GESTATIONAL DIABETES MELLITUS- SREENING

7/29/2019 GESTATIONAL DIABETES MELLITUS- SREENING

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Screening and Management

for

Gestational Diabetes Mellitus (GDM)

Operational Guidelines

State Health Society&

Directorate of Public Health and Preventive Medicine,Chennai -600 006


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State Health Societyand

Department of Public Health and Preventive Medicine

Screening and Management for Gestational Diabetes Mellitus

Operational Guidelines

Gestational Diabetes Mellitus (GDM) is diabetes detected for the first timeduring pregnancy. It is also defined as carbohydrate intolerance of variable severity

with onset or first recognition during the present pregnancy.

GDM is associated with a significant increase in stillbirths, macrosomia

related morbidity, neonatal hypoglycemia, hypocalcaemia and renal vein

thrombosis. Moreover due to the large babies associated with GDM, caesarean

section rates are also increased and may lead to operative and anaesthetic

morbidity and occasional mortality.India in general and Tamil Nadu in particular is fast developing into a

high prevalence area for diabetes. 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 Western women. The incidence

of GDM was found to be 16.55% in 2004. In the recent field study performed

under the Diabetes in Pregnancy Awareness and Prevention project, the

prevalence of GDM was 17.8% in the urban, 13.8% in the semi urban and 9.9% inthe rural areas.

GDM was previously thought to be not a problem at all. But now the

incidence is expected to increase to 20% (i.e.) one in every 5 th pregnant women is

likely to have GDM. With average annual births of 11 lakhs in Tamil Nadu about

1.5- 2.0 lakh pregnant mothers are estimated to have GDM. If the blood sugar

level is not appropriately managed, apart from the complications of GDM, the

mother and her offspring are at increased risk of developing diabetes in the future.

Thus two generations are at risk of developing diabetes. Hence, there is an urgent

need to screen all mothers for GDM early enough to detect and initiate appropriate

treatment to prevent and minimize its effects on the mother and the child.

Now facilities are available to detect and manage GDM in all Government

Institutions including the Primary Health Centres. Hence it is proposed to take up


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Gestational Diabetes Control Programme for improving the health of the mother

and the child. Screening all pregnant women for gestational diabetes and taking

care of them is the first step in the primordial / primary prevention of diabetes

mellitus.

The whole aim is to take care of pregnant women in the community. Hence

the diagnostic test has to be simple and easy to perform without disturbing the

routine life of the pregnant women.

WHEN TO SCREEN?

The ideal time to screen for GDM would be by 12-16 weeks or at the first

visit to the antenatal (AN) clinic. If she is found normal in the first visit, the next

screening is to be done between 24 and 28 weeks of gestation and later at 32-34

weeks. The schedule for screening is as follows:

GDM SCREENING SCHEDULE

Screening Week of pregnancy

I Screening Ideally 12 16 weeks or at the time of

first visit for AN Checkup

II Screening 24 28 weeks

III Screening 32 34 weeks

HOW TO SCREEN AND INTERPRET THE RESULTS?

Glucose Challenge Test (GCT) (WHO Criteria)

The woman should be given 75 gm of glucose in 300 ml of water irrespective of thetime of her last meal and whether she is fasting or not. (The glucose water can be

taken slowly over 5 minutes time to avoid nausea and vomiting)

Her venous blood is drawn after 2 hours of drinking of glucose solution and testedfor Plasma Glucose.

She is considered normal if the blood sugar at 2 hour post glucose load is140mg/dl, then she is considered asGDM.

Those women who tested normal in GCT at 12 16 weeks should undergo repeatGCT at 24 28 weeks and if found normal again, GCT to be repeated between 32

and 34 weeks.


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GDM MANAGEMENT

In the management of GDM, the aim is to maintain two hour post prandial

plasma glucose (PPPG) level in the range of 110 120 mg/dl. Since the screening

and diagnosis of GDM is based on two hour plasma glucose level, for monitoring

the control of blood sugar level, the same time point of two hour post meal is

recommended.

Note:

Estimation of fasting plasma glucose is not recommended in the guidelines as

fasting plasma glucose will not exceed 90 mgs/dl if 2 hour post meal glucose is

less than 120 mg/dl.

I. Meal Plan (Medical Nutrition Therapy)

Initiation of Medical Nutrition Therapy

All pregnant women who test positive for the first time

after GCT (i.e: women with post glucose blood sugar level

of 140 mg) should be started on meal plan for 2 weeks.

As a part of the medical nutrition therapy, pregnant diabetic women areadvised to wisely distribute their calorie consumption especially the

breakfast. This implies splitting the usual breakfast into two equal halves

and consuming the portions with a two hour gap in between. By this the

undue peak in plasma glucose levels after ingestion of the total quantity of

breakfast at one time is avoided.

For e.g. If 4 idlis / chapatti / slices of bread (applies to all types of breakfastmenu) is taken for breakfast at 8.00 a.m. and two hours plasma glucose at

10.00 a.m. is 140mg/dl; the same quantity divided into two equal portions

i.e., one portion at 8.00 a.m. and remaining after 10 a.m., the two hours

post prandial plasma glucose at 10.00 a.m. falls by 20-30 mg/dl.


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The principles of Meal Plan is to :

1. Avoid sugar, sweets, fruit juices and tubers like potatoes, tapioca, beet

roots, sweet potato etc.,

2. Avoid fasting and feasting

3. Eat to her appetite

4. Eat more of green leafy vegetables

After 15 days of Meal Plan, 2 hours Post Prandial (meal) Plasma

Glucose (PPPG) is to be repeated

If PPPG is 120 mg/dl, advise intermediate acting insulin (eg: Insulatard 4 units 30 minutes before breakfast).

Repeat 2hr PPPG after two weeks. If the plasma glucose is within normallimits, continue the same dose of insulin.

If the values are higher, then increase the dose by 2 to 4 units i.e., 6 to 8units 30 minutes before breakfast.


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Repeat the test every 15 days, and titrate the dose to achieve the 2 hrPPPG between 110-120mg/dl (at a single point of time the dosage should

not be increased by more than 2-4 units: the dosage should be adjusted

once in 15 days only after testing two hour PPPG).

If the insulin dose exceeds 16 units per day, (expecting that the woman mayrequire 20 units), split dose of insulin is recommended. i.e., 12 units in the

morning and 8 units in the night and to monitor every 15 days.

At the PHC Level:

If insulin requirement exceeds 20 units per day refer to CEmONC Centres.

Monitoring the control:

Control of blood sugar should be assessed by 2hr PPPG every 15 days till

delivery. (If required, the frequency of monitoring may be increased).

POSTPARTUM TESTING FOR MOTHERS WITH GDM

Women diagnosed with GDM in pregnancy should undergo 75 gm Oral

Glucose Tolerance Test (OGTT) to determine their glycemic status, ideally between

6 12 weeks postpartum. If normal, the OGTT has to be repeated at six monthsand thereafter every year after delivery.

NORMAL VALUES FOR POSTPARTUM75 gm GLUCOSE TOLERANCE TEST

Investigation Normal

Fasting plasma glucose (FPG)


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2. All pregnant women who come for AN check up for the first time

irrespective of duration of pregnancy should be screened for GDM.

3. The VHNs in PHCs and Health staff of other institutions should make sure

that all pregnant mothers undergo the screening test as per the schedule.

4. The field staff of PHCs should periodically visit all those mothers on

treatment for GDM in their area and ensure that they follow the advice on

meal plan and treatment schedule.

5. The VHNs of PHCs should also make sure that PN blood sugar check up is

done 6 12 weeks after delivery for all the mothers who were diagnosed as

GDM.

6. MO in-charge of antenatal clinics should make sure that periodic visits by the

GDM mothers are done as per schedule and there are no drop outs.

7. In case GDM mothers are moving out of the area, detailed report on the

management plan for continuing the care wherever she goes.

Reporting:

Every month the GDM report should be submitted by the lab technician to

PHC Medical Officer in the enclosed format (Annexure I)

Similarly, every month, the GDM reported collected from all PHCs with in the

Health Unit Districts should be consolidated at the HUD level and sent to the

Directorate of Public Health & Preventive Medicine in the enclosed format

(Annexure II).In the same way reports from DMS and DME side to be sent to concerned

directorates.

The soft copy of the report should be sent to the official email id created for

the GDM programme.


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GESTATIONAL DIABETES SCREENING & MANAGEMENT

Pregnant women first Visit75 gm. Glucose in 300ml of water(Glucose Challenge Test GCT)

12-16 weeks

140mg/dl

GDM

Meal Plan

After 2 weeks

2 hour PPPG(2hrs after food)

PPPG


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Standard Operating Procedures for

Glucose Challenge Test (GCT) in the Laboratory

Test Procedure:

1. Take a clean and dry test tube/screw capped vial containing sodium fluoride and potassiumoxalate anticoagulant.(commercially availablefluoride tubesmay be used)

2. Write the Name and OP number on the test tube/vial with a marker pen.3. Following standard safety precautions collect 2 ml of blood by venepuncture.4. Remove the needle and transfer the blood into the tube/vial containing sodium fluoride and

potassium oxalate anticoagulant and mix well by gentle but thorough shaking for complete

mixing.

5. Keep the sample in an upright position on the test tube rack.6. Centrifuge the sample for 10 minutes at 1500 rpm to separate the plasma. Plasma should

be separated within 1 hr of collection.

7. Switch on the semi auto analyser (at least 10 min prior to usage). The analyser has to becalibrated with standard glucose reagent (provided with the glucose test kit)

8. Prime the semi auto analyser with distilled water (2 times).9. Bring the glucose reagent to room temperature.10.By using a 100 l 1000 l micropipette, set the volume to 1000 l (one ml)and take 1 ml

of glucose reagent in a plain, clean, separate test tube/vial(without anticoagulant).

11.By using a 10 l 100 l micropipette and micro tip, set the volume to 10 l and aspirate10 l of plasma(wipe the micro tip with tissue paper to remove the excess plasma)and

add to the glucose reagent and mix it well.

12.Keep the mixture for 10 minutes in the place provided in the semi auto analyser forincubation at 37C.

13.Select the procedure in the analyzer using the touch screen/on board panel keys andaspirate the glucose reagent-plasma mixture.

14.Read the plasma glucose level on the LCD screen and record in the register.15.Follow the standard bio-safety and bio-waste management procedures to dispose used

syringe, needle and blood.

16.Run controls in parallel with every batch of samples.


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Lab.Materials and Equipment required for the GCT

S.No Name of the ItemQty/AN

MotherPurpose

1 Glucose Powder 75 gm /pkt For challenging (oral) the ANmother to screen for GDM.

2 Disposable Cups 2 Nos Dissolve Glucose

3 Drinking water 300 ml Dissolve glucose

4 Disposable syringe with needle( 2 ml)

1 Blood Collection

5 Surgical spirit Blood collection

6 Tourniquet Blood collection

7 Cotton Blood collection

8 Disposable Gloves Blood collection9 Test tube/vial with anticoagulant

(sodium fluoride and potassiumoxalate tube or Fluoride Tube)

1 No Blood collection-Plasma

10 Plain test tube/vial 1 No Mix plasma and glucosereagent

11 Marker pen Labeling

12 Test tube Rack To hold the sample tube/vial

13 Centrifuge To separate plasma fromblood

14 Micro pipette 100 l 1000 l Aspirate 1 ml(1000 l) glucosereagent

15 Micro pipette 10 l 100 l Aspirate 10 l Plasma

16 Micro tips 100 l 1000 l 1 No Aspirate 1 ml(1000 l)glucose reagent

17 Micro tips 10 l 100 l 1 No Aspirate 10 l Plasma

18 Semiauto analyser To run glucose test

19 Distilled water 5 lts/500 tests For priming the analyser

20 Colour coded bin Bio waste disposal

21 Sodium hypochlorite For disinfection

22 Towel For personal hygiene23 Soap for hand wash For personal hygiene

24 GDM lab Register For recording glucose values


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GDM-Frequently Asked Questions

What is Glucose Challenge Test (GCT)?

GCT is performed for AN mothers to diagnose the Gestational Diabetes Mellitus by

estimating the Plasma Glucose Level two hours after the intake of 75 gms of glucose dissolved in

300 ml of water.

Is GCT mandatory for all pregnant mothers?

Yes. Universal screening of all antenatal mothers, three times during pregnancy as per the

schedule is mandatory for diagnosing GDM.

Screening Week of pregnancy

I Screening Ideally 12 16 weeks or at the time of

first visit for AN Checkup

II Screening 24 28 weeks

III Screening 32 34 weeks

What is the screening schedule?

All the AN mothers should be screened for GCT during their 1st visit (12 16 weeks) Even if she is found to be normal, again she should be screened during 24 28 weeks

Even if she is found to be normal, again she should be screened during 32 34 weeksIs there any food restriction advised for AN mothers before GCT?

No. There is no diet restriction. She can undergo GCT irrespective of her previous meal status.

What is the preparation for AN mother to perform GCT?

The AN mother should be counseled about the screening procedure and GDM. 75 gram of glucose is dissolved in 300ml of water and it should be consumed slowly within

5 minutes time to avoid nausea and vomiting.

2 hours after consuming glucose solution, venous blood is drawn and tested for plasmaglucose level.

What is the plasma glucose level to diagnose GDM?

The AN mother is considered normal if the plasma glucose level is


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Annexure I

GDM Reporting Format

Name of the HUD : . Month:.. Year:.

Name of the PHC/Hospital :..

Antenatal mothers

Screening

No. screenedNo. found with

GDMOn treatment

During

the

Month

Up to

the

Month

During

the

Month

Up to

the

Month

On Meal

plan

On

insulinTotal

12-16 weeks

24-28 weeks

32-34 weeks

Postpartum screening for mothers with GDM

Screening


DiabetesOn treatment

During

the

Month

Up to

the

Month

During

the

Month

Up to

the

Month

On Meal

plan

On

insulinTotal

6 weeks

6 months12 months

Signature of the Medical Officer


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Annexure II

GDM Reporting Format

Name of the HUD : Month:.. Year:.

Antenatal mothers

Screening


GDMOn treatment

During

the

Month

Up to

the

Month

During

the

Month

Up to

the

Month

On Meal

plan

On

insulinTotal

12-16 weeks

24-28 weeks

32-34 weeks

Postpartum screening for mothers with GDM

Screening


DiabetesOn treatment

During

the

Month

Up to

the

Month

During

the

Month

Up to

the

Month

On Meal

plan

On

insulinTotal

6 weeks

6 months12 months

Signature of the Officer In-Charge


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Meal Plan for Women with Gestational Diabetes Mellitus(GDM)

Meal Plan refers to good eating habits, following a regular and well-balanced diet without

overeating. This is not only useful to control blood glucose levels and prevent complications in

pregnant women, but it is also the principle of eating habits for a long and healthy life. Diabetes

diet is not a special diet, but is rather a well-balanced diet.

As like general diabetes, pregnant women diagnosed with GDM should follow certain basic

principles of diet and meal plan. Once the pregnant women are detected to have elevated blood

sugar, it is better to avoid all sugary, oily and certain energy dense food items. For example,

adding sugar/jaggery (vellam) in the coffee/tea/milk to be avoided. Lot of greens and vegetables

to be added in the diet.

Breakfast:

The GDM mother can have their usual breakfast. But, most importantly, they can split the

quantity of breakfast by which the sharp rise in post breakfast blood sugar can be avoided i.e. 3

idlies by 8 AM and another 2 idlies by 11 AM if they feel hungry. They should avoid sugar added

milk/coffee. All supplementary health drinks and fruit juices are rich in sugar and it is better to

avoid them.

In between Breakfast and Lunch:

In between breakfast and lunch, if they feel hungry they can have butter milk, ordinary

milk, lemon/tomato juice, vegetable soup without sugar.

Lunch:

The GDM mother can have their usual quantity of rice with sambar, rasam and butter milk

with lot of greens and vegetables. They should avoid roots like potato, tapioca (Maravalli Kilangu),

payasam, soft drinks and sweets in any form.

Evening:


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The GDM mother can have some boiled grams (payaru) or dhal (paruppu) or two slices of

wheat bread and one cup of coffee or tea without sugar. Avoid snacks, sweets, cream biscuits

etc.,

Dinner:

The GDM mother can have either 3 to 4 chapatti with vegetable side dish / sambar / dhal or

similar to that of the lunch. It is better to avoid potato and coconut preparations as side dishes.

Before returning to bed, she can have one cup of milk without sugar.

This diet advice will give adequate calorie and nutrition not only to her but also to her

growing fetus. She can eat to her appetite by avoiding certain sugary and energy dense food

items.

Taking certain sugar and oil rich diet invites all sorts of complications like birth defects, big

baby and complicated delivery. During pregnancy, many women are tempted to frequently take

sugar rich fruit juices, honey soaked dates and certain sweets prepared in the ghee, dalda and

coconut. They are not only inviting diabetes in pregnancy but also putting to risk the future

generation.

Anything in Excess is Not Good

Documents

GESTATIONAL DIABETES MELLITUS- SREENING