Gestational diabetes mellitus in India

Apollo Hospitals, Chennai.
The Journal of the Association of Physicians of India 09/2004; 52:707-11.
Source: PubMed


Glucose intolerance during pregnancy predisposes the offspring for increased risk of developing glucose intolerance in the future. This vicious cycle is likely to influence and perpetuate the incidence and prevalence of glucose intolerance in any population.
No data is available about the prevalence of glucose intolerance during pregnancy in our country and hence a study was undertaken on this aspect.
This study was performed in the antenatal clinic of Government Maternity Hospital, Chennai, India. As a pregnant woman in second or third trimester checks into the antenatal clinic, she was given 50 gm oral glucose load and blood sample was collected after one hour. This test was performed on 1251 pregnant women. They were requested to come after 72 hours for the 75 gm OGTT recommended by WHO. Among the 1251 women, 891 responded. The blood sample was taken in the fasting state and at 2 hours after 75 gm of oral glucose. Diagnosis was based on the WHO criteria for gestational diabetes mellitus (GDM).
The mean age of these pregnant women was 23+/-4 years. There was a significant increase in the prevalence of GDM in relation to gravida. The effect of BMI did not quite reach statistical significance (chi2 (df=1) = 3.659, P = 0.055), but a model of linear trend was significant. Of the 1251 women who underwent the 50 gm oral glucose challenge test, 670 (53.55%) had one hour plasma glucose > or = 130 mg/dl. Among the 891 pregnant women who had 75 gms OGTT, 168 (18.9%) were diagnosed as GDM, taking both FPG > or = 126 mg/dl and/or 2 hr PPG > or = 140 mg/dl as cut-off values. Taking only 2 hr plasma glucose for analysis, 144 (16.2%) had a value > or = 140 mg/dl. A similar study was conducted in different parts of the country taking only the 2 hr 75 gm post-glucose value of > or = 140 mg/dl as diagnostic criteria for GDM. Of the total number of pregnant women (n = 3674) screened, 16.55% of them found to have GDM.
Our study has documented the increased prevalence of GDM in our population necessitating universal screening for glucose intolerance in pregnancy. Using 2 hr plasma glucose > or = 140 mg/dl as a one step procedure is simple and economical, particularly for the countries ethnically more prone to high prevalence of diabetes.

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Available from: Veeraswamy Seshiah, Dec 13, 2013
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    ABSTRACT: Hyperglycemia is one of the most common medical conditions women encounter during pregnancy. The International Diabetes Federation (IDF) estimates that one in six live births (16.8%) are to women with some form of hyperglycemia in pregnancy. While 16% of these cases may be due to diabetes in pregnancy (either preexisting diabetes type 1 or type 2 which antedates pregnancy or is first identified during testing in the index pregnancy), the majority (84%) is due to gestational diabetes mellitus (GDM). The occurrence of GDM parallels the prevalence of impaired glucose tolerance (IGT), obesity, and type 2 diabetes mellitus (T2DM) in a given population. These conditions are on the rise globally. Moreover, the age of onset of diabetes and pre-diabetes is declining while the age of childbearing is increasing. There is also an increase in the rate of overweight and obese women of reproductive age; thus, more women entering pregnancy have risk factors that make them vulnerable to hyperglycemia during pregnancy. GDM is associated with a higher incidence of maternal morbidity including cesarean deliveries, shoulder dystocia, birth trauma, hypertensive disorders of pregnancy (including preeclampsia), and subsequent development of T2DM. Perinatal and neonatal morbidities also increase; the latter include macrosomia, birth injury, hypoglycemia, polycythemia, and hyperbilirubinemia. Long-term sequelae in offspring with in utero exposure to maternal hyperglycemia may include higher risks for obesity and diabetes later in life. In most parts of low-, lower middle-, and upper middleincome countries (which contribute to over 85% of the annual global deliveries), the majority of women are either not screened or improperly screened for diabetes during pregnancy even though these countries account for 80% of the global diabetes burden as well as 90% of all cases of maternal and perinatal deaths and poor pregnancy outcomes. Given the interaction between hyperglycemia and poor pregnancy outcomes, the role of in utero imprinting in increasing the risk of diabetes and cardiometabolic disorders in the offspring of mothers with hyperglycemia in pregnancy, as well as increasing maternal vulnerability to future diabetes and cardiovascular disorders, there needs to be a greater global focus on preventing, screening, diagnosing, and managing hyperglycemia in pregnancy. The relevance of GDM as a priority for maternal health and its impact on the future burden of noncommunicable diseases is no longer in doubt, but how best to deal with the issue remains contentious as there are many gaps in knowledge on how to prevent, diagnose, and manage GDM to optimize care and outcomes. These must be addressed through future research. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to develop a document to frame the issues and suggest key actions to address the health burden posed by GDM. FIGO's objective, as outlined in this document, is: (1) to raise awareness of the links between hyperglycemia and poor maternal and fetal outcomes as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) to create a consensus document that provides guidance for testing, management, and care of women with GDM regardless of resource setting and to disseminate and encourage its use. Despite the challenge of limited high-quality evidence, the document outlines current global standards for the testing, management, and care of women with GDM and provides pragmatic recommendations, which because of their level of acceptability, feasibility, and ease of implementation, have the potential to produce significant impact. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as we ll as for research priorities to bridge the current knowledge andevidence gap. To address the issue of GDM, FIGO recommends the following: Public health focus: There should be greater international attention paid to GDM and to the links between maternal health and noncommunicable diseases on the sustainable developmental goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age must be prioritized. Universal testing: All pregnant women should be tested for hyperglycemia during pregnancy using a one-step procedure and FIGO encourages all countries and its member associations to adapt and promote strategies to ensure this. Criteria for diagnosis: The WHO criteria for diagnosis of diabetes mellitus in pregnancy [1] and the WHO and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for diagnosis of GDM [1,2] should be used when possible. Keeping in mind the resource constraints in many low-resource countries, alternate strategies described in the document should also be considered equally acceptable. Diagnosis of GDM: Diagnosis should ideally be based on laboratory results of venous serum or plasma samples that are properly collected, transported, and tested. Though plasmacalibrated handheld glucometers offer results that are less accurate and precise than those from quality-controlled laboratories, it is acceptable to use such devices for the diagnosis of glucose intolerance in pregnancy in locations where laboratory support is either unavailable or at a site remote to the point of care. Management of GDM: Management should be in accordance with available national resources and infrastructure even if the specific diagnostic and treatment protocols are not supported by high-quality evidence, as this is preferable to no care at all. Lifestyle management: Nutrition counselling and physical activity should be the primary tools in the management of GDM.Women with GDM must receive practical nutritional education and counselling that will empower them to choose the right quantity and quality of food and level of physical activity. They should be advised repeatedly during pregnancy to continue the same healthy lifestyle after delivery to reduce the risk of future obesity, T2DM, and cardiovascular diseases. Pharmacological management: If lifestyle modification alone fails to achieve glucose control, metformin, glyburide, or insulin should be considered as safe and effective treatment options for GDM. Postpartum follow-up and linkage to care: Following a pregnancy complicated by GDM, the postpartum period provides an important platform to initiate beneficial health practices for both mother and child to reduce the future burden of several noncommunicable diseases. Obstetricians should establish links with family physicians, internists, pediatricians, and other healthcare providers to support postpartum follow-up of GDM mothers and their children. A follow-up program linked to the child's vaccination and regular health check-up visits provides an opportunity for continued engagement with the high risk mother?child pair. Future research: There should be greater international research collaboration to address the knowledge gaps to better understand the links between maternal health and noncommunicable diseases. Evidence-based findings are urgently needed to provide best practice standards for testing, management, and care of women with GDM. Cost-effectiveness models must be used for countries to make the best choices for testing and management of GDM given their specific burden of disease and resources.
    Full-text · Article · Oct 2015 · International Journal of Gynecology & Obstetrics
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    • "The prevalence ranges between 1 and 14 % of all pregnancies [1]. But studies conducted in different parts of the country averages the incidence of GDM in Indian population to be 16.55% [3]. Highest frequency of GDM among Indian women necessitates early diagnosis of GDM using glucose tolerance tests between 24 and 28 week of gestational age, though reports claim that about 40 to 66% of women with GDM can be diagnosed even earlier during pregnancy [4] [5]. "
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    ABSTRACT: Early intervention and appropriate treatment in patients with GDM will help in preventing the adverse maternal and fetal outcome and protect them from long term complications. Several studies have shown the association of hyperuricemia with GDM. This study was undertaken to find out the association of elevated first trimester uric acid with development of GDM. This prospective observational study was conducted in Mahatma Gandhi Medical Collage and Research Institute, Pondicherry, India, between November 2010 and May 2012. A total of 70 pregnant women were included and parameters like age, parity, BMI, history of DM, serum uric acid at <15 weeks and at 24 to 28 weeks and one step test at 24 to 28 weeks were noted and compared. There was no significant correlation between the demographic variables and GDM, but a moderate significance noted between the family history of DM and one step test (p=0.048). Though there is a proportional increase in the serum uric acid with increase in the BMI, it was not statistically significant. A significant correlation was seen between BMI and risk of development of GDM (p= 0.001). Though there is a significant correlation between serum uric acid at <15 weeks and at 24 to 28 weeks, serum uric acid at <15 weeks of gestation is a better predictor of GGI and GDM (Pearson's correlation = 0.735). There is increase in the risk of development of GDM with increased levels of serum uric acid in the first trimester. Uric acid levels at <15 weeks of gestation is more significantly associated with risk of development of GDM than it's levels at 24 to 28 weeks of gestation.
    Full-text · Article · Dec 2014
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    • "In general, studies varied from reporting on prevalence only to reporting on prevalence, risk factors, pregnancy outcomes and interventions (data not shown). Fifteen studies reported on prevalence only (24, 25, 28–31, 34, 35, 37, 49, 53, 60, 61, 66, 67), 10 studies on prevalence and risk factors only (38, 40, 41, 46, 47, 50, 52, 54, 57, 62), 12 studies on prevalence, risk factors and pregnancy outcomes/obstetric complications (21, 25, 26, 35, 41–44, 54, 57, 62–64), and eight studies on prevalence, pregnancy outcomes/complications and some form of intervention (22, 31, 32, 38, 47, 50, 58, 59). The interventions in the latter group included diet/medical nutrition therapy only, insulin only or combined diet and insulin therapy. "
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    ABSTRACT: Background: Little is known about the burden of diabetes mellitus (DM) in pregnancy in low- and middle-income countries despite high prevalence and mortality rates being observed in these countries. Objective: To investigate the prevalence and geographical patterns of DM in pregnancy up to 1 year post-delivery in low- and middle-income countries. Search strategy: Medline, Embase, Cochrane (Central), Cinahl and CAB databases were searched with no date restrictions. Selection criteria: Articles assessing the prevalence of gestational diabetes mellitus (GDM), and types 1 and 2 DM were sought. Data collection and analysis: Articles were independently screened by at least two reviewers. Forest plots were used to present prevalence rates and linear trends calculated by linear regression where appropriate. Main results: A total of 45 articles were included. The prevalence of GDM varied. Diagnosis was made by the American Diabetes Association criteria (1.50-15.5%), the Australian Diabetes in Pregnancy Society criteria (20.8%), the Diabetes in Pregnancy Study Group India criteria (13.4%), the European Association for the Study of Diabetes criteria (1.6%), the International Association of Diabetes and Pregnancy Study Groups criteria (8.9-20.4%), the National Diabetes Data Group criteria (0.56-6.30%) and the World Health Organization criteria (0.4-24.3%). Vietnam, India and Cuba had the highest prevalence rates. Types 1 and 2 DM were less often reported. Reports of maternal mortality due to DM were not found. No geographical patterns of the prevalence of GDM could be confirmed but data from Africa is particularly limited. Conclusion: Existing published data are insufficient to build a clear picture of the burden and distribution of DM in pregnancy in low- and middle-income countries. Consensus on a common diagnostic criterion for GDM is needed. Type 1 and 2 DM in pregnancy and postpartum DM are other neglected areas.
    Full-text · Article · Jul 2014 · Global Health Action
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