Screening and Management for Gestational Diabetes Mellitus (GDM)

Operational Guidelines

State Health Society & Directorate of Public Health and Preventive Medicine, Chennai -600 006

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 5 th 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 2

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 I Screening II Screening III Screening Week of pregnancy Ideally 12 16 weeks or at the time of first visit for AN Checkup 24 28 weeks 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.

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 units 30 minutes before breakfast. to 8

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 POSTPARTUM75 gm GLUCOSE TOLERANCE TEST Investigation Fasting plasma glucose (FPG) 2-hour 75 gm glucose (PPPG) Normal <100mg/dl <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.

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. 7.

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. 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.

GESTATIONAL DIABETES SCREENING & MANAGEMENT Pregnant women first Visit 75 gm. Glucose in 300ml of water (Glucose Challenge Test GCT) 12-16 weeks 12

<140 mg/dl NORMAL

> 140mg/dl GDM

Repeat GCT at Repeat GCT at 24-28 weeks 24-28 weeks

<140 mg/dl NORMAL > 140mg/dl GDM Meal Plan

3234 weeks weeks weeks

Repeat GCT at

After 2 weeks

<140 mg/dl NORMAL

> 140mg/dl GDM PPPG <120 mg/dl Continue Meal Plan

2 hour PPPG (2hrs after food)

PPPG 120 mg/dl (Despite Meal Plan) Start on Insulin Monitor every 15 days and maintain PPPG110- 120mg/dl till delivery by suitable dose of insulin

Monitor every 15 days till delivery

PREVENTIVE MEDICINE (DIABETES) STARTS BEFORE BIRTH

Standard Operating Procedures for Glucose Challenge Test (GCT) in the Laboratory Test Procedure: 1. Take a clean and dry test tube/screw capped vial containing sodium fluoride and potassium oxalate anticoagulant.(commercially available fluoride tubes may be used) 2. Write the Name and OP number on the test tube/vial with a marker pen. 3. Following standard safety precautions collect 2 ml of blood by venepuncture. 4. Remove the needle and transfer the blood into the tube/vial containing sodium fluoride and potassium oxalate anticoagulant and mix well by gentle but thorough shaking for complete mixing. 5. Keep the sample in an upright position on the test tube rack. 6. Centrifuge the sample for 10 minutes at 1500 rpm to separate the plasma. Plasma should be separated within 1 hr of collection. 7. Switch on the semi auto analyser (at least 10 min prior to usage). The analyser has to be calibrated with standard glucose reagent (provided with the glucose test kit) 8. Prime the semi auto analyser with distilled water (2 times). 9. Bring the glucose reagent to room temperature. 10. By using a 100 l 1000 l micropipette, set the volume to 1000 l (one ml)and take 1 ml of glucose reagent in a plain, clean, separate test tube/vial(without anticoagulant). 11. By using a 10 l 100 l micropipette and micro tip, set the volume to 10 l and aspirate 10 l of plasma (wipe the micro tip with tissue paper to remove the excess plasma) and add to the glucose reagent and mix it well. 12. Keep the mixture for 10 minutes in the place provided in the semi auto analyser for incubation at 37C. 13. Select the procedure in the analyzer using the touch screen/on board panel keys and aspirate the glucose reagent-plasma mixture. 14. Read the plasma glucose level on the LCD screen and record in the register. 15. Follow the standard bio-safety and bio-waste management procedures to dispose used syringe, needle and blood. 16. Run controls in parallel with every batch of samples. 9

Lab.Materials and Equipment required for the GCT Qty/AN Mother 75 gm /pkt 2 Nos 300 ml 1

S.No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Name of the Item Glucose Powder Disposable Cups Drinking water Disposable syringe with needle ( 2 ml) Surgical spirit Tourniquet Cotton Disposable Gloves Test tube/vial with anticoagulant (sodium fluoride and potassium oxalate tube or Fluoride Tube) Plain test tube/vial Marker pen Test tube Rack Centrifuge Micro pipette 100 l 1000 l Micro pipette 10 l 100 l Micro tips 100 l 1000 l Micro tips 10 l 100 l Semiauto analyser Distilled water Colour coded bin Sodium hypochlorite Towel Soap for hand wash GDM lab Register

Purpose For challenging (oral) the AN mother to screen for GDM. Dissolve Glucose Dissolve glucose Blood Collection Blood collection Blood collection Blood collection Blood collection Blood collection-Plasma Mix plasma and glucose reagent Labeling To hold the sample tube/vial To separate plasma from blood Aspirate 1 ml(1000 l) glucose reagent Aspirate 10 l Plasma Aspirate 1 ml(1000 l) glucose reagent Aspirate 10 l Plasma To run glucose test For priming the analyser Bio waste disposal For disinfection For personal hygiene For personal hygiene For recording glucose values

1 No 1 No

1 No 1 No 5 lts/500 tests

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GDM-Frequently Asked Questions What is Glucose Challenge Test (GCT)? GCT is performed for AN mothers to diagnose the Gestational Diabetes Mellitus by estimating the Plasma Glucose Level two hours after the intake of 75 gms of glucose dissolved in 300 ml of water. Is GCT mandatory for all pregnant mothers? Yes. Universal screening of all antenatal mothers, three times during pregnancy as per the schedule is mandatory for diagnosing GDM. Screening I Screening II Screening III Screening What is the screening schedule? All the AN mothers should be screened for GCT during their 1st visit (12 16 weeks) Even if she is found to be normal, again she should be screened during 24 28 weeks Even if she is found to be normal, again she should be screened during 32 34 weeks Week of pregnancy Ideally 12 16 weeks or at the time of first visit for AN Checkup 24 28 weeks 32 34 weeks

Is there any food restriction advised for AN mothers before GCT? No. There is no diet restriction. She can undergo GCT irrespective of her previous meal status. What is the preparation for AN mother to perform GCT? The AN mother should be counseled about the screening procedure and GDM. 75 gram of glucose is dissolved in 300ml of water and it should be consumed slowly within 5 minutes time to avoid nausea and vomiting. 2 hours after consuming glucose solution, venous blood is drawn and tested for plasma glucose level. What is the plasma glucose level to diagnose GDM? The AN mother is considered normal if the plasma glucose level is <140mg If the plasma glucose level is 140 mg, then she is diagnosed as Gestational Diabetic Mellitus (GDM). 11

Annexure I GDM Reporting Format Name of the HUD : . Month:.. Year:.

Name of the PHC/Hospital :.. Antenatal mothers No. screened Screening During the Month 12-16 weeks 24-28 weeks 32-34 weeks Postpartum screening for mothers with GDM No. found with Diabetes During the Month Up to the Month On Meal plan Up to the Month No. found with GDM During the Month Up to the Month On Meal plan On treatment On insulin

Total

No. screened Screening During the Month 6 weeks 6 months 12 months Up to the Month

On treatment On insulin

Total

Signature of the Medical Officer

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Annexure II GDM Reporting Format Name of the HUD : Month:.. Year:.

Antenatal mothers No. found with GDM During the Month Up to the Month On Meal plan

No. screened Screening During the Month 12-16 weeks 24-28 weeks 32-34 weeks Up to the Month

On treatment On insulin

Total

Postpartum screening for mothers with GDM No. found with Diabetes During the Month Up to the Month On Meal plan

No. screened Screening During the Month 6 weeks 6 months 12 months Up to the Month

On treatment On insulin

Total

Signature of the Officer In-Charge

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Meal Plan for Women with Gestational Diabetes Mellitus (GDM) Meal Plan refers to good eating habits, following a regular and well-balanced diet without overeating. This is not only useful to control blood glucose levels and prevent complications in pregnant women, but it is also the principle of eating habits for a long and healthy life. Diabetes diet is not a special diet, but is rather a well-balanced diet. As like general diabetes, pregnant women diagnosed with GDM should follow certain basic principles of diet and meal plan. Once the pregnant women are detected to have elevated blood sugar, it is better to avoid all sugary, oily and certain energy dense food items. For example, adding sugar/jaggery (vellam) in the coffee/tea/milk to be avoided. Lot of greens and vegetables to be added in the diet. Breakfast: The GDM mother can have their usual breakfast. But, most importantly, they can split the quantity of breakfast by which the sharp rise in post breakfast blood sugar can be avoided i.e. 3 idlies by 8 AM and another 2 idlies by 11 AM if they feel hungry. They should avoid sugar added milk/coffee. All supplementary health drinks and fruit juices are rich in sugar and it is better to avoid them. In between Breakfast and Lunch: In between breakfast and lunch, if they feel hungry they can have butter milk, ordinary milk, lemon/tomato juice, vegetable soup without sugar. Lunch: The GDM mother can have their usual quantity of rice with sambar, rasam and butter milk with lot of greens and vegetables. They should avoid roots like potato, tapioca (Maravalli Kilangu), payasam, soft drinks and sweets in any form. Evening:

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The GDM mother can have some boiled grams (payaru) or dhal (paruppu) or two slices of wheat bread and one cup of coffee or tea without sugar. Avoid snacks, sweets, cream biscuits etc., Dinner: The GDM mother can have either 3 to 4 chapatti with vegetable side dish / sambar / dhal or similar to that of the lunch. It is better to avoid potato and coconut preparations as side dishes. Before returning to bed, she can have one cup of milk without sugar. This diet advice will give adequate calorie and nutrition not only to her but also to her growing fetus. She can eat to her appetite by avoiding certain sugary and energy dense food items.

Taking certain sugar and oil rich diet invites all sorts of complications like birth defects, big baby and complicated delivery. During pregnancy, many women are tempted to frequently take sugar rich fruit juices, honey soaked dates and certain sweets prepared in the ghee, dalda and coconut. They are not only inviting diabetes in pregnancy but also putting to risk the future generation. Anything in Excess is Not Good

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