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Gestational Diabetes

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IMPORTANT!  NOTE FROM THE EDITOR - Change of thinking about GD

Midwifery has often been skeptical of the idea of gestational diabetes and the idea that healthy women can suddenly become pathological during pregnancy.  This has often been true in the past.  However, I would now say that our cultural way of eating has become so pathological that pregnant women need to be very mindful of their blood sugar levels in order to have the best possible outcome.  For all women, regardless of the results of the gestational diabetes screen, I recommend a full day of self monitoring of blood sugars at 24, 28, 32 and 36 weeks to see how their diets and lifestyle are affecting their blood sugars.  The beauty of self-testing is that it allows you to find the carb culprits in your diet and provides an opportunity to do something about it right away, i.e. EXERCISE!

In the past, we were mostly concerned about borderline blood sugar issues making the baby bigger.

New research shows that high blood sugar levels also affect the maturation of the uterus and its ability to contract effectively.  This can explain the high levels of amniotic fluid we see,  the postdates, the postpartum hemorrhage, and the occasionally dysfunctional labor.

In addition, a woman's blood sugar levels during pregnancy affect her own likelihood of developing Type II diabetes either immediately after the pregnancy or later in life.

AND, in case you're not convinced yet, a woman's blood sugar levels during pregnancy seem to increase the child's risk of developing diabetes or obesity.

More later . . .

Peanuts Are Not Nuts.  They are legumes.  They are not a good late-night snack if you're trying to get your fasting glucose numbers down.  In fact, I find that most of my clients do best with no night-time snack at all.  The Sweet Success program encourages a late night snack to avoid the dawn phenomenon.  Maybe the dawn phenomenon is more common in women with true diabetes, but I rarely see it in my clients diagnosed with GD.  Try avoiding all carbs after 3 pm and see if your fasting numbers don't come down.

Aviva Romm, MD has a 3-part series of very helpful resources:

Gestational Diabetes: Please Don’t Drink the "Glucola" Without Reading the Label - this is a helpful introduction and focuses on the potentially toxic ingredients in some of the Glucola drinks. "at least one of the glucose test drinks EasyDex, by Aero Med (note that ingredient lists from the test companies are notoriously hard to find online!) contains something called BVO, or brominated vegetable oil. . . . the FDA removed BVO from its ‘Generally Recognized as Safe’ list of food ingredients.” . . . it was and remains banned from European and Japanese soft drinks. BVO is patented in the U.S. and overseas as a flame retardant." [NOTE - A Glucola brand that doesn’t contain artificial colors and is BVO-free can be obtained from Azer Scientific.]

What You Should Know About Gestational Diabetes and Glucose Tolerance Testing in Pregnancy - the GTT test has a wide margin of error – the test misses many women who have GDM, and diagnoses others who don’t have it at all. Thus women who need extra nutritional counseling might not get it at all, and others with normal healthy pregnancies might get unnecessarily put into high-risk categories. And all women end up getting a potentially toxic drink for the sake of a less than reliable test.

Glucose Testing in Pregnancy: Should it Be Routine?
- Aviva Romm describes her change of thinking about routine glucose testing in pregnancy.  She offers some sane, sensible approaches to safeguard the health of mother and baby around this issue.

She's still working on part 3, but you could search for gestational diabetes on her website.

Eating for Two by Esther Entin, M.D. [6/1/16] - Mothers' weight gain during pregnancy actually changes their babies' metabolism, predisposing kids to be overweight.

Pregnancy may be a critical window of opportunity to help set your child's metabolism on a healthy course, when this system is subject to being influenced by the intrauterine environment.
Changes initiated after the baby is born, such as dietary and lifestyle changes for mother and child, may not be able to alter the underlying metabolic vulnerability to later overweight and obesity. This means that pregnancy is a critical time for intervention.

Short Sleep a Modifiable Risk Factor for Gestational Diabetes [6/12/15] - the rate of GDM was significantly increased in women with short sleep duration (6.6% vs 3.1%). Short sleep duration was associated with GDM even after adjustment for age and BMI

Is Use of Diabetes Meds in Pregnancy Linked to ADHD? [9/22/16] by Becky McCall - Risk of attention-deficit/hyperactivity disorder (ADHD) may be increased in children of mothers who used medication for gestational diabetes or type 2 diabetes for more than 2 months during pregnancy, new research shows. [Ed: In my experience, the Sweet Success program is not very successful at reducing glucose levels sufficiently for women to avoid medications.  However, good attention to nutrition, activity and supplements does seem to work well for most women.]

Real Food for Gestational Diabetes: An Effective Alternative to the Conventional Nutrition Approach
by Lily Nichols - if the standard recommendations from the Sweet Success program aren't working for you, you might want to consider this approach.

7 Ways to Naturally Control Your Blood Sugar from Dr. Mercola - Increase Your Fiber, Reduce Your Net Carbs, High-Quality Fats, Exercise, Hydration, Reduce Your Stress, Sleep

Dr. Mercola's Nutrition Plan Introduction
- This contains very helpful information that can be applied to pregnancy nutrition.

The Deliberate Lies They Tell About Diabetes from Dr. Mercola - There is a staggering amount of misinformation on diabetes, a growing epidemic that afflicts more than 29 million people in the United States today. The sad truth is this: it could be your very OWN physician perpetuating this misinformation.  [Ed: Although this isn't specifically about gestational diabetes, the information about how our bodies handle carbs is applicable to GD.]

Ever growing number of women with gestational diabetes suggests future will be filled with children with early diabetes [8/25/14] - Children exposed to gestational diabetes in the wombs of their mothers are themselves around six times more likely to develop diabetes or prediabetes than children not exposed, research shows. With the increase in gestational diabetes (GDM), there is a growing need to understand the effects of glucose exposure on the newborn in the womb, at birth and later in life.

Helping your client avoid a Gestational Diabetes diagnosis - Milk products are also high in sugar and should be used in moderation according to the advice of a diabetic nutritionist.

I agree with Gloria.  The point of focusing on GD isn't just to avoid a diagnosis of gestational diabetes.  It's to protect the mother and baby from the ill effects of extremes of blood glucose.  For many women, this will require avoiding carbs, even the healthiest, most organic carbs such as whole grains and root vegetables (mostly potatoes).

Pregnant Obese Women May Benefit From Induction at 39 Weeks [5/5/14] - The routine induction of pregnant obese women at 39 weeks of gestation can minimize stillbirths, caesarean deliveries, and delivery-related healthcare costs.

[Ed: There are clear benefits to early induction for pregnant women diagnosed with gestational diabetes.  This study speaks to sub-clinical gestational diabetes, or "blood sugar issues".  Those women are at great risk of not going into labor at baby's ideal term because the higher blood sugar levels impede the maturation of the uterus.]

Diabetes and Pregnancy: Updated Screening and Treatment Guidelines to Improve Outcomes [2/27/15] - Free CME from Johns Hopkins

One of our local midwives reported that one of her clients had blood sugar issues until she received a chiropractic adjustment.  Apparently the nerves regulating insulin production or related function were under pressure from a skeletal issue that wasn't causing her any noticeable discomfort.

Multiparity among younger women raises obesity risk [6/3/14] -Women who have multiple children early in life are at increased risk for obesity early in adulthood, according to an analysis of National Health and Nutrition Examination Survey data.  . . .After adjustment for race, ethnicity, income, and NHANES study wave, multiparous women aged 20-25 years were almost twice as likely as nulligravid women in that age group to be obese (odds ratio, 1.91). No significant differences were seen for other age groups or for primiparous vs. nulligravid women in any of the age groups, Dr. Moniz found. [Ed: It seems that pregnancy changes a woman's basic metabolic function in some way.  We don't know for sure whether this can be prevented by good glucose control during pregnancy (for all women, not just those diagnosed with GD), but that seems like a good place to start.  So, even if women aren't worried about the effects of their blood sugar on their baby's well being or pregnancy outcome, maybe they'll at least be worried about their near-term obesity.]

Earlier Diagnosis of Gestational Diabetes Is Linked to Preterm Birth [Conference Report | May 13, 2014 | ACOG 2014]

“For high-risk populations, such as obese patients or those with previous gestational diabetes, patients should be screened at their first prenatal visit. And if they do screen positive early in their pregnancy, perhaps these patients should be considered even more high risk than the typical patient with gestational diabetes,” suggested Ngai.

Diabetes Mellitus and Pregnancy

Weight Gain in Pregnancy Is Key Risk Factor for Large Infants [updated 3/6/14 from Medscape - registration is free] - Excess maternal weight gain during pregnancy appears to be the greatest single contributor to large-for-gestational age (LGA) births, according to a study published online March 4 in Obstetrics & Gynecology. [Ed. I'm guessing that maternal weight gain during pregnancy is more of a predictor for LGA than GD because women with GD are watching their carbs to keep their blood sugars low.  A more sophisticated study would look at weight gain in the different trimesters to see whether weight gain in the last trimester is more of a predictor for LGA.  Better yet, they could look at blood sugar control as a predictor of LGA as well as going postdates.  I expect they will show that higher blood sugars prolong pregnancy as well as make the baby bigger for dates.]

Maternal Pre-Existing Diabetes Nearly Doubles Risk of Infant Death by Sarah Bruyn Jones | December 9, 2013
This isn't meant to scare women; it's meant to help them understand that there are things they can do to help their baby to be healthier, and keeping blood sugars low is an important factor.

Guidelines Issued to Properly Diagnose, Manage Diabetes in Pregnancy [11/7/13] - Pregnant women should be checked for diabetes by 13 weeks gestation and again between 24 and 28 weeks.

[Gestational diabetes: Diagnosis, short and long term management].
[Article in French]
Vambergue A.
Presse Med. 2013 May;42(5):893-9. doi: 10.1016/j.lpm.2013.02.316. Epub 2013 Apr 12.

Universal consensus on the diagnosis methods and thresholds has long been lacking. The recently published Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study has been used to confirm the link between hyperglycemia and materno-fetal complications. Consequently, in France, the Société francophone du diabète (SFD) and the Collège national des gynécologues et obstétriciens français (CNGOF) proposed an expert consensus on gestational diabetes mellitus for clinical practice. Fasting blood glucose should be measured at the first visit during early pregnancy for women with risk factors to identify the women with pregestational diabetes. It is proposed a selective screening on risk factors rather than universal screening. Specific treatment of gestational diabetes reduced materno-fetal complications compared to the absence of therapy. Women with a history of gestational diabetes mellitus are characterized by a high risk of type 2 diabetes mellitus.

Diabetes Skyrockets With High BMI Plus Weight Gain After GDM [3/23/15] - The risk of developing type 2 diabetes following gestational diabetes mellitus (GDM) is markedly increased among women who have a high body mass index (BMI) and who gain weight following pregnancy.  [Ed: Midwives can help a lot by supporting women in glucose self monitoring during pregnancy to learn how to eat to reduce their risk of GM as well as Type 2 diabetes.]

Metformin is an Effective Alternative to Insulin in Gestational Diabetes Mellitus [March 20, 2013] -  larger studies are needed to determine the safety of metformin during pregnancy.

Gestational Diabetes Drug Increases Adverse Newborn Outcomes [3/31/15] - WebMD reports on a study finding that glyburide, a treatment endorsed by ACOG, but not approved by the FDA for treating GDM, is associated with serious adverse newborn outcomes.

Panel Supports Maintaining Current Diagnostic Approach for Gestational Diabetes [March 6, 2013] - - An independent panel convened this week by the National Institutes of Health has concluded that despite potential advantages of adopting a new diagnostic approach for gestational diabetes mellitus (GDM), more evidence is needed to ensure that the benefits outweigh the harms.

NOTE TO PREGNANT WOMEN - It can come as a huge shock to be diagnosed with gestational diabetes, especially if you feel completely healthy and have had an uncomplicated pregnancy.  You may even wonder "what you did wrong" and you may worry about all the scary things you read online about diabetes and pregnancy.  DO NOT WORRY!  Gestational diabetes is very different from insulin-dependent diabetes, and you are not at risk for all the scary things that can happen with true diabetes.  And it's unlikely that you "did anything wrong" other than perhaps having genes that predispose you to blood sugar issues during pregnancy.

A diagnosis of gestational diabetes is something that you can be grateful for because it gives you information you need in order to help your pregnancy to continue on an even keel into the last trimester and to prevent complications.  The diagnosis simply means that your body is very efficient about turning your food into blood sugar and keeping it there to help your baby grow.  This was probably very helpful to your ancestors when food was scarce.  Unfortunately, with our modern processed foods, it's way too easy to turn foods into blood sugar, and this is where the problem comes in.

Taking care of yourself with a diagnosis of gestational diabetes just means that you need to take extra care so that your blood sugars don't get too high and stay too high.  You do this by eating foods with a low glycemic index (i.e. avoiding simple sugars or refined carbohydrates) and exercising after meals to help your body process your food in a healthy way.

When you think about it, this is what our ancestors did for thousands of years.  They didn't have access to processed sugars and carbohydrates, and they were always "exercising" by walking around.  If you're looking for something positive here, you can think about how this is reconnecting you with your long-ago maternal ancestors, and you can think about how they gave birth to a healthy baby without any interventions at all!  (Otherwise, you wouldn't be here.)

Gestational Diabetes - Great information for pregnant women diagnosed with gestational diabetes from diabetes.org

Management of Diabetes in Pregnancy by Yvonne Cheng, MD, MPH

Maternal Obesity and Postpartum Haemorrhage After Vaginal and Caesarean Delivery Among Nulliparous Women at Term [Medscape registration is free]

ACOG Stands By 2-Step Gestational Diabetes Screening Approach [8/24/11]

Effect of maternal weight, adipokines, glucose intolerance and lipids on infant birth weight among women without gestational diabetes mellitus.
Retnakaran R; Ye C; Hanley AJ; Connelly PW; Sermer M; Zinman B; Hamilton JK
CMAJ.  2012; 184(12):1353-60 (ISSN: 1488-2329)

INTERPRETATION: Among women without gestational diabetes, maternal adiposity and leptin levels were the strongest metabolic determinants of having a large-for-gestational-age infant rather than glucose intolerance and lipid levels.

Pregestational body mass index is related to neonatal abdominal circumference at birth-a Danish population-based study.

Tanvig M, Wehberg S, Vinter C, Joergensen J, Ovesen P, Beck-Nielsen H, Jensen D, Christesen H.
BJOG. 2013 Feb;120(3):320-30. doi: 10.1111/1471-0528.12062. Epub 2012 Nov 12.

CONCLUSION: Birth AC and weight are affected by maternal smoking status and pregestational BMI. Pregestational BMI correlated more to birthweight than to AC. Using data from healthy, nonsmoking mothers with normal pregestational BMI we have provided new reference curves for birth AC and birthweight. [Ed: This isn't really a huge surprise, but it does support increased attention to blood sugar issues in women with a higher BMI at the start of pregnancy.]

Our local chiropractor/nutritionist says that there is a link between trouble breaking down fat and blood sugar problems. Dr. Loomis of the Loomis Institute found this to be true based on clinical experience.  Enzyme therapy would help with this.  My notes about this are a bit sketchy, so please follow this up with a discussion with your own nutritionist / enzyme practitioner.  Gall bladder congestion can lead to adrenal problems, which can lead to gestational diabetes?  High lipase can be helped with vascular enzymes?

How to Lower Your Blood Sugar With Nutrition

I'm sure you've heard the phrase, "controlled through diet and exercise".  These are the keys.  In essence, it's a simple concept, but it's not always easy to change ingrained habits of eating and activity.  Checking your own blood sugars at least four times a day will really help you to see how changes in these habits are reflected in changes in your glucose numbers.  That is often the only motivation that pregnant women need to make changes, especially after they realize how profound are the effects of blood sugar on their pregnancy, the baby's future health, and their own future health.

Hydration is very important to keeping your blood sugars in a healthy range, and it can be the easiest way!  When you are dehydrated, your blood becomes more concentrated, so the relative glucose level goes up, even without eating anything.  If you're having trouble drinking lots of water, there are some excellent natural low-carb sweeteners that might help; I really like the Sweet Leaf flavored stevia drops.  Or just heating the water can increase a perception of sweetness, so try drinking plain hot water or adding some of the unsweetened flavoring drops available.

Gluten-Free Diets Are Beneficial for Many — Not Just Those With Celiac Disease [9/21/16] from Dr. Mercola - I believe most everyone would benefit from avoiding all grains, not just gluten, as doing so well help you burn fat much better.

When you're diagnosed with gestational diabetes, you'll likely need to change the foods you eat.  The Diet Doctor has some great information about eating low carb - LCHF for Beginners.

Netrition carries an excellent selection of Low Carbohydrate foods and treats from a wide variety of producers.  I list some of my favorite products, or you can do your own search:

Healthy Alternative Sweeteners for Pregnancy - safety of stevia, maltitol and other natural sweeteners with low glycemic index.

Effects of Fructose / Fruit Sugar
from Jonathan Carp, MD, Miracle Noodle Founder & President

Foods To Avoid on a Low-Carb Diet - David Mendosa Sep 18th, 2015 (updated Sep 24th, 2015) - This is a brief, effective set of seven slides.

A Diet Rich in Complex Carbs Can Achieve Glycemic Targets in Gestational Diabetes [4/2/14]

Dr. Hernandez and colleagues compared the CHOICE diet (a higher-complex, lower-glycemic index carbohydrate/lower-fat diet) with a carbohydrate-restricted, higher-fat diet in a crossover study of 16 women with diet-controlled GDM. During the 12 day trial, the bionutrition department provided all food.

Fasting and preprandial glucose levels did not differ between the two diets, and all values on both diets were lower than the currently recommended glycemic targets, the researchers report in Diabetes Care, online March 4.

There were no between-diet differences in mean nocturnal and 24-hour glucose, but daytime mean glucose was slightly higher with CHOICE than with the conventional diet (98 mg/dL vs. 93 mg/dL, p=0.03). The 24-hour total glucose AUC was about 6% higher on the CHOICE diet.

[Ed: For maternal glucose > 110, the baby starts spilling glucose in the urine, which the baby then swallows. Even minimal peaks in maternal glucose can persist in baby's environment for hours. Nocturnal glucose readings may have more effect on the uterine maturation and associated risks, but the daytime spikes may have more effect on the baby's risks of developing diabetes later in life.  We need more research on this, but I don't think it's responsible to tell women there's no difference.]

Low Carbs Cut Diabetes Inflammation by David Mendosa Health Guide June 05, 2014

As you can see, the experts are very divided on the role of carbohydrates in gestational diabetes.  It makes sense to try different approaches for a week or so to see how your glucose levels respond.

Gestational Diabetes from Indie Birth - has an excellent eating plan

Low-Carbohydrate Nutrition in Pregnancy - For many pregnant women, they will need to reduce their carbohydrate intake in order to maintain healthy blood sugar levels.

The Glycemic Index Explained by Dr. David Williams

Wheat Belly - information about the harmful effects (blood sugar and a host of other issues) of modern wheat....interesting.

Gestational Diabetes from The Brewer Pregnancy Diet

How to Lower Your Blood Sugar With Activity

If you just stand up for five minutes every half hour that you sit, your blood glucose level will be similar to the results of walking that much.

Late-Pregnancy Exercise May Trim Newborns' Baby Fat  by Anne Harding[7/16/14] - "Although we don't know exactly how body composition at birth is related to future risk of obesity, there is increasing evidence that adiposity early in life tracks over time and is associated with a higher risk of childhood obesity and adult obesity," she said.

[Ed: This isn't about wanting babies to be rail thin . . . it's about wanting them to start life with a healthy metabolism.  A baby whose mother is running higher blood sugar levels will also be getting higher blood sugar levels through the placenta.  Then the baby will need to generate insulin, which transforms the blood sugar into fat, thus protecting the baby's organs from the toxic effects of high blood sugar.  But this seems to predispose the baby to metabolic disorders later in life, including diabetes.]

The role of exercise in reducing the risks of gestational diabetes mellitus.
Hopkins SA, Artal R.
Womens Health (Lond Engl). 2013 Nov;9(6):569-81. doi: 10.2217/whe.13.52.

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy and is particularly prevalent among obese women. Both GDM and obesity confer significant comorbidities for the mother and her offspring, including perinatal complications, excessive fetal growth and long-term risks for maternal and offspring obesity and diabetes. Exercise has well-documented health benefits and reduces peripheral insulin resistance in nonpregnant individuals, a major risk factor for the development of diabetes. Observational studies conducted in large population-based cohorts suggest that women who are the most active before pregnancy are less insulin-resistant in late pregnancy and have lower rates of GDM. This article will review the evidence supporting a role for exercise in the prevention of GDM, the management of glycemic control in women with established GDM, and the reduction of GDM-associated maternal and offspring health consequences. Wherever possible, the discussion will focus on studies carried out on obese women. However, there are many areas where strong evidence is lacking in obese populations, and it may be inferred from similar studies performed in normal weight pregnant women.

How to Lower Your Blood Sugar With Supplements

If you poke around online, you'll find many different supplements that claim to lower blood sugar.  Many of these include exotic new herbs from Asia.  I wouldn't touch these with a ten-foot pole while pregnant.  We have absolutely no data about safety during pregnancy, and any herbs or extracted chemicals that are new should be regarded with a very jaundiced eye by any pregnant woman.

The same could be said about some of the new pharmaceuticals that are available, although we have at least SOME safety data about those.  It's not always reassuring.

The food products that are believed to be safe during pregnancy and have some reputation for lowering blood sugar are cinnamon and apple cider vinegar.  The Mosby's Handbook of Herbs & Natural Supplements says that cinnamon is fine during pregnancy when used as a spice or for flavoring.  If it's easier to take that same amount of cinnamon as a capsule, that's fine, too.  The same is true of apple cider vinegar, which Mosby's doesn't mention at all, presumably because it's a basic food product.

You want to avoid large amounts of supplemental vitamin C in the first trimester, just because there is a vague association between mega doses of vitamin C and miscarriage.  Mega doses of vitamin C can cause loose stools or diarrhea, and it's remotely possible that the sympathetic uterine contractions COULD cause a miscarriage.  It's more likely that these contractions simply cause the uterus to start expelling a pregnancy that had already ended for other reasons, but no woman ever wants to think that she accidentally caused a miscarriage.  So avoid large doses of vitamin C in the first trimester.

Once you're into the second trimester (12 weeks), then higher doses of vitamin C are good for you and baby.  Your body needs the vitamin C with bioflavonoids to make collagen, which is the building block of strong tissues for your baby, and for the new tissues that your own body is making.  (This includes the new perineal tissue that your body is making, and I've seen a good association in my clients between high doses of vitamin C and perineal tissues that are more elastic and less likely to tear.  This also applies to the amniotic membranes, and I've also seen an association in my clients between high doses of vitamin C and amniotic membranes that remain intact until the pushing stage, or sometimes even through the birth itself, i.e. the baby is born "in the caul".)

Vitamin C is also a liver tonic, and higher doses of vitamin C are the safest way to lower blood sugars, although the effect may be mild.  You will need to pay close attention to how changes in your vitamin C intake affect your glucose numbers.  My clients seem to benefit so much from vitamin C with bioflavonoids in so many ways that it's my first recommendation for supplements in addition to a prenatal vitamin with bioactive forms of folate (B9), B6 and B12.

How much Vitamin C to take?  Your body simply excretes excess vitamin C, which helps to loosen the stool and can cause diarrhea.  So it's not possible to overdose on vitamin C, but you don't want to waste your money, and who needs diarrhea?  There's a recommendation to take vitamin C "to bowel tolerance", meaning that you gradually increase the amount you're taking until you notice that your bowels are a little too active; then back off to the previous happy dosage.  I'd suggest starting with 500 mg of vitamin C with bioflavonoids daily (taken with any iron supplements to help absorb the iron), and then add another 500 mg with other meals or before bedtime until you reach your ideal level.  (And you've probably noticed that vitamin C is also an excellent remedy for pregnancy or postpartum constipation!  The bioflavonoids will also help prevent or heal hemorrhoids.  Vitamin C with bioflavonoids is truly the pregnant woman's friend!)  (My favorite product is Thorne's Vitamin C with Bioflavonoids.  It's hard to go wrong with vitamin C, but many forms will not have the bioflavonoids that are so important.  If you really need to watch your expenditure, you could take one of the Thorne per day and then take a less expensive form through the rest of the day.)

One of my clients was taking some silymarin to prevent a recurrence of intense itching from a previous pregnancy, and she noticed that it reliably reduced her blood sugars to a level that she couldn't achieve otherwise.  It makes sense that additional liver support might benefit blood sugars levels,   Silymarin is generally regarded as safe during pregnancy, but there is no formal research data to confirm this.  It is frequently used to increase milk production postpartum.  This wouldn't be my first recommendation to help keep blood sugars in a good range (I like to keep it simple), but if diet and exercise and cinnamon and vitamin C with bioflavonoids isn't enough for you, then this might be something to discuss with your healthcare provider. Even with the limited research, the Mayo Clinic says that milk thistle is generally safe, although it naturally recommends caution during pregnancy; since silymarin is the extract of milk thistle that is most helpful to the liver, taking silymarin instead of whole milk thistle avoids exposure to the other chemicals in milk thistle. My personal naturopath has told me that they consider silymarin to be safe for pregnancy women.  (My favorite product is Metagenic's Silymarin 80. )

To Burn More Fat, Drink Apple Cider Vinegar - One study found that taking two tablespoons of apple cider vinegar before bed lowered blood sugar levels in people with type 2 diabetes by up to 6 percent the following morning.[1] And the studies are only mounting…

For women who are really having trouble getting their numbers down, even with strict avoidance of all carbs, I will sometimes recommend some (or all!) of the following:
CLA - Conjugated Linoleic Acid - 1-2 grams w/each meal
Apple Cider Vinegar
Cinnamon, either as part of foods or in moderate amounts from capsules
Calcium - make sure she's getting the top end of the RDA for pregnant women
Chromium - RDA
Probiotics (not sure which is best)
Biotin (Vitamin B7)
Vitamin C - some sources say to take this on the higher end of bowel tolerance, and others say to avoid it at night if you're specifically trying to lower your fasting glucose numbers.
Coenzyme Q10, CoQ10
pH balancing may be important

Controlling Diabetes... The Natural Way By Angela Pirisi - CLA has the therapeutic potential to alter fat body mass and help manage insulin resistance. Studies have shown, for instance, the ability to decrease diabetes risk through dietary and supplemental means, such as fiber-rich cereal foods, magnesium, chromium picolinate, biotin, coenzyme Q10 and conjugated linoleic acid (CLA).

GDM: Vitamin D, Calcium Combo Improves Metabolic Profile [6/25/14] - Women with gestational diabetes mellitus (GDM) who took supplemental calcium plus vitamin D at 24 to 28 weeks' gestation experienced a number of benefits, including reduced fasting plasma glucose, serum insulin levels, and serum low-density lipoprotein (LDL) cholesterol levels and increased high-density lipoprotein (HDL) cholesterol levels . . .

Myo-Inositol Reduces Risk of Diabetes in Pregnancy [1/29/13] - Supplemental myo-inositol may help protect women at risk for gestational diabetes.  It appears to reduce the risk by over 50%, but more research is needed.

pH Balance and Diabetes - There is convincing evidence that people with diabetes can benefit by maintaining pH balance in their bodies.

Gestational Diabetes - Excerpted from The pH Miracle for Diabetes : The Revolutionary Diet Plan for Type 1 and Type 2 Diabetics - Diabetes . . . is the result of a pH imbalance in the fluids of the body-systemic acidosis-that interferes with the optimum functioning of the cells they surround. Beta cells surrounded by acids do not or cannot produce sufficient insulin. Acids destroy insulin receptor sites on the cellular membrane so body cells cannot properly use the hormone.

High Blood Sugars Affect Baby

Aspartame and Excess Pregnancy Weight Puts Baby at Risk for Obesity [5/25/16] - Research led by Meghan Azad, Ph.D. from the University of Manitoba examined the association between mothers who drank diet sodas sweetened with artificial sweeteners, such as NutraSweet, Splenda and Equal, and the effect on the baby's body mass index (BMI) in the first year after birth.

Association Between Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index.

Azad MB1, Sharma AK2, de Souza RJ3, Dolinsky VW4, Becker AB1, Mandhane PJ5, Turvey SE6, Subbarao P7, Lefebvre DL8, Sears MR8; Canadian Healthy Infant Longitudinal Development Study
JAMA Pediatr. 2016 May 9. doi: 10.1001/jamapediatrics.2016.0301. [Epub ahead of print]

Conclusions and Relevance: To our knowledge, we provide the first human evidence that maternal consumption of artificial sweeteners during pregnancy may influence infant BMI. Given the current epidemic of childhood obesity and widespread use of artificial sweeteners, further research is warranted to confirm our findings and investigate the underlying biological mechanisms, with the ultimate goal of informing evidence-based dietary recommendations for pregnant women.

Eating lots of sugar when pregnant may raise risk of allergies [7/6/17] - A study of 9,000 women found that those who ate high levels of sugar during pregnancy were around twice as likely to have a child that went on to develop allergic asthma than woman who ate relatively little sugar.

Maternal intake of sugar during pregnancy and childhood respiratory and atopic outcomes.
Bédard A1, Northstone K2,3, Henderson AJ3,4, Shaheen SO5,4.
Eur Respir J. 2017 Jul 5;50(1). pii: 1700073. doi: 10.1183/13993003.00073-2017. Print 2017 Jul.

The possible role of maternal consumption of free sugar during pregnancy in the inception of respiratory and atopic diseases has not been studied. We aimed to study the relationship between maternal intake of free sugar during pregnancy and respiratory and atopic outcomes in the offspring in a population-based birth cohort, the Avon Longitudinal Study of Parents and Children.We analysed associations between maternal intake of free sugar in pregnancy (estimated by a food frequency questionnaire), and current doctor-diagnosed asthma, wheezing, hay fever, eczema, atopy, serum total IgE and lung function in children aged 7-9 years (n=8956 with information on maternal diet in pregnancy and at least one outcome of interest).After controlling for potential confounders, maternal intake of free sugar was positively associated with atopy (OR for highest versus lowest quintile of sugar intake 1.38, 95% CI 1.06-1.78; per quintile p-trend=0.006) and atopic asthma (OR 2.01, 95% CI 1.23-3.29; per quintile p-trend=0.004). These associations were not confounded by intake of sugar in early childhood, which was unrelated to these outcomes.Our results suggest that a higher maternal intake of free sugar during pregnancy is associated with an increased risk of atopy and atopic asthma in the offspring, independently of sugar intake in early childhood.

Smoking, Extra Weight in Pregnancy Tied to Obesity Throughout Childhood [6/19/14] - Women who smoke during pregnancy and are overweight early in pregnancy are more likely to have children who become obese as toddlers and stay obese through their teenage years, according to a new study. [We know that smoking mobilizes blood sugar, so blood sugar levels must be higher.  Women overweight early in pregnancy probably had high blood sugars even pre-pregnancy and during the time when baby's genetic expression is being determined.]

Eating processed food and drinking sodas high in fructose during pregnancy increases the risk your child will suffer heart disease in later life. - Experts warn fructose is also linked to rising obesity and type 2 diabetes.  Pregnant women who treat themselves to a high-sugar diet while they are expecting are putting their babies at greater risk of developing heart disease, experts have warned. Specifically, consuming large quantities of fructose, which is commonly found in processed foods and fizzy drinks, is linked to a higher number of risk factors for heart disease.

High Blood Sugars Affect Uterine Contractions

This is another reason for being careful about blood sugars during pregnancy.  This would explain why moms with blood sugar issues often go very postdates and may have a lot of amniotic fluid.  The uterus doesn't tone as much to ripen the cervix and to reduce the amniotic fluid.  (Many doctors say that the presence of high levels of insulin in the blood causes extra water retention in the body [Eades, M. (1995) The Protein Power Lifeplan]  That could also be related to increased amniotic fluid.)

Maternal Obesity and Postpartum Haemorrhage After Vaginal and Caesarean Delivery Among Nulliparous Women at Term [Medscape registration is free] - Although this study doesn't make the direct correlation between high blood sugars and uterine atony, it seems probable that there's a connection.  I mention this in the hopes that future research will test blood sugars along with BMI.

Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study. [full text]
Fyfe EM, Thompson JM, Anderson NH, Groom KM, McCowan LM.
BMC Pregnancy Childbirth. 2012 Oct 18;12:112. doi: 10.1186/1471-2393-12-112.
CONCLUSION: Nulliparous obese women have a twofold increase in risk of major PPH compared to women with normal BMI regardless of mode of delivery. Higher rates of PPH among obese women are not attributable to their higher rates of caesarean delivery. Obesity is an important high risk factor for PPH, and the risk following vaginal delivery is emphasised. We recommend in addition to standard practice of active management of third stage of labour, there should be increased vigilance and preparation for PPH management in obese women.

Diabetes is associated with impairment of uterine contractility and high Caesarean section rate. [full text]

Al-Qahtani S, Heath A, Quenby S, Dawood F, Floyd R, Burdyga T, Wray S.
Diabetologia. 2012 Feb;55(2):489-98. Epub 2011 Nov 19.

CONCLUSIONS/INTERPRETATIONS: These are the first data investigating myometrium in diabetic patients and they support the hypothesis that there is poorer contractility even in the presence of oxytocin. The underlying mechanism is related to reduced Ca channel expression and intracellular calcium signals and a decrease in muscle mass. We conclude that these factors significantly contribute to the increased emergency CS rate in diabetic patients.

It doesn't have to even be frank Diabetes, it could even be insulin resistance and impaired glucose transport into the cell, and mitochondrial function impairment producing similar effects!

We need a lot more research about this, but I've observed that it seems that the uterus needs a good dip in blood sugar levels through the night in order to mature properly and be ready for labor when baby's ready to be born.  The best clue I've found as to why this might be is from Dr. Mercola's Fasting Can Help You Live Longer [3/25/16]: "There is compelling evidence that when cells are supplied with fuel when fuel is not needed, the cells leak electrons that react with oxygen, producing free radicals. Free radicals are responsible for damage to your cells . . . "

Blood Sugar Issues Affect Placenta

Consequences of gestational and pregestational diabetes on placental function and birth weight. [full text]
Vambergue A, Fajardy I.
World J Diabetes. 2011 Nov 15;2(11):196-203. doi: 10.4239/wjd.v2.i11.196.
Anne Vambergue, EA 4489 "Perinatal Environment and Fetal Growth", Department of Diabetology, Huriez Hospital, 59800 CHRU Lille, France.

Maternal diabetes constitutes an unfavorable environment for embryonic and fetoplacental development. Despite current treatments, pregnant women with pregestational diabetes are at increased risk for congenital malformations, materno-fetal complications, placental abnormalities and intrauterine malprogramming. The complications during pregnancy concern the mother (gravidic hypertension and/or preeclampsia, cesarean section) and the fetus (macrosomia or intrauterine growth restriction, shoulder dystocia, hypoglycemia and respiratory distress). The fetoplacental impairment and intrauterine programming of diseases in the offspring's later life induced by gestational diabetes are similar to those induced by type 1 and type 2 diabetes mellitus. Despite the existence of several developmental and morphological differences in the placenta from rodents and women, there are similarities in the alterations induced by maternal diabetes in the placenta from diabetic patients and diabetic experimental models. From both human and rodent diabetic experimental models, it has been suggested that the placenta is a compromised target that largely suffers the impact of maternal diabetes. Depending on the maternal metabolic and proinflammatory derangements, macrosomia is explained by an excessive availability of nutrients and an increase in fetal insulin release, a phenotype related to the programming of glucose intolerance. The degree of fetal damage and placental dysfunction and the availability and utilisation of fetal substrates can lead to the induction of macrosomia or intrauterine growth restriction. In maternal diabetes, both the maternal environment and the genetic background are important in the complex and multifactorial processes that induce damage to the embryo, the placenta, the fetus and the offspring. Nevertheless, further research is needed to better understand the mechanisms that govern the early embryo development, the induction of congenital anomalies and fetal overgrowth in maternal diabetes.

At the June 6-8, 2012, AP/IP conference at UCSF, they presented this information:

In women with GDM, it requires higher amounts of insulin produced by pancreas to keep sugars under control. Insulin both natural and injected is believed to have an aging effect on placenta, with injectable being more severe. That's why women on insulin are typically delivered around 38-39 weeks and women with diet control around 40, sometimes going to 40.5 with extra monitoring.

I've noticed that women with blood sugar issues also seem to have more problems with varicose veins.  I wonder if the high insulin levels that affect the placenta also affect other blood vessels.

Early Pregnancy Testing

Diagnosis of insulin resistance and/or prediabetes in the general population can point to several interventions that may reduce the risk of eventually developing full-blown diabetes and/or cardiovascular disease.  That is pretty important.

In pregnancy, the reason for doing an early (before 20 weeks) diabetes screen is to diagnose pre-existing diabetes.  Ideally, real diabetes would be picked up before even getting pregnant, because high sugars in the embryonic stage are teratogenic (as much as a 10% rate of major congenital anomalies including heart and kidney stuff).  Think about it this way - blood with elevated glucose is hyperosmolar and nutrients can't be transported properly across the cell membranes.  This sets off an inflammatory response as well, and the placenta doesn't embed properly, hence the higher association with pre-eclampsia and abruption later on (in uncontrolled pre-gestational diabetics).  The earlier the diagnosis is made, the earlier you can try to correct the situation.

The risk factors that would cause me to want to get an early glucose test in pregnancy are those for diabetes in anyone - obesity as defined by elevated BMI, history of prior glucose intolerance, PCOS (or hx of PCOS like symptoms), prior gestational diabetes, prior baby > 5000 gms.  I am not real thrilled with the idea of testing everyone at 28 weeks, but there are certainly some moms who I want to test early and repeat the test on (if first test was normal).  I have also been very surprised to find significant glucose intolerance in a couple of extremely thin Asian women recently. [Ed: I've heard a number of midwives observe that Asians are much more likely to be diagnosed as gestational diabetics; is this because we're using studies on non-Asians to establish blood sugar levels that may or may not be relevant for Asians?]

I like to do a hemoglobin A1C with the initial labs for all my clients to see what her glucose levels were like before pregnancy.

Recent Studies

Studies Suggest Ways to Improve Gestational Diabetes Outcomes [4/15/16] - Two new studies suggest that earlier screening for gestational diabetes and a lower diagnostic threshold for treatment each may reduce the maternal and fetal risks associated with the condition. . . . Both studies, she added, show that treating and controlling GDM even with earlier screening or broader criteria can improve outcomes. . . . Dr Sovio and colleagues found that fetuses of mothers with obesity and/or GDM grew more quickly between 20 and 28 weeks of gestation than the fetuses of mothers with neither condition.   . . . "In fact, the current data indicate that any intervention aimed at reducing the risk of [large for gestational age] in the infants of obese women may need to be implemented before 20 [weeks of gestational age]." . . . "In summary, women diagnosed with mild GDM by the less stringent Carpenter-Coustan criteria and by the stricter National Diabetes Data Group criteria both benefit from nutritional counseling, dietary therapy, and insulin when indicated," the authors conclude.

For good summaries of the most recent research, you can search in TRIP - Turning Research Into Practice.

Easy Steps to Diabetes Control by David Mendosa - The researchers from New Zealand showed that taking short walks every may be more effective at reducing the risk of type 2 diabetes than a 30-minute walk. How short is short? Is 100 seconds short enough for you? That’s the length of time that they used. One minute and 40 seconds.

Breaking prolonged sitting reduces postprandial glycemia in healthy, normal-weight adults: a randomized crossover trial.
Peddie MC, Bone JL, Rehrer NJ, Skeaff CM, Gray AR, Perry TL.
Am J Clin Nutr. 2013 Aug;98(2):358-66. doi: 10.3945/ajcn.112.051763. Epub 2013 Jun 26.

CONCLUSION: Regular activity breaks were more effective than continuous physical activity at decreasing postprandial glycemia and insulinemia in healthy, normal-weight adults. This trial was registered with the Australian New Zealand Clinical Trials registry as ACTRN12610000953033.

The Cochrane Collaboration has changed its official opinion on gestational diabetes. (Their previous finding, prior to 2008 was, "There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.".

Here are two relevant opinions:

Different ways of Identifying women with gestational diabetes - Evidence is insufficient to permit judgement of which is the best way to identify women who have gestational diabetes.

Treatments for gestational diabetes

These are two newer studies that suggest there may really be some benefit to testing and treating for gestational diabetes.

Hyperglycemia and Adverse Pregnancy Outcomes - Glucose levels that were increased during pregnancy but were below levels diagnostic of diabetes were significantly associated with increased risks of birth weight above the 90th percentile and C-peptide levels above the 90th percentile, as well as with other adverse pregnancy outcomes.

Metformin versus Insulin for the Treatment of Gestational Diabetes - This trial compared insulin with metformin for the treatment of gestational diabetes mellitus. These results provide support for the use of metformin as initial treatment for gestational diabetes in women who require pharmacologic therapy.

Then again, this new literature review isn't that enthusiastic about testing.

Guidelines Issued About Lack of Evidence for Screening for Gestational Diabetes  CME/CE [Medscape]

"Current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes mellitus, either before or after 24 weeks' gestation," the statement concludes. "Until there is better evidence, clinicians should discuss screening for GDM with their patients and make case-by-case decisions. The discussion should include information about the uncertain benefits and harms as well as the frequency and uncertain meaning of a positive screening test result."

Gestational diabetes: the consequences of not treating.
Langer O, Yogev Y, Most O, Xenakis EM.
Am J Obstet Gynecol. 2005 Apr;192(4):989-97.

    OBJECTIVE: Untreated gestational diabetes mellitus carries significant risks of perinatal morbidity at all severity levels; treatment will enhance outcome. STUDY DESIGN: A matched control of 555 gravidas, gestational diabetes mellitus diagnosed after 37 weeks, were compared with 1110 subjects treated for gestational diabetes mellitus and 1110 nondiabetic subjects matched from the same delivery year for obesity, parity, ethnicity, and gestational age at delivery. The nondiabetic subjects and those not treated for gestational diabetes mellitus were matched for prenatal visits. RESULTS: A composite adverse outcome was 59% for untreated, 18% for treated, and 11% for nondiabetic subjects. A 2- to 4-fold increase in metabolic complications and macrosomia/large for gestational age was found in the untreated group with no difference between nondiabetic and treated subjects. Comparison of maternal size, parity, and disease severity revealed a 2- to 3-fold higher morbidity rate for the untreated groups, compared with the other groups. CONCLUSION: Untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome.

[Ed: The untreated group was women who started care very late in pregnancy.  One can assume that these are women who were not getting a lot of health care before pregnancy either.  It occurs to me that although these women were diagnosed as having gestational diabetes, nothing was done postpartum to ascertain whether any of these women were actually overtly diabetic, a category excluded from the other study groups.  Given that this study was an attempt to use a case-control study to come as close to a RCT as ethically possible, it would have seemed obvious to repeat the OGTT at postpartum intervals to separate out the results from women who were frankly diabetic, and it would have been extremely useful to know whether the slight difference in stillbirths rate was associated with undiagnosed true diabetes.  The average age of the untreated GDM group is 27.6, compared to the average age of the treated GDM group, 29.1 years.  This hints at an increased incidence of true diabetes in the former group.  (This "oversight" is similar to the error made in the Australian study of women who weren't tested for GD; it seems obvious to me that postpartum testing would have provided some really useful additional information - maybe this is information that GD devotees don't want to know?)

The primary morbidity in this study is the baby's weight, which further affects 3 other co-morbidities: macrosomia, LGA and Ponderal Index.  If a higher birth weight is a bad thing, then all women should be treated for GDM since the untreated nondiabetic group had an average birth weight that was 45 grams (1.6 ounces) higher than the treated GDM group.  Or maybe GDM treatment is really making the babies smaller because it's depriving them of calories they need to grow normally?

I'm always skeptical of the hypoglycemia findings in these studies because hypoglycemia is irrelevant in a newborn who is otherwise normal, i.e. able to maintain body temperature (without the artificial cooling cause by premature bathing).  Babies who were starved in utero will weigh less, and they will not have as much brown fat to metabolize to sustain the brain in the hours immediately after birth; thus they must metabolize glucose stores, possibly depleting them more quickly than the babies metabolizing their brown fat.

Interesting side note - most of the women in this study were Hispanic, and the average gestational age at the time of birth was 39 weeks, fairly close for all study subject groups.]

Exercise may prevent pregnancy-related diabetes - 5/16/05 - (Reuters Health) - Engaging in regular vigorous physical activity before pregnancy reduces the risk of developing pregnancy-induced diabetes (a.k.a. gestational diabetes), according to researchers.

Treating diabetes in pregnancy curbs complications - 6/13/05

NEW YORK (Reuters Health) - Treating women who develop diabetes in pregnancy (gestational diabetes) reduces the rate of serious complications without increasing the rate of cesarean delivery, new research shows.

Although the risks related to gestational diabetes are well known, it has been unclear if screening and treatment to lower maternal blood sugar levels can reduce these risks, Dr. Caroline A. Crowther and her associates comment in their report, published in The New England Journal of Medicine.

The Journal released the article early to coincide with the authors' presentation at the American Diabetes Association meeting in San Diego.

To evaluate the effects of treating gestational diabetes, Crowther, with the University of Adelaide in Australia, and her associates studied women with signs of gestational diabetes between 24 and 34 weeks into pregnancy.

By random draw, a total of 490 women were assigned to intensive treatment, including dietary advice, blood sugar monitoring, and insulin therapy, the authors note. Another 510 patients were assigned to routine care.

Serious complications among the infants -- death, shoulder impeding delivery, bone fracture, and nerve palsy -- were significantly more frequent in the routine-care group (4 percent versus 1 percent) after accounting for factors such as maternal age, race or ethnic group, and number of previous pregnancies.

A higher percentage of infants in the intervention group were admitted to the neonatal nursery (71 percent versus 61 percent), and women in the intervention group were more likely to undergo labor induction (39 percent versus 29 percent), both of which the investigators attribute to the treating physicians' knowledge of their gestational diabetes.

The rates of cesarean section were similar in the two groups.

At three months after delivery, women in the intervention group had lower rates of depression and higher scores on quality of life scales.

The report "provides some long-awaited evidence to support the use of screening and treatment for women at risk," Drs. Michael F. Greene and Caren G. Solomon, from Massachusetts General Hospital in Boston, write in an accompanying editorial.

SOURCE: The New England Journal of Medicine, June 16, 2005.

Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. [Full-text article]
Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS.
N Engl J Med. 2005 Jun 12; [Epub ahead of print]

Background We conducted a randomized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications. Methods We randomly assigned women between 24 and 34 weeks' gestation who had gestational diabetes to receive dietary advice, blood glucose monitoring, and insulin therapy as needed (the intervention group) or routine care. Primary outcomes included serious perinatal complications (defined as death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labor, cesarean birth, and maternal anxiety, depression, and health status. Results The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group (1 percent vs. 4 percent; relative risk adjusted for maternal age, race or ethnic group, and parity, 0.33; 95 percent confidence interval, 0.14 to 0.75; P=0.01). However, more infants of women in the intervention group were admitted to the neonatal nursery (71 percent vs. 61 percent; adjusted relative risk, 1.13; 95 percent confidence interval, 1.03 to 1.23; P=0.01). Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group (39 percent vs. 29 percent; adjusted relative risk, 1.36; 95 percent confidence interval, 1.15 to 1.62; P<0.001), although the rates of cesarean delivery were similar (31 percent and 32 percent, respectively; adjusted relative risk, 0.97; 95 percent confidence interval, 0.81 to 1.16; P=0.73). At three months post partum, data on the women's mood and quality of life, available for 573 women, revealed lower rates of depression and higher scores, consistent with improved health status, in the intervention group. Conclusions Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman's health-related quality of life.

What really catches my eye is that in this most recent study, they finally admit that they have not previously had good evidence to support the use of screening and treatment for women at risk.  So they come up with this one study and claim that now this is the gold standard of GD studies.  I don't know . . . the credibility of the medical community on this issue is very poor . . . are they just flogging a dead horse or is this real science?

I also really have to wonder at their eagerness to make the full text of this article available to the general public.  They won't do this for really important articles about GBS or VBAC, but they'll do it for GD?  Is this a journal article or advertising for high-intervention obstetrics?

And suddenly obstetrics is concerned about the quality of a woman's birth experience?  Why isn't a woman's dissatisfaction with a bad birth experience considered a "serious perinatal outcome" when it comes to episiotomies, unnecessary cesareans and the unavailability of VBAC care?

What happens when you look at the details of this study?

Two stillbirths were unexplained intrauterine deaths at term of appropriately grown infants, and the other, at 35 weeks’ gestation, was associated with preeclampsia and intrauterine growth restriction. One infant had a lethal congenital anomaly, and one infant died after an asphyxial condition during labor without antepartum hemorrhage. There was no significant difference in the rates of shoulder dystocia between the intervention and routine-care groups (1 percent and 3 percent, respectively) (Table 2). No infant in the intervention group had a bone fracture or nerve palsy, whereas in the routine-care group, one infant had both a fractured humerus that was not related to a difficult birth and a radial-nerve palsy, one infant had Erb’s palsy related to shoulder dystocia, and one infant had Erb’s palsy alone (Table 2).
Five neonatal deaths in the untreated group sounds terrible, but look at the specific reasons for death.

"Two stillbirths were unexplained intrauterine deaths at term of appropriately grown infants" - in theory, the babies would have been macrosomic if their mothers' glucose levels were unusually high.

". . .  and the other, at 35 weeks’ gestation, was associated with preeclampsia and intrauterine growth restriction" - and this is related to gestational diabetes . . . how?

"One infant had a lethal congenital anomaly" - are the authors saying that GD care prevents congenital anomalies?

". . . and one infant died after an asphyxial condition during labor without antepartum hemorrhage" - it would be helpful to know more details about this case . . . was there a concealed placental abruption?  Was there a cord accident?  Did the mother's blood pressure drop drastically after she got an epidural?  Is there any evidence that this death could have been prevented by GD care?

"There was no significant difference in the rates of shoulder dystocia between the intervention and routine-care groups (1 percent and 3 percent, respectively) (Table 2). No infant in the intervention group had a bone fracture or nerve palsy, whereas in the routine-care group, one infant had both a fractured humerus that was not related to a difficult birth and a radial-nerve palsy, one infant had Erb’s palsy related to shoulder dystocia, and one infant had Erb’s palsy alone (Table 2)." - It would be helpful to know if the case of Erb's palsy related to shoulder dystocia resolved spontaneously, as this is the only negative outcome that is plausibly related to GD care.

I notice that no retrospective testing of the bereaved mothers was mentioned.  It would have seemed like really good science to do a hemoglobin A1C test on these mothers to get a good sense of their glucose levels in the preceding 3-4 months.  Better yet, all women in the study should have had the same prenatal testing done so that we would know whether these bad outcomes were even occurring in women who met treatment criteria for GD.

Each of these deaths is surely tragic, but it is intellectually dishonest for the authors to imply that they would have been prevented by glucose monitoring or insulin injections.  It is plausible that the 35-week death from pre-eclampsia complications might have been prevented by better overall nutrition, which is often the best side effect of GD "treatment".

If it didn't seem too outrageous to be even remotely possible, I would suggest that there were actually multiple "non intervention" groups, and the researchers simply chose the one with the worst outcomes to use as the control group.

It is mildly ironic that the hypoglycemia was lower in the "untreated" group.  So much for the big concerns about rebound hypoglycemia as a consequence of untreated GD.

It is refreshing that the article considers cesarean birth to be a perinatal complication, rather than simply "an alternative to vaginal birth".

My conclusion: Women really need caring support during their pregnancy, and if this is provided through diet counseling associated with GD treatment, that's better than nothing.  How about trying care that's really focused on supporting the quality of the mother's experience of pregnancy/birth/postpartum, such as is routine in midwifery care?  I'll bet that would really reduce depression and improve health status!

Ultrasound Measurement of Fetal Growth Facilitates Management of Gestational Diabetes  CME [Medscape registration is free]

Maternal carbohydrate intake and pregnancy outcome by James F. Clapp III [PubMed abstract]

"The best-studied substrate in human pregnancy is glucose, and there is a direct relationship between maternal blood glucose levels and size at birth. Altering the type of carbohydrate eaten (high- v. low-glycaemic sources) changes postprandial glucose and insulin responses in both pregnant and non-pregnant women, and a consistent change in the type of carbohydrate eaten during pregnancy influences both the rate of feto-placental growth and maternal weight gain."

Long-held prenatal beliefs challenged - [2/2/04] Screening for gestational diabetes may be another example of how resources could be better spent.

"An entire generation of obstetricians, almost two generations of obstetricians, have bought into the idea that screening for gestational diabetes is important and serves to improve pregnancy outcomes," says Ohio State OB-GYN Mark Landon.

But it's unclear whether treating mild cases, usually with diet, is beneficial, and some research suggests it could have drawbacks, such as an unnecessarily higher rate of C-sections. Landon leads an ongoing, government-sponsored study to determine the effectiveness of treating the condition.

Screening for gestational diabetes: a summary of the evidence for the U.S. Preventive Services Task Force. [Medscape has an expanded abstract, halfway down the page. Medscape registration is free]
Brody SC, Harris R, Lohr K.
Obstet Gynecol. 2003 Feb;101(2):380-92.

These authors wrote another article - Summary of the Evidence - Screening for Gestational Diabetes
"Screening for GDM is contentious. The reason for this controversy is largely a lack of high-quality research addressing the central issues."

Medscape offers an excellent summary

Oct., 2003 - From The UK's National Institute for Clinical Excellence (NICE)'s  CG6 Antenatal care - routine care for the healthy pregnant woman: "The evidence does not support routine screening for gestational diabetes mellitus and therefore it should not be offered." (on the bottom of page 4).

Gestational Diabetes Mellitus Diagnosed With a 2-h 75-g Oral Glucose Tolerance Test and Adverse Pregnancy Outcomes  [Medscape registration is free]

"GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes." and "Finally, our study, being observational in nature, cannot estimate gains to be made through diagnosis and treatment of this condition. "

In 2002, the Society of Obstetricians and Gynecologists of Canada (SOGC) issued guidelines that it is no longer advisable to screen every pregnant patient for gestational diabetes because the benefits of screening have not been proven scientifically. [September 17, 2002 Volume 38 Issue 33 Medical Post.]

However, In July, 2016, the JOGC published Diabetes in Pregnancy:

The best way of identifying and treating women with abnormal blood glucose tests in pregnancy is not known. Raised blood glucose levels during pregnancy is known as gestational diabetes. This abnormality may be associated with bigger babies, more difficult births and could be associated with higher rates of operative delivery such as caesarean section. The review of eight studies (1418 women) suggests that offering specific treatment for gestational diabetes may be associated with better baby and mother outcomes, but has not found robust evidence on the best choice of treatment which provides the better outcomes for these women and their babies, even if identified correctly. More research is needed to assess long-term mother and baby outcomes.

The American Diabetes Association released new recommendations for screening and retesting of diabetes. The ADA now recommends that women at low risk not be screened.  (Here is their outdated information sheet.)

Debate over screening for gestational diabetes by Malcolm Griffiths
BMJ 1998;316:861 ( 14 March ) - Letters

From: C-upi@clari.net (UPI / Stories of modern science...from UPI., Bill Clough (UPI))
Organization: Copyright 1997 by United Press International ** via ClariNet **
Date: Thu, 27 Nov 1997 0:51:14 PST

BOSTON, Nov. 26 (UPI) -- Toronto researchers say too many mothers-to- be are getting unnecessary blood tests for pregnancy related diabetes.

The scientists say they have developed a simple screening technique to determine who is really at risk. They estimate the technique could cut the number of such tests by one third, eliminating hundreds of thousands of tests a year.

The new screening method, an evaluation based on a woman's height, weight, age and race, would also limit false positive readings, which lead to more complicated, time consuming tests, the scientists say.

In a study in the New England Journal of Medicine, investigators from the University of Toronto used the method to screen more than 3,000 pregnant women, who were also given the standard blood test for diabetes. They found that nearly 35 percent did not need the blood tests.

Dr. C. David Naylor says the new method is "dead simple," and "picks up just as many cases as universal screening."

Naylor, a professor of medicine at the University of Toronto, also says the study found that false positives dropped about 5 percent with the new screening method.

Pregnant women are usually screened for gestational diabetes with a simple blood test, which costs around five dollars and takes an hour.

But if a women gets a false positive from the first test, she is then given an oral glucose tolerance test.

Naylor says this involves a two-day high-carbohydrate diet, fasting and giving blood four times during three hours in a blood-letting station. The woman also must drink large, sometimes nauseating, amounts of sugar water.

Naylor says, "This falls under the heading of serious nuisance for women who are already busy enough."

In a NEJM editorial, Dr. Michael F. Greene of Massachusetts General Hospital says that the study supports the American College of Obstetricians and Gynecologists and the American Diabetes Association, which call for selective screening.

But he says, "busy obstetricians are unlikely to wend their way" through a complex diagnostic screen for each pregnant woman.

(Written Mara Bovsun in New York)

Selective Screening for Gestational Diabetes Mellitus
Naylor CD, Sermer M, Chen E, Farine D
N Engl J Med 1997 Nov 27;337(22):1591-1596

Related editorial

I particularly recommend checking out the editorial. It's quite amusing, really. Well, it would be funny if it weren't so sad. The editorial acknowledges that GD testing is often unreproducible and "treatment" doesn't produce any statistically significant changes in outcome, but it still struggles to emphasize how very important it is to test as many women as possible.

Probably because of the combination of the low incidence of gestational diabetes and the extremely low incidence of perinatal mortality in developed countries, it has not been possible to demonstrate an association between gestational diabetes and perinatal mortality. More problematic has been the inability to demonstrate clearly and consistently that any intervention significantly reduces these risks. Although in some trials aggressive insulin therapy has reduced the incidence of macrosomia and operative delivery, (3) in others it has not. Despite some lingering uncertainties about the utility of making the diagnosis, (4) gestational diabetes mellitus is a real disorder, and obstetricians are obliged to recognize it.
Maybe it's just my reading of it.

And I'd appreciate any insight into how the author of that editorial can claim that one of the reasons we don't see statistically significant changes in outcome because of GD "treatment" is that neonatal mortality is so low. Wouldn't a lower mortality rate just highlight any changes in outcome from GD "treatment" because the relative improvement would be greater?

A lot of this just confirms what Henci Goer says in her Emperor's New Clothes article on GD.

Hypoglycemia Results for Glucose Tolerance Tests

Gestational hypoglycemia confers favorable obstetric outcome - 6/26/05 - Determining the perinatal significance of hypoglycemia during a 100 g glucose tolerance test in pregnant women.  . . . Pregnant women who experience hypoglycemia during a glucose tolerance test have a lower rate of gestational diabetes and lower neonatal birth weights than those with higher glucose levels, study results show.  . . .  "Based on our study, however, the patient can be reassured that such a phenomenon is not unusual, is transitory, and carries a favorable prognosis in terms of obstetric outcome," the team concludes.

Hypoglycemia during the 100-g oral glucose tolerance test: incidence and perinatal significance.
Weissman A, Solt I, Zloczower M, Jakobi P.
Obstet Gynecol. 2005 Jun;105(6):1424-8.

CONCLUSION: The incidence of reactive hypoglycemia during the 100-g oral glucose tolerance test in our population is 6.3%. Women who experience hypoglycemia during the test have a significantly lower incidence of gestational diabetes and neonatal birth weights.

Doubts About "Gestational Diabetes"

Gestational Diabetes: A Common-Sense Approach by Henci Goer

Gestational diabetes by Henci Goer - What is gestational diabetes?  An updated version of her classic work!

Gestational Diabetes: Does a New Study Tell Us What Investigators Think It Does? [2/27/17] by Henci Goer - Floating around the internet is news about a large French study of gestational diabetes mellitus (GDM) and the risks it poses. It’s a brilliant analysis because it separates gestational diabetes from Type 1 and Type 2 diabetes and reports outcomes according to severity of gestational diabetes, which have been major confounding factors in other analyses. Even so, its conclusions raise more questions than the investigators think they have answered if you look at the study with an unbiased eye.

Gestational Diabetes: The Emperor Has No Clothes by Henci Goer
Testing for and treating "gestational diabetes" does not improve outcomes. It does not reduce miscarriage and stillbirth rates, and it does not reduce complications typically associated with macrosomic babies. All it does is identify women who might be at risk for developing diabetes later in life.  This has no implications for the current pregnancy.

Gestational Diabetes: A Diagnosis Still Looking for a Disease? by Michel Odent, M.D.

All About Gestational Diabetes by Kmom

A Mother Summarizes Her Reasons for Declining Glucose Screen

Treatments for gestational diabetes and impaired glucose tolerance in pregnancy (Cochrane Review)

"Reviewers' conclusions: There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.."'

Childbirth Connections makes the entire chapter available.

Should we screen for gestational diabetes?

In this week's controversy (p 736) R J Jarrett argues that the concept of gestational diabetes is muddled and there is little point in screening for it. The maternal glucose values that define gestational diabetes also include non-insulin dependent diabetes, and there is, he says, no evidence that gestational diabetes is associated with adverse outcomes in pregnancy. Screening may identify diabetes early, but the benefits of this are unclear and uncosted. Soares et al, however, urge screening because it detects women at risk of future non-insulin diabetes and enables early treatment to prevent complications.
BMJ No 7110 Volume 315
This week in brief Saturday 20 September 1997

In that BMJ discussion, Soares makes it sound as if he believes that screening has no particular benefits for pregnancy but could be useful as part of a general health management approach. If this is the case, then they should be urging screening for everyone, not just for pregnant women.

Oh, and while we are talking about evidence based practice, is there any good evidence that glucose screening and defining women as "gestational diabetic" has any impact on outcome?

At a conference I attended last summer, a presentation was made on GDM. Among the issues was the re-calibrating of cutoffs which is apparently in the works and moving through committees at ACOG and will be published soon. But the presenter made the point that GDM testing and identification has changed neonatal and maternal outcomes only in the ability to further identify the sub-set of the GDM population that requires insulin. This is why they want to "tighten" the cutoffs, so that more insulin-requiring GDM can be found.

The notes are at my office, but compelling information was presented about the difference in neonatal and maternal outcomes when more insulin-requiring moms were identified.

So we should be thinking about GDM this way:

  1. Test everyone without risk factors at 24-28 weeks. Those that fail the GCT, get the GTT.
  2. Those that fail the GTT get diet counseling, periodic fasting and 2 hour blood glucose levels.
  3. Those whose fasting and 2 hour remain normal are at no greater obstetrical risk than any other pregnant woman. (This is a very important point. The latest issue of Williams explores this point and the most recent research on GDM shows that a diet controlled GDM is essentially a normal OB patient)
  4. Those who's fasting and 2 hour are abnormal, should be evaluated by and OB for insulin. If they are well controlled on insulin, their obstetrical outcome will most likely be normal, but more careful monitoring (NSTs, BPPs, etc.) is probably indicated.
The basic conclusion (If I understand this correctly), is that the whole point of glucose testing is not to find to larger group of glucose metabolism impaired pregnant women, but to find the smaller group within the larger GDM population that needs insulin, to prevent poor outcomes (such as stillbirths, greater cesarean delivery, etc.).

Notes from a GDM presentation by Steven Gabbe, M.D. in 1990

At 17 weeks my glucose test came back 105, and they keep saying, "Well, let's hope that it stays low in the next test". It would be really difficult for me to find time for the 3 hour test. Of course if it was the best thing to do for my baby, I would, but is it? What would the reasoning be for refusing the second test?

The reasoning for declining the second test would be the same as for declining the first test:

Testing and "treatment" doesn't improve outcomes.

Say that 100 times until you really believe it, because you'll be made to feel that you don't love your baby if you won't let them do everything they want to you, even if they have no evidence that this test will help you or your baby.

When my 1st baby was born, he weighed 9 lbs 10 ozs.  When the neo-natologist came in to talk to me about his treatment, she said that babies of mothers with GD often aspirate meconium.

Oh, I think this one takes the cake.

Yes, there is an association between higher blood sugar levels and larger babies.  There is also an association between starvation and smaller babies.

Yes, there is an association between older/larger babies and meconium, because mature babies start moving their bowels in utero.  Small babies also get "meconium aspiration syndrome", but they call it pneumonia if there's no meconium present, so the "association" doesn't show up on paper.

And, yes, there is an association between meconium and meconium aspiration syndrome, as in, if there's no meconium, they won't call pneumonia "meconium aspiration syndrome" - they'll just call it pneumonia.  (However, research shows that removing the meconium doesn't reduce "meconium aspiration syndrome".  Hmmmmm.)

Now, if they could just show that "association" has anything to do with cause and effect, then they'd have something to talk about.

I have never read anything remotely reliable about a cause-and-effect relationship between true diabetes and meconium aspiration syndrome (really pneumonia), and it is really really hard to imagine how high blood sugar levels in a mom could cause lung defects in the baby.  I just did a quick search through my files and could find absolutely no mention of meconium having anything to do with "gestational diabetes".

It seems irresponsible to me when people say that high blood sugar during pregnancy isn't a problem.  And why would they argue against it, anyway, when the treatment is mostly just eating a more healthy diet and getting lots of exercise.

Yes, pathologically high levels of blood sugar can cause problems for mother and babies.  The blood sugar levels used to define gestational diabetes are not pathologically high. The placenta specifically produces hormones to raise a pregnant woman's blood sugar levels.  Many birth professionals throughout the world recognize this as a normal and healthy aspect of pregnancy.

Yes, a good diet and getting lots of exercise are good things for anybody, and especially for a pregnant woman.  True informed consent guidelines dictate that this is exactly what I tell women.  I don't lie to them about complications that might result if they don't follow my advice.

I am not arguing against eating well in pregnancy.

I am arguing about mis-representing research on the subject. I am arguing against the erosion of self-confidence and the medical system's assertions that women with "gestational diabetes" couldn't grow a healthy baby without them.  I am arguing against the fallacy that testing for and treating "gestational diabetes" is going to improve a woman's pregnancy outcome.

Fallacy of Gestational Diabetes Treatment to Improve Chances of VBAC

A lot of the research about GD doesn't make sense to me - it's too technical.  I'm not sure whether or not it shows that "gestational diabetes" is really a disease or not, but I figure if being "treated" for it will result in a smaller baby and maybe decrease my risk of a repeat cesarean, why not go along with it?

What makes you think that treatment for "gestational diabetes" increases your chance of VBAC?  If someone has told you this, I suggest you ask for references to the studies; I don't think they exist.

Certainly, eating less is likely to decrease the size of your baby, but how is this going to increase the chance of VBAC?  It's easy to think that a baby that weighs less will have a smaller head and thus be easier to birth, but this isn't the case.

What happens to a two-year-old who eats more food than they need? Do they grow taller or have a bigger head?  No, they put on extra subcutaneous fat. What happens to a two-year-old who doesn't eat as much food as they need?  They will probably be skinny.  If they're getting way less food than they need, their growth may be stunted and they may not reach the full adult height that their genes dictated.

Restricting your food intake isn't going to result in a baby with a smaller head unless you're starving yourself. For women who are close to starvation levels, their baby may have a condition called "brain-sparing IUGR - brain-sparing IntraUterine Growth Retardation".  This is where a baby isn't getting enough nutrients so sends them primarily to the head, resulting in a normal head size with a grossly reduced body size.

Notice that the word "macrosomia" means "big body", not "big head".  It's no more difficult to birth a fat baby than a skinny baby, given the same size head and shoulder girdle.  Fat flows and conforms to the shape of the birth canal in a way that bones cannot.

Yes, women who are "treated for gestational diabetes" may grow a baby that weighs 6-8 ounces less than it otherwise would.  But the reduction is in the baby's body size and fat reserves, rather than in head size.  How is this going to increase your chances for a VBAC?

It doesn't take a great stretch of the imagination to wonder how  "treatment for gestational diabetes" actually increases risk of a cesarean.  Women diagnosed with GD typically experience a loss of faith in their ability to grow and birth a healthy baby.  Every time they measure their blood sugar or chart their food intake or inject insulin to themselves, this is a message to their body and their subconscious that there's something wrong with their body.  This disempowers them at a time when feeling their power is exactly what they need in order to give birth.  This loss of faith makes them more vulnerable to being pressured into making choices that aren't in their best interests, such as a pitocin induction.  They may be treated as high-risk during their labor, which increases the risk of c-section.

So, I'd be curious to hear your chain of reasoning as to how treatment for GD will increase your chance of VBAC.  A reference to a study would be well received.

There are many ways to improve your chances of a VBAC: it is well documented that hiring a midwife increases your chances, but you may not be able to take advantage of midwifery care if you've been diagnosed as having GD.  I don't have evidence about the increased chances of a VBAC if you plan a homebirth, but I know nobody does cesareans at home.

It is well recognized that squatting opens the pelvis 20-30%. If your care provider doesn't support squatting during pushing (lending new meaning to the phrase "supported squat"), I would suggest that putting energy into changing this would do a lot more for your chances of VBAC than restricting food intake.

From - Obstetrical Ultrasound Measurements (Creighton University Medical Center):

Head size is determined largely by brain growth which is relatively independent of nutritional (maternal/placental insufficiency) growth retarding processes, and head growth is often relatively "spared" in such growth retardation. When the head growth is retarded, it is often the result of non-nutritional "symmetric growth retardation" associated with genetic, toxic, or infectious damage to the fetus.

DeLee on Gestational Diabetes


We have learned that it is impossible to influence the size of the child through dieting the mother. Short of actual famine there is no effect from reduction or alteration of the food. The great hunger experience in Germany during the War blockade proved this. The babies were as large and as rosy as ever -- even when the mothers were half starved. Still some physicians believe it can be done.

Joseph DeLee AM, MD, 'Obstetrics For Nurses' -- 1937

Cow's Milk Protein Linked to Diabetes

Glycosuria Not Necessarily Gestational Diabetes

You say glycosuria is a normal finding of pregnancy?! At what point is the level NOT normal?

Yes, I did say that glycosuria is oftentimes a normal finding of pregnancy. We see women with 4+ glucose on dipstick urine who have perfectly normal bloodsugars.

I have had her do random sugars (all wnl) and we did a GTT at 28 weeks which consisted of a FBS followed by Anne Frye's high sugar breakfast and then we did 1 and 2 hour post-prandials all again wnl.

I have no idea what Anne Frye's high sugar breakfast is. However, normal FBS, normal postprandial glucoses, and normal glucoses after high glucose load pretty much rule out gestational diabetes.

About Preparing for the Glucose Tolerance Testing

I am still very curious as to why she is running such high glucose on the dipsticks??? Any ideas??

Increased renal blood flow, increased glomerular filtration, decreased reabsorption of glucose all result in glycosuria as a normal pregnancy finding. She is running high glucose on dipstick simply because she is a pregnant woman. There is nothing wrong with this woman!!! You have checked her blood glucoses and they are fine....therefore, her glycosuria is attributed to the normal physiologic renal changes of pregnancy.

Why isn't it clear to everyone that this woman's kidneys are filtering the glucose through rather than attributing it to elevated blood sugar despite the normal tests?

Renal function changes remarkably in pregnancy. Glomerular filtration rate increases nearly 50%. The capacity of the renal tubules to reabsorb filtered glucose decreases. Because more glucose is reaching the kidney, and less is being reabsorbed, glycosuria is a normal finding in pregnancy.

I think one can substantiate the statement "occasional glycosuria - trace to one plus - is normal in pregnancy", but large amounts and on every occasion is pretty unusual.

I would have to disagree (respectfully, of course [grin]). I've had three women in the last year who've consistently spilled large amounts (+3 to +4 on our dipsticks) of sugar in their urine. One came to care late from a family doc, with normal blood glucose results in hand, saying, "Yeah, I did this last pregnancy, too". The other two I tested, and both were fine. One of my partners has had one or two this year as well, with the same results. I've got another one right now, who says the same thing....that she spilled sugar her last pregnancy.

My complaint, frankly, is the 1 hr. 50 gm. glucose challenge. I'm almost at the point where I'd like to say, trash the damn thing. Almost every woman that I've sent for the challenge (or screen, whatever you call it) has come back high (>7.8 mmol/L). Then I send them for the 3 hr OGGT, and it's fine. Strikes me I should just save them the misery and cut to the chase.

I agree, It's a stupid test. Unless a mom has risk factors for DIABETES (the REAL thing!) there is little point in doing one. I believe that some women are "silent diabetics" and we might discover the disease during her pregnancy; but I don't believe we should be tagging normal women who have unusual gtts with the "gestational diabetic" label.

It may be unusual, but I have seen several women over the years like this. I have one young woman I've attended 4 births for who has off-the-stick glucose on every visit. Her blood sugar levels are always normal and her babies are in the 8-9 lb. range.

Glucometers have an area in which they are very accurate and at the upper and lower ends of the scale, they are not. All tests have "linearity" which is a range of values which are acceptable. Most test methods are not accurate above and below the stated linearity. For example, a glucometer might read numbers 0-30, but those values are NOT accurate when the meter's linearity states accuracy from 30-350. So , a value of 28 might actually be 12 or 38.......and the same goes for upper ranges. Often a reading over the linearity is actually higher than the machine reports.

Diet Preparation

Diet Preparation for the Three-Hour Glucose Tolerance Test

Anne Frye recommends 3 days of carbohydrate loading with complex carbohydrates, to equal a total of 150 grams daily (no sugar or white flour).  Note that she uses 120 as the upper limit for a healthy FASTING glucose number, which is way higher than mainstream medicine uses.  I have some concerns that this high carbohydrate intake might result in a high fasting number that could result in a GD diagnosis regardless of post-Glucola numbers.

Note that the classic testing for gestational diabetes used to start with a one-hour gestational diabetes screening test to identify women who needed the three-hour glucose tolerance test.  Now, some practices just go straight to a two-hour "screening test" which also doubles as a definite diagnostic test.  You might not need to do the diet preparation for the one-hour screen, but if you know that the test you're going to get isn't just a screen but actually the final test, then you might want to do the carb-loading.

Diet Preparation for a Glucose Tolerance Test from Australia

Do I Need an Oral Glucose Tolerance Test?
from WebMD - They recommend the carb-loading

PCOS: Preparing for Your Oral Glucose Tolerance Test
from Center for Young Women's Health - they recommend carb-loading

Carb-Loading Before 3-Hour Glucose Tolerance Test?
- this post and comments indicate that the carb-loading seems to help some women but not others!

Fasting GTT and carbohydrates in diet prior to test...?
- one of the responses details a diet to follow from the Path lab also for the long GTT test.
Another claims that "If you go low carb before you may get a false negative result." I'm not sure that's correct.  I think the point of the carb-loading is to prevent a false positive that can be generated from something called "starvation diabetes"; this is a situation where the body has had low glucose levels for some time and is then faced with a high glucose load, causing a temporary diabetic response.

Using Jelly Beans or Other Alternatives for Glucose Tolerance Test

Discussion of jellybeans as an alternative to a cola beverage containing fifty grams of glucose

Jelly beans as an alternative to a fifty-gram glucose beverage for gestational diabetes screening.
Lamar ME, Kuehl TJ, Cooney AT, Gayle LJ, Holleman S, Allen SR.
Am J Obstet Gynecol. 1999 Nov;181(5 Pt 1):1154-7.

CONCLUSIONS: Jelly beans may be used as an alternative to the 50-g glucose beverage as a sugar source for gestational diabetes mellitus screening. The 2 sources provoke similar serum glucose responses. Patients report fewer side effects after a jelly bean challenge than after a 50-g glucose beverage challenge.

I agree that food is different than lab-made glucola-- so my protocol is to do a 1 hour GCT with juice-- either apple, orange, grape or cranberry, soda or jellybeans.  If they have above 140 on the GCT we get a 3 hour and a consult with MFM.  Less false positives this way-- but we do find diabetic moms.

I send my clients to McDonald's for breakfast: Egg McMuffin is 30 g carb plus, 12 oz. OJ is 33 g carb for a total of 63 g OR Hot Cakes with 2 pats of margarine and 1 pkt of syrup is 26 g carb plus 12 oz. OJ is 33 g carb for a total of 59 g.

If they need a 3 hour challenge, they go to the lab for glucola.

I don't think it is valid to use a mixed protein/carb diet as a substitute for a pure carbohydrate load, as in the GCT.  Protein and/or complex carbohydrates will greatly alter the metabolism of glucose.  The fact that the diet contains the same amount of carbohydrate does not mean that it will be metabolized in the same way as 50g glucose.  Maybe just the hotcakes with syrup would be closer to an accurate test.

Healthy Alternatives to the Pregnancy Glucose Test [6/5/14] - This outlines self testing at home of your normal food intake.  It also lists the contents of the Glucola, which is pretty scary!

One alternative is simply to get a fasting glucose level:

Am J Obstet Gynecol. 1999 Nov;181(5 Pt 1):1158-61.
Alternative methods of diagnosing gestational diabetes mellitus.
Atilano LC, Lee-Parritz A, Lieberman E, Cohen AP, Barbieri RL.

CONCLUSION: An elevated glucose loading test result was associated with but not highly predictive of gestational diabetes mellitus. Omission of the 3-hour glucose tolerance test measurement resulted in failure to diagnose 13% of gestational diabetes mellitus cases. A fasting plasma glucose concentration >/=105 mg/dL was highly predictive of an abnormal glucose tolerance test result among patients with an elevated glucose loading test value.

Gestational Diabetes Protocols

Some people are doing a one-hour or two-hour postprandial glucose blood draw.  Page 9 of this handout has instructions.

We are doing early 1 hour glucose testing on pts with a first degree relative with a history of DM. If you are also doing this, does it make any difference when the first degree relative developed or was diagnosed with DM?

I think this is an interesting and useful discussion to have, because I struggle with this one quite a bit. I don't normally do the 50 gm GC (as it's called here), but will if there are risk factors (such as e.g. first order relative with type II diabetes, or persistent, heavy glycosuria). My problem is that I have, again and again, seen the 1 hour come back with a high value, and then have the woman have to move onto a 3 hour GTT, which almost always comes back with normal values. Makes me question the value of this screen a whole lot. There's not a lot of good evidence about how useful it is, yet community standards often dictate that we look better if we do it.

I have to say that I know that, a couple of times, the values on the 1 hr have been altered because of the woman's stress levels (one had to be poked by the lab tech 4 times, and had almost passed out by that point...which astounded me because she has great veins). We don't do the 1 hr ourselves, because we don't have the glucola. Does anybody do a 2-hr pc instead, and if so, is it "acceptable" by the powers that be?

I talk to my clients about the 50 gm glucola screen - let them know its standard of care and can help pick up a problem with glucose metabolism that they may have no other sx of. Most, however, don't eat much concentrated sweets and really don't want the glucola. There are other 50gm meals out there that I might try (just found a list of them in a conference syllabus), but I usually offer the option of a 2 hr PP glucose after a GOOD meal. I tell clients that this is not standardized and there isn't a firm desired result, but it does give us a good idea of how SHE metabolizes her own food.

Just had a primip who said she'd take the glucola - result came back 141 (and we're supposed to do a GTT for anything >140). She said the glucola made her feel awful for the next 24 hours and basically refused to do a GTT involving fasting and drinking 100 mg. So we compromised with a fasting BS and a 2 hr PP - will see if those two are normal and go from there. Again, she's another one that doesn't eat much sugar and almost no fruit due to allergies.

Routine GTT testing - we offer all clients @ 28 weeks a 1hour postdose GTT screening test. We explain this is the medical model standard of care, if they don't want it and they do not have risk factors that is fine with us, but I feel it is my job to offer it to them. Only if they have multiple risk factors we really push the test or if they don't want the test we have them follow a modified GDM regime, just in case. Our modified regime is really good for anyone: reduce/eliminate processed sugars, limit/dilute fruit juices, eat a complex carbo every 4-6 hours and exercise everyday.

Speaking of GDM, anyone using chromium with GDM management?

[from ob-gyn-l]

We are doing early 1 hour glucose testing on pts who have a first degree relative with a history of DM. If you are also doing this, does it make any difference when the first degree relative developed or was diagnosed with DM?

I might consider it if the relative was under 60; but I think it's pretty irrelevant if older.

we only do early 1 hr screens on women with prior hx of gestational diabetes (just to make sure they weren't real diabetics who just happened to be picked up during pregnancy). We don't screen early for family hx, large babies etc.

I going to give an unpopular opinion here. I believe in Gestational diabetes (GDM), and highly recommend all women with risk factors be screened, (listed below).

I have seen too many cases over the years. Only a few were severe, but I have seen lots of mild cases. Adult onset diabetes is rapidly growing in the US. Women who get it in pregnancy have an increased chance of getting it later on in life, however it can be prevented through diet and exercise. I think screening women with risk factors is a way to positively contribute to a woman's lifetime health outlook. As a type 2 diabetic myself, with a son with type 1, I am more than aware of all the potential negative health consequences to this illness. Preventing type 2 diabetes is a long term process, we have the opportunity to intervene in a positive way with young women to help prevent a potentially very serious disease. Not to mention increased risks to both mother and baby during pregnancy.

GDM is a condition in pregnancy that is treated with nutritional changes. Often that is all it takes.  Reducing sugars and simple carbohydrates, eating whole grains, frequent small meals, protein in the morning, are all healthy changes. I tell my client that not to treat GDM as a pathology but a tool for making dietary changes.

Listed below is the screening methods and values taken from the practice guidelines at Community Midwifery. From everything I have read glucometer readings are not accurate as a method of screening.

+++  Risk Factors for GDM include: +++
1)  Previous GDM or abnormal blood sugars
2)  Previous LGA infant (greater than 9#'s or 4000 gms) or macrosomia or suspected LGA fetus.
3)  History or presence of polyhydramnios
4)  Present or anticipated maternal weight of greater than 200 lbs.
5)  DM in parents or siblings
6)  Previous unexplained stillbirth, anomaly, or greater than 2 previous SAB's.
7)  Polyuria, Polydipsia
8)  Recurrent vaginitis or UTIs
 9)  Recurrent glycosuria
10) Women over 35% overweight
11) Women over 30

+++  I.  Screening test +++
A. Procedure for the one hour GTT is as follows:
1.  Client need not be fasting & FBS need not be obtained
2.  50 gm glucola  (or equivalent glucose load) is given orally,
3.  One hour later blood glucose is sent to the lab.
4. Clients with a confirmed blood glucose over 140mg/dl  require a three hour OGTT.

II.  Population to be screened, and timing for testing
A.  Only women with risk factors will be offered screening for GDM at 26 to 28 weeks gestation by a one hour  post 50 gram dose glucose tolerance screen.
B.  Women at high risk for gestational diabetes may be  screened with a one hour post dose GTT at the first prenatal visit.  If this is initially normal, the screen will be repeated at 26-28 weeks as in (A).

III.  Follow-up for abnormal values
A.  Women with abnormal values will have a three hour GTT performed and be scheduled to be seen by MD and by nutritionist if the three hour GTT is abnormal.
B.  The following values will be used to interpret the test, all referring to plasma glucose (not whole blood) after a 100 gram oral glucose load.

IV.  Normal values for 3 hour GTT (100 gm glucose load)
·   FBS less than 105 mg/dl
·   hour less than 190 mg/dl
·   hour less than 165 mg/dl
·   hour less than 145 mg/dl
V.  Diagnosis of Gestational Diabetes
A.  Two or more abnormal values of a 3 hour OGTT is considered diagnostic for Gestational Diabetes, (Class A1).
B.  A fasting Glucose greater than 120 is indicative of a  need for insulin (Class A2 or B or greater)

well, I believe in GD, too. I just think it is the diagnostic criteria are sloppy and not based on solid research -- and as a result diagnosing it seems to be almost at the whim of the care-provider.

the 50 gm carbo is a pretty good all around screen. Wouldn't hurt any of us to have one of these every five years or so. It might help if we could identify those at risk of developing type II diabetes early enough to make a difference in preventing it.

I just think the diagnosis -- and management - of "gestational diabetes" is still in its infancy.(unlike the diagnosis and treatment of diabetes mellitus). As such it is cause for confusion and still  subject to errors in interpretation and implementation.. and has some possibilities of harm.

However, we both agree on the point that women with risk factors should be screened. I understand the view of screening ALL women -- even those without risk factors -- but I think of it as more of a public health issue rather than a midwife issue in my own practice. I'll watch carefully for s/s symptoms of diabetes in pregnancy - and test as needed.

In  a perfect world every woman would get health screens and health education at every stage in her life... diabetes screens, mammograms, paps, etc. etc.  Those midwives who expand into women's health are nicely set up for that aren't they? What a great opportunity to make a difference in  a woman's life!

I think the key is to identify insulin resistance (the root of type 2 diabetes) before it develops into overt disease.  We don't have any real good markers yet, except in a small subset of women (PCOS) and the gold standard for diagnosis of insulin resistance is not a good clinical tool (the insulin clamp technique).  However, there is some preliminary research seeming to indicate that the ratio of the fasting glucose level to the fasting insulin level is a good surrogate marker. If the insulin is high, even though the glucose is normal, the pancreas is working overtime. A certain degree of insulin resistance is normal during pregnancy (human placental lactogen mediated) as insulin is a growth hormone (probably more significant than human growth hormone). The basic study I would like to do is to measure glucose and insulin levels with every blood draw during pregnancy for a large universe of pregnant women, and compare trends to outcomes, and see what is normal and what causes pathology. alas, no funding 

amen! Double AMEN! Because THAT is at the root of the mess we've made of gestational diabetes! We know that pregnant women are insulin resistant -- and we know that this is a NORMAL STATE in pregnancy (heck, that's very old research) ... but we just really don't know "how" normal, and which levels should be used as markers to detect the abnormal.

There is not enough research and we need a hell of a lot more. Considering that pregnant women are sort of a "captive audience", it seems rather surprising that there is not more research into establishing normal values for pregnant women.

Not surprising if you think about the diagnosis of GD as being one more woman who isn't eligible to receive midwifery care!

Well, call me a curmudgeon, but I don't believe enough in the research on "gestational diabetes" or believe in the validity or effectiveness (as far as preventing macrosomia) to believe in encouraging routine post-prandial testing.

The only  client I can imagine "I:" think should be monitoring her glucose levels -- would be a woman with overt diabetes -- and then, she would NOT be my client, but would be referred to a specialist!

So... I can't give you any advice on which numbers to use. The fact that the numbers vary so widely in recommendation is because the research is so dang lousy. Really disgustingly lousy.  And I like to quote  -- or paraphrase -- The Guide to Effective Care  which complains that the issue of "gestational diabetes" has been adopted with so little data that it is essentially experimentation on pregnant women and "in any other field would be considered unethical"!

Here's the deal.... research shows that restricting calories and carbohydrates will not make a statistical difference in size of the baby. Restriction of calories and carbs PLUS INSULIN "will" make a difference, but only of about 4 to 8 ounces which is not likely to be "obstetrically significant".

Any "research" you see which claims otherwise is probably based on a dozen or couple dozen moms -- read the abstracts yourself -- or on "I had this client once".

Diabetes is diabetes. A woman has it or she does not. Diagnosing gestational diabetes based on a the rather arbitrary numbers developed for GTTs is not accurate - -  because the test itself is inaccurate and because there are no "normal" values set for pregnant women  (who metabolise sugar differently from non-pregnant testees) There are only "abnormal" numbers based on non-pregnant people (white men) and on the guesses of various care-providers.

Diagnosing GD because the woman has a history of big babies makes no sense to me! It DOES make sense as a marker for diabetes --- because diabetic moms may tend to have larger babies -- but what about the very normal moms who are genetically programed to have big babies? they WILL have big babies -- if those babies are genetically programed to be big -- and we risk harming the mother and the baby by restricting the calories they need for their best health. They WILL have big babies anyway! Those are the facts -- and that's what the data shows.

Research does show that "normal" pregnant women need a certain level of calories and carbohydrates for optimal pregnancy health. Are we gonna deny the research proven to be true, and manipulate her diet -- depriving her of the optimum nutrition -- based on flimsy research and anecdote -- in spite of data which PROVES that diet manipulation is not effective at preventing macrosomia?  [Editor's note - Macrosomia is defined as a big body relative to overall size, i.e. a "really fat" baby.  Macrosomia has nothing to do with head size.  "Big babies" have proportional bodies, which aren't truly macrosomic.]

A diabetic woman needs careful monitoring -- including blood-checks after every meal -- because her bloodsugars will swing wildly and jump HIGH HIGH HIGH - -- probably well into the two hundreds. But the woman called "gestatational diabetic" doesn't swing outside of the normal swing  -- she has NORMAL bloodsugars for a pregnant woman -- yet the numbers are arbitrarily lowered BEYOND the normals (even normals for non-pregnancy)  -- in order to "control" a nonexistent problem!

I'm sorry to grumble, whine, and complain like a petulant child.  Just call me the "GD Curmudgeon".

I test my clients for DIABETES by running a random venous blood sugar when I do their labs... or if they are high risk or symptomatic  I send them for a venous postprandial. IF those results are abnormal, then we deal with it -- by consultation and referral -- because she has diabetes.

If she doesn't have diabetes, then she doesn't have diabetes. And that is the end of tests as far as I'm concerned  -- unless some overt signs/symptoms appear or there is some clinical reason for further testing. .

Ketones from Low-Carb Diets

Many midwives may remember that ketones in the urine may be a symptom of gestational diabetes, but this is only true when there is also glucose in the urine or the blood sugar is high.  This usually happens only with Type I diabetics who have absolutely no insulin, so their body is converting body fat to ketones to feed the brain since ketones are an alternative fuel source for the brain.

For a woman who is eating a low-carb diet with a daily carbohydrate intake of less than around 120 grams, they will also need ketones to feed the brain.  Fortunately, all that lovely, healthy fat they're eating is readily converted into ketones as brain fuel.  This is not necessarily a sign that the woman is burning body fat.

Our American diet has historically been so high in carbs that anytime a woman had ketones in her urine, we assumed that she wasn't getting enough calories overall and was burning body fat as fuel for her brain and muscles.  With a new focus on healthy fats as the main source of energy, it becomes clear that ketones will be produced routinely as brain fuel.  This is not a problem in any way.

Here are some references:

Some terrific information from "Good Calories, Bad Calories" by Gary Taubes:

"Though glucose is a primary fuel for the brain, it is not, however, the only fuel, and dietary carbohydrates are not the only source of that glucose.  If the diet includes less than 130 grams of carbohydrates, the liver increases its synthesis of molecules called ketone bodies, and these supply the necessary fuel for the brain and central nervous system.  If the diet includes no carbohydrates at all, ketone bodies supply three-quarters of the energy to the brain.  The rest comes from glucose synthesized from the muscle, and from a compound called glycerol that is released when triglycerides in the fat tissue are broken down into their component fatty acids.  In these cases, the body is technically in a state called ketosis, and the diet is often referred to as a ketogenic diet.  Whether the diet is ketogenic or anti-ketogenic - representing a difference of a few tens of grams of carbohydrates each day--might influence the response to the diet, complicating the question of whether carbohydrates are responsible for some effect or whether there is another explanation.  (Ketosis is often incorrectly described by nutritionists as "pathological."  This confuses ketosis with the ketoacidosis of uncontrolled diabetes.  The former is a normal condition, the latter is not.  The ketone-body level in diabetic ketoacidosis typically exceeds 200 mg/dl, compared with the 5 mg/dl ketone levels that are typically experienced after an overnight fast - twelve hours after dinner and before eating breakfast - and the 5-20 mg/dl ketone levels of a severely carbohydrate-restricted diet with only 5-10 percent carbohydrates.)" [p. 319]

"It is not the case, despite public health recommendations to the contrary, that carbohydrates are required in a healthy human diet.  Most nutritionists sill insist that a diet requires 120 to 130 grams of carbohydrates, because this is the amount of glucose that the brain and central nervous system will metabolize when the diet is carbohydrate-rich [sic]. But what the brain uses and what it requires are two different things.  Without carbohydrates in the diet, as we discussed earlier (see page 319), the brain and central nervous system will run on ketone bodies, converted from dietary fat and from the fatty acids released by the adipose tissue; on glycerol, also released from the fat tissue with the breakdown of triglycerides into free fatty acids; and on glucose,  converted from the protein in the diet. Since a carbohydrate-restricted diet, unrestricted in calories, will, by definition, include considerable fat and protein, there will be no shortage of fuel for the brain.  Indeed, this is likely to be the fuel mixture that our brains evolved to use, and our brains seem to run more efficiently on this fuel mixture than they do on glucose alone.  (A good discussion of the rationale for a minimal amount of carbohydrates in the diet can be found in the 2002 Institute of Medicine [IOM] report, Dietary Reference Intakes.  The IOM sets an "estimated average requirement" of a hundred grams of carbohydrates a day for adults, so that the brain can run exclusively on glucose "without having to rely on a partial replacement of glucose by [ketone bodies]."  It then sets the "recommended dietary allowance": at 130 grams to allow margin for error.  But the IOM report also acknowledges that the brain will be fine without these carbohydrates, because it runs perfectly well on ketone bodies, glycerol, and the protein-derived glucose.)" [p. 456]

The Better Baby Book by Lana Asprey, MD, and Dave Asprey recommends carb intake of about 50 grams per day.  They point out that fructose lowers insulin sensitivity, so it may be even more harmful than glucose.  They have a lovely "food pyramid" and "food plate" that mostly eliminate carbs.  Coming down from the top of the pyramid, they recommend: 1-2 servings of low-sugar fruit; 4-6 servings of animal protein, 5-9 servings of healthy fats, and 6-11 servings of healthy vegetables, i.e. non-starchy, not potatoes, legumes or roots.  This is the best-researched book about prenatal nutrition that I've ever seen and well worth reading for both midwives and pregnant mamas.

Chris Kresser (the Paleo educator) has a relevant web page written by a guest author.

She reports, "The Institute of Medicine recommends a minimum of 175 grams of carbohydrates per day during pregnancy . . .".  Her primary concern seems to be that cutting back on carbs can result in eating too much protein.  In my experience, it's very rare for a pregnant woman to be eating too much protein, since we recommend at least 100 grams daily for a normal pregnancy.  And all it takes is some education to help women learn how to shift calorie intake from carbohydrates to healthy fats.

The addition of coconut oil or (better) Upgraded MCT oil is sure to create ketones in the urine which are not the same as nutritional ketosis. Most common beliefs about nutrition assume that ketosis is always from fasting/burning body fat, not from dietary sources. 15% of coconut oil converts to ketones. Of that 15%, 11% converts with some difficulty, and 4% converts very well.  [from Dave Asprey, co-author of The Better Baby Book.]

Dr Mercola has an interesting article about the benefits of a ketogenic diet.

I am wondering if any of you might have reliable information to the safety of women continuing with a ketogenic diet after conception.  One of my clients has a BMI over 40; she started a ketogenic diet a few months ago and is losing about 2# a week on it.  She is healthy and energetic.  She hopes to continue to lose weight through her pregnancy, or at least not to gain (much).   She recognizes that she may need to 'tweak' the diet to ensure the baby is getting what it needs, but would prefer not to go off it or vary it too much.

I did some limited research and found the following article about a study on mice.
The article indicates that a ketogenic diet may have negative influences on fetal development.
The woman has done her own research and feels that most of the criticism of ketogenic diet is based on misperceptions of what it does and how it works.  I confess to not having enough of an understanding of it to be able to advise her.

Any comments or pointers to sources of further information on KG diet and how it could or should be 'tweaked' in pregnancy would be much appreciated!

Ketogenic Diet Plan is advised as a resource on the Ketogenic Diet by Dr. Dominic D’Agostino, an Assistant Professor in the Department of Molecular Pharmacology and Physiology at the University of South Florida Morsani College of Medicine, and a Senior Research Scientist at the Institute for Human and Machine Cognition (IHMC).  
The author of this website has a list of contraindications for doing the ketogenic diet and Pregnancy is on there, not sure what that's based on, however.

The Institute of Medicine Guidelines that suggest obese women should gain 11 - 20 pounds in pregnancy are not evidence-based. To the contrary. Obese women who gain no weight or lose a modest amount of weight in pregnancy have a lower incidence of gestational diabetes, gestational hypertension, fetal macrosomia, and operative delivery. As expected with an overall shift of the fetal growth curve to the left, they experience a small increase in likelihood of an SGA infant - however still well below the 10% expected to be below the 10th percentile in a "normal" population.

We universally recommend no weight gain in pregnancy for women with a BMI over 30. Modest weight loss is acceptable in women with a BMI over 35. In order to do this, women must catabolize a considerable amount of their fat reserves - a process accompanied by nutrititional or "starvation" ketosois. This process is completely different than diabetic ketoacidosis. For thousands of years, many human populations have survived and thrived on fat, meat, and raw plant-based diets with little carbohydrate. Fatty acids and ketones are part of the nutritional currency of human metabolism - readily used by mother and fetus. A problem arises, however, when well-intentioned caregivers notice ketonuria (sometimes +4), panic, and tell a mother to snack or eat sugar to suppress the ketones.

As the author of the website below correctly notes:

"...most doctors get very little training on nutrition and don't understand the general effect of foods on the body. They are also taught that ketosis is dangerous, and so they know even less about ketogenic diets. Hence, if you ask your physician about this diet, you may get push back and a scary "ketosis-is-dangerous" sermon. Keep in mind that the doctor is getting nutritional ketosis confused with a much more dangerous condition called ketoacidosis. These are two different conditions."

Even among healthy, non-diabetic mothers, an isocaloric low-glycemic diet results in a fetus that is healthy, but several hundred grams lighter than women with a normal North American Diet (Clapp). The probable explanation is that the area under the blood glucose curve is what determines fetal adiposity: i.e. an average maternal blood glucose of 4.5 leads to a leaner baby than one of 5.5 even though both are non-diabetic.  If a mother is not metabolizing carbohydrate, she is burning fat, and ketones are a result. Far from being worried about ketonuria in obese women who are not type 1 diabetics, we applaud them - they are doing exactly what we want them to do --> eating few enough calories that they are metabolizing their fat reserves. That said, it is important to ensure that obese women who are restricting caloric intake get enough calciium, vitamin D, iron, fiber, and protein. They do not need many calories from carbohydrate or fat as they have plenty in reserve.

Appended is our Diabetes and Obesity in Pregnancy guideline for reference. The logistics are specific to Yellowknife, but you may find the clinical guidance helpful. It is likely significantly different that what is being done in most centers.

 We also use metformin universally as first agent for GDM, but that is another debate.

References are at the bottom of the document.

Glucometer Values

So, I'm a bit confused at all the varying values available for pregnant women in regards to blood glucose. I have a client who feels she has blood sugar issues (last baby was 10#2), and after careful discussion, has opted to go with using a glucometer to check her values fasting and two hour postprandial. While I feel that she could easily birth another large baby, we do have concerns about wildly fluctuating blood sugar levels (if this is the case for her) and the effect it has on baby.

My question is this: I have about three different sets of values that are supposedly for pregnant women - from the ADA to the WHO. In addition, when I consulted Anne Frye's Diagnostic text, there are two that make sense to me, but they vary greatly in values.

Some of the confusion could be because the blood sugar values/number differ by about 15% between glucometer (capillary glucose) and the testing they do when they draw blood from the arm and analyze it in the lab.  Also, some places measure it in mmols, which is different than the mg/dl that I am more used to.

When I have a lady test her sugar with a glucometer, I use the same values they would use if they actually were GDM and monitoring their blood sugar.  There is still some variance in the recommended values, but it's not huge.  The fasting value for that is less than 95-105 (depending on whose standard you use; ACOG says 100); 1 hour after a meal should be less than 140, and 2 hours should be less than 120-130.  Most glucometers are not especially reliable (see article in a recent Consumer Reports), so I have them check one of each of those values for 2 days, and figure if they all come out ok, the odds are pretty good that their sugars run WNL.

The folks that make the Hemocue for hgb measurements also make a similar machine for measuring glucose which has FDA approval as being as accurate as laboratory measurements.  The catch is that the little plastic cuvettes, that you get the blood in, outdate rapidly, I think within a month of the time the container of 25 is opened, and for most of us, our volume isn't great enough to use that many, and they are expensive.  They are supposed to be working on another machine and packaging with fewer cuvettes for the lower volume user, but it has not yet passed FDA approval.

False Positives on GTT

[from ob-gyn-l]

Was one of the values on the GTT abnormal??? Langer has shown that people with one abn value on the 3 hr GTT who are called normal and not treated, have a higher incidence of fetal macrosomia than do Gestational diabetics who are treated. He recommends starting these people on a diabetic diet. As far as I know, nobody else agrees with him.

Even according to ACOG or ADA there should be 2 values  off on the 3 hour GTT. in order to Dx GDM anyway. The rise of the SECOND IS NO WAY AN INDICATION OF GDM..

In our practice we take care of many international students and faculty. We've been observing an interesting trend among our Japanese women. Surprisingly large numbers of these healthy, thin, young women with outstanding low-sugar/low-fat diets have abnormal glucose screening and then have a single elevated value on their 3 hour GTTs. The babies are normal sized. Frequently maternal weight gain in pregnancy is low by our standards, despite our exhortations for the women to eat more.

Is glucose screening based on American and/or European standards? Is there a different standard for Asian (specifically Japanese) women? Has anyone shown an innate difference in glucose metabolism between these groups or might the very different diet cause a difference in glucose metabolism?

The standards that I am aware of were established on the East coast by O'Sullivan in Boston. I think Langer in San Antonio has his own based on his mainly Hispanic population.

Are you giving your patient a 3 day carbohydrate load preparatory to their GTT ?? If you don't, you will have an increased number of false positives. Especially in patients who are on the type of diet you describe.

Yes, we give a handout with the 3 day carbohydrate load and instruct all women with abnormal glucose screening to follow that diet prior to their GTT. I'm not sure the women in question actually adhere to the diet, though. Their eyes kind of glaze over when they read it and they clearly think that we're asking them to add an enormous quantity of food -- more than many of them believe they can eat.

There is no such thing as GD. When we are looking for sugar we are looking for the women who have overt diabetes. They say there is no sense in doing urinalysis for sugar. Are they going to change what they check for in their clinics? NO!! Are they going to have us stop checking for sugar?? NO!!!

But I particularly like the following line: "As no benefit has yet been established for glucose screening during pregnancy, the method used for this screening is irrelevant" GECPC pg 59)( and I always feel a bit like giggling, because it's really a cute way of saying it)

The research on this topic has shown no different outcomes, regardless of treatment. Also, GD is poorly defined, as it is normal for Blood sugar values to rise during pregnancy, so a woman may test ok in early preg, and have high values later, be diagnosed with GD, even though she has had a normal rise in BS.!!!

We have decided no routine testing, (it just makes the labs rich, and doesn't help our clients at all). We would drop urine testing for glucose except its a community standard, so that's a hard one.

If mum spills sugar there, we do a fasting ac and 2 hour pc sugar, and consult. Haven't decided if there is any other time we would test. Probably previous GD, more for our protection than anything else.

This is my protocol for testing for diabetes.

No risk factors- no testing. Risk factors would include previous GDM, sister or mother with GDM, glucose and/or ketones in urine sample.

If a test is indicated I do a 1 and 2 hour PP in my office. I have the client eat a "normal" meal (including a protein source, a vegetable, a fruit and a complex carbo) an hour before her appointment. I stick her finger as soon as her appointment starts and an hour later. If these results are within normal range (<140) I do nothing more unless the mother wants more testing, if the results are borderline (140-160) I do another 1 and 2 hour PP test in my office at her next appointment, if the results are under 160 I discuss having a 2 hour glucose challenge done or I will teach her how to do her own checks at home for a few weeks with instructions to call me if any of her results go over 160. If the results of the 1and 2 hour PP are high (>160) I suggest she have a 2 hour glucose test at the lab. If this test comes in high, I have her make an appointment with my back-up doctor. The few times this had happened he has retested them and advised them to "eat better" and to call him if a problem comes up......so far none of my clients have needed insulin to control her high blood glucose levels.

Some of the hospitals in our city have diabetes classes that teach people how to do their own tests and how to eat properly. If my client can keep her levels normal and no other signs of problems arise, we continue with the home birth plans. If she is unable or unwilling to get this under control, I will transfer her care to a doctor. Period.

I would not consider mother or sister of GDM a risk factor, since I think the vast overdiagnosis makes it worthless[Grin] . I would of course consider DM a risk factor if in close family -- or appearing under age 60.

I would probably not test for only one spill of glucose either -- unless it was accompanied by ketones (then I want a full test!). Repeated glucose in the mom who is not gaining - - test! Glucose and ketones-- test today! Mom who is not gaining in spite of good diet -- or who has repeated ketones -- test! Any mom with symptoms of diabetes (thirst, frequent urination, hunger, fatigue, poor weight gain or weight loss) -- TEST  [Ed: NOTE - Ketones are relevant to diabetes only for Type I diabetes where there is absolutely no insulin available in the blood stream.]

I'm more concerned about hidden DIABETES in pregnancy than in simple "glucose intolerance of pregnancy" which is what our American definition of GD is all about anyway....

If I'm getting a blood sample anyway, I will run a random glucose on it (if mom has enough money for it[Grin]). It might tell you something -- if mom really has diabetes; it probably WILL tell you something....

If I'm worried about a mom, then I like the two hour postprandial, best!

I have had several women in the past who have had huge amounts of glucose in their urine (as in off the pee strip chart), but every glucose test comes back normal (or even low sometimes). These women have had super fast labors (the word precipitous works!), big babies and no problems at all! Anyone else see this?

yeah..... I guess by definition they might have GD, but I don't care (about the definition[Grin]). The only risk associated with low renal threshold/ glucose intolerance/GD is a big baby.. nothing else... Big baby/no problem -- I can live with that, nicely!

One of my clients always has +glucose. Is there something in her diet that could be causing it even if she's not eating any sugars? I've heard vitamin C can cause false +, but she's not taking any. Any ideas?

If you test her ascorbic acid and it comes out high, it could be a false positive from vitamin C, or possibly some kind of juice she's drinking.

Speaking from experience, some of us just have kidneys that filter sugar back into the blood less efficiently during pregnancy. In both of my pregnancies, I had amazingly colorful urine dipsticks - the glucose could go out of sight after a bowl of cornflakes and milk. But my blood glucose was always okay, and I have 8 pound kids. I guess I wouldn't worry about it. I didn't even bother changing my diet, nor would I advise clients to unless the blood glucose was also high or their diet was bad anyway.

I have a 39 yo G 2 P1 now at 36 wks who has been spilling glucose in her urine since 31 wks. Her 1 hr/50 gm glucola was 108. She tends towards hypoglycemia. She's been working on her diet- eliminating all refined carbos, eating 125 gms protein a day, and small frequent meals- but still gets between trace and +2 glucose on her urine dip every time.

The only significant med hx is that she's on a small dose of Synthroid, .112 mg a day. She has been thyroid tested twice this pregnancy and levels were all normal.

Just suggestions --

1: perhaps a three hour test??? (I hear rumors that sometimes a true diabetic can pass the one hour test, and if we are still suspicious then we should go for a three hour will show what's going on).

2: try cutting down on the protein to perhaps 80 (certainly adequate!) - - for a week and see what happens. She may be consuming far more calories than she needs. And does "eliminating refined carbohydrates" mean that she is still using honey, syrups, corn sugars etc? ASK ABOUT JUICE OR SOFT DRINKS -- fruit juices contain a LOT of sugar!

3: Postprandials? maybe running a few be more valuable than GTTs.

4: Evaluation by ophthalmologist for "sparkles"??

5: perhaps the Synthroid is the culprit. Why is she taking it? (was there a distinct need?)

Some women just spill glucose -- no problem for them. It's important to rule out other conditions though before we conclude that she is "just one of those women". I usually don't worry much about women who spill a trace or +1 from time to time -- but this woman who seems to do it everytime up to +2 would concern me some.

I had heard somewhere that women who work too hard can have a problem with their kidneys being overtaxed and thus not able to filter all of the sugar out of their urine.

I only test moms with risk factors, and then we start with a one hour challenge. We do a 3 hour only if necessary.

Chromium works great for borderlines.

We offer 1 hour, nonfasting 50 gram screens to all women. We do not do FBS, with the rationale that with gestational diabetes, FBS would not be elevated anyway.I know this is controversial. I think our midwives have made significant inroads in the past years in rx of GD. In the past, most of the women with abnormal 3hour GTTs were referred to an endocrinologist, and most were put on insulin. With greater emphasis on evidence based practice and the GECPC book, the midwives have become more assertive, rarely refer to endocrinologist for GD, put women on ADA diet and things are just fine.

I think the issue is maternal weight, anyway. i.e. heavier women are far more likely to have macrosomic infants and heavier women are more likely to have abnormal 3hour GTTs.

[from ob-gyn-l]

I work in a not for profit HMO situation as a CNM, we have a group of physicians who are very involved in evidenced based medicine (none of whom do OB) and are looking at many of the "standard of care" and "routines" that are done in our setting and have recently looked at screening for GDM (gestational diabetes mellitus) and have come to the conclusion that routine screening is not beneficial or cost effective, that no reliable evidence exists that GDM screening prevents macrosomia, and that no randomized trials of screening have been published. They did mention an article by Santini in the Surg Gynecol Obstet 1990;170:427-436 that determined that "the process of screening not only failed to decrease the rate of large infants, but also failed to improve otherwise pregnancy outcomes and was associated with more intensive surveillance during pregnancy and a significantly higher rate of primary cesarean delivery." What thoughts do any of you have on this subject?

I have not reviewed the literature on this topic for several years. The following is my opinion.

I believe some years ago a study showed that the majority of women who develop GDM do not have risk factors (family history, prior pregnancy with large baby, etc.) suggesting that they are at risk for GDM. Thus, in order to identify GDM you must screen for it. Using the 3 hour GTT is not cost effective and puts patients through an unpleasant testing procedure.

The 50 g. glucose screen was "invented" as a screening test to determine who should be subjected to the 3 hour GTT. A normal screen test implies that the 3 hour GTT will be normal and that the patient is at extremely low risk for GDM. An abnormal (elevated) 50 g. screening test means that the patient may have an abnormal GTT and is at increased risk for GDM. Thus, further testing is indicated to exclude GDM.

I see the glucose screening test in the same light as the MS-AFP. They indicate if further testing is indicated or not indicated.

You can not relate the screening test to the development of a macrosomic baby nor any other problem associated with GDM, but only to the probability that a pregnant lady will have or not have an abnormal GTT.

Whether or not a pregnancy with an abnormal GTT will have problems is another story.

Ill Effects from Glucola

I have a heart problem that was incredibly exacerbated by my last pregnancy...of course nobody wanted to believe it was my heart (I'm too young, and I'm a woman, so naturally there can't be a problem with my HEART!!), and they scheduled me for a GTT just to see if there was a problem there.  (I should have said no as soon as I heard it was "just to rule out this and that," but I was at my wit's end!)   Gawd, it was horrible!   I could barely stand about twenty minutes after drinking that garbage, was sweating and about to throw up.  When I approached the nurse to ask for help, she said, "Oh, you're doing great, we have lots of women pass out by now."

And this is a "routine" test!!

One of my clients had a two-day migraine from the Glucola.

Home Glucose Monitoring During Pregnancy

Many midwives consider home glucose monitoring to be more useful than the gestational diabetes screen.

David Mendosa has some good information about When to Test — And Why: "The exception, according to the ADA, is women who have diabetes and are pregnant. They could benefit more from testing one hour after eating."  This is for women who are not using insulin.

He also has a nice article about the Dawn Phenomenon - That’s when fasting blood glucose readings in the morning are higher than the previous bedtime.  Some women will have an elevated "fasting" glucose if they wait too long.  The liver can start to secrete glucose as adrenaline rises in the morning.

Diabetes Insurance Reimbursement - Resources & Information

Providing Diabetes Health Coverage: State Laws & Programs - Detailed list of laws for coverage of diabetes-related supplies in different states.

Most useful relevant insurance codes from the HCPCS Level II Code Set:


E0607 - Blood glucose monitor home - HOME BLOOD GLUCOSE MONITOR (Glucose Meter)

A4253 - Blood glucose/reagent strips (50) - BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS (Glucose Test Strips)

A4256 - Calibrator solution/chips - NORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPS (Control Solution)

A4258 - Lancet device each - SPRING-POWERED DEVICE FOR LANCET, EACH (Lancet Device)

A4259 - Lancets per box - LANCETS, PER BOX OF 100 (Lancets)

Relevant diagnoses:

648.81 - Abnormal glucose tolerance of mother, delivered, with or without mention of antepartum condition (related care during labor/birth/immediate postpartum)
648.82 - Abnormal glucose tolerance of mother, delivered, with mention of postpartum complication (related care during immediate postpartum)
648.83 - Abnormal glucose tolerance of mother, antepartum condition or complication (antepartum)

V12.21 - Personal history of gestational diabetes (for inter-pregnancy monitoring if no other suspicions)

Interventions for pregnant women with hyperglycaemia not meeting gestational diabetes and type 2 diabetes diagnostic criteria.
Cochrane Database Syst Rev.  2012; 1:CD009037 (ISSN: 1469-493X)

AUTHORS' CONCLUSIONS: This review found interventions including providing dietary advice and blood glucose level monitoring for women with pregnancy hyperglycaemia not meeting GDM and T2DM diagnostic criteria helped reduce the number of macrosomic and LGA babies without increasing caesarean section and operative vaginal birth rates.

Checking Your Blood Glucose - they have a nice Blood Glucose Journal.  Pregnant women might do better to check their blood sugar an hour after a meal; this really means about an hour and ten minutes after you really start eating.

Counterpoint: Glucose Monitoring in Gestational Diabetes - Lots of heat, not much light by Thomas A. Buchanan, MD and Siri L. Kjos, MD
In many respects, ongoing debates about the nuances of glucose monitoring for patients with gestational diabetes mellitus (GDM) are analogous to those past debates about dancing angels. The debates are heated, they are focused on very small nuances in the management of GDM that have minor if any impact on the outcomes of pregnancies complicated by GDM, and they are generally unencumbered by hard facts. While generating considerable heat, the debates shed very little real light on optimization of perinatal outcomes in pregnancies complicated by GDM.

Choosing a blood glucose meter

Gentle Testing for Diabetes - Genteel offers a new lancing device that finally lets people with diabetes check blood sugar levels without pain. David Mendosa tested it and says it works. Personally, I find the AccuChek lancets work fine for me.  But someone who is needlephobic might appreciate this extra level of comfort!

The Most Accurate Blood Glucose Meter [3/16/16] - David Mendosa's web pages are full of very helpful information.
As of May, 2012, David Mendosa recommends this new meter: The Nova Max Plus Meter

System accuracy evaluation of 43 blood glucose monitoring systems for self-monitoring of blood glucose according to DIN EN ISO 15197. [free full text]
Freckmann G1, Schmid C, Baumstark A, Pleus S, Link M, Haug C.
J Diabetes Sci Technol. 2012 Sep 1;6(5):1060-75.

Different meters require different amounts of blood, so if you're a petite person, you might be much happier with a model requiring less blood.  Here's a table that gives information about some meters:

2011 Diabetes Forecast Consumer Guide - Blood Glucose Meters

And Consumer Reports has a comparison and ratings (including accuracy and repeatability) from October, 2011.

As of Feb., 2012, I'm finding that the Accu-Chek Aviva System is the most accurate of the non-professional glucose meters.  Although this home glucose monitor tests whole blood, the results are given in plasma numbers for easier comparison with lab results.

In general, the meters themselves tend to be inexpensive because everyone wants you to buy theirs!  They make the money on the test strips, which can be quite expensive.

Some nice web sites try to keep tabs on where you can save money buying the test strips:

Accu-Chek has a program that allows you to subscribe to regular deliveries of test strips at a significantly reduced price.  (It's around $50/month for 100 strips, and their expiration dates are about a year out!  I've found comparable or even slightly better prices on Amazon, but there's added security in buying directly from Accu-Chek.)

Diabetic Test Strips - The Best Bargains and Discounts on Diabetes Glucometer Test Strips from diabeteswellbeing.com

Drug interactions (Supplements, too) - New meters from the leading manufacturers don’t interact with “the most dangerous substance,” icodextrin, used in some peritoneal dialysis fluids. But a D-xylose absorption test can affect any of them. High tolazamide, uric acid, or pralidoxime can affect LifeScan meters. High triglycerides, galactose, or ascorbic acid can affect Roche meters. High triglyceride or cholesterol can affect Ascensia meters. [Ed: My first recommendation for a glucose meter is the Accu-Chek Aviva, which is made by Roche.  Those readings can be changed by high levels of ascorbic acid in the blood.]

High Fasting Glucose with Low Postprandial Glucose

Some women experience the dawn phenomenon; in brief, this is when rising adrenaline levels mobilize glucose before the woman wakes.  Thus her "fasting" number is higher than her glucose was some time before she started to wake.  These women may have beautiful postprandial numbers, and it's very frustrating for them that their fasting numbers don't reflect their excellent diet/exercise program and low postprandial numbers. Here's the best information I've found about the dawn phenomenon.

When we're testing for a fasting glucose, we're really trying to identify the lowest number of the day.  For some women, they will have another low point around 5 in the afternoon.  Have them avoid eating for a few hours beforehand, and then check their glucose around 5 pm.  If it's lower than their fasting glucose number, then you know you're dealing with the dawn phenomenon.  So you can ignore their fasting numbers and instead use a number taken when they're awake and they're glucose is lowest.

Newborn Treatments for Maternal Gestational Diabetes

See also: Newborn Hypoglycemia

It is important that you ask your care provider how the baby will be treated differently because of a diagnoses of gestational diabetes in the mother.  Will the baby routinely be taken to the nursery?  Will the baby's heel be stuck with a lancet to collect blood to check glucose levels after the birth?  How often will this be done?  If the baby's blood sugar is low, will the nurses emphasize breastfeeding as the best treatment, or will they recommend glucose water instead?  If glucose water is given to the baby, can it be given in a sippy cup or with an SNS system so that the baby does not have to suck on a bottle and be vulnerable to nipple confusion when breastfeeding?

Diabetic moms' babies may have weak sucking reflex - Insulin May Cause Immature sucking patterns

"Immature sucking patterns are often seen in infants whose mothers developed diabetes during pregnancy and had to be treated with insulin, new research indicates. On the other hand, babies of mothers with diabetes that was managed with a careful diet do not seem to have impaired sucking reflexes.

"The findings suggest that the nervous system of newborns of insulin-treated diabetic mothers is less mature than that of babies born to healthy mothers, the researchers say. Diet-managed diabetes is a milder condition than insulin-managed diabetes and, therefore, the impact on sucking behavior is probably smaller, they add."

Breastfeeding Implications of Gestational Diabetes

Breastfeeding After Gestational Diabetes Pregnancy - Subsequent obesity and type 2 diabetes in women and their offspring

Whether breastfeeding affects the future health of offspring of women with GDM is uncertain based on limited and conflicting findings from studies of Native Americans or women with diabetes during pregnancy. Furthermore, no studies that examined the relation of breastfeeding to development of obesity and diabetes in the offspring of women with GDM have controlled for the intrauterine metabolic environment.

Lactation may also confer health benefits to women with a history of GDM. Lactation improves glucose tolerance in the early postpartum period, but it is unclear whether future risk of type 2 diabetes is reduced.

Postpartum Followup for Maternal Gestational Diabetes

A1C Testing Often Fails to Spot Postpartum Diabetes [Medscape, 7/12] - Hemoglobin A1C isn't reliable for assessing postpartum women who've had gestational diabetes mellitus (GDM), Spanish researchers say. This is true whether it's used alone or with a fasting glucose test, they say in a June 11 online paper in Diabetes Care.

Triad of Factors Ups Risk for Type 2 Diabetes [3/27/15] - Among women who had gestational diabetes, those who had a body mass index of 30 kg/m2 or higher before they became pregnant and then gained 5 kg  or more after giving birth were 43 times more likely to develop type 2 diabetes than women who had a BMI of less than 25 kg/m2 prior to pregnancy and who gained less than 5 kg in the years that followed.

This white paper says that fasting glucose is adequate, and that an OGTT is overly burdensome for a new mother, who is hopefully breastfeeding a dependent infant.  I would add that lactation is also an altered metabolic state and not an accurate reflection of the woman's non-lactating future.  (At a diabetes seminar I attended, the instructor referred to the fetus/newborn/infant as a "glucose siphon".)

It makes sense to use the less burdensome fasting glucose as a postpartum check, followed by annual assessments as recommended in this paper.  I would add that an OGTT would be a very sensible assessment of the woman's overall glucose metabolism some months after she has weaned, assuming she is not pregnant again.

Fasting glucose in the post-natal period
 Richard IG Holt, Matthew AG Coleman2

"It seems anomalous to insist on an OGTT in the postnatal period at a time which is probably the most inconvenient for the woman"

ACOG Committee Opinion No. 435: postpartum screening for abnormal glucose tolerance in women who had gestational diabetes mellitus.

Obstet Gynecol. 2009 Jun;113(6):1419-21.

Establishing the diagnosis of gestational diabetes mellitus offers an opportunity not only to improve pregnancy outcome, but also to decrease risk factors associated with the subsequent development of type 2 diabetes. The American College of Obstetricians and Gynecologists' Committee on Obstetric Practice recommends that all women with gestational diabetes mellitus be screened at 6-12 weeks postpartum and managed appropriately.

A1c May Not Accurately Reflect Postpartum Glucose - "A1c tests are easy to use after delivery for a diabetes screening test, but clinicians should be aware that they do not match up well with glucose in this time period when iron stores tend to be low and women's hemoglobin levels are in flux,"

Effects on Children

Related Articles

Maternal lifestyle characteristics during pregnancy, and the risk of obesity in the offspring: a study of 5,125 children. [Free full text article.]
Mourtakos SP1, Tambalis KD2,3, Panagiotakos DB4, Antonogeorgos G5, Arnaoutis G6, Karteroliotis K7, Sidossis LS8,9.
BMC Pregnancy Childbirth. 2015 Mar 21;15:66. doi: 10.1186/s12884-015-0498-z.

CONCLUSION: GWG (gestational weight gain), physical activity and smoking status during pregnancy were significantly associated with obesity for the offspring at the age of 8. Health care professionals should strongly advise women to not smoke and to perform moderate exercise during pregnancy to prevent obesity in the offspring in later life.


I have a friend who took cinnamon to lower her blood sugar levels - she was actually on insulin for her gestational diabetes but was unhappy to have to keep upping the dose.  She found that cinnamon measurably reduced her blood sugars but not to unsafe low levels.  There is some actual objective research on cinnamon.

1/4 tsp 2 to 3 times daily - in food if possible (like on oatmeal) .  Just plain old cinnamon powder.

Do Diet Drinks Mess Up Metabolisms?  - A multi-ethnic , which included some 5,000 men and women, found that diet soda consumption was linked to a significantly increased risk of both type-2 diabetes and metabolic syndrome.  [Although they weren't specifically looking at gestational diabetes, there is an obvious correlation with other insulin disorders.]

Taking apple cider vinegar is also supposed to help lower blood sugars.  It's worth trying anyway.

Make sure you have enough iron. Iron raises the red blood cell count and that helps lower the blood-sugar too. Other than that the only "natural" things that really help are no stress and enough sleep.

Vitamin and mineral deficiencies which may predispose to glucose intolerance of pregnancy.
Jovanovic-Peterson L, Peterson CM.
J Am Coll Nutr. 1996 Feb;15(1):14-20.

"Specific nutrient deficiencies of chromium, magnesium, potassium and pyridoxine may potentiate the tendency towards hyperglycemia in gestational diabetic women because each of these four deficiencies causes impairment of pancreatic insulin production."

Higher magnesium intake reduces risk of impaired glucose and insulin metabolism, and progression from prediabetes to diabetes in middle-aged Americans.
Hruby A, Meigs JB, O'Donnell CJ, Jacques PF, McKeown NM.
Diabetes Care. 2013 Oct 2. [Epub ahead of print]

Higher magnesium intake tended to associate with lower follow-up fasting glucose and IR, but not fasting insulin, postload values, or insulin sensitivity.

Cut Your Diabetes Risk in Half - German scientists discovered that magnesium supplementation improves the body’s sensitivity to insulin and significantly reduces the risk of developing Type 2 diabetes.

Any pregnant woman will benefit from the recommendations given to women who test positive for "gestational diabetes": good nutrition and regular, moderate exercise.  Here are some nutrition recommendations.

Diet & Weight Gain

My labor coach client, diagnosed with GD, told me that her nutritionist recommended she have no more than 1 oz/hr of Gatorade during labor.

Here are some rambling thoughts about gestational diabetes.  I've noticed that women with undiagnosed GD tend to have a lot more amniotic fluid in the last weeks and to go post-term.  (Both the GD and the degree of the baby's being post-term can be assessed after the birth, when we can look at the baby and notice the rolls of fat and the edema and the advanced gestational age assessment.)  I find myself wondering if the increased blood sugar causes the mom's body to retain fluids in an effort to dilute the blood sugar and if this contributes to the increased amniotic fluid.  I also wonder if the higher levels of blood sugar are somehow a kind of preservative that keep the cervix from ripening properly in the last weeks of pregnancy.  The high levels of amniotic fluid can also keep the baby "floating"off the cervix, which further delays the onset of labor.  All of these are going to lead to a larger baby with a hardened head.  No wonder OBs want to induce early for GD!  In theory, good control of blood sugars should prevent these problems.

Has anyone been giving B6 100mg with meals to lower blood sugar?  I have used this experimentally on patients with type 2 DM and have found a blood glucose drop of 25 from their previous averages.  {The original research for the use of B6 was for use in GDM and Glucose intolerance in pregnant women}

Gestational diabetes and cardiovascular risk factors in the offspring: results from a cross-sectional study.
Beyerlein A, Nehring I, Rosario AS, von Kries R.
Diabet Med. 2012 Mar;29(3):378-84. doi: 10.1111/j.1464-5491.2011.03454.x.

CONCLUSION: Gestational diabetes mellitus does not appear to have a relevant effect on cardiovascular disease correlates such as blood pressure or cholesterol levels in children, and the potential effect of gestational diabetes mellitus on body composition seems to be widely explainable by maternal BMI.

In PCOS, Glucose Impairment More Likely to Persist After Gestational Diabetes [Medscape 3/22/12]


I am also hypoglycemic, even when not pregnant.  Pregnancy makes it much worse and the symptoms of it too.  It was noticeable in my pregnancies with my other 4 children.  I am pregnant with twins now and boy the hypoglycemia is really bad.  I have to be very aware of eating.  I need to eat every hour.  I get moody and the worst part is I can get VERY ANGRY.  I found protein was a real key.  I normally don't eat meat, but the legumes and tofu just aren't cutting it right now.  We have chicken and fish at least twice a week now and a have almond butter a couple of times a day at least.  I added flax seed oil to my diet and noticed that really helped too. Oh yes, stay away from sugar!!!

Multiparity Trap

I was chatting with a very experienced L&D nurse, and she told me about the multiparity trap.  This is a situation where you just assume that because a mom has had at least one previous uncomplicated pregnancy and birth, you assume the current one will be fine.  But for some women, their babies get bigger with each pregnancy.  This used to be considered sort of normal, but in hindsight, I think we can guess that it's really because the woman becomes more intolerant of carbohydrates with each successive pregnancy.  At some point, her babies get too big for her, and she ends up with a c-section, which is kind of a shock to everyone!

Test Your Knowledge: Medical Remedies From 1919 [Medscapee, 9/9/14] - In the early 20th century, adequate rest, relaxation, and moderate exercise were considered important to a healthy pregnancy; although more vigorous exercise is now considered safe in pregnancy, the earlier guidance seems reasonable.  . . . For dinner, it was thought that pregnant women should have a "light" meal, consisting of poultry, sweetbreads, or tripe. [Ed: This recommendation would help to keep fasting blood sugars in the safe zone.]


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