Prevention
A 2015 review found
that when done during pregnancy moderate physical exercise is effective for the
prevention of gestational diabetes. A 2014 review however did not find a
significant effect. Theoretically,
smoking cessation may decrease the risk of gestational diabetes among smokers.
Management
Treatment of GDM
with diet and insulin reduces health problems mother and child. Treatment of
GDM is also accompanied by more inductions of labour.
A repeat OGTT
should be carried out 6 weeks after delivery, to confirm the diabetes has
disappeared. Afterwards, regular screening for type 2 diabetes is advised.
If a diabetic diet
or G.I. Diet, exercise, and oral medication are inadequate to control glucose
levels, insulin therapy may become necessary.
The development of
macrosomia can be evaluated during pregnancy by using sonography. Women who use
insulin, with a history of stillbirth, or with hypertension are managed like
women with overt diabetes.
Lifestyle
Counselling before
pregnancy (for example, about preventive folic acid supplements) and
multidisciplinary management are important for good pregnancy outcomes. Most
women can manage their GDM with dietary changes and exercise. Self monitoring
of blood glucose levels can guide therapy. Some women will need antidiabetic
drugs, most commonly insulin therapy.
Any diet needs to
provide sufficient calories for pregnancy, typically 2,000 to 2,500 kcal with
the exclusion of simple carbohydrates. The main goal of dietary modifications
is to avoid peaks in blood sugar levels. This can be done by spreading
carbohydrate intake over meals and snacks throughout the day, and using
slow-release carbohydrate sources—known as the G.I. Diet.
Since insulin
resistance is highest in mornings, breakfast carbohydrates need to be
restricted more. Ingesting more fiber in foods with whole grains, or fruit and
vegetables can also reduce the risk of gestational diabetes. Regular moderately
intense physical exercise is advised, although there is no consensus on the
specific structure of exercise programs for GDM.
Self monitoring can
be accomplished using a handheld capillary glucose dosage system. Compliance
with these glucometer systems can be low. Target ranges advised by the
Australasian Diabetes in Pregnancy Society are as follows:
- fasting capillary blood glucose levels <5.5 mmol/L
- 1 hour postprandial capillary blood glucose levels <8.0 mmol/L
- 2 hour postprandial blood glucose levels <6.7 mmol/L
Regular blood
samples can be used to determine HbA1c levels, which give an idea of glucose
control over a longer time period. Research suggests a possible benefit of
breastfeeding to reduce the risk of diabetes and related risks for both mother
and child.
Medication
If monitoring
reveals failing control of glucose levels with these measures, or if there is
evidence of complications like excessive fetal growth, treatment with insulin
might be necessary. This is most commonly fast-acting insulin given just before
eating to blunt glucose rises after meals. Care needs to be taken to avoid low blood
sugar levels due to excessive insulin.
Insulin therapy can
be normal or very tight; more injections can result in better control but
requires more effort, and there is no consensus that it has large benefits. A
2016 Cochrane review concluded that quality evidence is not yet available to
determine the best blood sugar range for improving health for pregnant women
with GDM and their babies.
There is some
evidence that certain medications by mouth might be safe in pregnancy, or at
least, are less dangerous to the developing fetus than poorly controlled
diabetes. The medication metformin is better than glyburide. If blood glucose
cannot be adequately controlled with a single agent, the combination of
metformin and insulin may be better than insulin alone.
Another review
found good short term safety for both the mother and baby with metformin but
unclear long term safety. People may prefer metformin by mouth to insulin
injections. Treatment of polycystic ovarian syndrome with metformin during
pregnancy has been noted to decrease GDM levels.
Almost half of the
women did not reach sufficient control with metformin alone and needed
supplemental therapy with insulin; compared to those treated with insulin
alone, they required less insulin, and they gained less weight. With no
long-term studies into children of women treated with the drug, here remains a
possibility of long-term complications from metformin therapy.
Babies born to
women treated with metformin have been found to develop less visceral fat,
making them less prone to insulin resistance in later life.
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