Lowering Risks from Gestational Diabetes for You and Your Baby

What Is Gestational Diabetes and Why Does It Happen?

Dr. Jones: About a million years ago, I was pregnant, and as part of my prenatal visits, I had to drink some sugary goop and get my blood drawn. What for, and why me?

This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah, and we're going to talk about diabetes in pregnancy, pregnancy-related diabetes, on the "7 Domains of Women's Health." So we're going to explore the who, what, when, where, and why of gestational diabetes, diabetes that comes with pregnancy.

And to do that, we have in our virtual Scope studio Dr. Michelle Debbink. She is a maternal fetal specialist providing prenatal care for patients with high-risk or rare medical conditions, such as diabetes and congenital heart disease. And she knows a lot about diabetes in pregnancy.

Welcome, Michelle, and thanks for helping us out.

Dr. Debbink: Thank you so much for having me, Dr. Jones.

Dr. Jones: Sure.

Dr. Debbink: I'm delighted to be here.

Dr. Jones: So, what is gestational diabetes? Can you help me with that?

Dr. Debbink: Sure. So gestational diabetes is a special form of diabetes. For people who are not familiar with diabetes in general, diabetes is a problem in the body where your body has trouble either listening to hormones that your body makes called insulin on how to process blood sugar, or doesn't make insulin at all, and it makes it very difficult for your body to process blood sugar.

During pregnancy, the placenta actually makes some extra hormones that talk to your body's cells and make it hard for your body to process blood sugar. It makes it hard for your body to listen to the insulin that you already make, and that extra blood sugar can be damaging to your own body, but also can cause difficulties with the way the baby grows or even difficulties with how the placenta functions over time. So that's why we look very closely for it in pregnancy.

Dr. Jones: It's so common, I almost think there must have been an evolutionary advantage for the placenta to do this. We were starving, and when you're pregnant and starving, you want some sugar, something to go to the fetus to make it grow. So there must be an advantage to this, for the placenta to do this really cool and weird thing.

Dr. Debbink: Yes.

How Does Gestational Diabetes Differ from Type 1 and Type 2?

Dr. Jones: And it differs from type 1 and type 2?

Dr. Debbink: Yes, it does.

Dr. Jones: Can you explain type 1 and type 2? People have heard of type 1 and type 2. Is this type 5 or type Q, or what type is this?

Dr. Debbink: That's great. There are actually many types of diabetes now, but the most common ones are type 1 and type 2. Type 1 diabetes is the type of diabetes I mentioned a moment ago, where something happened in someone's pancreas, which is the organ in the middle of our abdomen that makes insulin, among other important hormones. And something happened to someone's pancreas, often when they're very young, that caused it to stop making insulin altogether.

And when it stops making insulin, that means that your body cells all throughout your body can't get the instructions that they need to take in the glucose from your blood and use that as fuel.

So blood sugar is a fuel for all of our body cells, and insulin is the instruction to the body cells to take that fuel in and use it. So in type 1 diabetes, we don't have the instruction hormone. And so for folks with type 1 diabetes, they're what we call insulin-dependent. They require insulin in order to keep their blood sugars from skyrocketing very, very high.

If you know someone with type 1 diabetes, they're often diagnosed because they become hospitalized with what we call diabetic ketoacidosis, which is a very dangerous high blood sugar problem that can cause organs to shut down and can cause a lot of downstream problems. So often, people are diagnosed in childhood when they get their first episode of DKA, or diabetic ketoacidosis.

Type 2 diabetes is a type of diabetes that often occurs later in life, either in adulthood or even the middle years. The timing of type 2 diabetes can be a little bit variable. It often runs in families.

Type 2 diabetes occurs when your body develops something called insulin resistance. And what that means is that instead of not having that instruction hormone around that tells your body to bring in that blood sugar fuel and use it or store it, the insulin is there, but something in your body cells has changed, and they're not listening anymore.

So the insulin is knocking on the door and saying, "Hello. Please use the blood sugar," and the body cell is saying, "I can't hear you." That's type 2 diabetes.

And it is on a spectrum from more mild insulin resistance, sometimes called pre-diabetes, to overt type 2 diabetes, where the blood sugars can get very high.

People with type 2 diabetes are usually not as prone to diabetic ketoacidosis, but they can have pretty significant what we call hyperglycemic events. People with type 2 diabetes can sometimes take medications that make their body cells more sensitive, making it easier for them to listen to that insulin knocking on the door. But sometimes they actually just need more insulin in order for those knocks to be louder, and so then the body cell will listen and bring in the blood sugar and use it as fuel.

Why Pregnancy Triggers Blood Sugar Problems

During gestational diabetes, what makes gestational diabetes kind of cool and special, just as you were saying, is that it does seem to have some evolutionary purpose. The placenta actually makes hormones that are putting earmuffs on your body cells. The placenta hormones make it hard for your . . .

Dr. Jones: I wish our listeners could watch you covering up your ears. Sorry, listeners. You can't see Michelle doing that, but it's very cute. Keep going. Sorry to interrupt.

Dr. Debbink: So the placenta is putting earmuffs on your body cells and saying, "Don't listen to that insulin. Send all the blood sugar to me so I can give it to the baby."

Sometimes that process just works a little too well. And when that process works a little too well, or if you already have some underlying insulin resistance, then that's when blood sugars can become too high in pregnancy, and you develop an over-exuberant placenta response that makes it so that you have too much blood sugar running around, both for you and for your baby.

How Common Is Gestational Diabetes?

Dr. Jones: Right. So how common is it? I mean, I know that type 1 and type 2 are very important to manage correctly, and usually, people know when they walk into pregnancy, they have it. But how common is this gestational diabetes? Is it common?

Dr. Debbink: It's pretty common, actually, as far as pregnancy complications go. About 8% to 10% of people who are pregnant will ultimately develop gestational diabetes. And that number has been on the rise over time.

Screening for Gestational Diabetes

Dr. Jones: So, how do you screen for it? And do you remember the jelly bean test? I had to drink this bottle of goop. How are we testing now? And can I do it with jelly beans so I can pick my favorite flavors?

Dr. Debbink: I love it. So when I was pregnant, we only had one flavor, orange. It tasted like super-concentrated Tang. It was really gross.

We do generally screen towards the end of the second trimester, early third trimester. So, between 24 and 28 weeks is the typical screening time. The reason we wait until that time to screen for gestational diabetes is that's about the time the placenta is really ramping up its hormone production. And before that, for true gestational diabetes, there's really not enough hormone around to make people's blood sugars go significantly out of whack.

We also, at least at the University of Utah, include universal hemoglobin A1C screening at the beginning of pregnancy. This differs from institution to institution, and there aren't particularly strong guidelines about exactly how we should be looking for early insulin resistance in pregnancy. But at least in our current practice here, we do screen with a hemoglobin A1C, and that lab value lets us know how well someone's body has been processing blood sugar, kind of leading into pregnancy.

If that is an elevated value, we can either determine that maybe someone actually had pre-existing type 2 diabetes coming into pregnancy and didn't know it yet, or we can determine that they may have some underlying insulin resistance. So they already have some cells that aren't listening well, which puts them at risk of developing gestational diabetes. So there's kind of that early test and then the later test.

Who Is at Higher Risk for Developing Gestational Diabetes?

Dr. Jones: Well, I think as Americans get chubbier . . . And maybe they're not getting chubbier anymore, but they certainly have been on a 50-year accelerated chubbiness. We know that women who carry a little excess weight or come from certain ethnic groups that are predisposed to gestational diabetes, it's probably good to know earlier rather than later. Does everybody get screened?

Dr. Debbink: Yes, everyone gets screened because everyone is at risk. Once we put that placenta into the mix, all bets are off. Certainly, some people are at higher risk. As you mentioned, carrying a little bit of extra weight can put you at risk. Certain endocrine disorders can also put you at risk. So, for folks who have polycystic ovary syndrome or other endocrine disorders, they may be at risk.

But a lot of people who are diagnosed with gestational diabetes really have very few risk factors. And so we want to make sure that we don't miss anyone so that we can prevent the downstream consequences of gestational diabetes.

Dr. Jones: Well, this is HIPAA compliant because I'm doing it to myself. So I got tested and I was okay, and I had an 11-pound baby a million years ago. Would that put me at risk for baby number two if I got tested and was okay, but made this humongous kiddo?

Dr. Debbink: We do think there might be some connection. It's not a very strong risk factor, but there probably is some connection between people who have larger babies and later gestational diabetes in future pregnancies.

But there's also a genetic component of just who people are when they make babies and what their babies look like when they come into the world. And so we can't always tease those things apart.

I will also say that certain more recent studies have shown us that even a little bit of elevated blood sugar, maybe not even rising to the level of getting a diagnosis of gestational diabetes, may be associated with some other outcomes as well.

How Elevated Blood Sugar Affects Baby Growth and Delivery

Dr. Jones: Yeah. So what are the risks to the baby? We'll talk about the baby and the risks to the mom, but what are the risks to the baby if the mom's sugar is too high? What's the risk during either pregnancy or in early childhood and later? Can you talk about that?

Dr. Debbink: Yeah, absolutely. So if you have gestational diabetes in pregnancy, just like you were talking about, I do like to kind of break that up into three groups of risks. One is the baby risks, one is the mom risks, and one is what I call the obstetric risks, things that happen around the time of delivery.

Shoulder Dystocia Risks

And so for the baby, in addition to the excess blood sugar that they see during development, that can cause them to gain a little bit more weight than they otherwise would. And that weight is actually distributed in different ways from babies whose moms don't have gestational diabetes.

So they tend to put on a little bit more fat in their shoulders and a little bit more fat around their tummy than babies whose moms don't have gestational diabetes. And because of that differing weight distribution, they are at risk for something called shoulder dystocia.

Shoulder dystocia is a problem where, during a vaginal delivery, one of the baby's shoulders can get stuck as the baby is coming out of the birth canal, and that shoulder gets stuck underneath the mom's pubic bone.

Dr. Jones: Right. So usually the baby's head is the biggest thing that has to get out. But if a baby has shoulders bigger than their head, then their head can get out, but their shoulders can't.

Dr. Debbink: Exactly.

Dr. Jones: Oh, it's an obstetrical nightmare. For obstetricians, you've been there, and it makes your heart go faster than anything else I know.

Dr. Debbink: Yes, it is. As I tell patients, a true obstetric emergency. It makes everybody really get alert and start going through a whole series of maneuvers.

Most shoulder dystocias are quite short, but the ones that are not short can be very challenging, and they can also cause many downstream consequences for the baby. The baby's head is out, but the rest of the body is not, and the umbilical cord is often compressed, which cuts off the baby's oxygen source. And so we really want to work fast and hard to get that baby delivered.

But the way I describe it is babies whose moms have gestational diabetes who end up having a lot of high blood sugars, it's almost like they're little linebackers. They have these big shoulders compared to what they otherwise would.

And then the shoulder dystocia can also potentially cause consequences with nerves in the neck or the arm, which can cause some permanent damage there. They can be at risk for clavicle fractures or arm fractures, and at risk for some brain dysfunction if the oxygen deprivation is long-term.

Dr. Jones: Oh, my. All right. Everybody who's listening, who's pregnant, you just want to get tested. You just want to keep your . . .

Dr. Debbink: Exactly.

Dr. Jones: You don't want to go there. We don't want to go there.

Dr. Debbink: We don't want to go there. We need to know. Exactly right.

And so the other things that we think about . . . So, shoulder dystocia is overall quite rare, actually, in the general scheme of things, but it is one of the biggest things that we worry about because it's got really bad consequences.

Newborns Can Have Low Blood Sugar After Birth

The other thing that can sometimes happen to babies when they're very first born is that once the umbilical cord is cut, their blood sugar source is cut off because they've been getting that from Mom. Their little pancreas is making insulin and processing blood sugar, and then all of a sudden the sugar goes away, and their pancreas is still really active, and they can have very low blood sugars right after.

Dr. Jones: Yeah, they were living in the candy shop, and now their mom grabbed them out, and now they're going to need a little help until they get over it.

Dr. Debbink: The soda stream got cut off, and now we need a little bit of assistance. And so sometimes babies will need a little help, even in the NICU, to get their blood sugars under control and keep them elevated.

You mentioned actually the longer-term consequences. There does seem to be an increased risk of childhood diabetes or childhood insulin resistance related to having been exposed to gestational diabetes in utero, but that connection is a little bit less clear, just because there's also family history involved in that.

People who are at risk for gestational diabetes often have a strong family history of type 2 diabetes. And so there's some different family and genetics and things that are all wrapped up in that. So it's not as clear an association.

Short- and Long-Term Health Risks for the Mother

Dr. Jones: Well, does diabetes go away? I mean, for the baby, once the baby gets used to not living in the candy store and they've been checking the sugars pretty carefully after the baby's born, so they're not so low, and then the baby gets better, does the mom get better?

Dr. Debbink: Yes, technically. So, gestational diabetes, by its definition, does go away after pregnancy. We always test after pregnancy, about six to eight weeks after pregnancy ends, though, just to make sure that it hasn't stuck around and that there may have been some underlying component of type 2 diabetes.

But I think the most important takeaway about the long-term for mom is that if you develop gestational diabetes, you have about a 50% risk of developing overt type 2 diabetes in the next 5 to 10 years after that delivery.

And for a lot of people, that means developing type 2 diabetes, about a 50% chance of developing type 2 diabetes, at a pretty young age. If you have gestational diabetes when you're 24 or 25, that means you have a 50% chance of developing type 2 diabetes before you even reach age 40. That can be a long lifetime of living with a disease that causes serious consequences.

Managing Blood Sugar to Improve Pregnancy Outcomes

Dr. Jones: Well, the good news is if you're diagnosed with gestational diabetes and you're willing to walk the line, if you eat carefully . . . And sometimes people then go on to need some medication, but we can manage people's blood sugars during their pregnancy really well.

Dr. Debbink: That's right.

Lifestyle Approaches That Help Control Gestational Diabetes

Dr. Jones: And I think there are some studies to say, "If you play the rules, you can have the same outcome as pretty much anybody." Is that true?

Dr. Debbink: Yes, that's exactly right. So for folks who do get gestational diabetes, I think the other really important piece of this, and one of the reasons that I really enjoy treating diabetes in pregnancy, is that when you can get a good team together and you've got people around you helping to support you as you manage your blood sugars, you can actually have the same pregnancy outcomes as somebody without diabetes if we can get those blood sugars into a more normal range.

And so I think that's really a hopeful way to think about diabetes in pregnancy, is that it's a really motivating time. It's a time when we gather a lot more data about your diabetes.

So for people who have diabetes going into pregnancy, the amount of data we try to collect in pregnancy about diet and blood sugar levels and all of that is often much more in-depth than what they've been used to prior to pregnancy.

And so we really can help pinpoint specific foods for you that make your blood sugars go up, or specific activities, exercises, things that are really helpful in your day-to-day life that help bring your blood sugars down.

What are the eating patterns, and what are the foods that you want? How do you read labels and all of these sorts of things? Really, skills that you can take with you into your life after your pregnancy ends that can help you to really maintain a healthy blood sugar level throughout your life and put off that diagnosis of type 2 diabetes for as long as possible.

How to Build the Right Support System During Pregnancy

Dr. Jones: It turns out the diet that we often recommend for women with gestational diabetes looks a lot like the Mediterranean diet. It looks a lot like the diet we're all supposed to be eating. So if you can get a jump on it, good for you, and just eat this way forever.

Well, if you had one tip for a pregnant woman with gestational diabetes, what would you tell her?

Dr. Debbink: Oh, that's a really good question. I think social support and working with your family and partner, and friends to help create a space where you can have the support that you need to really take good control of your diabetes is really helpful. So building a little nest of friends and family and people who have your back is really helpful.

The other tip I would say is that as technology gets better and better, there are a lot of different new and interesting ways to keep track of your blood sugar. Timers and things, and reminders that can help you. You can use the camera on your phone to scan something in the store and find out if it's diabetes-friendly and things like that.

So really leaning in on your friends and leaning in a little bit on technology, but then working closely with your team, doctors, diabetes educators, nutritionists, etc.

Work closely with your team to be really honest about what your life looks like and what changes you can make, and then ask for help around the changes that are harder, and really build that super-trusting and helpful team on both your medical provider side and also on your family side.

Resources for Gestational Diabetes Education

Dr. Jones: Yeah. I think of many households where the pregnant mom has kids, maybe some older kids, and maybe she's doing the cooking for the entire family. Maybe they all have a way of eating that isn't good for them, but maybe she has to think about this baby and herself. And then I would just tell the whole family, "What she's going to be doing is the way you all should be eating."

Are there any good resources for more information for people?

Dr. Debbink: The American Diabetes Association actually has some wonderful recipe creators now. They have this huge cookbook, all online, all for free. You can make shopping lists, drag and drop to make a menu for the week with diabetes-friendly recipes that run the gamut from French cuisine to "I have this thing in my fridge. What can I make with that?"

And then there's also a great couple of resources on the California Department of Public Health's Sweet Success website. Sweet Success is specifically designed for folks with gestational diabetes, and it has a couple of really great resources that are easy to use without having to necessarily understand lots about carb counting or label reading or all these things.

There's something called the MyPlate resource, which is a good way to guesstimate how much of the starch you should eat, how much of the protein you should eat, and how much of the vegetables you should eat, just by dividing your plate up a little bit and filling up the plate with those different portion sizes to help regulate the amount of carbs.

Dr. Jones: So the first was the American Diabetes Association, and look for gestational diabetes. And the other is the California Public Health . . .

Dr. Debbink: Sweet Success.

Dr. Jones: Sweet Success. Well, we'll try to put those in the memory notes, the links. So thank you for joining us. I'm going to go check out some of those websites. Thank you, Dr. Debbink.

Babies should not develop in the uterus with high blood sugars. It can affect them for the rest of their lives. We're very good at helping women with gestational diabetes have a healthy baby, and there are specialists like Dr. Debbink who can make that happen, and the whole team can make you better.

Keep an eye out for your own future health. Keep yourself and your baby as safe as you can, and thanks for joining us on the "7 Domains of Women's Health."