Recent Updates on Gestational Diabetes2025.pptx

Diagnostic criteria & Management of Diabetes in pregnancy including per party’s & post partum period

1. GESTATIONAL DIABETES : OVERVIEW AND RECENT UPDATES Dr TARAK NATH CHATTOPADHYAY MBBS, MD GENERAL MEDICINE Consultant Physician & DND Faculty HEALTH WORLD HOSPITAL DURGAPUR

2. No Conflict of interest to Disclose

3. FLOW OF PRESENTATIONS DEFINITION TERMINOLOGY EPIDEMIOLOGY PATHOPHYSIOLOGY DIGNOSTIC CRITERIA MANAGEMENT

4. DEFINITION TERMINOLOGY EPIDEMIOLOGY PATHOPHYSIOLOGY DIGNOSTIC CRITERIA MANAGEMENT

5. HISTORY Diabetes in pregnancy was first described in 1824 by Bennewitz in Germany White’s classification 1949 was named after Priscilla White. This is still used today to distinguish between gestational DM and pre-existing DM prior to pregnancy. She was the first woman to be invited to give the  Banting Memorial Lecture and to receive the Banting Medal, the highest scientific award of the American Diabetes Association The term “gestational diabetes” (GDM) was first introduced by Carrington in 1957 Landmark publication by O’Sullivan and Mahan in 1964

6. O’Sullivan and Mahan diagnostic criteria for GDM (1964 Study carried out by O’Sullivan and Mahan in 1964 Included 752 pregnant women , screened for GDM using 3-h 100 g OGTT Women were followed postpartum with annual glucose tolerance test 0ver a period of 7-8 years, 29% of women whose whole blood glucose values were more than two standard deviations above the mean, develop T2DM Diagnostic criteria for GDM were proposed on the basis of pregnancy glucose tolerance test’s ability to predict future diabetes Accordingly , the cut-off values for diagnosis of GDM were estimated based on the mean plus two standard deviations rounded to the nearest 5 mg/ dL

7. DEFINITION TERMINOLOGY EPIDEMIOLOGY PATHOPHYSIOLOGY DIGNOSTIC CRITERIA MANAGEMENT

8. TERMINOLOGY G estational diabetes mellitus (GDM) - A ny degree of glucose intolerance with onset or first recognition during pregnancy.Classically it is diagnosed after 24-28 weeks of gestation EARLY GDM - eGDM refers to intermediate degrees of hyperglycemia detected before 20 weeks (<24 weeks initially) of pregnancy that fulfill the criteria for GDM but fall short of the threshold for overt diabetes . OVERT DIABETES - W hen hyperglycaemia during pregnancy meets non-pregnant diagnostic criteria (i.e. Fasting > 126 mg/dl and/or PP2hr (75 gm OGTT)- > 200 mg/dl and/or Random Plasma Glucose > 200 mg/dl with symptoms) HYPERGLYCEMIA IN PREGNANCY – All cases of hyperglycemia in Pregnancy (, eGDM , GDM)

9. DEFINITION TERMINOLOGY EPIDEMIOLOGY PATHOPHYSIOLOGY DIGNOSTIC CRITERIA MANAGEMENT

10. Older Studies Newer Data The global prevalence of gestational diabetes is estimated to be 14% by th e International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria The prevalence of gestational diabetes screened before 20 weeks of gestation, irrespective of the diagnostic criteria used, ranges from 0.7% to 36.8% between countries. The prevalence in studies that screen for gestational diabetes before 12 weeks of gestation ranges from 0.7% to 14.2%. Epidemiology and management of gestational diabetes – Lancet 2024

11. Nature Review Endocrinology 2023

12. Nature Review Endocrinology 2023 80–90% of diabetes-related pregnancies are GDM. Hyperglycemia in Pregnancy and Women’s Health in the 21st Century - Int. J. Environ. Res. Public Health   2022

13. DEFINITION TERMINOLOGY EPIDEMIOLOGY PATHOPHYSIOLOGY DIGNOSTIC CRITERIA MANAGEMENT

14. Gestational diabetes mellitus (GDM) is caused by a complex combination of maternal, feto placental, genetic, and environmental factors T he pancreatic beta-cells cannot cope with a persistent fuel surplus, leading to insulin resistance, hyperglycaemia , and increased glucose supply to the developing fetus . Placental variables, adipose expandability, low-grade chronic inflammation, gluconeogenesis, and oxidative stress also contribute to the pathophysiology of GDM

15. DIAGNOSTIC CRITERIA O’Sullivan and Mahan 1964 National Dbetes Data Group (NDDG ) 1979 (Carpenter and Coustan criteria) 1982 IADPSG 2008 DIPSI 2014 (Based on WHO 1999)

16. HAPO 2008 >25000 pts, 15 centers, 9 countries

17. The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study 2008 HAPO study demonstrated a continuous relationship and clearly ↑ risk between glycemia (fasting, and 1 or 2 h post glucose load) and each of the following primary outcomes Primary outcomes Birth weight >90th percentile for GA Primary cesarean delivery Clinically diagnosed neonatal hypoglycemia Cord-blood serum C-peptide level >90th percentile AIM  T o determine a level of glycaemia beyond which maternal and infant risks clearly increased Finding  C ontinuous, independent relationships between untreated maternal blood glucose (fasting, 1-h and 2-h post-glucose load) with cord blood C-peptide level (reflecting fetal hyperinsulinaemia )  Birth weight >90th centile showing the strongest association with maternal blood glucose.  No association between perinatal mortality and blood glucose levels

18. HAPO study 1 hr value has better correlation with complications

19. International Association of Diabetes Pregnancy Study Groups (IADPSG) 2008 Based on HAPO study finding Screening for “overt diabetes” be undertaken at the first antenatal visit, with the diagnosis based on a fasting plasma glucose ≥ 126 or an HbA1c ≥6.5% A single glucose tolerance test could be adequate and that two step testing be abandoned Timing : 24-28 week Sample : Fasting, 1hr, 2hr Dose of glucose load : 75 gm Diagnostic cut off (mg/dl) : Fasting  ≥ 92 1 hr  ≥180 2 hr  ≥ 153 Any one value should be abnormal for diagnosis Remark : Higher number of women diagnosed with GDM

20. IADPSG Pro s Outcome based criteria Identifies peak glucose timing – useful for monitoring Fasting hyperglycaemia = persistent postpartum Cons Over diagnosis Fasting state More pricks /cumbersome

21. Diabetes in Pregnancy Study Group India (DIPSI) criteria Criteria DIPSI Screening Universal, one step screening Time and periodicity of screening First at 16 week; repeated at 24-28 week and after 32-34 week Method of screening 75 gm OGTT ( in the fasting or non- fasting state) Diagnostic cut-off 2 hr blood glucose ≥ 140 mg/dl

22. DIPSI

23. TESTING FOR GESTATIONAL DIABETES: RELEVANT FACTS SCREENING SHOULD BE UNIVERSAL DONE AT FIRST ANTENATAL VISIT AND THEN AT 24 TO 28 WEEKS DONE AFTER 8-14 HOUR OF FASTING NORMAL CARBOHYDRATE INTAKE FOR PAST 3 DAYS USE 75 GRAM ANHYDROUS GLUCOSE(82.5 GRAM GLUCOSE MONOHYDRATE) PATIENT SHOULD BE SEATED AND NOT ALLOWED TO SMOKE TAKE 0, 1 AND 2 HOUR POST GLUCOSE SAMPLE

24. WHAT DIAGNOSES GDM PRACTICAL POINTS 1.A 3 SAMPLE GTT IDENTIFIES CASES WITH ISOLATED FASTING AND 1 HOUR HYPERGLYCAEMIA AND SHOULD BE DONE WHENEVER POSSIBLE 2.WHENEVER NOT POSSIBLE A SINGLE SAMPLE POST 2 HR GLUCOSE DONE BY GLUCOMETER IS FAIR 3. AT LEAST IN OUR POPULATION 1 HOUR VALUE BETWEEN 140-180 AND 2 HOUR VALUE BETWEEN 120-153 NEEDS MEDICAL NUTRITION AND CAREFUL MONITORING AND FOLLOW UP Diagnosis and management of gestational diabetes mellitus guidelines by DIPSI (Revised).  Int J Diabetes Dev Ctries   43 , 485–501 (2023)

25. Early gestational diabetes mellitus

26. DEFINITION OF EARLY GDM Early GDM ( eGDM ) refers to intermediate degrees of hyperglycemia detected before 24 weeks of pregnancy that fulfill the criteria for conventional GDM ( cGDM ) but fall short of the threshold for overt diabetes Early gestational diabetes mellitus: Diagnostic strategies and clinical implications, MDPI,2021

27. NEED FOR DETECTING EARLY HYPERGLYCEMIA IN PREGNANCY With the increasing prevalence of undiagnosed DM in women of the reproductive age group, the primary purpose of this strategy is to detect preexisting hyperglycemia The compelling need to rule out overt DM in early pregnancy arises from the risk of congenital malformation associated with it ADA and the ACOG proposed risk-based screening in early pregnancy Early pregnancy fasting hyperglycemia associated with adverse perinatal outcome irrespective of the development of late-pregnancy GDM Early gestational diabetes mellitus: Diagnostic strategies and clinical implications, MDPI,2021

28. FASTING PLASMA GLUCOSE IN EARLY GDM Intermediate elevations in FPG in early pregnancy correlate with an increased risk for cGDM and adverse feto -maternal events FPG ≥ 92 mg/dl in early pregnancy is associated with worsened perinatal outcome, including a higher chance of LGA infants and macrosomia , even in the absence of the later development of cGDM Pre-pregnancy BMI in the overweight range or above with FPG ≥ 92 mg/dl , may represent pregnancies at higher risk of complications and should be considered for close monitoring. Early gestational diabetes mellitus: Diagnostic strategies and clinical implications, MDPI,2021

29. OGTT & HBA1C IN EARLY GDM Deranged OGTT in the first trimester could also be a marker of metabolic dysfunction in obese women An OGTT performed later toward the end of the second trimester more closely corresponds to cGDM Early pregnancy HbA1c ≥ 5.9% is associated with an increased risk of cGDM and might correlate with worse perinatal outcomes Early gestational diabetes mellitus: Diagnostic strategies and clinical implications, MDPI,2021

30. Perinatal Outcomes in Early and Late Gestational Diabetes Mellitus After Treatment From 24–28 Weeks’ Gestation: A TOBOGM Secondary Analysis Diabetes Care. 2024;47(12):2093-2101. doi:10.2337/dc23-1667

31. Early intervention does not improve most pregnancy outcomes, except NRD. Sensitivity analysis , additionally revealed a reduction in macrosomia .

32. DEFINITION TERMINOLOGY EPIDEMIOLOGY PATHOPHYSIOLOGY DIAGNOSTIC CRITERIA MANAGEMENT

33. MANAGEMENT OF GDM Lifestyle Intervention SMBG INSULIN Oral antidiabetic

34. MOHFW,GOI, 2018

35. ADA 2022 Recommendations for screening for diabetes in pregnanacy Timing Recommendation At first contact ( 4-12 week POG) Screen for pre-existing diabetes FBS & HbA1C ( FBS ≥ 126 and HbA1c ≥ 6.5) At 24-28 weeks of gestation Screen for GDM 75 gm OGTT ( Diagnostic cut off is same as IADPSG) At 4-12 weeks post partum Screen for prediabetes or diabetes 75 gm OGTT (Non pregnanacy cutoffs )

36. GLYCEMIC TARGETS IN GDM (ADA 2025) Fasting < 95 mg/dl 1 hour < 140 mg/dl 2 hour < 120 mg/dl

37. MEDICAL NUTRITION THERAPY: THE CORNERSTONE SHOULD BE UNIVERSALLY PRESCRIBED PRACTICAL CONTROLS MAJORITY OF GESTATIONAL DISBETICS REEMPHASIZED FROM TIME TO TIME

38. MEDICAL NUTRITION THERAPY (MNT) Medical nutrition therapy for GDM is an individualized nutrition The food plan should provide adequate calorie intake to promote fetal/ neonatal and maternal health, achieve glycemic goals, and promote weight gain according to Institute of Medicine recommendations Diet includes mainly low- glycemic -index carbohydrates 3 main meals and 2–4 snacks Nature review, 2019

39. As per ICMR guidelines, for an average weight gain of 10-12 Kg, an addition of 350 kcal/ day above the adult requirement is recommended during second and third trimester Institute of Medicine (IOM) recommends a diet with ≥175 g of carbohydrates daily ( 35% of 2,000-calorie diet) 175 g carbs 71 gms protein 28 gm fibre Fasting urine ketone testing may be useful to identify women who are severely restricting carbohydrates to control blood glucose

40. WEIGHT MANAGEMENT Women with overt or GDM follow the Institute of Medicine revised guidelines for weight gain during pregnancy Obese women with overt or GDM reduce their calorie intake by ~ 1/3 rd (compared with their usual intake before pregnancy) while maintaining a minimum intake of 1600 to 1800 kcal/d 04.11.2019 A Krishna 47

41. PHYSICAL ACTIVITY Duration of exercise (20–50 min/ day) 2–7 days/week of moderate intensity Light exercise, such as walking, swimming and cycling Post meal walk Nature review, 2019

42. GLUCOSE MONITORING Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in women with GDM Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted Postprandial monitoring is associated with better glycemic control and a lower risk of preeclampsia Frequent SMBG based on postprandia l rather than preprandial monitoring, has shown to be superior in improving glycaemic control in insulin treated women. ADA,2022

43. MONITORING FASTING 1 OR 2 HR POST MEAL PRE LUNCH 1 OR 2 HOUR POST LUNCH PRE DINNER 1 OR 2 HOUR POST DINNER 3 AM MON TUE WED THU FRI SAT SUN MINIMUM X X X X MAXIMUM X X X X X X X **MONITORING AT 1 OR 2 HOUR IS DECIDED BASED ON GTT RESULTS- MONITOR WHEN IT IS MORE DERANGED

44. CARBOHYDRATE INTAKE REDUCE TO 35-45% OF TOTAL CALORIES INTAKE TAKEN OVER 3 MAJOR AND 2-4 MINOR MEALS 650 KCAL-140 GRAM CARB 30 GRAM PER MAJOR MEAL AND 15 GRAM PER MINOR MEAL

45. OTHER COMPONENTS OF DIET PROTEINS:ENSURE ADEQUACY 1G/KG +23 GRAMS IS PROTEIN INTAKE SUGGESTED MAKE UP EITHER BY MEAL REPLACERS OR HIGH QUALITY DIETARY PROTEIN-EG. PANNER , LEGUMES, PULSES, EGG, FISH FAT:SHOULD BE LESS SHOULD BE LESS UNSATURATED FAT INTAKE TO BE ENCOURAGED FIBERS:SHOULD MAKE THE BULK FLAX SEED, PSYLLIUM HUSK, OAT BRAN, LEGUMES FRUITS AND VEGETABLES

46. CONTINUOUS GLUCOSE MONITORING ADA  C ontinuous blood glucose monitoring would be helpful for selected women if there are problems with hypoglycemia unawareness NICE  CGMS should be considered in pregnant women on insulin therapy who have severe hypoglycemia (with or without impaired awareness of hypoglycemia) or who have unstable blood glucose levels (to minimize variability) Target range 63–140 mg/ dL TIR, goal >70% TAR (>140 mg/ dL ), goal <25% TBR ( < 54 mg/dl) goal < 1%

47. Multicentre, randomized control trial Participant : 325 women were pregnant ( < 14 week) or were planning for pregnancy Participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone Primary outcome : Change in HbA1c from randomisation to 34 weeks’ gestation in pregnant women and to 24 weeks of conception in women planning pregnancy Finding : MILD IMPROVEMENT IN A1C WITHOUT AN INCREASE IN HYPOGLYCEMIA AND REDUCTIONS IN LGA BIRTHS, LENGTH OF STAY IN HOSPITAL AND NEONATAL HYPOGLYCEMIA

48. ROLE OF HBA1C IN GDM HbA1c is slightly lower in normal pregnancy than in the non-gravid state due to the increased turnover and decreased half-life of red blood cells Early first trimester  HbA1c levels fall Reaching a nadir in early second trimester Another critical factor influencing HbA1c levels is iron deficiency, which prolong red cell survival and increasing HbA1c Early gestational diabetes mellitus: Diagnostic strategies and clinical implications, MDPI,2021

49. Women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy As A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia A1C < 6% in 2 nd & 3 rd trimester  low risk of LGA, preterm delivery and pre- ecmlampsia ADA,2022

50. Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after blood glucose monitoring Target of < 6% is optimal during pregnancy if it can be achieved without significant hypoglycemia Due to alteration in red blood cell kinetics during pregnancy and physiological changes in glycemic parameters, A1C levels may need to be monitored more frequently than usual A1c is recommended in 1 st trimester to exclude overt diabetes ADA,2022

51. PHARMACOLOGICAL THERAPY When glycemia remains elevated after ≥1–2 weeks of lifestyle interventions, daily glucose testing should be continued and pharmacological treatment should be initiated Ultrasonography -based assessment of fetal growth may also assist in guiding the intensity of glucose control that is needed in an individual woman If the baby is growing appropriately, in particular if fetal abdominal circumference is < 75 centile , safe to postpone initiation of pharmacological treatment Nature review, 2019

52. Lifestyle changes x 2weeks Pharmacotherapy If FPG not ≤ 95 mg/dl 2hr PP not ≤ 120 mg/dl

53. INSULIN THERAPY Insulin is the primary medical treatment if the glycemic treatment goals are not achieved with lifestyle intervention within 1–2 weeks None of the currently available human insulin preparations have been demonstrated to cross the placenta Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies, and neither has been shown to be superior to the other during pregnancy Human insulin and insulin analogues (for example, insulin aspart , insulin lispro and insulin detemir ) have been formally tested and are considered safe to use in pregnancy Main issue  discomfort, fear of needles, the cost of treatment and the risk of hypoglycaemia Nature review, 2019

54. Insulin Regimens for GDM Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectrum May 2016, 29 (2) 92-97; DOI: 10.2337/diaspect.29.2.92

55. CHOICE OF INSULIN Human insulin is the least immunogenic of the commercially available preparations. Rapid-acting insulin analogs ( lispro , aspart , glulisine ) are comparable in immunogenicity to human regular insulin But only lispro & aspart have been investigated in pregnancy 62 Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectrum May 2016, 29 (2) 92-97; DOI: 10.2337/diaspect.29.2.92

56. NPH INSULIN IN PREGNANCY There are good data supporting the safety and effectiveness of NPH in pregnancy, and doses can be adjusted frequently and quickly in response to changing requirements in pregnant women Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectrum May 2016, 29 (2) 92-97; DOI: 10.2337/diaspect.29.2.92

57. LONG ACTING INSULIN IN GDM Long-acting insulin analogs have not been studied extensively in pregnancy. In 2012, a multinational trial 1 on the safety and efficacy of insulin detemir for the treatment of women with T1DM reported reassuring safety & efficacy results, which led the FDA to reclassify insulin detemir from "C" to "B”. Detemir is preferred over glargine because it has been studied more extensively in pregnancy & can be dosed twice per day more predictably than glargine 1. Mathiesen ER, Hod M, Ivanisevic M, Garcia SD, Brøndsted L, Jovanovič L, Damm P, McCance DR, Detemir in Pregnancy Study Group. Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes. Diabetes care. 2012 Oct 1;35(10).

58. Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectrum May 2016, 29 (2) 92-97; DOI: 10.2337/diaspect.29.2.92

59. INSULIN REGIMEN BEST CASE RESOURCE LIMITED SETTINGS

60. INSULIN CAN BE CONTINUED Recent allowed

61. SULFONYLUREA Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia Concentrations of glyburide in umbilical cord plasma are approximately 50–70% of maternal levels Glyburide was associated with a higher rate of neonatal hypoglycemia, macrosomia , and increased neonatal abdominal circumference than insulin or metformin in meta-analyses and systematic reviews Glyburide was as effective as insulin in achieving glycemic control Insulin and/or metformin treatment is therefore considered superior to glyburide ADA,2022

62. Total 461 patients Meta- anylysis , include 18 RCT’s Objective : To evaluate the efficacy and safety of oral antidiabetic drugs (OADs) for gestational diabetes melitus Finding : No significant difference in maternal FBG or HbA1c levels in patients treated with insulin, metformin , and glyburide : Metformin  Lower maternal weight gain, increased premature birth (Compared to insulin) : Glyburide  Higher neonatal birth weight, increased incidence of neonatal hypoglycemia, increased incidence of macrosomia JCEM,2015

63. METFORMIN FDA pregnancy category B Initial dose : 500mg OD/BD ; max dose – 2500mg/day Associated with lesser risk of neonatal hypoglycemia and maternal weight gain ( compare to sulfonylurea) However, it crosses the placenta in high amounts Metformin in umbilical artery= 200% of maternal blood . Barbour LA et al. Metformin for GDM: progeny, perspective and a personalized approach. Diabetes Care 2019:45:396-99

64. METFORMIN PROS LESS WEIGHT GAIN LESS NEONATAL HYPOGLYCAEMIA NO INCREASED RISK OF CONGENITAL ANOMALIES IN FETUS OR ADDITIONAL RISK IN MOTHER CONS DOES CROSS PLACENTA-LONG TERM EFFECT ON OFF SPRING UNKNOWN NEARLY HALF WILL NEED ADDITIONAL INSULIN ANYWAY MORE CHANCES OF PRETERM BIRTH?

65. Offspring of women with GDM randomized to metformin or insulin treatment during pregnancy have similar total and abdominal body fat percent and metabolic measures at 7–9 years of age. The 9-years-old offspring of women randomized to metformin were larger than those whose mothers had been randomized to insulin Possible explanation is metformin exposure resulted in smaller newborns with postnatal growth acceleration that leads to ↑ BMI, WHR and fat mass in childhood MiG TOFU study March 2018

66. MANAGEMENT OF GDM IN PERIPARTUM PERIOD

67. TIMING OF DELIVERY Well-controlled Expectant management until 39th week Reaasure antenatal testing Expectant management after 40 weeks is not recommended Diabetic complications : Deliver between 36w0d to 38w6d ACOG, 2018

68. MANAGEMENT HYPERGLYCEMIA DURING LABOUR Latent phase of labor  Metabolic demands are stable & hepatic glucose supply is sufficient Active phase labor  I ncreased metabolic demand and decreased insulin requirement  H epatic glucose supply is depleted so calorie supplementation is required  S upplementation is mostly in the form of intravenous glucose After delivery once the placenta is extracted  insulin resistance rapidly comes down  sudden drop in insulin requirement  close monitoring During breast-feeding blood glucose levels fall because of high metabolic demand and women need to take extra calories to maintain the levels Peripartum management of diabetes, IJEM,2017

69. INTRAPARTUM TARGETS FOR GLUCOSE Target blood glucose between 70 and 110 mg/dl during labor (ACOG) Target is same irrespective of whether the women has type 1 diabetes, type 2DM or GDM Some studies recommend an upper target of 100 mg/dl[10] to minimize the risk of neonatal hypoglycemia A maternal blood glucose > 180 mg/dl  associated with high risk of neonatal hypoglycemia Peripartum management of diabetes, IJEM,2017

70. Peripartum management of diabetes, IJEM,2017

71. MONITORING OF BLOOD SUGARS DURING INTRAPARTUM PERIOD Patients with GDM controlled only on life-style modification  Monitoring once in every 4-6 h is sufficient during labor Patients on insulin  Monitor the blood sugar every 1-2 hourly In all cases the blood sugars should be maintained between 80 and 110 mg/dl . Peripartum management of diabetes, IJEM,2017

72. POSTPARTUM CARE Insulin resistance decreases dramatically immediately postpartum, and insulin requirements need to be evaluated and adjusted Roughly half the prepregnancy requirements for the initial few days postpartum A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential Screen women with a recent history of GDM at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test ADA,2022

73. Women with a history of gestational diabetes mellitus found to have prediabetes should receive lifestyle interventions and/or metformin to prevent diabetes. Women with a history of gestational diabetes mellitus should have lifelong screening for the development of type 2 diabetes or prediabetes every 1–3 year Women with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations in next pregnancy ADA,2022

74. ACOG, 2018

75. OTHER MONITORING FETAL SURVELIENCE MORE FREQUENTLY TO LOOK FOR ANY STIGMATA BP MONITORING WEIGHT MONITORING FUNDUS(RETINA) IF DIABETES DIAGNOSED IN FIRST TRIMESTER SCREENING URINE FOR MICROALBUMIN FOR DIABETES DIAGNOSED IN FIRST TRIMESTER