Clinical Guidelines for Management of Diabetes in Pregnancy Alka Pandey, Pikee Saxena, Anupam Prakash
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdomen pain 179
Abdominal girth 122
Abortion 118
Abruptio placentae 114
Adiponectin 150
Albuminuria 89
Alpha-glucosidase inhibitors 86
Ambulatory glucose profile 55f
American Academy of Ophthalmology 103
American College of Obstetricians and Gynecologists 24, 32, 58, 66, 128,131, 138, 140, 145, 182t
American Diabetes Association 24, 33, 75, 83, 87, 91, 103, 111, 204, 205
Amniotic fluid 43
Anemia 97, 102
Anencephaly 43
Aneuploidy 135
screening
early 136
second trimester 136
Angiopoietins 150
Angiotensin converting enzyme inhibitor 29, 91, 111
Angiotensin receptor
antagonists 29
blockers 91
Anomaly scan, second trimester 136
Antenatal care 93, 95, 117, 120, 196
Antidiabetic agents 152
Antidiuretic hormone, levels of 14
Antigen-2 antibody 7
Antihyperglycemic therapy, selection of 30
Antihypertensive
drugs 114t
therapy 94, 114
Antivascular endothelial growth factor therapy 106
Apgar score 86
Asthma 174
Asymmetric dimethylarginine 8
Asymptomatic hypoglycemia 159
Atopic dermatitis 174
Australian carbohydrate intolerance study 129
Autoimmunity 203
Azathioprine 98
B
Bariatric surgeries 192, 193
Beta human chorionic gonadotropin 136
Beta-cell
destruction 117
function, genetic mutations of 118
Bifidobacterium lactis 62
Biguanides 85
Biliopancreatic diversion 194
Birth injuries 119
Blood
glucose 113
control 102, 144
measurements 50
self-monitoring of 125
targets and monitoring 125
pressure control 94
sugar levels, monitoring 187
urea nitrogen 97
Body mass index 4, 4f, 33, 59, 122, 164
Brachial plexus injury 143
Breastfeeding 164
benefits of 164, 169
challenges 159
inhibits ovulation 174
C
Calcineurin inhibitor 99
Calcium
channel blockers 94, 114, 115
metabolism 14
supplementation 197
Canadian Diabetic Association 145
Capillary blood glucose 145
management of 187t
Capillary glucose measurements 57
Cardiomyopathy 157
Cardiovascular
diseases 22
health 96
system 111, 136
Carpenter-Coustan and National Diabetes Data Group 34
Central nervous system 136
Cervical cerclage 187
Cesarean
delivery 169
section 74, 187
elective 146
risk of 195
Chest pain 179
Childhood
leukemia 174
obesity 11
Chronic hypertension 11, 111
Chronic kidney disease, progressive 89
Clonidine 94, 115
Concomitant hypertensive disorder 108
Congenital anomalies 135, 155
Congenital heart disease 147
Congenital malformation 119
Congenital rubella 118
Contraception 165, 177
barrier and natural methods of 180
different methods of 178
long-acting reversible 180
Copper-T 380A 180
Corticosteroid-binding globulin 13
Coxsackie virus 118
C-reactive protein 8
C-telopeptide 9
Cushing syndrome 118
Cystectomy 187
Cytomegalovirus 118
D
Deoxyribonucleic acid 136
Depot medroxyprogesterone acetate 181
Depression 181
Dextrose normal saline 80, 145
Diabetes 74, 82, 117, 143
control and complications trial 102
diagnosis of 206
duration of 102
in pregnancy 32
study group India 33, 37, 75, 119
management of 79, 83, 206
mellitus 10, 20, 82, 89, 104t, 135, 169, 177, 181, 184, 189, 190b
complication of 101
etiological classification of 117
prevalence of 1
perioperative management of 186
Diabetic kidney disease 89, 90, 95
effect of 90
Diabetic nephropathy 89
Diabetic pregnancy 128
Diabetic retinopathy 96, 101, 102b, 104t, 106, 118
effect of 102
management of 103
Dialysis 97
Diastolic blood pressure 10
Disseminated intravascular coagulation 114
Down syndromes 118
Duodenal malformation 43
Dyslipidemia 10, 11
E
Eclampsia 11, 110, 114
Elevated liver enzymes 111
Emergency contraception 181
Encephalocele 43
Endocrinopathies 118
Endometriosis 174
Endothelial cell adhesion molecule 8
Endothelial colony-forming cells 22
Erythropoiesis-stimulating agent 96
Erythropoietin 150
European Association for Study of Diabetes 74
Exercise, types of 69
Exocrine pancreas, disease of 118
Eye
checkup 113
problems 179
F
Fasting blood glucose 12, 121, 124, 163
Fasting glucose 18
impaired 163
Fasting insulin 18
Fasting plasma glucose 125
Fatty acids, free 7
Fertility issues 201
Fetal
abdominal circumference 129
activity assessment, daily 122
anomalies 154
biometry 139
cardiac dysfunction 44
death 119
echocardiography 137
heart sound 122
hyperglycemia 144, 150
hyperinsulinemia 150
lung maturity, assessment of 140
macrosomia 129, 150
monitoring 113, 135
surveillance 122
testing 137
Fetomaternal complications 194
Fetopelvic disproportion 169
Fibroblast growth factor 150
Folic acid supplementation 198
Fundal height 122
G
Gastrectomy 193
Gastroplasty 193
Genetic syndromes 118
Genital infections 203
Genital trauma 143
Gestational diabetes 10, 17, 48, 57, 118, 169, 192
mellitus 1, 3f, 7, 32, 35t, 42, 48, 58, 80, 82, 107, 117, 119, 120, 120fc, 120t, 121, 121fc, 124, 135, 138, 143, 144, 151f, 154,169, 170, 171, 189, 192, 193
antenatal screening for 162
development of 194
diet-controlled 138
prevalence of 2, 2f, 169
Gestational glucose tolerance 120
Gestational hypertension 11, 111
Glucocorticosteroids 118
Glucometer testing, advantages of 49b
Glucose 150b
challenge test 34
homeostasis 212
metabolism 18
monitoring 111, 119
continuous 53
tolerance 120
impaired 163
test 34
transporter 1 150, 152
Glutamic acid decarboxylase 7
Glycemic control 93, 184
monitoring of 75
Glycemic goals 48
Glycemic index 61t
Glycemic targets 186
Glycosuria 93
Glycosylated hemoglobin 53, 75
levels of 185
Great arteries, transposition of 155
Growth restriction 119
H
Headaches 179
Hepatic enzymes 178
High-density lipoprotein cholesterol level 204
Hormonal contraception, combined 178, 179
Human chorionic somatomammotropin 74, 149
Human placental lactogen 74
Hydralazine 94, 115
Hyperbilirubinemia 74, 83, 119, 143, 147, 157
Hyperglycemia 32, 33t, 36fc, 38t, 57, 140,150, 201, 203, 206
diagnosis of 37t
Hyperinsulinemia 144, 212
Hypertension 10, 11, 111, 115
pregnancy induced 195
uncontrollable severe 114
Hypertensive disorders 11, 110
types of 110
Hypocalcemia 74, 119, 143, 157, 169
Hypoglycemia 74, 119, 123, 125, 147, 156, 169
Hypomagnesemia 119, 157
Hypothermia 169
Hypoxia 150
stimulates erythropoietin 43
I
Infections 118
Inositol 207
deficiency 212
Insulin 78, 150b, 207
analogs 78
basal 76
independent 207
like growth factor 101, 150
binding protein 203
metabolism 18
requirement 144
resistance 7, 10, 12
secretion 18
sensitivity 18
sensitizing drugs, use of 209
therapy 74, 123, 186
Intensive glucose control 76
Intercellular adhesion molecule 8
Interleukin-6 8
Intermediate insulin 76
International Diabetes Federation 1
Intrapartum fetal demise 114
Intrauterine growth restriction 122, 135, 139
Intrauterine method 165
Intravitreal antivascular endothelialgrowth factor therapy 106
Iodide supplementation 198
Iron supplementation 197
K
Ketoacidosis 111, 118, 140
Kidney
disease 89, 90
function 90
Klinefelter syndromes 118
Labetalol 94, 114
Labor
induction 189
preterm 118
L
Lactation failure 118
Lactational amenorrhea method 165
Lactobacillus rhamnosus 62
Lactogenesis 170
Laparoscopic adjustable gastric banding 193
Large for gestational age 130
Leptin 150
Levonorgestrel-releasing intrauterinesystem 180
Lipolysis 8
Lipoprotein, low-density 12
Low-platelet count 111
Luteinizing hormone 13
M
Macrosomia 74, 119, 128, 131, 135, 156
management of 128
Macrosomic fetuses 129
Macular edema 106
Maternal anemia 196
Maternal blood flows 149
Maternal diabetic environment, effect of 150
Maternal hyperglycemia 43, 150
uncontrolled 160
Maturity onset diabetes of young 7, 17, 118
Medical nutrition therapy 58, 74, 82, 119, 122, 124
Medical termination of pregnancy 107
Membranes, premature rupture of 135
Meningomyelocele 43
Menopause, premature 203
Metabolic
disturbances 8
syndrome 10, 12, 13, 20, 160, 204, 206
Metabolism, basal 18
Metformin 93, 207, 209, 211
effect of 210
use of 166
Methyldopa 94, 114
Mycophenolate mofetil 98
Myoinositol 212
supplementation 62
N
National Institute for Health and Care Excellence 33, 83, 119
National Institute of Clinical Excellence 173, 186
National insulin summit 145
Neonatal hypoglycemia 83, 143, 144
Neonatal intensive care unit 147b
admission 86
Neonatal macrosomia 156
Nephropathy 118
Nonreassuring fetal status 114
Nonstress test 138
Normoglycemia 164
Nuchal translucency 130
Nutritional deficiencies 196
O
Obesity 20, 174
Oligoamenorrhea 209
Oral
antidiabetic agents 83, 125
antidiabetic drugs 125, 173
antihyperglycemic drugs 82, 83
contraceptive pills, combined 178
glucagon-like peptide-1 86
glucose tolerance test 163, 171
hypoglycemic agents 207
Organogenesis, period of 154
Osteoporosis 181
Otitis media, acute 174
Ovarian autoantibodies 203
Ovarian cancer 174
Ovarian hyperstimulation syndrome, risk of 210
Oxidative stress 44, 150
Oxygen 150b
P
Pancreatitis cystic fibrosis 118
Pedersen hypothesis 150
Pelvic inflammatory disease 203
Perinatal morbidity 90
Perinatal mortality 211
rate 42
Peripheral cellular glucose 208
Peripheral hyperinsulinemia 213
Pharmacotherapy 119, 123
Pheochromocytoma 118
Pioglitazone 209
Placenta 149, 152
hypervascularity of 150b
size of 130
Placental angiogenesis 150
Placental cytokines 151
Placental growth factor 150
Placental hormones 149
Plasma
concentration 207
glucose 75, 120
self-monitoring of 50
half-life 207
protein A, pregnancy-associated 130, 136
Polycystic kidneys 43
Polycystic ovary 203
syndrome 208, 209
Polycythemia 119, 143, 147, 157
Polyhydramnios 118
Postpartum
glucose testing 163
hemorrhage 118, 143
Postprandial blood glucose 84, 85
Postprandial plasma glucose 121, 124
Preconception counseling, effect of 25
Preeclampsia 11, 110, 111, 118
prevention of 95, 112
Pregestational diabetes 38, 113, 138
mellitus 143
Pregnancy loss, first trimester 135
Progesterone
only injectable contraceptives 180
only pill 179
only subdermal implant 180
Progestins, types of 178
Proliferative diabetic retinopathy 103f,105f
Protein
creatinine ratio 99
foods 62
metabolism 14
supplementation 197
Proteinuria 89, 96
Puerperal sepsis 118
Pulmonary edema 114
R
Randomized controlled trials 83
Renal disease 22
end-stage 89
Renin-angiotensin-aldosterone system 90
Respiratory
distress syndrome 86, 119, 140, 157
tract infections, severe lower 174
Retinopathy 96, 102
progression of 108
Rosiglitazone 209
Roux-en-y gastric bypass 194
S
Sepsis 143
Serum creatinine 113
Sex hormone-binding globulin 203
Sexual dysfunction 203
Shoulder dystocia 86, 118, 143
Sirolimus 98
Sonographic methods 130
Steroid hormones 179
Subcutaneous insulin infusion pump, continuous 76
Subfertility 209
Sudden infant death syndrome 174
Sulfonylureas 83, 93
Symptomatic hypoglycemia 159
Systolic blood pressure 94
T
Target capillary plasma glucose 27
Thiazides 118
Thromboembolic disease 96
Thyroid
disease 111
dysfunction 10, 12
function test 113
Tissue distribution 208
Total oxidant status 44
Total serum cholesterol 11
Transdermal contraceptive patch 179
Triglyceride 11
Tumor necrosis factor 8, 150, 151
Turner syndrome 118
U
Urinary tract infection 99
Urine
glucose testing 50
ketone 113
Uterine artery-pulsatility index 130
V
Vaginal ring, combined 179
Vascular cell adhesion molecule 8
Vascular complications, hyperglycemia-induced 112fc
Vascular disease 110
Vascular endothelial growth factor 101, 150
Venous thromboembolic events 96
Vertical band gastroplasty 193
Vitamin
A supplementation 198
B12 supplementation 198
K supplementation 198
W
Weight gain 181
Weight loss 193, 206
Western pacific regional office 59
Z
Zinc supplementation 198
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Chapter Notes

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Epidemiology of Diabetes in PregnancyCHAPTER 1

Taru Gupta,
Shweta Singh,
Snigdha Kumari
 
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.24 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
zoom view
Fig. 1.1: Prevalence of gestational diabetes mellitus in different regions of India.
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
zoom view
Fig. 1.2: Increasing prevalence of gestational diabetes mellitus (GDM).
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:
  1. Higher parity
  2. Advanced maternal age
  3. 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
    zoom view
    Fig. 1.3: Comparison of various studies done in India. (BMI: Body mass index)
  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.
  5. Caucasians/non-white race: Due to genetic variation in different population, Caucasians have high-risk of genes for insulin resistance.
  6. 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.
  7. History of GDM
  8. 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.
  9. 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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