Ask a Midwife: Gestational Diabetes

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Stephanie Momot: Can you sort of give us an overview of what gestational diabetes is and how it differs from other types of diabetes that people might have?

Michele Augur:  So you might have heard of somebody in your family that has diabetes, and they're regularly checking their blood sugar. Maybe they need to take medication or keep an eye on specific foods. That's a lifelong condition. With gestational diabetes, we say “gestational” because it's pregnancy specific. It's likely that this condition will go away after you're no longer pregnant.

Pregnancy hormones sometimes can cause your body to not use insulin as well as it might when you are not pregnant. Insulin is what’s in your body's chemical system that helps you move the sugar in your blood from your bloodstream out into your tissues. And if your insulin isn't moving that blood sugar through, it's floating around your bloodstream. This can make you have high blood sugar, which is then passed potentially across the placenta. It can affect fetal growth and how you're feeling.

Farrah Ka’Healani Rivera:  There is a stereotype that with gestational diabetes, people worry they are going to grow big babies. And while that is true, because sugar levels are not normalized, the way that it can affect the baby is yes, the child can grow exponentially and be bigger. But the opposite side effect can also happen where babies are actually too small. The baby might be growing in a way that may not be helpful or healthy. The testing and screenings that we do in pregnancy help to ensure that we're making good recommendations for the pregnant person to change their lifestyle, whether it's a form of nutrition and/or movement.

SM: So we've established that you only get gestational diabetes when pregnant. How long does it take before it goes away?

FKR: It really is dependent on the individual. If the pregnant person continues to consume the diet and resume the lifestyle which established gestational diabetes, then it doesn't really go away. What I have seen is that even within one to two weeks, if a person is drastically changing their nutrition as well as their lifestyle, their blood sugars actually do see an improvement quite quickly.

MA: Exactly. Not everybody who has gestational diabetes continues to check their blood sugars after birth. We don't have good data to see at what point we are getting changes in blood sugar. But typically around that six week postpartum visit, we recommend that clients do a blood sugar check, similar to the one that they did in pregnancy, to make sure that gestational diabetes appears to be resolved. If they still look like they have diabete-type test results, it's possible that they have become diabetic. But it's no longer gestational because they're not pregnant.

SM: So we talked a little bit about what gestational diabetes might do to affect the baby. Can you talk about what happens if you have diabetes that goes unchecked throughout your pregnancy and what some of the more unwanted side effects of that might be?

FKR: I want to first acknowledge, when do you screen for gestational diabetes? In the early part of the third trimester between 26 weeks and 28 weeks gestation, we do a glucose test. If you've already been pregnant, that’s that sugar drink that tastes “delicious.” 

I also want to acknowledge that there is this mindset that happens when people get pregnant and they think, “Free for all! I'm gonna get chunky and get big. My baby's gonna be chubby. So I'm gonna eat and just live the way that I want to.” That's a real conversation that comes up often with clients. And it's actually the opposite truth. You really would like to go into pregnancy healthy. And if that's not the case, pregnancy is a really wonderful time to change lifestyles and change nutrition in order to be as healthy as you can be. 

And it goes back to your question about what this means for the baby as well as for the pregnant person. If there is uncontrolled gestational diabetes, what that means for the kiddo is that when they're born, their sugars are not regulated. That can actually cause seizures. Seizures are the extreme of what can happen with an undiagnosed, uncontrolled gestational diabetic pregnancy. It also means later on in life, the pregnant person as well as the baby have a higher incidence of developing diabetes.

MA: Sometimes if people don’t have well-controlled blood sugars, they may not feel very good and have all sorts of symptoms. And so helping regulate your blood sugar can help you feel better in the long run of your pregnancy. 

Besides seizures, there is also potentially the risk of stillbirth if it's a very uncontrolled diabetes situation. And then there's also situations where babies have been getting this fairly constant higher level of glucose coming to them. So then after they're born, that umbilical cord is cut and they’re separated from their constant glucose source. That may cause difficulty regulating  typical processes of life, like breathing or temperature regulation. These babies may need extra support from machines or closer monitoring. It's going to make for a more challenging newborn season as you're trying to care for your baby.

FKR: The ideal situation is that after your baby's born, you have them close to you. And if that baby requires extra help, they're going to get help. But that help is away from a pregnant person and their partner’s arms. And that is something that I like to remind families about and why you want to be very mindful of what you're consuming and how you're moving.

MA: As a reminder, we're giving these kinds of risks and situations that are based on uncontrolled diabetes. We don't want to scare or shame you if you have a diagnosis of gestational diabetes. It's not necessarily your fault that this is happening. It just means you may need some more support and some extra tools to support you and your baby during this time.

FKR: What we know through research, and what we also see in communities, is that BIPOC populations are more affected by gestational diabetes, diabetes, and heart disease. I feel it's an important conversation to understand why that is. Part of it is food access. It’s also being displaced and/or colonization in general. We don’t necessarily talk about cultured foods in general life, nor in pregnancy. What I mean by cultured foods is, what foods were two to three generations before you eating? What did they have access to? Where were they getting their food? Were they growing their foods in their own gardens, or were they getting food shipped into their homes like we do these days? Are we talking about where this person is coming from? What kind of foods do they eat? Because not everybody eats kale. What other foods can we incorporate or add in that they might already be eating? That might include whole foods that aren’t what Western society eats.

What I've discovered is that it really creates a conversation of reclamation. “Oh, yeah, that's right. When I was five, grandma made this stew. And she fed it to all of my Aunties when they were having babies.” Or, “My uncle would go catch this fish, or he would harvest this thing on our lands.” How can we open up other doors of what it would look like for a person to explore what other types of food their community is eating? 

If that's not available, what other foods could be available and accessible to a family? What's really wonderful is that we have a lot of great food programs like WIC. And when we're thinking about food access, that's something that's also available for many families throughout the United States.

SM: Thank you for bringing up all those lovely points. I want to backtrack just a little bit – are there any warning signs or reasons that you might test someone for gestational diabetes before that 26- to 28-week mark that might indicate that they have gestational diabetes?

MA: Sometimes you hear of people describing symptoms that do kind of remind you of people with diabetes, such as “I’m thirsty all the time, I can never get enough.” With pregnancy, you often have to urinate frequently anyway. So that's not a very reliable sign of being pre-diabetic. 

Hypoglycemia, that’s this big word, but basically it means you have instances of low blood sugar. Some people know that that's something their body tends to do if they don't eat regularly. They might get faint, sweaty, or dizzy. That can actually be a sign that possibly your body is struggling to keep a blood sugar balance. So it's not necessarily that your blood sugar is always high. It's a regulation issue. That might happen earlier on. 

But part of what causes gestational diabetes is that your placenta puts out a hormone that interacts with insulin. That placental hormone peaks at that 26 to 28-week window. So that's why we test at that point. Because if we test earlier, we might get some good information. But we might not be able to identify what's happening when that hormone gets to higher levels.

FKR: So in Hawaii, we call it “kanak attack.” And other communities call it the “itis.” When you eat a lot of food, and you have that delicious cake, and then you get all sleepy and just pass out: that's actually a symptom of blood sugar spikes. People with diabetes might experience these regularly. That in itself is when we start to worry about gestational diabetes. When people's blood sugars are spiking and dropping, it can also affect nausea and drastic mood swings. “Hangry” is a real thing! And if you're not eating or regulating your sugars, then that's something that can happen.

I also want to talk about the stereotype that people who have bigger bodies are more likely to get gestational diabetes. That's actually not true. Individuals who have smaller frames can get gestational diabetes as well. 

Another piece that happens in pregnancy is if your baby's measuring smaller or larger. Sometimes that can be a sign, because something that gestational diabetes can cause is polyhydramnios. This causes extra fluid inside of your inside of your uterus because of the way that your body is processing sugar. So there are some incidences where we would make recommendations to test sooner, especially if a person had gestational diabetes in their previous pregnancies. Unfortunately, if you have gestational diabetes in one pregnancy, it's very likely that you can develop it in later pregnancies as well. So if there's a history there, we do sometimes test earlier. Then we can make recommendations about how to try to prevent or minimize the effects of gestational diabetes.

SM: And on that tricky note of prevention, I'm sure both of you have thoughts. Are there things that you can do to prevent gestational diabetes? Or are you really just working to mitigate your risk?

MA: If we look at generations past, what foods have your families traditionally been able to enjoy? Historically we're looking at, in basic terms, eat real food and move your body. So if your great grandma would recognize a food, that's a good sign. If it's really processed and put into a package with a cute label, it may have lost its nutritional value along the way in all of that processing. So look at what you can do to get food in its most original form. Get a variety of fresh foods that are prepared in a way you enjoy. And consume those in a way that really nourishes your body.

And then move your body 20 to 30 minutes a day. If you can, go for a walk, go up and down stairs at work, take your dog for a walk, or chase around your kiddo and play with them. Moving your body helps the glucose in your bloodstream get moved into your muscles and used throughout your system. If you're working hard running around on your feet all day at work, maybe that's sufficient for you. If you're sitting throughout the day, maybe going for a walk after dinner might help. 

But also, we know that people can have no apparent risk factors and still end up being diagnosed with gestational diabetes. Sometimes your body is just struggling with these pregnancy hormones to be able to move that glucose through. And that's where we talk about all these things that might be supportive, but there is no foolproof way to 100% guarantee you will never get gestational diabetes.

MA: Another unfortunate fact is as you age, you also increase your risk of gestational diabetes. 

I want to acknowledge that gestational diabetes isn't only just dealing with the baby and your pancreas. It's actually a whole-system function. Your liver’s involved, your pancreas is involved, your kidneys are involved, and your womb is involved. Your liver actually plays a huge part in pregnancy, because not only is it regulating a person's waste products, it's also processing the little kiddo’s waste as well. The liver also helps to regulate fat. It also helps to regulate hormones. And if you are caring for your liver in pregnancy, it can also prevent itchy skin, and skin things are very related to the liver. 

There are delicious teas and foods that you can eat to care for that liver and help regulate sugar levels. Things like dandelion and burdock (in Asian culture they call it gobo) are really wonderful nutritional things for your liver. Most researched is milk thistle. It can be consumed in salads. I personally like it in tea. You can have that on a regular basis. It's safe in pregnancy. Or if you have skin conditions, it’s really helpful to be preventative. 

I also wanted to touch on regulating your sugar levels. A lot of times when we're thinking about gestational diabetes, something I run into is people think, “Okay, I'm gonna, I'm not going to snack, I'm gonna go eat three times a day. That's it.” No, that's not what we want. We want you to regulate your blood sugars. And what that means is that you actually should be consuming something at least every two to three hours to avoid the drops and the spikes. 

If you're only eating three times a day, you're actually dropping your sugars and spiking them when you eat. People who have gestational diabetes can feel shaky. That's because their blood sugar is dipping. What happens with your system is that your liver, your heart, your brain say, “Oh my gosh, I need to put sugar into the body because the sugar is dropped.” So your body starts to shake in order to release the glucose that’s in your muscles, your liver, and other parts of your system. 

So yes, I don't recommend eating only three times to a pregnant person. I actually don't recommend it for anybody. Everybody should be eating something every two to three hours. It’s important to regulate your blood sugars.

There are so many food combinations that you can do to maintain blood sugar. It could be as simple as a bite of a fruit that you're eating in combination with protein. Something that I enjoy to help regulate and keep me sustained is a combination of apples and peanut butter, or a pear and a piece of cheese. The other day I had blueberries with chia seeds and hemp seeds with some honey on them. You could also have lemonade with chia seeds and honey. Am I taking away the sugar? No, I'm not. I'm adding things in order for the combination of that food to be nutritious to my body. 

I also love that you brought up movement. Because when you're moving in pregnancy, it's not about strengthening your muscles. You're not trying to build your muscles. You're already carrying a person. You also have extra weight because of placenta and amniotic fluid. So you're actually walking to be comfortable. You're also walking for mental health. 

When you are in labor, if you haven't moved your body as much you may not actually be sure how your body moves. And in order to move in labor, you want to be mindful about what that means if you turn this way, or how does that feel in your hips? Or if you move your hand this way, how has your body changed? And what does that mean for your body in labor and postpartum? So movement is important. I’m not saying lift weights. It's mostly for comfort in your body, learning about your body, and also mental health. I recommend exercising with people. I feel like that's also a really wonderful thing that you can do.

When we're looking at movement, we don't recommend doing something you haven't been doing for at least six months. Maybe you thought you'd learn how to ride a bike for the first time? No, don't learn when you're pregnant. You're gonna be off balance. 

There are a handful of things that you can do that may be new that are safe. Yoga is definitely one of the things that can be new in pregnancy that is safe, as long as the instructor knows what they're doing. If walking is new to a person, that is absolutely okay to do in pregnancy. Swimming is also something that people can do in pregnancy that might be brand new. You don't have to learn how to swim. You can just get into a body of water and walk. That in itself is quite good for your mental health and healing. 

And do it with people. Do it with pregnant friends, or do it with your partner, or do it with a person who says, “I want to help out with your pregnancy.” You know how you can help me out? You can wake me up at six o'clock tomorrow, and we can go for a 30 minute walk. It's a beautiful way to ask for help. It's also a beautiful way to make connections, because this person you might be exercising with during your pregnancy may also be the person who's gonna take care of your babies and bring you food after birth. Exercise can be mindful not only for your mind, but your body, spirit and community. 

In a holistic look at prevention, I like to also add that when you're actually eating food with others, it helps to regulate how much you're consuming. Your hunger cues are probably more prevalent because you're also being filled with conversation and with friendships and not just consuming food. Eating food with company has also been shown to help with regulation of sugars. And it's good for your mental health. 

Gestational diabetes can also open up opportunities for other pieces of a person's life. I'm hoping part of the conversation is not just about the sugars. Pregnant people can feel very isolated in pregnancy, and the less happy or the less social you are can also affect your sugar levels. So I want to be mindful about what that means for a pregnant person. They may enjoy being out with people and then not get to experience that. It's a really good reminder that pregnant people need people, too.

MA: Yes, I think you're really touching on how important it is to feel nurtured. And not just in this physical sense of eating foods that help you feel good. Food is part of community and part of culture. Hopefully, when we're moving our body or have support from our community and feel loved and cared for, it also decreases stress. That might also help lower blood pressure. High blood pressure can affect our blood sugar, which can be a risk factor for gestational diabetes.

SM: I would love to get your perspectives on midwifery care and gestational diabetes. How might having gestational diabetes impact your care? Of course, this can change from state to state. But I would love to get both of your experiences as well as any tips that you might have for people who are experiencing gestational diabetes.

MA: Like you mentioned, every state has different regulations around midwifery practices and the approach for people who were diagnosed with gestational diabetes. But for the most part, any midwife is going to offer you screening for gestational diabetes. They'll talk with you about making a plan if you have that diagnosis. Typically that starts out with making what is called a diet diary. You list out what foods you're consuming every day, what movement you're able to get in, and do finger poke blood sugar testing and write down your numbers. So that gives your midwife information on how your body is handling daily life, and if there's any food that might be triggering higher numbers. 

If you're able to keep those blood sugar results within a normal range by adjusting what food you're consuming or how much you're moving your body, that's called diet controlled gestational diabetes. Those folks don’t need any medications to help keep their numbers within that normal range. You might get referred to a dietitian, or you might get referred to a high-risk perinatologist (also known as a maternal fetal medicine doctor) for a consult. They can give you more education. 

They might also request that you get additional ultrasounds to measure fetal growth. We want to keep an eye on all the markers of well-being. There are some midwives who, due to state regulations or their personal practice guidelines, may say that they can't continue to care for you with that diagnosis. They'll help connect you with a provider who has that skill set and feels comfortable caring for someone with gestational diabetes. 

But many midwives are trained and absolutely happy to support you throughout pregnancy with gestational diabetes. They'll let you know what feels like a good plan as far as monitoring or extra consults. If medications are needed, then that might come to a point where they need to risk you out of midwifery care depending on what it is you need to take. That decision is often made collaboratively with you and a consulting OB or maternal fetal medicine doctor to help get you the care you need.

FKR: In the event that a pregnant person is diagnosed with gestational diabetes, we spoke about a dietitian or nutritionist. When a person does develop gestational diabetes, I strongly strongly recommend speaking to someone who has a nutrition and dietitian background. It is vital in that we figure out what your body is doing with certain foods.

I want to share a quick story. There was someone who came into my care, and they were very resistant to doing these diet diaries. But what we found out through her diet diary was that she had Starbucks in the morning and that was spiking her sugars. And that when she ate a particular type of meal, this one thing spiked her blood sugars. We found out in a week – one week! – of writing down what she was eating what was spiking her sugars. 

And then we asked, hey, would you be interested in doing something different? This sugar spike is happening with this one particular meal and in the morning because you're having this drink every day. Would you be interested to see if we can control your sugar levels by eliminating these and adding something new? She got tea. (She was very upset about that.) And then she eliminated that one piece of that one particular meal, and it regulated her blood sugars. We were able to correct that in about three weeks to a month. It took a little bit of time because there were more pieces of adding things in and having conversations about it. But we were able to regulate her sugars and she did not need medication. 

She grew her baby perfectly in the sense where there was a diagnosis, but she had controlled gestational diabetes. Writing down your food and poking your finger is another step, but it's more information of what can holistically be better and healthier, not only for pregnancy, but for later on in life. What I can tell you is that she took that lesson with her. 

This is why I really advocate for nutritionists who know what they're talking about. And if your nutritionist or your dietitian does not have gestational diabetes experience, that's a time I would highly recommend finding a different provider.

And there’s also the self-respect and self-collaborative responsibility. You have to take the information so that you can hold it, and then share it with providers so that they can interpret it. Collaborative care doesn't mean that everybody else is taking responsibility for your sugars. It's really a self-piece that other people will help you to do. But it really comes from the center. All these people can tell you, “don't do this, do this.” But if you're not starting with yourself, all that help is not going to be helpful.

MA: I love how you individualized care for this client. It is extra work to do blood triggers and make a diet diary. But then you were able to really individualize your recommendations instead of making food shaming lists that give you a list of “good foods” and “bad foods.” Sometimes it may have been a healthy food, but it just wasn't working for this pregnancy. And that is such helpful information.

Also, if you have a provider that's not talking to you about how to individualize your movement and your nutrition and wants to just give you medication, that would be a reason to say “Hey, can I meet with a dietician?” It may be that your provider doesn't have a lot of background in nutrition. But they can often do a referral for you so you can get access to the information if your existing provider doesn't have those tools on hand.

SM: Michele and Farrah, thank you so much for taking the time out of your day to share your knowledge and expertise.