What is Gestational Diabetes?

Gestational diabetes was first noted in 1824 by Bennewitz in Germany. It is a temporary but serious condition that develops during pregnancy, affecting how the body processes sugar. Unlike other types of diabetes, it usually goes away after childbirth, but it requires careful management to protect both the mother and baby’s health.

Understanding the signs, causes, and ways to prevent gestational diabetes can help expectant mothers take proactive steps for a healthier pregnancy.

Key Takeaways

• • Gestational diabetes is caused by pregnancy-related insulin resistance.

• • GDM is a common pregnancy complication. It affects a significant number of pregnancies worldwide, with prevalence varying due to differences in screening methods.

• • Maternal age, obesity, genetics, and family history of diabetes significantly raise the chances of developing GDM. Lifestyle factors, such as low physical activity, also play a role.

• • Pregnant individuals undergo either a one-step or two-step glucose test between 24 and 28 weeks to determine if they have gestational diabetes.

• • Many women with GDM can control their blood sugar levels by following a structured meal plan and engaging in regular physical activity, reducing the need for medication.

• • If diet and exercise fail to maintain normal blood sugar levels, insulin is the preferred treatment. Some may use oral diabetes medications, though these are less commonly recommended.

• • Poorly managed GDM can lead to complications like macrosomia, preterm birth, neonatal hypoglycemia, and an increased risk of type 2 diabetes for the mother later in life.

• • Women with well-controlled GDM can carry to full term, but those with uncontrolled diabetes may need early delivery to reduce risks for the baby.

What Is Gestational Diabetes Mellitus?

Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy in individuals without a prior history of diabetes. It typically develops around the 24th week of pregnancy (second trimester) due to hormonal changes that affect insulin sensitivity.

GDM is classified into two types based on how it is managed:

• • A1GDM (Diet-Controlled): In this form, blood sugar levels can be kept within a healthy range through dietary changes and lifestyle adjustments alone, without the need for medication.

• • A2GDM (Medication Required): This type requires medication, such as insulin or oral diabetes drugs, to control blood sugar levels effectively.

Is Gestational Diabetes Common?

GDM in pregnancy is a common complication. In 2019, the International Diabetes Federation (IDF) estimated that 1 in 6 live births worldwide were affected by GDM.

More recent research analyzing 1.55 million pregnancies in the United States and Canada found that 6.9% of pregnant women had GDM. However, the reported prevalence varied due to differences in screening and diagnostic methods. One screening approach identified a higher prevalence of GDM (13.7%).

How Does Gestational Diabetes Happen?

Insulin is a hormone that allows glucose (sugar) to enter the body’s cells, where it is used for energy. Without enough insulin, or if the body becomes resistant to insulin, glucose builds up in the bloodstream, leading to high blood sugar levels (hyperglycemia).

Pregnancy Affects Insulin Sensitivity

During pregnancy, the placenta produces hormones like human placental lactogen (hPL) that naturally make the body less responsive to insulin, a condition called insulin resistance. Studies suggest that the body’s cells become 50-60% less responsive to insulin during the third trimester.

As a result, more glucose stays in the mother’s bloodstream. However, this is a normal adaptation because the excess glucose will then cross the placenta and enter the baby’s circulation, where it will serve as the baby’s primary energy source, required for brain development and overall growth.

How the Body Normally Compensates

In a healthy pregnancy, the body counteracts this insulin resistance by:

• • Increasing insulin production, producing 2 to 3 times more insulin than usual.

• • Promoting the growth of beta-cells, which are responsible for insulin production. Limited human autopsy studies suggest that beta-cell mass increases by about 40% during pregnancy to meet this increased demand.

However, in some cases, this compensatory process does not function properly. Either the pancreas does not produce enough insulin, or the beta-cells respond too slowly.

When there isn’t enough insulin to regulate blood sugar levels effectively, excess glucose accumulates in the bloodstream, causing blood sugar levels to rise too high.

Why Do People Get Gestational Diabetes?

Researchers have yet to determine the exact cause of gestational diabetes, but several known risk factors can make GDM more likely. These include:

Maternal Age

Data collected from over 120 million participants showed that GDM risk increases with age.

Overweight or Obese (BMI >25, or >23 for Asian Americans)

Each person has a limit for how much fat their body can store safely. Once this limit is exceeded, excess fat gets stored in organs where it shouldn’t be, like the liver and pancreas.

According to studies, when this excess fat reaches the pancreas, it builds up in insulin-producing beta-cells, damaging their function. Experts believe that this beta-cell dysfunction is the primary cause of GDM.

Lack of Physical Activity

Research shows that physical activity helps improve insulin sensitivity in several ways, reducing the risk of diabetes. Additionally, low physical activity during pregnancy increases the chances of other pregnancy complications.

Family History of Diabetes

A family history of diabetes, particularly from the father or mother, is a significant risk factor for GDM. A 2021 study found that women with a diabetic father had a 3.68 times higher risk, while those with a diabetic mother had up to a 4.73 times higher risk.

Similarly, results from another study showed that having a family history of type 2 diabetes increases GDM risk.

• • Women with a first-degree relative with diabetes had 1.91 times higher risk.
  • Women with a second-degree relative with diabetes had a 1.88 times higher risk.
  • Women with both first- and second-degree relatives with diabetes had 2.64 times higher risk.
  • The risk was highest when both parents had diabetes (4.69 times greater).

Genetics

Researchers revealed that specific genetic variations (polymorphisms) affect insulin production, glucose metabolism, and insulin resistance. These include:

• • MTNR1B
  • TCF7L2
  • HKDC1
  • GCKR
  • PPP1R3B
  • IRS1

These genetic factors have been linked to both type 2 diabetes and GDM, indicating that the two conditions may share a common cause.

Ethnicity

Some racial and ethnic groups have higher rates of GDM than others:

Race also influences pregnancy complications related to diabetes. Black women are less likely to have macrosomia (a condition where the baby grows too large) compared to other groups, even when their blood sugar levels are similar.

Hispanic women, however, have higher rates of macrosomia and birth injuries, even when their diabetes is well-managed.

Medical History

Medical history provides important clues about a woman’s metabolic health and insulin function. Several pre-existing conditions and past pregnancy complications are linked to a higher likelihood of developing GDM. These include:

• • Previous gestational diabetes
  • Having a baby weighing more than 4,000 g (8.8 lbs) at birth
  • Heart disease or high blood pressure
  • Low HDL cholesterol (<35 mg/dL) or high triglycerides (>250 mg/dL)
  • Polycystic ovary syndrome (PCOS)
  • Hemoglobin A1C >5.7% (a sign of prediabetes)
  • Abnormal oral glucose tolerance test (OGTT)
  • Signs of insulin resistance (e.g., acanthosis nigricans, a skin condition linked to insulin resistance)

What Are the Symptoms of Gestational Diabetes?

Many individuals with gestational diabetes may not experience noticeable symptoms. However, some potential indicators include:

• • Nausea
  • Fatigue
  • Blurred vision
  • Increased thirst
  • Frequent urination
  • Frequent infections, such as yeast infections

Since these symptoms can be subtle or overlap with normal pregnancy changes, healthcare providers typically conduct tests to diagnose gestational diabetes.

What Test Is Used to Diagnose Gestational Diabetes?

Several laboratory tests and screenings for genetic abnormalities (aneuploidy screening) are done during the second trimester to allow time for necessary interventions.

The American College of Obstetricians and Gynecologists (ACOG) and the US Preventive Services Task Force (USPSTF) recommend that all pregnant individuals be tested for GDM between 24 and 28 weeks of pregnancy. However, the testing methods and cut-off levels used to diagnose GDM may differ among experts.

1. One-Step Glucose Testing

The International Association of Diabetes and Pregnancy Study Groups (IADPSG) and the American Diabetes Association (ADA) recommend a one-step screening method for GDM. The main benefit of this approach is that it screens and diagnoses GDM in a single visit, making the process easier for both patients and doctors.

Test procedure:

• • Fasting is required for 8 to 14 hours before the test, except for small sips of water. Eating is also not allowed during the test.

• • The patient will drink a solution containing 75 grams of glucose.

• • Blood samples will be collected before drinking the solution and then two more times, at 60-minute intervals after consumption.

• • The test takes approximately 2 hours to complete.

Interpreting results:

Gestational diabetes may be diagnosed if one or more of the following values are higher than the cutoff levels:

• • Fasting: greater than or equal to 92 mg/dL (5.1 mmol/L)
  • 1-hour: greater than or equal to 180 mg/dL (10.0 mmol/L)
  • 2-hour: greater than or equal to 153 mg/dL (8.5 mmol/L)

If only one value is high, a healthcare provider may recommend dietary changes and retest later. However, if two or more values are high, the patient will be diagnosed with gestational diabetes.

If all blood sugar levels remain below the abnormal thresholds, then the patient does not have gestational diabetes.

2. Two-Step Glucose Testing

ACOG endorses this screening method to help minimize unnecessary testing and interventions for individuals who do not have gestational diabetes.

Step 1 of the test procedure (50-g glucose screening test):

• • No special preparation or dietary changes are needed.
  • The patient will drink a solution containing 50 grams of glucose.
  • A blood sample will be taken 1 hour later to measure the blood sugar level.

Interpreting results of step 1:

• • If blood sugar is 140 mg/dL (7.8 mmol/L) or lower, the result is normal (no gestational diabetes).

• • If blood sugar exceeds 140 mg/dL (7.8 mmol/L), the patient must take a 3-hour glucose tolerance test for further analysis.

Note that since no single optimal cut-off threshold has been established, different cut-off values are used to determine an abnormal result for the 50-g glucose tolerance screening, including:

• • Greater than or equal to 135 mg/dL (7.5 mmol/L)
  • Greater than or equal to 130 mg/dL (7.22 mmol/L)

For patients with a positive 50-g glucose screening test, a second diagnostic test is required to confirm gestational diabetes.

Step 2 of the test procedure (3-hour glucose tolerance test):

• • Fasting is required for 8 to 14 hours before the test, except for small sips of water. Eating is also not allowed during the test.

• • The patient will drink a solution containing 100 grams of glucose.

• • Blood samples will be collected before drinking the solution and then three more times, at 60-minute intervals after consumption.

• • The test takes about 3 hours to complete.

Interpreting results of step 2:

Gestational diabetes may be diagnosed if two or more of the following values are higher than the cutoff levels:

• • Fasting: greater than or equal to 95 mg/dL (5.3 mmol/L)
  • 1-hour: greater than or equal to 180 mg/dL (10.0 mmol/L)
  • 2-hour: greater than or equal to 155 mg/dL (8.6 mmol/L)
  • 3-hour: greater than or equal to 140 mg/dL (7.8 mmol/L)

If only one value is high, a healthcare provider may recommend dietary changes and retest later. If all blood sugar levels remain below the abnormal thresholds, then the patient does not have gestational diabetes.

What Does Gestational Diabetes Cause?

If not managed properly, gestational diabetes can lead to complications for both the mother and the baby. Potential risks include:

For the Baby

A 2015 peer-reviewed study outlined the possible neonatal complications associated with gestational diabetes:

• • Macrosomia: A newborn with a birth weight of 4,000 g (8.8 lbs) or more. Research indicates that all types of maternal diabetes increase the risk of macrosomia, potentially leading to delivery complications.

• • Shoulder Dystocia: A birth complication that occurs when a baby’s shoulder gets stuck behind the mother’s pelvic bone after the head has already been delivered.

• • Preterm Birth: Birth occurring before 37 weeks of pregnancy, which increases the risk of health complications.

• • Neonatal Hypoglycemia: Low blood sugar levels in newborns.

• • Hypocalcemia: Low calcium levels in newborns, which may cause muscle twitching, irritability, or seizures.

• • Hyperbilirubinemia: Excess bilirubin in the blood, which leads to neonatal jaundice (yellowing of the skin and eyes).

• • Normovolemic Polycythemia: A condition where a newborn has too many red blood cells, increasing blood viscosity and the risk of complications.

• • Myocardial Hypertrophy: Thickening of the heart muscle, which can obstruct blood flow and affect heart function. This condition has been observed in infants born to mothers with both pregestational diabetes and gestational diabetes, with reported occurrence rates ranging from 25% to 75%.

• • Cardiac Malformations: Refers to congenital heart defects that affect the heart’s structure and function, requiring monitoring or surgery. The most frequently reported fetal cardiac defects include:

• • • • • Transposition of the great arteries – Two main arteries that carry blood from the heart are switched in position.

• • • • • Double outlet right ventricle – Misalignment of two main arteries that carry blood from the heart.

• • • • • Truncus arteriosus – Instead of having two separate arteries, a baby is born with one large artery carrying oxygen-rich and oxygen-poor blood.

• • • • • Hypoplastic left heart syndrome – The left side of the heart is underdeveloped, making it too weak to pump blood properly.

• • • • • Ventricular septal defects – A hole in the wall (septum) between the two lower chambers (ventricles) of the heart.

• • Perinatal Asphyxia: Oxygen deprivation before, during, or shortly after birth, which can cause brain damage or organ dysfunction. Macrosomia raises the risk of perinatal asphyxia, particularly in the presence of shoulder dystocia.

• • Brachial Plexus Injuries: Nerve damage in the shoulder or arm, often caused by excessive pulling during delivery, leading to weakness or paralysis. The occurrence of brachial plexus palsy in newborns of diabetic mothers is rare, ranging from 0.2% to 3%. The most frequently reported types are:

• • • • • Erb’s Palsy – The baby’s arm is turned inward at the shoulder, and the wrist is bent.

• • • • • Total Plexus Palsy – The baby’s arm is limp, lacks movement, and has no sensation. The hand may appear claw-like because the fingers stay curled.

• • Poor Suckling: Difficulty latching or feeding, which can lead to poor weight gain and dehydration in newborns.

• • Neonatal Small Left Colon Syndrome: A condition that causes functional lower intestinal obstruction. This condition can resemble Hirschsprung disease, a congenital disorder where nerve cells are missing in parts of the intestine, leading to severe constipation and bowel blockage.

For the Mother

Maternal complications in women with GDM include:

• • Preeclampsia: A pregnancy complication marked by high blood pressure, protein in the urine, and organ damage (often the liver or kidneys).

• • Increased risk of type 2 diabetes: Women who had GDM in a previous pregnancy are 11 times more likely to develop type 2 diabetes later in life compared to women who never had GDM.

• • Higher likelihood of requiring a C-section: This is due to potential delivery complications from macrosomia. In a 2017 study involving patients with GDM, 57.4% had cesarean deliveries.

• • Future gestational diabetes: Women who experience GDM once are at a higher risk in subsequent pregnancies.

• • Urinary Tract Infections (UTIs): Bacterial infections in the urinary system, commonly affecting the bladder (cystitis) or kidneys (pyelonephritis). Symptoms include painful urination, frequent urges to pee, and lower abdominal discomfort.

What Is the Treatment for Gestational Diabetes During Pregnancy?

According to studies, treating GDM can reduce the likelihood of preeclampsia from 18% to 12%. Early intervention also helps prevent progression to type 2 diabetes, lowering the risk by 35% to 40% over 10 years. Additionally, even a small decrease in BMI can reduce the risk of developing diabetes by 25%.

The primary goal is to maintain blood sugar levels within a safe range through the following interventions:

1. Dietary Modifications

The ADA and the ACOG recommend that women with GDM receive nutritional counseling from a registered dietitian. A personalized meal plan should be developed based on the patient’s BMI to ensure proper nutrition while avoiding excessive weight gain.

Dietary recommendations for GDM include:

However, losing weight during pregnancy is not recommended, as it may lead to small-for-gestational-age (SGA) infants. A meta-analysis provided the following recommended weight gain ranges for pregnancy based on pre-pregnancy BMI:

2. Regular Physical Activity

Women with gestational diabetes are advised to do 30 minutes of moderate exercise at least 5 days a week or a total of 150 minutes per week. Exercising after meals (postprandial exercise) is also recommended because it helps control blood sugar levels for up to 3 hours after eating.

3. Blood Sugar Monitoring

Checking blood sugar four times a day is generally recommended, but there is no strict rule on the best frequency. The most common method is:

• • One test in the morning before eating (fasting)
  • One test after each meal (either 1 or 2 hours later)

Some experts suggest monitoring four times a day for two weeks. If blood sugar levels are too high, insulin therapy may be started. If results stay within the normal range, testing may be done less frequently.

The ADA and ACOG recommend the following blood sugar targets:

• • Fasting: Below 95 mg/dL
  • 1 hour after eating: Below 140 mg/dL
  • 2 hours after eating: Below 120 mg/dL

Patients should keep a log of their blood sugar readings and review them with their doctor at weekly prenatal visits or as needed.

4. Medication and Insulin Therapy

If diet and exercise alone do not keep blood sugar levels under control, medication is recommended.

Insulin does not cross the placenta, making it the first-line treatment recommended by the ADA. A typical insulin plan includes both long-acting (basal) and short-acting insulin to control fasting and post-meal blood sugar levels.

Examples of long-acting insulin:

• • Insulin Glargine (Lantus, Basaglar, Toujeo) – Lasts up to 24 hours
  • Insulin Detemir (Levemir) – Lasts 12 to 24 hours
  • Insulin Degludec (Tresiba) – Lasts more than 24 hours (ultra-long-acting)

Examples of short-acting insulin that starts working in 10-30 minutes and peaks in 1-2 hours (rapid-acting insulin):

• • Insulin Lispro (Humalog, Admelog)
  • Insulin Aspart (NovoLog, Fiasp)
  • Insulin Glulisine (Apidra)

Examples of short-acting insulin that starts working in 30-60 minutes and peaks in 2-4 hours (regular short-acting insulin):

• • Humulin R
  • Novolin R

Insulin dosage is based on weight and gestational age and adjusted as needed. The total daily insulin dose is split in half:

• • One-half is given as basal insulin at bedtime.
  • The other half is divided among three meals using rapid-acting or regular insulin before eating.

Some may be unable to use insulin safely or effectively due to various factors. In these cases, oral medications may be considered as an alternative, but only after discussing the potential risks and the lack of long-term safety data for the baby.

Metformin (Glucophage) and glyburide (Diabeta) may be used off-label, but they cross the placenta and reach the baby, so they should not be the first-choice treatments. Other oral and injectable diabetes medications have insufficient safety data for use in pregnancy.

Other Obstetric Considerations for GDM

Due to pregnancy risks associated with GDM, management depends on fetal growth, blood sugar control, and overall health status.

• • • • • Diet-controlled GDM: Delivery is recommended by 40 weeks, 6 days (just before the due date).

• • • • • Medication-controlled GDM: Delivery is recommended between 39 weeks, 0 days and 39 weeks, 6 days (a little earlier than the due date).

• • • • • Uncontrolled GDM: Delivery should happen between 37 weeks, 0 days and 38 weeks, 6 days (about 2 to 3 weeks before the due date).

• • • • • Severe cases (poor fetal health or abnormal monitoring): Earlier delivery may be needed.

Final Thoughts

Gestational diabetes mellitus is a common condition that occurs during pregnancy due to hormonal changes affecting insulin sensitivity. Risk factors include maternal age, obesity, genetics, and family history of diabetes. It is diagnosed through glucose screening tests and, if left unmanaged, can lead to complications like macrosomia, neonatal hypoglycemia, and preeclampsia.

Management includes diet, exercise, blood sugar monitoring, and, if necessary, insulin or medication. Regular prenatal care and monitoring help prevent complications and ensure a healthy pregnancy and delivery.

Explore More on Diabetes!

Want to learn more about different types of diabetes? Check out these in-depth articles:

• • Type 1 Diabetes – Learn how type 1 diabetes develops, its symptoms, and the best ways to manage blood sugar levels with insulin therapy and lifestyle adjustments.

• • Type 3 Diabetes – Discover the emerging research behind type 3 diabetes, its potential link to Alzheimer’s disease, and what scientists say about this debated condition.

Get the facts, stay ahead of the risks, and make informed choices!

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