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POSITION STATEMENT
DEFINITION, DETECTION, AND DIAGNOSIS
Definition: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy (1). The definition applies whether insulin or only diet modification is used for treatment and whether or not the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy.
Approximately 4% of all pregnancies are complicated by GDM, resulting in ~135,000 cases annually. The prevalence may range from 1 to 14% of all pregnancies, depending on the population studied and the diagnostic tests employed.
Detection and diagnosis: Risk assessment for GDM should be undertaken at the first prenatal visit. Women with clinical characteristics consistent with a high risk of GDM (marked obesity, personal history of GDM, glycosuria, or a strong family history of diabetes) should undergo glucose testing (see below) as soon as feasible. If they are found not to have GDM at that initial screening, they should be retested between 24 and 28 weeks of gestation. Women of average risk should have testing undertaken at 24 to 28 weeks of gestation. Low-risk status requires no glucose testing, but this category is limited to those women meeting all of the following characteristics:A fasting plasma glucose level >126 mg/dl (7.0 mmol/l) or a casual plasma glucose >200 mg/dl (11.1 mmol/l) meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge. In the absence of this degree of hyperglycemia, evaluation for GDM in women with average or high-risk characteristics should follow one of two approaches:
- Age 25 years.
- Weight normal before pregnancy.
- Member of an ethnic group with a low prevalence of GDM.
- No known diabetes in first-degree relatives.
- No history of abnormal glucose tolerance.
- No history of poor obstetric outcome.
One-Step approach: Perform a diagnostic oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening. The one-step approach may be cost-effective in high-risk patients or populations (e.g., some Native-American groups).
Two-Step approach: Perform an initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-g oral glucose load (glucose challenge test [GCT]) and perform a diagnostic OGTT on that subset of women exceeding the glucose threshold value on the GCT. When the two-step approach is employed, a glucose threshold value >140 mg/dl (7.8 mmol/l) identifies approximately 80% of women with GDM, and the yield is further increased to 90% by using a cutoff of >130 mg/dl (7.2 mmol/l).
With either approach, the diagnosis of GDM is based on an OGTT. Diagnostic criteria for the 100-g OGTT are derived from the original work of O'Sullivan and Mahan, modified by Carpenter and Coustan, and are shown in Table 1. Alternatively, the diagnosis can be made using a 75-g glucose load and the glucose threshold values listed for fasting, 1 h, and 2 h; however, this test is not as well validated as the 100-g OGTT.
OBSTETRIC AND PERINATAL CONSIDERATIONS
The presence of fasting hyperglycemia (>105 mg/dl or >5.8 mmol/l) may be associated with an increase in the risk of intrauterine fetal death during the last 4 to 8 weeks of gestation. Although uncomplicated GDM has not been associated with increased perinatal mortality, GDM increases the risk of fetal macrosomia and other neonatal morbidities including hypoglycemia, hypocalcemia, polycythemia, and jaundice. GDM is associated with an increased frequency of maternal hypertensive disorders and the need for cesarean delivery. The latter complication may result from fetal growth disorders and/or alterations in obstetric management due to the knowledge that the mother has GDM.
Long-term considerations: Women with GDM are at increased risk for the development of diabetes, usually type 2, after pregnancy. Obesity and other factors that promote insulin resistance appear to enhance the risk of type 2 diabetes after GDM, while markers of islet cell directed autoimmunity are associated with an increase in the risk of type 1 diabetes. Offspring of women with GDM are at increased risk of obesity, glucose intolerance, and diabetes in late adolescence and young adulthood.
THERAPEUTIC STRATEGIES DURING PREGNANCY
Monitoring
- Maternal metabolic surveillance should be directed at detecting hyperglycemia severe enough to increase risks to the fetus. Daily self-monitoring of blood glucose (SMBG) appears to be superior to intermittent office monitoring of plasma glucose. For women treated with insulin, evidence indicates that postprandial monitoring is superior to preprandial monitoring.
- Urine glucose monitoring is not useful in GDM. Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction.
- Maternal surveillance should include blood pressure and urine protein monitoring to detect hypertensive disorders.
- Increased surveillance for pregnancies at risk for fetal demise is appropriate, particularly when fasting glucose levels exceed 105 mg/dl (5.8 mmol/l) or pregnancy progresses past term. The initiation, frequency, and specific techniques used to assess fetal well-being will depend on the cumulative risk the fetus bears from GDM and any other medical/obstetric conditions present.
- Assessment for asymmetric fetal growth by ultrasonography, particularly in early third trimester, may aid in identifying fetuses that can benefit from maternal insulin therapy (see below).
Management
- All women with GDM should receive nutritional counseling, by a registered dietitian when possible, consistent with the recommendations by the American Diabetes Association. Individualization of medical nutrition therapy (MNT) depending on maternal weight and height is recommended. MNT should include the provision of adequate calories and nutrients to meet the needs of pregnancy and should be consistent with the maternal blood glucose goals that have been established. Non-caloric sweeteners may be used in moderation.
- For obese women (BMI > a 30 to 33% calorie restriction (an intake of ~1,800 kcal/day) has been shown to reduce hyperglycemia and plasma triglycerides with no increase in ketonuria (2). Obese women may do well with moderate calorie restriction as a goal.
- Insulin is the only pharmacologic therapy that has been shown to reduce fetal morbidities when added to MNT. Selection of pregnancies for insulin therapy can be based on measures of maternal glycemia with or without assessment of fetal growth characteristics. When maternal glucose levels are used, insulin therapy is recommended when MNT fails to maintain fasting whole blood glucose levels < 95 mg/dl (5.3 mmol/l) or 2-h postprandial whole blood glucose levels < 120 mg/dl (6.7 mmol/l). Insulin should be administered to maintain maternal glycemia below these levels.
- Measurement of the fetal abdominal circumference early in the third trimester can identify a large subset of infants with no excess risk of macrosomia in the absence of maternal insulin therapy. This approach has been tested primarily in pregnancies with maternal fasting serum glucose levels < 105 mg/dl (5.8 mmol/l).
- Human insulin should be used when insulin is prescribed, and SMBG should guide the doses and timing of the insulin regimen. The use of insulin analogs has not been adequately tested in GDM.
- Oral glucose-lowering agents are not recommended during pregnancy.
- Women with an active lifestyle should be encouraged to start or continue a program of moderate exercise, which has been shown to lower maternal glucose concentrations.
- GDM is not of itself an indication for cesarean delivery or for delivery before 38 weeks completed gestation. Prolongation of gestation past 38 weeks increases the risk of fetal macrosomia without reducing cesarean rates, so that delivery during the 38th week is recommended unless obstetric considerations dictate otherwise.
- Breast-feeding, as always, should be encouraged in women with GDM.
LONG-TERM THERAPEUTIC CONSIDERATIONS
Reclassification of maternal glycemic status should be performed at least 6 weeks after delivery and according to the guidelines of the "Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus" (3). If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals. Women with IFG or IGT in the postpartum period should be tested at more frequent intervals. Patients should be educated regarding lifestyle modifications that lessen insulin resistance, including maintenance of normal body weight through MNT and physical activity. Medications that worsen insulin resistance (e.g., glucocorticoids, nicotinic acid) should be avoided if possible. Patients should be advised to seek medical attention if they develop symptoms suggestive of hyperglycemia. Education should also include the need for family planning to assure optimal glycemic regulation from the start of any subsequent pregnancy. Low-dose estrogen-progestogen oral contraceptives may be used in women with prior histories of GDM, as long as no medical contraindications exist.
Offspring of women with GDM should be followed closely for the development of obesity and/or abnormalities of glucose tolerance.
REFERENCES
1. Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2):B1- B167, 1998
2. Franz MJ, Horton ES, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, Henry RR, Hoogwerf BJ, Stacpoole PW: Nutrition principles for the management of diabetes and related complications (Technical Review). Diabetes Care 17:490-518, 1994
3. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 23 (Suppl. 1):S4-S19, 2000
The recommendations in this paper are based on the evidence reviewed in the following publications: Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 21 (Suppl. 1):S5 S19, 1998; and the Proceedings of the 4th International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2):B1 B167, 1998.
Originally approved 1986. Most recent review/revision, 1999.
Abbreviations:
- GCT, glucose challenge test
- GDM, gestational diabetes mellitus
- IFG, impaired fasting glucose
- IGT, impaired glucose tolerance
- MNT, medical nutrition therapy
- OGTT, oral glucose tolerance test
- SMBG, self-monitoring of blood glucose.
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MOONDRAGON'S DIABETIC DIET SUGGESTIONS
Dietary changes are an important aspect of the treatment and specific diet instructions will be provided. Following the prescribed diet will decrease the risks to mother and unborn child. A low fat, high fiber diet including raw vegetables and fresh vegetable juice is recommended. Avoid saturated fats and simple sugars. Avoid or restrict alcohol use.
These diet changes will involve increased fiber intake, fat restriction, elimination of concentrated sweets, and possibly the monitoring of caloric intake to prevent excessive weight gain.
Consultation with a dietician is often recommended for educational purposes, to answer your dietary questions and to provide follow-up encouragement.
BENEFICIAL DIETARY SUPPLEMENTS & PRODUCTS
The nutrients below may be taken in combination with one another unless otherwise noted or as recommended by your midwife or health care provider. Those suffering from gestational diabetes should consult a midwife, health care provider or dietary consultant before using any supplement or herb.
Multi-vitamin & Multi-Mineral for Diabetics, Complete Diabetic Vitamin Formula, 90 Tabs, Iron Free, All Natural, Nature's Way, Vegetarian - Twice daily multivitamin formula for diabetics with Alpha Lipoic Acid, Fenugreek and GTF Chromium for daily support.
Once-A-Day Diabetic Multiple Vitamins, Alpha Betic, 30 Caplets - Alpha Betic vitamins are the multi-vitamin mineral supplement designed by doctors for people with diabetes, their families, and those On weight-reducing diets. In addition to Lutein, this formula contains chromium and 20 other diabetes specific nutrients.
Blood Sugar Formula w/ Gymnema Extract, Nature's Way, 90 Caps - Contains GTF Chromium part of an important cofactor for insulin as well as other herbs and minerals used in support of healthy blood sugar levels. This formula represents the powerful synergy of current scientific research and traditional herbal medicines.
Insulin Health X-Factors, Blood Sugar Supplement, 60 Tablets, trace Minerals - Insulin Health X-Factors is a revolutionary cutting edge dietary supplement specifically designed to support healthy insulin metabolism as well as cardiovascular function.
Sugar Balancer, TCM Formula, Huafen Yuxiao, 60 Caps - Chinese medicine uses the time-honored formula to supplement the Qi and Yin and to maintain healthy blood and urine sugar level and healthy functions of the autonomic nerve.
Diabetes Extract Formula Tincture, 100% Organic, 2 fl. oz. - Truman's Diabetes Tea is targeted to enable the pancreas to produce its own insulin and to bring blood sugar levels to a safe range of somewhere between 110-140 without additional medication.
Diabetes Formula Tincture, 100% Organic, 2 fl. oz. - This diabetic formula may help decrease the amount of insulin required by the individual.
Reversing Diabetes, Revised and Updated, by Julian Whitaker, M.D. - This bestselling guide will arm you with safer and equally effective ways of treating diabetes through a sensible diet, exercise, and specific nutritional supplement suggestions. You can improve blood sugar control, reduce if not eliminate reliance on medication, decrease risk of complications and diseases associated with diabetes.
Sugar Control Herbal Tea, 20 Tea Bags - For maintaining normal blood sugar and blood fat level, urine sugar level.
Stevia Extract Powder, NOW Foods, 100 Packets per Box - This Stevia Extract Powder is a packeted form of Stevia rebaudiana, the "Honeyleaf" with zero fat, zero glycemic index, zero calories, and no bitter aftertaste. Stevia is an excellent all natural sugar substitute.
Liquid Flavored Sweetleaf Stevia, 4 Flavored Stevia Bottles, 6 ml, 60 Servings Each - Flavored Sweetleaf Stevia has four exciting all natural, zero calories, zero carbs, zero glycemic index. Flavored Stevia bottles at an exciting value of only one penny per drop.
All Natural Travel Size Stevia Sweetener, SteviaClear Liquid, 6 ml, 60 Servings - Stevia Sweetener is an all natural, no calories, no carbs, no bitter aftertaste sugar substitute sweetener with endless uses.
Noni Juice, Trace Minerals, 32 fl. oz. - Trace Minerals Noni Juice product may provide nutritional support for Bio-Electric Health and Body Mineral Balancing.
Omega 3 Fish Oil Mood Aid, EFA Gold, Enteric Coated, Nature's Way, 60 Softgels - Research suggests a correlation between consuming more omega-3 fatty acids from fish and better emotional health. MoodAide provides a convenient way to add an effective amount to your diet.
Flax Protein / Fiber / Lignan Cold Milled Powder Plus Omega 3, Certified Organic, Nature's Way, 16 oz. - With 6 grams of fiber, 300 mg Lignan and 5 grams Protein (including 18 amino acids) per serving, Nature's Way EFAGold is one of nature's richest sources of protein, fiber and essential fatty acids.
Ginkgo Biloba Extract, Standardized, Nature's Way, 60 mg, 120 Vcaps - Supports circulation to the brain as well as the extremities. This is achieved by maintaining healthy blood vessel tone and reducing blood viscosity. Additionally, Ginkgo biloba is a proven free radical scavenger and antioxidant.
Opuntia (Prickly Pear), Nature's Way, 250 mg, 100 Caps - Nature's Way Opuntia prickly pear flowers (Opuntia ficusindica) were traditionally used as medicine for male urinary discomforts. It was also used externally as an ointment.
Glucomannan (Konjac Fiber), Nature's Way, 665 mg, 180 Caps - Nature's Way Glucomannan (Amorphophallus konjac fiber) is a 100% dietary fiber source obtained from the root of the konjac plant.
Gymnema Sylvestre Tincture, 100% Organic, 2 fl. oz. - For diabetes, hypoglycemia, and as a digestive tonic. Used for weight reduction, to help prevent tooth decay, and restore pancreatic function. Helps to block the absorption of sugar in the digestive tract.
Cinnamon Bark (Cinnamonum verum), NOW Foods, 600 mg, 240 Caps - Experiments conducted by the USDA have shown that this - the variety we call "True Cinnamon" can lower blood sugar by mimicking insulin, activating insulin receptors and working with insulin in the cells to reduce blood sugar by up to 20 percent.
Bhumy Amalaki Powder (Phyllanthus niruri), 100% Organic, 8 oz. Bulk - Bhumy Amalaki is employed for numerous conditions including blennorrhagia, colic, diabetes, dysentery, fever, flu, tumors, jaundice, vaginitis, and dyspepsia.
Huckleberry (Vaccinium myrtillus) Tincture, 100% Organic, 2 fl. oz. - Huckleberry leaf is used by Naturopathic Physicians to treat sugar diabetes and ailments of the kidneys and gallbladder. Huckleberry promotes insulin production.
Diabetic Insulin Support Tincture, 100% Organic, 2 fl. oz. - The Diabetic Insulin Support Formula provides synergistic support for the adrenals, kidneys and pancreas and may help those with insulin dependent diabetes.
Stevia Clear Liquid Tincture, Wisdom Herbs, 4 fl oz. - Stevia Clear Liquid Tincture is an excellent diabetic aid which nourishes the pancreas, helping to achieve healthful blood sugar levels.
Stevia Clear, Chocolate Raspberry Liquid Tincture, 2 fl oz. - The best selling SteviaClear has added delicious natural flavors to create the world's most amazing and versatile zero calorie, zero carb dietary supplement.
Stevia Clear, Vanilla Creme Liquid Tincture, 2 fl oz. - The best selling SteviaClear has added delicious natural flavors to create the world's most amazing and versatile zero calorie, zero carb dietary supplement.
Stevia Clear, Valencia Orange Liquid Tincture, 2 fl oz. - The best selling SteviaClear has added delicious natural flavors to create the world's most amazing and versatile zero calorie, zero carb dietary supplement.
Stevia Glycerite, Alcohol Free, NOW Foods, 2 fl oz. - Stevia glycerite is intended for dietary supplement purposes only. Stevia Glycerite can be mixed into water and diluted.
Stevia Extract White Powder, 25 grams - Stevia extract has a delicious and refreshing taste that can be 30 times sweeter than sugar. Stevia is also an excellent diabetic aid which nourishes the pancreas, helping to achieve healthful blood sugar levels.
Manuka Honey Bio Active 10+, 500 grams - Comvita Bio Active 10+ Manuka Honey contains a high level of antibacterial activity not found in other honeys. For digestive health and to assist the digestive process.
Coral Calcium (Okinawa) Plus Magnesium & Vitamin D, 100% Natural, NOW Foods, 500 mg, 100 Vcaps - Okinawa Coral Calcium Plus with Magnesium, Vitamin D and 70 other trace minerals provides essential minerals, restores body alkalinity, supports the immune system, and is bio available for better absorption.
Buchu Leaves Tincture, 100% Organic, 2 fl. oz. AHH - Buchu leaves act as a diuretic and antiseptic, and today is used in treating inflammation of the urethra, blood in the urine, bladder infections, and other chronic urinary tract disorders.
Vanadium Ionic Mineral Supplement, Fully Absorbable, 100 +/- ppm, 16 fl. oz. - WaterOz Ionic Vanadium is a pure liquid Vanadium supplement. Vanadium regulates the circulatory system, helps reduce cholesterol levels and buildup in the central nervous system, lowers elevated blood sugar and is believed to help reduce the incidence of heart attack. Vanadium assists insulin in metabolizing glucose.
GlyMordica Bitter Melon, 100% Natural, 450 mg, 60 Caps - Bitter Melon is one of the few agents which has the potential to bolster a flagging pancreas. Bitter Melon regulates blood sugar levels. Known for it's ability to help with liver problems, Diabetes and HIV, also an excellent natural common cold remedy.
Alpha Lipoic Acid w/ Rosemary, Nature's Way, Pharmaceutical Grade, 50 mg, 60 Caps - Alpha Lipoic Acid from Nature's Way is central to recycling other antioxidants like Vitamin E, Vitamin C, and GSH glutathione. Alpha Lipoic Acid is used for the treatment of nerve damage and helps control blood sugar levels.
Alpha Lipoic Acid, NOW Foods, 250 mg, 60 caps - Alpha Lipoic Acid is a versatile water and fat soluble metabolic antioxidant. Another benefit is that is also acts as a potent free radical quencher and aids other vitamins in their antioxidant activities. Alpha Lipoic Acid is used for the treatment of nerve damage and helps control blood sugar levels.
Momordica Tincture, 100% Organic, 2 fl. oz. - It has been suggested that Bitter Melon, Momordica, has anti-tumor and anti-viral actions. MAP 30 is a protein found in Bitter Melon that is believed to have multiple functions that could be beneficial in treating HIV infection. Bitter Melon regulates blood sugar levels.
Natural Treatments For Diabetes, By R.N. Ellsworth - This book offers essential information on the types of diabetes and symptoms, as well as dietary recommendations and current research.
Chromium Picolinate, 100% Natural, Nature's Way, 200 mcg, 100 Caps - Nature's Way Chromium Picolinate is 100 percent natural, patented Chromium Picolinate. It contains no artificial ingredients or preservatives. Chromium Picolinate improves the ability of insulin to lower blood sugar levels. If you are diabetic, consult your health care provider before taking chromium.
Garlicin Cholesterol Control, Odor Free, Nature's Way, 350 mg, 90 Enteric Coated Tabs - In clinical studies, garlic has been shown to lower serum cholesterol and help maintain circulatory efficiency. The greatest effect resulted from garlic products with standardized amounts of allicin release in doses of 5,000 mcg per day. Garlic improves circulation, enhances immunity and reduces blood sugar levels.
Siberian Eleuthero Root, Nature's Way (Eleuthero, Eleutherococcus Senticosus Root), 410 mg, 100 Caps - Siberian Ginseng Root improves physical and mental vitality. It is an adaptogenic herb, which helps the body to adapt to daily stress. It is an ideal supplement for those leading a demanding and hectic lifestyle. Ginseng Tea lowers blood sugar levels, but is not recommended for those with high blood pressure.
L-Glutamine Powder, 100% Pure Free Form Amino Acid & GH Releaser, Vegetarian, NOW Foods, 1 lb. - L-Glutamine powder may be used for reducing fatigue and improving exercise endurance. L-Carnitine, L-Glutamine and Taurine help mobilize fat, reduce sugar cravings and assist the release of insulin.
Vitamin E (as d-alpha Tocopheryl Acetate), 100% Natural, NOW Foods, 400 IU, 250 Softgels - Vitamin E is a major antioxidant and the primary defense against lipid peroxidation. It is particularly important in protecting the body's cells from free radical and oxidative damage.
Flax Seed, Whole, Certified Organic, 1 lb. Bulk - Flax seeds are an important source of polyunsaturated fatty acids, including Omega-3, plus magnesium, zinc, and dietary fiber. Flax oil from flax seeds is the richest known source of linolenic acid.
Zinc Lozenges w/ Echinacea & Vitamin C, Nature's Way, 23 mg, 60 Lozenges - Nature's Way Zinc Lozenges boosts cold season defense with zinc, widely recognized as an important nutritional support during the cold season, and echinacea purpura, clinically shown to support the immune system, and vitamin C. a vitally important vitamin for general health maintenance. Zinc has shown to be deficient in diabetic patients. Zinc is best absorbed as lozenges.
Spirulina Powder, 100% Natural, Certified Organic, NOW Foods, 1 lb. - Spirulina has numerous health benefits. In addition, it is the highest known vegetable source of B-12 and provides optimum levels of vitamins, minerals, trace elements, cell salts, amino acids and enzymes. Spirulina is an excellent natural food supplement that helps stabilize blood sugar levels.
Quercetin, NOW Foods, 500 mg, 100 Vcaps - Quercetin helps protect the membranes of the eye from high glucose levels.
Ultimate B, Vitamin B Complex Formula, Nature's Secret, 60 Tabs - Vitamin B-Complex with extra B-12 and folic acid helps improve the metabolism of glucose. B-12 assists in the prevention of nerve damage/neuropathy.
Dandelion Root Tincture, 100% Organic, 2 fl. oz. - Dandelion Root protects the liver. This plant produces a mild diuretic effect and reduces serum cholesterol levels. It is used to improve appetite and minor digestive problems.
Fenugreek Tincture, 100% Organic, 2 fl. oz. - Fenugreek reduces serum cholesterol and blood sugar levels. Evidence for Fenugreek helps combat diabetes by regulating the rate of which the body absorbs sugars. In addition, fenugreek increases breast milk production and has been used to treat arthritis, kidney problems and male reproductive conditions.
Aloe Vera Juice, Pure Aloe Force, Organically Grown Unprocessed Whole Raw Aloe Vera, 33.8 fl. oz. - The magnificent Aloe plant, that is designed to be self-sufficient and thrive in the desert, feeds us in unique ways with its 250+ naturally occurring constituents including: enzymes, amino acids, essential fatty acids, vitamins, minerals, glycoproteins, sterols, growth factors, and all sizes of uniquely complex aloe polysaccarides and mannans.
Aloe Vera Juice, Herbal Aloe Force, Organically Grown, Unprocessed, Whole Raw Aloe Vera, 33.8 fl. oz. - Herbal Aloe Force, Aloe Vera Juice, Re-Natures the cells, tissues, glands, organs and all the systems of the body to function as originally designed.
Diabetes Treatment Books - Books about Diabetes, Diabetics & Insulin Resistance and their treatment.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You are 24 to 28 weeks pregnant and have not had a screening test for gestational diabetes mellitus.
Following diagnosis of gestational diabetes, you develop any new signs or symptoms that cause you concern.
You have difficulty in following a recommended diet or exercise program.
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