Gestational diabetes: from the glucose test to life after delivery

What is gestational diabetes and how does it happen?

Gestational diabetes (GDM) is high blood sugar first detected during pregnancy in a woman who did not have diabetes before. The cause is not a suddenly failing pancreas. As the placenta grows, it produces hormones, particularly human placental lactogen, that progressively resist the action of insulin. In healthy pregnancies, the pancreas compensates by producing more insulin. In women who begin pregnancy with limited pancreatic reserve, significant body fat, or underlying undiagnosed insulin resistance, this compensation proves insufficient and blood glucose rises.

Gestational diabetes rarely causes obvious symptoms. You may notice slightly more thirst, tiredness, or frequent urination, but these are common in any pregnancy. This is why symptoms alone cannot be relied on, and a blood glucose test is necessary for every pregnant woman regardless of how she feels.

Being diagnosed with gestational diabetes does not mean you were doing anything wrong before or during the pregnancy. It reflects a combination of individual physiology and the hormonal demands of pregnancy. Understanding the cause clearly matters because it removes guilt and allows you to focus on what is actually useful, which is managing blood glucose through diet, activity, and when necessary medication.

Why is gestational diabetes so common in the Arab world?

A 2021 systematic review and meta-analysis covering studies from across the Middle East and North Africa between 2000 and 2019, published in Frontiers in Endocrinology, found that GDM prevalence in the region is among the highest globally. A 2022 UAE cohort study, the Mutaba'ah Study, compared six different diagnostic criteria in the same population and found GDM rates ranging from 14% to 26% depending on which criteria were applied. This wide variation reflects the absence of a regionally agreed standard, which has real implications for how results are communicated to patients.

Several factors converge in the region to raise gestational diabetes risk. Obesity rates in Gulf countries and Egypt are among the highest in the world, and many women begin pregnancy carrying excess weight. A 2020 study of Saudi women, published in Frontiers in Endocrinology, found that the presence of metabolic syndrome at the start of pregnancy significantly increased the likelihood of developing GDM, suggesting that many women already have undiagnosed insulin resistance before conception.

Physical activity is restricted by extreme summer heat across much of the region, and traditional diets are becoming increasingly reliant on refined carbohydrates, processed food, and sweetened drinks. Later age at first pregnancy also raises risk. These factors compound each other, and the regional health burden from gestational diabetes and its downstream consequences for type 2 diabetes is substantial.

How the glucose tolerance test works and what it measures

The oral glucose tolerance test (OGTT) is the standard diagnostic test for gestational diabetes. It is performed between weeks 24 and 28 in women without specific risk factors, and earlier for those with a history of gestational diabetes, obesity, or a strong family history of type 2 diabetes. You fast for 8 to 12 hours, a fasting blood sample is taken, you then drink a solution containing 75 grams of dissolved glucose, and further blood samples are taken at one hour and two hours.

The one-hour and two-hour samples show how effectively your body clears the glucose load. In a healthy glucose metabolism, the spike after the drink returns to near-fasting levels within two hours. In gestational diabetes, one or more of the three readings exceeds the diagnostic threshold. Some hospitals in the region still use a 100-gram glucose load with four samples following older American criteria, so the thresholds your doctor uses may differ from those below.

If your result is borderline, it is worth asking which diagnostic standard your hospital follows before assuming the result is normal. The difference between a 1-hour result of 9.8 and 10.0 mmol/L is clinically real when the threshold is 10.0 but may be handled differently by different hospitals.

What happens if gestational diabetes is not managed?

Elevated glucose in the mother's blood crosses the placenta and reaches the baby. The baby's own pancreas responds by producing extra insulin, driving growth. The typical result is macrosomia: a baby weighing above 4 kilograms, which increases the likelihood of a caesarean section, shoulder dystocia during vaginal delivery, and perineal injury. A large baby does not automatically mean a healthy baby.

In the hours after delivery, the supply of maternal glucose stops abruptly, but the baby's pancreas continues producing elevated insulin. This causes neonatal hypoglycaemia (low blood sugar in the newborn), which requires careful monitoring and early feeding. Repeated or prolonged unrecognised hypoglycaemia can affect the newborn brain.

Over the longer term, children born to mothers with gestational diabetes carry higher risks of obesity and type 2 diabetes in childhood and adulthood. This is not a certainty for any individual child, but it underlines why controlling blood glucose during pregnancy benefits not only the delivery outcome but also the child's long-term health.

What to eat: the diet that controls gestational diabetes

Diet is the first and most effective treatment for gestational diabetes, controlling blood glucose without medication in 70% to 80% of cases. The goal is not to eliminate carbohydrates entirely but to choose slower-releasing types and spread them across smaller, more frequent meals. Three main meals with two or three planned snacks between them produce a steadier glucose curve than two large meals. A 2020 review in Nutrients confirmed that carbohydrate quality and distribution remain the cornerstone of GDM management.

Slow-release carbohydrates (whole grains, legumes, freekeh, bulgur, chickpeas, lentils) cause a more gradual glucose rise than white rice, white bread, and sugary foods. In Levantine and North African cooking, freekeh or bulgur can replace white rice; ful medames (fava beans) and hummus are naturally high in protein and fibre. The problem is not traditional food itself but the shift toward refined, processed versions of those dishes.

Concentrated sugars require particular care. Dates, honey, fruit juice, sweetened tea and coffee, soft drinks, and Arabic pastries all raise blood glucose sharply. This does not mean fruit is forbidden, but a single date or two taken with a meal containing protein and fibre is very different from three or four dates on an empty stomach. Sweetened tea taken repeatedly through the day adds a significant glucose load that many women do not account for when they describe their diet to their doctor.

Exercise: safe physical activity in gestational diabetes

Physical activity increases muscle cells' sensitivity to insulin, allowing glucose to enter cells without requiring as much insulin from the pancreas. A 2022 systematic review found that both aerobic exercise and resistance training improve glycaemic control and pregnancy outcomes in gestational diabetes. The effect begins after a single session and is cumulative with consistent activity.

Walking is the simplest and safest option for most pregnant women. A 30-minute walk at a comfortable pace after the main meal helps flatten the post-meal glucose peak. Swimming and water aerobics are particularly practical in hot-climate countries. Light resistance exercises such as wall squats or gentle weight training are also acceptable when there are no obstetric contraindications. Exercise does not need to be strenuous to be effective in gestational diabetes.

Avoid exercises that carry a fall risk, involve lying flat on the back after the first trimester, or require high abdominal pressure. If you were not exercising regularly before pregnancy, do not start an intensive programme. Begin with 10-minute walks and increase gradually. Always check with your doctor if you have placenta praevia, cervical incompetence, preterm labour risk, or any other condition that might restrict activity.

When is medication or insulin needed?

If diet and exercise do not achieve blood glucose targets after one to two weeks, medication is started. Typical targets are: fasting glucose below 5.3 mmol/L (95 mg/dL), one-hour post-meal glucose below 7.8 mmol/L (140 mg/dL), and two-hour post-meal glucose below 6.7 mmol/L (120 mg/dL). Your doctor may set slightly different thresholds based on local protocol.

Metformin is sometimes used in gestational diabetes and is an accepted option, though it crosses the placenta. Insulin is the globally preferred treatment because it does not cross the placenta, its dose can be adjusted precisely to daily glucose readings, and its safety record in pregnancy is extensive. Fear of injections is a common and understandable barrier, but insulin is not a sign of failure and does not indicate a more serious form of the condition. It simply means your body's response to diet and activity alone was not sufficient.

Insulin dose is calculated by your doctor based on your glucose readings, your weight, and how far along the pregnancy is. It changes as the pregnancy progresses and placental hormones intensify. Never adjust your insulin dose on your own. Bring your glucose log to every appointment so your doctor has the data needed to make precise adjustments.

After delivery: the risk that most women are never told about

In most cases gestational diabetes resolves within days to weeks of delivery. The glucose test taken six to twelve weeks postpartum usually returns to normal. However, resolving does not mean the risk is gone. A 2020 BMJ systematic review and meta-analysis covering over one million women found that women with a history of gestational diabetes have more than ten times the risk of developing type 2 diabetes compared with women who were not affected.

The recommended schedule is a glucose test six to twelve weeks after delivery to confirm resolution, then repeat testing every one to three years for life. Many women in the Arab world are never told about this recommendation, and many doctors do not mention it at the postpartum visit. If your doctor has not raised it, ask specifically: what is my follow-up plan for diabetes screening?

Breastfeeding for longer periods is associated with lower rates of progression to type 2 diabetes in mothers with a history of gestational diabetes, in addition to its well-established benefits for the baby. Returning to a healthy body weight after delivery, maintaining regular physical activity, and reducing refined carbohydrates are the three lifestyle changes with the best evidence for preventing type 2 diabetes in this high-risk group.

Home glucose monitoring: the practical questions

A home glucometer is an essential tool when gestational diabetes is diagnosed. Typical targets for home monitoring are: fasting below 5.3 mmol/L (95 mg/dL) and one to two hours after meals below 7.8 or 6.7 mmol/L respectively, depending on your doctor's preference. Ask your doctor for your specific targets in writing, because they vary between protocols.

Test strips and lancets are a recurring cost that can be a real barrier, particularly in resource-limited settings. If cost is a concern, discuss with your doctor the minimum number of daily readings that give enough information to manage your glucose safely, rather than stopping monitoring altogether. Even fasting readings alone and one post-meal reading per day provide meaningful data.

A home glucometer typically reads 10 to 15% lower or higher than a laboratory venous sample, which is within the accepted range. If you are uncertain whether your device is accurate, bring it to your next laboratory blood draw and compare both readings taken at the same time. Keep a dated log of all readings, because the pattern over days and weeks is more informative than any single number.

Sources

• Al-Rifai RH, Abdo NM, Paulo MS et al: Prevalence of Gestational Diabetes Mellitus in the Middle East and North Africa, 2000-2019: A Systematic Review, Meta-Analysis, and Meta-Regression, Frontiers in endocrinology, 2021
• Bashir MM, Ahmed LA, Elbarazi I et al: Incidence of gestational diabetes mellitus in the United Arab Emirates; comparison of six diagnostic criteria: The Mutaba'ah Study, Frontiers in endocrinology, 2022
• Vounzoulaki E, Khunti K, Abner SC et al: Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis, BMJ (Clinical research ed.), 2020
• Rasmussen L, Poulsen CW, Kampmann U et al: Diet and Healthy Lifestyle in the Management of Gestational Diabetes Mellitus, Nutrients, 2020
• Keating N, Coveney C, McAuliffe FM et al: Aerobic or Resistance Exercise for Improved Glycaemic Control and Pregnancy Outcomes in Women with Gestational Diabetes Mellitus: A Systematic Review, International journal of environmental research and public health, 2022
• Wani K, Sabico S, Alnaami AM et al: Early-Pregnancy Metabolic Syndrome and Subsequent Incidence in Gestational Diabetes Mellitus in Arab Women, Frontiers in endocrinology, 2020