Dipsi guidelines

622 www.japi.org © JAPI • VOL. 54 • AUGUST 2006
JAPI - DIPSI Guidelines
Gestational Diabetes Mellitus – Guidelines*
V Seshiah, AK Das, Balaji V, Shashank R Joshi, MN Parikh, Sunil Gupta
For Diabetes In Pregnancy Study Group (DIPSI)+
tuning of glycemic level during pregnancy is possible
due to the compensatory hyperinsulinaemia, as the
normal pregnancy is characterized by insulin resistance.
A pregnant woman who is not able to increase her
insulin secretion to overcome the insulin resistance that
occurs even during normal pregnancy develops
gestational diabetes.
The metabolic goals of pregnancy are 1) in early pregnancy
to develop anabolic stores to meet metabolic demands in
late pregnancy and 2) in late pregnancy to provide fuels
for fetal growth and energy needs.
- Dr Patrick Catalano
Gestational Diabetes Mellitus (GDM) is defined as
‘carbohydrate intolerance with recognition or onset during
pregnancy’, irrespective of the treatment with diet or
insulin. The importance of GDM is that two generations
are at risk of developing diabetes in the future. Women
with a history of GDM are at increased risk of future
diabetes, predominately type 2 diabetes, as are their
children1
GDM occurs when the woman’s beta cell function is not
able to overcome the antagonism created by the anti-insulin
hormones of pregnancy and the increased fuel consumption
required to provide for the growing fetomaternal unit.
- Dr Alberto de Leiva
INTRODUCTION
The maternal metabolic adaptation is to maintain the
mean fasting plasma glucose of 74.5 ± 11 mg/dl and
the post prandial peak of 108.7 ± 16.9mg/dl.1
This fine
+DIPSI GDM Guidelines Committee
Chairman : Prof V Seshiah
(President : Diabetes In Pregnancy Study group India)
Members : Dr A K Das, Dr Balaji V, Dr Shashank R Joshi, Dr
MN Parikh, Dr Sunil Gupta
DIPSI National Meeting Experts: Dr Anil S Bhoraskar, Dr
Anjalakshi C, Dr Aparna Agarwal, Dr Balaraman V T, Dr
Bharti Kalra, Dr Bhavatharini A, Dr Cynthia Alexander, Dr
Dorendra Singh I, Dr Hariharan R S, Dr Himangi Lubree, Dr
Jitendra Singh, Dr Jothi S Parthasarathy, Dr Krishnaveni G V,
Dr Kumaravel V, Dr. Lakshminarayanan S, Dr Lilly John, Dr
Madhini V, Dr Madhuri S Balaji, Dr Mala Chettri, Dr Marina
Packiaraj, Dr Mary John, Dr Mayur Patel, Dr Mirudhubashini
G, Dr Mohan V, Dr Munichoodappa C, Dr Nalini Shah, Dr
Panneerselvam A, Dr Paulose KP, Dr Padma Menon, Dr Pratiba
D, Dr Rajan S K, Dr Rajendran N, Dr Rakesh M Parikh, Dr
Ramachandran A, Dr Rao PV, Dr Rastogi S S, Dr Sahay B K,
Dr Samar Banerjee, Dr Sanjay Kalra, Dr Saraswathy K, Dr
Shailaja Kale, Dr Sharad Pendsey, Dr Shyam Mukundan, Dr
Siddharth N Shah, Dr Smita P Bhavsar, Dr Sridhar C B, Dr
Sundaram A, Dr Suresh S, Dr Vitull K Gupta, Dr Yajnik C S
International Faculty : Dr Alberto de Leiva, Dr Lois Jovanovic,
Dr Patrick Catalano, Dr Sylvie Hauguel
*Based on the deliberations of the First National Conference of
Diabetes In Pregnancy Study Group India at Chennai, February
11 and 12, 2006.
Abstract
The Diabetes In Pregnancy Study group India (DIPSI) is reporting practice guidelines for GDM in the Indian
environment. Due to high prevalence, screening is essential for all Indian pregnant women. DIPSI recommends
that as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oral
glucose load and at 2 hrs a venous blood sample is collected for estimating plasma glucose. This one step
procedure of challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible.
Screening is recommended between 24 and 28 weeks of gestation and the diagnostic criteria of ADA are
applicable. A team approach is ideal for managing women with GDM. The team would usually comprise an
obstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician. Intensive monitoring,
diet and insulin is the corner stone of GDM management. Oral agents or analogues though used are still
controversial. Until there is evidence to absolutely prove that ignoring maternal hyperglycemia when the
fetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintain
normoglycemia in every pregnancy complicated by gestational diabetes. The maternal health and fetal outcome
depends upon the care by the committed team of diabetologists, obstetricians and neonatologists. A short
term intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in the
offspring, as the preventive medicine starts before birth. ©

© JAPI • VOL. 54 • AUGUST 2006 www.japi.org 623
SCREENING
The controversy concerning optimal strategy still
continues for the detection and diagnosis of GDM.
American Diabetes Association (ADA) recommends two
step procedures for screening and diagnosis of diabetes
and that too in selective (high risk) population.
Compared with selective screening, universal screening
for GDM detects more cases and improves maternal and
neonatal prognosis.3
In the Indian context, screening is
essential in all pregnant women as the Indian women
have 11 fold increased risk of developing glucose
intolerance during pregnancy compared to Caucasian
women.4
The recent data on the prevalence of GDM in
our country was 16.55% by WHO criteria of 2 hr PG ≥
140 mg/dl.5
As such Universal screening during
pregnancy has become important in our country. For
this we need a simple procedure which is economical
and feasible.
DIPSI Recommended Method
As a pregnant woman walks into the antenatal clinic
in the fasting state, she has to be given a 75g oral glucose
load and at 2 hrs a venous blood sample is collected for
estimating plasma glucose. This one step procedure of
challenging women with 75 gm glucose and diagnosing
GDM is simple, economical and feasible.6
DIAGNOSTIC CRITERIA
American Diabetes Association (Carpenter and
Couston) recommends 3 hour 100 gm OGTT and
Gestational Diabetes Mellitus is diagnosed if any 2
values meet or exceed FPG > 95 mg/dl, 1 hr PG > 180
mg/dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140 mg/dl.
This criteria was originally validated against the future
risk of these women developing diabetes and not on the
fetal outcome. Carpenter himself now recommends a 2
hour OGTT with 75 gm glucose. The reason for this is
that “when a glucose tolerance test is administered to
non-pregnant individuals, it is standard to use the 75-g,
2-hour OGTT. Using a different glucose challenge in
pregnant versus non-pregnant patients leads to
confusion in the laboratory and may result in errors in
applying the proper diagnostic criteria. Further, the 75-
g, 2-hour OGTT is in use during pregnancy in many
countries around the world, typically using the same
thresholds as in non-pregnant individuals”.7
To
standardize the diagnosis of GDM, the World Health
Organisation (WHO) proposed using a 2 hour 75 gm
OGTT with a threshold plasma glucose concentration
of greater than 140 mg/dl at 2 hour, similar to that of
IGT, outside pregnancy.8
Still all these recommendations
(ADA and WHO) have not projected the influence of the
glycemic level on fetal outcome.
Clarity in Labelling The Different Magnitude of
Abnormal Glucose Intolerance on Pregnancy
Increasing maternal carbohydrate intolerance in
pregnant women without GDM is associated with a
graded increase in adverse maternal and fetal outcomes9
implying that fetal morbidity starts at a lower maternal
glycemic level (< 140 mg/dl). A number of prospective
and retrospective studies have substantiated the
observation that the frequency of adverse fetal outcome
increases with 2hr PG > 120mg/dl and taking care of
these women had resulted in a better fetal outcome.10-14
Thus, the data is robust and indicates that 2 hr > 120mg/
dl needs cognizance.
The term ‘Impaired Gestational Glucose Tolerance
(IGGT)’ is used by few authors to indicate pregnant
women whose 2 hr PG is > 120mg/dl. It may be
appropriate to use the term ‘Decreased Gestational
glucose tolerance (DGGT)’ instead of impaired
gestational glucose tolerance. The use of the term
‘Decreased’ is appropriate as it implies only ‘Low’
whereas the term ‘Impaired’ means both high and low.
Further, quiet frequently we come across, labeling any
abnormal value in the OGTT not meeting the diagnostic
criteria of GDM as IGT.15
The use of this term ‘IGT’ during
pregnancy may be confusing, as this terminology is also
being used in non pregnant adult with 2 hr PG > 140
mg/dl. This level is also applied to diagnose GDM by
WHO criteria. Hence it may be prudent to label 2 hr
plasma glucose value > 140 mg/dl as GDM and a 2 hr
plasma glucose value > 120 mg/dl as ‘Decreased
Gestational Glucose Tolerance’ (DGGT). The term IGT
should not be used to denote any abnormal value during
pregnancy. The figures suggested below are easy to
remember.
With 75 gm OGTT (WHO criteria);
In Pregnancy Outside Pregnancy
2 hr ≥ 200 mg/dl Diabetes Diabetes
2 hr ≥ 140 mg/dl GDM IGT
2 hr ≥ 120 mg/dl DGGT —
Gestational Weeks at Which Screening is
Recommended
Practically all the pregnant women should undergo
screening for glucose intolerance. The usual
recommendation for screening is between 24 and 28
weeks of gestation. The recent concept is to screen for
glucose intolerance in the first trimester itself as the fetal
beta cell recognizes and responds to maternal glycemic
level as early as 16th
week of gestation.16
If found negative
at this time, the screening test is to be performed again
around 24th
– 28th
week and finally around 32nd
– 34th
week.
MANAGEMENT OF GDM
A team approach is ideal for managing women with
GDM. The team would usually comprise an obstetrician,
diabetes physician, a diabetes educator, dietitian,
midwife and pediatrician. In practice, however, the team
approach is not always possible due to limited resources.

In such circumstances, management by an obstetrician
and physician, with the assistance of an appropriately
skilled dietitian, diabetes educator, is acceptable.
A) Patient Education
The importance of educating women with GDM (and
their partners) about the condition and its management
cannot be overemphasized.
The compliance with the treatment plan depends on
the patient’s understanding of:
The implications of GDM for her baby and herself
The dietary and exercise recommendations
Self monitoring of blood glucose
Self administration of insulin and adjustment of
insulin doses
Identification and treatment of hypoglycemia
(patient and family members)
Incorporate safe physical activity
Development of techniques to reduce stress and cope
with the denial.
Care should be taken to minimise the anxiety of the
women.
B) Medical Nutrition Therapy (MNT)
a) General Principles : All women with GDM should
receive nutritional counseling. The meal pattern should
provide adequate calories and nutrients to meet the
needs of pregnancy. The expected weight gain during
pregnancy is 300 to 400 gm/week and total weight gain
is 10 to 12 kg by term. Hence the meal plan aims to
provide sufficient calories to sustain adequate nutrition
for the mother and fetus and to avoid excess weight gain
and post prandial hyperglycemia. Calorie requirement
depends on age, activity, pre pregnancy weight and stage
ofpregnancy.Approximately30to40Kcal/kgidealbody
weight or an increment of 300 kcal/day above the basal
requirement is needed. Pregnancy is not the ideal time
for obesity correction. Underweight subjects or those
not gaining weight as expected, particularly in the third
trimester, require admission to ensure adequate nutrition
to prevent low birth weight infants.
b) Calorie Counting : As a part of the medical nutrition
therapy, pregnant diabetic woman are advised to wisely
distribute their calorie consumption especially the
breakfast. This implies splitting the usual breakfast into
two equal halves and consuming the portions with a
two hour gap in between. By this the undue peak in
plasma glucose levels after ingestion of the total quantity
of breakfast at one time is avoided. For example if 4 idlis
/ chappathi / slices of bread (applies to all type of
breakfast menu) is taken for breakfast at 8 am and two
hours plasma glucose at 10 am is 140mg: the same
quantity divided into two equal portions i.e., one portion
at 8 am and remaining after 10 am, the two hours post
prandial plasma glucose at 10.00 am falls by 20 – 30 mg.
This advice has scientific basis as the peaking of
plasma glucose is high with breakfast (due to Dawn
phenomenon) than with lunch and dinner. Further in a
normal person, insulin secretion is also high with
breakfast than with lunch or dinner.17
GDMmothershave
deficiency in first phase insulin secretion and to match
this insulin deficiency the challenge of quantity of food
at one time should also be less.
Insulin Therapy
Insulin is essential if medical nutrition therapy fails
to achieve euglycemia. Various criteria have been
proposed for the initiation of insulin therapy. Fourth
International Workshop on GDM recommended
lowering capillary blood glucose concentration to 140
mg/dl at 1 hour and 120 mg/dl at 2 hours,18
whereas
ADA recommended the option of measuring 1 hour post
meal values with cut off of 120mg/dl.19
These
recommendations are based on one single determination,
which reflects a “snap shot” of glucose evaluation rather
than a “video” of continuous glucose profile.20
The
continuous glucose monitoring system has established
that in normal pregnancy, peak plasma glucose occurs
at 60 minutes and the value was 108.7 ± 16.9 mg/dl.1
In
a woman with GDM, the peak occurs between 70 – 110
minutes (at approximately 90 minutes) and with a good
glycemic control the value was 103 ± 26 mg/dl.20
However, being interstitial fluid glucose it has its own
limitation.
If the FPG concentration on the OGTT is >120mg/dl,
then the patient is started on insulin immediately along
with meal plan. Other GDM women are seen within 3
days and are also taught self monitoring of blood glucose
(SMBG). SMBG is to be performed in fasting and 1 ½
hours after each meal. GDM women usually have high
post breakfast plasma glucose level compared to post
lunch and post dinner. A few GDM women do have
post dinner plasma glucose also high. Insulin is started
within 1 to 2 weeks, if the majority (i.e., at least four of
seven per week) of fasting values exceed 90 mg/dl.
Similarly, if the majority of post prandial values after a
particular meal exceed 120 mg/dl, insulin is started.21
Pen injectors are very useful and the patient’s acceptance
is excellent.
The initial dose of NPH insulin could be as low as 4
units and the dose of insulin can be adjusted on follow
up. A few GDM patients may require combination of
short acting insulin and intermediate acting insulin in
the morning and evening.
If a patient has elevated prelunch blood sugar,
regular insulin is usually necessary in the morning
to handle the post breakfast hyperglycemia, as there
is a lag period before the intermediate-acting insulin
begins to work. The above regimen of regular and
intermediate-acting insulin in the morning controls
hyperglycemia in most cases.

If the post dinner blood sugar is high, a small dose
of regular insulin is necessary before dinner in
addition to the regular and intermediate acting
insulin given in the morning.
Combination of regular and intermediate acting
insulin before dinner may be necessary if fasting
blood sugar is high. This combination of short and
intermediate acting insulin in the morning and as
well as in the evening is known as mixed and split
dose of insulin regimen. In this regimen two-third
of the total daily dose of insulin is given in the
morning and one third in the evening. For each
combination one-third dose should be regular
insulin and two-third intermediate acting insulin.
With this regimen if the patient continues to have
fasting hyperglycemia, the intermediate acting
insulin has to be given at bedtime instead of before
dinner. Insulin dose is individualized.
Target Blood Glucose Levels
Maintenance of Mean Plasma Glucose (MPG) level ~
105 mg% is ideal for good fetal outcome.22
This is possible
if FPG and post prandial peaks are around 90 mg/dl
and 120 mg/dl respectively (MPG should not be < 86
mg/dl as this may cause small for gestational age
infants).22
Species of Insulin
It is ideal to use human insulins are least
immunogenic. Though insulin does not cross the
placenta, the insulin antibodies due to animal source
insulin can cross the placenta, and stress the fetal beta
cell, increase insulin production and induce
macrosomia. Rapid acting insulin analogues,
(Novorapid/Humalog) have been found to be safe and
effective in achieving the targeted post prandial glucose
value during pregnancy.23
Lyspro the first analogue to
get category B approval by US FDA and aspart has also
been used in pregnancy.
Oral Antidiabetic Drugs
Recently reports have shown good fetal outcome in
GDM women who were on glyburide (micronised form
of Glibenclamide). A randomized unblinded clinical trial
compared the use of insulin and glyburide in women
with GDM who were not able to meet glycemic goals on
meal plan. Treatment with either agent resulted in similar
perinatal outcomes. All these patients were beyond the
first trimester of pregnancy at the initiation of therapy.24
More studies are required before routinely
recommending glibenclamide during pregnancy
especially during the first trimester itself. Metformin has
been found to be useful in women with polycystic
ovarian disease (PCOD) who failed to conceive.
Continuing this drug after conception is still a
controversy. But there are a few studies favouring
continuation of metformin throughout pregnancy.25
Currently, oral agents are not routinely recommended
during pregnancy though emerging data on
glibenclamide and metformin is interesting.
MONITORING GLYCEMIC CONTROL
The success of the treatment for a woman with GDM
depends on the glycemic control maintained with meal
plan or pharmacological intervention. To know the
effectivenessoftreatment,monitoringofglycemiccontrol
is essential.
Once diagnosis is made, medical nutritional therapy
(MNT) is advised initially for two weeks. If MNT
fails to achieve control i.e., FPG ≥ 90mg/dl and/or
1 ½ hr PPG ≥ 120mg/dl, insulin may be initiated.
Once target blood glucose is achieved, woman with
GDM till the 28th
week of gestation require lab
monitoring of both fasting and 1 ½ hr post breakfast
once a month and at other time of the day as the
clinician decides.
After the 28th
week of gestation, the laboratory
monitoring should be more frequent atleast once in
2 weeks, if need be more frequently.
After 32 weeks of gestation, lab monitoring should
be done once a week till delivery.
In high risk pregnancies, frequency of monitoring
may be intensified with SMBG.
Continuous glucose monitoring devices are available
but these equipments need special training and are
expensive. These devices may be useful in high risk
pregnancies to know the glycemic fluctuations and
to plan proper insulin dosage.
Throughout the stages and phases of a diabetic woman, her
health status is directly dependent on her nutritional status
and her blood glucose control. As a woman ages, to prevent
the increased risk of osteoporosis and cardiovascular disease
of the diabetic woman, exercise and hormonal replacement
therapy can minimize the ravages of diabetes per se on the
aging process. Normoglycemia throughout the lifecycle of
a diabetic woman results in a lifecycle of health.
- Dr Lois Jovanovic
HbA1
c Levels
If the glucose intolerance is detected in the early
pregnancy, HbA1
c level will be helpful to differentiate
between a pre gestational diabetic and GDM. If the
HbA1
c level is more than 6%, she is likely to be a pre
GDM. HbA1
c is useful in monitoring the glucose control
during pregnancy, but not for the day to day
management. A1
c level may serve as a prognostic value.
Estimation of fructosamine during pregnancy is less
frequently used.
Measuring Other Parameters
The blood pressure has to be monitored during every
visit. Examination of the fundus and estimation of
microalbuminuria, every trimester is recommended.

e) Ultrasound Fetal Measurement : The management of
gestational diabetes, based on the foetal growth by
ultrasonogram demands that the fetus at risk must first
manifest overgrowth before treatment decisions are
made. Further, the cost of performing a number of
ultrasonograms to monitor the foetal growth and
recommending therapy has to be kept in mind. Until
there is evidence to absolutely prove that ignoring
maternal hyperglycemia when the fetal growth patterns
appear normal on the ultrasonogram, it is prudent to
achieve and maintain normoglycemia in every
pregnancy complicated by gestational diabetes.
Until there is evidence to absolutely prove that ignoring
maternal hyperglycemia when the fetal growth patterns
appear normal on the ultrasonogram, it is prudent to
achieve and maintain normoglycemia in every pregnancy
complicated by gestational diabetes.
- Dr Lois Jovanovic
OBSTETRIC CONSIDERATIONS
Fetal Evaluation
An ultrasound scan has to be performed around 18 –
20 weeks of gestation focusing on structures namely the
spine, skull, kidney and heart. Fetal echocardiography
has to be done around 20 – 24 weeks which allows to
view all the four chambers of the heart. From 26th
week
onwards, fetal growth and liquor volume has to be
monitored every 2-3 weeks. Fetal abdominal
circumference provides baseline for further serial
measurements which gives growth acceleration or
restriction.Fetalmovementsaremonitoredfrom20weeks
onwards. Screening for chromosomal anomalies is
necessary in pre GDM. Screening should be done for
Down’s syndrome, alpha feto protein for neural defects
and human chorionic gonadotrophin to identify any
chromosomal abnormalities (16 – 20 weeks of gestation).
The obese fetus of GDM mother is also hyperinsulinemic,
thus interaction between leptin and insulin may be a link
between maternal diabetes and increased adiposity in the
fetus.
- Dr Sylvie Hauguel-de Mouzon
GDM or severe obesity is superimposed to pregnancy, the
resulting metabolic syndrome becomes detrimental for the
fetus, evolving towards fetal overgrowth with increased
adiposity at birth. This may be one major component for in
utero programming of obesity later in life.
- Dr Sylvie Hauguel-de Mouzon
Timing of Delivery
Sudden intrauterine fetal demise in the third trimester
of diabetic pregnancy is not uncommon. To avoid this
risk, preterm delivery is recommended. But with this,
respiratory distress syndrome (RDS) is likely to occur.
Administering steroids for lung maturity or ß adreno
receptor agonist to inhibit premature uterine contractions
are likely to induce adverse metabolic effects due to their
glycolytic, glycogenolytic and lipolytic effects. In this
situation, extra insulin may be required to maintain
euglycemia. Foetal demise can also occur due to
preeclampsia, which can produce fetal hypoxia via
decreased uteroplacental perfusion. Some centres allow
women with uncomplicated diabetes to go into
spontaneous labor irrespective of the gestational age,
but most still advocate delivery at 38 weeks as perinatal
mortality and morbidity appear to increase after this
time. Induction at 38 weeks gestation may be slow or
unsuccessful due to unfavourable conditions of the
cervix but this has to be balanced against the poorly
defined and predictable risk of late intra uterine death,
if pregnancy is allowed to continue more than 38 weeks.
Fetal health may deteriorate suddenly, hence obstetric
management should not be rigid and each case needs
individual care and attention. Having a neonatologist
support at the time of delivery is advisable.
Intra Partum Management
If labor is to be induced in GDM, the usual evening
insulin dose should be taken the night before, but
no subcutaneous insulin is given the following
morning when induction begins.
Once labor begins, insulin is not necessary.
In a gestational diabetic the requirement of insulin
is likely to fall precipitously and no insulin may be
required immediately after expulsion of placenta.
DELIVERY
A paediatrician experienced in resuscitation of ‘the
newborn should be present whether delivery is vaginal
or by caesarean section. As soon as the infant is born,
the following actions are mandatory:
early clamping of the cord, i.e. within 20 seconds of
delivery, to avoid erythrocytosis;
evaluate vital signs; Apgar scores at 1 and 5 minutes;
clear oropharynx and nose of mucus; later empty
the stomach - be aware that stimulation of the
pharynx with the catheter may lead to reflex
bradycardia and apnoea;
avoid heat loss, keep neonate warm, transfer to
incubator pre-warmed to 34o
C;
perform a preliminary physical examination to
detect major congenital malformations;
monitor heart and respiratory rates, colour, and
motor behaviour for at least the first 24 hours after
birth;
start early feeding, preferably breast milk, at 4-6
hours after delivery: aim at full caloric intake (125
kcal/kg/24 hours) at 5 days, divided into six to eight
feeds a day;
promote early infant-parent relationship (bonding).

The neonate is usually best cared for, in a specialized
neonatal unit. Interference with the infant should be
minimal. The neonate should be observed closely after
delivery for respiratory distress. Capillary blood glucose
should be monitored at 1 hour of age and before the first
four breast feedings (and for up to 24 hours in high- risk
neonates). Amperometric blood glucose meters are
acceptable for use in neonates, provided that suitable
quality-control procedures and operator training are in
place.Thecut-offof44mg%(2.6mmol/l)isnowcurrently
used as the working definition for hypoglycemia. This
“Operational threshold” is not a diagnosis of a disease
but an indication for action.26
If the baby is obviously
macrosomic, calcium and magnesium levels should be
checked on day 2. Breastfeeding, as always, should be
encouraged in women with GDM.
Both maternal pregravid obesity and GDM are significant
risk factors for obesity in the offspring of the woman with
GDM both at birth and at the time of long term follow up.
- Dr Patrick Catalano
FOLLOW UP OF GDM
GDM may be viewed as:
1. An unidentified preexisting disease, or
2. The unmasking of a compensated metabolic
abnormality by the added stress of pregnancy, or
3. A direct consequence of the altered maternal
metabolism stemming from the changing hormonal
milieu.
Gestational diabetic women require follow up.
Glucose tolerance test with 75g oral glucose is performed
after 6 weeks of delivery and if necessary repeated after
6 months and every year to determine whether the
glucose tolerance has returned to normal or progressed.
A small proportion of gestational diabetic women may
continue to have glucose intolerance.
Prevention of adverse maternal and perinatal outcomes in
GDM are based in achieving maternal blood glucose as
close to normal as possible. Precise glycemic thresholds
remain undetermined.
Prepregnancy BMI, duration and severity of maternal
hyperglycemia during pregnancy, are most important
predictors of the progression to abnormal glucose tolerance/
diabetes in the follow up.
- Dr Alberto de Leiva
GDM recurs approximately in 50% of subsequent
pregnancies. The future risk of developing diabetes for a
gestational diabetic is two fold, if she becomes
overweight. But maintaining ideal weight approximately
halves the risk. The requirement of insulin in addition
to diet to maintain euglycemia during the index
pregnancy is also predictive of future diabetes.
The maternal health and fetal outcome depends upon
the care by the committed team of diabetologists,
obstetricians and neonatologists. A short term intensive
care gives a long term pay off in the primary prevention
of obesity, IGT and diabetes in the offspring, as the
preventive medicine starts before birth.
REFERENCES
1. Yogev Y, Chen R, Langer O, Hod M. Diurnal Glycemic profile
characterization in non diabetic non obese subjects during
the first trimester. The 37th Annual Meeting Of The Diabetes
And Pregnancy Study Group, Myconos – Hellas: September,
2005.
2. Dornhost A, Rossi M. Risk and Prevention of type 2 diabetes
in women with gestational diabetes. Diabetes Care 1998;21:
Suppl 2,B43–B49.
3. Cosson E, et al. Screening and insulin sensitivity in gestational
diabetes. Abstract volume of the 40th
Annual Meeting of the
EASD, September 2004: A 350.
4. Dornhost A, Paterson CM, Nicholls JS, Wadsworth J, Chiu
DC, Elkeles RS, Johnston DG, Beard RW. High prevalence of
GDM in women from ethnic minority groups. Diabetic Med
1992;9:820-2.
5. Seshiah V, Balaji V, Madhuri S Balaji, Sanjeevi CB, Green A.
Gestational Diabetes Mellitus in India. JAssoc Physic of India
2004;52:707–11.
6. Seshiah V, et al. One Step procedure for screening and
diagnosis of gestational diabetes mellitus. J Obstet Gynecol
India 2005;55:525–29.
7. Coustan, Donald R. MD, “Making the diagnosis of Gestational
Diabetes Mellitus (Diabetes and Pregnancy)”. Clin Obstet
Gynecol 2000;43:99-105.
8. Alberti K, Zimmett P. WHO Consultation. Definition,
diagnosis and classification of diabetes mellitus and its
complications, 1: diagnosis and classification of diabetes
mellitus. Diabet Med 1998;15:539-53.
9. Sermer M, et al. The Toronto Tri Hospital Gestational diabetes
project – A preliminary review. Diabetes Care 1998;21: suppl
2,B33–42.
10. Vijayam Balaji, Shyam Mukundan, Madhuri S Balaji,
Veerasamy Seshiah “Correlation Between Maternal Glycemic
Levels And Birth Weight In Asian Indians” At The 36th
Annual Meeting Of The Diabetes And Pregnancy Study
Group, Luso, Portugal September, 2004.
11. Sunil Gupta. Gestational Diabetes Mellitus (GDM): We Need
To Revise The Standard Criteria For Diagnosis – Indian
Experience. Australian Diabetes in Pregnancy Group (ADIP)
meet: Sydney; August 2004.
12. Seshiah V, et al. Diabetes In Pregnancy Awareness &
Prevention (DIPAP) Project. Data presented at WDF Diabetes
Summit, Hanoi 21st - 23rd February 2006.
13. de Sereday MS, et al. Diagnostic criteria for gestational
diabetes in relation to pregnancy outcome. J Diabetes
Complications 2003;17:115-9.
14. Paul W Franks, et al. Gestational Glucose tolerance and risk
of type 2 diabetes in Young Pima Indian Offspring. Diabetes
2006;55:460–65.
15. Ravi Retnakaran, et al. Impaired Glucose Tolerance of
Pregnancy Is a Heterogeneous Metabolic Disorder as Defined
by the Glycemic Response to the Oral Glucose Tolerance
Test. Diabetes Care 2006;29:57-62.
16. Nahum GG, Wilson SB, Stanislaw H. Early-pregnancy
glucose screening for gestational diabetes mellitus. J Reprod
Med 2002;47:656-62.
17. Polonsky KS, Given BD, Van Cauter E. Twenty –four – hour

profiles and pulsatile patterns of insulin secretion in normal
and obese subjects. J Clin Invest 1988;81:442–8.
18. Metzger BE, Coustan DR. Summary and recommendations
of the fourth international workshop-conference on
gestational diabetes mellitus. Diabetes Care
1998;21(suppl):B161-7.
19. American Diabetes Association. Gestational diabetes
mellitus. Diabetes Care 2003;26 (suppl):S103-5.
20. Ben-Haroush A, et al. The post prandial glucose profile in
the diabetic pregnancy. Am J Obstet Gynecol 2004;191:576-
81.
21. Jovanovic. Medical management of pregnancy complicated
by diabetes: 3rd
ed, Alexandria, V A: ADA 2000.
22. Langer O, Levy J, Brustman L, Anyaegubunam A, Merkatz
R, Divon MY: Glycemic control in gestational diabetes
mellitus: how tight is tight enough: small for gestational age
versus large for gestational age? Am J Obstet Gynecol
1989;161:646–53.
23. Patmore JE, Mason EA, Brash PD, Boxter M, Caldwell G,
Gallen J, Price PA, Vice PA, Walker J, Lindow SW. Maternal
outcome in type 2 diabetic pregnancy treated with insulin
lispro. Abstract 2275 PO, the 61st
Scientific sessions,
American Diabetes Association, 2001; Philadelphia PA. June
22–26.
24. Langer L, Conway DL, Berkus MD, Xenakis EM – J, Gonzales
O. A comparison of glyburide and insulin in women with
gestational diabetes mellitus. N Engl J Med 2000; 343: 1134–
38.
25. Jakubowicz DJ, Iuorno MJ, Jakubowicz S, Roberts KA, Nestler
JE. Effects of metformin on early pregnancy loss in the
polycystic ovary syndrome. J Clin Endocrinol Metab
2002;87:524-9.
26. Cornblath M, Ichord R. Hypoglycemia in the neonate. Semin
Perinatol 2000;24:136–49.
Announcement
Chest Research Foundation, Pune presents a 2-day 'Refresher Course on Obstructive Airways Diseases
( ROAD)' on 19th
and 20th
Aug. 2006 for Physicians and General Practitioners.
For booking and further details please contact : Dr. Madhav Bhaware, Program Coordinator, Chest Research
Foundation, Marigold, Kalyani Nagar, Pune, 411014, India. Course Fee is Rs. 2, 500 only.
Email: mahabhav@crfindia.com Tel. : 020 27035361 / 71
Website : www.crfindia.com Mobile : 9860703990

Dipsi guidelines

More Related Content

What's hot (20)

Similar to Dipsi guidelines (20)

More from mariam hamzah (9)

Recently uploaded (20)

Dipsi guidelines