DIPSI Guideline on GDM

Invited lecture by Dr Sujoy Dasgupta in a Webinar on “A to Z of Diabetes” by “Diabetes Awareness and You” held in May, 2021

1. DIPSI Guideline on GDM Dr Sujoy Dasgupta MBBS (Gold Medalist, Hons ) MS (OBGY- Gold Medalist) DNB (New Delhi) MRCOG (London) Advanced ART Course for Clinicians (NUHS, Singapore) Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata Visiting Consultant, RSV Hospital, Kolkata Bhagirathi Neotia Women and Child Care centre Woodlands Multispeciality Hospital, Kolkata Managing Committee Member, Bengal Obstetric & Gynaecological Society ( BOGS ) Secretary, Subfertility and Reproductive Endocrinology Committee , BOGS Executive Committee Member, Indian Fertility Society ( IFS )- West Bengal Chapter Executive Committee Member, Indian Society for Assisted Reproduction ( ISAR )- Bengal Member, Endocrinology Committee, Federation of Obstetric and Gynaecological Societies of India ( FOGSI ) Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019

2. Diabetes in Pregnancy 1. Pre-existing ( Overt DM) 2. Newly Diagnosed in Pregnancy (GDM)

3. Complications of GDM

4. Diabetes During Pregnancy Terratogenic effect on foetal  cell & adipocytes Mother with DM Infant of diab . mother Child or women with DM Vicious cycle DM in pregnancy

5. O’ Sullivan 2 Step Screening Test 2 nd stage- OGTT (after overnight fasting) 0 hr ≥105 mg 1 hr ≥190 mg 2 hr ≥165 mg 3 hr ≥145 mg) 2 out of 4 if abnormal  GDM 1st Stage- 1 hr PPBS taking 50 gram glucose (Glucose Challenge Test- GCT ) Value of GCT > 140 mg  perform 3 hr 100 G Oral glucose Tolerance Test ( OGTT )

6. OGTT 100 gm 3- hour OGTT performed after overnight fast ( ACOG ) 2 or more blood glucose level ≥ the above v alue- positive diagnosis. Time Venous glucose value fasting 95mg/dl 1 hour 180mg/dl 2 hour 155mg/dl 3 hour 140mg/dl

7. ACOG Low risk Average risk High risk Ethnic group with low prevalence of GDM Ethnic group with high prevalence of GDM Marked obesity No known diabetes in 1 st degree relatives Diabetes in 1 st degree relatives Strong family h/o of type 2 DM Age <25yrs Age >25yrs Previous h/o of GDM, impaired glucose metabolism or glycosuria Weight normal before pregnancy Overweight before pregnancy Weight normal at birth Weight high at birth No h/o of abnormal glucose metabolism

8. ACOG Low risk Average risk High risk Ethnic group with low prevalence of GDM Ethnic group with high prevalence of GDM Marked obesity No known diabetes in 1 st degree relatives Diabetes in 1 st degree relatives Strong family h/o of type 2 DM Age <25yrs Age >25yrs Previous h/o of GDM, impaired glucose metabolism or glycosuria Weight normal before pregnancy Overweight before pregnancy Weight normal at birth Weight high at birth No h/o of abnormal glucose metabolism

9. WHO, NICE No role of urine sugar exam. Most acceptable is WHO criteria Overnight Fasting  FPG  75 g glucose  2 hr PPBS 2 hr PPBS > 140 mg = GDM

10. Diabetes In Pregnancy Study group of India ( DIPSI )

11. Irrespective of fasting/ feeding status- 2 hr after taking 75 gram glucose pregnancy Non-pregnant 2hr≥200mg/dl DM DM 2hr≥140mg/dl GDM IGT 2hr≥120mg/dl DGGT

12. HAPO Study

13. In the Indian context, screening is essential in all pregnant women (DIPSI)

14. When to screen Early Pregnancy 24-28 wk (if early screen is negative)

15. Management

16. Management Fasting glucose >120- Insulin/ OHA FPG <120- MNT

17. Medical Nutritional treatment (MNT) Total caloric intake- 30kcal/kg for average weight women 25kcal/kg for overweight women 12kcal/kg for morbidly obese women

18. MNT 3 meals and 1 to 3 snacks 40-50% complex carbohydrate-10-15% at breakfast, 20-30% at lunch and 30-40% at dinner Snacks 0-10% carbohydrate 30-40% fat, predominantly unsaturated Rest proteins Ingestion of carbohydrates with low glycemic index Rest calories from fat and proteins Unrefined, high-fiber food

19. Exercise Resistance exercises decrease requirement for insulin Strenuous exercises is discouraged Stretching exercises is encouraged

20. Glucose monitoring Self glucose monitoring Fasting and 1 or 2 hour postprandial glucose level Goal-fasting<95mg/dl 1 st hour pp<140mg/dl 2 nd hour pp<120mg/dl

21. Laboratory monitoring Once target blood glucose is achieved Till 28 wk- FBS , PPBS - once a month/ as decided by the clinician 28-32 wk- once every 2 weeks >32 wk- weekly

22. If goal is not met by MNT in 2 weeks Insulin/ OHA

23. Insulin Indication GDM with FBS > 120mg/dl during OGTT GDM with majority of FBS > 90 mg/dl & majority of PPBS > 120 mg /dl despite diet & exercise

24. Which OHA Metformin Glibenclamide (Glyburide)

25. Obstetric management Combined Screen 11-13 weeks An ultrasound scan performed around 18 –20 weeks congenital malformation Fetal echocardiography around 20 – 24 weeks

26. Fetal surveillance EFW by USG- 28, 32 36 weeks Doppler- From 38 weeks (If uncomplicated)

27. Delivery

28. When to induce? Low risk GDM- allow to develop spontaneous labour at term At 40wks –induce labour High risk GDM-induction at 38wks

29. Mode of delivery Vaginal route preferred Cesarean section- Past obstetric history Other obstetric complications Fetal weight 4.5 kg or more Patient’s will

30. Intrapartum management Eat usual meal and take their insulin dose night before induction or section Morning dose of insulin omitted Blood glucose level measured <70mgldl 70-110mg/dl >110mg/dl 5% or 10% dextrose in 0.45% NS 0.9% NS 50u insulin in 500ml of 0.9% NS @0.5u/hr

31. Blood glucose and urinary ketones measure every 2 hourly Once patient enters active stage of labour -switch to 5% dextrose in 0.45% NS Strict intrapartum fetal heart rate monitoring Analgesia during labour Partograph

32. Postpartum management Insulin requirement decreases drastically after delivery Do not need insulin for 24-48 hours postpartum Encourage breatfeeding

33. Neonatal care Early clamping of the cord Apgar score at 1 min and 5 min Screening for congenital malformation Start early feeding Capillary blood glucose should be monitored at 1-2 hour of age and before the first four breast feedings (and for up to 24 hours in high- risk neonates). Blood tests for polycythaemia , hyperbilirubinaemia , hypocalcaemia and hypomagnesaemia should be carried out for babies with clinical signs.

34. Follow up 50% women with GDM develops overt DM within 20yrs Also at risk of metabolic syndrome Risk of GDM in future pregnancies Modify lifestyle Time Test Post delivery (1-3 day) Fasting or random blood glucose Early postpartum(6-12wks) 75g-2hour OGTT 1yrs postpartum 75g-2hour OGTT Annually 75g-2hour OGTT Pre-pregnancy 75g-2hour OGTT

35. What we need Awareness- Before, During, After pregnancy Pre- conceptional care Glycaemic Control Obstetric Management Monitoring Delivery Plan Multidisciplinary Team

36. Thank You