International Journal of Diabetes in Developing Countries

, Volume 34, Issue 1, pp 18–23

Current practices of prevention, detection & management of gestational diabetes mellitus in Punjab

Authors

    • Department of MedicineAdesh Institute of Medical Sciences and Research
  • Arun K. Maria
    • Department of MedicineAdesh Institute of Medical Sciences and Research
  • Anurag Amaroz Singh
    • Department of MedicineAdesh Institute of Medical Sciences and Research
  • Ashwani Maheshwari
    • Department of PaediatricsAdesh Institute of Medical Sciences and Research
  • Jagjeet Singh Bahia
    • Department of MedicineAdesh Institute of Medical Sciences and Research
  • Sonia Arora
    • Kishori Ram Hospital and Diabetes Care Centre
  • Varun Gupta
    • Adesh Institute of Medical Sciences and Research
Original Article

DOI: 10.1007/s13410-013-0141-3

Cite this article as:
Gupta, V.K., Maria, A.K., Singh, A.A. et al. Int J Diabetes Dev Ctries (2014) 34: 18. doi:10.1007/s13410-013-0141-3
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Abstract

Gestational Diabetes Mellitus (GDM) is common in India with inherent challenges for prevention, detection and management. There is little data on methods adopted by consultants for prevention, detection and management of GDM in India. So studied the current practice of prevention, detection and management of GDM by physicians and obstetricians in Punjab. Consultants both obstetricians and physicians answered a structured questionnaire. 77.6 % of consultants rely on FBG for screening and diagnosis of GDM, 3.8 % rely on OGTT. 29.9 % screened all the pregnant females for GDM, 88.8 % screened pregnant females for GDM at their 1st visit, 73.9 % did risk assessment in all the pregnant females, 20.9 % screened high risk pregnant females with OGTT, Glycosylated Hemoglobin was recommended by only 10.4 % consultants, 79.2 % consultants favored insulin, 62.7 % consultants educated GDM patients for regular follow up. Implementation of recommendations and guidelines for prevention, detection, diagnosis and management of GDM is suboptimal in Punjab. There is need to sensitize and educate consultant.

Keywords

PhysiciansObstetricians

Introduction

India would be having the highest population of diabetes by 2025 [1]. Gestational diabetes mellitus (GDM) defined as carbohydrate intolerance of varying degrees of severity with onset or first recognition during pregnancy is seen in approximately 1 to 14 % of pregnancies depending on the population studied [24]. Over the coming decades worldwide, there will be 80 million reproductive age women with diabetes. Of these 20 million will live in India alone creating a potential for high rates of maternal and infant morbidity [5]. Women, with GDM, develop overt diabetes at a young age, substantially increasing their lifetime risk of developing complications from diabetes. Exposure to a diabetic environment in utero is associated with increased occurrence of impaired glucose tolerance (IGT), precursor of diabetes in the infant, independent of genetic factors [6, 7]. The “fetal origin of disease” hypothesis proposes that gestational programming may critically influence adult health and disease [8], whereby stimuli or stresses that occur at critical periods of development, permanently change structure, physiology and metabolism, predisposing individuals to disease in adult life [9]. Moreover maternal carbohydrate intolerance in pregnant women without GDM is associated with a graded increase in adverse maternal and fetal outcomes [10]. Special attention must be paid to this segment of population [11].

Though women revert to normal glucose tolerance post-partum there is risk (30 to 60 %) of developing DM later in life making them and their children an ideal group for the primary prevention of DM. Compared with selective screening, universal screening for GDM detects more cases and improves maternal and offspring prognosis [12, 13]. Selective screening recommended by American Diabetes Association [ADA] based on risk factors scored poorly in predicting GDM [14, 15]. In Indian context, screening is essential in all pregnant women as Indian women have an 11 fold increased risk of developing glucose intolerance during pregnancy compared to Caucasian women [16]. GDM diagnosis is overlooked in about 1/3rd of the women where selective rather than universal screening is performed [14]. For universal screening in most parts of the world, a WHO diagnostic criterion is followed. ‘A one step procedure with a single glycemic value’, is recommended by the Diabetes in pregnancy Study group India (DIPSI) and GDM is diagnosed if 2-h plasma glucose is ≥140 mg/dl after a 75 g oral glucose load, irrespective of fasting or non fasting state, without regard to the time of the last meal [17]. The latest Hyperglycemia and Adverse Pregnancy Outcomes [HAPO] Study: used directly the 75 g OGTT for the diagnosis of GDM [18]. Early screening for glucose intolerance and care could avoid some diabetes related complications in women with gestational diabetes [19].

Risk assessment for GDM should be undertaken at the first prenatal visit. If they are found not to have GDM at that initial screening, they should be retested between 24 and 28 weeks of gestation [20]. HbA1c is useful in monitoring the control during pregnancy but not for day-to-day management [21]. There is paucity of data regarding the practices adopted by consultants for prevention, detection and management of GDM in India, which really determines how GDM is being managed.

Material and methods

134 consultants including 56 obstetricians and 78 physicians participated in the study. A structured questionnaire of 12 questions was administered to assess their current practices adopted regarding prevention, detection and management of GDM. The results were expressed in percentages. Questions and their probable answer options are presented in the Table 1.
Table 1

Questions to assess the current practices adopted by consultants regarding prevention, detection and management of GDM

Questions

Answers

1. Detection & diagnose of GDM is done on the basis of?

FBG >126 mg%

RBG or PPG >200 mg%

OGTT 75 g

2. Screening for GDM is recommended in?

In all pregnant females

In high risk only

In some

3. Screening for GDM is done at?

1st visit

16–20 weeks

24–28 weeks

4. If 1st visit screening test is negative do you repeat screening test?

Yes

No

5. Do you do risk assessment in all pregnant females for GDM?

Yes

No

Some times

6. What risk factors do you consider for GDM?

Obesity

F/H. DM

BOH.

Sedentary

H. of GDM

7. Do you screen high risk patients with 75 g OGTT?

Yes

No

Some times

8. How frequently you suggest FBG/ RBG in a GDM patient who is on insulin treatment?

Daily

Once a week

Once in 15 days

Once a month

9. Do you get Glycosylated Hemoglobin (HbA1c) done in GDM patients?

Yes

No

10. What is your treatment of choice in a GDM female?

Insulin

Sulfonylurea

Metformin

Pioglitazone

11. Do you educate for postpartum follow up of GDM patients?

Yes

No

Some times

12. Suggested postpartum follow up is with?

FBG

RBG or PPG

OGTT

Results

77.6 % of consultants rely on FBG, 18.6 % on RBG and only 3.8 % of consultants rely on OGTT (75 g glucose WHO criteria) for detection and diagnosis of GDM. Screening for GDM was recommended in all the pregnant females by more obstetricians than physicians where as less number of obstetricians and more physicians screened only the high risk pregnant women. 88.8 % of consultants including most of the obstetricians (85.7 %) and physicians (91.0 %) preferred to screen pregnant females for GDM at their 1st visit and only 4.5 % of consultants did screening at 16–20 weeks and 6.7 % consultants did it at 24–28 weeks. If 1st screening test was negative for diagnosis of GDM only 13.4 % consultants repeated the screening test for diagnosis of GDM. 73.9 % consultants did risk assessment in all the pregnant females where as no risk assessment was done by 14.2 % consultants and risk assessment was done only some times by 11.9 % consultants. Obesity was considered as a risk factor by less number of obstetricians as compared to physicians, family history of DM by 85.8 % consultants less number of obstetricians than physicians, bad obstetrical history was thought as a major risk factor by 91.1 % obstetricians as compared to 80.8 % physicians, sedentary life style by 30.6 % consultants and history of GDM was considered as an important risk factor by 97.8 % consultants. Only 20.9 % consultants responded positively to the question of screening high risk pregnant females with OGTT where as others (67.6 %) did not recommend OGTT for screening high risk pregnant females. In pregnant females on treatment for GDM 8.9 % consultants suggested daily assessment of FBG or RBG, 28.4 % consultants suggested once a week, 62.7 % consultants suggested once in 15 days. During the treatment of a GDM patient only 10.4 % consultants regularly got Glycosylated hemoglobin (HbA1c) done. Regarding the question of choice of treatment 79.2 % consultants favored insulin, 5.9 % consultants favored sulfonylureas, 14.9 % consultants choice was metformin. 62.7 % consultants educated GDM patients for regular postpartum follow up, 87.3 % consultants suggested follow up with FBG, 8.2 % consultants by RBG and only 4.5 % consultants suggested follow up by OGTT. Detailed results are shown in the Table 2.
Table 2

Analysis of answers by consultants regarding current practices adopted for prevention, detection and management of GDM

Questions

Response % (n)

Obstetricians % (N-56)

Physicians % (N-78)

Total % (N-134)

1. Detection & diagnose of GDM is done on the basis of?

FBG >126 mg%

80.4 (45)

75.6 (59)

77.6 (104)

RBG/PPG >200 mg%

14.3 (8)

21.8 (17)

18.6 (25)

OGTT (75 g)

5.3 (3)

2.6 (2)

3.8 (5)

2. Screening for GDM is recommended in?

100 % Females

51.8 (29)

14.1 (11)

29.9 (40)

In High Risk

32.1 (18)

79.5 (62)

59.7 (80)

In some

16.1 (9)

6.4 (5)

10.4 (14)

3. Screening for GDM is done at?

1st visit

85.7 (48)

91.0 (71)

88.8 (119)

16–20 weeks

5.4 (3)

3.8 (3)

4.5 (6)

24–28 weeks

8.9 (5)

5.2 (4)

6.7 (9)

4. If 1st visit screening test is negative do you repeat screening test?

Yes

10.7 (6)

15.4 (12)

13.4 (18)

No

89.3 (50)

84.6 (66)

86.6 (116)

5. Do you do risk assessment for GDM?

Yes

67.8 (38)

78.2 (61)

73.9 (99)

No

17.9 (10)

11.5 (9)

14.2 (19)

Some times

14.3 (8)

10.3 (8)

11.9 (16)

6. What risk factors do you consider?

Obesity

23.2 (13)

43.6 (34)

35.1 (47)

F/H. DM

76.8 (43)

92.3 (72)

85.8 (115)

BOH.

91.1 (51)

80.8 (63)

85.1 (114)

Sedentary

23.2 (13)

33.9 (28)

30.6 (41)

H. of GDM

94.6 (53)

100 (78)

97.8 (131)

7. Do you screen high risk patients with OGTT?

Yes

16.1 (9)

24.4 (19)

20.9 (28)

No

71.4 (40)

65.3 (51)

67.9 (91)

Some times

12.5 (7)

10.3 (8)

19.2 (15)

8. How frequently You suggest FBG/ RBG in GDM patient on insulin?

Daily

5.4 (3)

11.5 (9)

8.9 (12)

Once a week

21.4 (12)

33.3 (26)

28.4 (38)

Once in 15 days

73.2 (41)

55.2 (43)

62.7 (84)

Once a month

00.0 (0)

00.0 (0)

00.0 (0)

9. Do you get HbA1c done in GDM patients?

Yes

7.1 (4)

12.8 (10)

10.4 (14)

No

92.9 (52)

87.2 (68)

89.6 (114)

10. What is your treatment of choice?

Insulin

80.4 (45)

78.2 (61)

79.2 (106)

Sulfonylurea

5.4 (3)

6.4 (5)

5.9 (8)

Metformin

14.2 (8)

15.4 (12)

14.9 (20)

Pioglitazone

0 (0)

0 (0)

0 (0)

11. Do you educate for follow up of GDM patients?

Yes

55.4 (31)

67.9 (53)

62.7 (84)

No

33.9 (19)

16.7 (13)

23.9 (32)

Some times

10.7 (6)

15.4 (12)

13.4 (18)

12. Suggested follow up is with?

FBG

85.7 (48)

88.5 (69)

87.3 (117)

RBG or PPG

10.7 (6)

6.4 (5)

8.2 (11)

OGTT

3.6 (2)

5.1 (4)

4.5 (6)

Discussion

There is severe paucity of data and almost no Indian data exploring attitude, preferences and practices adopted by consultants for prevention, detection, diagnosis & management of GDM patients. Inspite of the fact that fasting plasma glucose (FPG) as a screening procedure is not favored by the DIPSI and WHO for diagnosing GDM [17, 22], 77.6 % of the of consultants including 80.4 % obstetricians and 75.6 % physicians rely on FBG for screening, detection and diagnosis of GDM and only 3.8 % of consultants (5.3 % obstetricians and .6 % physicians) rely on OGTT (75 g) for detection and diagnosis of GDM. Our findings were in contrast to recommendations of ADA 2010 guidelines [23] that in absence of this degree of hyperglycemia (FBG of >126 mg% and PPG >200 mg%.), evaluation for GDM in women with average or high-risk characteristics should follow one of two approaches of one step or two step OGTT. One step WHO procedure of OGTT (75 g) is the recommended procedure for screening, diagnosis and detection of GDM [23, 24]. Results of our study suggest that very few consultants use OGTT as recommended test for screening and diagnosis of GDM.

In the United States, 96 % of obstetricians universally screen pregnant patients for diabetes [25]. In the United Kingdom, 17 % screen universally and 72 % screen if other risk factors exist [26]. The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening [27, 28]. Where as in our study only 29.9 % consultants, more obstetricians (51.8 %) than physicians (14.1 %) screened all the pregnant females for GDM and 59.7 % screened only high risk pregnant females. In Indian context, women have an 11 fold increased risk of developing glucose intolerance during pregnancy compared to Caucasian women [16]. More over compared with selective screening, universal screening for GDM detects more cases and improves maternal and offspring prognosis [13]. Hence, universal screening during pregnancy has become important in India because universal screening appears to be the most reliable and desired method for the detection of GDM [29] particularly in those populations with high risk for GDM [16, 30].

Most of the obstetricians (85.7 %) and physicians (91.0 %) screened pregnant females for GDM at their 1st visit, but only 5.4 % obstetricians, 3.8 % physicians did screening at 16–20 weeks and 8.9 % obstetricians and 5.2 % physicians did it at 24–28 weeks. Screening pregnant females at their 1st visit by most of the consultants is in accordance with the observation that women diagnosed to have GDM in the early weeks of pregnancy represent a higher risk of sub group and should be promptly identified and managed as pre-GDM. 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 [31]. But at the same time, pregnancy induces a state of progressive glucose intolerance as gestation advances. Hence women with normal glucose tolerance in the first visit require repeat screening in subsequent visits around 24th–28th week and finally around 32nd–34th week. But in our study only 13.4 % consultants (10.7 % obstetricians & 15.4 % physicians) repeated screening test again when it was found to be negative at the first visit, which again shows neglect of recommendations for repeat screening test if previous was found to be negative.

ADA 2010 [23] recommends risk assessment be undertaken in all the pregnant females at first prenatal visit but 73.9 % consultants did risk assessment in all the pregnant females. Contrary to recommendation of screening pregnant females for GDM with OGTT (75 g), only 20.9 % consultants (16.1 % obstetricians & 24.4 % physicians) screening high risk pregnant females with OGTT signifying suboptimal implementation of recommendations regarding appropriate test for screening pregnant females for GDM.

ADA 2010 guidelines [23] recommends self-monitoring of blood glucose (SMBG) should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy but in our study 8.9 % consultants suggested only once daily assessment of blood glucose levels, while 28.4 % suggested once a week and 62.7 % consultants suggested once in 15 days in GDM patients on insulin.

During the treatment of a GDM patient, glycosylated hemoglobin (HbA1c) was recommended by only 10.4 % consultants (7.1 % obstetricians & 12.8 % physicians) to monitor the control of GDM. HbA1c estimation is useful in pre-gestational diabetes to know the retrospective blood glucose control at the time of conception if performed in the early first trimester. It is also useful in monitoring the control during pregnancy but not for day-to-day management [21]. In our study consultants sub optimally used this investigation to detect pre gestational diabetes and monitor control of GDM during the treatment. Currently, oral hypoglycemic agents are not routinely recommended during pregnancy though emerging data on glibenclamide and metformin is interesting [32, 33]. But currently agents other than insulin are not advisable. In our study most of the consultants (79.2 %) favored insulin rightly implementing the guidelines, whereas 5.9 % consultants favored sulfonylureas, 14.9 % consultants choice was metformin and pioglitazone was not favored by any of the consultants.

Guidelines [23, 24] recommend that gestational diabetic women require follow up and OGTT with 75 g oral glucose is performed after 6 weeks of delivery and if necessary repeated after 6 months and every year to determine whether the glucose tolerance has returned to normal or progressed. In our study in accordance with the recommendations, 62.7 % consultants (55.4 % obstetricians & 67.9 % physicians) educated GDM patients for regular follow up but only 4.5 % consultants (3.6 % obstetricians & 5.1 % physicians) suggested follow up by OGTT (75 g) rest 87.3 % consultants (85.7 % obstetricians & 88.5 % physicians) suggested follow up with FBG and 8.2 % consultants (10.7 % obstetricians & 6.4 % physicians) with RBG. This aspect of postnatal follow up of GDM patients is also not in accordance with the recommendations of follow up with OGTT.

Limitations

There are limitations to our study. Our sample size was relatively small and only local area consultants were involved in the study to access the current practices adopted by the consultants which may not reflect the practices else where. We did not identify barriers to adherence of guidelines and recommendations, which may account for suboptimal implementation of current clinical practice guidelines and recommendations. These include physician-related barriers such as a lack of guideline awareness, lack of familiarity with the guideline, disagreement with the guideline, or inability to judge or trust the quality of the guideline development process and the quality of the recommendations. So we suggest that to overcome these limitations as larger study should be undertaken to study current practices adopted by the consultants and simultaneously to explore the barriers to adherence to the guidelines and recommendations.

In conclusion, implementation of recommendations and guidelines for prevention, detection, diagnosis and management of GDM is suboptimal in Punjab. There is need to sensitize and educate consultant.

Conflicts of interest

None

Copyright information

© Research Society for Study of Diabetes in India 2013