INTRODUCTION
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
PREVALENCE
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 2000.42
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
TREND
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 2030.3
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
RISK FACTORS
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.4
- 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).
CONCLUSION
Diabetes hence is emerging as an epidemic in India. Due to lack of physical exercise, diet control and genetic predisposition of Indian population they 5are at risk to develop diabetes. Hence, health awareness, timely diagnosis, and lifestyle modification can decrease the morbidity associated with the disease.
KEY POINTS
- 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.
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