Gestational Diabetes Mellitus (GDM)

Definition

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy (Metzger BE, 1998). Gestational diabetes occurs when pancreatic function is not sufficient to overcome the insulin resistance created by changes in diabetogenic hormones (estrogen, prolactin, human chorionic somatomammotropin, cortisol, and progesterone) during pregnancy.

Pathophysiology

The characteristic of GDM is increasing in insulin resistance. Insulin resistance is a normal phenomenon that present in the second trimester of pregnancy. Pregnancy hormones are thought to disrupt the action of insulin as binding to the insulin receptor. The disruption probably occurs at the level of the cell signalling pathway behind the insulin receptor. Since insulin promotes the entry of glucose into most of the cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin injection is needed to overcome this resistance.

Risk Factor

·         A previous diagnosis of gestational diabetes or pre-diabetes, impaired glucose tolerance, or impaired fasting glycaemia

·         A family history revealing a first-degree relative with type 2 diabetes

·         Maternal age - a woman's risk factor increases as she gets older (especially for women over 35 years of age).

·         Ethnic background

·         Being overweight, obese or severely obese

·         A previous pregnancy which resulted in a child with a macrosomia (baby with large size)

·         Previous poor obstetric history

Complication

Mother

·         The risk largely related to uncontrolled high blood glucose levels and its consequences.

·         Increases with higher blood glucose levels.

·         Higher risk for congenital malformations (a defect that is present in birth).

·         Still unclear whether women with GDM have a higher risk of preeclampsia. (High blood pressure and excess protein in the urine after 20 weeks of pregnancy for women who previously had normal blood pressure.)

Baby

·         Growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit.

·         Macrosomia in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section) or problems during vaginal delivery.

                     

                     

Figure: forceps (left) and ventouse (right)

·         Increased risk of low blood glucose (hypoglycemia), jaundice (a condition with yellow color of the skin, mucus membranes, or eyes), high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia).

·         Not been clearly shown to be an independent risk factor for birth defects because birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy.

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Type 2 Diabetes Mellitus (NIDDM)

Definition

Type 2 diabetes is a chronic (lasting) disease with the condition of hyperglycemia (high level of glucose in the blood). It results from insulin resistance and relative insulin deficiency.The body is unable to respond to either endogenous or exogenous insulin to reduce blood glucose level. This condition causes the body cells cannot able to take up the glucose and utilize it.

Pathophysiology

The level of insulin that arising from the body or derived within the body (endogenous insulin) may be normal, decreased or even elevated. Nevertheless, this insulin production usually is not sufficient to overcome the insulin resistance. 

Increased blood glucose level first appears after meal (postprandial) and then followed by an elevation in fasting glucose concentration. This condition happens because of the decreased insulin secretion accompanied by increased glucose production by the liver.

Besides that, insulin resistance which happens on fat cells can causes high amount of lipids in the blood. At this time, lipolysis (the process of breaking down of lipid, particularly triglycerides into fatty acids and glycerol) will take place frequently. This free fatty acid (FFA) will be transported to the liver. This influx of FFA to the liver will further increase in insulin resistance. High level of free fatty acids will impair the function of pancreas to secrete insulin and increase the glucose production by the liver.

Risk factor

• Age greater than 45 years
• Experience previous diabetes during pregnancy
• Excessive body weight especially around the waist.

• Born a baby weighing more than 9 pounds (4.1kg).
• HDL cholesterol (good cholesterol help in transportation of bad cholesterols) which is under 35 mg/dL.
• High blood levels of triglycerides, a type of fat molecule (250 mg/dL or more)
• High blood pressure (greater than or equal to 140/90 mmHg)
• Impaired glucose tolerance (IGT) - High blood glucose level but is below the level of diabetic patient. This is associated with the insulin resistance and abnormal insulin secretion.
• Low activity level (exercising less than 3 times a week)
• Metabolic syndrome (a group of risk factors that increases the risk for heart disease, diabetes, stroke and other diseases.)
• Polycystic ovarian syndrome - a condition in which a woman has an imbalance sex hormones regulation which causes difficulty to get pregnant. It happens mostly among obese people.
• Acanthosisnigricans (presence of dark and thickened skin around the neck or armpits.)

• Ethnic background including African Americans, Hispanic Americans, Asian Americans, and Native Americans.

Source: 

http://www.nlm.nih.gov,2012.

National Library of Medicine  National Institutes of Health

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Type 1 Diabetes Mellitus (1DDM)

WHAT IS THE DEFINITION?

It is an autoimmune disease in which the body views the beta cells (insulin producing cells found in the islets of the pancreas) as a foreign substance, so the patient's immune system attacks the islets and kills them. The insulin is needed to control the normal blood glucose level in the body by the conversion of the carbohydrate in simple form to glycogen (a storage form) in the liver, muscle cell and adipocyte. 

Pathophysiology

Risk factor

Some group of people are high in risk to develop T1DM than others due to the damage of the beta cell of pancreas to function properly. The primary risk factor for type 1 diabetes is a genetic and family history of this lifelong, macrosomic baby and chronic diseases.

·         Genetics and family history. ( This also exists among patient with T2DM) 

Having family members with diabetes is a major risk factor especially anyone with a first-degree relative with type 1 diabetes such as a mother, father, sister, or brother. They should get screened for diabetes.

·         Diseases of the pancreas. 

Injury or diseases of the pancreas can inhibit its ability to produce insulin that control blood glucose level.

·         Macrosomia infant ( the large baby born than average)

Refer to the mother with gestational diabetes mellitus during pregnancy.

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What are THE PROBLEM occurred in Type 1, Type 2 and Gestational Diabetes Mellitus???

 1) Hypoglycaemia

Hypoglycaemia occurs if blood glucose levels fall below normal which is below 70 mg/dL or 3.9mmol/L.

Insufficient intake of food and excess exercise or alcohol intake may cause hypoglycaemia. Hypoglycaemia may be mild, moderate and severe. Usually the condition is manageable. But, occasionally, it can be severe or even life threatening. Particularly if the patient fails to recognize the symptoms, especially while continuing to take insulin or other hypoglycaemic drugs. Severe hypoglycaemia occurs most often in people with type 1 diabetes who must take insulin for survival.

Hypoglycaemia has been associated with reduced cognitive functioning and can, rarely, be a cause of death. Co-morbidities such as coeliac disease (An autoimmune disease characterized by a permanent intolerance of gluten) and Addison’s disease (A disorder of inability of endocrine gland to produce enough hormones) can increase the risk of hypoglycaemia.

2) Diabetic Ketoacidosis (DKA)

It can happen in all types of diabetes mellitus however it is commonly seen in T1DM patient. DKA occurs when the blood glucose is too high (blood glucose > 11 mmol/L), associated with the absence of insulin. This problem affects the regulation of two hormones. 

When there is lack of insulin in the body, it will increase the glucagon hormone secretion by the liver lead to the glucose formation results from glycogen. Thus, the glucose level increases in the blood and inhibit the glucose uptake by the liver and muscle cell as energy. When cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones.

What is ketone?

      DKA can be diagnosed by blood and urine tests.

The symptoms of DKA

• Deep, rapid breathing
• Dry skin and mouth
• Flushed face
• Fruity breath odour
• Nausea or vomiting, inability to keep down fluids
• Stomach pain

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What are the COMMON SYMPTOM???

Common Symptoms

* High levels of sugar in the blood (hyperglycemia)
* High levels of sugar in the urine (Glycosuria)
* Frequent urination (Polyuria)
* Extreme hunger (Polyphagia)  lead to excessive eating
* Long term extreme thirst (Polydipsia) 
* The presence of ketone in the blood (Ketonemia)
* The presence of ketone in the urine (Ketonuria)
* Weakness and tiredness.
* Involuntary weight loss
* Irritability
* Frequent infections
* Blurred vision
* Cuts/bruises that are slow to heal
* Tingling/numbness in the hands/feet
* Recurring skin, gum, or bladder infections

(ADA, 1995-2012)
 

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Do you know what are THE CRITERIA for diagnosis???

The American Diabetic Association (ADA) had deal out diagnostic criteria for diabetic mellitus in 1997 with follow-up in 2003 and 2010. There are four types of tests can be used for diagnosis of diabetes mellitus:

ü  Casual plasma glucose concentrationalso called as random venous plasma glucose concentration

– Casual referred to the blood is taken at any time of day without regarding the last meal times.

ü  Fasting plasma glucose (FPG)

– Fasting is defined as no caloric intake for 8 hours but water consumption is allowed.

ü  Oral glucose tolerance test(OGTT)

– Drink a glucose load containing the equivalent a 75 g of anhydrous glucose dissolved in 100 ml of water. The glucose level is compared before and 2 hours after glucose load intake. 

ü  A1C test also called the heamoglobinA1c, HbA1c, or glycohemoglobin test.

 – Blood glucose level is measured by the amount of glycosylated heamoglobin (HbA1c) in blood.

Table below show the criteria of blood glucose level diagnosis with diabetes mellitus published by World Health Organization (WHO) in 2006.  

In 2011, WHO had recommended anaddition of new criterion in diagnosis of diabetes mellitus which is A1c test. The result of HbA1c test reported in percentage form. The higher the percentage, the higher the blood glucose levels in an individual. The criteria show in a table below. 

The following table provides the blood test levels for diagnosis of normal, prediabetes (also called Impaired Fasting Glucose (IFG)), and diabetes.

 Source: Adapted from American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(Supp 1):S12,

Take note for pre-diabetes:

Ø  Fasting plasma glucose refer to impaired fasting glucose

Ø  OGTT refer to impaired glucose tolerance (1GT)

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