J Clin Hyperglycekia ; Whelton Doabetes, Carey RM, Aronow WS, Hyperglycemia and gestational diabetes DE, Collins KJ, Himmelfarb CD, et al. Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base.

Hyperglycemia and gestational diabetes -

If your screening test blood sugar level is high but not very high, you will need another test to know for sure if you have gestational diabetes. This test is called an oral glucose tolerance test GTT. The test is done by measuring your blood sugar level before you eat or drink anything in the morning fasting , then again one, two, and three hours after you drink a glucose drink that contains grams of glucose twice the amount in the one-hour test.

Similar to the one-hour test, this is usually in the form of a specially formulated orange, lemon-lime, or cola drink. Gestational diabetes is diagnosed if you have two or more elevated blood sugar values during the GTT, although some doctors may recommend treatment after a single elevated value, especially if you have other signs of gestational diabetes a big fetus or extra fluid around your fetus.

One-part test — Some doctors and nurses test for diabetes with a one-part test. The test is done by measuring your blood sugar level before you eat or drink anything in the morning fasting , then again one and two hours after you drink a glucose drink that contains 75 grams of glucose.

This is usually in the form of a specially formulated orange, lemon-lime, or cola drink. Gestational diabetes is diagnosed if you have one or more elevated blood sugar values.

After you are diagnosed with gestational diabetes, you will need to make changes in what you eat and learn to check your blood sugar level.

You may also be advised to get more exercise. See "Gestational diabetes mellitus: Glucose management and maternal prognosis". The main goal of treatment for gestational diabetes is to reduce the risk of complications such as those mentioned above.

One of the main complications is an overly large baby weighing more than 9 to 10 lbs at birth. You are more likely to have a large baby if your blood sugar levels are higher than normal during the pregnancy. A large baby can be difficult to deliver vaginally.

The baby can get stuck after the head is born called "shoulder dystocia". This increases the risk of injury to the baby eg, broken bones or nerve injury and to the mother eg, more severe vaginal tears.

If labor does not progress normally, you may need a cesarean birth. Eating plan — The first treatment for gestational diabetes is eating right. To help you achieve the changes you should make in your diet, you will meet with a dietitian, nurse, or certified diabetic educator a nurse or dietician that specializes in diabetes.

The general guidelines below will help you until you receive your individualized food plan:. This includes candy, cake, cookies, ice cream, donuts, jams and jellies, syrups, and sweet sauces.

Also avoid adding sugar to your food or drinks, sweetened soda, punch, sweet tea, and other fruity beverages. Moderation is suggested. These sweeteners have not been linked to an increased risk of congenital anomalies birth defects.

Other protein foods like cheese, eggs, nuts, seeds, and peanut butter are also good for you and your baby. Avoid fruit juice or limit percent fruit juice to one-half cup 4 ounces per serving. Many dieticians recommend avoiding fruits for breakfast because of concerns about higher blood sugar levels in the early morning.

Choose low-fat yogurt that is plain, "light," or Greek style. Include plenty of salads, greens spinach, collards, kale , broccoli, carrots, green beans, tomatoes, onions, mushrooms, and other vegetables you enjoy. Half of the plate at your meals can be non-starchy vegetables.

Blood sugar monitoring — You will learn how to check your blood sugar level and record the results figure 1. Instructions for choosing a blood sugar meter, checking blood sugar levels at home, and ways to record the results are discussed separately.

See "Patient education: Glucose monitoring in diabetes Beyond the Basics ". This information can help to determine whether your blood sugar levels are on target.

If your levels stay higher than they should be, your doctor will probably recommend that you start using insulin. See 'Insulin' below. Exercise — Although exercise is not a necessary part of gestational diabetes treatment, it might help to control blood sugar levels.

If you were exercising before, you should continue after being diagnosed with gestational diabetes. If you did not previously exercise, ask your doctor or nurse if exercise is recommended.

Most individuals who do not have medical or pregnancy-related complications are able to exercise, at least moderately, throughout their pregnancy.

Walking is a great form of exercise for those starting an exercise regimen. Insulin — Approximately 15 percent of patients with gestational diabetes will require insulin. Insulin is a medicine that helps to reduce blood sugar levels and can reduce the risk of gestational diabetes-related complications.

Insulin is the most common medicine for treating gestational diabetes. You must give insulin by injection because it does not work when it is taken by mouth. Most pregnant people start by giving one to two shots of insulin per day.

If your blood sugar levels are high after eating, you may need to give yourself a shot three or four times per day. Instructions for drawing up and giving insulin shots are available separately. See "Patient education: Type 2 diabetes: Insulin treatment Beyond the Basics ".

If you take insulin, you should check your blood sugar level at least four times per day. You also need to write down your results or store them in the meter and how much insulin you took and review these records at each prenatal visit or more frequently based on your doctor's recommendation figure 1.

Keeping accurate records helps to adjust insulin doses and can decrease the risk of complications. The bedtime snack is especially important to help keep your fasting first blood sugar of the day before eating in range. Oral diabetes medicines, such as those taken by people with type 2 diabetes, are sometimes used during pregnancy in the United States.

We prefer insulin therapy for pregnant patients with diabetes who cannot control blood glucose levels adequately by their diet nutritional therapy. Insulin is effective and safe and does not cross the placenta to the fetus.

Most oral diabetes medicines pass from the pregnant individual to their baby through the placenta; while they have not been shown to harm the fetus or newborn, it is not known if there are longer term effects on children.

There are studies underway to help answer this question. However, oral anti-hyperglycemic agents are a reasonable alternative for individuals who will not take, or are unable to comply with, insulin therapy, as long as they understand the lack of information on long-term risks or benefits.

Prenatal visits — Most pregnant individuals who develop gestational diabetes have more frequent prenatal visits eg, once every week or two , especially if insulin is used.

The purpose of these visits is to monitor your and your baby's health, discuss your diet, review your blood sugars, and adjust your dose of insulin if you are taking it to keep your blood sugar levels near normal. It is common to change the dose of insulin as the pregnancy progresses.

You may also be asked to have one or two ultrasound examinations to check on the growth and size of the baby. See "Gestational diabetes mellitus: Obstetric issues and management". Nonstress testing — You may need tests to monitor the health of the baby during the later stages of pregnancy, especially if your blood sugars have been high, you are using insulin, or if you have any pregnancy-related complications eg, high blood pressure.

The most commonly used test is the nonstress test. Assuming universal screening, the method of screening can be either a sequential 2-step or a 1-step process. Methods for sequential screening include the use of glycosuria, A1C, FPG, random plasma glucose RPG and a glucose load.

Aside from the glucose load, all the other methods mentioned have not been adopted due to their poorer performance as screening tests in most populations — The performance of the GCT as a screening test depends on the cut-off values used, the criteria for diagnosis of GDM and the prevalence of GDM in the screened population.

Results from a Canadian prospective study show that sequential screening is associated with lower direct and indirect costs while maintaining equivalent diagnostic power when compared with 1-step testing. Recent observational data demonstrated the feasibility and good uptake of the 2-step approach An additional question is whether there is a GCT threshold above which GDM can be reliably diagnosed without continuing to the diagnostic OGTT.

Since there is no clear glucose threshold above which pregnancy outcomes responsive to glycemic management occur ,, , controversy persists as to the best diagnostic thresholds to define GDM.

The International Association of the Diabetes and Pregnancy Study Groups IADPSG Consensus Panel decided to create new diagnostic thresholds for GDM based on data from the Hyperglycemia and Adverse pregnancy Outcome HAPO study.

IADPSG thresholds are the maternal glucose values from HAPO associated with a 1. These arbitrary thresholds, when applied to the HAPO cohort, led to a GDM incidence of However, since this publication, national organizations have published guidelines that are divergent in their approach to screening and diagnosis of GDM — , thus perpetuating the international lack of consensus on the criteria for diagnosis of GDM.

However, it was recognized that the IADPSG 1-step strategy has the potential to identify a subset of women who would not otherwise be identified as having GDM and could potentially benefit with regards to certain perinatal outcomes.

As outlined in the CPG, those who believe that all cases of hyperglycemia in pregnancy need to be diagnosed and treated i. increased sensitivity over specificity will support the use of the 1-step method of GDM diagnosis.

LGA rate and birth weight progressively increased with more dysglycemia and were increased in both groups. However, in this study, only women who were positive by HAPO 2. Figure 1 Preferred approach for the screening and diagnosis of gestational diabetes.

Figure 2 Alternative approach for the screening and diagnosis of gestational diabetes. Since the publication of the IADPSG consensus thresholds, there have been numerous retrospective studies that have examined the impact of adoption of these criteria.

It is difficult to apply the results of these studies to clinical practice due to their retrospective nature and the wide variation in the comparison groups used.

In all of these studies, adoption of IADPSG criteria has led to an increase in the number of cases diagnosed while the impact on perinatal outcomes is inconsistent — Studies comparing pregnancy outcomes before and after changing from a variety of different GDM diagnostic criteria to the IADPSG criteria show differing results.

LGA was lower in 1 study and caesarean delivery was lower in several studies , after adoption of the IADPSG criteria. However, others did not find reductions in LGA ,,, , and 1 study found an increase in primary caesarean section rate Given this lack of evidence, it is possible that the decision regarding the recommended screening method will be determined by the economic implications on health-care resources.

Decision analysis modelling studies done in other countries ,— have yielded a variety of results and many are of questionable applicability in the Canadian setting because of differing cost and screening and diagnostic strategies.

A small observational study from Ireland suggested that maternal BMI may be an important consideration in choice of which diagnostic thresholds to use Furthermore, secondary analysis of the Landon et al trial, that used a 2-step screening approach, found that GDM therapy had a beneficial effect on fetal growth only in women with class 1 and 2 obesity and not in women with normal weight or with more severe obesity Further higher-quality evidence would be helpful in establishing if maternal BMI and other clinical risk factors should guide which diagnostic thresholds are used.

Most cost analysis evaluations support a sequential screening approach to GDM. Therefore, adequately powered prospective studies to compare these 2 approaches are needed. Since pregnancy may be the first time in their lives that women undergo glucose screening, monogenic diabetes may be picked up for the first time in pregnancy.

Monogenic diabetes first diagnosed in pregnancy should be suspected in the women with GDM who lack risk factors for GDM and type 1 diabetes and have no autoantibodies see Definition, Classification, and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome chapter, p.

A detailed family history can be very helpful in determining the likely type of monogenic diabetes. This is important because the type of monogenic diabetes influences fetal risks and management considerations. The most common forms of monogenic diabetes in Canada are maturity onset diabetes of the young MODY 2 heterozygotes for glucokinase [GCK] mutations or MODY 3 hepatocyte nuclear factor [HNF] 1 alpha mutation During pregnancy, the usual phenotype for MODY 2 of isolated elevated FBG is not always seen, even though this phenotype may be present outside of pregnancy in the same woman Fetuses without the GCK mutation of mothers with GCK mutation are at increased risk of macrosomia.

The best way to manage women with GCK mutation during pregnancy has yet to be established, but regular fetal growth assessment can aid in the establishment of appropriate glucose targets during pregnancy for women with documented or strongly suspected GCK mutations.

MODY 1 HNF4 alpha mutation has a similar phenotype to MODY 3 but is much less common. These forms of monogenetic diabetes have greater increased risk of macrosomia and neonatal hypoglycemia that may be prolonged especially in neonates that have MODY 1 HNF4 alpha mutation.

Although women with these later forms of monogenic diabetes are usually exquisitely sensitive to sulfonylureas, they should be transitioned to insulin as they prepare for pregnancy or switched to insulin during pregnancy, if this has not occurred preconception, for the same reasons as avoiding glyburide use in women with GDM.

Weight gain. The IOM guidelines for weight gain during pregnancy were developed for a healthy population and little is known regarding optimal weight gain in women with GDM.

Retrospective cohort studies of GDM pregnancies show that only Those gaining more than the IOM recommendations had an increased risk of preeclampsia , caesarean deliveries , , macrosomia , , LGA — and GDM requiring pharmacological agents Modification of IOM criteria, including more restrictive targets of weight gain, did not improve perinatal outcomes of interest A large population-based study including women with GDM, concluded that while pre-pregnancy BMI, GDM and excessive GWG are all associated with LGA, preventing excessive GWG has the greatest potential of reducing LGA risk These researchers suggest that, in contrast to obesity and GDM prevention, preventing excessive GWG may be a more viable option as women are closely followed in pregnancy.

A large number of women with overweight or obesity and with GDM gain excessive weight in pregnancy , and a large proportion exceed their IOM total target by the time of GDM diagnosis A systematic review found that pregnant women with overweight or obesity who gain below the IOM recommendation, but have an appropriately growing fetus, do not have an increased risk of having a SGA infant , leading some to recommend that encouraging increased weight gain to conform with IOM guidelines will not improve maternal or fetal outcomes A Cochrane review 49 trials of 11, women was performed to evaluate the effectiveness of diet or exercise or both in preventing excessive gestational weight gain and associated adverse pregnancy outcomes Study interventions involved mainly diet only, exercise only and combined diet and exercise interventions compared with standard care.

Low glycemic load GL diets, supervised or unsupervised exercise only or diet and exercise in combination all led to similar reductions in the number of women gaining excessive weight in pregnancy. There was no clear difference between intervention and control groups with regards to preeclampsia, caesarean section, preterm birth and macrosomia.

Further studies are needed to develop weight gain guidelines for GDM patients and to determine whether weight gain less than the IOM guidelines or weight loss in pregnancy is safe.

Until this data are available, women with GDM should be encouraged to gain weight as per the IOM guidelines for the BMI category to reduce adverse maternal and neonatal outcomes and postpartum weight retention.

Nutrition therapy. Nutrition therapy is a cornerstone for managing GDM. All women at risk for or diagnosed with GDM should be assessed, counselled and followed up by a registered dietitian when possible — Nutrition therapy should be designed to promote adequate nutritional intake without ketosis, achievement of glycemic goals, appropriate fetal growth and maternal weight gain — Recommendations for nutrition best practice and a review of the role of nutrition therapy in GDM management is available.

A great variety of diets are used for managing GDM. While carbohydrate moderation is usually recommended as first-line strategy to achieve euglycemia , evidence available to support the use of a low-glycemic-index GI diet is increasing. A randomized controlled trial of 70 healthy pregnant women, randomized to low glycemic index GI vs.

a conventional high-fibre diet from 12 to 16 weeks' gestation, showed a lower prevalence of LGA without an increase in SGA in the low-GI group This led to the hypothesis that a low-GI diet may be beneficial in women with GDM.

An earlier systematic review of 9 randomized controlled trials, in which 11 different diet types were assessed within 6 different diet comparisons, did not support the recommendation of 1 diet type over another as no significant differences were noted in macrosomia, LGA or caesarean section rates However, a more recent systematic review and meta-analysis does support the use of low GI diets Only the low-GI diet was associated with less frequent insulin use and lower newborn weight without an increase in numbers of SGA and macrosomia Results of a meta-analysis of 5 randomized controlled trials and a systematic review in GDM patients showed that low-GI diets reduce the risk of macrosomia and LGA, respectively.

Low-GI diets are associated with lower postprandial blood glucoses in recent randomized controlled trials , In summary, current evidence although limited, suggests that women with GDM may benefit from following a low-GI meal pattern Physical activity.

In combination with nutritional intervention, physical activity appears to be more effective for GDM management than GDM prevention. No studies had an effect on infant birth weight or macrosomia rate and only 1 was successful in reducing GWG.

It can be argued that these studies were not powered enough to demonstrate any impact on birthweight or on adverse pregnancy outcomes. Indeed, relevant limitations for these studies include the following: samples were small mean of 43 participants per study , participants had different metabolic profiles and risks factors, and different diagnostic criteria for GDM were used.

The best type of intervention that should be recommended is unclear since all the successful programs used different exercise modalities in terms of intensity, type, duration and frequency.

More recently, an initiative in India, the Wings Project, demonstrated that an intervention based on increasing total footsteps with pedometers was able to improve glycemic control in women with GDM and reduce adverse neonatal outcomes in the more active tertiles when compared to their GDM counterparts in the upper tertiles of sedentary behaviour Since no exercise-related injuries were experienced during pregnancy in all those studies, physical activity intervention seems safe to recommend.

All together, current knowledge suggests that physical activity interventions in women with GDM should be encouraged unless obstetrical contraindications exist as physical activity may be an important component of GDM management.

However, identification of a specific program of physical activity that should be prescribed to GDM women is currently not possible. Further studies are needed involving larger populations to enable the prescription of an evidence-based physical activity intervention.

Glycemic control. In a systematic review of reports of BG levels in non-GDM pregnancies, normal BG levels during later pregnancy mean and 1 SD above mean were: fasting 3.

The peak postprandial BG occurred at 69±24 minutes However, it should be noted that the mean FBG derived from the total of subjects in this report was 0. The HAPO study was the largest prospective study of glycemia in pregnancy and reported a mean FBG of 4. BG levels in pregnant women with obesity without diabetes were slightly higher than their lean counterparts in a study in which CGM was performed in early and late pregnancy after placing pregnant women with obesity or normal weight on a controlled diet Importantly, it has been demonstrated that the diagnostic OGTT values were not the best predictors of outcomes whereas CBG levels during treatment were strongly correlated to adverse pregnancy outcomes Even if BG can normally and physiologically decrease during pregnancy below the traditional level of 4.

On the other hand, recent studies have questioned the upper limit of the FBG target. Risks of maternal hypoglycemia or fetal low birth weight were not evaluated in this review and adjustment for maternal BMI and different diagnostic criteria for GDM was not performed.

Even if the frequency of SGA infants was lower across the tertile of mean maternal fasting glycemia in this study, SGA rate in women with the lowest mean FBG was not increased and was, in fact, comparable with the rate of the background population.

SGA rate was inversely correlated with maternal weight gain before assessment, suggesting that SGA could be partly prevented by adequate follow up of GWG in those women. However, large, well-conducted and randomized controlled trials comparing different BG targets are needed to directly address optimal fasting and postprandial BG targets.

Further studies should also assess the risk of maternal hypoglycemia, SGA, insulin use and cost-effectiveness of such modification. Despite reduced perinatal morbidity with interventions to achieve euglycemia in women with GDM, increased prevalence of macrosomia persists in this population.

To improve outcomes, 4 randomized controlled trials — have examined the use of fetal abdominal circumference AC as measured sonographically and regularly in the third trimester to guide medical management of GDM.

Indeed, it may be difficult to apply this flexible approach given the extreme glycemic targets that were used, the fact that routine determination of AC is not done or sufficiently reliable, and frequent ultrasounds may not be accessible to most centres. Further analyses are needed to establish safe stricter and relaxed glycemic targets that should be recommended for women with GDM to limit LGA and SGA rates.

Frequent SMBG is essential to guide therapy of GDM , Both fasting and postprandial testing are recommended to guide therapy in order to improve fetal outcomes 89, CGMS have been useful in determining previously undetected hyperglycemia, but it is not clear if it is cost effective — Recent randomized controlled trials suggest that CGM may be of benefit in the treatment of GDM.

In a randomized trial, women were randomized to undergo blinded 3-day CGM every 2 to 4 weeks from GDM diagnosis at 24 weeks GA or routine care with SMBG Women using CGM had less glucose variability, less BG values out of the target range, as well as less preeclampsia, primary caesarean section and lower infant birthweight.

In a similar study of women with GDM, given CGM from 24 to 28 weeks or 28 weeks to delivery, excess maternal weight gain was reduced in the CGM group compared to women doing only SMBG, especially in women who were treated with CGM earlier, at 24 weeks GA A1C was lower in the CGM group but not statistically significantly different.

More studies are needed to assess the benefits of CGM in this population. In an effort to control their BG by diet, women with GDM may develop starvation ketosis. Older studies raised the possibility that elevated ketoacids may be detrimental to the fetus 94, While the clinical significance of these findings are questionable, it appears prudent to avoid ketosis.

Use of new technologies and web-based platforms for BG monitoring in pregnant women with diabetes in Canada and worldwide is rapidly increasing. These initiatives allow for 2-way communication with women monitoring and transmitting their BG results in real time to health-care providers for feedback.

Studies have demonstrated Enhanced patient empowerment and greater satisfaction with the care received are also reported in groups using new monitoring technology —,,, However, generalizability of those studies is questionable as these studies were small, conducted in very specific settings and used different types of technologies and e-platforms.

Furthermore, acceptance of these interventions by marginalized population subgroups and in remote regions would also be important to determine. Finally, studies assessing cost effectiveness of these measures, both direct health system resources utilization and indirect work absenteeism, parking, daycare fees are needed.

Systematic reviews of the literature on the use of technology to support healthy behaviour interventions for healthy pregnant women and women with GDM , showed that good quality trials in this area are few and research on this topic is in its infancy stage.

This is evidenced by the focus on intervention acceptance measures, use of small sample sizes, lack of demonstration of causality and lack of examination of long-term effects or follow up. In summary, new technologies and telehomecare programs have so far shown encouraging results to reduce medical visits and favour patient empowerment without increasing complication rates in pregnant women with diabetes.

In an era of increased prevalence of GDM, well designed and sufficiently powered randomized controlled trials are needed to evaluate the effectiveness of technology as a tool for glucose management, healthy behaviour interventions and a way of relieving health-care system burden.

If women with GDM do not achieve BG targets within 2 weeks of initiation of nutritional therapy and exercise, pharmacological therapy should be initiated , The use of insulin to achieve glycemic targets has been shown to reduce fetal and maternal morbidity , A variety of protocols have been used, with multiple daily injections MDI being the most effective Insulin usually needs to be continuously adjusted to achieve glycemic targets.

Although the rapid-acting bolus analogues aspart and lispro can help achieve postprandial targets without causing severe hypoglycemia — , improvements in fetal outcomes have not been demonstrated with the use of aspart or lispro compared to regular insulin , see Pre-Existing Diabetes Type 1 and Type 2 in Pregnancy: Pharmacological therapy.

Glargine and detemir have primarily been assessed in women with pre-existing diabetes in pregnancy see Pre-Existing Diabetes Type 1 and Type 2 in Pregnancy: Pharmacological therapy.

Randomized trial evidence suggests levemir is safe and may afford less maternal hypoglycemia compared to neutral protamine hagedorn NPH , while observational studies suggest that glargine, although theoretically less desirable, is also safe.

In several meta-analyses of randomized trials studying the use of metformin compared with insulin in women with gestational diabetes, women treated with metformin had less weight gain and less pregnancy-induced hypertension compared to women treated with insulin — Infants of mothers using metformin had lower gestational age and less neonatal hypoglycemia.

On the other hand, there was conflicting evidence regarding preterm birth, with some studies finding a significant increase with the use of metformin, while others did not. This finding was mainly demonstrated by the Metformin in Gestational diabetes MiG trial , where there was an increase in spontaneous preterm births rather than iatrogenic preterm births.

The reason for this was unclear. While metformin appears to be a safe alternative to insulin therapy, it does cross the placenta. Results of The Offspring Follow Up of the Metformin in Gestational diabetes MiG TOFU trial, at 2 years, showed that the infants exposed to metformin have similar total fat mass but increased subcutaneous fat, suggesting a possible decrease in visceral fat compared to unexposed infants In another follow-up study of infants exposed to metformin during pregnancies with gestational diabetes, children exposed to metformin weighed more at the age of 12 months, and were heavier and taller at 18 months, however, body composition was similar as was motor, social and linguistic development.

Studies looking at neurodevelopment showed similar outcomes between exposed and nonexposed infants at 2 years of age , In summary, long-term follow up from 18 months to 2 years indicate that metformin exposure in-utero does not seem to be harmful with regards to early motor, linguistic, social, , metabolic , and neurodevelopmental , outcomes.

Longer-term follow up is not yet available. Glyburide has been shown to cross the placenta. In 2 meta-analyses of randomized trials studying the use of glyburide vs. insulin in women with GDM, glyburide was associated with increased birthweight, macrosomia and neonatal hypoglycemia compared with insulin , In the same meta-analyses, compared to metformin, glyburide use was associated with increased maternal weight gain, birthweight, macrosomia and neonatal hypoglycemia , Therefore, the use of glyburide during pregnancy is not recommended as first- or second-line treatment, but may be used as third-line treatment if insulin is declined by the mother and metformin is either declined or insufficient to maintain good glycemic control.

There is only 1 small randomized trial looking at the use of acarbose in women with GDM. Other antihyperglycemic agents.

There is no human data on the use of DPP-4 inhibitors, GLP-1 receptor agonists or SGLT2 inhibitors. The use of these noninsulin antihyperglycemic agents is not recommended during pregnancy.

The primary goal of intrapartum glucose management in women with gestational diabetes is to prevent neonatal hypoglycemia, which is thought to occur from the fetal hyperinsulinism caused by maternal hyperglycemia Longer-term follow-up studies have found that infants with neonatal hypoglycemia had increased rates of neurological abnormalities at 18 months, especially if hypoglycemic seizures occurred or if hypoglycemia was prolonged , and at 8 years of age with deficits in attention, motor control and perception Maternal hyperglycemia during labour, even when produced for a few hours by intravenous fluids in mothers without diabetes, can cause neonatal hypoglycemia , Studies have generally been performed in mothers with pregestational diabetes or insulin- treated GDM.

These have been observational with no randomized trials deliberately targeting different levels of maternal glycemia during labour.

Most have found that there is a continuous relationship between mean maternal BG levels during labour and the risk of neonatal hypoglycemia with no obvious threshold.

Insulin requirements tend to decrease intrapartum , There are very few studies although many published protocols that examine the best method of managing glycemia during labour , Given the lack of studies, there are no specific protocols that can be recommended to achieve the desired maternal BG levels during labour.

Women with GDM should be encouraged to breastfeed immediately after delivery and for at least 4 months postpartum, as this may contribute to the reduction of neonatal hypoglycemia and offspring obesity , and prevent the development of metabolic syndrome and type 2 diabetes in the mother ,— Longer duration and more intense breastfeeding is associated with less diabetes in the mother with hazard ratios as low as 0.

Furthermore, offspring that are breastfed for at least 4 months have lower incidence of obesity and diabetes longer term However, GDM is associated with either similar or poor initiation rates compared to those without diabetes, as well as poor continuation rates Factors associated with cessation of breastfeeding before 3 months include breastfeeding challenges at home, return to work, inadequate support, caesarean section and lower socioeconomic status In conclusion, women with GDM should be encouraged to breastfeed as long as possible as intensity and duration of nursing have both infant and maternal benefits current recommendation by Canadian Paediatric Society is up to 2 years , but more support is needed as this group is at risk for early cessation.

Long-term maternal risk of dysglycemia. With the diagnosis of GDM, there is evidence of impairment of both insulin secretion and action , These defects persist postpartum and increase the risk of impaired fasting glucose, IGT and type 2 diabetes , The cumulative risk increases markedly in the first 5 years and more slowly after 10 years , While elevated FPG during pregnancy is a strong predictor of early development of diabetes — , other predictors include age at diagnosis, use of insulin, especially bedtime insulin or oral agents, and more than 2 pregnancies — A1C at diagnosis of GDM is also a predictor of postpartum diabetes , Any degree of dysglycemia is associated with increased risk of postpartum diabetes Some women with GDM, especially lean women under 30 years of age who require insulin during pregnancy, progress to type 1 diabetes , Women with positive autoantibodies anti-glutamic acid decarboxylase [anti-GAD], anti-insulinoma antigen 2 [anti- IA2] are more likely to have diabetes by 6 months postpartum Postpartum testing is essential to identify women who continue to have diabetes, those who develop diabetes after temporary normalization and those at risk, including those with IGT.

However, many women do not receive adequate postpartum follow up, and many believe they are not at high risk for diabetes — Despite this finding, more work in this area is needed to improve uptake. Women should be screened postpartum to determine their glucose status. Postnatal FBG has been the most consistently found variable in determining women at high risk for early postpartum diabetes Some recent trials have shown that early postpartum testing day 2 postpartum may be as good at detecting diabetes as standard testing times; however, follow up in the standard testing group was poor.

If this can be confirmed in more rigorous trials, it may be useful to do early postpartum testing in women at high risk for type 2 diabetes or at high risk for noncompliance with follow up A1C does not have the sensitivity to detect dysglycemia postpartum and, even combined with FBS, did not help improve its sensitivity , Given the increased risk of CVD OR 1.

Education on healthy behaviour interventions to prevent diabetes and CVD should begin in pregnancy and continue postpartum , Awareness of physical activity for prevention of diabetes is low , and emphasis on targeted strategies that incorporate women's exercise beliefs may increase participation rates Although 1 study showed women with prior gestational diabetes and IGT reduced their risk of developing diabetes with both a lifestyle intervention or metformin, these women were, on average, 12 years postpartum.

More recent intervention studies of women with GDM alone who were closer to the time of delivery were often underpowered and compliance with the intervention was low. The 2 largest randomized controlled trials to date were conflicting.

The Mothers After Gestational Diabetes in Australia MAGDA study randomized women within the first year postpartum to a group-based lifestyle intervention vs. standard care. In another randomized controlled trial, women were randomized to receive the Mediterranean diet and physical activity sessions for 10 weeks between 3 to 6 months postpartum, and then reinforcement sessions at 9 months, 1, 2 and 3 years.

At 3 years, women in the intervention group had a lower BMI and better nutrition but similar rates of physical activity. However, engaging women to adopt health behaviours may be challenging soon after delivery. More studies are needed to explore interventions that may help this population reduce their risk.

Long-term metabolic impact of fetal exposure to maternal GDM. Observational studies have linked maternal GDM with poor metabolic outcomes in offspring However, 3 systematic reviews — have concluded that maternal GDM is inconsistently or minimally associated with offspring obesity and overweight and this relationship is substantially attenuated or eliminated when adjusted for confounders.

The HAPO offspring study extended their follow up to 5- to 7-year-olds and found that after adjustment for maternal BMI, higher maternal plasma glucose PG concentrations during pregnancy were not a risk for childhood obesity In contrast, a recent cohort found an association between maternal FPG and offspring BMI at 7 years of age that persisted after adjustment for birth weight, socioeconomic status and maternal pre-pregnancy BMI Current evidence fails to support the hypothesis that treatment of GDM reduces obesity and diabetes in offspring.

Three follow-up studies of offspring whose mothers were in randomized controlled trials of GDM management found that treatment of GDM did not affect obesity at 4 to 5 years, 5 to 10 years or a mean age of 9 years — This follow up may be too short to draw conclusions about longer-term impact.

However, it is interesting to note that the excess weight in offspring of women with diabetes in the observational work by Silverman et al was evident by 5 years of age. Furthermore, a subanalysis of another trial follow-up study revealed that comparison by age at follow up 5 to 6 vs.

Association between maternal diabetes and other long-term offspring outcomes, such as childhood academic achievement and autism spectrum disorders ASD , have been explored in observational studies. Reassuringly, offspring of mothers with pre-existing type 1 diabetes had similar average grades when finishing primary school compared to matched controls Associations between autism and different types of maternal diabetes during pregnancy have been inconsistent and usually disappear or are substantially attenuated after adjustment for potential confounders , Unspecified antihyperglycemic medications were either not associated with ASD or not independently associated with ASD risk , , but merit further investigation to assess if there are differences in the association between different types of antihyperglycemic agents and ASD.

The overall mean of fasting blood glucose was 4. The overall mean for OGTT was 5. The selected risk factors were analyzed using multiple logistic regression analysis to determine their association with HIP. A significant association was observed with increased body fat percentage AOR 1.

The second model replaced body fat percentage with MUAC and the association remained consistently significant in all factors of the first model with addition of MUAC AOR 1. The current study was carried out to determine the prevalence of HIP and influence of body fat percent and other risk factors on development of HIP among women in Arusha District.

The overall prevalence of HIP was found to be Gestational diabetes mellitus is not the only form of hyperglycemia which may first be detected during pregnancy as DIP is a more severe form of HIP in which diagnostic glucose levels are the same as those of non-pregnant adults [ 3 ].

Therefore, the prevalence of hyperglycemia in pregnancy in this study combined GDM and DIP as it is important to include pregnant women with pre-existing diabetes in designing interventions. Moreover, DIP increases the vulnerability to complications because of the degree of hyperglycemia and the uncertainty as to whether the onset of hyperglycemia was prior to pregnancy or it developed during pregnancy [ 2 ].

This study provides evidence for designing interventions like pre-pregnancy testing of blood glucose levels, emphasis on health education to improve health seeking behaviors among women of reproductive age. In Tanzania, due to limited resources, most women are not tested for glucose levels before pregnancy.

It is therefore important that HIP is considered to ensure thorough glucose control before conception, throughout pregnancy and postpartum for prevention of diabetes in progressive pregnancies. Hence, including DIP and GDM together may strengthen the approach and allow recognition of general prevalence of hyperglycemia to open dialogue on future GDM approaches that align with global standards for all women in Tanzania.

The observed prevalence of HIP may increase burden to the health system if no immediate actions are taken. The need exists to explore the associated modifiable risk factors including body fat to enhance self-care practices and prevent poor pregnancy outcomes as well as T2DM later in life.

A similar study conducted in Tanzania using the same WHO [ 3 ] criteria reported that the prevalence of GDM was The differences in prevalence of hyperglycemia observed may be due to nature of the diets, cultural differences in food preparation, and care during pregnancy which needs further exploration.

In addition, another similar study done in India supported our findings on the consideration of HIP in screening hyperglycemia during pregnancy and reported that, HIP was prevalent in When body fat percentage was replaced by MUAC in the second model, increased in MUAC was independently associated with HIP.

In this case, body fat percentage together with MUAC can be used instead of BMI as determinants of HIP due to their independent association with HIP. Moreover, the majority of the women in the current study could not recall their pre-pregnancy weight making it difficult to estimate their BMI.

This finding is supported by Mwanri et al. Another study reported that less than half of the mothers could recall their pre-gestational weight [ 39 ]. Hence, information on changes in body fat content is required due to its independent association with HIP which is further supported in a previous report that the risk of GDM was independently associated with high body fat percent, similar to the findings in people with T2DM [ 23 ].

With these associations, it would be important to utilize these simple factors to identify pregnant women at risk for HIP so that prevention measures, such as lifestyle modifications, can be implemented to prevent poor pregnancy outcomes [ 40 ]. This finding reveals how maternal health status is the determinant of health of the newborn.

This finding means that a woman with history of previous pregnancy, which resulted in a child with a high birth weight, is at an increased risk of GDM in progressive pregnancies [ 42 ].

Another study showed that GDM is considered to result from interaction between genetic and environmental risk factors [ 43 ]. Pregnancy triggers a series of metabolic imbalances that lead to a diabetic state in women who are already genetically predisposed to develop diabetes [ 44 ]. Of note, GDM and T2DM share a similar genetic background [ 45 ] which might be a reason to why women with strong first-degree family history of T2DM are at high risk of HIP.

Hence, genetic predispositions to T2DM or HIP should not be ignored. Other studies concur with the current report that family history of diabetes remained significantly associated with GDM even after adjustment for other co-variates [ 37 , 46 ].

Nevertheless, some women with HIP reported having one or more symptoms of T2DM, such as extreme tiredness, diaphoresis excessive sweating , and polydipsia excessive thirst and increased frequent urination. These symptoms were found to have a strong independent association with HIP even after adjusting for MUAC, BMI, gestational age and family history of T2DM.

Considering the asymptomatic nature of HIP [ 19 ], these women may have pre-existing T2DM which was not diagnosed before pregnancy because, 3. This creates a need to promote pre-pregnancy preparation that include regular screening for diabetes before conception for earlier efforts to prevent the development of HIP.

Hyperglycemia in pregnancy has few symptoms and should be diagnosed by screening during pregnancy [ 47 ]. Another study reported that overt symptoms of HIP are rare and may be difficult to distinguish from normal pregnancy symptoms creating a need for confirmatory OGTT [ 19 ].

Hence, symptom clusters with other risk factors can be used for identification of women who need screening for HIP especially in low- and middle-income countries where universal screening is not possible. For example, BMI was based on recall data where almost half of the respondents could not report their pre-pregnancy weight leading to missing data; hence, interpretations on the rate of overweight and obesity need to be done carefully.

In addition, GDM was tested by one out of two elevated glucose levels instead of one out of three values as recommended [ 3 ].

The prevalence of HIP was observed to be high in urban areas of Arusha District and significantly associated with family history of T2DM, increased MUAC, body fat percentage, and having one or more symptoms of T2DM. The reported risk factors can be used to identify women at risk of HIP early enough for earlier interventions to be taken to prevent poor pregnancy outcomes especially in resource poor settings where universal screening is challenging.

Modifiable risk factors, like body fat percentages for assessing nutrition status in pregnancy, need to be further explored to identify the proper methods for body fat estimation and develop criteria for classification in pregnancy.

Prevention strategies for HIP need to be directed towards the knowledge and control of the risk factors reported in this study and others for promoting self-care before, during, and after pregnancy.

This proactive approach can potentially reduce the impacts of non-modifiable risk factors, such as age and genetic predisposition in developing HIP. The datasets used and analyzed during the current study will be available on reasonable request to the corresponding author.

This is because the data set contains other data that have not yet been analyzed as the study involves a prospective cohort part which is still going on in the area.

Negrato CA, Gomes MB. Historical facts of screening and diagnosing diabetes in pregnancy. Diabetol Metab Syndr. Article PubMed PubMed Central Google Scholar. Hod M, Kapur A, Sacks DA, Hadar E, Agarwal M, Di Renzo GC, et al. The International Federation of Gynecology and Obstetrics FIGO initiative on gestational diabetes mellitus: a pragmatic guide for diagnosis, management, and care.

Int J Gynaecol Obstec. Article Google Scholar. World Health Organization. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy. Geneva: World Health Organization; Accessed 20 June Google Scholar. American Diabetes Association. Economic costs of diabetes in the U.

in Diabetes Care. Article PubMed Central Google Scholar. Palani S, Joseph NM, Tegene Y, Zacharia A, Marew T. Gestational diabetes-a review. International Diabetes Federation. IDF Diabetes Atlas 6th edition. Brussels: International Diabetes Federation; Macaulay S, Dunger DB, Norris SA.

Gestational diabetes mellitus in Africa: a systematic review. PLoS One. Article PubMed PubMed Central CAS Google Scholar. Njete HI, John B, Mlay P, Mahande MJ, Msuya SE. Prevalence, predictors and challenges of gestational diabetes mellitus screening among pregnant women in northern Tanzania.

Tropical Med Int Health. Article CAS Google Scholar. Ministry of Health, Community Development, Gender, Elderly and Children MoHCD [Tanzania Mainland], Ministry of Health MoH [Zanzibar], National Bereau of Statistics NBS , Office of the Chief Government Statistician OCGS , and ICF.

Tanzania Demographic Health Survey and Malaria Indicator Survey TDHS-MIS — Dar es Salaam and Rockville: MoHCDGEC, MoH, NBS, OCGS and ICF; Wendland EM, Torloni MR, Falavigna M, Trujillo J, Dode MA, Campos MA, et al.

Gestational diabetes and pregnancy outcomes - a systematic review of the World Health Organization WHO and the International Association of Diabetes in pregnancy study groups IADPSG diagnostic criteria.

BMC Pregnancy Childbirth. Imoh LC, Ogunkeye OO, Isichei CO, Gadzama AA, Ekwempu CC. Combining the IADPSG criteria with the WHO diagnostic criteria for gestational diabetes mellitus optimizes predictability of adverse pregnancy outcome.

Trop J Obstet Gynaecol. Larijani B, Hossein-nezhad A, Rizvi SW, Munir S, Vassigh AR. Cost analysis of different screening strategies for gestational diabetes mellitus. Endocr Pract. Article PubMed Google Scholar. Jensen DM, Ovesen P, Beck-Nielsen H, Mølsted-Pedersen L, Sørensen B, Vinter C, et al.

Gestational weight gain and pregnancy outcomes in obese glucose-tolerant women in Denmark. Ay L, Knuithof CJ, Bakker R, Steegers EA, Witteman JC, Moll HA, et al. Maternal anthropometrics are associated with fetal size in different periods of pregnancy and at birth: the generation R study.

Article CAS PubMed Google Scholar. Reilly JJ, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I, et al. Early life risk factors for obesity in childhood: cohort study. Fakier A, Petro G, Fawcus S. Mid-upper arm circumference: a surrogate for body mass index in pregnant women.

S Afr Med J. Kotnik KZ, Golja P. Changes in body composition of university students in a country in socio-economic transition. Anthropol Anz. Berggren EK, Groh-wargo S, Presley L, Hauguel-de mouzon S, Catalano PM. Am J Obstet Gynecol. Diagnosis and classification of diabetes mellitus.

Ravikumar B, Carey PE, Snaar JE, Deelchand DK, Cook DB, Neely RD, et al. Real-time assessment of postprandial fat storage in liver and skeletal muscle in health and type 2 diabetes. AJP-Endocrinol Metab. Weyer C, Foley JE, Bogardus C, Tataranni PA, Pratley RE. Enlarged subcutaneous abdominal adipocyte size, but not obesity itself, predicts type II diabetes independent of insulin resistance.

Qing X, Ying GZ, Ming LL, Lu W, Qian Z, Yue T, et al. The association of maternal body composition and dietary intake with the risk of gestational diabetes mellitus during the second trimester in a cohort of Chinese pregnant women.

Biomed Environ Sci. Iqbal R, Rafique G, Badruddin S, Qureshi R, Cue R, Gray-Donald K. Increased body fat percentage and physical inactivity are independent predictors of gestational diabetes mellitus in south Asian women.

Eur J Clin Nutr. Kim SY, Saraiva C, Curtis M, Wilson HG, Troyan J, England L. Am J Public Health. Lear SA, Humphries KH, Kohli S, Chockalingam A, Frohlich JJ, Birmingham CL.

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