Gestational Diabetes Mellitus (GDM): A Silent Threat In Pregnancy

Gestational Diabetes Mellitus has become one of the major concerns in India which can lead to poor outcome in pregnancy and increases the risk to both mother and new-born baby. The term GDM should now be limited to hyperglycaemia discovered during normal prenatal testing (usually between 24 and 28 weeks) that does not fulfil the criteria for overt diabetes, according to recent consensus¹. Therefore, many diagnostic criteria and glucose cut off values have been proposed by different organizations and professional bodies to diagnose GDM.

It is owing to a defect in pancreatic β cell function that occurs both during and after pregnancy, indicating a state of chronic cell dysfunction rather than the simple development of relative insulin deficiency in the face of increasing insulin resistance during pregnancy. This implies that GDM is a stage in the progression of type 2 diabetes mellitus (T2DM) in women. Moreover, women with a history of GDM, as well as their offspring, are at an elevated risk of future diabetes, primarily type 2 diabetes, resulting in transgenerational risk transmission^2,3.

Prevalence of GDM in India:

Prevalence of GDM is higher in Asian countries than western and European countries. Many patients in India remain undiagnosed with T2DM which leads to further complication during pregnancy. The prevalence of GDM in India has varied significantly and presently between 5 to 8 million women are affected by GDM ⁴. Moreover, the age greater than 35 years was found to be a risk factor for GDM.

Risk factors in GDM⁵

Several risk factors are associated with GDM including

1. Late pregnancy (more than 35 years old)
2. Pre-pregnancy obesity orexcess weight gain during pregnancy
3. Pregnancy state (Lower insulin response to oral glucose)
4. Polycystic Ovary Syndrome
5. Family history of type 2 diabetes mellitus
6. GDM in earlier pregnancy
7. Sedentary and unhealthy lifestyle
8. Hypertension in pregnancy

Complications to mother and foetus⁵

Maternal Risks:

Abortion, Polyhydramnios, Pre-eclampsia, Prolonged labour, Obstructed labour, Caesarean section, Uterine atony, Postpartum haemorrhage, Infection

Foetal Risks:

Spontaneous abortion, Intra-uterine death, Stillbirth, Congenital malformation, Shoulder dystocia, Birth injuries, Neonatal hypoglycaemia, Infant respiratory distress syndrome

Screening of GDM:

Screening for GDM is usually done at 24-28 weeks of gestation because insulin resistance increases during the second trimester and glucose levels rise in women who do not have the ability to produce enough insulin to adopt this resistance.⁶In 2014, Government of India has released a “National Guidelines on Diagnosis and Management of Gestational Diabetes Mellitus” which clearly states that GDM test is mandatory at the first antenatal visit. Oral glucose tolerance test (OGTT) is the diagnostic test of choice recommended by WHO. This test is usually administered at the first antenatal visit and between 24 and 28 weeks of gestation. The threshold of 2-hour blood glucose level ≥140 mg/dL (more than or equal to 140) is consider as the cut off value for diagnosis of GDM as per the guidelines.

The following flowchart need to consider

Different healthcare professionals including ASHA (Accredited Social Health Activist) & ANMs (Auxiliary Nurse Midwife) are actively involved in connecting pregnant women in the rural areas for community health facilities and therefore they are playing a crucial role in detection & follow up of GDM cases. Hence, testing of GDM for all pregnant women should be an integral part of existing antenatal care.

Therefore, GDM can be considered as the mother of non-communicable diseases, so focus is much needed on the foetus for the future.⁷

References:

1. Diagnosis and management of Gestational Diabetes Mellitus Technical and Operational Guidelines (Maternal Health Division, Ministry of Health and Family Welfare of India) https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCH_MH_Guidelines/Gestational-Diabetes-Mellitus.pdf
2. Buchanan TA, Xiang A, Kjos SL, Watanabe R. What is gestational diabetes? Diabetes Care 2007;30 Suppl 2:S105‑11.
3. Ferrara A. Increasing prevalence of gestational diabetes mellitus: apublic health perspective. Diabetes Care 2007;30 Suppl 2:S141‑6.
4. Thanawala, U.; Divakar, H.; Jain, R.; Agarwal, M.M. Negotiating Gestational Diabetes Mellitus in India: A National Approach. Medicina 2021, 57, 942.
5. Buchanan, T. A., Xiang, A. H., & Page, K. A. (2012). Gestational diabetes mellitus: risks and management during and after pregnancy. Nature reviews. Endocrinology, 8(11), 639–649.
6. Rani, P. R., & Begum, J. (2016). Screening and Diagnosis of Gestational Diabetes Mellitus, Where Do We Stand. Journal of clinical and diagnostic research: JCDR, 10(4), QE01–QE4.
7. Jaipuriar et al., Vol 17 Gestational Diabetes Endocrinology Committee of FOGSI 2021.

Dr. Anuradha Palnitkar MBBS,MD, DGO Palnitkar Hospital, Bhagyanagar, Aurangabad.