| Generally, gestational diabetes does not have any symptoms. A woman may experience increased fatigue, increased urination, and excessive thirst, but these are all quite normal occurrences during pregnancy. Since gestational diabetes is usually asymptomatic, glucose testing is generally done to identify woman at risk for gestational diabetes. Gestational diabetes is detected through glucose tolerance testing. Since gestational diabetes is generally asymptomatic and up to 50% of the women have no risk factors, many (but not all) practitioners test all women. Glucose tolerance testing is usually done at 26-28 weeks, although the physician may recommend earlier testing in a high risk woman. Management of gestational diabetes is directed toward controlling the blood glucose level. In most cases, blood sugar can be controlled through a combination of diet and exercise. Quite commonly, the pregnant woman will meet with a nutritional counselor to help her modify her diet. She will be encouraged to eat a healthy diet, eliminate concentrated sweets, and monitor her caloric intake to avoid excessive weight gain. She may receive assistance with planning meals and snacks (although snacks may be discouraged for obese patients). Typically, moderate exercise is recommended after meals (when blood glucose levels are highest). A woman should discuss diet and exercise with the practitioner before trying to implement changes. The physician will want to monitor the woman’s blood glucose level. The doctor will probably see the woman on a weekly basis and test the glucose at each visit. However, most physicians want a better picture of control than the once a week testing allows. In many cases, the mother will be taught to test her blood sugar using a home test kit. Blood glucose testing is done by pricking a finger with a special device, obtaining a small drop of blood on a test strip, and placing the strip in a small machine (a glucometer) which provides a numerical reading of the glucose level. Home glucose testing is easy to learn. Typically, the pregnant woman will be asked to test her blood sugar each morning before breakfast (a "fasting blood sugar level") and two hours after eating (a "postprandial level"). Sometimes, the women obtains a third blood glucose level in the mid-afternoon. The woman keeps careful record of all the readings. This record allows the physician to determine if the blood glucose is being adequately controlled. In most cases of gestational diabetes, the blood glucose can be controlled adequately with changes in diet and exercise. If these measures are insufficient, though, the pregnant woman will be started on daily insulin injections. Oral medications to control diabetes are contraindicated in pregnancy. After the diagnosis of gestational diabetes, the physician will see the effected woman on a weekly basis. In addition, in the final weeks of pregnancy the physician may recommend weekly monitoring of the baby to assess well being. Fetal tests may include non-stress tests, contraction stress tests, or biophysical profiles. In addition, an ultrasound may be done to estimate the baby’s size and weight in preparation for birth. A very large baby is more likely to require cesarean birth. Most babies are born at term. Unless the mother’s pelvis is obviously too small for the baby’s size, a vaginal birth is generally attempted and often successful. However, in some instances the baby’s size causes labor to fail to progress Post-term delivery is generally avoided because of the increased risk of large sized babies. If the mother does not spontaneously start labor, the physician may opt to induce labor. If gestational diabetes is diagnosed and blood sugar is well controlled, the baby is not at increased risk for complications of birth. However, if blood glucose levels are poorly controlled during the pregnancy, the baby has an increased risk of problems. The baby is at increased risk for stillbirth and newborn death. The newborn baby of the uncontrolled diabetic mother is quite likely to be large (called macrosomia and defined as greater than 4500 grams or 9 pounds). These babies appear quite plump. The large size increases the risk that the baby will be injured during the birth process, which requires lots of squeezing through a small space. In addition, they are more likely to suffer fetal distress during birth. During delivery, the baby is monitored carefully. The newborn is also at risk for the development of low blood sugar. In utero, the infant of the diabetic mother is accustomed to receiving unusually high levels of glucose. In response, these babies secrete higher than normal levels of insulin to maintain proper blood glucose levels (which accounts for the excessive growth and fat deposits). At birth, the high glucose supply is eliminated and the high insulin production may cause a drop in blood glucose. If no intervention is done, the baby can suffer neurological damage or death. To prevent problems, the newborn’s blood sugar is monitored after birth. Testing is done by obtaining a blood sample from the baby’s heel. Often, the newborn requires early feeding. Often, glucose water or other non-glucose carbohydrate drinks are given. Occasionally, intravenous glucose is necessary. About half of the babies do quite well after birth. However, the other infants may require close monitoring for a few days until blood glucose control is well established. | 
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