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Chapter 44Diagnosis and Management of Gestational Diabetes Mellitus: Indian Guidelines Seshiah V, Sahay BK, Das AK, Balaji V, Siddharth Shah, Samar Banerjee, A Muruganathan, Rao PV, Ammini A, Shahsank R Joshi, Sunil Gupta, Sanjay Gupte, Hema Divakar, Sujata Misra, Uday Thanawala, Vitull K Gupta, Navneet Magon Representation from the National Bodies World Health Organization Procedure To standardize the diagnosis of GDM, the World Health Organization Diabetes in Pregnancy Study Group India (DIPSI)—Madhuri S Balaji, A Pannerselvam, Anuj Maheswari, Mary John, C Munichoodappa, (WHO) recommends using a 2-hour 75 g oral glucose tolerance test Shailaja Kale. Association of Physicians of India (API)—Anand Moses, (OGTT) with a threshold plasma glucose concentration of greater Banshi Saboo, A Ramachandran. Indian Medical Association (IMA)—A than 140 mg/dL at 2 hours, similar to that of IGT (> 140 mg/dL and < Bhavatharini. Federation of Obstetric and Gynecological Societies of 199 mg/dL), outside pregnancy.6 India (FOGSI)—Ambarish Bandiwad, Cynthia Alexander, Anjalakshi C, Bharti Kalra, Sujatha Sharma, Ritu Joshi, Kartikeya Bhagat. Diabetic American Diabetes Association Procedure Association of India (DAI)—Anil Bharoskar. Research Society for the Study of Diabetes in India (RSSDI)—HB Chandalia, CS Yajnik, Jitendra American Diabetes Association (ADA) procedure has become Singh, Mayur Patel, V Mohan. Endocrine Society of India—Abdul Hamid obsolete. Zargar, SK Sharma, Rakesh Sahay, KM Prasanna Kumar, GR Sridhar, Ambrish Mithal. Diabetes India—Shaukat Sadikot, SR Aravind, Anand The International Association of the Diabetes and Nigam. Indian Society of Neonatology—Geetha. Epidemiologist— Pregnancy Study Groups7 Manjula Datta. Based on the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, International Association of the Diabetes and INTRODUCTION Pregnancy Study Groups (IADPSG) suggested the guidelines. In this HAPO study, population from India, China, South Asian countries “Gestational diabetes mellitus” (GDM) is defined as carbohydrate (except city of Bangkok, Hong Kong), Middle East and Sub Saharan intolerance with onset or recognition during pregnancy. Women countries were not included. Thus, essentially HAPO study was diagnosed to have GDM are at increased risk of future diabetes performed in Caucasian population. predominantly type 2 diabetes mellitus (DM) as are their children. • The IADPSG recommends that diagnosis of GDM is made when Thus, GDM offers an important opportunity for the development, any of the following plasma glucose values meet or exceed: testing and implementation of clinical strategies for diabetes Fasting: ≥ 5.1 mmol/L (92 mg/dL), 1-hour: ≥ 10.0 mmol/L (180 prevention. Timely action taken now in screening all pregnant women mg/dL), 2-hour: ≥ 8.5 mmol/L (153 mg/dL)7 with 75 g OGTT. for glucose intolerance, achieving euglycemia in them and ensuring • The IADPSG also suggests: Fasting plasma glucose (FPG) > 7.0 adequate nutrition may prevent in all probability, the vicious cycle mmol/L (126 mg/dL)/A1C > 6.5% in the early weeks of pregnancy of transmitting glucose intolerance from one generation to another.1 is diagnostic of overt diabetes. Fasting > 5.1 mmol/L and < 7.0 mmol/L is diagnosed as GDM.7 EPIDEMIOLOGY Disadvantages of the IADPSG suggestions are: The prevalence of GDM in India varied from 3.8 to 21% in different • Most of the time pregnant women do not come in the fasting state parts of the country, depending on the geographical locations and because of commutation and belief not to fast for long hours. diagnostic methods used. GDM has been found to be more prevalent The dropout rate is very high when a pregnant woman is asked in urban areas than in rural areas.2 For a given population and to come again for the glucose tolerance test.8 Attending the first ethnicity, the prevalence of GDM corresponds to the prevalence of prenatal visit in the fasting state is impractical in many settings.7 impaired glucose tolerance (IGT) (in nonpregnant adult) within that • In all GDM, FPG values do not reflect the 2-hour post glucose given population.3 with 75 g oral glucose [2-hour plasma glucose (PG)], which is the hallmark of GDM.9 Ethnically Asian Indians have high SCREENING AND DIAGNOSIS insulin resistance and as a consequence, their 2-hour PG Compared to selective screening, universal screening for GDM is higher compared to Caucasians.10 The insulin resistance detects more cases and improves maternal and neonatal prognosis.4 during pregnancy escalates further11 and hence FPG is not an Hence, universal screening for GDM is essential, as it is generally appropriate option to diagnose GDM in Asian Indian women. In accepted that women of Asian origin and especially ethnic Indians this population by following FPG > 5.1 mmol/L as cut-off value, are at a higher risk of developing GDM and subsequent type 2 76% of pregnant women would have missed the diagnosis of diabetes.5 GDM made by WHO criterion.12 17 week and finally around 32nd–34th week.21 After a meal. If they are asked to come on another day in Initiating Insulin Therapy the fasting state many of them do not return. whereas it will. WHO level increases with a meal and with glucose challenge. seldom pregnant women visiting the antenatal clinic for the first time come in the fasting state. GDM is diagnosed if 2-hour PG is ≥ 140 mg/dL • The A1C is not possible to perform in the less resource countries.26 A relation to mother as well the child. not only because it is expensive but also due to lack of technically If 75 g glucose packet is not available. The glucose marketed is in anhydrous Evidence-based WHO Criterion form.23 This cascading effect is advantageous impact best buy for less resource settings. If MNT fails to achieve control. Short-term Outcome as glucose concentrations are affected little by the time since the last • Economical test: meal in a normal glucose tolerant woman. in a woman – This procedure requires one blood sample drawn at 2 hours with gestational diabetes. she may be a pre-GDM and A1C of ≥ 6. as is 300–400 g per week and total weight gain is 10–12 kg by term. The expected weight gain during pregnancy difficulty in performing glucose tolerance test in the fasting state. irrespective of whether she is in the fasting or nonfasting • Center to center differences occur in GDM frequency and relative state and without regard to the time of the last meal. quality of life. also suggest one-step diagnostic procedure the first trimester. found that treatment of • Pregnant women need not be fasting18 GDM diagnosed by WHO criterion reduces serious perinatal • Causes least disturbance in a pregnant woman’s routine activities morbidity and may also improve the women’s health-related • Serves as both screening and diagnostic procedure. cost-effective and high excursion exaggerates further. the cumulative risk of offspring developing type 2 DM was 30% at Treatment the age 24 years. sustainable. initiated.27 Long-term Outcome MANAGEMENT OF GESTATIONAL • A long-term outcome study conducted by Franks et al. whereas. the glycemic procedure is feasible. a normal glucose tolerant after 75 g oral glucose load for estimating plasma glucose.20 Hence. In hospitals where glucose is supplied in bulk.8 mmol/L in diagnosis and management of GDM for a missed. medical nutritional therapy (MNT) is to have a test that detects the glucose intolerance without the woman advised initially for 2 weeks. it is important Once diagnosis is made. has to be given a 75 g oral glucose Bangkok and 26% in Hong Kong.13 load*.28 This is possible if FPG Study Group India)19 and 2-hour postprandial peaks are ~90 mg/dL and ~120 mg/dL.15 By following the usual recommendation for screening between 24 – Wahi et al. respectively. mg/dL) and treatment in a combined diabetes antenatal clinic is worthwhile with a decreased macrosomia rate and fewer Gestational Weeks at which Screening emergency cesarean sections. the cost challenge due to brisk and adequate insulin response. Note: Diabetes in Pregnancy Study Group India (DIPSI diagnostic criteria 2-hour PG ≥ 140 mg/dL is similar to WHO criteria 2-hour PG ≥ Medical Nutrition Therapy 140 mg/dL to diagnose GDM) All women with GDM should receive nutritional counseling. Government of India24 and also recommended by WHO. Thus. a cup or container of 75 g may be used. as this would not result in false-positive diagnosis of GDM. observed in their randomized controlled study.8 mmol/L (140 Health.e. weeks and 28 weeks of gestation. a pregnant woman after undergoing preli­ A diagnostic FPG was present in only 24% of those with GDM in minary clinical examination.25 If the 2-hour PG is > 200 mg/dL in the early weeks of preg- significantly positive effect on pregnancy outcomes both in nancy.7 available.8 mmol/L. i. This may impact strategies used for the diagnosis of GDM.14 This single-step procedure has been approved by Ministry of – Diagnosis of GDM with OGTT 2-hour PG ≥ 7. 202 .8 mmol/L) to diagnose GDM. In the antenatal clinic. the chance of detecting unrecog- the advantage of adhering to a cut-off level of 2-hour PG nized type 2 diabetes before pregnancy (pre-GDM) is likely to be ≥ 7. remove and discard 5 level qualified staff. The meal pattern should provide adequate calories and nutrients to meet “A Single-step procedure” was developed due to the practical the needs of pregnancy. DIABETES MELLITUS documented that when maternal 2-hour PG was ≥ 7. (7. • Evidence-based: Advantages of the DIPSI procedure are: – A study performed by Crowther et al. insulin may be to perform the diagnostic test at the first visit itself. in – Perucchini et al. Diabetology Section 5 • Asian and South Asian ethnicity are both independently Procedure associated with increased insulin resistance in late pregnancy.18 Target A Single Test Procedure to Diagnose GDM Maintaining a mean plasma glucose (MPG) level ~105–110 mg/ in the Community (Diabetes in Pregnancy dL is desirable for a good fetal outcome. woman would be able to maintain euglycemia despite glucose Even if the test is to be repeated in each trimester.8 mmol/L).22 her glycemic performing IADPSG recommended procedure. should be tested for GDM again around 24th–28th (2-hour PG ≥ 7. The cost and standardization of A1C testing are teaspoons (not heaped) of glucose from a 100 g packet which is freely issues for consideration. The treatment of GDM women as defined by WHO criterion was associated with reduced risk is Recommended of pregnancy outcome.16 pregnant woman found to have normal glucose tolerance (NGT).13 GOD-POD method. 1-hour and 2-hour glucose sample is collected at 2 hours for estimating plasma glucose by the levels. Performing this test procedure in the nonfasting state is rational. a in performing the procedure will be 66% less than the cost of woman with GDM who has impaired insulin secretion. FPG necessarily undergoing a test in the fasting state and it is preferable ~90 mg/dL and/or post-meal glucose ~120 mg/dL. A venous blood diagnostic importance of fasting.5 is confirmatory. High prevalence of (SMBG) on a daily basis. advise alpha-methyldopa Women.56:109-13. Balaji V. et al. a starting dose of should be performed at 6–8 weeks postpartum. B-cell function and insulin resistance in pregnancy and their relation to fetal development. et al. Paterson CM. using WHO criteria for the nonpregnant population 3. Gayle C. venous plasma glucose has to be estimated for adjusting the dose of 6. 46. *Initially if post-breakfast plasma glucose is high → Start Premix FOLLOW-UP OF GESTATIONAL DIABETES MELLITUS 50/50 2. oral glucose. N Engl J Med. Section 5 Chapter 44  Diagnosis and Management of Gestational Diabetes Mellitus. 1998. Balaji MS. A Review with blood sugar test → Adjust dose further neonatologist’s presence at the time of delivery is ideal. Tamussino K. 125 mg and dose to be adjusted on follow-up. The blood pressure has to be monitored during every visit. Taylor & Francis Group plc. 2000. Screening and insulin sensitivity in gestational diabetes. MNT is advised for a Gestational diabetic women require follow-up. checked again on follow-up. whichever time Dunitz. Diabet Med. Hod M. Gabbe SG. Moss JR. it is essential to maintain good glycemic ↓ control. but not yet approved by drug controller of India. while avoiding hypoglycemia. London: Martin for monitoring is the same. Along determine whether the glucose tolerance has returned to normal with insulin therapy. 2005. Yogev Y. An OGTT with 75 g week. at least weekly monitoring gestational diabetes in women from ethnic minority groups.30 9.. Hadden DR. If found normal. Benedetti TJ. Cosson E. diagnosis and classification insulin. 2007. Magee MS.A 350. 1993. in the morning and one-third in the evening. If self-monitoring is not possible. A considerable proportion of gestational diabetic women may continue to have glucose intolerance. 24 hours ↓ postpartum and if found to be high. If blood 12. Das S.35(3):526-8. 2010. Misra S. rapid-acting insulin analogs. Persson B. Dornhorst A. monitoring is recommended at least every trimester. of diabetes mellitus and its complications. et al. Balaji M. Diabetologia. Comparing pregnancy outcomes Timing of delivery: Delivery before full term is not indicated for intensive versus routine antenatal treatment of GDM based on a 75 unless there is evidence of macrosomia. Marsh MS. MNT is also advised. Diabetes Care. J Assoc Physicians India. i. Seshiah V. ovarian disease (PCOD) who failed to conceive. 203 . It is important Insulin Analogs that women with GDM be counseled with regard to their increased If postprandial glucose is still not under control—consider using risk of developing permanent diabetes. is targeted for monitoring glycemic control and adjusting insulin Abstract volume of the 40th Annual Meeting of the EASD. Germain S. Measuring Other Parameters 11. as the time for diagnosis and also (Eds). Hiller JE. more so if Total insulin dose per day can be divided as two-thirds significant neonatal morbidity is suspected. However. 2010. Lower insulin requirements If FPG remains > 90 mg/dL advise → 6 units before are common during labor (often no insulin is necessary). with increased perinatal complications as compared with insulin. In: Hod M. Ben-Haroush A. Pregnancy and diabetes scenario the glycemic control maintained with meal plan or pharmacological around the world: India. 2011. Balaji V. pre-eclampsia Starting dose: 4 units before breakfast or intrauterine growth retardation). every trimester is diabetes mellitus at collaborating centers based on IADPSG consensus recommended particularly in women with pregestational diabetes. Walden CE. Inadequacy of fasting plasma glucose to diagnose gestational diabetes mellitus in Asian Indian pressure is found to be more than 130/80. Metzger BE. Frequency of gestational fundus and estimation of microalbuminuria. Crowther CA. et al. Balaji MS. Indian J Med Res. Anjalakshi C. 1st edition. et al. Zimmet PZ. failing which. 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