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Mera desh mahaan

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India

The Diabetes Capital of the world!

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GDM

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Every fourth diabetic in the world is an Indian!

Diabetes - Shift from cure to prevention!!

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GDMrevention at the Pre- diabetic stage

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

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GDM

Dr. Susheela Rani

Bengaluru

Screening for Gestational DM

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GDMestational Diabetes Mellitus is

Carbohydrate intolerance with recognition or

onset during pregnancy

irrespective of treatment with diet or insulin

Whether or not condition persists after pregnancy

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GDM

Why should we screen?

Whom should we screen?

How should we screen?

When should we screen?

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GDM


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GDM

Does GDM pose serious risks?

Does treatment reduce those risks?


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GDMMinor adverse health effects for offspring

Birth Wt (g) 330364 364951 384972

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GDMCNS 6.4% 18.4%

Congenital heart disease 7.5% 21.0%

Respiratory disease 2.9% 7.9%

Intestinal atresia 0.6% 2.6%

Anal atresia 1.0% 2.6%

Renal & Urinary defect 3.1% 11.8%

Upper limb deficiences 2.3% 3.9%

Lower limb deficiences 1.2% 6.6%

Upper + Lower spine 0.1% 6.6%

Caudal dysgenesis 0.1% 5.3%

Normal DM

Major adverse health effects for offspring

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GDMaternal Morbidity Polyhydramnios

Hypertension

Preeclampsia and Eclampsia

Abruptio placenta

Pre term labour

Cesarean delivery

Post-partum uterine atony

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GDM

Does treatment reduce those risks?

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GDM

Increasing evidence that

identifying women with GDM is

important because appropriate

therapy can decrease fetal and

maternal morbidity, particularly

macrosomia

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GDMWhom should we screen?

Selective Screening

Universal Screening

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Risk factors:

>25 yrs

Ethnicity (Hispanic, Native American, South or East Asian, PacificIslands, African American)

BMI >25

Previous H/o glucose intolerance

Past H/o GDM

H/o diabetes in a first degree relative

Selective Screening

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GDMRisk Stratification for GDMHigh 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

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GDMWhom to Screen?Low Risk Group

No screening required for GDM

Intermediate Risk GroupScreen around 2428 weeks of gestation

High Risk Group

As soon as possible after conception

Must - before 2428 weeks of gestation

If negativescreening in 3rd trimester

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In the Indian context, screening is essential in all

pregnant women as the Indian women have 11 foldincreased risk of developing glucose intolerance inpregnancy as compared to Caucasians

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GDMPrevalence 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

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GDM

How should we screen?

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GDMScreening tests

RBS

FBS

50 g glucose challenge test (GCT)

75/100 g oral glucose tolerance test (OGTT)

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GDMScreening test - RBS

Value greater than 200mg/dl repeated and

confirmed on second day is diagnostic of overt DM

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GDMScreening test - FBS

>125mg/dl is diagnostic of overt DM

> 95mg/dl is cut off for GDM

High False positive rate - 30 to 57%

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GDMScreening test GCT

50gm glucose at any time of the day

Blood sugar after 1hour

>180mg/dl

GDM

>140mg/dl

Suspicion of GDMOGTT

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GDMScreening test OGTT

Both screening and diagnostic

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

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GDM

ADA - two-step procedure

WHO - one-step procedure

Recommendations for 75gm OGTT

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GDM

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Criteria for Diagnosis of GDM with 75gm OGTT

Organization Fasting 1hPG 2hPGDiagnostic

criteria

ADA 95mg/dl 190mg/dl 160mg/dl2 or moreabnormal

WHO 126mg/dl Notmeasured

140mg/dl Oneabnormal

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GDMDIPSI Recommended method

One step procedure

Irrespective of previous meal

75gm oral glucose load

2 hrs later Plasma Glucose

Simple, economical and feasible

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GDM

The term IGT should not be used to indicate any glucose intolerance

in pregnancy (as this terminology is used outside pregnancy)

2hr PlasmaGlucose

In PregnancyOutside

Pregnancy

>200mg/dl Diabetes Diabetes

>140 -199mg/dl GDM IGT

120-139mg/dl GGI

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GDM

3times more pick up than with two step Suitable for Indian setting Saves time Saves cost Avoids repeated visits Reduces repeated invasive sampling

One step 75gm OGTT - Advantages

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GDMIncreased 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

Gestational Glucose Intolerance

Seshiah et al. Maternal glycemia and neonatesbirth weight in Asian Indian Women. Diabetes Res Clin Pract 2006;

73: 223- 4.

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GDM

When to screen?

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GDMhen to screen?

First Trimester or at booking

2428wks

32 wks

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GDMhy first trimester?

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

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GDMhen to screen?

A pregnant woman found to have NGT in the first

trimester should be tested for GDM again around24th 28th week and finally around 32nd 34th week

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GDM

Why should we screen? Explained

Whom should we screen? All pregnant women

How should we screen? 75gms2hr Blood sugar

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

To summarise,

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GDMhe primary motivation for screening is the

concern for pregnancy outcome

Early Foetal lossCongenital anomalyMacrosomia- GTI from one generation to nextSudden IUFDMaternal complications PEMedical Complications of diabetes

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GDMhe secondary motivation for screening is to

identify and prevent

The increased risk of progression to Diabetes in

mother

30% - 5 - 10 yrs

50% - 24 - 25 yrs

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GDMhe ultimate objective is.

Preventing the perpetuation of Diabetes!!!!

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GDMate effects on the offspring

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

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Franks PW et al. Gestational glucose tolerance and risk of type 2 diabetes in young Pima Indian offspring.Diabetes 2006; 55: 460- 5.

III trimester Plasma Glucose Risk

120-139mg/dl 19%

140-199mg/dl 30%

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GDMGlu Intolerance and Cardiometabolic risk inAdolescents Exposed to Maternal GDM

A 15-year follow-up study

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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GDMate effects on the offspring

Increased risk of IGT, Type II DM

Increased risk of Obesity

Increased risk of Metabolic syndrome

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J d Adi S k h

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GDMpunarapi jananam punarapi maranamOnce 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 trothkripayaa paarae paahi muraarae ||

O! lord, save us from this cyclical myth

Jagadguru Adi Sankaracharyas

Bhaja Govindam

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Punarapi GarbhamYet another conception

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Punarapi PrasavamYet another child-birth

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Punarapi JananeeOnce again for the mom

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Sisuvau KaTinamand the babe, the miseries

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Iha Madhu maehaeThis Diabetes you see

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Bahu DustaraeTerrible to the core

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Kripaya NivaaarePlease put an end to this

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Nipunarae vaidyaeO! Doctor, the expert !

DIPSI declaration Diabetes free generation

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GDMDIPSI declarationDiabetes free generation

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Focus on the Fetus for the Future

Feb, 2010, Kolkata

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GDMLets break the cyclical perpetuation of Diabetes

Lets screen & take care of our mothers

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