National Guidelines for GDM Diagnosis & Management by Dr. Rajesh Jain MD

1. National Guidelines for GDM - Diagnosis & Management Dr Rajesh Jain MD Medicine Project Manager Gestational Diabetes Project, Uttar Pradesh

2. Child is the father of a nation the ‘designer’ of the child Mother is …..

3. Objective • To define GDM • To understand the need for diagnosis & management of GDM • To understand protocol for diagnosis of GDM • To understand the MNT for management of GDM • To understand the counselling tips for GDM

4. PREGNANCY IS A DIABETOGINEC STATE • Increased placental hormones • Increased free fatty acid which interfere with glucose uptake As pregnancy advances insulin resistance and diabetogenic stress due to placental hormones necessitate compensatory increase in insulin secretion. When this compensation is inadequate gestational diabetes develops.

5. Why do you want to screen for Diabetes in Pregnancy ? • Incidence is high in our country • Index pregnancy has risk for the mother and the fetus • Neonatal period is stormy • Long term risks for the mother and the baby

7. Contribution of India, China, and USA in estimated global prevalence of Type 2 DM during 2010 (Global Prevalence being 284.81 million)

8. Prevalence of GDM in our country is 16.55% by WHO criteria of 2 hr post prandial glucose >140mg/dl(75 g glucose). Seshaiah V, Balaji V, J ObstetGynecol India 2005

9. Gestational Diabetes mellitus is defined as impaired Glucose tolerance with onset or first recognition during pregnancy

10. GDM is a public health problem • GDM higher in India than west – 10 -14.3 % • 50-60% risk for women to develop Type II diabetes in next 10 years • 20-30% risk of developing Type II diabetes for children in early life • 40-50% risk of developing GDM in next pregnancy

11. Effect of Gestational diabetes in Mother Keto-acidosis Increased Infections In later life in 60% after pregnancy women can develop DM Pre-eclampsia Poly-hydramnios Obstructed labor, Increased LSCS Prolonged labor, PPH

12. Effect of Gestational diabetes in Baby Early Abortion Congenital abnormality Large size baby, birth injuries Preterm births, Fetal Death Stormy neonatal period

13. Why screen for GDM??Consequences of diabetes on the fetus –

14. Vicious cycle of diabetes in pregnancy Lifecycle rather than Lifestyle approach

15. Whom to screen?

16. Universal Testing for GDM • All pregnant Women in community should be tested for diagnosis of GDM at all delivery points

17. When to Screen ?Guidelines

18. When to screen? • First trimester or at booking • 24-28 weeks • 32 weeks

19. Protocol for Investigation • Testing of GDM twice during ANC • First testing at first antenatal contact in 1st trimester • 1st test is negative – 2nd test at 24-28 weeks • A gap of 4 weeks between two tests • If PW comes after 28 weeks only once test done • Test positive at any time management followed

20. Challenges with the OGTT • Cumbersome test • Cut off values - C&C or NDDG ?? • What to do if only one level abnormal ? • What if GCT positive and OGTT negative ?

21. Test for GDM diagnosis • Single step testing - 75 gm oral glucose in 300 ml of water orally irrespective of last meal • GDM Diagnosis - 2 hour PP equal or >140 mg/dl • Plasma standardized glucometer used • If vomiting with in 30 min - repeat test next day

22. DIPSI Recommended method

23. GOVERNMENT DIRECTIVE

24. Two hour plasma glucose

25. One step 75gm OGTT - Advantages • 3times more pick up than with two step • Suitable for Indian setting • Saves time & cost. • Avoids repeated visits • Does away the need to confirm by OGTT • No need to remember many values • Reduces repeatedinvasivesampling. • V Seshiah, AK Das, Balaji V, Shashank R Joshi, MN Parikh, Sunil Gupta For Diabetes In Pregnancy Study Group (DIPSI)+

26. Logistics required for screening • For plasma glucose testing • Glucose pouches 75gms • Disposable glasses and stirrers • Drinking water 300ml • Glucometer with calibration strips • Sterile lancet • Cotton spirit swab or alcohol wipes • Register to record the results • Yellow and black dust bins • Puncture proof container Glucometer calibration is recommended after 20 measurements, using calibration strips, provided with glucometer

27. Pregnant Woman in Community Testing for GDM at 1st Antenatal visit (75 g oral glucose- 2 hr Plasma Glucose value) Negative (2 hr PG <140mg%) Positive (2 hr PG ≥ 140 mg%) Repeat Testing at 24-28 weeks Manage as GDM as per guidelines Positive (2 hr PG ≥140 mg%) Negative (2 hr PG <140mg%) Manage as GDM as per guidelines Manage as Normal ANC Universal testing for GDM

28. Calibration of glucometer • Glucometer to be calibrated after every 20 glucose testing by calibration strips or fluid • Calibration means checking accuracy & correctness to get accurate results

29. Assessment for Diabetes in Pregnancy Diabetes in previous pregnancy Family history of diabetes. Delivery of a large baby (> 4kgm) Poor Obstetric history(previous stillbirth) More than 3 spontaneous abortions

30. Assessment for Diabetes in pregnancy Age >30 years, <30 years with obesity Persistent Glycosuria. Polyhydramnios. Chronic hypertension or early onset pre-eclampsia. Recurrent or persistent candidiasis or urinary tract infection

31. High risk gestational diabetes • History of stillbirth. • History of neonatal death. • History of fetal macrosomia. • Concomitant obesity and/or hypertension. • Development of oligohydramnios, polyhydramnios or pre-eclampsia • Inadequate metabolic control with diet alone.

32. VALUE OF HBA1C… HBA1c is a measure of glucose control over 8-10 weeks Cut off is taken as 6 % Helps distinguish between pre GDM and GDM, when GDM diagnosed in early pregnancy > 9.5 % -- congenital anomalies 22 % Spontaneous abortions -- 14 % > 11 % --- terminate pregnancy ??

33. Cut off for Blood Sugar in Non pregnant • F blood sugar > 126 mg% • Impaired fasting 100-125 mg% • Normal fasting < 100 mg% • 2 Hour PP blood sugar > 200 mg% • Impaired PP 140 – 199 mg% • Normal 2 hour PP < 140 mg%

34. Traditional management of GDM 1 3 2 Diet Insulin Exercise GDMGynecologists (Obstetricians) Dietitians Medicine (Endocrinologists) Safety in every step of the way

36. Pregnant Woman with GDM Medical Nutrition Therapy (MNT) After 2 weeks 2 hr PPPG < 120 mg% Continue MNT  120 mg% Start Insulin Therapy Monitor 2 hr PPPG - Upto 28 wks: Once in 2 weeks - After 28 wks: Once a week - Monitor FBG &2 hr PPPG every 3rd day or more frequently till Insulin dose adjusted to maintain normal plasma glucose levels - Monitor 2 hr PPPG once weekly Management of Pregnant Woman with GDM

37. Medical Nutrition Therapy Diet Counseling

38. Medical nutrition therapy • MNT is carbohydrate controlled balanced meal plan • Nutritional assessment should be individualized • Pre-pregnancy BMI, optimal weight gain & Energy requirement (BMR x PAL) during pregnancy to be defined

39. First step-Medical Nutrition Therapy • General principles: 10 -12 kg weight gain (300 kcal/d) • Calorie counting: wise distribution of calories • No fasting • Dietician charts a diet plan according to Body Weight • Obese women : 25-30 kcal / kg • Non-obese : 30-35 kcal /kg • Underweight: 35-40 kcal/kg • Dietary compliance is evaluated and reinforced during hospital visits • Dietary variety/choices should be added ,

40. Ideal BMI chart

41. Pre-pregnancy weight, BMI & Optimal Weight gain during Pregnancy

42. Energy Requirement (BMR x PAL) Calculations ICMR 2009

45. Glycemic index of foods Diet with low GI are generally rich in fibre and high fibre improves glucose tolerance

46. Signal system Healthy vs unhealthy food choices What to Eat? (Quality of food)

47. Understanding Food properly • Carbohydrates foods are essential for healthy diet of mother & baby • Large amount of carbohydrate at one time should be avoided • Complex carbohydrates preferred over simple carbohydrates • Carbohydrate should be spread over 3 small meals and 2-3 snacks • Have 2-3 carbohydrates at each major meals & 1-2 at every snack • Saturated fat like ghee should be less than 10% of total calories • Obese & overweight PW should take low fat diet • Moderate caloric restriction in GDM may improve glycemic control • Hypocaloric diet may lead to ketonemia & ketonuria

48. Protein – requirement increases to allow fetal growth – additional 23 g/d is required • 2-3 servings should be consumed every day • Fiber - High fiber foods control blood sugar better

49. Composition of Dinner & Lunch Thali

50. 1800 Calories sample meal plan for GDM