3235

Introduction

Gestational diabetes (GD) is considered a prevalent health issue that has been reported to represent an increasing trend in the past two decades following the increment of diabetes prevalence [1-3]. GD, a type of diabetes that is primarily detected in pregnancy with an increase in blood glucose levels, is widespread irrespective of country’s income status and is frequently associated with complications of maternal and fetal due to maternal hyperglycemia. In fact, maternal hyperglycemia is described as one of the primary and major predictors of maternal-fetal complications and conflicting results have been reported regarding the effectiveness of HbA1c levels [4-6]. Preeclampsia and birth trauma are two main maternal complications related to GD, meanwhile, fetal complications associated with GD could include shoulder dystocia, macrosomia, intrauterine death, and stillbirth [7-9]. In addition, both the mother and newborn are prone to develop diabetes mellitus for the rest of their lives [10].

The growing incidence of GD has caused crucial concerns for the health system throughout the world [11, 12]. However, it is widely suggested that interventions based on health empowerment are able to improve the glucose levels in the blood of pregnant mothers with GD in order to reduce the risk of mentioned complications [13, 14]. Indeed, it has been evidenced by a variety of studies that monitoring blood glucose levels and modifications of lifestyle may overcome related complications [15, 16]. For this purpose, females are required to be educated regarding diabetes-related self-care skills according to approved standards after diagnosis and according to their personalized requirements [17]. Although the suggested strategies represent the potency to improve the health outcomes of both mothers and newborns, they could be challenging for pregnant females with GD as these approaches require education and adopting skills related to self-care in a short period [18].

As a result, it appears to be necessary to determine the best approach that can achieve the lowest costs and requirements with the highest productivity and the most ideal output, which is the prevention of complications in the mother and fetus. For this purpose, the current study aimed to review the conducted investigations by focusing on a variety of domains including parental awareness of diabetes pathophysiology, blood sugar monitoring, healthy lifestyle, mental health of parents, and approaches based on smartphone applications. First of all, the current study represents a basic summary of the pathophysiology of GD, risk factors, preventive strategies, and current treatment approaches.

Overview of Gestational Diabetes

GD could be described as a metabolic disorder in which diabetes has occurred during pregnancy. It is reported that GD affects 14% of total pregnancies all around the world and corresponds to approximately 20 million births each year [19]. It is widely accepted that spontaneous hyperglycemia occurs during GD and major risk factors of the onset of GD include a parental history of diabetes, obesity, being overweight, a diet consisting of high fat and low carbohydrate, and a sedentary lifestyle [20, 21]. In fact, valid sources such as the American Diabetes Association have defined GD as a metabolic disorder and a chronic state of glucose intolerance that corresponds to any degree of insulin resistance that occurs with the onset of pregnancy [22, 23]. It is believed that GD represents no time-bound occurrence rate during the period of pregnancy, hence it could be triggered at any stage. Insufficient insulin secretion is considered the main reason for higher levels of blood glucose in patients with GD [24].

The most frequent symptoms of GD include elevated levels of thirst, dry mouth, repeated urination, and continuous fatigue [25]. Clinical investigations have revealed that the pathophysiological effects of GD are temporary, however, the aftereffects of GD on maternal and fetal health are prominently negative [25]. Indeed, it is widely accepted that GD is a temporary state in which its main symptoms are resolved when the period of pregnancy is over. Nevertheless, GD may cause a remarkable increase in the occurrence of metabolic complications including obesity, diabetes mellitus, and cardiovascular disorders. Unfortunately, no current medication is available to completely treat GD [26, 27]. The oral glucose tolerance test (GTT) is considered a direct evaluation of an individual response to glucose intake that could effectively benefit the diagnosis of patients with GD as well as diabetes mellitus.

The fasting blood glucose (FBS) level at almost 105 mg/dl, and shifting of blood glucose levels from 190 mg/dl one hour postprandial to levels of 165 mg/dl two hours postprandial and 145 mg/dl three hours postprandial are main laboratory markers of GD. It has been widely demonstrated that FBS levels remain more than 126 mg/dl during the first trimester of pregnancy, the levels of glycated hemoglobin (HbA1c) remain at 6.5%, levels of random glucose are over 200 mg/dl, and levels of glucose two hours after a load of 75 g of oral glucose would be more than 200 mg/dL [28, 29]. As mentioned earlier the pathoetiology of GD could be assumed to be related to metabolic complications such as obesity, insulin resistance, and dysregulation of other hormones and adipokines [30, 28]. The hyperproduction of pro-inflammatory cytokines from the adipocytes that cause a chronic inflammatory state is considered the main reason for obesity’s contribution to GD incidence [31, 32]. It has been revealed that inflammatory markers such as tumor necrosis factor (TNF), proinflammatory interleukins (IL), visfatin, and adipokines are actively secreted by adipocytes and/or immune cells as a result of established chronic inflammation [33, 34], all of which reveals the close association between diabetes, obesity, and inflammation [35, 36]. Indeed, the interplay between both proinflammatory and antiinflammatory cytokines during a healthy pregnancy preserves the metabolic homeostasis between the mother and fetus, however, in obese pregnant women, the higher secretion of proinflammatory cytokines is followed by metabolic dysregulation including insulin resistance and increased levels of glucose in both mother’s and fetal’s blood. Importantly, insulin resistance could be followed by elevated glycogenes (build-up of glucose), hyperglycemia, and hyperlipidemia that repeats the vicious cycle of obesity [37, 38]. In addition, dysregulation of factors such as adiponectin, leptin, visfatin, sex hormone binding globulin, human placental lactogen, estrogen, progesterone, cortisol, and prolactin may play a role in the etiology of gestational diabetes through influencing insulin resistance, inflammation, atherogenesis, hypertension, food intake, and imbalance of glucose and fatty acid levels [39-41, 28].

Self-Care Strategies During Gestational Diabetes

As discussed above, GD is a chronic and common condition that may occur due to metabolic, hormonal, and inflammatory disorders. Perhaps the complicated and multifactorial pathophysiological of the disease can be assumed as the most important reason that has led to the lack of complete treatment of GD. Nevertheless, early diagnosis and approaches based on self-care have been described as the two main strategies for confronting GD and preventing its consequences in both the mother and the fetus [42, 43]. In general, self-care has been defined as processes related to establishing behaviors in order to ensure the holistic well-being of oneself, promote a healthy state of the person, and actively manage the disease as it occurs [44]. Self-care related to GD could be described as a set of actions that include increasing the level of health literacy, improving mental health, and considering effective procedures such as changing lifestyle and monitoring the symptoms of the disease [45]. A plethora of studies have suggested the effectiveness of self-care-based approaches to dealing with GD, however, each of them may represent limitations and strengths. According to the extent of investigations that have been conducted in this context, the present study has attempted to review the related studies in four separate chapters including the mother’s information regarding GD, blood glucose monitoring, healthy lifestyle, and parental mental health.

Parental Knowledge Information on GD

Previously, it has been determined that mothers must know about the pathophysiology, characteristics, and consequences of GD. In fact, knowledge of GD needs to consist of information about the definition, symptoms, causes, treatment, consequences, and complications of GD on maternal and fetal health [46]. The educational sessions could be delivered through a variety of teaching strategies such as lectures, prints, PowerPoint presentations, and videos. In addition to the teaching method, the duration of educational interventions has been mentioned as one of the influencing factors on clinical outcomes [47, 1], which will be further discussed.

It has been suggested that patient education could be considered a major component of positive pregnancy and childbearing experiences, particularly in women with GD. A recent randomized controlled trial on 61 patients with GD who received a self-care education program with the usual care plan for GD revealed that implementing a tailored care education was able to improve clinical outcomes [48]. In fact, the researchers reported that self-care education along with the usual care plan for GD compared to the usual care plan resulted in a significant reduction in maternal and neonatal hospitalizations, preterm labor, cesarean section, fetal distress, macrosomia, newborn respiratory complications, and more importantly hypoglycemia [48]. Interestingly, a variety of studies have shown that self-care education can positively affect clinical outcomes and assist gestational diabetes management by reducing perceived stress, increasing health literacy, and improving self-care behaviors [49, 50]. Moreover, it has been believed that self-care can be considered the first step to helping patients to manage their pathological condition more appropriately, therefore it is necessary for the patient to believe in his ability to do a task or adapt to a stressful situation, an ability that is known as self-efficacy. In fact, by examining 400 pregnant women with gestational diabetes, Kordi and colleagues have shown that self-belief can significantly improve the self-care behavior of patients [51].

In addition to the patient’s self-efficacy, determining the appropriate method of education may depend on other factors such as society’s culture, the patients’ spirituality and religion, the supportive role of spouse and family, etc [52].

On the other hand, the perfect pattern of self-care education for women with GD can be determined by evaluating the state of mental health, monitoring blood glucose, and observing a healthy lifestyle including adherence to physical activity, following a healthy diet, and considering waist circumference and body weight. In addition, a randomized controlled trial on 92 pregnant women with GD aimed to evaluate the effect of a four-session educational intervention, one session per week, consisting of usual prenatal care along with self-care education through lectures and question and answer. Moreover, an educational booklet was given to patients at the end of the first session. Interestingly, it was demonstrated that the intervention group had higher knowledge of the disease and self-care behaviors that resulted in improved impaired glucose tolerance [53]. Concordantly, one-to-one education has been assumed as a suitable approach for self-care education of pregnant women with GD, which can lead to the desired clinical outcomes [54]. Moreover, the possibility of using smartphone applications to educate women and follow up on self-care is suggested [13].

Glycemic Status Monitoring

Blood sugar monitoring can be included in the evaluation of FBS, 2-hour postprandial glucose (2hpp) levels, and the levels of HbA1C. A majority of the previous studies have considered the evaluation of FBS and 1h/2h postprandial glucose levels as a suitable approach to assess the status of pregnant women with GD [55-57]. However, conflicting results have been reported regarding the effectiveness of HbA1c levels evaluation [58, 59].

Blood glucose monitoring could be considered one of the self-care behaviors that may be represented to women with GD as routine self-care training or through designed smartphone applications [13, 54, 53]. The efficacy of continuous blood glucose monitoring in improving the clinical outcomes of mothers and fetuses has been investigated by several studies. A randomized clinical trial involving 71 pregnant women with diabetes revealed that continuous glucose monitoring, as an educational tool to inform shared decision-making and future therapeutic changes at intervals of 4-6 weeks during pregnancy, could result in lower mean HbA1c levels, decreased mean birthweight, decreased birthweight centiles, and reduced risk of macrosomia [60]. In addition, the efficacy of continuous blood glucose monitoring and cost implications have been emphasized by other similar studies [61-63]. Concordantly, similar studies have emphasized the effectiveness of continuous blood glucose monitoring in improving diabetes-related laboratory parameters including FBS, A1c, 2hpp, etc., as well as clinical outcomes related to mother and fetal health complications [64, 65, 32]. Nevertheless, it appears that further large-scale investigations are required to confirm the most appropriate approach for continuous glucose monitoring in pregnant women with GD.

Healthy Lifestyle

A healthy lifestyle in women with GD can be described as consisting of two main components including a healthy diet/nutrition and appropriate physical activity [54, 66, 67]. Determining a healthy diet for diabetic mothers should include dos and don’ts regarding foods rich in carbohydrates, fats, and proteins. Whereas, none of the previous studies have introduced a specific index of the healthiness of a diet based on its nutritional composition, but have only considered generalities. On the other hand, the manner of mothers’ self-care education about a proper diet should be determined by further studies, because previous investigations do not support face-to-face follow-up of women with GD with a smartphone application in the presence of high-standard usual care [68].

Excessive gestational weight gain has been associated with adverse health outcomes in both the mother and newborn. Thereby, women are encouraged to be active physically before, during, and after pregnancy. A plethora of evidence is available that supports antenatal physical activity in order to bring health benefits for both the mother and child. In addition, lifestyle changes and behavior modifications are considered to be able to promote healthy postpartum weight loss and contribute to the prevention of GD [69-71]. A pilot study involving 30 overweight pregnant women revealed that health coach behavioral support can lead to encouraging mothers to participate in interventions to increase physical activity and observe healthy lifestyles [72]. However, a health coach does not appear to be available for all pregnant women with GD, especially those living in underdeveloped countries. Meanwhile, education related to self-care may lead to increased physical activity, regular exercise, and postpartum weight loss [73, 74].

Mental Health

According to the definition provided by the World Health Organization, mental health is a state of mental well-being that makes a person capable of coping with the stresses that occur in life, realizing their personal abilities, learning and working well, and contributing appropriately to their community [75, 76]. Mental health is considered an integral component of well-being that underpins individual and collective abilities in order to make decisions [75, 76]. As mentioned earlier, the ability of pregnant women with gestational diabetes to be aware of the characteristics of the disease as well as learn self-care is dependent on self-belief. Self-belief can be considered one of the components of mental health, while other components are also considered effective. In this regard the state of depression, religious beliefs, positivity, belief in individual abilities, and family support can be considered other important aspects involved in mental health [49, 51]. Considering that some of these aspects have been discussed previously in the “parental knowledge information on GD” section, the present study reviews other related investigations.

Horsch et al have examined the association between maternal mental health and the improvement of cardiometabolic complications in women with GD and their offspring [77]. In addition, Zandinava et al conducted a randomized controlled trial on 92 pregnant women with GD to evaluate the effect of educational package on self-care behavior, quality of life, FBS, and GTT. The results of their study demonstrated that self-care education for pregnant mothers with GD can improve the mental health and quality of life of patients, and more importantly, significantly improve diabetic indicators [53]. In addition, another study found that although blood sugar was not monitored by mothers with GD, self-care education, especially by health professionals, a positive attitude toward disease control, along with a healthy diet and regular exercise as self-care behaviors was able to affect blood glucose levels significantly [78]. On the other hand, postpartum depression in women who have had gestational diabetes leads to disrupting the lifestyle and can have unwanted results [79].

Conclusion

The current review demonstrated that increasing the level of awareness of pregnant mothers with GD and educating them on self-care behaviors including monitoring blood glucose levels, changing lifestyle, and maintaining mental health can improve indicators related to blood glucose and possibly metabolic complications. However, the studies conducted appear to be preliminary, hence further research into this content is required.

Conflict of Interest

None.

Mohebbi B, Tol A, Sadeghi R, Mohtarami SF, Shamshiri A. Self-management intervention program based on the health belief model (HBM) among women with gestational diabetes mellitus: A quazi-experimental study. Arch Iran med. 2019;22(4):168-73.
Rollo ME, Baldwin JN, Hutchesson M, Aguiar EJ, Wynne K, Young A et al. The feasibility and preliminary efficacy of an eHealth lifestyle program in women with recent gestational diabetes mellitus: a pilot study. Int jour env res pub health. 2020;17(19):7115.
McIntyre HD, Catalano P, Zhang C, Desoye G, Mathiesen ER, Damm P. Gestational diabetes mellitus. Nat Rev Dis Primers. 2019;5(1):47.
Borgen I, Småstuen MC, Jacobsen AF, Garnweidner-Holme LM, Fayyad S, Noll J, Lukasse M. Effect of the Pregnant+ smartphone application in women with gestational diabetes mellitus: a randomised controlled trial in Norway. BMJ open. 2019;9(11):e030884.
Lefkovits YR, Stewart ZA, Murphy HR. Gestational diabetes. Medicine. 2019;47(2):114-8.
Hasan AK, Ali SH, Hussein WA. Impact of Serum level of L-Carnitine on Chitotriosidase in Women with Gestational Diabetes Compared to T2DM Pregnant & Non Pregnant Iraqi Women. Prof(Dr) RK Sharma. 2020;20(4):41075.
Moon JH, Jang HC. Gestational diabetes mellitus: diagnostic approaches and maternal-offspring complications. Diabetes Metab J. 2022;46(1):3-14.
Reece EA. The fetal and maternal consequences of gestational diabetes mellitus. J Matern Fetal Neonatal Med. 2010;23(3):199-203.
Tu F, Fei A. Maternal and neonatal outcomes of singleton versus twin pregnancies complicated by gestational diabetes mellitus: A systematic review and meta-analysis. Plos one. 2023;18(1):e0280754.
McLean M, Chipps D, Cheung NW. Mother to child transmission of diabetes mellitus: does gestational diabetes program Type 2 diabetes in the next generation? Diabet Med. 2006;23(11):1213-5.
La Verde M, Torella M, Riemma G, Narciso G, Iavarone I, Gliubizzi L et al. Incidence of gestational diabetes mellitus before and after the Covid-19 lockdown: A retrospective cohort study. J Obstet Gynaecol Res. 2022;48(5):1126-31.
Sweeting A, Wong J, Murphy HR, Ross GP. A clinical update on gestational diabetes mellitus. Endocrine rev. 2022;43(5):763-93.
Borgen I, Garnweidner-Holme LM, Jacobsen AF, Bjerkan K, Fayyad S, Joranger P et al. Smartphone application for women with gestational diabetes mellitus: a study protocol for a multicentre randomised controlled trial. BMJ open. 2017;7(3):e013117.
Mirfeizi M, Tourzani ZM, Jafarabadi MA, Hanjani SM, Hasanzad M. Health Education in Gestational Diabetes Mellitus and Quality of Life. J of Midwifery & Reprod Health. 2017;5(4):1066.
Allehdan SS, Basha AS, Asali FF, Tayyem RF. Dietary and exercise interventions and glycemic control and maternal and newborn outcomes in women diagnosed with gestational diabetes: Systematic review. Diabetes Metab Syndr. 2019;13(4):2775-84.
Carolan-Olah M, Duarte-Gardea M, Lechuga J. A systematic review of interventions for Hispanic women with or at risk of Gestational diabetes mellitus (GDM). Sex Reprod Health. 2017;13:14-22.
Care D. Standards of medical care in diabetes 2012. Diabetes care. 2012; 35 (Suppl 1):11-63.
Haron Z, Sutan R, Zakaria R, Abdullah Mahdy Z. Self-care educational guide for mothers with gestational diabetes mellitus: A systematic review on identifying self-care domains, approaches, and their effectiveness. Belitung nurs j. 2023;9(1):6-16.
Kapur A. Links between maternal health and NCDs. Best Practice & Research Clinical Obstetrics & Gynaecology. 2015;29(1):32-42.
Care D. Care in Diabetesd2018. Diabetes care. 2018;41(1):S137-S43.
Lim S, Takele WW, Vesco KK, Redman LM, Hannah W, Bonham MP et al. Participant characteristics in the prevention of gestational diabetes as evidence for precision medicine: a systematic review and meta-analysis. Commun Med. 2023;3(1):137.
Madan S, Kurian N, Nagpal N. Gestational Diabetes-An Endocrinologist’s Perspective. Series Endo Diab. 2023:5(1):22-24.
Retnakaran R, Ye C, Hanley AJ, Connelly PW, Sermer M, Zinman B. Treatment of Gestational Diabetes Mellitus and Maternal Risk of Diabetes After Pregnancy. Diabetes care. 2023;46(3):587-92.
Martín-Estal I, Castorena-Torres F. Gestational diabetes mellitus and energy-dense diet: what is the role of the insulin/IGF axis? Fron Endocrinol. 2022;13:916042.
Goyal A, Gupta Y, Singla R, Kalra S, Tandon N. American diabetes association “standards of medical care—2020 for gestational diabetes mellitus”: a critical Appraisal. Diabetes Ther. 2020;11:1639-44.
Castillo WC, Boggess K, Stürmer T, Brookhart MA, Benjamin DK, Funk MJ. Association of adverse pregnancy outcomes with glyburide vs insulin in women with gestational diabetes. JAMA pediat. 2015;169(5):452-8.
Nethery EM. Gestational diabetes screening changes and impacts on diagnosis. University of British: Columbia; 2022.
Sharma AK, Singh S, Singh H, Mahajan D, Kolli P, Mandadapu G et al. Deep Insight of the Pathophysiology of Gestational Diabetes Mellitus. Cells. 2022;11(17):2672.
Trout KK, Compher C, Durnwald CP. 753-P: Protein vs Carbohydrate in Gestational Diabetes. Diabetes. 2019;68(Supplement_1):753.
Plows JF, Stanley JL, Baker PN, Reynolds CM, Vickers MH. The pathophysiology of gestational diabetes mellitus. Int j mol sci. 2018;19(11):3342.
Parrettini S, Caroli A, Torlone E. Nutrition and metabolic adaptations in physiological and complicated pregnancy: focus on obesity and gestational diabetes. Front Endocrinol. 2020;11:611929.
Zehravi M, Maqbool M, Ara I. Correlation between obesity, gestational diabetes mellitus, and pregnancy outcomes: an overview. Int J Adolesc Med Health. 2021;33(6):339-45.
Permana PA, Menge C, Reaven PD. Macrophage-secreted factors induce adipocyte inflammation and insulin resistance. Biochem Biophys Res Commun. 2006;341(2):507-14.
Zhang Z, Wu Y, Zhong C, Zhou X, Liu C, Li Q et al. Association between dietary inflammatory index and gestational diabetes mellitus risk in a prospective birth cohort study. Nutrition. 2021;87:111193.
Jafari Khorchani M, Samare-Najaf M, Abbasi A, Vakili S, Zal F. Effects of quercetin, vitamin E, and estrogen on Metabolic-Related factors in uterus and serum of ovariectomized rat models. Gynecol Endocrinol. 2021;37(8):764-8.
Kawai T, Autieri MV, Scalia R. Adipose tissue inflammation and metabolic dysfunction in obesity. Am J Physiol Cell Physiol. 2021;320(3):C375-C91.
Qiu C, Sorensen TK, Luthy DA, Williams MA. A prospective study of maternal serum C-reactive protein (CRP) concentrations and risk of gestational diabetes mellitus. Paediatr Perinat Epidemiol. 2004;18(5):377-84.
Wolf M, Sauk J, Shah A, Smirnakis KV, Jimenez-Kimble R, Ecker JL, Thadhani R. Inflammation and glucose intolerance A prospective study of gestational diabetes mellitus. Clin Diabetol. 2004;5(2):85-94.
Chandran M, Phillips SA, Ciaraldi T, Henry RR. Adiponectin: more than just another fat cell hormone? Diabetes care. 2003;26(8):2442-50.
Fasshauer M, Blüher M, Stumvoll M. Adipokines in gestational diabetes. Lancet Diabetes Endocrinol. 2014;2(6):488-99.
Qiu C, Williams MA, Vadachkoria S, Frederick IO, Luthy DA. Increased maternal plasma leptin in early pregnancy and risk of gestational diabetes mellitus. Obstet Gynecol. 2004;103(3):519-25.
Farina A, Eklund E, Bernabini D, Paladino M, Righetti F, Monti G, Lambert-Messerlian G. A first-trimester biomarker panel for predicting the development of gestational diabetes. Reprod sci. 2017;24(6):954-9.
Moradi F, Ghadiri-Anari A, Enjezab B. COVID-19 and self-care strategies for women with gestational diabetes mellitus. Diabetes & Metabolic Syndrome: Clin Res Rev. 2020;14(5):1535-9.
Shan Y, Chen J, Zhou S, Wen G. Nursing Interventions and Care Strategies for Patients with Coronary Heart Disease: A Comprehensive Review. Galen Med J. 2023;12:e2994-e.
Karavasileiadou S, Almegewly W, Alanazi A, Alyami H, Chatzimichailidou S. Self-management and self-efficacy of women with gestational diabetes mellitus: a systematic review. Global Health Action. 2022;15(1):2087298.
Elamurugan S, Arounassalame B. What do mothers know about gestational diabetes: knowledge and awareness. Indian J Obstet Gynecol Res. 2016;3(4):393-6.
Al-Hashmi I, Hodge F, Nandy K, Thomas E, Brecht M-L. The effect of a self-efficacy-enhancing intervention on perceived self-efficacy and actual adherence to healthy behaviours among women with gestational diabetes mellitus. Sultan Qaboos Univ Med J. 2018;18(4):e513.
Chahed S, Lassouad L, Dardouri M, Mtiraoui A, Maaroufi A, Khairi H. Impact of a tailored-care education programme on maternal and neonatal outcomes in pregnant women with gestational diabetes: a randomized controlled trial. Pan Afr Med J. 2022;43:1.
Karbalai Harafteh F, Karami Mohajeri Z, Kia S. The Effect of Self-care Training on Perceived Stress, Health Literacy, and Self-care Behaviors in Women with Gestational Diabetes. Commun Health J. 2020;14(2):30-9.
Khadivzadeh T, Hoseinzadeh M, Azhari S, Esmaily H, Akhlaghi F, Sardar MA. Effects of self-care education on perceived stress in women with gestational diabetes under insulin treatment. Evid Based Care. 2015;5(3):7-18.
Kordi M, Banaei M, Asgharipour N, Mazloum SR, Akhlaghi F. Prediction of self-care behaviors of women with gestational diabetes based on Belief of Person in own ability (self-efficacy) Iran J Obstet Gynecol. Infertil. 2016;19(13):6-17.
Kolivand M, Keramat A, Rahimi M, Motaghi Z, Shariati M, Emamian M. Self-care education needs in gestational diabetes tailored to the Iranian culture: a qualitative content analysis. Iran J Nurs Midwifery Res. 2018;23(3):222.
Zandinava H, Shafaei FS, Charandabi S-A, Homayi SG, Mirghafourvand M. Effect of educational package on Self-Care behavior, quality of life, and blood glucose levels in pregnantwomen with gestational diabetes: A randomized controlled trial. Iran Red Crescent Med J. 2017;19(4): e44317.
Cao X, Wang Z, Yang C, Mo X, Xiu L, Li Y, Xiao H. Comprehensive intensive therapy for Chinese gestational diabetes benefits both newborns and mothers. Diabetes Technol Therapeut. 2012;14(11):1002-7.
He R, Lei Q, Hu H, Li H, Tian D, Lai Z. The effect of health education combined with personalized psychological nursing intervention on pregnancy outcome of pregnant women with gestational diabetes mellitus. BioMed Res Internat. 2022;2022:3157986.
Rokni S, Rezaei Z, Noghabi AD, Sajjadi M, Mohammadpour A. Evaluation of the effects of diabetes self-management education based on 5A model on the quality of life and blood glucose of women with gestational diabetes mellitus: An experimental study in eastern Iran. J prev med hyg. 2022;63(3):E442.
Xie Y, Zhao H, Zhao M, Huang H, Liu C, Huang F, Wu J. Effects of resistance exercise on blood glucose level and pregnancy outcome in patients with gestational diabetes mellitus: a randomized controlled trial. BMJ Open Diabet Res and Care. 2022;10(2):e002622.
Al-Ofi EA, Mosli HH, Ghamri KA, Ghazali SM. Management of postprandial hyperglycaemia and weight gain in women with gestational diabetes mellitus using a novel telemonitoring system. J Internat Med Res. 2019;47(2):754-64.
Kim Y-S, Kim H-S, Kim Y-L. Effects of a web-based self-management program on the behavior and blood glucose levels of women with gestational diabetes mellitus. Telemed and e-Health. 2019;25(5):407-14.
Murphy HR, Rayman G, Lewis K, Kelly S, Johal B, Duffield K et al. Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial. Bmj. 2008;337:a1680.
Ahmed RJ, Gafni A, Hutton EK, Hu ZJ, Sanchez JJ, Murphy HR, Feig DS. The cost implications of continuous glucose monitoring in pregnant women with type 1 diabetes in 3 Canadian provinces: a posthoc cost analysis of the CONCEPTT trial. Can Med Assoc J. 2021;9(2):E627-E34.
Feig DS, Donovan LE, Corcoy R, Murphy KE, Amiel SA, Hunt KF et al. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. The Lancet. 2017;390(10110):2347-59.
Paramasivam S, Chinna K, Singh A, Ratnasingam J, Ibrahim L, Lim L et al. Continuous glucose monitoring results in lower HbA1c in Malaysian women with insulin-treated gestational diabetes: a randomized controlled trial. Diabetic Med. 2018;35(8):1118-29.
Kestilä KK, Ekblad UU, Rönnemaa T. Continuous glucose monitoring versus self-monitoring of blood glucose in the treatment of gestational diabetes mellitus. Diabetes res clin practice. 2007;77(2):174-9.
Wei Q, Sun Z, Yang Y, Yu H, Ding H, Wang S. Effect of a CGMS and SMBG on maternal and neonatal outcomes in gestational diabetes mellitus: a randomized controlled trial. Scientific reports. 2016;6(1):19920.
Nagle C, Skouteris H, Morris H, Nankervis A, Rasmussen B, Mayall P, Kennedy RL. Primary prevention of gestational diabetes for women who are overweight and obese: a randomised controlled trial. BMC Pregnancy Childbirth. 2013;13:1-6.
Hagobian TA, Phelan S, Gorin AA, Phipps MG, Abrams B, Wing RR. Effects of maternal lifestyle intervention during pregnancy on untreated partner weight: Results from fit for delivery study. Obesity. 2016;24(1):23-5.
Garnweidner-Holme L, Henriksen L, Torheim LE, Lukasse M. Effect of the pregnant+ smartphone app on the dietary behavior of women with gestational diabetes mellitus: secondary analysis of a randomized controlled trial. JMIR mHealth and uHealth. 2020;8(11):e18614.
Brown J, Alwan NA, West J, Brown S, McKinlay CJ, Farrar D, Crowther CA. Lifestyle interventions for the treatment of women with gestational diabetes. Cochrane Database Syst Rev. 2017;(5):14651858.
Rasmussen L, Poulsen CW, Kampmann U, Smedegaard SB, Ovesen PG, Fuglsang J. Diet and healthy lifestyle in the management of gestational diabetes mellitus. Nutrients. 2020;12(10):3050.
Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. The J Clin Endocrinol Metab. 2008;93(12):4774-9.
Seward MW, Simon D, Richardson M, Oken E, Gillman MW, Hivert M-F. Supporting healthful lifestyles during pregnancy: a health coach intervention pilot study. BMC Pregnancy Childbirth. 2018;18:1-11.
da Silva SG, Hallal PC, Domingues MR, Bertoldi AD, Silveira MFd, Bassani D et al. A randomized controlled trial of exercise during pregnancy on maternal and neonatal outcomes: results from the PAMELA study. Int J Behav Nutr Phys Act. 2017;14(1):1-11.
Stith BJ, Buls SM, Keim SA, Thung SF, Klebanoff MA, Landon MB et al. Moms in motion: weight loss intervention for postpartum mothers after gestational diabetes: a randomized controlled trial. BMC Pregnancy Childbirth. 2021;21(1):461.
Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World psychiat. 2015;14(2):231.
Organization WH. The World Health Report 2001. Mental health: new understanding, new hope; 2001.
Horsch A, Gilbert L, Lanzi S, Gross J, Kayser B, Vial Y et al. Improving cardiometabolic and mental health in women with gestational diabetes mellitus and their offspring: study protocol for MySweetHeart Trial, a randomised controlled trial. BMJ open. 2018;8(2):e020462.
Ge L, Wikby K, Rask M. ‘Is gestational diabetes a severe illness?’exploring beliefs and self-care behaviour among women with gestational diabetes living in a rural area of the south east of C hina. Aust J Rural Health. 2016;24(6):378-84.
Nicklas JM, Miller LJ, Zera CA, Davis RB, Levkoff SE, Seely EW. Factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus. Matern Child Health J. 2013;17:1665-72.