Our aim is to reduce morbidity and mortality related to Non communicable diseases such as hypertension, diabetes, cardiovascular disease, stroke, Obesity, Cancer and lifestyle diseases among those least able to withstand the burden of the disease.

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

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

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
1. Increased placental hormones
2. 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.
‘Gestational Diabetes Mellitus’ [GDM] is defined as
carbohydrate intolerance with onset or recognition
during pregnancy.’

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 Obstet Gynecol
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
Pre-eclampsia
Poly-hydramnios
Obstructed labor, Increased LSCS
Prolonged labor, PPH
In later life in 60%
after pregnancy
women can develop
DM

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

13. Why screen for GDM??
Consequences of diabetes on the fetus –
First trimester-
Malformations;
fetal wastage
Second
Trimester-
Hypertrophic
cardiomyopathy;
Polyhydramios;
PIH; Fetal
loss;Prematurity
Third Trimester
Macrosomia;
Hypoglycemia;
Hypocalcaemia;
IUD
Neonatal Problems
Birth Injuries ;
Metabolic
disturbances; RDS,
polycythemia
hyperbilirubinemia

14. Vicious cycle of diabetes in pregnancy
Pregnant
woman with
diabetes
Child of a
diabetic
woman
Young
woman with
diabetes
Lifecycle
rather than
Lifestyle
approach

15. Whom to screen?
National Diabetes Data Group advocates
universal screening for GDM.
Selective Screening - Righ risk Factors –45%
of the pregnant women will go unscreened.
35% - 50%of GDMs would be missed

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
Early screening –
to pick up
undiagnosed
preexisting
diabetes( HbA1c
>6)
Early Screening - In
patients with High
Risk factors
Repeat at 24-
28weeks
Also around 32- 34
weeks

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
One step procedure Irrespective of
previous meal
75gm oral glucose load
2 hrs later Plasma glucose
Simple Economical and feasible

23. GOVERNMENT DIRECTIVE

24. Two hour plasma glucose
Plasma glucose level Status
>200 mg/dl Diabetes
>140-199mg/dl GDM
120-139 mg/dl GGI
<120 mg/dl Normal

25. 3 times 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 repeated invasive sampling.
V Seshiah, AK Das, Balaji V, Shashank R Joshi,
MN Parikh, Sunil Gupta For Diabetes In
Pregnancy Study Group (DIPSI)+
One step 75gm OGTT - Advantages

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

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
Safety in every step of the way
Diet Exercise Insulin
GDM  Gynecologists (Obstetricians)
Dietitians
Medicine (Endocrinologists)

35. Create Awareness

36. Management of 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
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
Pre-pregnancy
Weight
BMI (kg/m2) Total wt gain range
(kg) in pregnancy
Normal weight 18.5 to 24.9 11.5 to 16 kg
Under weight < 18.5 12.5 to 18 kg
Over weight 25 to 29.9 7 to 11.5 kg
Obese (include
all classes
grade I, II, III)
Equal/more than
30
5 to 9 kg

42. Energy Requirement (BMR x PAL) Calculations
ICMR 2009
• BMR
calculation
• BMR (KCal/d) for
adult female 18-30
years = 14 x BW
(Kg) + 471
• BMR (K.Cal/d) for
adult female 30-60
years = 8.3 x BW
(Kg) + 788
• PAL (Physical
activity level)
values
Sedentary work –
1.53
Moderate work –
1.8
Heavy work – 2.3
• 350 K.Cal to
be added in
2nd & 3rd
trimester for
additional
energy
requirement

43. 43
Choice of diet
• CHO with low GI
• Lean proteins
• Balance of Poly and mono
unsaturated fats
Avoid
• Eating for two
• Fast & feasts
• Health Drinks

45. Low GI Legumes & lentils, dried beans, peas,
green gram, Bengal gram (rich in fibre)
(30-40%)
Medium GI Fruits (45-55%)
High GI Cereals like rice, white bread, root
vegetables-potato, carrot, candy bars
and syrupy foods (65-70%)
Diet with low GI are generally rich in fibre and high fibre
improves glucose tolerance
Glycemic index of foods

46. Signal system
Healthy vs unhealthy food choices
Steamed
brown rice
White rice Biryani
Whole grain
bread
White
bread
Cakes,
cookies,
croissants
Steamed/
grilled fish
Stir fry fish Deep fry fish
Fresh fruit
Unsweeten
ed fruit
juice
Candied fruit,
sweetened
fruit juice
Whole
wheat roti
Maida
roti/Naan
Paratha
/Puri
Green salad
Salad with
mayonnaise
Salad with
cream and
cheese
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

51. Delivery
• Controlled GDM on diet/insulin - at 39 or 40 weeks -
spontaneous delivery / induction
• GDM on insulin - uncontrolled blood glucose to be referred
for delivery by gynecologists – may need LSCS
• LSCS for obstetrical indication/ macrosomia > 4kg fetal weight

52. Immediate neonatal Care
• Essential new born care for every newborn
• Early breast feeding to avoid hypoglycemia
• Monitoring for hypoglycemia (cut off < 44 mg/dl)
– to be started after one hour of delivery
– every 4 hours (prior to next feed)
– till four stable glucose values are obtained
• Evaluate neonate for RDS, convulsions, hyperbilirubinemia

53. OGTT to be done 6
weeks after
delivery with 75
gm of glucose to
evaluate glycemic
status
GDM women
are at higher
risk of DM &
CVS diseases
Intensive life style
intervention
delays & reduces
the risk for
development of
DM & CVS
problems

54. Post delivery follow up
• Maternal glucose levels usually returns to normal after delivery
• FPG & 2 hr PPPG is performed on 3rd day of delivery
• 75 gm GTT at 6 weeks postpartum
• Cut off for normal blood glucose values are
– F plasma glucose equal or > 126 mg/dl
– 75 g OGTT 2 hour plasma glucose
• Normal < 140 mg/dl
• IGT 140-199 mg/dl
• Diabetes equal or > 200 mg/dl
• Test normal - Women is counselled about life style modifications, weight
monitoring & exercise
• Test positive women should consult physician

55. The postpartum period is an important platform to initiate
contraception, early preventive health for mother and the child
who are both at higher risk of:
• Future Obesity
• Metabolic Syndrome
• Diabetes
• Hypertension
• Cardiovascular Disorders
This can best be achieved by linking mother’s follow up to the child’s vaccination and well baby clinic visit
A sticker of red dot can
alert care giver about
GDM offspring and
follow up for
contraception &
discussion about life
style changes

56. Preconception care – Goals of Treatment
Optimal HbA1C
Medical Nutrition therapy (MNT)
Self monitoring of blood glucose (SMBG)
Self administration & adjustment of insulin doses
Education about hypoglycemia
Physical activity

57. Contain the epidemic of Diabetes
The timely action taken now in screening all pregnant
women for glucose intolerance, achieving euglycemia in
them and ensuring adequate nutrition may prevent in all
probability, the vicious cycle of transmitting glucose
intolerance from one generation to another.
To contain the epidemic of diabetes we have to
“Focus on the Fetus for the Future”.

58. Counselling Tips
• Blood sugar control is very important for neonate & female
• Modification in diet is easy and very important
• GDM women needs Insulin injections only during pregnancy
• Injecting insulin over abdomen is 100% safe
• As of now Oral hypoglycemic not recommended
• GDM on Insulin should always keep sugar/ glucose
• GDM should have institutional delivery

59. Thank
you….

60. Management of GDM
• GDM +ve PW should be started on MNT for 2 weeks
• 2 hrs PPPG repeated after 2 weeks
• 2 hr PPPG is > 120 mg/dl Insulin to be started
• 2 hr PPPG is < 120 mg/dl
– test repeated every 2 weeks in 2nd tri
– every week in 3rd trimester

61. Target Blood Sugar during Pregnancy
• GDM diagnosis DIPSI Test Blood Sugar > 140
mg%
• F Blood Sugar < 95 mg%
• 2 hour PP Blood Sugar < 120 mg%
• Cut off for Hypoglycemia < 70 mg%
• Cut off neonatal blood sugar > 45 mg%

62. Recognition & Management of
Hypoglycemia
• Hypoglycemia - when blood glucose < 70 mg/dl
• Symptoms & Signs of Hypoglycemia
– Early – tremors of hands, sweating, palpitation, hunger, easy fatigue,
headache, mood changes, irritability, low attentiveness, tingling around
mouth or lips, any other abnormal feeling
– Severe – Confusion, abnormal behavior, visual disturbances, nervousness,
anxiety,
– Uncommon – seizures & loss of consciousness
• Take 3 spoon full (15-20 gm) of glucose in water/5-6 TSF
sugar /fruit juice/any sweet food

63. Pre-conception care & counselling
• Women with h/o GDM to be counselled for plasma glucose
estimation before next pregnancy
• Desired plasma glucose levels
– Fasting -< 100 mg/dl
– 2 hr PPPG -< 140 mg/dl
• Appropriate anti hypertensive to be started if needed
• Counselled to consult gynecologist as soon as she misses her
period

64. Carbohydrate - are a problem !
Choice Based On Glycaemic Index of Foods
Glycaemic index of food
 It is the extent of rise in blood sugar in response to a food in
comparison with the response to an equivalent amount of
glucose
The CHO that produce only small fluctuation in blood glucose
are called low GI foods and are recommended for GDM
women

65. Thank you !!!