Moms, Minds & Medicine (M3): Inside Maternal Health Research

Understanding Gestational Diabetes: Risks, Diagnosis, and Management

• Maternal Health Research Collaborative • Season 1 • Episode 7

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In this comprehensive interview, Dr. Abimbola Aina, a Maternal Fetal Medicine Specialist, joins Dr. Kimberly Turner to discuss gestational diabetes — its definition, diagnosis, risk factors, treatment, and ongoing research. Gain expert insights into managing this common pregnancy complication to ensure the health of both mother and baby.

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Introduction to Moms, Minds, & Medicine: Inside Maternal Health Research

SPEAKER_01

Hi, I'm Dr. Kimberly Turner, and welcome to Moms, Minds, and Medicine Inside Maternal Health Research. This podcast is your trusted companion on the pregnancy journey, where we break down the latest insights, answer the real questions, and empower you to make informed decisions every step of the way.

Welcome Dr. Abimbola Aina

SPEAKER_01

Hello, and welcome to Mom's Minds and Medicine Inside Maternal Health Research. I'm your host, Dr. Kimberly Turner, and with us today we have Dr. Abimbola Aina, a Johns Hopkins maternal fetal medicine specialist with an interest in gestational diabetes, which will be our talk. Thank you so much, Dr. Aina, for your time and expertise for our viewership. Hello. Thank you for the invitation.

SPEAKER_00

Happy to be here.

SPEAKER_01

Great. So I think it's an interesting thing to start with. A little of your background. What led you to this area of interest? We know that there are hundreds of thousands of women, if not tens of thousands of women that are affected with this problem. So can you give us a little of your background? What led you to medicine? What led you to OB? What led you to MFM? And here today.

SPEAKER_00

My interest in medicine is almost lifelong at this point. But uh when I got to medical school, I was unsure of what I was going to um choose to practice. I was leaning towards pediatrics, actually. Um did my OBGYN residence uh clerkship. Um it was just fascinating to me, and it included everything that I had an interest in. I could deal with the babies, um, but dealing with moms, including the medicine, which which, you know, it's always interesting to have these puzzles that you hope to solve. And then the surgery. I did actually like surgery, which I would not have been able to do as a pediatrician. And so all of those together led me to an OBGYN uh residency. And during my residency, I thought I would just come out and be a generalist. And during my residency, I was pulled aside by a few of my attendings um who just saw something in me, and they said, We really pursue a specialty. And at the time, I thought, do they not think I'm gonna be a good OBGYN? But um they really just pointed out to me. They said, you know, you really seem to have an interest in obstetrics. You're doing a research project, which is not required. You're doing all this extra information. You love your clinic um with your OB patients. I we really think maternal fetal medicine might be for you. And so I looked into it more and um

Dr. Aina's Journey to Maternal Fetal Medicine

SPEAKER_00

chose to pursue a fellowship, and I have not been disappointed.

SPEAKER_01

I love it. And you're an excellent attending, as I know. I wonder if also many viewers don't even really understand the difference between a generalist, like what I did for close to 30 years, and a subspecialist. I'm not sure we define maternal fetal medicine for them, or MFM, I may have said. So can you just talk a little bit more about that?

SPEAKER_00

Sure. So, for my role as a maternal fetal medicine specialist, what happens is you complete a four-year program in obstetrics and gynecology, and then you pursue a fellowship. So it's additional training, it involves three years of additional training in maternal fetal medicine. And what that entails is learning how to read ultrasound so that you can impact fetal care. Um, so we are looking for uh conditions in the fetus that might need intervention, that might need evaluation, that might need moms to uh pursue investigation to know what's going on and prepare for a baby that may have ongoing issues. And so we do three extra years. Most of it is included, including ultrasound training. Uh, so we learn how to scan, how to interpret ultrasounds, and then we also do research training so that we learn how to investigate, how do we take our interest, our questions in certain conditions, and turn that into a research project or a way to answer that question. So we learn those techniques as well.

SPEAKER_01

Excellent. Remind me when we get to the end of the meet to go back and talk about what your research has been, particularly in this area. So let's just start with our basic definition. What is gestational diabetes?

SPEAKER_00

So gestational diabetes is diabetes diagnosed during pregnancy. That's the basic definition. Diabetes in general affects uh between 7 to 8% of all pregnancies. And so when you think of how many people are pregnant, that's a lot of women. We use the term gestational because it was recognized during the pregnancy.

SPEAKER_01

Okay. Okay. And in follow-up, how does that differ from we most of us have heard of type 1 diabetes, type 2 diabetes? What is the difference?

Understanding Gestational Diabetes

SPEAKER_00

So again, gestational diabetes just means it was diagnosed during the pregnancy. So there are some women who have the diagnosis of diabetes before they get pregnant. Some started in childhood, and that's type 1 usually diabetes, especially for women who do not make enough insulin. So the the type 1 diabetics are women who their pancreas isn't functioning well enough and they don't make enough insulin on their own, and so need additional medication to cover their nutrition needs. Type 2 diabetics, on the other hand, make a lot of insulin, but their bodies are resistant to that insulin and don't use it effectively. And so type 2 diabetes is pretty common, um, but basically women know that diagnosis coming in. And so gestational diabetes again means that we diagnosed it during pregnancy. But what can happen is if we diagnose it in the first half of pregnancy, there is a suspicion that that diabetes was pre-existing. So we know most pregnant women are young, they're generally healthy. Most of them aren't seeing in our primary care physicians because they don't need to, they don't have an issue. Um, and so some women enter pregnancy not knowing, not ever having been evaluated for diabetes. And so when we see them in early pregnancy and make that diagnosis early, we call it gestational. But a lot of times when it's in that first half of pregnancy, the suspicion is that it could have been type 2 diabetes that just was unrecognized.

SPEAKER_01

Okay. That's the perfect segue because my next area of questioning is about how do you diagnose gestational diabetes? I know I know some of the ways, and I used to always have patients asking me some non-traditional ways to take the testing. When should they take it? What should they do? How do you prepare? Can you give us some insight there?

SPEAKER_00

Sure. So if we have a woman who seems to have some risk factors for diabetes, particularly a family history, um, sometimes obesity, um, and certain ethnic groups and age, we all are at risk as we get older. So if all of those things align, we would offer them an early screen. So that would be sometime in the first trimester if they register for their pregnancy that early. And so the ways that we can test them include doing what we call a glucola screen, where they get a 50 gram drink that they have to take, and then we draw their blood one hour later. That screen, if it's elevated, um, prompts us to do a confirmation test. And that confirmation test is called a three-hour glucose tolerance test. And that involves again taking a drink,

Diagnosis of Gestational Diabetes

SPEAKER_00

but this time instead of going in randomly with the glucola screen, the three-hour glucose tolerance test requires you come in fasting. And then you get fasting blood sugar drawn. They give you the drink, and then you get your blood drawn at one, two, and three hours after. And so there's really no preparation for the glucola screen, other than we tell patients, don't eat a heavy meal right before you go. And for the three-hour glucose tolerance test, you have to come in fasting. So we tell our patients no eating or drinking anything other than water, really, um, for at least eight hours before you come in for that fasting blood draw.

SPEAKER_01

Okay. I remember with my first pregnancy, and how busy and we were all moving around we are, um, that I had to stay in the lab the entire hour. I expected to go get the drink and then go about my one hour and come on back. Is that common for both of those tests? You have to kind of sit there and be present and yes.

SPEAKER_00

So when you're in the midst of the test, of course, they want to make sure that you don't eat anything else. Um, they want to test that they can interpret. They also want to make sure, because we all know that when we eat, to get rid of some of the sugar, exercise will um impact your sugar levels. And so that also plays into it. They don't want you running around trying to lower your um sugar levels falsely. Um, they truly want to see what your body does in response to that sugar load.

SPEAKER_01

Okay. So once we make this diagnosis, if it's early, if it's well, first let's ask, let's answer the question, what's the typical time? You talked about um early screening, but what's the typical time that we offer this test to mothers um in pregnancy?

SPEAKER_00

So we often start um for a low risk, what we consider a low-risk uh patient, we offer them that screening test, the glucola screen, somewhere between 24 and 28 weeks of pregnancy. Um, but again, if someone has a higher risk and we're suspecting that they are at greater risk for developing diabetes, we'll do it at their first presentation. So sometimes that's first trimester, sometimes it's early second trimester. And if it's normal early in the pregnancy, we will still do that repeat um screen in the third trimester. Okay.

SPEAKER_01

So what if I have um hyperemesis or I'm have nausea and vomiting of pregnancy,

Risk Factors for Gestational Diabetes

SPEAKER_01

and that glucose tolerance test or glucola screen makes me nauseate and I can't tolerate it. Is there another way? Can I do a urine test? Can I eat a bunch of candy? What is the current thinking on that?

SPEAKER_00

So there are some ways. Um, there are certain candies, if you will, jelly beans, um, and a specific type of jelly bean where they know exactly how much glucose is in a certain amount. So there sometimes is an offer to eat jelly beans up to a 50 gram load and then get your blood drawn. Um but another option uh for a lot of women who can't even tolerate the jelly beans is to get them a glucose monitor and get them the option of testing at home. So some women don't like their blood drawn, things like that. But if they can um get a glucose monitor and test their blood sugars at home, we often tell them four times a day. So first thing in the morning and then one hour after their major meals, so up to four times a day, do that for about a week, and then we interpret those values to determine whether or not they have diabetes. Right.

SPEAKER_01

That seems like more work in my mind than the screen. But of course, if you can't tolerate it, you can't tolerate it. So that would be the other way.

SPEAKER_00

The 50 gram, not just because of nausea, but just because, for instance, they usually don't eat sweets. And so to put that much in makes them sick where they weren't sick before. Um, and so a lot of women actually opt for checking at home because they feel like their diet is a lot better and they want to see what's happening exactly with their foods. Interesting.

SPEAKER_01

Okay. I think you covered the risk factors quickly, but I think there are a few more. So you said family history, um, being overweight or obese. Are there other risk factors for developing gestational diabetes?

SPEAKER_00

So, yes, definitely. The strongest risk factor is you had diabetes in a prior pregnancy. Um so that automatically gets you an early screen in a future pregnancy. But family history is certainly a strong link, and then racial backgrounds. Um, we do know that if you're black, Hispanic, or Asian, um, you have a higher risk than the Caucasian population. So sometimes that plays into it. Age certainly plays into it, and we factor that in for our older moms as we all navigate um childbearing a little later in life these days. Uh, so our patients, particularly the ones that will be 40 or older uh during their pregnancy, we test them earlier as well.

Treatment and Management of Gestational Diabetes

SPEAKER_01

Okay. What if I had a 10-pound baby? Is that one or the other?

SPEAKER_00

I've heard that's another that's be still. I mean, certainly 10-pound babies can just be genetic if the parents also were large at birth. Um, but that could also be a reason to have an early screen just to make sure that we're not missing something. Excellent.

SPEAKER_01

Okay, so we now know what gestational diabetes is. We know how to test for it, we know what the risk factors are. So now can you tell us a little bit about treatment goals? I have diabetes. What am I what's one of my first steps? Am I going to change my diet? Am I going to go on medication? Walk us through that, please.

SPEAKER_00

Yeah, so anyone diagnosed with diabetes in pregnancy, we often start with education. Um a lot of people just don't understand that what they're eating has such an impact. And so we start with, you know, the basics, how to read a food label. Um, learning how to figure out how many carbohydrates are in the meal that they're about to take. And so a lot of people have never even thought about the food label. And so learning how to read it is key. And so we start with a a session, often 60 to 90 minutes to get all that information through to a patient on how many carbs they're allowed to eat. And so in pregnancy, we often limit carbs to a degree in a patient that is diabetic. Um, we tell them to limit their carbs in the morning to about 30 grams. At lunch and dinner, they can go up to about 45, sometimes up to 60. A lot of the education is to just learn that the carbohydrates are going to raise their blood sugar. And then we give them the ranges that they would like to remain in. And that's where sometimes we receive some pushback from patients because they know someone who's diabetic or their family member is diabetic. And in pregnancy, our allowances are less than that outside of pregnancy. And so a lot of times patients feel like we are restricting them unnecessarily. Um, and so we tell them the impact, your sugars need to be lower because your baby sees all of that sugar, and we want to prevent any um consequences to baby from seeing too much of it. And so we start with the carbohydrate limits. We do tell them we're not trying to starve them. So if they're still hungry, they are allowed to increase the protein source of their meal and not the carb source of their meal. Um and then we look at their values. So fasting blood sugars, we want below 95, and one hour post-meal, we want below 140. And so when we are teaching patients, we tell them the ways to try and keep themselves in check, other than medication. So one is make sure you stay within your targets, and then two is doing a little bit of exercise, taking a 15-minute walk after you're done eating. All of those things help your body utilize the sugar so that less is coming over to baby, and your value when you go to check is a little bit less. But if all else fails, we do add medication. And so there are two options that we use in pregnancy. Uh, one is a pill and one is insulin, which is an injection. Um, a pill known as metformin, we can uh give to patients, but what we find is that metformin isn't as good at targeting a specific time point. And so some women as they start to record their blood sugars, they can pinpoint what time of day they seem to have trouble. For instance, breakfast is always good, lunch is always good, dinner is always high. But unfortunately, when you use things like metformin, you can't say, I'm taking this, I'm targeting dinner, I'm trying to bring that down. Because when you take pills in pregnancy, we do know that the entire gut and response to hormones slows down. And so your body doesn't absorb things from the stomach in a consistent fashion. And you can't time a pill, take you know, taking a pill with covering your meal. And so if it's in response to meals that you're still having elevations, metformin is not the best thing. It can be used though if it's just your fasting values that are elevated, because then if you take that metformin at bedtime, your body has all night to absorb it and you use it to control your fasting blood sugar. But insulin is our go-to when you have um elevated responses to food, and so insulin is an injection, but it works very good at controlling your meal time values.

SPEAKER_01

Okay. It's part of that 60 to 90 minute counseling session teaching patients how to monitor their blood sugar. I remember my dad used to have to prick his finger for diabetes after a meal, and I couldn't help him do it even though I'm a physician.

SPEAKER_00

So is that a part of it can be. Oftentimes, by the time patients get to us, they have received that instruction. But certainly when we are first diagnosing them, that does include teaching on how to use the glucometer, it's called, um, and how to test their their blood sugar. I think the main thing people um get wrong in testing their blood sugar is they poke the pads of their finger. And we always tell them the pad is the most sensitive part of your finger. Lots of nerves there. So don't poke the pad, and that's what makes their fingers so sore. And so we often tell them to poke along the sides. The sides of the finger have more blood flow and they're less sensitive. And so they they a little bit better.

Monitoring and Testing During Pregnancy

SPEAKER_01

Wow, I I did not realize that, and I actually have. Gestational diabetes with one of my pregnancies, so I remember how painful that can be. Yes. Okay, so we talked about diagnosis, treatment, um, risk factors. What do we do to monitor these? So now I've checked my blood sugar. I know where it is with my diet and exercise. It might be a little elevated or not, I might be medication or not. When is it time to do extra testing like to the baby or for the mother during this course?

SPEAKER_00

So again, it will depend on when you were diagnosed with diabetes. If you're diagnosed at the typical time frame, somewhere around that third, early third trimester, what we do is we do an ultrasound to make sure baby's not getting too big. Sometimes even before the baby becomes large, the amniotic fluid volume can become increased in response to extra sugar. And so we're looking for that. So we look for extra water around the baby, we look for a large baby. All of those things can tell us maybe this sugar isn't as as good a control as we'd like. And so that is one way we can keep track of blood sugars because quite frankly, we get it all the time. Patients say, well, it's not that high. My lunch values are just 143 and 144 and 146. It's just a little bit elevated. But that's just and the baby is measuring greater than the 95th percentile, that means bigger than most other babies of its own age. That's concerning. And so it might not seem like large elevations above our cutoff of 140, but your baby's telling us a different scenario. And so that's where we start to help them understand that you know these mild elevations may not mean a whole lot to you, and you may not get any bad symptoms from it, but your baby's telling us it's seeing a lot. And so that's how we manage them. And then if you are on medicine for your diabetes control, we also add in what we call non-stress testing, which basically just means we record the baby's heart rate for about 30 minutes twice a week. What that test provides to us is information about your baby's well-being. And so the babies sometimes, if they're doing too much work, can show small drops in the heart rate on this monitoring session that again clue us into how baby's tolerating the diabetes in the mother. And so we're looking for signs that baby's not doing well. Um, and so that's where we start. Ultrasound and the monitoring. The other thing we can see on ultrasound sometimes when babies have been experiencing or being exposed to too much blood sugar, is that the heart wall, the the baby's heart walls, can thicken and become bigger than they should be. And that tells us that baby's doing more work to pump its own blood around. And again, that's another factor we look at to say, okay, even though there are only mild increases in the blood sugar, your baby's telling us a story that doesn't match or doesn't make sense from what we are seeing from the blood sugars, and we need to make a change.

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Wow.

Preventing Gestational Diabetes Before Pregnancy

SPEAKER_01

Okay, so those mild elevations can be serious as well as the higher ones. That's great information. Um, is there a way that I can decrease my risk if I know I'm at risk? Say before pregnancy or early pregnancy.

SPEAKER_00

Absolutely. So we always advocate for women to be in their best health pursuing pregnancy. And so sometimes it just means making an appointment with your OBGYN before you conceive and going in and getting some blood work done and making sure that there's nothing in your current status that is a red flag or puts you at greater risk. We certainly talk about nutritional status. We recommend that patients be as close to their recommended or ideal body weight as possible. We always advocate for exercise. So even if you're not at your ideal weight, even just exercising enough to lose 5% of your um body weight will make you healthier. Um, and so exercise is key to sometimes having a successful healthy pregnancy. So even if you're not at your ideal body weight or what we call the body mass index, we recommend that women just add a form of exercise and become consistent with it before getting pregnant, because that will help certainly as you achieve pregnancy and progress in a pregnancy to keep you in the best health possible.

SPEAKER_01

Okay. We did a podcast actually on the preconceptual consultation. So for the viewers that don't know the value of that, they should also check that out. But seeing a doctor doesn't always have to be your OBGY, but seeing a doctor prior to pregnancy can be really helpful. And that also just kind of reminded me to talk briefly about how the generalist and the maternal fetal medicine specialists work together. Yes. We, as the generalist, would do the basic prenatal care, but when we would diagnose a problem or when something was going on with the baby on ultrasound, then the MFM would step in and give us a more detailed recommendation and just the standard prenatal care. And then you, at least at our Johns Hopkins system, and I assume this is throughout the nation, um, would do the monitoring. Correct me if any of that has changed or is incorrect.

SPEAKER_00

You are correct. You are correct. Most maternal fetal medicine physicians will do um the extra surveillance and manage the diabetes. Um, the caveat to that in in parts of the nation are that a maternal fetal medicine doctor is not available in a reasonable distance from the patient. And so there are places where a patient may come to see a maternal fetal medicine specialist, and that specialist designs a care plan that is shared with the generalist OBGYN, and then that generalist just executes the plan because they're the more local one where the patient is. Sometimes it's just not feasible for patients to travel more than an hour twice a week to come get monitoring or discuss their blood sugars. And so we outline that plan and then give it to the generalist to follow wherever the patient is.

SPEAKER_01

I guess it's kind of a blessing that we were in this place where there's not a maternity desert where care is so easily accessible, where we have coverage for women with insurance, but that would lead us down to their discussions. So just to wrap it up, um, I did want to ask you about your area of research. Were you starting this research path in your fellowship? You alluded to doing research and fellowship. Are you still doing research? Is there anything new that we need to

Research Insights on Gestational Diabetes

SPEAKER_01

know about in research ingestational diabetes?

SPEAKER_00

I do have an interest in ingestational diabetes. And my research most recently, my project was looking at ultrasound as an indicator for diabetes control or to also diagnose it. And so what we did was we looked at patients who've already done the screening. They've had their screening at the early third trimester, but they came to us because maybe their primary OB thought they were measuring large in the office, and we did an ultrasound and we found either increased amniotic fluid or we found a large baby. And in those circumstances, what we did, even though again they've already passed their screening, um, using those ultrasound indicators, we actually retested some women for diabetes. And some were found indeed later in the pregnancy to have diabetes. And it was the baby that was telling us that there was something going on. And so when we looked at those babies of the ones that had extra water or the ones that measured large, we found that yes, we were diagnosing diabetes in a large proportion of them. But whether or not we could diagnose diabetes in the mother in those babies, there was an increased risk for those babies when they delivered of having very low blood sugar and having trouble in those first few hours of life. And so some of these babies ended up in the neonatal intensive care unit. There was a higher proportion of those large babies and the babies with extra water that ended up in the ICU for observation after delivery. And so sometimes ultrasound can help us identify the mom who is at greater risk. And so we've begun using ultrasound even earlier in the pregnancy when we assess baby's weight to make that early diagnosis, even in the mom who ordinarily doesn't have all those risk factors that we talked about and wouldn't have ordinarily had an early screen, but their baby's measuring very large early in the pregnancy. We would then say, you know what, let's do an early screen on you.

SPEAKER_01

Sounds like the baby is a little bit smarter than the mother in some instances to me. Anything else? Take-home message for this portion of our gestational diabetes talk.

Conclusion and Key Takeaways

SPEAKER_00

I think the main thing that we want patients to know is we are here to help. We are not, again, trying to starve you. We're not trying to torture you by having you check your blood sugars during pregnancy. Our goal is to get mom and baby through the pregnancy safely. And we know that having good sugar control impacts that. On the mom side, if you don't have good sugar control, you're at increased risk for blood pressure problems, interestingly enough. And things like pre-clampsia, which involves high blood pressure protein in the urine, those things can be influenced by your sugar control. And so the more control you have, the better off you are. Also, on baby side, if baby is seeing a lot of high blood sugars, um, it can make a baby big and sometimes too big for a mom's pelvis, and it can lead to birth trauma, it can lead to inability to have a vaginal delivery at all, and uh a cesarean delivery is increased in women with diabetes. And then once baby is here, I've mentioned before about a tough transition. Sometimes those babies that have been seeing a lot of blood sugars from the mom side often go through a rocky early course where mom can't hold their baby, be with their baby because the baby's in trouble and needs blood sugar support in the neonatal intensive care unit. Sometimes it leads to the babies being quite jaundice and needing light therapy. Sometimes it leads to a baby that has just difficulty in breathing because we do know that high blood sugars in the mother delays the lung maturity in the baby. Um there are lots of consequences to poor control. And you'd be amazed at how many patients, once we give them their limits for their blood sugar control, actually record values that they think we want to see in their actual blood sugar values, and it's not helpful. Um, you're not doing yourself a service doing that, you're not doing your baby service doing that. And so I think the take home is we're trying to get you through. We're trying to get you through as healthy as possible, we're trying to get your baby through as healthy as possible. And so we are here to work with you. Um, if you're having trouble, we're here to help. Um, if you just can't poke your finger, we do try our best for patients that insurance will cover a continuous glucose monitor to try and get them that, to limit how often they have to poke their finger. We try our best to work with you where you are and get you through as as safely as possible.

SPEAKER_01

Okay. You did say one medical term that maybe everyone's not familiar with. Can you tell the reviewers what jaundice is?

SPEAKER_00

So jaundice basically occurs when a baby has too many red blood cells around. Those are the cells that carry oxygen. And when babies see a lot of high sugars on the inside before they're born, they produce a lot more red blood cells because they need the extra oxygen to process the sugars from mom. But then when they come out, they don't need all those red blood cells. And so they start to destroy them. They destroy the extra, but all that destroying leads to an increase in iron in the baby's system because it doesn't need all those red blood cells, and the baby can then develop some liver damage because your liver, the baby's liver is trying to deal with all those byproducts of the destruction. And in that situation, babies often need light therapy. So they put them under UV lights to try and help the liver process all of those byproducts and get them out of baby's system. And so it can be quite challenging for a baby that is jaundiced to navigate those first few hours of life or days sometimes of life. Um, but jaundice typically can make a baby more yellow if you think of even in an adult, when they're jaundice, their eyes become yellow, the whites of their eyes become yellow. Well, the same thing happens for babies as well. And so poor control in the mother puts baby at risk for that.

SPEAKER_01

Okay, thank you so much. That was an excellent definition of jaundice. So I think that wraps it up. We want to thank Dr. Ina again for her time, her expertise, and her very excellent way of making all of this complicated medicine so plain. Thank you. Thank you for having me.