gestational diabetes mellitus, temporary condition in which blood sugar (glucose) levels increase during pregnancy and return to normal after delivery.
A healthy pregnancy is characterized by increased nutrient utilization, increased insulin resistance, and increased insulin secretion. Blood glucose concentrations tend to be lower in pregnant women than in nonpregnant women because the mother is supplying glucose to the growing fetus. All pregnant women have some degree of insulin resistance as a result of the normal secretion of several placental hormones, including placental growth hormone, placental lactogen, progesterone, and corticotropin-releasing hormone, which stimulates the production of adrenocorticotropic hormone (ACTH) in the pituitary gland and cortisol in the adrenal glands. In some cases, insulin resistance is increased by excessive weight gain during pregnancy. If insulin secretion does not increase sufficiently to counter the insulin resistance imposed by these changes, gestational diabetes occurs. The condition is diagnosed when blood glucose concentrations reach 92–125 mg per 100 ml (5.1–6.9 mmol/l) after fasting or when blood glucose concentrations equal or exceed 180 mg per 100 ml (10.0 mmol/l) one hour after ingesting a glucose-rich solution or reach 153–199 mg per 100 ml (8.5–11.0 mmol/l) two hours after ingesting the solution.
The frequency worldwide of gestational diabetes varies from about 1 to 15 percent of pregnant women. The large variability in frequency is partly due to the fact that there is no widely agreed upon definition of gestational diabetes. However, no matter how it is defined, it is more common among obese women and African American and Asian women than among women of European descent. The outcomes of gestational diabetes also vary widely, ranging from large babies (fetal macrosomia), birth trauma, and neonatal hypoglycemia (abnormally low blood glucose levels) to maternal preeclampsia and increased perinatal morbidity.
Risk factors for gestational diabetes include older age, obesity, previous delivery of a large baby, and a family history of diabetes mellitus. Some physicians believe that all pregnant women should be tested for gestational diabetes at 24 to 28 weeks of gestation, whereas other physicians limit testing to women who have risk factors for gestational diabetes. The primary method used to diagnose the condition is an oral glucose tolerance test, in which blood glucose is measured hourly for several hours after ingestion of a large quantity of glucose (usually 75 or 100 grams). While gestational diabetes is by definition transient, affected women have an increased risk of developing type II diabetes later in life.
diabetes mellitus, disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood.
diabetesSelf-testing glucose meter for measuring blood glucose levels in patients with diabetes mellitus.
Diabetes is a major cause of morbidity and mortality, though these outcomes are not due to the immediate effects of the disorder. They are instead related to the diseases that develop as a result of chronic diabetes mellitus. These include diseases of large blood vessels (macrovascular disease, including coronary heart disease and peripheral arterial disease) and small blood vessels (microvascular disease, including retinal and renal vascular disease), as well as diseases of the nerves.
Causes and types
The role of the islets of LangerhansThe islets of Langerhans are responsible for the endocrine function of the pancreas. Each islet contains beta, alpha, delta, and pancreatic polypeptide (PP) cells that are responsible for the secretion of pancreatic hormones. Beta cells secrete insulin, a well-characterized hormone that plays an important role in regulating glucose metabolism.
Insulin is a hormone secreted by beta cells, which are located within clusters of cells in the pancreas called the islets of Langerhans. Insulin’s role in the body is to trigger cells to take up glucose so that the cells can use this energy-yielding sugar. Patients with diabetes may have dysfunctional beta cells, resulting in decreased insulin secretion, or their muscle and adipose cells may be resistant to the effects of insulin, resulting in a decreased ability of these cells to take up and metabolize glucose. In both cases, the levels of glucose in the blood increase, causing hyperglycemia (high blood sugar). As glucose accumulates in the blood, excess levels of this sugar are excreted in the urine. Because of greater amounts of glucose in the urine, more water is excreted with it, causing an increase in urinary volume and frequency of urination as well as thirst. (The name diabetes mellitus refers to these symptoms: diabetes, from the Greek diabainein, meaning “to pass through,” describes the copious urination, and mellitus, from the Latin meaning “sweetened with honey,” refers to sugar in the urine.) Other symptoms of diabetes include itching, hunger, weight loss, and weakness.
There are two major forms of the disease. Type 1 diabetes, formerly referred to as insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, usually arises in childhood. Type 2 diabetes, formerly called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes, usually occurs after age 40 and becomes more common with increasing age.
Learn about type I and type II diabetes mellitus, the genetic and environmental risk factors and ways to manage itA discussion of type I and type II diabetes mellitus.
Type 1 diabetes accounts for about 5 to 10 percent of cases of diabetes. Most cases of type 1 diabetes develop in children or adolescents, but about 20 percent of new patients are adults. The frequency of type 1 diabetes varies widely in different countries, from less than 1 case per 100,000 people per year in China and parts of South America to more than 20 cases per 100,000 people per year in places such as Canada, Finland, Norway, Sweden, and the United Kingdom. Most patients present with symptoms of hyperglycemia, but some patients present with diabetic ketoacidosis, a clear indication that insulin secretion has significantly deteriorated.
Type 1 diabetes is usually caused by autoimmune destruction of the islets of Langerhans of the pancreas. Patients with type 1 diabetes have serumantibodies to several components of the islets of Langerhans, including antibodies to insulin itself. The antibodies are often present for several years before the onset of diabetes, and their presence may be associated with a decrease in insulin secretion. Some patients with type 1 diabetes have genetic variations associated with the human leukocyte antigen (HLA) complex, which is involved in presenting antigens to immune cells and initiating the production of antibodies that attack the body’s own cells (autoantibodies). However, the actual destruction of the islets of Langerhans is thought to be caused by immune cells sensitized in some way to components of islet tissue rather than to the production of autoantibodies. In general, 2 to 5 percent of children whose mother or father has type 1 diabetes will also develop type 1 diabetes.
Type 2 diabetes is far more common than type 1 diabetes, accounting for about 90 percent of all cases. The frequency of type 2 diabetes varies greatly within and between countries and is increasing throughout the world. Most patients with type 2 diabetes are adults, often older adults, but it can also occur in children and adolescents. There is a stronger genetic component to type 2 diabetes than to type 1 diabetes. For example, identical twins are much more likely to both develop type 2 diabetes than to both develop type 1 diabetes, and 7 to 14 percent of people whose mother or father has type 2 diabetes will also develop type 2 diabetes; this estimate increases to 45 percent if both parents are affected. In addition, it is estimated that about half of the adult Pima Indian population in Arizona has type 2 diabetes, whereas in the entire United States it is estimated that about 10 percent of the population has type 2 diabetes.
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Many patients with type 2 diabetes are asymptomatic, and they are often diagnosed with type 2 diabetes when routine measurements reveal high blood glucose concentrations. In some patients the presence of one or more symptoms associated with the long-term complications of diabetes leads to a diagnosis of type 2 diabetes. Other patients present with symptoms of hyperglycemia that have been present for months or with the sudden onset of symptoms of very severe hyperglycemia and vascular collapse.
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Type 2 diabetes is strongly associated with obesity and is a result of insulin resistance and insulin deficiency. Insulin resistance is a very common characteristic of type 2 diabetes in patients who are obese, and thus patients often have serum insulin concentrations that are higher than normal. However, some obese persons are unable to produce sufficient amounts of insulin, and thus the compensatory increase in response to increased blood glucose concentrations is inadequate, resulting in hyperglycemia. If blood glucose concentration is increased to a similar level in a healthy person and in an obese person, the healthy person will secrete more insulin than the obese person.
People with type 2 diabetes can control blood glucose levels through diet and exercise and, if necessary, by taking insulin injections or oral medications. Despite their former classifications as juvenile or adult, either type of diabetes can occur at any age.
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