Gestational Diabetes Mellitus(GDM) or Hyperglycemia in Pregnancy(HIP)
Gestational Diabetes is high blood glucose that develops throughout maternity and frequently disappears once giving birth. … It happens if your body cannot turn out enough IInsulina hormone that helps manage blood glucose levels – to fulfill the additional wants in Pregnancy.
GDM(Gestational Diabetes Mellitus), the leading cause of Diabetes in Pregnancy, affected about 21 million live births.
One in 7 births is affected by Gestational Diabetes Mellitus. The proportion of women with GDM is 85.1%. The balance of women with Diabetes first detected in Pregnancy is around 14% in India and 3-7% in Europe. The proportion of women with Diabetes seen before Pregnancy is 7.5 %
Symptoms Of Gestational Diabetes
Most women with Gestational Diabetes have no symptoms, though a few may experience
- Sugar in urine (revealed in a test done in your doctor’s office)
- Unusual thirst.
- Frequent urination.
- Fatigue.
- Nausea.
- Frequent vaginal, bladder, and skin infections.
- Blurred vision.
Risk Factors of Gestational Diabetes
- You have a higher risk of gestational diabetes if you’ve crossed 25 age
- Your risk of developing gestational diabetes increases if you have prediabetes — slightly elevated blood sugar
- You’re also more likely to develop gestational Ddiabetesif you had it during a previous pregnancy, if you delivered a baby who weighed more than 9 pounds (4.1 kilograms) or if you had an unexplained stillbirth
- You’re more likely to develop gestational Ddiabetesif you’re significantly overweight
- a family history of type 2 diabetes
Treatment Of Gestational Diabetes
- Choose foods high in fiber and low in fat and calories. Focus on fruits, vegetables, and whole grains.
- If you plan to get pregnant, losing extra weight beforehand may help you have a healthier pregnancy.
- Testing your blood glucose levels at home at specific times or after meals will be recommended to determine if your glucose levels are within acceptable limits.
- Regular exercise or Yoga can also contribute to tight glucose control.
- alcohol can lead to serious lifelong health problems for your baby
Diagnosis of GDM with 2-h PG ≥ 7.8 mmol/dl and treatment is worthwhile with a decreased macrosomia rate, fewer emergency cesarean sections, and severe perinatal morbidity, and may also improve the women’s health-related quality of life. Furthermore, the advantage of this “single test
procedure” is that pregnant women do not need to fast.
b. It causes the slightest disturbance in a pregnant woman’s routine activities.
c. It serves as screening and diagnostic procedures (universal testing is possible).
d. Laboratory glucose measurement is often unavailable, and testing with a portable plasma glucose standardized meter is the only option.
e. RCT shows the benefit of treating GDM women, identified primarily by post-load PPG values.
f.There is no high-quality evidence that women and their fetuses benefit from treatment if only the fasting value is abnormal.
g. Fasting glucose measurement is insufficient for detecting GDM, particularly in the non-Caucasian population.
Given the above, the DIPSI single test procedure may be most appropriate for screening during the COVID pandemic.
Metabolic Management during Pregnancy
MNT requires the guidelines to maintain maternal plasma glucose in the normal range, and OHA or IInsulin should be recommended whenever necessary for improved perinatal outcomes.
The goal is to maintain fasting plasma glucose (FPG) ~ 90 mg/dl (5.0 mmol/dl) and 2-h postprandial plasma glucose ~120 mg/dl (6.7 mmol/dl) in GDM patients to avoid perinatal complications. Managing GDM is like primary prevention of the disease for the next generation, as it helps to
decrease the incidence of type 2 DM in the generations to come
Drug management (metformin or insulin therapy) & Metformin or insulin therapy is the accepted medical management of pregnant women with GDM not controlled on MNT. Insulin is the first drug of choice. & IInsulincan is started during Pregnancy for GDM if MNT fails.
& If a pregnant woman is not willing for insulin, Metformin can be recommended provided gestational
The Week is more than 12 weeks. The starting dose of Metformin is 500 mg twice daily orally up to a
maximum of 2 g/day. If the woman’s blood sugar is not controlled with the total quantity of Metformin
(2 g/ day) and MNT, there is no other option but to advise insulin
& Hypoglycemia and weight gain with Metformin are less in comparison with insulin
GDM study in Uttar Pradesh with national health mission.
OGTT is performed in pregnant women by measuring the plasma glucose after 2 hours of fasting or non-fasting after ingesting 75 grams of glucose (Monohydrate Dextrose Anhydrous). The Indian Guidelines (DIPSI Test) are simple for diagnosing gestational diabetes (GDM). They can be done quickly in low-resource settings, where many pregnant women visit for ANC check-ups. A single value of ≥140 mg/dl is diagnostic for Gestational Diabetes Mellitus.
The severity of GDM increases because the action of IInsulinis diminished (insulin resistance) due to raised hormone secretion by the placenta. Other risk factors for GDM are being elderly, increased BMI or obesity, weight gain in pregnancy, history of Diabetes in the family, stillbirth, or a congenital abnormality in previous deliveries.
GDM has previously been considered transient during Pregnancy and resolved after Pregnancy, but pregnant women with hyperglycemia are at higher risk of developing GDM in subsequent pregnancies. About half of the women with a history of GDM will develop type II diabetes within five to ten years after delivery.
DIPSI’s simple testing protocol is endorsed by the National Health Mission (GOI) Guideline on GDM and supported by the FIGO guideline on HIP for use in South Asia. Sri Lanka, Pakistan, and Bangladesh have followed this regional testing protocol.
In India, Tamil Nadu and Uttar Pradesh launched a Universal GDM Program in 2007 and 2016, covering all pregnancies by testing and managing GDM with MNT, Metformin, and Insulin in most healthcare facilities. Around 28,000 ANM have been given glucometers, strips, and 75 gm packets of glucose to implement the most extensive GDM program in Uttar Pradesh, India.
OGTT is performed in pregnant women by measuring plasma glucose after 2 hours of fasting or non-fasting after ingesting 75 grams of glucose (Monohydrate Dextrose Anhydrous). Indian guidelines are simple and can be used quickly to diagnose gestational diabetes (GDM) in low-resource settings, where many pregnant women visit for ANC check-ups.
The severity of GDM increases because the action of IInsulinis diminished (insulin resistance) due to raised hormone secretion by the placenta. Other risk factors for GDM are being elderly, increased BMI or obesity, weight gain in pregnancy, history of Diabetes in the family, stillbirth, or a congenital abnormality in previous deliveries.
GDM previously used to be transient during Pregnancy and resolved after Pregnancy. Still, pregnant women with hyperglycemia are at higher risk of developing GDM in subsequent pregnancies. About half of the women with a history of GDM will develop type II diabetes within five to ten years after delivery.
GDM women have a lifetime risk for type II diabetes and obesity and adverse outcomes for women and fetuses. The most common shared features are hypertension and LGA significant for gestation age (macrosomia). Tight blood sugar control during all trimesters can reduce adverse outcomes in the mother and fetus. All the women who have diabetes before conception need counseling, antenatal care, and good management of hyperglycemia, including. Postpartum care for good outcomes.
Management of GDM
NHM Govt of India Guidelines, Management of GDM
National Health Mission, Ministry of Health & Family Welfare, Govt of India released GDM Guidelines and Management in which MNT is the mainstay of the Treatment once GDM is Diagnosed for two weeks, and after that, if Blood Sugar Post Prandial failed to reach <120 mg/dl, Metformin can be initiated after 20 weeks of Pregnancy. Insulin can be added if the patient cannot achieve the target with or without Metformin.
Management of GDM, Guidelines 2018( NHM 2018 Guidelines, GOI)
Medical Management (Oral Anti-diabetic Drug-Metformin and Insulin Therapy)
- Metformin or Insulin therapy is the accepted medical management of pregnant women with GDM not controlled on MNT. Insulin is the first drug of choice, and Metformin can be considered after 20 weeks of gestation for the medical management of GDM.
- Insulin can be started at any time during Pregnancy for GDM management. If pregnant women with GDM before 20 weeks, and Medical Nutrition Therapy (MNT) fails, IInsulinshould be started.
- Metformin can be started at 20 weeks of Pregnancy if MNT has failed to control the woman’s blood sugar. Suppose the woman’s blood sugar is uncontrolled with the maximum dose of Metformin (2 gm/ day) and MNT; insulin is to be added. Metformin is 500 mg twice daily orally up to a maximum of 2 gm/day.
- Hypoglycemia and weight gain with Metformin are less in comparison to insulin.
- If insulin is required in high doses, Metformin may be added to the treatment.
- At PHC, MO should initiate treatment & refer pregnant women with GDM to a higher center if blood sugar levels are not controlled or other complications.
A trained dietician should frame a personalized diet plan to provide the necessary healthy nutrition for the increased demand of the mother and fetus. Lifestyle modification is the most critical intervention for GDM control and can control around 70-80% of all pregnant women with GDM.
In Pregnant women, especially those with T1DM and pre-existing type ll diabetes, ADA advocates for the use of IInsulinhowever, changing the physiological demand in Pregnancy may require more monitoring and titration of IInsulinand should frequently be self-monitored by the women.
In the 1st trimester: Generally, IInsulincontinues in DIP, but GDM rarely requires insulin Type 2 diabetes. T1DM may experience Hypoglycemia. Therefore, insulin titration may be needed more frequently in this group.
In the 2nd trimester: Insulin requirement increases in the second trimester because of an increase of anti-insulin hormones & Placental lactogen, which is increased bi-weekly or twice a week to achieve glycaemic goals. Generally, 50% insulin is given as a basal dose and 50% as a prandial dose to gain reasonable control.
Late in 3rd trimester:
Treatment with IInsulinis complex needs a referral to higher centers where a specialized team of Obstetricians, endocrinologists, and trained Dieticians is required.
Diabetes in Pregnancy is associated with a high risk of preeclampsia; hence, women with type 1 or type 2 should be prescribed a low dose aspirin 81mg/day from the first trimester until the baby is born.
In T1DM during Pregnancy, the risk of Hypoglycemia is increased many folds, and unawareness of hypos is also grown as counter-regulatory hormone disturbances occur. Therefore, patient education about hypos is crucial throughout pregnancy. After delivery during the postpartum period, placental hormones decrease, and insulin resistance drops, which may lead to hypos and may lead to diabetic ketoacidosis (DKA). DKA should also be treated immediately to prevent diabetic retinopathy.
GDM is not at high risk of diabetic retinopathy. Still, DIP or pregnant women who have Diabetes before conception are at increased risk of diabetic retinopathy. Therefore, they should be screened for diabetic retinopathy after birth, at the earliest during the first trimester, and follow-ups should be done three months in NPDR and monthly in severe NPDR.
Family planning should be addressed to all women with the HIP before conception. Tight blood sugar controls; HBAIc<6.5% to reduce risk of outcomes like anencephaly, congenital heart disease, microcephaly, and caudal regression syndrome in the fetus.
GDM, adverse outcomes include abortion, fetal malformations, preeclampsia, macrosomia, raised bilirubin, and neonatal Hypoglycemia. In the future, it increases the risk of Type II Diabetes and obesity in mothers and offspring.
All the Women & adolescents with diabetes risk during the reproductive period should be educated about the outcomes of unplanned pregnancies; Preconception counseling is a very effective method to reduce health costs and burden of complications associated with hyperglycemia in Pregnancy & offspring, family planning methods should be negotiated until the women become pregnant.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480657/
Ref: International Journal of Diabetes in Developing Countries
https://doi.org/10.1007/s13410-020-00860-1
NATURAL TREATMENT
- drinking enough water may help you keep your blood sugar levels within healthy limits.
- One study showed that exercise, Yoga, relaxation, and meditation significantly reduced stress and lowered blood sugar levels for a pregnant lady
- most ladies focus on avoiding sweet food and eating healthy; however, they forget to control their intake habits.
- Irregular eating is thought to be one of the most significant causes that trigger gestational Diabetes.
More articles on the topic can be found at:
https://www.globalnewbornsociety.org/
You publish on GDM and Infants of Diabetic Mothers IDM in Newborn Journal https://www.newbornjournal.org/journalDetails/JNB
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