This document discusses gestational diabetes mellitus (GDM), including its definition, prevalence, risk factors, diagnostic criteria, complications, management, and monitoring. Some key points: - GDM is glucose intolerance that is first recognized during pregnancy and can cause complications for both mother and baby if not properly managed. - The prevalence of GDM is rising worldwide and varies significantly between populations, ranging from 1.4-17.9% depending on location. - Risk factors include pre-pregnancy overweight/obesity, family history of diabetes, and certain ethnicities. - Treatment involves medical nutrition therapy, physical activity, blood sugar monitoring, and possibly medication like metformin or insulin to control blood

1. HYPERGLYCEMIA OF PREGNANCY
OR
GESTATIONAL DIABETES
DEFINED AS GLUCOSE INTOLERANCE RESULTING IN HYPERGLYCEMIA
DETECTED AFTER 1ST TRIMESTER OF PREGNANCY

2. Gestational Diabetes Mellitus (GDM)
• GDM was defined as any degree of glucose
intolerance that was first recognized during
pregnancy (WHO, 2016)
• Limitations –
• Most cases of GDM represent preexisting hyperglycemia
• Severity of hyperglycemia that is clinically important was not
taken into consideration.
• The term itself adds to the anxiety , since the terminology is
familiar.

3. Prevalence of GDM
• Worldwide prevalence was found to be around 1.4% to 12.3% of
pregnancies (Girgis, Gunton & Cheung, 2012)
• The prevalence of GDM in India has been reported to range from 3.8% in
Kashmir, to 6.2% in Mysore, 9.5% in Western India and 17.9% in Tamil
Nadu (Mithal, Bansal & Kalra, 2015)
• RISING PREVALANCE DUE TO LATE CHILD-BEARING , SEDENTARY LIFESTYLE ,
CONCEIVING AFTER PCOS TREATMENT,Universal screening ETC.
1 in 7
births is
affected by
GDM
1 in 2 Women
with GDM
develops T2DM
within 5-10 yrs
after delivery
IDF, 2017

4. Criteria Method Fasting 1 hr 2 hr
WHO
(any one criterion)
[OGTT]
8 hrs Fasting
sample, 75 gms
glucose in 200
ml of water
3 samples taken
92–125 mg/dL (5.1–
6.9 mmol/L )
180 mg/dL (10.0
mmol/L) with 75g
glucose
153–199 mg/dL
(8.5–11.0
mmol/L)
DIPSI
Cut-off GDM>200
If >200mg% -Overt
diabetes
Non-fasting 75-g
glucose in
300ml water in
5-10 mins
-[IF VOMITING
OCCURS WITHIN 30
MINS THEN IT IS
REPEATED THE
NEXT DAY]
[If vomiting occurs
after 30 mins ,the
test continues]-
≥ 140 mg/dl
Diagnostic Criterion
SCREENING 1ST TRIM:FBG >126mg%
RBS >200mg%
HbA1C >6.5

5. Diagnostic Criterion
Criteria Method Fasting 1 hr 2 hr 3 hr
ADA (one step)
(any one
criterion)
Fasting
OGTT with
75g glucose
92 mg/dL (5.1
mmol/L)
180 mg/dL
(10.0 mmol/L)
153 mg/dL
(8.5 mmol/L)
ADA (two step)
at 24– 28
weeks
Non-fasting
50-g glucose
- If ≥ 130 mg/dl
proceed to 100
g OGTT
(at least two
criterion)
Fasting
OGTT with
100 g glucose
95 mg/dL (5.3
mmol/L)
180 mg/dL
(10.0 mmol/L)
155 mg/dL
(8.6
mmol/L)
140 mg/dL (7.8
mmol/L)

6. Risk factors for GDM
• Patient is overweight with BMI of > 25 (>23 in Asian
Americans), and one of the following:
• Physical inactivity
• Known impaired glucose metabolism
• Previous pregnancy history of:
• GDM
• Macrosomia (≥ 4000 g)
• Stillbirth
-"Updated ACOG Guidance on Gestational Diabetes - The ObG Project", 2020

7. • Hypertension (140/90 mm Hg)
• HDL cholesterol ≤ 35 mg/dl
• Fasting triglyceride ≥ 250 mg/dL
• PCOS, acanthosis nigricans
• Hb A1C ≥ 5.7%, IGT or IFG
• Cardiovascular disease
• Family history of diabetes – 1st degree relative (parent or sibling)
• Ethnicity of African American, American Indian, Asian American,
Hispanic, Latina, or Pacific Islander
Risk factors for GDM
-"Updated ACOG Guidance on Gestational Diabetes - The ObG Project", 2020

8. Complications associated with GDM
- Garrison A, 2015. Am Fam Physician. 2015 Apr 1;91(7):460-467
Maternal
• Risk of T2DM
• Gestational HTN
• Preeclampsia
• Risk of C-section delivery
• Polyhydamnios
• UTI & Candidiasis
• Preterm Labour
• PROM
• CVD in Future
Fetal
• Shoulder dystocia
• Birth trauma
• Macrosomia
• Birth defects
• Neonatal hypoglycemia
• RDS
• Hypocalcemia
• Hypomagnesemia
• Decrease PTH
• Hyperbilirubinemia

9. - Organs involved in pathogenesis of GDM (Plows et al, 2018)

10. WINGS management protocol for GDM, (Mohan et al., 2016)

11. WINGS management protocol for GDM, (Mohan et al., 2016)

12. GDM Management
Medical
Nutrition
Therapy
Medicinal
Management
Lifestyle
Modification

13. •Maintain Normoglycemia
•Fasting Blood Sugar below 90 mg/dl
•2 hour PPBS below 120mg/dl
•HDL > 40 mg/dl
•Triglycerides< 150 mg/dl
AIM OF TREATMENT IN GDM

14. Pharmacologic Treatment
• Failure to achieve normoglycaemia with dietary changes and physical
activity , drug treatment needed
• Metformin is added to MNT and dosage titrated by monitoring PPBS
• ACOG recommends that insulin be the preferred therapy if glycemic
control is not obtained with non pharmacologic treatment
• Substantial number of patients started on oral therapy will require insulin
during pregnancy
• Starting insulin dose 0.7-1.0 units/kg daily
• Dosage should be divided and long-acting or intermediate-acting insulin in
combination with short-acting insulin should be used
• Individualize based on patients glycemic pattern
("Updated ACOG Guidance on Gestational Diabetes - The ObG Project", 2020)

15. Insulin Management
• Short acting analogues (e.g. insulin lispro and aspart) preferred over regular
insulin due to more rapid onset
• NPH insulin still used for but insulin glargine and detemir available for long-
acting coverage

16. • If a patient cannot take insulin or declines, metformin can be used
• Counsel about metformin risks including placental cross
over and no long term studies in offspring available
• May be associated with preterm birth
• Starting dose: 500 mg nightly for 1 week, increase to 500 mg
twice daily
• Check baseline creatinine
• Adverse events include abdominal pain and diarrhea –
recommend with meals
• Maximal dose is 2.5-3.0 g/day, in two or three divided doses
Pharmacologic Treatment
("Updated ACOG Guidance on Gestational Diabetes - The ObG Project", 2020)

17. Monitoring during antenatal visit
HBA1C in 1st trimester
Single step OGTT recommended by DIPSI & FOGSI
(75 gm glucose in 250-300 ml water within 5-10 minutes
irrespective of the time of her last meals ).
BP Monitoring and weight gain every 15 days
TIFFA Scan & Uterine Artery PI at 11 weeks
Quadruple Test at 16 weeks [HRP]
Level 2 Scan 18 weeks
Abnormal fetal growth (macrosomia/growth restriction)
Amniotic Fluid Index
Proteinuria

18. • Ultrasonography (USG) – Thrice with minimum gap at least 3
weeks
• At 18–20 weeks for fetal anatomical survey,
• Growth scan at 28–30 weeks
• Growth scan 34–36 weeks
• USG also includes fetal biometry and amniotic fluid index
• Blood sugar monitoring (“high-risk pregnancy” protocol)
• Additional four ANC visits, along with four routine visits (at
least every month) until delivery and during sixth week
postpartum
Monitoring during antenatal visit
("Updated ACOG Guidance on Gestational Diabetes - The ObG Project", 2020)

19. When to Deliver?
• Controlled on diet: ≥ 39 weeks
• Weekly NST to be done
• Well controlled on medication: Deliver at 39 weeks 0 days to 39
weeks 6 days
• Poorly controlled:
• Delivery between 37 weeks 0 days Glucocorticoids may be justified
• Delivery between 34 weeks 0 days and 36 weeks 6 days reserved for
(1) failure of in-hospital glycemic control or
(2) abnormal fetal testing ,decreased FM ,Non reactive NST ,FGR etc.
• Estimated fetal weight ≥ 4500: Counsel regarding risks and
benefits of a scheduled cesarean section
("Updated ACOG Guidance on Gestational Diabetes - The ObG Project", 2020)

20. Immediate Newborn Care
• Evaluate new born for immediate hypoglycemia (<45
mg/dL) within first hour of birth and at 4 hours interval
using glucometer till four stable readings glucose values are
achieved (≥45 mg/dL)
• Exclusive breast-feeding is promoted preferably by direct
breast-feeding
• If hypoglycemia occurs (<20 mg/dL) infant is referred to higher
center with 10% dextrose IV infusion drip (100 mL/kg/day) where
pediatrician is available
• Respiratory rate ,S.Calcium ,S.Magnesium levels ,BS to be
monitored .[Reduced PTH response due to hypomagnesemia sec. to
excessive excretion of magnesium ]

21. • In addition, newborns are monitored for
• Respiratory distress
• TTN is 3 times more common because of reduced
fluid clearance in the diabetic fetal lung
• Hypocalcemia & Hypomagnesemia
• Convulsions
• Hyperbilirubinemia
Immediate Newborn Care

22. Postpartum Care
Detail clinical assessment
BS ,Weight, Fundal height for involution ,Lochia ,Urine
examination ,Low GI diet to be followed
Lifestyle modification counseling - Weight
management, physical activity
Follow up testing at 48 hours after delivery to adjust
the dose of Metformin & Insulin .
Then after6 weeks by OGTT (75 g Glucose) with
fasting BSL
Preconception care and counseling before conceiving
again
Contraceptive advice – Barrier Methods & IUCDs if
blood sugar reverts to normal.

23. Medical Nutrition Therapy
• Nutrition-based treatment provided by a qualified dietitian,
nutritionist
• Includes nutrition diagnosis, nutrition therapy and counseling
• A variety of interventions like exchange list, plate method
• Involves developing best suitable short term and long term
nutritional plans with clients

24. Successful implementation of MNT
• Improved glucose control
• Improvement in lipid profile
• Weight management
• Decreased need for medications
• Reduced risk for complications

25. Pre-Pregnancy BMI
(kg/m2)
Weight Gain in kg
BMI <18.5 12.5-18 kg
BMI 18.5 - 24.9 11-16 kg
BMI 25.0 - 29.9 9-11.5 kg
BMI >30 7-9 kg
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
Institute of Medicine Guidelines for Gestational Weight Gain
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus Report. May 2009. The National
Academies Press. Washington, DC

26. CALORIE REQUIREMENT -1800/DAY
BMI STATUS Energy IBW
Intake[Kcal/KG/DAY]
<18.5 [LOW] ~ UPTO 40
18.5-24.9 [NORMAL] 30
25-29.9 [OVER WEIGHT] 22-25
>30 [OBESE ] 15 -20

27. FOOD COMPOSITION &
PROPORTION OF ENERGY IN DIET
American Diabetes Association. Nutrition principles and recommendations in diabetes. Diabetes care. 2004 Jan 1;27(suppl 1):s36-..
FOOD SOURCE ENERGY %
CARBOHYDRATE 45
PROTEIN 35
FATS 20

28. • Liberal amount complex CHO
with restriction in total CHO intake
for effective glucose control
• Complex CHO - whole grain
cereals, pulses, legumes, fruits and
vegetables are consumed
• Reduce simple CHO intake, by
decreasing consumption of added
sugars, sweets, refined cereal
products, bakery products, soft
drinks and fruit juices
Carbohydrates

29. Excess sugar intake can also lead to Obesity
has shown to increase risk of complications
in GDM
Excess sugar
intake
Obesity
Increased
complications
LGA
Macrosomia
Metabolic complications
Hypertensive disorders

30. POWDERED
NUTRITIONAL
SUPPLEMENTS
Few hidden sources of sugar in our daily foods
BE WARY OF FOODS WITH EXCESS SUGAR AND CHOOSE WISELY!

31. FSSAI – EAT RIGHT
MOVEMENT
WHO RECOMENDATION
FSSAI AND WHO recommend reducing intake of
sugar in diet

32. FIBRE – helps in satiety and blood glucose management
Fibre – helps in satiety and blood
glucose management

33. Glycemic Index (GI)
• Glycemic index ranking of food based on how it affects BSL
• Rate of Digestion
• Effect of processing
• Type of starch
• Degree of ripeness
• Types of sugars
• Addition of fat, protein
• Fiber
• Acidity

34. LOW GI – HELPS IN WEIGHT MANAGEMENT
AND OTHER BENEFICIAL EFFECTS
Significantly
higher weight
loss (P<0.05)
Significant
improvement
in lipid profile
(P<0.05)
Significant
decrease in
total fat mass
(P<0.05)
COCHRANE REVIEW: 6 RCT’S IN WHICH LOW GI DIETS
SHOWED BENEFICIAL EFFECTS COMPARED TO CONTROL
DIETS IN TERMS OF:
Thomas D, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight
and obesity. Cochrane Database of Systematic Reviews. 2007(3).

35. Glycemic Load (GL)
• Glycemic load considers quality and quantity of CHO
• Substituting Low to High GL - modestly improve glycemic control
• Use the foods with GL is to choose foods with the lowest GI within a food
group or category, and to control portion size
• The GL of a mixed meal or diet can simply be calculated by summing
together the GL values for each ingredient or component
• 20 & above
High GL
• 11 - 19
Medium
GL
• 10 & below
Low GL

36. Protein
• Moderate protein intake is suggested
• Around 30 -35% of total calorie
intake
• Wise choice of protein to limit intake of
saturated fat
• Healthy protein sources – Lean meats,
fish, eggs, low fat milk and milk products
like low fat curd, paneer, pulses, legumes,
nuts
American Diabetes Association. Nutrition principles and recommendations in diabetes. Diabetes care. 2004 Jan 1;27(suppl 1):s36-..

37. High PrHigh protein diets help in weight managementotein Diet fo
satiety & Weight Management
1. Sustained satiety:
How:
Hunger hormone ghrelin
Appetite-reducing hormones GLP-1,
peptide YY and cholecystokinin.
Effect : Increased satiety helps to
decrease energy intake – helps in
successful weight loss and management.
Source: Longland et al.. The American journal of clinical nutrition. 2016 Jan 27;103(3):738-
46.
Westerterp KR.. 2004 Dec;1(1):5.; Paddon-Jones et al. The American journal of clinical
nutrition. 2008 May 1;87(5):1558S-61S.
2. Diet-induced thermogenesis (DIT)
Thermogenesis is highest for protein (20-30%)
compared to carbohydrates (5-10%) and fats (0-
3%)
Effect : More energy required for metabolizing
protein and hence leading helps in successful
weight loss and management.

38. Fat
• Fat intake of ≤30% of total calories
• Limit intake of saturated fat in overweight and obese woman
• Saturated fat sources – Red meat, organ meat, hydrogenated fat,
ghee, cream
American Diabetes Association. Nutrition principles and recommendations in diabetes. Diabetes care. 2004 Jan 1;27(suppl 1):s36-..

39. Choose Fat Wisely
• Fat quality appears to be far more important than quantity
• High intake of MUFA improve BSL and ↓ in CVD risk
• olive oil, canola oil, groundnut oil or blended oils
• SFAs not more than 7 % of the total calories.
• Saturated Fat (SFA) - Identify sources of & ↓ intake
• Predominant in animal foods - ghee, butter, cream , whole milk &
dairy products, lard, fatty meat
• Plant sources: palm oil, coconut oil, Coconut milk & cocoa butter
• Cholesterol < 300 mg /day
• Limit trans fat as much as possible

40. Trans Fats
• Manufactured fats created during hydrogenation
• To keep vegetable oils solid at room temperature
• To improves shelf life and stability of flavors
• Even worse than saturated fat
• ↓ HDL –C -↑ LDL –C
• Sources
• Packaged foods: biscuits, cookies, wafer, chocolates, etc
• Fast-food: French fries fried chicken burgers
• Instant noodles & instant soup
• Chips & crackers: e.g. potato chips, corn chips
• How to Limit?
• Read food label carefully – hydrogenated fat, bakery shortening, margarine

41. Choose Healthier PUFA
• Omega –3, alpha-linolenic acids, EPA, DHA
• Sources
• Found in deep sea fish: salmon, mackerel, herring, sardine, cod, tuna
• Plant sources -flaxseed, pumpkin seeds, canola, walnuts, almonds
• Help suppress the synthesis of TG (↓ plasma TG)
• Omega3 supplement?
• not enough scientific evidence about dosage as well as side effects of long term use
• Omega-6 fatty acids (linoleic acids) -Most abundant PUFA in human diet
• Found in sunflower, corn, soy, safflower oils
• Reduce both LDL-C & HDL-C
• High consumption may lead to weight gain( central obesity), risk factor for CVD

42. Excess weight gain to be avoided by choosing
appropriate foods that promote satiety and prevent
obesity

43. Important tips for planning meals for GDM
mother
Breakfast
10-15% of total
calories.*
Limit CHO to 15-45 g
1st Snack
5-10% of
total
calories*
Lunch
20-30 % of
total
calories *
2nd
Snack
5-10% of
total
calories *
Dinner
30-40 % of
total
calories*
3rd Snack -
5-10 % of total
calories *
Nutrition Practice Guidelines for Gestational Diabetes Mellitus Diabetes Care and Education and Women and Reproductive
Nutrition Practice Groups of the American Dietetic Association, 2001 (www.eatright.org)
*Protein added to early low-carbohydrate breakfast and snacks is helpful in reducing hunger

44. Vitamins and Minerals
• Folic acid supplementation 3 months before trying to conceive
• Starting dose 5 mg/ day reducing to 0.4-1.0 mg /day at 12 weeks of gestation
(Endocrine society, NICE guidelines)
• RDA for vitamins and minerals should be satisfied
• Insufficient evidence for recommending specific vitamin / mineral
supplementation
• Monitor dietary intake of
• B complex vitamins
• Ca, Vit. D, Mg
• Iron
• Iodine
• If inadequate, supplementation may be
needed to satisfy the requirement

45. Sweeteners
• Clear evidence – sugar alcohols and non –caloric sweeteners are
safe if consumed within acceptable daily levels

46. • MYOINOSITOL
• RCT - 24 Caucasian women (mean BMI, 24–25kg/m2)
compared to 45 controls (mean GA= 26 weeks)
• Open-label treatment for 8 weeks
• Decrease in Insulin and glucose levels after 8wk
• Greater improvement in insulin sensitivity (HOMA-IR) in
the myo-inositol group (50% improvement vs. 29%)
• Increase adiponectin (by 28%) in the study group
(D’Anna et al., 2011)

47. Diabetes Care 2019;42:364–371
Probiotic in GDM Prevention /Management

48. Zhang et al., Journal of Diabetes Research, Volume 2019
Conclusion:
Probiotic supplementation
Reduce the risk of a newborn’s
hyperbilirubinemia
Improvement in maternal
• Glycemic control
• Blood lipid profiles
• Inflammation and oxidative stress
Limitations of studies:
• Heterogeneity among existing studies
• Surrogate nature of outcomes
• Same geographic location
Probiotic in GDM Prevention /Management

49. Useful Tools in MNT
• High fiber, low GL –
Vegetables, Whole grains
Eat Most
• Medium GL, high protein
with high fat
Eat Moderate
• Simple Sugars, high GL
foods, fried fod
Eat Less
Food Choices - Signal Method Plate Method
Portion Control

50. Exercise guidelines for GDM
• Exercise – proven to improve pregnancy outcome in GDM women
• Better glucose control
• Delayed or prevents need for insulin
• Exercise prescription
• Moderate intensity exercises
• Aerobic and Strength training
• Recreational physical activity
(Padayachee, 2015)

51. Exercise Guidelines
• Under the guidance of trained professionals
• Avoid exercises/ sports with increase risk of forceful contact, falling
• Consent from medical professional before starting exercise program
• Consume snack having complex CHO before starting exercise to avoid
hypoglycemia
• Frequent monitoring of BSL before, during and after exercise
(Padayachee, 2015