Gestational Diabetes - What do I need to know?

Shellie Poulter
Jun 16
10 min read

Watch the recording of our podcast episode here

Being told you have developed diabetes in pregnancy can be a scary thing, and often means a whole host of medical intervention pushed on to you to prevent "risks", but are they always necessary and how big ARE the risks? I chatted with Erin of https://www.better-birth.co.uk about the differences between type 1, 2 and gestational diabetes, the interventions that may be recommended, and whether the research backs up early induction of babies on her podcast. You can listen here to the episode:

https://open.spotify.com/episode/5BWk6DawTPiz6pwgrWZXlB?si=iTKEgqzyTAGbKiZOZBX-tw

If you are interested in having further information including what you can do to help prevent developing gestational or type 2 diabetes including supplement, dietary and lifestyle advice and hacks, then check out my Bitesize Birth Lecture which includes a PDF with loads of helpful information, meal plans, recipes, further information and resources, etc.

To celebrate the launch of the podcast, you can use this link to get 50% off the usual price of the resources.

⁠https://chipper-teacher-4208.kit.com/products/june-bitesize-gestational-diabetes?promo=SERENITY50

What is diabetes?

When we eat food, it is broken down and absorbed in our digestive tract, starting in the mouth. Carbohydrates, fats and proteins are broken down into smaller molecules that enter our blood stream. The less complex the substances, the more rapidly they are absorbed into the bloodstream. So simple sugars, like refined white sugar, fruit juices, white flours, pastas, etc are all absorbed very quickly, as they are simple to break down and absorb. They are not coated with fibre, protein, fats, etc that make the process take longer.

Our bodies like balance, homeostasis, they don’ like extremes of things because those extremes cause things to malfunction, they cause damage to tissues, to our mitochondria, etc. When we eat, the substances are broken down and absorbed into our blood stream and our blood glucose levels rise. Insulin is released as a result, from our pancreas in order for the glucose to be able to enter our cells and fuel our bodies. If insulin isn’t being produced or is not working effectively, the sugars remain in the bloodstream. If the levels continue to remain high, the pancreas has to keep making more insulin. This is diabetes.

What are the different kinds of diabetes?

Type 1 is an autoimmune condition that causes destruction/disruption of insulin producing cells in the pancreas. Usually discovered in early childhood. But now due to the rise of autoimmune conditions can be diagnosed later in life. Often need medication to control blood sugars as insulin can not be produced effectively in the body.

Type 2 is basically carbohydrate intolerance. Your body cannot cope with a high carb diet with the level of activity you currently have. It happens where insulin produced in your pancreas isn’t working properly due to insulin resistance or your pancreas is not able to make enough insulin in response to raises in your blood glucose levels (BGL). Insulin resistance is when your body stops responding normally to insulin – usually because BSL are too high too much of the time. Like an irritating person always knocking and pestering, eventually you begin to ignore the knocking even if there is a problem.

If diet and lifestyle are adjusted for type 2, most people can reverse type 2 diabetes. If this isn’t successful or whilst adjusting, metformin, insulin and other medications can be used – now GLP1 products like Ozempic, etc are becoming more popular.

Gestational diabetes is different again and it happens at around 20 weeks gestation (so if you are diagnosed BEFORE this time, then it is likely type 2). At this time there is a surge in growth hormone, cortisol, progesterone and human placental lactogen which do various things to your body to increase glucose absorption and also to increase insulin resistance. Why is your body doing this? Well it is so your blood glucose levels remain higher for longer so that your baby can use that glucose to grow and develop. Your BGLs are naturally higher so that the baby can grown. If your body is functioning well, these higher BGLs are then reduced within a few hours. If things are not working then the baby basically slurps up more sugar than they need and after 20 weeks of gestation this means that they will grown bigger than they would if your diet and lifestyle were working well for you and your baby.

It is important to understand the difference between diabetes that is present before 20 weeks gestation and that after because the outcomes when bgls are not controlled in those different periods is very different and they are often combined together when looking at outcomes in studies and so make it sound FAR scarier and like outcomes are FAR worse for people with GD than they are in reality. The majority of poor outcomes are happening only for people with uncontrolled blood sugar levels early in pregnancy (before when GD develops).

How Common is Gestational Diabetes?

Of people who have diabetes in pregnancy, around 10% of people have pre-gestational diabetes and around 90% have GD. If blood sugars are not well controlled in early pregnancy during the 1st 8 weeks of life, when organogenesis is occurring, this can cause significant abnormalities and a higher rate of miscarriage. Also further maternal complications – kidney damage, retina, etc which is aggravated by the extra stress of pregnancy.

Gd affects around 4-5% of pregnancies in the uk. It develops around 20 weeks, AFTER organogenesis and the main complication is macrosomia. Both can cause preterm labour, growth issues, still birth and macrosomia but gd does not generally cause miscarriage or significant abnormalities.

Risk factors for GD include age 40+ in white, 25+ if Afro-Carribean, Black African or South Asian (Oakistani and Bangladeshi) and Chinese populations.

If you are obese or overweight at conception, if you have a large abdominal circumference, medical history of high blood pressure, heart attack or stroke, family history of GD, prediabetes or type 2, previous “large” baby 8lb 13oz of over 3.99kg, unexplained still-birth or malformed infant. However 50% of people with GD have NONE of those risk factors. 41-53% of GD is attributed to being overweight or obese. It does increase your chances of developing GD but it does not mean you definitely will have or will develop it.

There are lots of risk factors, some of which you can control and some you cannot.

GD is basically an early warning sign for your and your baby’s long term health that your body does not do well on a high carb diet and you need to change things for your and your baby’s long term health.

What are the risks for babies?

Insulin levels rise in response to high bgls, excess glucose is converted to additional fat stores concentrated around the upper body, chest and shoulders of the baby when BGLs are high– this increases the chance of shoulder dystocia and perineal injury. This only happens if you BGLs are not controlled, otherwise you and your baby are healthy and normal. Please be aware that your chance of NOT having a shoulder dystoica even when your BGLS have been out of control and your baby is suspected to be over 4kg is around 91-95% that you will not. The chance of injury to you or your baby is very small and the chance of lasting damage from any injury is smaller still.

A higher presence of insulin in the body delays the production of surfactant which is needed for lungs to work well. It is extremely frustrating that medics ignore this life threatening cause for concern about a baby being able to breathe well when they are evicting babies prematurely for a 1-5% chance of SD that is easily resolvable with no lasting injury for the vast majority and seemingly not telling anyone about this potential risk. The chance of serious injury with SD which is so small they stopped the recent big baby trial because injuries were happening SO rarely that it would take tens of thousands of people to see enough poor outcomes to prove anything.

Diabetes was associated with increased risk of neonatal respiratory morbidity beyond what can be attributed to prematurity. Neonatal respiratory morbidities were increased with pregestational diabetes compared with gestational diabetes. Kawakita et al, Am J Perinatol 2017

Surfactant is a complex molecule at the alveolar air liquid interface in the lungs that reduces the surface tension allowing for gaseous exchange from the air in the lungs into the blood stream. If the surfactant is deficient, gaseous exchange is not as effective. This is particularly important to note if induction/caesarean is being recommended early because the mother has GD. Babies are MORE likely to have breathing difficulties, be whisked off and separated, cords cut prematurely, feeding and bonding disrupted, cascade of intervention. For this reason alone, allowing the baby to stay in until they are ready is important.

Red blood cell production in the baby is increased if BGL are high. This leads to higher levels of jaundice. Interestingly early feeding/glucose infusions did not affect the course of bilirubinaemia in a study in 1989, in a study in 2022, higher gestational age was protective against jaundice.. He et al (2022), so another pro to waiting until the baby is ready to be born.

At birth the sudden drop in BGLs when the placenta is no longer attached to the maternal blood circulation can cause hypoglycaemia because it takes time for the baby’s insulin levels which have been extra high to reduce down. So too much bg is converted. Babies need this fuel for their brains and body to work, muscles to function, energy to keep warm, liver to function etc. Causes babies to be restless, /jitteriness, irritability, pale/blue skin colouring, apnea (stopping breathing), rapid breathing or grunting sounds, poor body tone, poor feeding or vomiting, lethargy, listless, difficulty controlling body temperature, tremors, sweating, shakiness or seizures.

Exposure to untreated gd in utero increases the chance of obesity and type 2 diabetes for babies 6 fold (Herath et al 2021, Holder et al)

It is a marker for the development of type 2 diabetes in up to 70% of women within 5 years of pregnancy (Newton 2002)

It is an early warning sign for you that your diet and lifestyle are not working for your body.

How is Gestational Diabetes Diagnosed?

Diagnostic levels are different in different trusts, hospitals, countries and are often based on the finances available at the hospital to cope with the extra care recommended for people diagnosed with GD rather than an improvement in outcomes with diagnosis.

Generally GD is diagnoised if fasting plasma is above 5.6mmol/litre or above or 2 hour blood plasma glucose levels of 7.8mmol/litre or above.

This is lower than normal diabetic thresholds.

With no sympotoms, GD should not be diagnoses on a single blood glucose determination. It requires confirmation.

Target Level NICE Fasting blood sugar levels less than or equal to 5.3mmol/L

Post meal 1 hour 7.8mmol/L

Post meal 2 hour 6.4mmol/L

If taking insulin maintain capillary plasma glucose above 4.0mmol/L

What does The World Health Organization Recommend for Gestational Diabetes?

WHO recommends that IOL should NOT be offered for GD unless there is evidence of other abnormalities such as abnormal BGLs.

However there is no evidence for this either.

What if I am told my baby's life is at risk?

If your BGLs are under control, you have exactly the same generalised chance of stillbirth as everyone else in the population which is around 0.33 in 2000 at 40 weeks, 0.8 in 2000 at 41 weeks and 0.88 in 2000 at 42 weeks.

That is a 99.96% of not having a stillbirth

What about Shoulder Dystocia?

If your BGLS are under control, you have the same generalised chance of SD as everyone else which is around 1% or 99% chance that you won't.

Also bear in mind the vast majority are easily resolved and do not cause lasting damage to you or your baby. If you are interested in learning more abour shoulder dystocia, how it is resolved and evidence based information around its prevelance what does and doesn't cause it, you can purchase it here: https://chipper-teacher-4208.kit.com/products/may-bitesize-birth-shoulder-dystoci?_gl=1*rw135g*_gcl_au*MTQ5MzIwODc4LjE3NDQ4Nzk4OTkuMTQ0NTM0NDU4Mi4xNzUwMDc3NDg0LjE3NTAwNzc0ODM.

Only you can decide what feels right for you. No choices are risk free.

There is NO evidence that Induction of Labour reduced stillbirth for Gestational Diabetes alone.

Having several risk factors also does not necessarily justify an induction or a cesarean. The choice is yours and very individual. Ask for the evidence to justify medical intervention for each risk factor you are given so you can make your own mind up. If medical professionals are using coercive language or tactics, this is breeching their ethical code of conduct.

Being at higher risk is very different to actually having an issue. Very few people labelled as high risk actually go on to have an issue.

There has been one small trial of 425 woman that shownd no difference between birth options with regard to the number of large babies, shoulder dystocia, breathing problems, low blood sugar or admission to NICU. no baby in the trial experienced brith trauma. In the induction group, the incidence of jaundice was higher (Biesty et al 2018)

"women with gestational diabetes have comparable outcome to pregnant women who are not affected by gestational diabetes and can be considered as low risk until any evidence is round" Jabak & Hameed 2020

"With women with well controlled GD, we find it difficult to recommend women give birth in obstetric led units with continuous fetal monitoring and deny them a chance to have a home birth or idwifery-led birth. there isa n urgent need for large scale trials to establish evidence against this recommendation" Jabak & Hameed 2020

If induction is suggested "just in case". Know that there is considerable evidence that induction causes avoidable harm including increasing the likelihood of cesarean and instrumental birth and with increased intervention this leads to more adverse outcomes.

Women are often not given adequate information about the risks and short and long term consequences associated with induction or about the significant benefits for awaiting spontaneous birth when the baby and mother are ready for labour and birth to begin.

What Medications May Be Offered

If you are interested in understanding more about the medications and side effects of these, please see my lecture on the subject: https://chipper-teacher-4208.kit.com/products/june-bitesize-gestational-diabetes?promo=SERENITY50

What can you do to help yourself?

If you are eating adequate fats and proteins, you actually require no extra carbohydrates in the forms of grains, pasta, sugar, etc in order to survive. Our body can produce glucose needed from amino acids, fats and proteins. Many cultures have low-carbohydrate diets and it is when western diets are introduced into these societies that levels of GD skyrocket. If you are in a nutritional ketosis, circulating glucose and insulin concentrations decrease by 20-50% (Institute of medicine 2005).

Normal pregnancy favours a state of ketosis.

Understand that high blood sugar levels can be reduced by moving your body. Be that cardio, weight lifting, dancing to your favourite tunes, doing some housework or pointing and flexing your feet whilst watching netflix after a meal.