Welcome to "Gestational Diabetes Mellitus (GDM): What Every Obstetrician Should Know" Overview of the presentation's objectives and key topics to be covered

1. • Immediate Past Chairperson ICOG –Indian College of
OB/GY
• National Corresponding Editor-Journal of OB/GY of
India JOGI
• National Corresponding Secretary-AMWI Association
of Medical Women, India
• President –ISOPARB Vidarbha Chapter 2019-21
• Chairperson-IMS Education Committee 2021-23
• Chairperson-fertility enhancement Committee-
ISOPARB
• Member-SAFOG Education Committee
• President-Association of Medical Women, Nagpur
AMWN 2021-24
• Senior Vice President FOGSI 2012
• President Menopause Society, Nagpur 2016-18
• President Nagpur OB/GY Society 2005-06
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra
 Nagpur Ratan Award @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 2007-2009
 Received appreciation letter from
Maharashtra Government for her
work in the field of SAVE THE
GIRL CHILD
 Delivered 22 orations and
450 guest lectures
 Publications- 42 National &
21 International
 Sensitized 2 lakh boys and
girls on adolescent health
issues
Awards
Positions

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

4. 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

5. Prevalence
 22 million women between 20-39 years 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

6. Overview
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7. 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.

8. Screening versus diagnostic testing
The purpose of screening is to identify asymptomatic
individuals with a high probability of having or
developing a specific disease.

9. 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. Why DIPSI Criteria ?
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13. 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

14. Interpretation of DIPSI Test

16. Screening
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17. Are there clear threshold glucose levels
above which the risk of adverse neonatal
or maternal outcomes increases?
Diagnosis of Gestational Diabetes
2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy

19. Role of HbA1c in diagnosis
 There are very little data on the use of A1c to diagnose diabetes in
pregnancy.
 Consequently the 2013 WHO guideline does not include A1c as a
means of diagnosing diabetes in a pregnant woman and for
monitoring15.
 The standardization of A1c is impossible in countries like India
where all the laboratories do not posses equipment and
standardization is a problem.
Stephen Colagiuri, Maicon Falavigna, Mukesh M. Agarwal, Michel Boulvain, Edward Coetzee, et el. Strategies for Implementing
the WHO Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy. DRCP. 103 (2014) 364-372.

20. 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.

21. Maternal problems
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22. Fetal problems
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23. GDM diagnosed - what
next ?

24. Outline for GDM management
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25. Medical Nutrition Therapy (MNT)
Therapeutic goals:
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26. GDM Diet
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27. Individualized diet plan based on level of activity and
BMI

28. 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

29. 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

30. 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

31. Insulin initiation during pregnancy
 The recommended starting dose of insulin in GDM is 0.1 unit/kg of
body weight per day.
 Dose can be increased on follow up till 2hr PG is around 120 mg/dl.
 Rarely a GDM woman may require more than 20 units of insulin per
day.
 Insulin analogs are safer during pregnancy.

33. Insulin Therapy

35. Hypoglycaemia
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36. How to recognize
hypoglycaemia?
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37. How to manage hypoglycaemia?
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38. 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

39. OHA in pregnancy
Metformin
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40. Metformin vs Glyburide

41. The use of oral hypoglycemics (OH):
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Thanawala, U.; Divakar, H.; Jain, R.; Agarwal, M.M. Negotiating Gestational Diabetes Mellitus in India:
A National Approach. Medicina 2021,57, 942. https://doi.org/10.3390/medicina57090942

42. 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

43. Glycemic targets
 Mean plasma glucose -105 mg/dl
 aintain FPG at 90 & PP at 120
 Mean plasma glucose should never go below 86

44. GOI, MOHFW

45. Monitoring during pregnancy

46. Fetal monitoring
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48. When to deliver ?
The optimal time of labour for patients with different classes
of GDM is determined by a combination of maternal and fetal
factors, and the choice should be made considering the
advantages and disadvantages of inducing labour compared
to waiting for a spontaneous contraction to optimize both
maternal and fetal outcomes.
Li X, Li TT, Tian RX, Fei JJ, Wang XX, Yu HH, Yin ZZ. Gestational diabetes mellitus: The optimal time of delivery. World J Diabetes. 2023 Mar 15;14(3):179-187.
doi: 10.4239/wjd.v14.i3.179. PMID: 37035228; PMCID: PMC10075038.

49. When to deliver ?(FIGO
recommendations)

50. When to deliver ?
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Li X, Li TT, Tian RX, Fei JJ, Wang XX, Yu HH, Yin ZZ. Gestational diabetes mellitus: The optimal time of delivery. World J Diabetes. 2023 Mar 15;14(3):179-187.
doi: 10.4239/wjd.v14.i3.179. PMID: 37035228; PMCID: PMC10075038.

52. When to deliver ?
In the future, more prospective randomized studies should be
conducted on the time of labour in patients with different
classes of GDM, incorporating factors such as type of diabetes,
level of glycemic control, Bishop score, fetal lung maturity,
and presence of complications in order to provide better
quality data for decision making.
Li X, Li TT, Tian RX, Fei JJ, Wang XX, Yu HH, Yin ZZ. Gestational diabetes mellitus: The optimal time of delivery. World J Diabetes. 2023 Mar
15;14(3):179-187. doi: 10.4239/wjd.v14.i3.179. PMID: 37035228; PMCID: PMC10075038.

53. Special precaution during labour
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54. During Labour
Diagnosis and management of Gestational Diabetes Mellitus Technical and Operational
Guidelines (Maternal Health Division, Ministry of Health and Family Welfare of India)

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

56. 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.

57. Insulin Management during Labour & Delivery
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58. Breast feeding
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59. 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

60. 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

61. Immediate postpartum care-GDM on Insulin
 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

62. 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.

63. Monitor for persistent diabetes
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64. Contraceptive choices
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65. Can we Prevent GDM ?
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66. Preconception
Recommendations
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multidisciplinary clinic
 focused attention on achieving glycemic targets, standard preconception care
should be augmented with extra focus on nutrition
 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have
become pregnant should be counselled on the risk of development and/ or progression of diabetic
retinopathy.
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67. Pre pregnancy counselling
 Offer preconceptionally individualized dietary advice
 If BMI above 27 kg/m2 advice on how to lose weight
 Desired blood sugar levels:
FBS - <95 mg/dL
1 hr PPBS - <140mg/dl
2 hr PPBS - <120 mg/dL
HbA1c - <6.5%
 Counsel to consult Gynaecologist as soon as she misses her period
ADA 2018

69. Health across the
Life Cycle

70.  Pregnant women with GDM
and their offspring’s are at
increased risk of developing
Type II Diabetes mellitus in
later life.
 They should be counselled for
healthy lifestyle and
behaviour, particularly role of
diet & exercise

71. Key points
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Universal testing of all pregnant women for GDM
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Testing recommended twice in pregnancy; at 1st antenatal visit and then at 24-28 weeks of gestation. DIPSI
recommends additional screening at ~34 weeks.
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Single step 75 gm 2 hr OGTT test performed.
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Pregnant women testing positive(2hr OGTT≥140mg/dL) should be started on MNT for 2 weeks.
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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.
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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
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Vaginal delivery preferred, LSCS for only obstetric indications or fetal macrosomia.
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Neonatal monitoring for hypoglycemia and other complications
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Postpartum evaluation of glycemic status by a 75 g OGTT at 6 weeks after delivery.

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

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