Mera desh mahaan

India
The Diabetes Capital of the world!

GDM
Every fourth diabetic in the world is an Indian!

Diabetes - Shift from cure to prevention!!

Prevention at the Pre- diabetic stage

GDM

By identifying people in the Pre-diabetic stage, implementing lifestyle modifications and reducing the weight by 7% it is possible to reduce the incidence of DM

by 58%
Since pregnancy is a diabetogenic state, it provides an opportunity to identify pre diabetic women

Screening for Gestational DM

Dr. Susheela Rani Bengaluru

GDM
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Gestational Diabetes Mellitus is

GDM

Carbohydrate intolerance with recognition or onset during pregnancy

irrespective of treatment with diet or insulin Whether or not condition persists after pregnancy

GDM
Why should we screen?

Whom should we screen?

How should we screen? When should we screen?

GDM
Why should we screen?

Why should we screen?

Does GDM pose serious risks?
Does treatment reduce those risks?

GDM

Minor adverse health effects for offspring

Normal GDM DM P

GDM
384972 47 14 52 7 21 11 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01

Birth Wt (g) Macrosomia(%) C-S Hypoglycemia Hypocalcemia

330364 8 5 2 0

364951 36 10 28 4 23 7 2.070.12 1032.9

Hyperbilirubinemia 15 Polycythemia Cord C-Pep Cord Glu 0 1.180.1 1003.6

2.980.22 <0.01 1145.5 <0.01

Major adverse health effects for offspring

Normal DM

GDM
18.4% 21.0% 7.9% 2.6% 2.6% 11.8% 3.9% 6.6% 6.6% 5.3%

CNS Congenital heart disease Respiratory disease Intestinal atresia Anal atresia Renal & Urinary defect Upper limb deficiences Lower limb deficiences Upper + Lower spine Caudal dysgenesis

6.4% 7.5% 2.9% 0.6% 1.0% 3.1% 2.3% 1.2% 0.1% 0.1%

Maternal Morbidity
Polyhydramnios

GDM

Hypertension
Preeclampsia and Eclampsia Abruptio placenta Pre term labour Cesarean delivery

Post-partum uterine atony

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Does treatment reduce those risks?

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Increasing evidence that identifying women with GDM is

important because appropriate

therapy can decrease fetal and maternal morbidity, particularly

macrosomia

Whom should we screen?

GDM

Selective Screening Universal Screening

Whom should we screen?

Selective Screening
Risk factors: >25 yrs

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Ethnicity (Hispanic, Native American, South or East Asian, Pacific

Islands, African American)

BMI >25

Previous H/o glucose intolerance

Past H/o GDM H/o diabetes in a first degree relative

Risk Stratification for GDM

GDM

High Risk Group (Indians mostly) BMI 30; PCOD; Age > 35 years F h/o DM; Ethnic predisposition; Acanthosis Previous h/o GDM, IGT, Macrosomic baby Low Risk Group Age < 25, BMI < 23, No F h/o DM or IGT No bad obstetric history; No risk ethnicity Intermediate Risk Group Not falling in the above two classes

Whom to Screen?
Low Risk Group

GDM

No screening required for GDM

Intermediate Risk Group

Screen around 2428 weeks of gestation

High Risk Group

As soon as possible after conception Must - before 2428 weeks of gestation If negative screening in 3rd trimester

Whom should we screen?

GDM

In the Indian context, screening is essential in all

pregnant women as the Indian women have 11 fold increased risk of developing glucose intolerance in pregnancy as compared to Caucasians

GDM
Prevalence of GDM in our country is 16.55% by WHO criteria of 2 hr PG>140mg/dl
Seshaiah V, Balaji V, J Obstet Gynecol India 2005

GDM
How should we screen?

Screening tests

GDM

RBS
FBS 50 g glucose challenge test (GCT) 75/100 g oral glucose tolerance test (OGTT)

Screening test - RBS

GDM

Value greater than 200mg/dl repeated and confirmed on second day is diagnostic of overt DM

Screening test - FBS

GDM

>125mg/dl is diagnostic of overt DM > 95mg/dl is cut off for GDM

High False positive rate - 30 to 57%

Screening test GCT

GDM

50gm glucose at any time of the day Blood sugar after 1hour
>140mg/dl Suspicion of GDM OGTT

>180mg/dl GDM

Screening test OGTT

Both screening and diagnostic

GDM

Previous 3 days of unrestricted CHO diet (>150gm) Overnight fast for 8hours No smoking before the test & should remain seated 75gm oral glucose in 150ml of water

Recommendations for 75gm OGTT

GDM

ADA - two-step procedure

WHO - one-step procedure

Criteria for Diagnosis of GDM with 75gm OGTT

GDM
Diagnostic criteria
2 or more abnormal One abnormal

Organization

Fasting

1hPG

2hPG

ADA

95mg/dl

190mg/dl

160mg/dl

WHO

126mg/dl

Not measured

140mg/dl

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DIPSI Recommended method

GDM

One step procedure

Irrespective of previous meal

75gm oral glucose load 2 hrs later Plasma Glucose

Simple, economical and feasible

GDM
2hr Plasma Glucose In Pregnancy Outside Pregnancy

>200mg/dl >140 199mg/dl 120-139mg/dl <120mg/dl

Diabetes GDM GGI Normal

Diabetes IGT

Normal

The term IGT should not be used to indicate any glucose intolerance in pregnancy (as this terminology is used outside pregnancy)

One step 75gm OGTT - Advantages

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3times more pick up than with two step

Suitable for Indian setting Saves time

Saves cost
Avoids repeated visits Reduces repeated invasive sampling

Gestational Glucose Intolerance

GDM

Increased birth weight of neonates was observed even

when the mothers glucose tolerance was less than the glycemic criteria recommended by WHO for diagnosing GDM. The occurrence of macrosomia was continuum as the 2 hr Plasma Glucose with 75 gm OGTT, increased from 120mg/dl
Seshiah et al. Maternal glycemia and neonates birth weight in Asian Indian Women. Diabetes Res Clin Pract 2006; 73: 223- 4.

GDM
When to screen?

When to screen?

GDM

First Trimester or at booking 24 28wks

32 wks

Why first trimester?

GDM

Insulin is first detected in fetal Pancreas at 9wks

Fetal hyperinsulinemia in response to maternal

hyperglycemia occurs by 16wks This leads to accelerated growth despite good

metabolic control in later pregnancy

Unrecognis ed Type II DM can be picked up

When to screen?

GDM

A pregnant woman found to have NGT in the first trimester should be tested for GDM again around 24th 28th week and finally around 32nd 34th week

To summarise,
Why should we screen?

GDM
Explained

Whom should we screen? All pregnant women

How should we screen?

75gms 2hr Blood sugar

When should we screen? At booking, 24wks, 34wks

The primary motivation for screening is the concern for pregnancy outcome

GDM

Early Foetal loss Congenital anomaly

Macrosomia- GTI from one generation to next

Sudden IUFD Maternal complications PE Medical Complications of diabetes

The secondary motivation for screening is to

identify and prevent

GDM

The increased risk of progression to Diabetes in mother

30% - 5 - 10 yrs
50% - 24 - 25 yrs

The ultimate objective is.

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Preventing the perpetuation of Diabetes!!!!

Late effects on the offspring

GDM
Risk 19% 30%

Risk of developing Type II DM in offspring at Age 24yrs

III trimester Plasma Glucose

120-139mg/dl
140-199mg/dl

Franks PW et al. Gestational glucose tolerance and risk of type 2 diabetes in young Pima Indian offspring. Diabetes 2006; 55: 460- 5.
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Glu Intolerance and Cardiometabolic risk in Adolescents Exposed to Maternal GDM

A 15-year follow-up study

GDM

In utero hyperinsulinemia was associated with a 17-fold

increase in metabolic syndrome and a 10-fold increase in overweight at adolescence, independent of birth weight, Tanner stage, maternal GD status, & mothers BMI

Diabetes Care 33:13821384, 2010

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Late effects on the offspring

GDM

Increased risk of IGT, Type II DM Increased risk of Obesity

Increased risk of Metabolic syndrome

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Jagadguru Adi Sankaracharyas Bhaja Govindam

punarapi jananam punarapi maranam

GDM

Once again is the birth, sure follows the death

punarapi jananee jaTarae shayanam | Yet again, is the slumber in the uterine filth

iha samsaarae bahu dustaarae

he! what to say of this miserable troth kripayaa paarae paahi muraarae || O! lord, save us from this cyclical myth

Punarapi Garbham
Yet another conception

Punarapi Prasavam
Yet another child-birth

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Punarapi Jananee
Once again for the mom

Sisuvau KaTinam
and the babe, the miseries

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Iha Madhu maehae

This Diabetes you see

Bahu Dustarae
Terrible to the core

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Kripaya Nivaaare
Please put an end to this

Nipunarae vaidyae
O! Doctor, the expert !

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DIPSI declaration Diabetes free generation

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Focus on the Fetus for the Future

Feb, 2010, Kolkata
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Lets break the cyclical perpetuation of Diabetes

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Lets screen & take care of our mothers