DIPSI is the recommendation of Study Group formed in 2002:-??

•Treatment of GDM::  Once diagnosis is made, medical nutritional therapy (MNT) is advised initially for two weeks. If MNT  fails to achieve control i.e., FPG = 90mg/dl and/or1 ½ hr PPG = 120mg/dl, insulin may be initiated. • Once target blood glucose is achieved, woman with  GDM till the 28th week of gestation require lab monitoring of both fasting and 1 ½ hr post breakfast once a month and at other time of the day as the clinician decides.• After the 28th week of gestation, the laboratory monitoring should be more frequent at least once in2 weeks, if need be more frequently.• After 32 weeks of gestation, lab monitoring should be done once a week till delivery.• In high risk pregnancies, frequency of monitoring may be intensified with SMBG.• Continuous glucose monitoring devices are availablebut these equipments need special training and are expensive. These devices may be useful in high risk pregnancies to know the glycemic fluctuations and to plan proper insulin dosage.

Throughout the stages and phases of a diabetic woman, her health status is directly dependent on her nutritional status and her blood glucose control. As a woman ages, to prevent the increased risk of osteoporosis and cardiovascular disease of the diabetic woman, exercise and hormonal replacement therapy can minimize the ravages of diabetes per se on the aging process. Normoglycemia throughout the lifecycle of a diabetic woman results in a lifecycle of health.- Dr Lois Jovanovich

HbA1c Levels If the glucose intolerance is detected in the early  pregnancy, HbA1c level will be helpful to differentiate  between a pre gestational diabetic and GDM. If theHbA1c level is more than 6%, she is likely to be a pre GDM. HbA1c is useful in monitoring the glucose control  during pregnancy, but not for the day to day management. A1c level may serve as a prognostic value. Estimation of fructosamine during pregnancy is less frequently used.

Measuring Other Parameters The blood pressure has to be monitored during every visit. Examination of the fundus and estimation of microalbuminuria, every trimester is recommended.

e) Ultrasound Fetal Measurement : The management of gestational diabetes, based on the foetal growth by  ultrasonogram demands that the fetus at risk must first manifest overgrowth before treatment decisions are  made. Further, the cost of performing a number of ultrasonogram to monitor the foetal growth and recommending therapy has to be kept in mind. Until there is evidence to absolutely prove that ignoring maternal hyperglycemia when the fetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintain normoglycemia in every  pregnancy complicated by gestational diabetes. Until there is evidence to absolutely prove that ignoring  maternal hyperglycemia when the fetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintain normoglycemia in every pregnancy complicated by gestational diabetes

OBSTETRIC CONSIDERATIONS

Fetal Evaluation An ultrasound scan has to be performed around 18 –20 weeks of gestation focusing on structures namely the spine, skull, kidney and heart. Fetal echocardiography has to be done around 20 – 24 weeks which allows to view all the four chambers of the heart. From 26th week onwards, fetal growth and liquor volume has to be monitored every 2-3 weeks. Fetal abdominal circumference provides baseline for further serial measurements which gives growth acceleration or restriction. Fetal movements are monitored from 20 weeks onwards. Screening for chromosomal anomalies is necessary in pre GDM. Screening should be done for Down’s syndrome, alphafetoprotein for neural defects and human chorionic gonadotrophin to identify any chromosomal abnormalities (16 – 20 weeks of gestation).

The obese fetus of GDM mother is also hyperinsulinemic, thus interaction between leptin and insulin may be a link between maternal diabetes and increased adiposity in the fetus.-  GDM or severe obesity is superimposed to pregnancy, the resulting metabolic syndrome becomes detrimental for the fetus, evolving towards fetal overgrowth with increased adiposity at birth. This may be one major component for in utero programming of obesity later in life.-

Timing of Delivery Sudden intrauterine fetal demise in the third trimester of diabetic pregnancy is not uncommon. To avoid this risk, preterm delivery is recommended. But with this, respiratory distress syndrome (RDS) is likely to occur. Administering steroids for lung maturity or ß adreno receptor agonist to inhibit premature uterine contractions are likely to induce adverse metabolic effects due to their  glycolytic, glycogenolytic and lipolytic effects. In this situation, extra insulin may be required to maintain euglycemia. Foetal demise can also occur due to   preeclampsia, which can produce fetal hypoxia via decreased uteroplacental perfusion. Some centres allow women with uncomplicated diabetes to go into spontaneous labor irrespective of the gestational age, but most still advocate delivery at 38 weeks as perinatal mortality and morbidity appear to increase after this time. Induction at 38 weeks gestation may be slow or unsuccessful due to unfavourable conditions of the cervix but this has to be balanced against the poorly defined and predictable risk of late intra uterine death, if pregnancy is allowed to continue more than 38 weeks. Fetal health may deteriorate suddenly, hence obstetric management should not be rigid and each case needs individual care and attention. Having a neonatologist support at the time of delivery is advisable.

Intra Partum Management

• If labor is to be induced in GDM, the usual evening insulin dose should be taken the night before, but no subcutaneous insulin is given the following morning when induction begins. • Once labor begins, insulin is not necessary. • In a gestational diabetic the requirement of insulin is likely to fall precipitously and no insulin may be required immediately after expulsion of placenta.

DELIVERY

A pediatrician experienced in resuscitation of ‘the newborn should be present whether delivery is vaginal or by caesarean section. As soon as the infant is born, the following actions are mandatory:

• early clamping of the cord, i.e. within 20 seconds of delivery, to avoid erythrocytosis; • evaluate vital signs; Apgar scores at 1 and 5 minutes; • clear oropharynx and nose of mucus; later empty the stomach - be aware that stimulation of the  pharynx with the catheter may lead to reflex bradycardia and apnea; • avoid heat loss, keep neonate warm, transfer to incubator pre-warmed to 34oC; • perform a preliminary physical examination to detect major congenital malformations; • monitor heart and respiratory rates, colour, and motor behaviour for at least the first 24 hours afterbirth; • start early feeding, preferably breast milk, at 4-6hours after delivery: aim at full caloric intake (125kcal/kg/24 hours) at 5 days, divided into six to eight  feeds a day; • promote early infant-parent relationship (bonding).

The neonate is usually best cared for, in a specialized neonatal unit. Interference with the infant should be minimal. The neonate should be observed closely after delivery for respiratory distress. Capillary blood glucose should be monitored at 1 hour of age and before the first four breast feedings (and for up to 24 hours in high- risk neonates). Amperometric blood glucose meters are acceptable for use in neonates, provided that suitable  quality-control procedures and operator training are in  place. The cut-off of 44mg% (2.6 mmol/l) is now currently used as the working definition for hypoglycemia. This “Operational threshold” is not a diagnosis of a disease but an indication for action.26 If the baby is obviously macrosomic, calcium and magnesium levels should be checked on day 2. Breastfeeding, as always, should be encouraged in women with GDM.

Both maternal pregravid obesity and GDM are significant risk factors for obesity in the offspring of the woman withed both at birth and at the time of long term follow up.-

GDM may be viewed as: 1.An unidentified preexisting disease, or 2.The unmasking of a compensated metabolic abnormality by the added stress of pregnancy, or 3.A direct consequence of the altered maternal metabolism stemming from the changing hormonal milieu.

Gestational diabetic women require follow up. Glucose tolerance test with 75g oral glucose is performed after 6 weeks of delivery and if necessary repeated after6 months and every year to determine whether the glucose tolerance has returned to normal or progressed. A small proportion of gestational diabetic women may continue to have glucose intolerance.

Prevention of adverse maternal and perinatal outcomes in GDM are based in achieving maternal blood glucose as close to normal as possible. Precise glycemic thresholds remain undetermined. Prepregnancy BMI, duration and severity of maternal hyperglycemia during pregnancy, are most important predictors of the progression to abnormal glucose tolerance/diabetes in the follow up.-

GDM recurs approximately in 50% of subsequent pregnancies. The future risk of developing diabetes for a gestational diabetic is twofold, if she becomes overweight. But maintaining ideal weight approximately halves the risk. The requirement of insulin in addition to diet to maintain euglycemic during the index pregnancy is also predictive of future diabetes.

The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists. A short term intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in the offspring, as the preventive medicine starts before birth.