Universal screening for gestational diabetes by DIPSI test by Dr.Preksha

pilot study, gestational diabetes mellitus, screening by post glucose blood sugar DIPSI test fetal and maternal outcome

1. UNIVERSAL SCREENING OF ANTENATAL WOMEN FOR GESTATIONAL DIABETES MELLITUS AND THEIR FETOMATERNAL OUTCOMES Dr. Preksha Jain, Junior resident Dr. Sunita Ghike , Professor Dept. of ObGy , Nkp salve institute of Medical Sciences

2. Motherhood is a joy of living life once again

3. DEFINITION Gestational diabetes mellitus (GDM) is carbohydrate intolerance with recognition or onset first time during pregnancy, irrespective of the treatment with diet or insulin.

4. One of major causes of complications during pregnancy Good glycemic control-improves perinatal outcome

5. IMPORTANCE OF GDM 2 GENERATIONS AT RISK TYPE 2 DM CHILDHOOD OBESITY TYPE 2 DM

6. In the Indian context, there is 11 fold increased risk of developing glucose intolerance during pregnancy compared to Caucasian women . 16.55% prevalence of GDM Urban 17.8% Rural 9.91%.

7. EFFECT ON PREGNANCY Insulin resistance : Production of placental HPL. Increased production of cortisol, estriol , progesterone . Increased insulin destruction by kidney and placenta. Increased lipolysis : F or her caloric needs and saves glucose for fetal needs. Changes in gluconeogenesis : F etus uses preferentially alanine and other amino acids and deprives the mother of a major gluconeogenic source.

8. Hormonal events during early Pregnancy Early pregnancy Estrogen Progesterone Pancreatic B-cell hyperplasia Insulin secretion Peripheral utilization of glucose Maternal FBS Hepatic glucose production Glycogen storage

9. Hormonal events during mid pregnancy Mid-trimester pregnancy HPL Cortisol Prolactin Progesterone Estrogen Insulin resistance in peripheral tissues

10. COMPLICATIONS NICU admission

11. SCREENING Selective & Universal Selective screening approach will miss a proportion of GDM, 30 %. 45% unscreened.

12. Various screening tests Blood tests Fasting blood glucose (FBG) test DIPSI 75gm glucose Glycosylated hemoglobin

13. AIMS & OBJECTIVES The objective is to estimate PGBS in antenatal women and follow up them till delivery for fetomaternal outcomes . To screen for GDM & GGI as early as possible. Determine f etomaternal outcome.

14. MATERIAL & METHODS STUDY DESIGN : Prospective Longitudinal Observational Time bound hospital based study . DURATION: 07 months. SETTINGS: Dept. of ObGy , NKP Salve Institute Of Medical Sciences Nagpur STUDY POPULATION: Women attending antenatal OPD. SAMPLE SIZE : 400 SELECTION: Consecutive Institutional Ethical committee permission

15. INCLUSION CRITERIA: Singleton pregnancies . Patients willing to comply . Patients willing to deliver at LMH EXCLUSION CRITERIA : Multiple pregnancies . History of previous GDM . Patients not willing for any intervention . Patients not willing to deliver at LMH

16. Demographic data, Medical, Obstetric & Surgical history, antepartum, intra partum & postpartum data was collected. Analysis was done regarding number of patients with GDM & GGI, distribution according to age, parity & their fetomaternal outcomes . Statistical evaluation was done.

17. OUTCOME MEASURES MATERNAL Age Parity Preeclampsia/PIH Polyhydramnios BOH Mode of delivery FETAL Preterm IUGR Baby weight NICU Admissions Respiratory distress Perinatal mortality

18. METHODOLOGY Detailed history, consent, examination done DIPSI TEST was done 75gm of glucose dissolved in 200ml of water, consumed over period of 15min (regardless of day or time of last meal) Venous blood samples taken at 2hrs.

19. DIPSI CRITERIA PLASMA GLUCOSE IN PREGNANCY <120 gm /dl Normal 120-139 gm /dl Gestational glucose Intolerance 140-199 gm /dl Gestational Diabetes Mellitus >200 gm /dl Overt diabetes

20. OBSERVATION & RESULTS

21. TOTAL PATIENTS SCREENED & DISTRIBUTION ACCORDING TO INTOLERANCE GGI GDM OVERT 54(13.5%) 37(9.25%) 6(1.5%) TOTAL SCREENED TOTAL NORMAL DERANGED PGBS 400 303 97(24.25%) 13.5% patients had normal PGBS in early trimester but later diagnosed with GDM by repeat screening .

22. AGE DISTRIBUTION TABLE AGE GGI GDM OVERT <19 8% 8.3% 0% 20-25 13.52% 8.6% 0% 26-30 12% 10.93% 2.3% >31 31% 12.5% 6.25% Advancing age was associated with increasing trend of GGI & GDM

23. Distribution by gravidity Prevalence of glucose intolerance increased with gravidity

24. Gestational Age GGI GDM OVERT <24wk 6.1% 2.06% 24-32 11.34% 8.24% 1.03% >32 41.23% 27.80% 5.10% Increased incidence was noted in third trimester because maximum patients presented in third trimester

25. Maternal Complications NORMAL GDM+GGI PIH 14% 18.55% POLY 2.3% 3% CPD 0.3% 2.06% PROM 2.6% 5.1% BOH 20.46% 24.74%

26. Fetal Complications

27. Fetal Complications NORMAL GDM+GGI RESP DISTRESS 7.9% 9.2% PRETERM 2.3% 3% IUGR 5.9% 6.1% NICU 4.9% 6% PERINATAL MORTALITY 1.05% 1.09% CONG ANOMALY 0.3% 1.03% MOST COMMAN COMPLICATION FOUND TO BE RESPIRATORY DISTRESS

28. HbA1c HbA1c% GDM & GGI < 5.7 4.10% 5.7-6.1 1% >6.1 8.20% MAXIMUM PATIENTS WITH GDM HAD HbA1c MORE THAN 6.1%

29. MODE OF DELIVERY NORMAL GDM+GGI NVD 21.10% 19.5% LSCS 32% 44.5% INSTRUMENTAL 1.9% 1.3% S&E 0.6% 1.03% INCIDENCE OF CESAREAN SECTION WAS MAXIMUM AMONG GDM PATIENTS

30. MANAGEMENT MODALITY GDM & GGI DIET 91.7% DIET & INSULIN 8.3%

31. SUMMARY Out of 400 antenatal women, 54 had GGI (13.5%) 37 had GDM (9.25 %) according to screening by DIPSI Prevalence rate of GDM was 9.25% which was significant Advancing age was associated with increasing trend of GGI & GDM

32. Pregnancy complications noted in the present study in patients with GDM were -- PIH in 18.55%,Poly in 3%, PROM in 5%, CPD in 2.06% Operative deliveries were found more in GDM patients 44.5% Fetal complications noted were 9.2% of neonates had respiratory distress, 6% had NICU admissions Perinatal mortality rate 1.09% were high in GDM patients 8.3% patients managed by insulin & diet

33. ROLE OF OBSTETRICIAN PRIMARY PREVENTION: Obesity, PCOS- lifestyle modification SECONDARY PREVENTION: GDM screening & care TERTIARY PREVENTION: Future long term complication

34. Obstetrician Diabetologist Dietician Pediatrician & Patient

35. TAKE HOME MESSAGE GDM continues to be an important obstetrical condition with significant feto maternal morbidity. This study thus recommends screening of all antenatal women for GGI & GDM as early as possible & proper management to ameliorate morbidity & mortality associated with it.