Speaker 1: 0:10

Hey guys, welcome back to PreviewLions podcast. This is Sarah, and today I'm very excited that we are going to break down that sugary drink that everybody loves to chug and take down in pregnancy and figure out why. And to do this I brought in an expert, dr Kevin Shrestha and I'm sorry if I murdered your last name, correct me there, but he is a high risk doctor, an OB, that's going to tell us exactly why we should care about this sugary drink, what is gestational diabetes and, more importantly, why it impacts not just our physical health for us and baby but also our mental health. So welcome, kevin, and thank you for the Preview Alliance podcast guest.

Speaker 2: 0:55

Thank you so much for having me. You nailed my last name, congratulations.

Speaker 3: 0:58

Okay, good.

Speaker 2: 0:59

Not the easiest to say, but I love that you're doing this. You know this is something that a lot of women deal with, and having avenues like yours, I think, is great, because I myself learned a lot from podcasts. Nowadays that's where I learned medical things, non medical things, and I think it's such an easy thing that we have at our fingertips so to have people like myself and other experts on to share some of our knowledge that you know you will experience in a pregnancy. But knowing a little bit ahead of time can help kind of calm some of that anxiety and just the unknown with everything related to it. So thank you again for having me.

Speaker 1: 1:30

Perfect. Well, let's dive into this. Okay, so what is gestational diabetes? It's a big, big word. Break it down for us and tell us is it like diabetes? We may have heard that, maybe our grandma has, or we know it's in our family history. Just give us the lay of the land here.

Speaker 2: 1:48

Yeah, so breaking it down into its two words gestational meaning relating to pregnancy or in the pregnancy time period, and then diabetes, some sort of abnormal processing of sugar that your body has right, and so that's essentially what it is is that inability to produce enough insulin or metabolize those sugars or carbohydrates that so happen to occur in pregnancy.

Speaker 2: 2:10

And, as you were alluding to, it is a little bit different from some of the other types of diabetes that we commonly know of type 1 and type 2 diabetes. Typically, when we think of type 1 diabetes, most patients that we see are going to be diagnosed relatively younger in age and really that comes from, we say, an autoimmune destruction or sort of their pancreas isn't making insulin. So not necessarily that they're resistant to insulin like our type 2 diabetics, which are commonly diagnosed later in life, but they just don't have enough. Type 2 is what we sometimes develop when we get older, what our moms, dads, aunts, uncles you know a lot of people have, and that truly is, over time, whether it's genetics or lifestyle or some combination of a lot of different factors, makes our body more resistant to insulin. So we are still making insulin, but it's just not enough and it's almost kind of like your type two physiology than more so your type one.

Speaker 1: 3:03

Okay. So how common is it? Is it at risk? You know, I think it's. It's one of those things that we're just like. We know we have to do it at this point of pregnancy. But why is it at this point of pregnancy? I mean, do I really have to do it? You know, these are things that go through my mind that I would love just to know more about it, just to say, okay, this is what we're doing Like. I know why I get my blood pressure checked, I know why I come in and you listen for the heartbeat, but why am I drinking this drink?

Speaker 2: 3:32

Yeah, that's totally fair. So it's relatively uncommon. So it probably affects less than 10% of pregnancies, somewhere around seven to 8% of pure gestational diabetes, and the timing that we usually recommend this for most patients is between 24 to 28 weeks, and there's a nice timing in that to where after 20 weeks, that's when we really see some of the changes in physiology of pregnancy starting to affect your body, right? You can imagine if you were well, 14, 16 weeks and we were to do a sugar test there. A lot of patients still get that test done that early, but in that instance it's really to see if you had any pre-existing diabetes or things that we may not have known about.

Speaker 2: 4:12

For a lot of different reasons, some people, like myself, don't go to the doctor that regularly, right, but when you're pregnant you are there all the time and so you're getting these checkups for your blood pressure, for sugar checks you probably wouldn't have had otherwise, and so it is a nice timing to sort of say all right, after 20 weeks, 24 to 28 weeks, what we are seeing here, we are confident, is due to your pregnancy related changes and there are some patients that are going to be more at risk. So we know patients who are overweight, if they have a family history of diabetes, if they're an older patient over 25, 30 years old, they have PCOS, so polycystic ovarian syndrome, or we know certain ethnicities are more likely to have it too, our Hispanic patients, african-american patients more likely to have it than our Caucasian patients. But you know, I sit here and tell you risk factors go out the window if you have someone with none of those things that end up testing positive for diabetes, which also happens a lot too.

Speaker 1: 5:08

And I think the common question is, like you know, we always say well, I think we're trying to do everything right. Right, you know, we survived the first trimester, we're feeling like we're normal, we're trying to eat what we should, we're trying to navigate this, and then we get this diagnosis and go on. Well, what did I do, you know? Is it a me thing? Where are we at? What does this mean? It can feel very overwhelming to get any kind of diagnosis when you're pregnant, right, let alone when you don't know anything about. So for that mom who's seen you and you have to, unfortunately, tell her hey, you failed your sugary, your sugar drink your first exam, right, then you go on. Correct me if I'm wrong, but it's like a three hour.

Speaker 2: 5:49

Correct we generally do in most places. We'll do a two step. So you do your one hour test, where you don't have to be fasting for it, and you'll get your blood drawn one hour later, and then your second test, like you were alluding to, is your three hour test.

Speaker 1: 6:10

We do like you to be fasting for your second test and you'll get blood drawn at the fasting level one, two and the three-hour to kind of look at all four values. So we're really seeing when we're drinking that drink. We're seeing if our body will respond appropriately to that super like charge of sugar. Is that what we're looking for?

Speaker 2: 6:21

Correct. We're assessing to see how well your body is metabolizing all those sugars, and what I tell moms who get this diagnosis is a lot of these things are out of your control. Some of it would be things that have been going on you know, your entire 20s, 30s or 40s.

Speaker 2: 6:36

Some of it are genetic factors, some of it are pregnancy specific things. I have patients who have gestational diabetes in one pregnancy and, for whatever reason, don't develop it in the next pregnancy, even though they're more likely to. So even specific pregnancy factors can change whether or not you develop diabetes and ultimately, it's not anything that we can do that we know can for sure prevent it. There are things that we know can reduce our risk factor for it, which I think we'll get into later on, but it is something that screening for can help watch out and reduce a lot of the complications that we see with this diagnosis.

Speaker 1: 7:11

So let's say she fell, now her three hour and you've gave her this diagnosis. What is she to expect from here? What is her day to day going to look like with this? What is seeing you going to look like with this?

Speaker 2: 7:37

doing it. Some patients who are with an OBGYN who may not be as experienced or as familiar may send you to myself or someone like myself which is a maternal fetal medicine high-risk specialist. So you may or may not see somebody in high-risk obstetrics. From here, what we generally recommend is you meet with a nutritionist and you meet with a dietician. Pregnancy changes a lot of things and your listeners and your people who are in this podcast know a lot more about that than I do. But it changes a lot of things and one of those things is how your body processes different foods and sugars and just kind of reacts to your day to day. So we always find it's helpful and we have a great set of diabetic educators and nutritionists that help patients with what snacks they should eat, how they should eat, the timing of meals. All those things play a factor in addition to increasing your exercise.

Speaker 2: 8:19

If you're a little bit more sedentary and kind of those typical lifestyle changes that we all hear about, that is kind of what the first step that I always say that patients should look out for, because diabetes or gestational diabetes comes in two flavors. Right, you have your A1 patients, who are generally well-controlled with just diet and lifestyle. And then there are other patients, which we classify as A2, that need an additional help, so need some medications, namely insulin, to do that. And how we know if you are well-controlled or not is by checking your blood sugar. Most, if not all, my patients who I diagnose with gestational diabetes for their first time this is a new thing for them. They're not a diabetic.

Speaker 2: 8:56

Outside of pregnancy they haven't routinely checked their blood sugar, and so from what I've seen, that can be one of the biggest adjustments, because for that time period when we are figuring out, are we at a point where we feel good about your blood sugars or do we need additional interventions or medications? We generally recommend to check it about four times a day, so that can be fasting first thing when you wake up in the morning without any food, and then about two hours after you eat each meal breakfast, lunch and dinner. And that's not easy. I get my skin pricked when I go to the doctor and kind of testing things out, and even just doing one is not comfortable. But doing it every day for weeks on end can be very stressful in the beginning.

Speaker 1: 9:35

Totally, and then it's a two-step right. So she starts medicine, and that could be another thing. I mean, you probably get this question a lot. Just, we don't really feel a certain way about starting medicine sometimes, right. So I think it all comes to a good point of why would she be taking medicine? Why do we care? What is the negative outcomes for her and baby if this is not controlled?

Speaker 2: 9:57

Yeah, that's a great question and that's what I always come back to as really helping patients understand why we're doing something right, because it always makes me feel better when I'm doing something if I know that I'm preventing or going towards a certain aim, and so I always like to link the two and what we know in patients who have gestational diabetes that have sugars that are above goal so uncontrolled sugar values is there a risk for both mom and for baby.

Speaker 2: 10:21

So, looking at mom, we have increased risks of high blood pressure diseases, things like preeclampsia, gestational hypertension, increased risk of needing a C-section in labor or having an obstructed labor, and then for a woman's life, there's actually an increased risk of developing diabetes decades down the road too, in patients who do and don't have gestational diabetes.

Speaker 2: 10:42

When we look at babies that extra sugar obviously babies need that sugar, but there's a point in time where too much can be bad, so that extra sugar can cause macrosomia for large babies, can cause risk that babies may have hypoglycemia or trouble keeping their sugar levels good after birth, in addition to having the difficulties or struggles that women with big babies may struggle with right. So shoulder dystocia or that shoulder getting stuck in birth, causing damage there, needing a C-section because of the obstructed labor. In very rare instances, uncontrolled sugars can cause stillbirth and then, just like a mom, can have consequences later on of obesity and type 2 diabetes. We can still see similar things in babies too, and a lot of these things can be reduced, especially things related to pregnancies and the birth process, by controlling your sugars to a normal range at the goal and that's ultimately what we try to stress is controlling your sugars really can help you and baby.

Speaker 1: 11:38

And is there anything? If a woman's trying to get pregnant, she's early pregnant, she's listening to this and she going okay, we don't want to go down this way. What tell me things to do? Tell me, what should I be doing? That's preventative. Like you said, there's some things out of control, and that's what we tell people from mental health too. We can't control our family history, we can't control our husband's deploy, we can't control this. But what can you tell patients who are like give me something to control.

Speaker 2: 12:04

Yeah, and I think a lot of the things are similar with keeping a healthy weight right. Doing exercise like they tell us to do, about 30 minutes of moderate intensity exercise each day throughout the week. Keeping a balanced diet right. So keeping a diet that has a reasonable percentage of your carbohydrates, of your proteins and your fat, not eliminating things completely, but something well balanced, using things like complex carbohydrates. So all of the things that we hear about truly does help reduce your risk of developing gestational diabetes, and part of that comes from helping with your own insulin profile, helping with your own weight to keep that in a more normal range as well.

Speaker 1: 12:41

And I would say most OBs offices, right, and certainly MFMs, but if they go and she's going, I don't even know where to start with macros. I don't even know about protein, I don't know this. She could look, she could say help educate me. Can I meet with a dietician? Can I meet with a nutritionist? You know, tell me what my risk factors are here and just really going in with like, hey, let's see where I'm at, let's see where I'm at risk for, and I think that's a good segue to something that we have seen.

Speaker 1: 13:09

So we always scream for this, for maternal mental health conditions, and there is a lot of research that says it seems like there's a lot of research that says it seems like there's a lot of things that go bi-directionally with postpartum depression and anxiety, but gestational diabetes is one of them, you know. Have you seen this in your practice? Do you see the correlation? Does that make sense to you as someone who's seen patients day in and day out?

Speaker 2: 13:30

I definitely can and a lot of my job when I see women with gestational diabetes and a lot of other pregnancy conditions is a lot of reassurance for them, you know, reassurance that they're doing the right thing, that they're not the one to blame quote, unquote, you know for doing this to themselves in their pregnancy, because it is a lot. It is a lot of anxiety with what your blood sugars are going to be. There's an entire lifestyle change that some women have to take up to do the finger sticks, which aren't comfortable. They can be pretty painful. We talk about these risks and we say these things not to scare patients and not to scare the person in front of us, but to sort of indicate why these things are important to care about and why we take the steps to do all of these blood sugar checks and add insulin and things.

Speaker 2: 14:10

But it still can be anxious to hear that I might have a baby that need to go to the NICU because it's having trouble picking sugar up. I may need to have a C-section. If I have a really big baby. What does my life look like later on? All these things I've had to talk to patients about and see flowing through their heads and, like you were saying, it can be overwhelming at times, and so a lot of what I do is provide reassurance, saying that we are doing the right thing. Sitting here in front of me looking at your sugars, taking your insulin. Those are the steps that you can do to get the best outcome for you and baby and, at the end of the day, some of this is not in our control. It's not in your control either. It's just how your pregnancy goes, just like having gestational diabetes isn't necessarily in either control too, but I definitely see that connection a good bit in our practice.

Speaker 1: 14:56

And do you think, just in general, if someone is experiencing gestational diabetes, she needs to be aware of just of her mental health and talking to her provider about you know if she hasn't ever been screened? Or what is postpartum depression? What is depression? What does anxiety look like? How would you, as a provider, like to be approached about a patient wanting to talk to her about mental health? I think people sometimes think, oh my gosh, I got five minutes with him. We've talked about all my sugars for the past week and now I'm feeling anxious. How do I tell you I'm feeling anxious?

Speaker 2: 15:26

Yeah, and that's the biggest hurdle right Is just to be out with it.

Speaker 2: 15:30

That is the biggest thing I think in general in medicine and pregnancy and anything to help you is we have to know what's going on.

Speaker 2: 15:37

And it can be super anxious and very self-conscious and hard just to be out there and saying, hey, I'm struggling with this new diagnosis or the insulin or the sugars, but the person sitting on the other side can't necessarily help you if we don't know what's going on, and that's easier said than done. But hopefully the more times you hear about how we truly want to know everything that's going on to be able to plug you into the right resources or see more frequently and kind of talk about these things, just knowing about it. And you know, in our practice we like to screen for mental health pretty frequently because no matter if it's the first trimester or patient in their first trimester dealing with hyperemesis, someone just struggling through normal pregnancy, things that are difficult postpartum, like that can happen at any point in a pregnancy and so truly would like to know about it as soon as it can. That way we can do something or at least get the help and talk about it, which hopefully can help.

Speaker 1: 16:28

That's reassuring. And so the mom who said, okay, I had gestational diabetes last pregnancy, am I going to get it again? What do you say to them?

Speaker 2: 16:38

It's always hard to have that crystal ball and be able to predict, but our antennas are up and my awareness for you and your next pregnancy is going to be higher, and we touched on this a little bit.

Speaker 2: 16:49

But there are some patients who get an earlier sugar test, usually around 14, 16 weeks or so, at around the end of the first, beginning of the second trimester, and these would be patients exactly like this person right who has had this in a previous pregnancy. The other part in having a pregnancy and then delivering is the important thing really is to see all right, is this gestational diabetes, which by the definition should go away after I deliver and once I'm out of my pregnancy window? Or is this a sign that I probably had some insulin resistance? Not maybe not always type two diabetes, but almost kind of like a pre diabetes, if you will. That may be lingering on that I will now have to deal with for my life, right? So what we recommend is around that six to eight week period when you're seeing us back for your postpartum visit, we do, surprise, surprise, another sugar test. We call it a two hour sugar test here and that really is the test to see. Do we have anything lingering on that. Now we need to follow in when we're not pregnant.

Speaker 3: 17:47

What did?

Speaker 2: 17:48

all this resolve, and if we were to get pregnant again, we kind of are on alert one more time. We kind of, you know, are on alert one more time.

Speaker 1: 17:54

And you know, I can imagine just hearing well, you have this now, even in postpartum, and that six weeks checkup is not a fun checkup for many people. That news there, the correlation with postpartum depression, of going now, this is my life, now I have to check. You know, and I think to your point. I think this age group of moms we don't really have primary care providers. You guys become our primary care providers and OBs. So we're not. We wouldn't have known if we were struggling with our sugars, we wouldn't have known. Maybe we do have high blood pressure, but heck, no one's ever checked it before, right All these things. So I think that's an important thing is again looking. You guys, you're not just there for us during the pregnancy, it's the postpartum part that we have to lean in on and figure it out with you as well.

Speaker 2: 18:44

Exactly exactly, and we commonly talk about the six-week visit, but the postpartum period lasts much longer than that. You know, we think of looking at four, five, six, some people go out to 12 months, but truly is a longer period of time than just your six-week checkup.

Speaker 1: 18:59

That is, I think you know I feel a lot better. I wish I would have known this conversation before I had two children. But you know that's the world, we're evolving and learning. But if there's one thing that you could say to a mom just to encourage her as a provider about, it doesn't even have to be about gestational diabetes, just being pregnant, postpartum what is some kind of advice or just goodwill you would want to pass along to her that you know we don't have time to hear that from our providers, often in the exam rooms.

Speaker 2: 19:28

Yeah, I really do think the biggest thing that I always tell women is you're doing a good job, you are doing great. And it may not seem like it when we are tweaking blood sugars and insulin or talking about blood pressure to bring you into the hospital, but truly, there are a lot of things in pregnancy that you can't control and that we can't control. But sitting in front of us and coming to your clinic visits and doing your insulin and medications and all the things that are anxious and time consuming and things that we just don't want to do, that is the thing that you are doing to keep you safe and keep your baby safe.

Speaker 1: 20:02

That's wonderful and that is something we all need to hear every single day. So thank you, Kevin. We appreciate you Listeners. I hope this has been just as educational for you as it's been me. I will make sure to link some great gestational diabetes information in the podcast notes and, Kevin, thank you for what you do and we would love to have you back.

Speaker 2: 20:21

We'd love to be back. Thanks for having me.

Speaker 1: 20:22

All right, guys, we will see you next week. Take care.

Speaker 3: 20:27

Maternal mental health is as important as physical health. The Preview Alliance podcast was created for and by moms dealing with postpartum depression and all its variables, like anxiety, anger and even apathy. Hosted by ceo founder sarah parkhurst and licensed clinical social worker whitney gay, each episode focused on specific issues relevant to pregnancy and postpartum. Join us and hear how other moms have overcome mental health challenges, as well as access tips and suggestions on dealing with your own challenges as moms. You can also browse our podcast library and listen to previous episodes at any time. Please know you're not alone on this journey. We're here to help.