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PCPs play critical role in preventing, treating gestational diabetes
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Gestational diabetes, one of the many health consequences caused by obesity can affect up to 10% of pregnancies in the U.S. each year, according to the CDC.
Stephen Thung, MD, director of maternal fetal medicine at The Ohio State University Wexner Medical Center, told Healio Family Medicine primary care physicians may not realize the critical role they can play in raising awareness of diabetes and gestational diabetes.
“Primary care physicians are often thinking about hypertension, cancer, heart disease, and those kinds of medical conditions. They don’t always talk about gestational diabetes and post-pregnancy diabetes, because they think their patients’ OB/GYN addressed diabetes and gestational diabetes with the patient. But PCPs need to talk about diabetes with their female patients before, during and after their pregnancies,” he said in an interview.
In recognition of November being National Diabetes Month, Healio Family Medicine asked Thung to discuss which patients are at risk for gestational diabetes, what treatment options are available, how to care for these women after the baby is born, and other important information about the condition. – by Janel Miller
Question: What are some of the risk factors f or developing gestational diabetes?
Answer: Obesity is the most common risk factor. That’s because the higher a person’s BMI, the more insulin resistant their bodies become-a critical contributor to developing gestational diabetes. Another common risk factor is age and we know than many couples are delaying having children until later in their lives. Older women are at risk for a variety of reasons and it is likely a combination of increasing insulin resistance (we all gain weight as we get older) and declining insulin production ability from an aging pancreas. Women who become pregnant in their mid- to late- thirties and forties also need to be particularly concerned about gestational diabetes. Other risk factors including having had gestational diabetes during a previous pregnancy, giving birth to a baby who weighed more than 9 pounds, having a family history of diabetes, having polycystic ovary syndrome and are Black, Hispanic/Latino American, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander.
Q: When should a PCP first talk to their female patients about gestational diabetes?
A: When talking to women who are contemplating pregnancy, it is important to review their risk factors to assure a safe risk-free pregnancy before it actually occurs. By the time a woman is pregnant, modifying risk factors is difficult. Obesity is an important risk factor for gestational diabetes, unfortunately most are going to have a hard time losing weight during pregnancy — and this work needs to be done far before pregnancy. Moreover, women who are at risk for gestational diabetes may also be at risk for overt diabetes. We know that women with overt diabetes with a high HbA1c are at higher risks for birth defects and miscarriage — all potentially preventable if diabetes is identified before pregnancy. I cannot emphasize enough the importance for usual diabetes screening in women with strong family histories, morbid obesity, or other conditions that predispose such as polycystic ovarian syndrome.
Therefore, it is critical that PCPs add gestational diabetes to their discussions with patients about the importance of healthy diet and exercise months, perhaps even years, before the patient becomes pregnant. Women should also be screened for overt diabetes as early as possible in their family planning processes for the same reason.
Q: When should a PCP begin screening women who are pregnant for gestational diabetes?
A: Most of the time, an obstetrician or midwife, or family medicine physician performing prenatal care will initiate this screening. Pregnancy is a moving target, and women who are pregnant often don’t see changes to the insulin hormone until about they are halfway through their pregnancy time. As they get further along in their gestation, the insulin hormone gets weaker (insulin resistance increases). Consequently, it’s best to wait until the second or third trimester, or between 24 and 28 weeks, to screen them for gestational diabetes. This timing is a balance—waiting long enough to identify women with gestational diabetes and early enough to offer therapy that will be impactful to improve pregnancy.
Some women with significant risk factors for overt diabetes should be screened as early as feasible—perhaps in the first trimester. Women with morbid obesity or a history of gestational diabetes are at sufficiently high risk for diabetes prior to pregnancy/early pregnancy that this screening is worthwhile.
When screening, women can take the 50 grams of sugar glucose test to see how well their body is processing sugar. If the level is more than a certain threshold, then have the woman take the 3-hour glucose tolerance test. If the woman tests positive for gestational diabetes, she should begin treatment immediately.
Q: What treatment options are available for women with gestational diabetes?
A: The best thing women can do is to eat a healthy, balanced diet with proteins and carbohydrates. One of my biggest challenges I notice when first meeting someone who has been diagnosed with gestational diabetes is they do not know what is a healthy diet. Although I do encourage eating some fruits, some increase their fruit and fruit juice intake significantly as they perceive it is natural and healthy, and that simply is not true. Fruit juice is sweet and chock full of simple sugars that can make gestational diabetes very difficult to manage. If achieving a healthy diet fails to achieve euglycemia we offer pharmacotherapy. Our two most common choices are insulin or metformin. Insulin is thought to be the first line therapy but can be challenging as it is an injectable medication. Weight gain and symptomatic hypoglycemia can be other concerns. Metformin has become a more popular oral therapy. Although many women may ultimately require insulin (50% need some insulin due metformin failure) most prefer to begin their gestational diabetes treatment with metformin. Though this latter treatment option can cause adverse events like diarrhea, muscle pain and weakness, patients are usually more comfortable with oral medications and patients receiving metformin are less likely to gain weight or have significant hypoglycemic episodes.
Q: What are the risks to the baby whose mother has gestational diabetes?
A: Babies of mothers with gestational diabetes can be exposed to higher than normal sugar levels, if not well controlled. This can result in excessive fetal growth and babies with higher than normal fat content. As you can imagine, larger babies are more difficult to delivery when the time comes. We know that women with gestational diabetes are at higher risk for cesarean section. We also know that good diabetes control can mitigate this risk. Babies of mothers who had gestational diabetes are also at higher risk for shoulder dystocia. Delivering this baby safely can be challenging. Fortunately, obstetricians and midwives have special maneuvers that can relieve this problem. Unfortunately, these stuck babies are at immediate risk for birth injuries to the bones and peripheral nerves. In rare cases, some of these injuries can be permanent. Beyond delivery challenges, babies with mothers who had gestational diabetes are at risk for other immediate neonatal challenges such as hypoglycemia, jaundice, and longer neonatal ICU stays. As these babies grow older, they are at risk for obesity and/or type 2 diabetes.
Q: What advice can a PCP give a woman with gestational diabetes, after her baby is born, to prevent or delay developing type 2 diabetes?
A: About half of all women who had gestational diabetes will develop overt diabetes after birth. This can occur as early as 5 to 10 years after delivery. That’s why it’s so important to ask female patients who have had a baby if they had gestational diabetes. It is really an important part of their medical history. Don’t assume the OB/GYN mentioned it. Current recommendations suggest testing for overt diabetes within 12 weeks of giving birth to assure resolution and to identify women who actually have prediabetes or overt diabetes that has not been previously recognized. Women with prediabetes should be tested for diabetes annually. If the test results are normal, then the woman should be tested every 3 years to assure diabetes does not quietly develop. We know that diagnosing diabetes and managing it well can reduce the terrible sequelae of long-standing disease such as blindness, renal failure, and peripheral neuropathy.
In addition, women should continue to be physically active and make healthy food choices after the baby is born. Improving life style and attaining a healthy weight can reduce her risks of future diabetes. The health benefits of doing so stretch far beyond preventing or delaying type 2 diabetes and its complications, and ultimately the end stage concerns such as blindness, renal disease and amputation.
Disclosure: Thung reports no relevant financial disclosures.
Reference: CDC.gov. Gestational diabetes. https://www.cdc.gov/diabetes/basics/gestational.html. Accessed Nov. 8, 2018.