Diabetes in Pregnancy explained by Dr. Laxmi Shrikhande

2. • Medical Director-Shrikhande Fertility Clinic, Nagpur
• Chairperson Designate ICOG 2020
• National Corresponding Editor-Journal of OB/GY of India JOGI
• National Corresponding Secretary AMWI
• Senior Vice President FOGSI 2012
• Founder Patron & President –ISOPARB Vidarbha Chapter
• Received Nagpur Ratan Award at the hands of Union Minister Shri
Nitinji Gadkari
• Received Bharat excellence Award for women’s health
• Received Mehroo Dara Hansotia Best Committee Award for her work as
Chairperson HIV/AIDS Committee, FOGSI
• Received appreciation letter from Maharashtra Government for her work
in the field of SAVE THE GIRL CHILD
• Immediate Past President Menopause Society, Nagpur
• President Nagpur OB/GY Society 2005-06
• Delivered 11 orations and 450 guest lectures
• Publications-Twenty National & Eleven International
• Sensitized 2 lakh boys and girls on adolescent health issues
Dr. Laxmi Shrikhande
Nagpur

3. Diabetes in Pregnancy
Dr Laxmi Shrikhande
Nagpur

4. Diabetes in
pregnancy
Pre-existing
diabetes
Gestational
diabetes
IDDM
(Type1)
NIDDM
(Type2)
Pre-existing
diabetes
True GDM

5. Gestational diabetes
mellitus
Pre Existing Diabetes
Hyperglycemia during
pregnancy that is not
diabetes
Diagnosed before the
start of pregnancy OR
Hyperglycemia diagnosed for the
first time in pregnancy. Meets
WHO criterion for diabetes
mellitus in the nonpregnant
state
Hyperglycemia diagnosed for
the first time during
pregnancy
May occur any time during
pregnancy including the first
trimester
May occur any time during
pregnancy but most likely
>24 weeks

6. Prevalence
22 million women between 20-39 yrs have diabetes -2010 data
Expected to rise by 20% in next 10 years
 54 million women with IGT or pre diabetes have the potential to develop
GDM if they become pregnant.
 The prevalence of GDM in India varies from 3.8 to 21% in different parts
of the country, depending on the geographical locations and diagnostic
methods used.
 GDM has been found to be more prevalent in urban areas than in rural
areas

7. Overview
Definition
Screening
Diagnosis
Ante natal Management
Intra natal Management
Post natal Management
Prevention

8. Pathophysiology of GDM
Gestational
diabetes
mellitus
Insulin resistance
due to placental
secretion of anti-
insulin hormones
Maternal hepatic
glucose production
increases by 15%-
30% to meet fetal
demand late in
pregnancy Pancreatic -cell
dysfunction due to
• Genetics
• Autoimmune disorders
• Chronic insulin resistance
Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40:703-726. Metzger BE, et al. Diabetes Care. 2007;30(2):S251-S260.

9. SCREENING VERSUS DIAGNOSTIC TESTING
 The purpose of screening is to identify asymptomatic
individuals with a high probability of having or
developing a specific disease.

10. Whom to screen ?
Universal screening appears to be the optimum approach as
the Indian women have 11 fold increased risk of developing
glucose intolerance during pregnancy compared to
Caucasian women .

11. Which screening method ?
Diabetes in Pregnancy Study Group of India (DIPSI) Criteria
One step approach - The one step approach has been
proposed by the DIPSI and endorsed by the GOI .
On 14th March 2007, Government of India issued the
instructions that universal screening of glucose intolerance
during pregnancy should be mandatory.
The order recommends that all women should be screened
between 24 and 28 weeks of gestation with 2 h 75 g oral
glucose.

12. How to do it ?
 75 gms glucose with 300 ml water
 Irrespective of last meal
 Ingestion to be completed within 5-10 min
 Measure blood sugar after 2 hour
 If vomiting within 30 min of intake-repeat test next day

13. Interpretation of DIPSI Test

14. Advantages of DIPSI Criteria
 simple, feasible, convenient, economical and acceptable in Indian
scenario
In India, women have to travel long distances for check-up, hence
this non-fasting single test becomes more acceptable to the
pregnant women
Indian population is diverse and variable, hence international
criteria on Indian population may not be practical and feasible.

15. Screening
Universal
screening
First booking
visit - GOI /
DIPSI
24- 28 weeks -
GOI / DIPSI
32-34 weeks -
DIPSI

16. Why Diagnose and Treat GDM?
 Identifying women with GDM is important because appropriate
therapy can decrease maternal and fetal morbidity .
 Can prevent two generations from developing diabetes in the
future.

17. Maternal problems
Early pregnancy - spontaneous miscarriage
Pregnancy - PE, Gestational HT, UTI, Macrosomia, hydramnios
Delivery - PTB, instrumental delivery, traumatic delivery, CS, Postpartum
infections, PPH, maternal mortality/ morbidity
Puerperium - infections, lactation failure
Long term postpartum - weight retention , GDM in subsequent pregnancy ,
DM, CVD

18. Fetal problems
Still birth / Neonatal deaths
congenital malformations
Shoulder dystocia / Erb’s palsy
RDS
cardiomyopathy
Hypoglycaemia
Hyperbilirubinaemia / Polycythemia
Hypocalcimia

19. GDM diagnosed - what next ?

20. Outline for GDM management
Primary management strategy for GDM: dietary changes
and exercise
If uncontrolled hyperglycemia with lifestyle change:
Insulin should be first line therapy
Use Metformin, if insulin cannot be used

21. Management Issues-
 Patient education
 Medical Nutrition therapy
 Pharmacological therapy
 Glycemic monitoring: SMBG & Targets
 Fetal monitoring: ultrasound
 Planning on delivery
 Postpartum care

22. GDM: Management During Pregnancy
 Receive nutrition counseling by registered dietician to
achieve their nutrition, weight and blood glucose goals
 Eat healthy diet and Replace high-Glycemic Index foods
with low-Glycemic Index foods to reduce need for insulin
initiation
 Discuss appropriate weight gain and healthy lifestyle
interventions throughout pregnancy

23. Medical Nutrition Therapy (MNT)
Therapeutic goals:
adequate nutrition
Adequate weight gain
prevention of ketosis
Prevention of postprandial hyperglycemia.

24. Individualized diet plan based on level of
activity and BMI

25. GDM Diet
Diet- 30 kcal/kg – normal weight women, 24 Kcal/kg for overweight
women, and 12 Kcal/kg for morbidly obese women.
Diet should contain carbohydrate 50%, protein 20% and fat 25-30%.
Usually three meal regimen, with breakfast 25% of the total intake,
lunch 30%, dinner 30%.

26. Physical Activity
 Unless contraindicated, physical activity should be included
in a pregnant woman’s daily regimen
 Regular moderate-intensity physical activity (eg, walking)
can help to reduce glucose levels in patients with GDM
 Other appropriate forms of exercise during pregnancy
 Cardiovascular training with weight-bearing, limited to
the upper body to avoid mechanical stress on the
abdominal region

27. Target weight gain in GDM
Prepregnancy BMI Category Total weight gain
<18.5 Underweight 12.5-18 Kg
18.5-24.9 Normal weight 11.5-16 Kg
25-29.9 Overweight 7-11.5 Kg
>30 Obese 5-9 Kg

28. Insulin initiation during pregnancy
 About 50% of women initially treated with diet alone will require
additional therapy, and insulin therapy usually is recommended.
 Insulin management must be individualized, but most pregnant
women require about 0.7 units/kg daily.
 two thirds of the insulin is administered in the morning and one
third is administered in the evening, with a 1:2 ratio of short- to
intermediate- (or long-) acting insulin.
Kahn, CR, King GL., Moses AC., . Joslin's Diabetes Mellitus (14th Edition).Weir GC., Jacobson AM., Smith RJ JOSLIN
DIABETES CENTER. Boston, Lippincott Williams & Wilkins, 2005, chapter 61

30. Status of OHA in pregnancy
Metformin and the sulfonylurea glyburide are the 2 most commonly
prescribed oral antihyperglycemic agents during pregnancy
transfer category B, others
Due to efficacy and safety concerns, the ADA and DIPSI does not
recommend oral antihyperglycemic agents for gestational diabetes mellitus
(GDM) or preexisting T2DM
Medication Crosses Classification Notes
Placenta
Metformin Y
es Category B Metformin and glyburide may be
insufficient to maintain normoglycemia at
all times, particularly during postprandial
period
Glyburide Minimal Some formulations
category C

31. OHA in pregnancy
Metformin
Insulin sensitizer
Give with meal
Start at 500 mg once or twice daily with food
Increase slowly weekly to 2000 mg per day (2500 mg/day)
No teratogenic risks demonstrated
pregnancy risk factor: B (No evidence of risk in studies)
Not FDA approved for use in pregnancy

32. Monitoring Blood Glucose
 At least 4 times-self monitoring
 Fasting and 3 one and half hour postprandial
 After achieving target level, lab monitoring till 28wks- once in
a month
 28-32 weeks once in 2 weeks
 >32 once a week
 Other parameters to be monitored: fundus,micro albuminuria

33. Glycemic targets
 Mean plasma glucose -105 mg/dl
 maintaine FPG at 90 & PP at 120
 Mean plasma glucose should never go below 86

34. GOI, MOHFW

35. Monitoring during pregnancy

36. Fetal monitoring
Baseline ultrasound : fetal size
At 18-22 weeks -major malformations
& fetal echocardiogram
26 weeks onwards -growth and liquor
volume
III trimester –frequent USG for
accelerated growth (abdominal: head
circumference), weight gain, AFI

37. When to deliver ?
(FIGO recommendations)

38. Care in labour & delivery
 Institutional delivery
 Presence of expert obstetrician
 Close electronic monitoring

39. Care in labour & delivery
Close monitoring in second stage
W/F foetal distress
Vaginal delivery should be preferred and LSCS should be done for obstetric indications only.

40. Insulin Management during Labour &
Delivery
Usual dose of intermediate-acting insulin is given at bedtime
 Morning dose of insulin is withheld
 I.V infusion of normal saline is begun
Once active labor begins or glucose levels fall below 70 mg/dl, infusion is
changed from saline to 5% dextrose & delivered at a rate of 2.5 mg/kg/min
Glucose levels are checked hourly using a portable meter allowing for
adjustment in infusion rate
Regular (short-acting) insulin is administered by iv infusion if glucose levels
exceed 140 mg/dl

41. Immediate postpartum care-
GDM on MNT
Cease blood glucose monitoring immediately after delivery
Regular postnatal care
 OGTT 6 weeks postpartum
American Diabetes Association. Standards for medical care in diabetes 2018.
Diabetes Care 2018

42. Immediate postpartum care
GDM on OHAs
In most women, glucose tolerance will normalize immediately after delivery
 Cease pharmacological therapy immediately after delivery
 Continue pre prandial BGL monitoring QID for 24 hrs
 If preprandial BGL 72 – 126mg/dl – discontinue monitoring
 If BGL <72mg/dl or >126mg/dl – seek medical review and continue monitoring
1 – 8% may continue to be glucose intolerant and need OHAs
 Metformin, glibenclamide / glyburide safe during lactation
Queensland clinical guideline 2015

43.  Preprandial BGL monitoring QID for 24 hrs
If BGL >126mg/dl –medical review & start OHAs
Insulin therapy is generally not indicated unless marked
fasting hyperglycemia (200–250 mg/dL)
Queensland clinical guideline 2015
Immediate postpartum care
GDM on Insulin

44. Risk factors for persistent diabetes
Pregnancy fasting glucose levels greater than or equal to 126 mg/dL
Diagnosis of GDM during the first trimester
A prior history of GDM without documented normal glucose
tolerance outside of pregnancy
Metzger BE. Summary and recommendations of the 4th International Workshop-
Conference on Gestational Diabetes Mellitus. Diabetes Care 1998;21(Suppl 2):B1617.

45. Monitor for persistent diabetes
Recommend OGTT at 6 weeks postpartum to screen for persistant
diabetes
Recommend lifelong screening for diabetes every 3 yrs
 Early glucose monitoring in future pregnancy

46. Breast feeding
should be encouraged to breastfeed immediately after delivery
in order to avoid neonatal hypoglycemia [Grade D, Consensus]
and
to continue for at least 3-4 months postpartum in order to
prevent childhood obesity [Grade C, Level 3] and diabetes in
the offspring [Grade D, Level 4] and
to reduce risk of type 2 diabetes and hypertension in the
mother [Grade C, Level 3]

47. Contraceptive choices
Barrier
LARC
POP / DMPA
COC / implants/ rings - contraindicated with
macrovascular disease

48. Can we Prevent GDM ?
In women at high risk for GDM based on pre-
existing risk factors, nutrition counseling should
be provided on healthy eating and prevention of
excessive gestational weight gain in early
pregnancy, ideally before 15 weeks of gestation,
to reduce the risk of GDM [Grade B, Level 2]

49. Key points

Universal testing of all pregnant women for GDM

Testing recommended twice in pregnancy; at 1st antenatal visit and then at 24-28 weeks of gestation. DIPSI
recommends additional screening at ~34 weeks.

Single step 75 gm 2 hr OGTT test performed.

Pregnant women testing positive(2hr OGTT≥140mg/dL) should be started on MNT for 2 weeks.

If 2 hr PPBS ≥120 mg/dL after MNT and physical exercise, medical management (metformin or insulin therapy) of
pregnant women to be started as per guidelines.

Early delivery with administration of prophylactic corticosteroid therapy for fetal lung maturity to be planned only if
uncontrolled blood sugar or any other obstetric indication

Vaginal delivery preferred, LSCS for only obstetric indications or fetal macrosomia.

Neonatal monitoring for hypoglycemia and other complications

Postpartum evaluation of glycemic status by a 75 g OGTT at 6 weeks after delivery.

50. The Path Forwards
Health across the
Life Cycle

51. My World of sharing happiness!
Shrikhande Fertility Clinic
Ph- 91 8805577600
shrikhandedrlaxmi@gmail.com

53. The Art of Living
Anything that helps
you to become
unconditionally
happy and loving is
what is called
spirituality.
H. H. Sri Sri Ravishakar