Gestational Diabetes Mellitus (GDM) is defined as any glucose intolerance with the onset or first recognition during pregnancy. This definition helps for diagnosis of unrecognized pre-existing Diabetes also. Hyperglycemia in pregnancy is associated with adverse maternal and prenatal outcome. It is important to screen, diagnose and treat Hyperglycemia in pregnancy to prevent an adverse outcome. There is no international consensus regarding timing of screening method and the optimal cut-off points for diagnosis and intervention of GDM. DIPSI recommends non-fasting Oral Glucose Tolerance Test (OGTT) with 75g of glucose with a cut-off of ≥ 140 mg/dl after 2-hours, whereas WHO (1999) recommends a fasting OGTT after 75g glucose with a cut-off plasma glucose of ≥ 140 mg/dl after 2-hour. The recommendations by ADA/IADPSG for screening women at risk of diabetes is as follows, for first and subsequent trimester at 24-28 weeks a criteria of diagnosis of GDM is made by 75 g OGTT and fasting 5.1mmol/l, 1 hour 10.0mmol/l, 2 hour 8.5mmol/l by universal glucose tolerance testing. Critics of these criteria state that it causes over diagnosis of GDM and unnecessary interventions, the controversy however continues. The ACOG still prefer a 2 step procedure, GCT with 50g glucose non-fasting if value > 7.8mmol/l followed by 3-hour OGTT for confirmation of diagnosis. In conclusion based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study as mild degree of dysglycemia are associated with adverse outcome and high prevalence of Type II DM to have international consensus It recommends IADPSG criteria, though controversy exists. The IADPSG criteria is the only outcome based criteria, it has the ability to diagnose and treat GDM earlier, thereby reducing the fetal and maternal complications associated with GDM. This one step method has an advantage of simplicity in execution, more patient friendly, accurate in diagnosis and close to international consensus. Keeping in the mind the diversity and variability of Indian population, judging international criteria may not be conclusive, thus further comparative studies are required on different diagnostic criteria in relation to adverse pregnancy outcomes

1. DR ALKA MUKHERJEE
NAGPUR M.S. INDIA
SCREENING FOR GESTATIONAL DIABETES

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. WHY SCREENING IS REQUIRED FOR
GESTATIONAL DIABETES?
• India today is recognized as the Diabetic capital of the
world.
• The prevalence of GDM in India varies from 9.9% in rural
population to 17.8% in urban areas.
• Women of Asian origin and especially Ethnic Indians, are at a
higher risk of developing GDM and subsequent type 2
diabetes.
• Lifestyle of today's urban population has made them more
prone to lifestyle diseases like Obesity, PCOD and
Gestational Diabetes.

4. • As per the recent data, obesity is present in
• 30%, Mumbai,
• 50%, Delhi,
• 27% Chennai and
• 20% of women of Kerala respectively.
• Keeping all these facts in mind, there is no doubt that
universal screening, instead of selective, is ideal for our
population.

5. WHAT CAN BE THE RISK FACTORS FOR
GESTATIONAL DIABETES?
• In India, being a high prevalence area "universal screening at
earliest” is recommended.
• At the same time we need to triage the ones who are even
at more risk.
• Periodontal disease and low maternal birth weight and high
consumption of sugar sweetened colas are recently
published associations.

6. a) Overweight,
b) Moderate to severe obesity,
c) Prior gestational diabetes,
d) Prior macrosomic infant,
e) Greater maternal age,
f) Multiple gestation,
g) South east asians,
h) Hispanic, PCOD,
i) Parent or sibling with diabetes
Risk factors for Gestational Diabetes are

7. • Women with GDM have an increased incidence of hypertensive
disorders during pregnancy, including gestational hypertension, pre-
eclampsia, and eclampsia.
• increase risk of polyhydramnios that may increase the risk of preterm
labor.
• Excessive fetal growth
• Consequences of excessive fetal growth include birth trauma, maternal
morbidity from cesarean deliveries, shoulder dystocia, and neonatal
hypoglycemia.
• hyperbilirubinemia, hypocalcemia, erythema, and respiratory distress
syndrome.
• Long-term complications of GDM include diabetes and cardiovascular
disease in the mothers, obesity and diabetes in the offspring.
• Congenital anomalies do not occur at an increased rate in patients with
gestational diabetes, as GDM usually occurs at the late second trimester
when embryogenesis is completed.
What are the health risks of gestational
diabetes?

8. WHEN SHOULD AN INDIAN WOMAN SCREENED FOR
GESTATIONAL DIABETES MELLITUS?
• Insulin is detectable in fetal pancreas as early as 9 weeks
after conception.
• An increase in pancreatic beta cell mass and insulin secretion
in the fetus occurs by the 16th week of gestation, in
response to maternal hyperglycemia.
• The priming of fetal beta cells may account for the
persistence of fetal hyperinsulinemia throughout pregnancy
and the risk of accelerated fetal growth
• This necessitates performing the test procedures to diagnose
GDM in the first trimester itself.

9. WHICH TEST AND HOW OFTEN SHOULD WE
SCREEN?
• The controversy concerning optimal strategy still continues
for the detection and diagnosis of GDM.
• DIPSI (Diabetes in pregnancy study group in India) has
endorsed the WHO criteria and recommended universal
screening at
• first contact and
• again at 24 to 28 weeks
• using a 2 hour 75 g OGTT with a threshold plasma glucose
concentration of greater than 140 mg/dL at 2 hours

10. IADPSG criteria
• For IADPSG criteria an OGTT is done in the fasting
state using 75 g of glucose at 24-28 weeks and GDM
diagnosed if any one of the following cut-off is met
i.e.
• Fasting ≥ 92 mg/dl (≥ 5.2 mmol/l) or
• 1-hour ≥ 180 mg/dl (≥ 10 mmol/l) or
• 2-hour ≥ 153mg/dl (≥ 8.5 mmol/l)

11. RATIONALE FOR NONFASTING STATUS OGTT
• Adequate and brisk insulin response in normal women
maintains euglycemia state despite glucose challenge where
as women with GDM have an increase in glycemic levels
with glucose challenge due to impaired insulin secretion.

12. ADVANTAGES
• A single test procedure to screen and diagnose
gestational diabetes mellitus in the community
• Least disturbances to routine activity and economical
• The pregnant women need not be fasting
• It requires only a single sample (compared to three with
IADPSG and four with the Carpenter and Coustan criteria)
• There is clarity of labelling the different magnitude of
abnormal glucose intolerance in pregnancy and outside
pregnancy.

13. DISADVANTAGES
• Nonfasting OGTT has been shown to have low sensitivity in
two studies done by Mohan et al.4 and Vijayalakshmi et al.
They concluded that DIPSI non fasting OGTT criteria cannot
be recommended for diagnosis of GDM due to low
sensitivity
• Venous plasma glucose values also depend on the timing of
the day when it was done. Lee et al.6 and Goldberg et al., in
their study observed that glucose tolerance decreases in the
afternoon and evening as detected by glucose tolerance
tests and give rise to false positive results which will lead to
unnecessary diet control, insulin therapy, regular follow-up
and anxiety

14. • Pulkit et al. found that diagnosis of GDM by DIPSI leave
22.36% undiagnosed cases which can easily be detected
using IADPSG criteria and concluded that IADPSG criteria is
better for screening GDM than DIPSI as it missed substantial
number of patients.

15. WHAT IS THE INTERNATIONAL ACCEPTANCE
FOR SCREENING?
• IADPSG is the outcome based screening test and adapted by
many professional bodies.
• For the IADPSG criteria, an OGTT is done in the fasting state
using 75 g of glucose at 24-28 weeks, and GDM is diagnosed
if any one of the following cut-points is met,
• i.e., fasting >92 mg/dL, or
• 1 hour >180 mg/dL or
• 2 hour >153 mg/dL.

16. WHAT IS THE IMPROVEMENT IN MATERNAL AND
NEONATAL OUTCOME WITH EARLY DIAGNOSIS AND
TREATMENT OF MILD HYPERGLYCEMIA?
• To clarify the adverse outcomes associated with degrees of
maternal glucose intolerance less severe than overt diabetes
mellitus HAPO study was done. It studied both primary and
secondary outcomes

17. PRIMARY OUTCOMES
• Birth weight above the 90th percentile for gestational age
• Primary cesarean delivery
• Clinical neonatal hypoglycemia
• Cord-blood serum C-peptide level above the 90th percentile
(fetal hyperinsulinemia).

18. SECONDARY OUTCOMES
• Premature delivery (before 37 weeks of gestation)
• Shoulder dystocia or birth injury.
• Need for intensive neonatal care Hyperbilirubinemia
Preeclampsia.
• The data showed associations between increasing levels of
fasting, 1-hour, and 2-hour plasma glucose obtained on oral
glucose-tolerance testing and birth weight above the 90th
percentile and cord blood serum C-peptide level above the
90th percentile,

19. • With weaker associations between glucose levels and
primary cesarean delivery and clinical neonatal
hypoglycemia.
• It also found positive associations between increasing
plasma glucose levels and each of the five secondary
outcomes examined:
1. Premature delivery,
2. Shoulder dystocia or birth injury,
3. Intensive neonatal care,
4. Hyperbilirubinemia, and
5. Pre eclampsia.

20. CONCLUSION
• Indian population is diverse and variable.
• We must do screening at first contact and again at 24-28
weeks using a 2 hour 75 g OGTT with a threshold plasma
glucose concentration of greater than 140 mg/dL at 2 hours.
• In order to obtain international standardization, we
recommend, wherever possible, a single test.

21. Thanks