get tested in the postpartum period within the first 4 to 12 weeks to see if you still have any impaired glucose tolerance. And then after that, if that test is negative, you need to continue to get tested every one to three years to make sure you don't develop diabetes in the future because you are at increased risk. Okay, whew. I know that was a lot. If you still have questions then hop on over and let me know in the free Facebook group All About Pregnancy and Birth. That is a great group of really supportive women. It's a place where we can continue the conversation after the podcast so if anything is unclear or if you have additional questions then for sure hop on over to the Facebook group. It's called All About Pregnancy and Birth and you can search for that on Facebook or I'll link to it in the show notes and I will definitely answer your question if you post it in the group.

: Also be sure to subscribe to the podcast in Apple podcast or Spotify or wherever you listen to podcasts and you know I love it if you leave honest reviews in Apple podcasts in particular. Apple podcast is the biggest podcast platform, so when you have reviews there it helps other women to find my show. It helps the show to grow, but most importantly, I just love hearing from you and hearing what you think about the show. So definitely drop me a review in Apple podcast if you feel so inclined to do so and are finding the show helpful to you.

: Next week on the podcast I have Brooke Kates. She is the founder and creator of the bloom method. She's also a pre and postnatal exercise specialist, a core rehabilitation specialist, and a pre and post natal holistic health coach. So great conversation. She is super passionate about what she does. I know you're going to find what she has to share useful, so come on back next week. And until then, I wish you a healthy and happy pregnancy and birth.

Speaker 2: Today's episode is brought to you by Women's Wellness Coaching by Dr. Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan as well as my comprehensive online childbirth education class, The Birth Preparation Course with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, confident, and empowered going into your birth. Head to www.ncrcoaching.com to learn more.

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