Screening and Management for Gestational Diabetes Mellitus (GDM)

State Health Society and Department of Public Health and Preventive Medicine Screening and Management for Gestational Diabetes Mellitus Operational Guidelines Gestational Diabetes Mellitus (GDM) is diabetes detected for the first time during pregnancy. It is also defined as carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy. GDM is associated with a significant increase in stillbirths, macrosomia related morbidity, neonatal hypoglycemia, hypocalcaemia and renal vein thrombosis. Moreover due to the large babies associated with GDM, caesarean section rates are also increased and may lead to operative and anaesthetic morbidity and occasional mortality. India in general and Tamil Nadu in particular is fast developing into a high prevalence area for diabetes. In the Indian context, screening is essential in all pregnant women as the Indian women have 11 fold increased risk of developing glucose intolerance during pregnancy compared to Western women. The incidence of GDM was found to be 16.55% in 2004. In the recent field study performed under the Diabetes in Pregnancy – Awareness and Prevention project, the prevalence of GDM was 17.8% in the urban, 13.8% in the semi urban and 9.9% in the rural areas. GDM was previously thought to be not a problem at all. But now the incidence is expected to increase to 20% (i.e.) one in every 5th pregnant women is likely to have GDM. With average annual births of 11 lakhs in Tamil Nadu about 1.5- 2.0 lakh pregnant mothers are estimated to have GDM. If the blood sugar level is not appropriately managed, apart from the complications of GDM, the mother and her offspring are at increased risk of developing diabetes in the future. Thus two generations are at risk of developing diabetes. Hence, there is an urgent need to screen all mothers for GDM early enough to detect and initiate appropriate treatment to prevent and minimize its effects on the mother and the child. Now facilities are available to detect and manage GDM in all Government Institutions including the Primary Health Centres. Hence it is proposed to take up 3 Gestational Diabetes Control Programme for improving the health of the mother and the child. Screening all pregnant women for gestational diabetes and taking care of them is the first step in the primordial / primary prevention of diabetes mellitus. The whole aim is to take care of pregnant women in the community. Hence the diagnostic test has to be simple and easy to perform without disturbing the routine life of the pregnant women. WHEN TO SCREEN? The ideal time to screen for GDM would be by 12-16 weeks or at the first visit to the antenatal (AN) clinic. If she is found normal in the first visit, the next screening is to be done between 24 and 28 weeks of gestation and later at 32-34 weeks. The schedule for screening is as follows: GDM – SCREENING SCHEDULE Screening Week of pregnancy I Screening Ideally 12 – 16 weeks or at the time of first visit for AN Checkup II Screening 24 – 28 weeks III Screening 32 – 34 weeks HOW TO SCREEN AND INTERPRET THE RESULTS? Glucose Challenge Test (GCT) (WHO Criteria) . The woman should be given 75 gm of glucose in 300 ml of water irrespective of the time of her last meal and whether she is fasting or not. (The glucose water can be taken slowly over 5 minutes time to avoid nausea and vomiting) . Her venous blood is drawn after 2 hours of drinking of glucose solution and tested for Plasma Glucose. . She is considered normal if the blood sugar at 2 hour post glucose load is <140mg/dl . If the 2-hour post glucose load is >140mg/dl, then she is considered as GDM. . Those women who tested normal in GCT at 12 – 16 weeks should undergo repeat GCT at 24 – 28 weeks and if found normal again, GCT to be repeated between 32 and 34 weeks. GDM MANAGEMENT In the management of GDM, the aim is to maintain two hour post prandial plasma glucose (PPPG) level in the range of 110 – 120 mg/dl. Since the screening and diagnosis of GDM is based on two hour plasma glucose level, for monitoring the control of blood sugar level, the same time point of two hour post meal is recommended. Note: Estimation of fasting plasma glucose is not recommended in the guidelines as fasting plasma glucose will not exceed 90 mgs/dl if 2 hour post meal glucose is less than 120 mg/dl. I. Meal Plan (Medical Nutrition Therapy)  Initiation of Medical Nutrition Therapy All pregnant women who test positive for the first time after GCT (i.e: women with post glucose blood sugar level of ≥ 140 mg) should be started on meal plan for 2 weeks. As a part of the medical nutrition therapy, pregnant diabetic women are advised to wisely distribute their calorie consumption especially the breakfast. This implies splitting the usual breakfast into two equal halves and consuming the portions with a two hour gap in between. By this the undue peak in plasma glucose levels after ingestion of the total quantity of breakfast at one time is avoided. For e.g. If 4 idlis / chapatti / slices of bread (applies to all types of breakfast menu) is taken for breakfast at 8.00 a.m. and two hours plasma glucose at 10.00 a.m. is 140mg/dl; the same quantity divided into two equal portions i.e., one portion at 8.00 a.m. and remaining after 10 a.m., the two hours post prandial plasma glucose at 10.00 a.m. falls by 20-30 mg/dl. 5  The principles of Meal Plan is to : 1. Avoid sugar, sweets, fruit juices and tubers like potatoes, tapioca, beet roots, sweet potato etc., 2. Avoid fasting and feasting 3. Eat to her appetite 4. Eat more of green leafy vegetables After 15 days of Meal Plan, 2 hours Post Prandial (meal) Plasma Glucose (PPPG) is to be repeated  If PPPG is <120 mg/dl, she is under control by meal plan. Continue the meal plan and repeat 2 hours PPPG once in four weeks till delivery, provided every time the values are normal. II. Insulin Schedule:  If blood sugar is not controlled by Meal plan, initiate Insulin therapy based on 2hr PPPG after breakfast.  If 2hr PPPG is >120 mg/dl, advise intermediate acting insulin (eg: Insulatard – 4 units 30 minutes before breakfast).  Repeat 2hr PPPG after two weeks. If the plasma glucose is within normal limits, continue the same dose of insulin.  If the values are higher, then increase the dose by 2 to 4 units i.e., 6 to 8 units 30 minutes before breakfast. 6  Repeat the test every 15 days, and titrate the dose to achieve the 2 hr PPPG between 110-120mg/dl (at a single point of time the dosage should not be increased by more than 2-4 units: the dosage should be adjusted once in 15 days only after testing two hour PPPG).  If the insulin dose exceeds 16 units per day, (expecting that the woman may require 20 units), split dose of insulin is recommended. i.e., 12 units in the morning and 8 units in the night and to monitor every 15 days. At the PHC Level: If insulin requirement exceeds 20 units per day refer to CEmONC Centres. Monitoring the control: Control of blood sugar should be assessed by 2hr PPPG every 15 days till delivery. (If required, the frequency of monitoring may be increased). POSTPARTUM TESTING FOR MOTHERS WITH GDM Women diagnosed with GDM in pregnancy should undergo 75 gm Oral Glucose Tolerance Test (OGTT) to determine their glycemic status, ideally between 6 – 12 weeks postpartum. If normal, the OGTT has to be repeated at six months and thereafter every year after delivery. NORMAL VALUES FOR POSTPARTUM–75 gm GLUCOSE TOLERANCE TEST Investigation Normal Fasting plasma glucose (FPG) <100mg/dl 2-hour 75 gm glucose (PPPG) <140mg/dl OPERATIONALISATION OF THE PROGRAMME: 1. The MOs of PHCs, Govt. Hospitals and Medical College Hospitals should ensure that the equipment is functional, chemicals and disposables are available and trained personnel are present. 7 2. All pregnant women who come for AN check up for the first time irrespective of duration of pregnancy should be screened for GDM. 3. The VHNs in PHCs and Health staff of other institutions should make sure that all pregnant mothers undergo the screening test as per the schedule. 4. The field staff of PHCs should periodically visit all those mothers on treatment for GDM in their area and ensure that they follow the advice on meal plan and treatment schedule. 5. The VHNs of PHCs should also make sure that PN blood sugar check up is done 6 – 12 weeks after delivery for all the mothers who were diagnosed as GDM. 6. MO in-charge of antenatal clinics should make sure that periodic visits by the GDM mothers are done as per schedule and there are no drop outs. 7. In case GDM mothers are moving out of the area, detailed report on the management plan for continuing the care wherever she goes. Reporting: Every month the GDM report should be submitted by the lab technician to PHC Medical Officer in the enclosed format (Annexure I) Similarly, every month, the GDM reported collected from all PHCs with in the Health Unit Districts should be consolidated at the HUD level and sent to the Directorate of Public Health & Preventive Medicine in the enclosed format (Annexure II). In the same way reports from DMS and DME side to be sent to concerned directorates. The soft copy of the report should be sent to the official email id created for the GDM programme.