Early Gestational Diabetes Mellitus - Type or Hype.pptx

Gestational Diabetes screening starts at 20 weeks Gestation. In this lecture we will discuss about an entity that is being commonly encountered in Clinical Practice that falls in the grey area of Clinical Guidelines

1. Early GDM Type or Hype Dr R Deepak Anand R DNB (Med), MRCP (UK)

2. The Noblest aspects of Medical Practice are restoring one’s vision & assisting with birth of a new life aka Ophthalmology or OBG are the best specialities

3. Glucose Homeostasis in Pregnancy Insulin Sensitivity starts decreasing in pregnancy from 12-14 weeks onwards Progressively reduces to reach only 40 – 60 % of non-gravid state Pregnancy induced hormonal changes are the reason Viz. Progesterone and Human Placental Lactogen (due to its similarity with growth hormone) Still we expect Blood sugars to be much lower during pregnancy than in the non-gravid state

4. As far as GDM goes, Long story Short No Uniform Consensus on How much glucose to give One step or two step The cut-offs Universal or targeted screening When to screen

5. The Different Bodies that release consensus statements & Guidelines

6. Evolution of the cut-offs

7. Different Cut-offs adding to the confusion

8. DIPSI - 2020

9. Why GDM is increasing The Prevalence of Obesity in the young is increasing Advancing maternal Age The Prevalence of PCOS is increasing More awareness and universal screening More stringent (or rather aggressive) cut offs for diagnosis The Prevalence of Diabetes in the young is increasing, hence Diabetes complicating Pregnancy cases are also on the rise ODIP – Overt Diabetes In early Pregnancy – Newly Diagnosed DM on routine screening during ante-natal check ups

10. FBS, A1C Weeks Nongravid 0-4 4-8 8-12 12-16 16-20 20-24 24-28 28-32 < 92 Normal 92 - 110 Normal GREY AREA e-GDM GDM GDM GDM 110 - 126 IFG GDM GDM GDM > 126 OVERT DIABETES IN PREGNANCY Weeks Nongravid 0-4 4-8 8-12 12-16 16-20 20-24 24-28 28-32 * < 4.8 * Normal Upto 5.7 Normal GREY AREA e-GDM GDM GDM GDM 5.7-6.5 preDM GDM GDM GDM >6.5 OVERT DIABETES IN PREGNANCY

11. Crux of the Issue Intermediate levels of hyperglycemia, or e GDM, is a commonly encountered clinical conundrum in early pregnancy. The current diagnostic strategies for e GDM are not based on adequate evidence. The criteria for the diagnosis of c GDM have been applied for convenience in early pregnancy.

12. Crux of the Issue However, newer data indicate that intermediate levels of hyperglycemia in early pregnancy may be associated with an increased risk of adverse outcomes. Thus, an earlier diagnosis might offer a chance for timely intervention and improve pregnancy results

13. Crux of the Issue The available guidelines do not address the management of e GDM due to insufficient evidence. The therapeutic approach to such cases is not clearly defined. There is a need to analyze the evidence and plan further research to formulate an appropriate testing and therapeutic strategy for e GDM.

14. e-GDM vs c-GDM May or may not a clinical Continuum About upto Half of the patients revert to normal glucose tolerance during second trimester Still poses independent risk with increasing levels of FBS

15. Will HbA1C come to our rescue in streamlining e-GDM Diagnosis atleast ??? The Answer is NO.

16. Are e-GDM & c-GDM distinct pathophysiological entities or a continuum In e GDM – Predominantly it is Fasting Hyperglycemia In c GDM – Impaired Glucose Tolerance and Postprandial Hyperglycemia

17. Evidence for Early Intervention

18. At present, there is no consensus on what should be the ideal strategy for e-GDM

19. No one talks about the elephant in the room…

20. Negative impact on the mental health of the expecting mother and the family

21. Let’s wait for PINTO (New Zealand) ToBOGM (Australia) TESGO (Taiwan)

22. Or try & generate our own evidence Through Collaborative research

23. Thank You Dr R Deepak Anand DNB (Med), MRCP (UK)