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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
No. screenedNo. found with
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
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
No. screenedNo. found with
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