Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with the onset or first recognition during pregnancy with/without remission after the end of pregnancy.1
The prevalence of diabetes mellitus (DM) is increasing worldwide and more in developing countries including India. The increasing prevalence in developing countries is related to increasing urbanization, decreasing levels of physical activity, changes in dietary patterns, and increasing prevalence of obesity.2–4 Diabetes is a major public health problem in India with prevalence rates reported to be between 4.6% and 14% in urban areas, and 1.7% to 13.2% in rural areas. India has an estimated 62 million people with Type 2 diabetes mellitus; this number is expected to go up to 79.4 million by 2025.5 Management of diabetes and its complications imposes a huge economic burden on the society; hence, effective strategies are urgently needed to control this epidemic. Not surprisingly, in parallel with the increase in diabetes prevalence, there seems to be an increasing prevalence of GDM, that is, diabetes diagnosed during pregnancy.
The International Diabetes Federation (IDF) estimates that as of 2015, 16.2% of women with live births had some form of hyperglycemia in pregnancy, 85% of which were due to gestational diabetes.6 Prevalence of GDM varies widely among racial and ethnic groups. Prevalence is higher in Blacks, Latino, Native Americans, and Asian women than in White women. There is a notable difference in the prevalence of GDM, with the South East Asia Region having the highest prevalence (87.6%) of all the low- and middle-income countries (LMICs), where access to care is often limited. Asian women are more prone to develop GDM than European women and Indian women have 11-fold increased risk of developing glucose intolerance in pregnancy compared to Caucasian women.7 Studies done in the 1980's have shown that the prevalence of GDM in India was 2%,8 which subsequently increased to 16.55% in 2000.4
The true prevalence of GDM remains variable due to variation in screening and diagnostic tests as well as due to ethnicity, which affects the prevalence rate without any bias.
Prevalence of GDM worldwide ranges from 1% to 14%;9 while in India, it is between 3.8% and 21% in different regions of the country;10 depending upon the geographical location, genetic makeup and method of diagnostic test used for screening.
Karnataka accounts for 10.2%, Tamil Nadu has 16.5%,11 Andhra Pradesh has 12% and Kerala has 17%;12 while central India like Madhya Pradesh has 3% rate and Kashmir has prevalence of 3.8%.13 However, Haryana,14 Uttar Pradesh15 and western Rajasthan16 have 7.1%, 9.7%, and 6.6% of prevalence according to the random studies. In more recent studies, using different criteria, prevalence rates as high as 35% from Punjab17 and 41% from Lucknow have been reported (Fig. 1.1).18 The geographical differences in prevalence have been attributed to differences in age and/or socioeconomic status of pregnant women in these regions. It is estimated that about 4 million women are affected by GDM in India, at any given time point.19
There is increasing trend of GDM nowadays due to changes in lifestyle, food habits, and reduced physical activity. Obesity has accelerated the onset of GDM in predisposed population. Earlier diabetes was considered as a disease of rich; but due to rapid urbanization, it is increasing in rural population also.
The prevalence of gestational diabetes is increasing globally and number of women with this condition is projected to rise from 171 million in 2000 to 366 million in 2030.
India is expected to have 79.4 million in 2030 that will account for 15.1% increase from 31.7 million in 2000 (Fig. 1.2).12
Gestational diabetes mellitus contributes to about 90% of diabetes complicating pregnancy.20 GDM imposes risks for both mother and fetus, some of which continues throughout the life of mother and child. Immediate maternal complications include preeclampsia, need for cesarean sections, and poly-/oligohydramnios.21 Complications in the baby include hyperinsulinemia, macrosomia, shoulder dystocia, neonatal hypoglycemia, and respiratory distress syndrome. Women with GDM are at an increased risk of GDM in future pregnancies and also at a higher risk of developing Type 2 diabetes in the future.22 GDM also increases the risk of obesity and glucose intolerance in the offspring.23 GDM is therefore an important public health issue that has major repercussions for both mother and offspring. Detection of GDM thus provides a window of opportunity to intervene and reduce adverse perinatal outcomes.24
There are various risk factors, which predispose a woman to develop GDM. Identification of those risk factors is important:
- Higher parity
- Advanced maternal age
- Family history of Type 2 DM: Family history is significant because some genetic factors transmit from generation-to-generation among families. GDM in first-degree relative increases risk of GDM in patient. Managing diabetes is important not only to improve the maternal outcome but also avert diabetic risk across generations. Children born to diabetic mother have impaired glucose intolerance and have metabolic complication; and in long-term, they have tendency to develop diabetes mellitus, obesity, and hypertension. Hence to decrease the prevalence of GDM, prevention of diabetes in mother is of paramount importance.
- History of big baby: Due to lack of proper antenatal screening and lack of antenatal care (ANC) checkup, 60% of GDM is missed, but history suggestive of macrosomia in previous pregnancy raises the suspicion of GDM in present pregnancy.
- Caucasians/non-white race: Due to genetic variation in different population, Caucasians have high-risk of genes for insulin resistance.
- History of perinatal loss: Diabetes increases risk of sudden fetal demise, hence history of perinatal loss suggests that patient is high risk for developing GDM in this pregnancy.
- History of GDM
- Obesity/overweight/body mass index (BMI) more than 25 kg/m2: Obesity accounts for 50% development of GDM. Lack of physical activity and exercise and also changes in diet eventually leads to obesity and hence increases risk of GDM. Routine ANC should include counseling regarding nutrition and physical activity, so that women gain appropriate weight during pregnancy.
- Lack of physical exercise and diet control: Insulin resistance is main pathological key in developing GDM. Improving insulin sensitivity with exercise can decrease risk of diabetes (Fig. 1.3).
Diabetes hence is emerging as an epidemic in India. Due to lack of physical exercise, diet control and genetic predisposition of Indian population they are at risk to develop diabetes. Hence, health awareness, timely diagnosis, and lifestyle modification can decrease the morbidity associated with the disease.
- Diabetes is a major public health problem in India with prevalence rates reported to be between 4.6% and 14% in urban areas, and 1.7% and 13.2% in rural areas.
- Gestational diabetes mellitus contributes to about 90% of diabetes complicating pregnancy.
- Due to rapid urbanization, lack of exercise, poor diet habits it is increasing in rural population also.
- Detection of GDM provides a window of opportunity to intervene and reduce adverse perinatal outcomes.
- Postpartum followup of GDM is very important for early detection of Type II DM, hypertension and metabolic Syndrome.
- O'Sullivan JB. Gestational diabetes and its significance. In: Camerini–Davalos R, Cole HS (eds). Early Diabetes. New York: Academic Press; 1970:339–44.
- American Diabetes Association. Gestational Diabetes Mellitus (Position Statement). Diabetes Care. 2004;27(Suppl 2):S88–90.
- Schmidt MI, Ducan BB, Reichelt AJ, et al. For the Brazilian Gestational Diabetes Study Group. Gestational diabetes mellitus diagnosed with a 2-h 75 gm oral glucose tolerance test and adverse pregnancy outcomes. Diabetes Care. 2001;24:1151–5.
- Seshiah V, Balaji V, Balaji MS, et al. Gestational diabetes mellitus in India. J Assoc Physicians India. 2004;52:707–11.
- Anjana RM, Pradeepa R, Deepa M, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia. 2011;54:3022–7.
- International Diabetes Federation. IDF Diabetes Atlas, 7th edition. Brussels, Belgium: International Diabetes Federation; 2015.
- Dornhorst A, Paterson CM, Nicholls JS, et al. High prevalence of gestational diabetes in women from ethnic minority groups. Diabet Med. 1992;9:820–5.
- Agarwal S, Gupta AN. Gestational diabetes. J Assoc Physicians India. 1982;30:203–5.
- DeSisto CL, Kim SY, Sharma AJ. Prevalence Estimates of Gestational Diabetes Mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007–2010. Prev Chronic Dis. 2014;11:130415.
- Seshiah V, Balaji V, Balaji MS, et al. pregnancy and diabetes scenario around the world: India. Int J Gynaecol Obstet. 2009;104(Suppl 1):S35–8.
- Seshiah V, Balaji V, Balaji MS, et al. Prevalence of Gestational Diabetes Mellitus in South India (Tamil Nadu)—A community Based Study. JAPI. 2008;56:329–33.
- Sreekanthan K, Belicita A, Rajendran K, et al. Prevalence of Gestational Diabetes Mellitus in a Medical College in South India: A Pilot Study. Indian J Clin Pract. 2014;25(4):342–7.
- Rajput FR, Yadav Y, Nanda S, et al. Prevalence of gestational diabetes mellitus & associated risk factors at a tertiary care hospital in Haryana. Indian J Med Res. 2013;137:728–33.
- Swaroop GN, Rawat R, Lal P, et al. Gestational diabetes mellitus: study of prevalence using criteria of diabetes in pregnancy study group in India and its impact on maternal and fetal outcome in a rural tertiary institute. Int J Reprod Contracept Obstet Gynecol. 2015;4:1950–3.
- Kalra HP, Kachhwaha CP, Singh HV. Prevalence of gestational diabetes mellitus and its outcome in western Rajasthan. Indian J Endocr Metab. 2013;17:677–80.
- Arora GP, Thaman RG, Prasad RB, et al. Prevalence and risk factors of gestational diabetes in Punjab, North India: Results from a population screening program. Eur J Endocrinol. 2015;173:257–67.
- Gopalakrishnan V, Singh R, Pradeep Y, et al. Evaluation of the prevalence of gestational diabetes mellitus in North Indians using the International Association of Diabetes and Pregnancy Study groups (IADPSG) criteria. J Postgrad Med. 2015;61:155–8.
- Kayal A, Anjana RM, Mohan V. Gestational diabetes—An update from India, 2013. Diabetes Voice. 2013;58:1–5.
- Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 2003;26(Suppl 1):S5–20.
- Wendland EM, Torloni MR, Falavigna M, et al. Gestational diabetes and pregnancy outcomes—A systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria. BMC Pregnancy Childbirth. 2012;12:23.
- Mpondo BC, Ernest A, Dee HE. Gestational diabetes mellitus: Challenges in diagnosis and management. J Diabetes Metab Disord. 2015;14:42.
- Jovanovic L, Pettitt DJ. Gestational diabetes mellitus. JAMA. 2001;286:2516–8.
- Mithal A, Bansal B, Kalra S. Gestational diabetes in India: Science and society. Indian J Endocrinol Metab. 2015;19:701–4.