JAPI - DIPSI Guidelines
Gestational Diabetes Mellitus – Guidelines*
V Seshiah, AK Das, Balaji V, Shashank R Joshi, MN Parikh, Sunil Gupta For Diabetes In Pregnancy Study Group (DIPSI)+

Abstract
The Diabetes In Pregnancy Study group India (DIPSI) is reporting practice guidelines for GDM in the Indianenvironment. Due to high prevalence, screening is essential for all Indian pregnant women. DIPSI recommendsthat as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oralglucose load and at 2 hrs a venous blood sample is collected for estimating plasma glucose. This one stepprocedure of challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible.Screening is recommended between 24 and 28 weeks of gestation and the diagnostic criteria of ADA areapplicable. A team approach is ideal for managing women with GDM. The team would usually comprise anobstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician. Intensive monitoring,diet and insulin is the corner stone of GDM management. Oral agents or analogues though used are stillcontroversial. Until there is evidence to absolutely prove that ignoring maternal hyperglycemia when thefetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintainnormoglycemia in every pregnancy complicated by gestational diabetes. The maternal health and fetal outcomedepends upon the care by the committed team of diabetologists, obstetricians and neonatologists. A shortterm intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in theoffspring, as the preventive medicine starts before birth. ©

INTRODUCTION
The maternal metabolic adaptation is to maintain themean fasting plasma glucose of 74.5 ± 11 mg/dl andthe post prandial peak of 108.7 ± 16.9mg/dl.1 This fine tuning of glycemic level during pregnancy is possibledue to the compensatory hyperinsulinaemia, as thenormal pregnancy is characterized by insulin resistance.A pregnant woman who is not able to increase herinsulin secretion to overcome the insulin resistance thatoccurs even during normal pregnancy developsgestational diabetes.

+DIPSI GDM Guidelines Committee
Chairman : Prof V Seshiah
(President : Diabetes In Pregnancy Study group India)
Members : Dr A K Das, Dr Balaji V, Dr Shashank R Joshi, Dr MN Parikh, Dr Sunil Gupta DIPSI National Meeting Experts: Dr Anil S Bhoraskar, Dr Anjalakshi C, Dr Aparna Agarwal, Dr Balaraman V T, Dr Bharti Kalra, Dr Bhavatharini A, Dr Cynthia Alexander, Dr Dorendra Singh I, Dr Hariharan R S, Dr Himangi Lubree, Dr Jitendra Singh, Dr Jothi S Parthasarathy, Dr Krishnaveni G V, Dr Kumaravel V, Dr. Lakshminarayanan S, Dr Lilly John, Dr
Madhini V, Dr Madhuri S Balaji, Dr Mala Chettri, Dr Marina Packiaraj, Dr Mary John, Dr Mayur Patel, Dr Mirudhubashini G, Dr Mohan V, Dr Munichoodappa C, Dr Nalini Shah, Dr Panneerselvam A, Dr Paulose KP, Dr Padma Menon, Dr Pratiba D, Dr Rajan S K, Dr Rajendran N, Dr Rakesh M Parikh, Dr Ramachandran A, Dr Rao PV, Dr Rastogi S S, Dr Sahay B K, Dr Samar Banerjee, Dr Sanjay Kalra, Dr Saraswathy K, Dr Shailaja Kale, Dr Sharad Pendsey, Dr Shyam Mukundan, Dr Siddharth N Shah, Dr Smita P Bhavsar, Dr Sridhar C B, Dr Sundaram A, Dr Suresh S, Dr Vitull K Gupta, Dr Yajnik C S International Faculty : Dr Alberto de Leiva, Dr Lois Jovanovic,
Dr Patrick Catalano, Dr Sylvie Hauguel *Based on the deliberations of the First National Conference of Diabetes In Pregnancy Study Group India at Chennai, February 11 and 12, 2006.

The metabolic goals of pregnancy are
1) in early pregnancyto develop anabolic stores to meet metabolic demands inlate pregnancy and
2) in late pregnancy to provide fuelsfor fetal growth and energy needs.
- Dr Patrick Catalano
Gestational Diabetes Mellitus (GDM) is defined as‘carbohydrate intolerance with recognition or onset duringpregnancy’, irrespective of the treatment with diet orinsulin. The importance of GDM is that two generationsare at risk of developing diabetes in the future. Womenwith a history of GDM are at increased risk of futurediabetes, predominately type 2 diabetes, as are their children1
GDM occurs when the woman’s beta cell function is notable to overcome the antagonism created by the anti-insulinhormones of pregnancy and the increased fuel consumptionrequired to provide for the growing fetomaternal unit.- Dr Alberto de Leiva
SCREENING
The controversy concerning optimal strategy stillcontinues for the detection and diagnosis of GDM.American Diabetes Association (ADA) recommends twostep procedures for screening and diagnosis of diabetesand that too in selective (high risk) population.Compared with selective screening, universal screeningfor GDM detects more cases and improves maternal andneonatal prognosis.3 In the Indian context, screening isessential in all pregnant women as the Indian womenhave 11 fold increased risk of developing glucoseintolerance during pregnancy compared to Caucasianwomen.4 The recent data on the prevalence of GDM inour country was 16.55% by WHO criteria of 2 hr PG =140 mg/dl.5 As such Universal screening duringpregnancy has become important in our country. Forthis we need a simple procedure which is economicaland feasible.
DIPSI Recommended Method
As a pregnant woman walks into the antenatal clinicin the fasting state, she has to be given a 75g oral glucoseload and at 2 hrs a venous blood sample is collected forestimating plasma glucose. This one step procedure ofchallenging women with 75 gm glucose and diagnosingGDM is simple, economical and feasible.6
DIAGNOSTIC CRITERIA
American Diabetes Association (Carpenter andCouston) recommends 3 hour 100 gm OGTT andGestational Diabetes Mellitus is diagnosed if any 2values meet or exceed FPG > 95 mg/dl, 1 hr PG > 180mg/dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140 mg/dl.This criteria was originally validated against the futurerisk of these women developing diabetes and not on thefetal outcome. Carpenter himself now recommends a 2hour OGTT with 75 gm glucose. The reason for this isthat “when a glucose tolerance test is administered tonon-pregnant individuals, it is standard to use the 75-g,2-hour OGTT. Using a different glucose challenge inpregnant versus non-pregnant patients leads toconfusion in the laboratory and may result in errors inapplying the proper diagnostic criteria. Further, the 75-g, 2-hour OGTT is in use during pregnancy in manycountries around the world, typically using the samethresholds as in non-pregnant individuals”.7 Tostandardize the diagnosis of GDM, the World HealthOrganisation (WHO) proposed using a 2 hour 75 gmOGTT with a threshold plasma glucose concentrationof greater than 140 mg/dl at 2 hour, similar to that ofIGT, outside pregnancy.8 Still all these recommendations(ADA and WHO) have not projected the influence of theglycemic level on fetal outcome.
Clarity in Labelling The Different Magnitude of Abnormal Glucose Intolerance on Pregnancy
Increasing maternal carbohydrate intolerance in pregnant women without GDM is associated with agraded increase in adverse maternal and fetal outcomes9implying that fetal morbidity starts at a lower maternalglycemic level (< 140 mg/dl). A number of prospectiveand retrospective studies have substantiated theobservation that the frequency of adverse fetal outcomeincreases with 2hr PG > 120mg/dl and taking care ofthese women had resulted in a better fetal outcome.10-14Thus, the data is robust and indicates that 2 hr > 120mg/dl needs cognizance.
The term ‘Impaired Gestational Glucose Tolerance(IGGT)’ is used by few authors to indicate pregnantwomen whose 2 hr PG is > 120mg/dl. It may beappropriate to use the term ‘Decreased Gestationalglucose tolerance (DGGT)’ instead of impairedgestational glucose tolerance. The use of the term‘Decreased’ is appropriate as it implies only ‘Low’whereas the term ‘Impaired’ means both high and low.Further, quiet frequently we come across, labeling anyabnormal value in the OGTT not meeting the diagnosticcriteria of GDM as IGT.15 The use of this term ‘IGT’ duringpregnancy may be confusing, as this terminology is alsobeing used in non pregnant adult with 2 hr PG > 140mg/dl. This level is also applied to diagnose GDM byWHO criteria. Hence it may be prudent to label 2 hrplasma glucose value > 140 mg/dl as GDM and a 2 hrplasma glucose value > 120 mg/dl as ‘DecreasedGestational Glucose Tolerance’ (DGGT). The term IGTshould not be used to denote any abnormal value duringpregnancy. The figures suggested below are easy toremember.
With 75 gm OGTT (WHO criteria);
In Pregnancy
Outside Pregnancy
2 hr = 200 mg/dl
2 hr = 140 mg/dl
2 hr = 120 mg/dl
Diabetes
GDM
DGGT
Diabetes
IGT
Gestational Weeks at Which Screening is Recommended
Practically all the pregnant women should undergoscreening for glucose intolerance. The usualrecommendation for screening is between 24 and 28weeks of gestation. The recent concept is to screen forglucose intolerance in the first trimester itself as the fetalbeta cell recognizes and responds to maternal glycemiclevel as early as 16th week of gestation.16 If found negativeat this time, the screening test is to be performed againaround 24th – 28th week and finally around 32nd – 34thweek.
MANAGEMENT OF GDM
A team approach is ideal for managing women withGDM. The team would usually comprise an obstetrician,diabetes physician, a diabetes educator, dietitian,midwife and pediatrician. In practice, however, the teamapproach is not always possible due to limited resources.
In such circumstances, management by an obstetricianand physician, with the assistance of an appropriatelyskilled dietitian, diabetes educator, is acceptable.

A) Patient Education
The importance of educating women with GDM (andtheir partners) about the condition and its managementcannot be overemphasized.

The compliance with the treatment plan depends onthe patient’s understanding of:

• The implications of GDM for her baby and herself

• The dietary and exercise recommendations

• Self monitoring of blood glucose

• Self administration of insulin and adjustment ofinsulin doses

• Identification and treatment of hypoglycemia(patient and family members)

• Incorporate safe physical activity

• Development of techniques to reduce stress and copewith the denial.

Care should be taken to minimise the anxiety of thewomen.
B) Medical Nutrition Therapy (MNT)
a) General Principles : All women with GDM shouldreceive nutritional counseling. The meal pattern shouldprovide adequate calories and nutrients to meet theneeds of pregnancy. The expected weight gain duringpregnancy is 300 to 400 gm/week and total weight gainis 10 to 12 kg by term. Hence the meal plan aims toprovide sufficient calories to sustain adequate nutritionfor the mother and fetus and to avoid excess weight gainand post prandial hyperglycemia. Calorie requirementdepends on age, activity, pre pregnancy weight and stageof pregnancy. Approximately 30 to 40 Kcal/kg ideal bodyweight or an increment of 300 kcal/day above the basalrequirement is needed. Pregnancy is not the ideal timefor obesity correction. Underweight subjects or thosenot gaining weight as expected, particularly in the thirdtrimester, require admission to ensure adequate nutritionto prevent low birth weight infants.
b) Calorie Counting : As a part of the medical nutritiontherapy, pregnant diabetic woman are advised to wiselydistribute their calorie consumption especially thebreakfast. This implies splitting the usual breakfast intotwo equal halves and consuming the portions with atwo hour gap in between. By this the undue peak inplasma glucose levels after ingestion of the total quantityof breakfast at one time is avoided. For example if 4 idlis/ chappathi / slices of bread (applies to all type ofbreakfast menu) is taken for breakfast at 8 am and twohours plasma glucose at 10 am is 140mg: the samequantity divided into two equal portions i.e., one portionat 8 am and remaining after 10 am, the two hours postprandial plasma glucose at 10.00 am falls by 20 – 30 mg.
This advice has scientific basis as the peaking ofplasma glucose is high with breakfast (due to Dawnphenomenon) than with lunch and dinner. Further in anormal person, insulin secretion is also high withbreakfast than with lunch or dinner.17 GDM mothers havedeficiency in first phase insulin secretion and to matchthis insulin deficiency the challenge of quantity of foodat one time should also be less.
Insulin Therapy
Insulin is essential if medical nutrition therapy failsto achieve euglycemia. Various criteria have beenproposed for the initiation of insulin therapy. FourthInternational Workshop on GDM recommendedlowering capillary blood glucose concentration to 140mg/dl at 1 hour and 120 mg/dl at 2 hours,18 whereasADA recommended the option of measuring 1 hour postmeal values with cut off of 120mg/dl.19 Theserecommendations are based on one single determination,which reflects a “snap shot” of glucose evaluation ratherthan a “video” of continuous glucose profile.20 Thecontinuous glucose monitoring system has establishedthat in normal pregnancy, peak plasma glucose occursat 60 minutes and the value was 108.7 ± 16.9 mg/dl.1 Ina woman with GDM, the peak occurs between 70 – 110minutes (at approximately 90 minutes) and with a goodglycemic control the value was 103 ± 26 mg/dl.20However, being interstitial fluid glucose it has its ownlimitation.
If the FPG concentration on the OGTT is >120mg/dl,then the patient is started on insulin immediately alongwith meal plan. Other GDM women are seen within 3days and are also taught self monitoring of blood glucose(SMBG). SMBG is to be performed in fasting and 1 ½hours after each meal. GDM women usually have highpost breakfast plasma glucose level compared to postlunch and post dinner. A few GDM women do havepost dinner plasma glucose also high. Insulin is startedwithin 1 to 2 weeks, if the majority (i.e., at least four ofseven per week) of fasting values exceed 90 mg/dl.Similarly, if the majority of post prandial values after aparticular meal exceed 120 mg/dl, insulin is started.21Pen injectors are very useful and the patient’s acceptanceis excellent.
The initial dose of NPH insulin could be as low as 4units and the dose of insulin can be adjusted on followup. A few GDM patients may require combination ofshort acting insulin and intermediate acting insulin inthe morning and evening.
• If a patient has elevated prelunch blood sugar,regular insulin is usually necessary in the morningto handle the post breakfast hyperglycemia, as thereis a lag period before the intermediate-acting insulinbegins to work. The above regimen of regular andintermediate-acting insulin in the morning controlshyperglycemia in most cases.

• If the post dinner blood sugar is high, a small doseof regular insulin is necessary before dinner inaddition to the regular and intermediate actinginsulin given in the morning.

• Combination of regular and intermediate actinginsulin before dinner may be necessary if fastingblood sugar is high. This combination of short andintermediate acting insulin in the morning and aswell as in the evening is known as mixed and splitdose of insulin regimen. In this regimen two-thirdof the total daily dose of insulin is given in themorning and one third in the evening. For eachcombination one-third dose should be regularinsulin and two-third intermediate acting insulin.With this regimen if the patient continues to havefasting hyperglycemia, the intermediate actinginsulin has to be given at bedtime instead of beforedinner. Insulin dose is individualized.

Target Blood Glucose Levels
Maintenance of Mean Plasma Glucose (MPG) level ~105 mg% is ideal for good fetal outcome.22 This is possibleif FPG and post prandial peaks are around 90 mg/dland 120 mg/dl respectively (MPG should not be < 86mg/dl as this may cause small for gestational ageinfants).22
Species of Insulin
It is ideal to use human insulins are leastimmunogenic. Though insulin does not cross theplacenta, the insulin antibodies due to animal sourceinsulin can cross the placenta, and stress the fetal betacell, increase insulin production and inducemacrosomia. Rapid acting insulin analogues,(Novorapid/Humalog) have been found to be safe andeffective in achieving the targeted post prandial glucosevalue during pregnancy.23 Lyspro the first analogue toget category B approval by US FDA and aspart has alsobeen used in pregnancy.

Oral Antidiabetic Drugs
Recently reports have shown good fetal outcome inGDM women who were on glyburide (micronised formof Glibenclamide). A randomized unblinded clinical trialcompared the use of insulin and glyburide in womenwith GDM who were not able to meet glycemic goals onmeal plan. Treatment with either agent resulted in similarperinatal outcomes. All these patients were beyond thefirst trimester of pregnancy at the initiation of therapy.24

More studies are required before routinelyrecommending glibenclamide during pregnancyespecially during the first trimester itself. Metformin hasbeen found to be useful in women with polycysticovarian disease (PCOD) who failed to conceive.Continuing this drug after conception is still acontroversy. But there are a few studies favouringcontinuation of metformin throughout pregnancy.25Currently, oral agents are not routinely recommended during pregnancy though emerging data onglibenclamide and metformin is interesting.
MONITORING GLYCEMIC CONTROL
The success of the treatment for a woman with GDMdepends on the glycemic control maintained with mealplan or pharmacological intervention. To know theeffectiveness of treatment, monitoring of glycemic controlis essential.

• Once diagnosis is made, medical nutritional therapy(MNT) is advised initially for two weeks. If MNTfails to achieve control i.e., FPG = 90mg/dl and/or1 ½ hr PPG = 120mg/dl, insulin may be initiated.

• Once target blood glucose is achieved, woman withGDM till the 28th week of gestation require labmonitoring of both fasting and 1 ½ hr post breakfastonce a month and at other time of the day as theclinician decides.

• After the 28th week of gestation, the laboratorymonitoring should be more frequent atleast once in2 weeks, if need be more frequently.

• After 32 weeks of gestation, lab monitoring shouldbe done once a week till delivery.

• In high risk pregnancies, frequency of monitoringmay be intensified with SMBG.

• Continuous glucose monitoring devices are availablebut these equipments need special training and areexpensive. These devices may be useful in high riskpregnancies to know the glycemic fluctuations andto plan proper insulin dosage.

Throughout the stages and phases of a diabetic woman, herhealth status is directly dependent on her nutritional statusand her blood glucose control. As a woman ages, to preventthe increased risk of osteoporosis and cardiovascular diseaseof the diabetic woman, exercise and hormonal replacementtherapy can minimize the ravages of diabetes per se on theaging process. Normoglycemia throughout the lifecycle ofa diabetic woman results in a lifecycle of health.- Dr Lois Jovanovic
HbA1c Levels
If the glucose intolerance is detected in the earlypregnancy, HbA1c level will be helpful to differentiatebetween a pre gestational diabetic and GDM. If theHbA1c level is more than 6%, she is likely to be a preGDM. HbA1c is useful in monitoring the glucose controlduring pregnancy, but not for the day to daymanagement. A1c level may serve as a prognostic value.Estimation of fructosamine during pregnancy is lessfrequently used.
Measuring Other Parameters
The blood pressure has to be monitored during everyvisit. Examination of the fundus and estimation ofmicroalbuminuria, every trimester is recommended.
e) Ultrasound Fetal Measurement : The management ofgestational diabetes, based on the foetal growth byultrasonogram demands that the fetus at risk must firstmanifest overgrowth before treatment decisions aremade. Further, the cost of performing a number ofultrasonograms to monitor the foetal growth andrecommending therapy has to be kept in mind. Untilthere is evidence to absolutely prove that ignoringmaternal hyperglycemia when the fetal growth patternsappear normal on the ultrasonogram, it is prudent toachieve and maintain normoglycemia in everypregnancy complicated by gestational diabetes.
Until there is evidence to absolutely prove that ignoringmaternal hyperglycemia when the fetal growth patternsappear normal on the ultrasonogram, it is prudent toachieve and maintain normoglycemia in every pregnancycomplicated by gestational diabetes.- Dr Lois Jovanovic
OBSTETRIC CONSIDERATIONS
Fetal Evaluation
An ultrasound scan has to be performed around 18 –20 weeks of gestation focusing on structures namely thespine, skull, kidney and heart. Fetal echocardiographyhas to be done around 20 – 24 weeks which allows toview all the four chambers of the heart. From 26th weekonwards, fetal growth and liquor volume has to bemonitored every 2-3 weeks. Fetal abdominalcircumference provides baseline for further serialmeasurements which gives growth acceleration orrestriction. Fetal movements are monitored from 20 weeksonwards. Screening for chromosomal anomalies isnecessary in pre GDM. Screening should be done forDown’s syndrome, alpha feto protein for neural defectsand human chorionic gonadotrophin to identify anychromosomal abnormalities (16 – 20 weeks of gestation).

The obese fetus of GDM mother is also hyperinsulinemic,thus interaction between leptin and insulin may be a linkbetween maternal diabetes and increased adiposity in thefetus.- Dr Sylvie Hauguel-de Mouzon

GDM or severe obesity is superimposed to pregnancy, theresulting metabolic syndrome becomes detrimental for thefetus, evolving towards fetal overgrowth with increasedadiposity at birth. This may be one major component for inutero programming of obesity later in life.- Dr Sylvie Hauguel-de Mouzon

Timing of Delivery
Sudden intrauterine fetal demise in the third trimesterof diabetic pregnancy is not uncommon. To avoid thisrisk, preterm delivery is recommended. But with this,respiratory distress syndrome (RDS) is likely to occur.Administering steroids for lung maturity or ß adreno receptor agonist to inhibit premature uterine contractionsare likely to induce adverse metabolic effects due to theirglycolytic, glycogenolytic and lipolytic effects. In thissituation, extra insulin may be required to maintaineuglycemia. Foetal demise can also occur due topreeclampsia, which can produce fetal hypoxia viadecreased uteroplacental perfusion. Some centres allowwomen with uncomplicated diabetes to go intospontaneous labor irrespective of the gestational age,but most still advocate delivery at 38 weeks as perinatalmortality and morbidity appear to increase after thistime. Induction at 38 weeks gestation may be slow orunsuccessful due to unfavourable conditions of thecervix but this has to be balanced against the poorlydefined and predictable risk of late intra uterine death,if pregnancy is allowed to continue more than 38 weeks.Fetal health may deteriorate suddenly, hence obstetricmanagement should not be rigid and each case needsindividual care and attention. Having a neonatologistsupport at the time of delivery is advisable.

Intra Partum Management

• If labor is to be induced in GDM, the usual eveninginsulin dose should be taken the night before, butno subcutaneous insulin is given the followingmorning when induction begins.

• Once labor begins, insulin is not necessary.

• In a gestational diabetic the requirement of insulinis likely to fall precipitously and no insulin may berequired immediately after expulsion of placenta.

DELIVERY
A paediatrician experienced in resuscitation of ‘thenewborn should be present whether delivery is vaginalor by caesarean section. As soon as the infant is born,the following actions are mandatory:

• early clamping of the cord, i.e. within 20 seconds ofdelivery, to avoid erythrocytosis;

• evaluate vital signs; Apgar scores at 1 and 5 minutes;

• clear oropharynx and nose of mucus; later emptythe stomach - be aware that stimulation of thepharynx with the catheter may lead to reflexbradycardia and apnoea;

• avoid heat loss, keep neonate warm, transfer toincubator pre-warmed to 34oC;

• perform a preliminary physical examination todetect major congenital malformations;

• monitor heart and respiratory rates, colour, andmotor behaviour for at least the first 24 hours afterbirth;

• start early feeding, preferably breast milk, at 4-6hours after delivery: aim at full caloric intake (125kcal/kg/24 hours) at 5 days, divided into six to eightfeeds a day;

• promote early infant-parent relationship (bonding).

The neonate is usually best cared for, in a specializedneonatal unit. Interference with the infant should beminimal. The neonate should be observed closely afterdelivery for respiratory distress. Capillary blood glucoseshould be monitored at 1 hour of age and before the firstfour breast feedings (and for up to 24 hours in high- riskneonates). Amperometric blood glucose meters areacceptable for use in neonates, provided that suitablequality-control procedures and operator training are inplace. The cut-off of 44mg% (2.6 mmol/l) is now currentlyused as the working definition for hypoglycemia. This“Operational threshold” is not a diagnosis of a diseasebut an indication for action.26 If the baby is obviouslymacrosomic, calcium and magnesium levels should bechecked on day 2. Breastfeeding, as always, should beencouraged in women with GDM.
Both maternal pregravid obesity and GDM are significantrisk factors for obesity in the offspring of the woman withGDM both at birth and at the time of long term follow up.- Dr Patrick Catalano
GDM may be viewed as:
1.An unidentified preexisting disease, or
2.The unmasking of a compensated metabolicabnormality by the added stress of pregnancy, or
3.A direct consequence of the altered maternalmetabolism stemming from the changing hormonalmilieu.
Gestational diabetic women require follow up.Glucose tolerance test with 75g oral glucose is performedafter 6 weeks of delivery and if necessary repeated after6 months and every year to determine whether theglucose tolerance has returned to normal or progressed.A small proportion of gestational diabetic women maycontinue to have glucose intolerance.
Prevention of adverse maternal and perinatal outcomes inGDM are based in achieving maternal blood glucose asclose to normal as possible. Precise glycemic thresholdsremain undetermined.

Prepregnancy BMI, duration and severity of maternalhyperglycemia during pregnancy, are most importantpredictors of the progression to abnormal glucose tolerance/diabetes in the follow up.- Dr Alberto de Leiva
GDM recurs approximately in 50% of subsequentpregnancies. The future risk of developing diabetes for agestational diabetic is two fold, if she becomesoverweight. But maintaining ideal weight approximatelyhalves the risk. The requirement of insulin in additionto diet to maintain euglycemia during the indexpregnancy is also predictive of future diabetes.
The maternal health and fetal outcome depends upon the care by the committed team of diabetologists,obstetricians and neonatologists. A short term intensivecare gives a long term pay off in the primary preventionof obesity, IGT and diabetes in the offspring, as thepreventive medicine starts before birth.

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