What are the recommendation of DIPSI(Diabetes Intervention Pregancy Study Group of India)

	:JAPI - DIPSI Guidelines
Gestational Diabetes Mellitus – Guidelines*
Q.1 . What do we mean by the word DIPSI?  Ans:- DIPSI GDM Guidelines Committee Q. 2: What is the recommendation of Study Group formed in 2002:-?? Ans:-DIPSI recommends 2hr PPBS after 75 Glucose -(to be taken in empty stomach-if woman concerned comes to OPD your clinic after breakfast or say at afternoon/ evening session then one should not perform DIPSI  on   that day because the primary recommendation of The Diabetes In Pregnancy Study group India (DIPSI)” is to carry out the evaluation after ingestion of 75 Gm of glucose after a fasting state. .Diabetes Prevention  as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oral   glucose load and at 2 hrs a venous blood sample is collected for estimating plasma glucose. This one step procedure of challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible. Q.3;When to screen?? Screening is recommended between 24 and 28 weeks of gestation and the diagnostic criteria of ADA (American Diabetic Association)  are applicable. But, DIPSI members retrievated that a  team approach is ideal for managing women with GDM. The team would usually comprise an obstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician. Summary of the DIPSI:-What we the obstetricians must know:- Take home message from the “The Diabetes In Pregnancy Study group India (DIPSI)”of 2002  headed by V Seshiah, AK Das, Balaji V, Shashank R Joshi, MN Parikh, Sunil Gupta For Diabetes In Pregnancy Study Group (DIPSI)+:- - (President : Diabetes In Pregnancy Study group India) Chairman : Prof V Seshiah reporting practice guidelines for GDM in the Indian environment. Due to high prevalence, screening is essential for all Indian pregnant women. V Seshiah, AK Das, Balaji V, Shashank R Joshi, MN Parikh, Sunil Gupta For Diabetes In Pregnancy Study Group (DIPSI)+ DIPSI means “The Diabetes In Pregnancy Study group India (DIPSI)”- is A) Implementation of DIPSI is  like intelligent  investment in  few basic stapes followed in preg can prevent  Obesity, IGT and Diabetes in the offspring can fairly be prevented by a  short term intensive care  in pregnancy gives a long term pay off in the primary prevention of as the preventive medicine starts before birth.     B) DIPSI recommends screening is essential for all Indian pregnant women.      C)  The team would usually comprise an obstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician.        D) DIPSI recommends 2hr PPBS after 75 Glucose anhydrous (to be taken in empty stomach)  that as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oral   glucose load and at 2 hrs a venous blood sample    E) ”Intensive monitoring by , diet and insulin are the corner stone of GDM management G) They , at that time 2002 expressed doubts and concerns on the efficacy of  oral agents or analogues.  At that time d(during the study period( 2002) use of ODA(oral Aantidiabetics ) use in GDM was controversial though their use now slowly being established .But still many aged Obstet & Diabetologists are hesitant feels that efficacy of oral agents are controversial. DIPSI Recommended Method As a pregnant woman walks into the antenatal clinician the fasting state, she has to be given a 75 g oral glucose load and at 2 hrs a venous blood sample is collected for estimating plasma glucose. This one step procedure of challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible.6 DIAGNOSTIC CRITERIA  ADA:- What’s wrong with ADA method?? American Diabetes Association (ADA) recommends two step procedures for screening and diagnosis of diabetes and that too in selective (high risk) population. Compared with selective screening, universal screening for GDM detects more cases and improves maternal and neonatal prognosis. Depending on the risk of the women developing diabetes and not on the fetal outcome.  American Diabetes Association (Carpenter and Couston) recommends 3 hour 100 gm OGTT and Gestational Diabetes Mellitus is diagnosed if any 2 values meet or exceed FPG > 95 mg/dl, 1 hr PG > 180 mg/ dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140 mg/dl. This criteria was originally validated against the future  risk of these women developing diabetes and not on the fetal outcome. Carpenter himself now recommends a 2 hour OGTT with 75 gm glucose. The reason for this is that “when a glucose tolerance test is administered to non-pregnant individuals, it is standard to use the 75-g,2-hour OGTT. Using a different glucose challenge in pregnant versus non-pregnant patients leads to  confusion in the laboratory and may result in errors in applying the proper diagnostic criteria. Further, the 75-g, 2-hour OGTT is in use during pregnancy in many countries around the world, typically using the same thresholds as in non-pregnant individuals”. B) WHO:-the World Health Organisation To standardize the diagnosis of GDM, the World Health Organisation (WHO) proposed using a 2 hour 75 gm  OGTT with a threshold plasma glucose concentration of greater than 140 mg/dl at 2 hour, similar to that of IGT, outside pregnancy. Still all these recommendations (ADA and WHO) have not projected the influence of the glycemic level on fetal outcome. They 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. The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists.  It’s like share / Mutual Fund in Share / Obesity, IGT and Diabetes in the offspring can fairly be prevented by a short term intensive care in pregnancy gives a long term pay off in the primary prevention of as the preventive medicine starts before birth.
INTRODUCTION
The maternal metabolic adaptation is to maintain the mean fasting plasma glucose of 74.5 ± 11 mg/dl and  the post prandial peak of 108.7 ± 16.9mg/dl. This fine tuning of glycemic level during pregnancy is possible due to the compensatory hyperinsulinaemia, as the normal pregnancy is characterized by insulin resistance. A pregnant woman who is not able to increase her insulin secretion to overcome the insulin resistance that occurs even during normal pregnancy develops gestational diabetes.
The metabolic goals of pregnancy are 1) in early pregnancy to develop anabolic stores to meet metabolic demands in late pregnancy and 2) in late pregnancy to provide fuels for fetal growth and energy needs. -
Gestational Diabetes Mellitus (GDM) is defined as   ‘carbohydrate intolerance with recognition or onset during pregnancy’, irrespective of the treatment with diet or insulin. The importance of GDM is that two generation   is at risk of developing diabetes in the future. Women   with a history of GDM are at increased risk of future   diabetes, predominately type 2 diabetes, as are their children.
GDM occurs when the woman’s beta cell function is notable to overcome the antagonism created by the anti-insulin   hormones of pregnancy and the increased fuel consumption   required to provide for the growing fetomaternal unit
How to screen?? Methodology of screening for  GDM.
The controversy concerning optimal strategy still continues for the detection and diagnosis of GDM.. 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 Caucasianwomen.4 The recent data on the prevalence of GDM in  our country was 16.55% by WHO criteria of 2 hr PG =140 mg/dl.5 As such Universal screening during pregnancy has become important in our country. For this we need a simple procedure which is economical and feasible.
DIPSI Recommended Method
As a pregnant woman walks into the antenatal clinic  in the fasting state, she has to be given a 75g oral glucose load and at 2 hrs a venous blood sample is collected for          estimating plasma glucose. This one step procedure of      challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible.
DIAGNOSTIC CRITERIA FOR  GDM.
American Diabetes Association (Carpenter and Couston) recommends 3 hour 100 gm OGTT and Gestational Diabetes Mellitus is diagnosed if any 2values meet or exceed FPG > 95 mg/dl, 1 hr PG > 180mg/dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140 mg/dl.  This criteria was originally validated against the future   risk of these women developing diabetes and not on the  fetal outcome. Carpenter himself now recommends a 2 hour OGTT with 75 gm glucose. The reason for this is that “when a glucose tolerance test is administered to  non-pregnant individuals, it is standard to use the 75-g,2-hour OGTT. Using a different glucose challenge in  pregnant versus non-pregnant patients leads to  confusion in the laboratory and may result in errors in    applying the proper diagnostic criteria. Further, the 75-g, 2-hour OGTT is in use during pregnancy in many countries around the world, typically using the same thresholds as in non-pregnant individuals”.7 To  standardize the diagnosis of GDM, the World Health  Organisation (WHO) proposed using a 2 hour 75 gm  OGTT with a threshold plasma glucose concentration of greater than 140 mg/dl at 2 hour, similar to that of  IGT, outside pregnancy.8 Still all these recommendations(ADA and WHO) have not projected the influence of the     glycemic level on fetal outcome.
Clarity in Labeling The Different Magnitude of Abnormal Glucose Intolerance on Pregnancy  GDM.
Increasing maternal carbohydrate intolerance in pregnant women without GDM is associated with a graded increase in adverse maternal and fetal outcomes implying that fetal morbidity starts at a lower maternal glycemic level (< 140 mg/dl). A number of prospective and retrospective studies have substantiated the observation that the frequency of adverse fetal outcome increases with 2hr PG > 120mg/dl and taking care of these women had resulted in a better fetal outcome.10-14Thus, the data is robust and indicates that 2 hr > 120mg/dl needs cognizance.
The term ‘Impaired Gestational Glucose Tolerance(IGGT)’ is used by few authors to indicate pregnant      women whose 2 hr PG is > 120mg/dl. It may be appropriate to use the term ‘Decreased Gestational glucose tolerance (DGGT)’ instead of impaired gestational glucose tolerance. The use of the term ‘Decreased’ is appropriate as it implies only ‘Low’ whereas the term ‘Impaired’ means both high and low. Further, quiet frequently we come across, labeling any    abnormal value in the OGTT not meeting the diagnostic criteria of GDM as IGT  The use of this term ‘IGT’ during pregnancy may be confusing, as this terminology is also being used in non pregnant adult with 2 hr PG > 140mg/dl. This level is also applied to diagnose GDM  by WHO criteria. Hence it may be prudent to label 2 hr plasma glucose value > 140 mg/dl as GDM and a 2 hr plasma glucose value > 120 mg/dl as ‘Decreased  Gestational Glucose Tolerance’ (DGGT). The term IGT  should not be used to denote any abnormal value during  pregnancy. The figures suggested below are easy to remember.
With 75 gm OGTT (WHO criteria);
In Pregnancy Outside Pregnancy 2 hr = 200 mg/dl 2 hr = 140 mg/dl 2 hr = 120 mg/dl Diabetes GDM DGGT Diabetes IGT —
Gestational Weeks at Which Screening is Recommended
Practically all the pregnant women should undergo screening for glucose intolerance. The usual    recommendation for screening is between 24 and 28weeks of gestation. The recent concept is to screen for glucose intolerance in the first trimester itself as the fetal beta cell recognizes and responds to maternal glycemic       level as early as 16th week of gestation.16 If found negative at this time, the screening test is to be performed again  around 24th – 28th week and finally around 32nd – 34thweek.
MANAGEMENT OF GDM
A team approach is ideal for managing women with GDM. The team would usually comprise an obstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician. In practice, however, the team approach is not always possible due to limited resources.
In such circumstances, management by an obstetrician and physician, with the assistance of an appropriately skilled dietitian, diabetes educator, is acceptable.
A) Patient Education The importance of educating women with GDM (and their partners) about the condition and its management cannot be overemphasized.
The compliance with the treatment plan depends on the patient’s understanding of:
• The implications of GDM for her baby and herself • The dietary and exercise recommendations • Self monitoring of blood glucose • Self administration of insulin and adjustment of   insulin doses • Identification and treatment of hypoglycemia(patient and family members) • Incorporate safe physical activity • Development of techniques to reduce stress and cope  with the denial.