Sunday 25 September 2016

The danger of gestational diabetes: 'If you are planning a pregnancy you should be looking how much weight you are carrying'

You don't have to be overweight or have a medical family history to develop this pregnancy related disease, as Niamh Bracken found out when having her fourth child

Published 26/07/2016 | 02:30

Niamh Bracken with her kids (l-r) Finlay, India, Grayson and Cooper. Photo: Gerry Mooney
Niamh Bracken with her kids (l-r) Finlay, India, Grayson and Cooper. Photo: Gerry Mooney

Fruit juice, chocolate and ice cream regularly feature among women’s top pregnancy cravings. Yet despite craving these foods intensely, Niamh Bracken (40) couldn’t have them with impunity during the latter stage of her last pregnancy.

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Niamh, from Stamullen, Co Meath, was diagnosed with gestational diabetes — a temporary, largely symptomless form of diabetes affecting pregnant women — when she was 28 weeks gone with her fourth child.

As soon as she tested positive during a routine screening, she was put on a diet designed to keep her blood glucose levels under control. Needless to say, sweet treats were off limits.

“I was craving orange juice and granola,” she recalls. “The diet was very restrictive and I really felt for people who are diabetic full-time.”

Gestational diabetes is on the rise in this country. According to Diabetes Ireland Health Promotion & Research Officer, Dr Anna Clarke, gestational diabetes will complicate one in eight pregnancies in Ireland.

“Both gestational diabetes and type 2 diabetes have become very prevalent in recent years,” she says. “The danger of having gestational diabetes is that the extra glucose circulating in the mother’s blood crosses the placental barrier and causes increased weight of the baby. Obviously the delivery of that baby then becomes more troublesome and you can run into problems during delivery.”

Dr Clarke says the obesity epidemic is fuelling the rapid increase in rates of gestational diabetes. “We always had gestational diabetes, regardless of obesity levels,” she explains. “We just didn’t have as much of it.

“Excess weight puts extra demand on the body,” she continues. “In pregnancy, the hormones work against the naturally produced insulin to cause insulin resistance. Blood sugar levels then rise and that causes problems.

“We know that type 2 diabetes is sort of similar to gestational diabetes in that both conditions are caused by an imbalance between insulin production and body demand,” she adds. “However, we also know that type 2 diabetes can occur in 20pc of people of normal weight.”

Obesity is just one of the many risk factors that increase the likelihood of developing gestational diabetes. Women are also at higher risk if they are over the age of 35; have a family history of type 2 diabetes; have previously given birth to a large baby; have previously given birth to a baby born with an abnormality; or have previously had a stillbirth late in pregnancy.

Prof Brendan Kinsley, a consultant endocrinologist at the Mater Misericordiae University Hospital and Coombe Women and Children’s University Hospital, adds that women are also screened for gestational diabetes if it is noticed that the baby is large for dates or if there is glucose in her urine.

Women who don’t fall into these categories are generally not screened. “For now, testing is not universal,” explains Prof Kinsley. “We do focused, risk factor-based screening instead.

“Almost all ethnic groups other than Caucasians have higher incidents [of gestational diabetes],” he adds. “It’s much higher in Arab populations, Indian subcontinent populations and African populations. That’s why the decision, in most cases, is not to do universal testing in the Caucasian population.”

Niamh Bracken was screened for gestational diabetes because she was 37 when she became pregnant with her fourth child. She was also tested when she was pregnant with her third child, but the result came back negative.

She wasn’t overweight, nor did she have a family history of type 2 diabetes. “It was a hormonal thing,” she explains. “It wasn’t anything I was eating or doing. I’ve always been very active.”

As is the case for most women, Niamh was diagnosed during the third trimester of her pregnancy. “Gestational diabetes usually doesn’t appear until the latter stage of pregnancy,” explains Dr Clarke.

This isn’t to say that women can’t be diagnosed earlier in their pregnancy.

“Diabetes diagnosed for the first time in pregnancy is called gestational diabetes,” adds Prof Kinsley, “but there are always women who are likely to have had diabetes before pregnancy and didn’t know it. In fact, the earlier it is diagnosed, the more we wonder if we’re really dealing with gestational diabetes.”

Niamh didn’t have any symptoms, however, it should be noted that the two predominant symptoms of gestational diabetes are tiredness and frequent urination. Because these symptoms are experienced by most pregnant women, they tend to go overlooked.

Once a woman is diagnosed, they are advised to control their glucose intake and increase their level of physical activity. “You can’t do heavy physical activity when you’re pregnant,” says Dr Clarke. “But in actual fact, we can all be more active than we already are.”

All women diagnosed with gestational diabetes are closely monitored and must attend a diabetes clinic every two weeks.

In some cases, they may be prescribed the oral hypoglycaemic agent Metformin alongside or instead of insulin.

A few days after she was diagnosed, Niamh had an appointment with a dietitian who told her what foods to avoid. She was also taught how to use a home glucose testing kit.

“I had to test myself five times a day by pricking myself on the finger,” she recalls. “And I had to do a reading first thing in the morning and one hour after each meal.”

These readings were noted and reviewed during her twice-monthly appointments at the diabetes clinic where her weight and blood pressure was also checked.

Back at home, her diet had to be closely monitored.

“It was quite restrictive but it was only for 12 weeks so it wasn’t so bad. I had to eat a lot more protein and stay away from carbohydrates — especially first thing in the morning. Cereal and fruit was shooting it [my blood glucose level] up and even stuff that I thought was healthy I had to avoid. I stayed away from cereal completely and started eating a lot more fish.”

Occasionally she’d cave in and eat some chocolate. Curiously, it didn’t spike her blood sugar as sharply as pastas and breads.

Niamh paid very close attention to her diet but, despite her better efforts, she was prescribed Metformin during the last six to eight weeks of her pregnancy. “I was really trying to avoid going on the tablets,” she says. “I felt a bit defeated that I wasn’t able to control my diet but it’s purely hormonal.”

The Metformin prescription cost her €40 a week — a considerable expense during a time when all funds are directed towards buggies, car seats and nappies.

Niamh adds that the needles and test strips are yet another expense. “You go through quite a lot of them because sometimes you get it [the reading] wrong.”

“Gestational diabetes is not treated in the same way by our health service because they don’t see it as being a lifelong condition,” explains Dr Clarke. “Therefore any medication or monitoring that needs to be done at home has to be paid for by the individual.

“That could be a substantial amount of money over three months and we do hear stories of people who can’t afford it. That will affect the future health of the next generation and also increases the likelihood of requiring intervention during delivery.”

Dr Clarke also notes that most pregnant women in Ireland now fall into the high-risk category. “The average age for pregnancy has gone up, our BMI has gone up, the incidence of type 2 diabetes has gone up. Obviously our diet is contributing to the obesity epidemic and we need urgent attention and implementation of the obesity report recommendations.

“The rise of gestational diabetes needs to be looked at urgently.

“Primarily, I would say to all readers, if they are planning a pregnancy or not actively using contraception to prevent a pregnancy, they should be looking at their overall health, and part of that is how much weight they are carrying.”

This advice is echoed by Prof Kinsley, who advises women trying for a baby to adopt a “pre-pregnancy approach”. “If you have a family history, it’s something you should keep in mind.

“Become fitter and lose some weight, if you need to, in the six to 12 months prior to becoming pregnant. If you can get those habits in place beforehand, they pay off in spades.”

Niamh gave birth to a healthy, 9lb baby boy, Grayson (now two), and she celebrated with a generous serving of granola and orange juice.

“I thought I would be induced early, but he wasn’t measuring big and I wasn’t measuring big so I ended up going a week over. Funnily enough, I was smaller with Grayson than I was with my third child (Finlay, four). He was 9lb 11oz.”

There were also some advantages to the diagnosis. Compared to her other children, she gained less weight during her pregnancy with Grayson. “I got back into my regular clothes very quickly, so that was good.

“Having said that, the gestational diabetes diagnosis puts me at a higher risk of developing type 2 diabetes in the future.”

Niamh was screened again six weeks later — this time she tested negative. She now has to get tested every year. Gestational diabetes may be a temporary complaint, but once diagnosed, it can become a lifelong concern.

* For more on gestational diabetes, or to download an information leaflet, see diabetes.ie.

Who is more likely to get  gestational diabetes?

Women are more at risk if they:

• have a family history of type 2 diabetes;

• are over the age of 35;

• are obese;

• have previously given birth to a large baby;

• have previously given birth to a baby born with an abnormality;

• have previously had a stillbirth late in pregnancy

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