By - Dr. Mrs. Sagira Chimthanawala (Prof. & Head, Dept of Hom Gynecology & Obstetrics)
Diabetes that develops in pregnancy or Gestational diabetes as it is known in medical parlance is a well known entity that is increasing day by day. It can develop during pregnancy in a woman who hasn't previously had the condition. At the Academy we have found that it affects around 1% of pregnant women at least in Vidarbha. Gestational Diabetes (GD) is a condition in which the blood sugar level is high either because there isn't enough insulin or the insulin released by the Beta cells of the islets of Langerhans isn't working properly. Insulin enables the human body to break down blood glucose to be used as energy. During pregnancy, high levels of hormones like placental lactogen, estrogen, progesterone, cortisol and thyroxine retard the action of insulin. Further, placenta also degrades insulin so that the fetus gets enough glucose. Mother’s body needs to produce more insulin to cope it. GD develops when the mother’s body can't meet the extra insulin demands of pregnancy. It usually begins in the 2nd pregnancy and subsides after the baby is born. If GD persists after the baby is born, it's possible that the parturient already had DM and it was excited during the pregnancy.
1. Predisposition - A state in which a person is prone to a disease. It is due to internal and external factors.
Internal factors are -
i) Previous birth of an overweight baby of 4 kg or more
ii) History of previous stillbirths or unexplained abortions
iii) Family History positive for DM
vi) Miasms are THE fundamental cause for every sickness. In DM, the Tubercular miasm (psoro-sycosis) is responsible for nurturing the sickness. If psora is dominant, the parturient is likely to present with high glucose values on investigation. But this is transient and may not require any medication as on repeated investigations it will normalize. A close monitoring is essential. If sycosis is dominant the blood glucose values will increase on repeated examinations.
v) Temperament – The active Tubercular miasmatic state makes the female oversensitive. She becomes easily frustrated; tormented and become easy target for diseases as diabetes, hypertension, hypothyroidism, etc.
vi) History of Polycystic Ovary Syndrome in the pre-parturient state
vii) External factors are
viii) Modes of living – irregular habits and sedentary life
ix) Overweight or Obesity in the pre-parturient state
x) Smoking / Tobacco chewing
2. Exciting Factors -
i) A psoric state where mental & physical shocks on the domestic, financial or occupational fronts increase glucose levels.
ii) Mechanical interventions excite tubercular miasm – DM is one outcome
iii) Vaccination & Drugs those are potent enough to excite the sycotic miasm.
3. Maintaining Factors – Unresolved mental & physical stress during pregnancy promote the evolution of GD.
Clinical manifestations- DM is an evolutionary disease and in pregnancy itself may pass through 2 conditions:-
Diabetic diathesis- Generally seen in the 1st trimester. In this state patient may have abnormal weight gain (normal=1kg/month), increased appetite & urination, obesity, pustular eruptions or fungal infection, pruritis vulva or spontaneous abortion. Blood sugar levels are normal but close monitoring is necessary.
Disease proper – The latter is generally seen in the 2nd trimester. The classical symptoms of polydipsia, polyuria, polyphagia and fatigue develop. Hyperglycemia & glycosuria is seen on investigation. These continue unabated till treated. In pregnancy, the affection of target organs like kidneys, eyes, heart, etc is rare. If the maintaining cause persists, the miasmatic complex evolves. It channelizes itself disturbing other metabolisms. Hence frequently diabetics also develop hypertension, rheumatism, etc.
Effects of End Results –
1. Spontaneous Abortion or Premature labor
2. Prolonged labor due to big baby
3. Greater chances of Pre-eclampsia
4. Polyhydramnios i.e. increase quantity of amniotic fluid & glucose concentration of liquor
5. Large baby and large placenta leading to polyuria.
6. Recurrent infections – especially urinary tract infections.
7. Risk of GD in future pregnancies and of Type 2 diabetes later in life.
1. Large baby (macrosomia) making vaginal delivery difficult.
2. Hypoglycaemia after birth due to the extra insulin generated to respond to the high blood sugar levels of the mother. After birth, the baby may continue to generate extra insulin causing its blood sugar level to be too low.
3. Increased risk of congenital heart defect and respiratory distress syndrome since the lungs have not matured fully (Antim Tart).
4. Higher chances of stillbirth or intra-uterine death.
5. At our centre we have seen that there is a high risk of childhood obesity.
6. Mental retardation & Cerebral Palsy have been observed in many cases
Diagnosis & Investigations -
1. Glucose tolerance test- Done generally at 24-28 weeks of gestation. 50 grams oral Glucose solution is given without regard to time of day or last meal. Blood samples at different intervals are taken. A Whole blood glucose value of 130 mg% at 1 hour is considered as cut off point for DM.
2. Urine for sugar at all antenatal visits
3. Serum HbA1c before 14 weeks of gestation
5. Maternal Serum Alpha Fetoprotein levels at 16 weeks Diabetes Management action plan:
Mother: We at Shaad recommend
1. Frequent ANC’s, ultrasound/prenatal screening tests for monitoring fetal development and testing of blood glucose levels
2. Planned diet - plenty of rice, potatoes, fruits and vegetables each day.
4. Regular walking for 30 minutes/day or till she gets breathless.
5. The Obstetrician determines the best time and safest way to deliver the baby. Sometimes labor is allowed to begin naturally. In other cases, labor is induced by Pulsatilla, Gelsemium or Caulophyllum early. During labor, mother’s blood sugar level is done. If the baby is too large or if complications develop then one may need to deliver by C-section.
6. Medicines- It is possible that the blood sugar levels may stay high even after lifestyle changes. By homoeopathic constitutional remedies known cases of DM (even on Insulin) will help reduce the Insulin doses and prevent complications. However those patients diagnosed early and with proper homoeopathic management will not need insulin. As palliatives we use drugs to decrease the symptoms of DM as are Syzygyium Jambolinum, Cephlandra, Phosphoric Acid, Uranium Nitrate, Rhus Aurum &Acetic Acid.
Foetus: After the delivery the newborn's blood sugar level should be checked periodically. It is best to start breastfeeding within an hour of delivery. It may be enough to correct the baby's hypoglycemia. Occasionally babies are administered intravenous dextrose.
Infine – At the hands of a good homoeopathic obstetrician GD can be managed well by close monitoring and by anti-miasmatic/constitutional treatment the fetus too being free from the manifestations of the presenting miasm.