Today is World Diabetes Day
DIABETES : PROTECT OUR FUTURE
Diabetes is the most common medical complication of pregnancy and it has increased about 40% . The increasing prevalence of Type 2 Diabetes in general and younger people in particular has led to an increasing number of pregnancies with this complication .
Women can be separated into :
– those who were known to have Diabetes before pregnancy – Pregestational or Overt
– those diagnosed during pregnancy – Gestational .
There is keen interest in events that precedes Diabetes which includes the mini environment of the uterus , where it is believed that early imprinting can have effects later in life ( Saudek 2002) . For example in utero exposure to maternal hyperglycemia leads to fetal hyperinsulinemia , causing an increase in fetal fat cells, which leads to obesity and insulin resistance in childhood . This in turn leads to impaired glucose tolerance and Diabetes in adulthood . Thus a cycle of fetal exposure to Diabetes leading to childhood obesity and glucose intolerance is set in motion .
GESTATIONAL DIABETES MELLITUS :
Gestational Diabetes Mellitus is defined as carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy . An alternative explanation is that Gestational Diabetes is Type 2 Diabetes unmasked or discovered during pregnancy .
Risk Factors :
a) Positive family history of Diabetes
b) Having a previous birth of an overweight baby of 4 kg or more
c) Previous stillbirth
d) Unexplained perinatal loss
e) Presence of polyhydramnios ( excessive amniotic fluid ) or recurrent vaginal infection in present pregnancy
f) Persistent glycosuria
g) Age over 30 years
h) Obesity
i) Ethnic groups ( East Asian , Pacific Island)
Screening :
The method employed is by using 50 gm oral glucose challenge test without regard to time of day or last meal , between 24 – 28 weeks of pregnancy . A plasma glucose value of 140 mg percent or that of whole blood of 130 mg percent at 1 hour is considered as cut off point for consideration of a 100 gm ( WHO – 75 gm ) glucose tolerance test .
Complications :
a) Increased perinatal loss is associated with fasting hyperglycemia . Fetal anomalies are not increased due to the absence of metabolic disturbance during organogenesis in early pregnancy.
b) Increased incidence of Macrosomia ( Fetal Macrosomia is defined as infants whose birth weight exceeds 4500 gm) .
c) Polyhydramnios
d) Birth trauma
e) Recurrence of GDM in subsequent pregnancies is about 50 %
OVERT DIABETES :
A patient with symptoms of Diabetes Mellitus ( increased urination , increased thirst , weight loss ) and random plasma glucose concentration of 200 mg / dl or more is considered overt diabetic . The condition may be pre existing or detected for the first time during present pregnancy .
According to American Diabetic Association , diagnosis is positive if
a) The fasting plasma glucose exceeds 126 mg / dl
b) The 2 hour post glucose ( 75 gm ) value exceeds 200 mg / dl
Patients with poor glycemic control and vascular disease are at increased risk of complication of IUD , IUGR , Pre eclampsia and Ketoacidosis .
Complications :
MATERNAL :
During Pregnancy :
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Abortion
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Preterm Labour ( 20% )
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Infection – Urinary tract infection and vulvo vaginitis
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Increased incidence of Pre eclampsia ( 25 % )
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Polyhydramnios ( 25 – 50% )
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Maternal distress
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Diabetic Retinopathy
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Diabetic Nephropathy
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Ketoacidosis
During Labour :
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Prolongation of labour due to big baby
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Perineal injuries
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Postpartum haemorrhage
FETAL :
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Fetal Macrosomia – With good Diabetic control , incidence of Macrosomia is markedly reduced .
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Congenital Malformation – It is related to the severity of Diabetes affecting organogenesis , in the first trimester ( both in Type 1 and Type 2 Diabetes ) .
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Birth injuries
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Fetal death
NEONATAL :
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Hypoglycemia ( < 37mg / dl )
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Respiratory distress syndrome
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Hyperbilirubinemia
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Cardiomyopathy
AYURVEDA :
In Ayurveda Madhumeha disease can be correlated with Diabetes Mellitus . Though there is no direct reference of Gestational Diabetes but Garbha Vriddhi is described as a complication .
Garbha Vriddhi : In Garbha Vriddhi , there is excessive increase in size of abdomen and perspiration . Labour is difficult .
This can be understood as Overweight fetus or Macrosomia .
MANAGEMENT :
Ayurveda helps in limiting the maternal and fetal complications . Herbs are helpful as a supportive treatment along with the modern medicine under supervision .
Generally beneficial , congenial , purifying and suppressive dietetics and mode of life , not causing loss of doshas and dhatus but capable of decreasing the increased doshas and dhatus should be used .
Garbhadhan Vidhi : Pre conception counseling is a must .
Diet : Following can be included in the diet ( in moderation ) :
Vegetables : Bitter gourd , fenugreek leaves , tomatoes , bell pepper , spinach , cucumber , radish , sponge gourd , drumstick leaves & fruits , broccoli , kale , lettuce , cauliflower , cabbage .
Pulses : Mainly beans – green gram , bengal gram , black eyed pea , garbanzo beans , chick pea .
Spices : Turmeric , cinnamon , garlic , fenugreek seeds .
Cereals : Wheat , barley , pearl millet , oats .
Fruits : Plums , kiwi , lime , oranges , guava , java plum / black plum , apple, peaches , gooseberry .
Dry Fruits : Almond , apricot , walnut .
Though the most appropriate diet for women with Gestational Diabetes has not been established , it is suggested that obese women with a body mass index greater than 30 kg / m2 may benefit from a 30 – 33 % caloric restriction .
This should be monitored with weekly tests for ketonuria because maternal ketonemia has been linked with impaired psychomotor development in the offspring .
Physical Activity : Physical activity during pregnancy reduces the risk of Gestational Diabetes .Resistance exercise helps avoid insulin therapy in overweight women with Gestational Diabetes .
Pranayam and Yogasana is beneficial .
DR BALJOT BHARAJ 