Screening and diagnosis of gestational diabetes in India: a systematic review and meta-analysis

Epidemiology and management of gestational diabetes

Gestational diabetes is defined as hyperglycaemia first detected during pregnancy at glucose concentrations that are less than those of overt diabetes. Around 14% of pregnancies globally are affected by gestational diabetes; its prevalence varies with differences in risk factors and approaches to screening and diagnosis; and it is increasing in parallel with obesity and type 2 diabetes. Gestational diabetes direct costs are US$1·6 billion in the USA alone, largely due to complications including hypertensive disorders, preterm delivery, and neonatal metabolic and respiratory consequences. Between 30% and 70% of gestational diabetes is diagnosed in early pregnancy (ie, early gestational diabetes defined by hyperglycaemia before 20 weeks of gestation). Early gestational diabetes is associated with worse pregnancy outcomes compared with women diagnosed with late gestational diabetes (hyperglycaemia from 24 weeks to 28 weeks of gestation). Randomised controlled trials show benefits of treating gestational diabetes from 24 weeks to 28 weeks of gestation. The WHO 2013 recommendations for diagnosing gestational diabetes (one-step 75 gm 2-h oral glucose tolerance test at 24-28 weeks of gestation) are largely based on the Hyperglycemia and Adverse Pregnancy Outcomes Study, which confirmed the linear association between pregnancy complications and late-pregnancy maternal glycaemia: a phenomenon that has now also been shown in early pregnancy. Recently, the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) trial showed benefit in diagnosis and treatment of early gestational diabetes for women with risk factors. Given the diabesity epidemic, evidence for gestational diabetes heterogeneity by timing and subtype, and advances in technology, a life course precision medicine approach is urgently needed, using evidence-based prevention, diagnostic, and treatment strategies.

Epidemiology of hyperglycemia during pregnancy in Ethiopia: prevalence, associated factors, and feto-maternal outcomes: systematic review and meta-analysis

BACKGROUND

Hyperglycemia in pregnancy (HIP) is a significant medical complication affecting pregnant women globally and is considered a public health burden due to the negative outcomes it can cause for both mother and infant. The aim of this systematic review and meta-analysis was to examine the prevalence, risk factors, and feto-maternal outcomes of HIP in Ethiopia.

METHODS

To gather relevant information for this study, both published and unpublished studies were searched for in several major databases, including PubMed, Embase, HINARI, Web of Science direct, and Google Scholar, as well as other sources. The Joanna Briggs Institute (JBI) tool was used to evaluate the methodological quality of the findings from these studies. Data was then extracted and summarized using a template in Microsoft Excel software, and the extracted data was analyzed using Stata software version 16.0. If significant heterogeneity was found between studies, subgroup analyses were conducted to further examine the data.

RESULT

Eighteen studies were included in this systematic review and meta-analysis, involving a total sample size of 50,816 pregnant women in Ethiopia. The prevalence of HIP among pregnant women varied considerably across the primary studies, ranging from 0.4 to 26.2%. The pooled prevalence of HIP among pregnant women in Ethiopia was found to be 6.9% (95% C 2.2-11.6). Pregnant women with a family history of diabetes had 2.5 times higher odds of developing HIP compared to those without a family history of diabetes (OR = 2.49; 95% CI = 2.02, 2.96). However, there was no significant association found between HIP and maternal obesity (OR 2.31, 95% CI = 0.85, 3.78) or previous history of abortion (OR 3.89; 95% CI 0.85, 6.94). The common fetal outcomes associated with HIP were admission to the intensive care unit (46.2; 95% CI 27.4, 65.1), macrosomia (27.3%; 95% CI 9.4%, 45.1%), and preterm birth (16.9; 95% CI 12.5, 21.3). Additionally, hypertensive disorders of pregnancy (28.0%; 95% CI 15.2, 40.8) and operative delivery (51.4%; 95% CI 35.9, 66.8) were more common among women with HIP in Ethiopia.

CONCLUSION

Although there was some variation between studies, the meta-analysis revealed that approximately seven out of 100 pregnant women in Ethiopia had HIP. A family history of diabetes was found to be a significant predictor of HIP in Ethiopia. Additionally, HIP was associated with various serious adverse outcomes for both mothers and infants in Ethiopia. These findings highlight the need for national guidelines to ensure that pregnant women are uniformly screened for HIP.

National and regional prevalence of gestational diabetes mellitus in India: a systematic review and Meta-analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is frequently misdiagnosed during pregnancy. There is an abundance of evidence, but little is known regarding the regional prevalence estimates of GDM in India. This systematic review and meta-analysis aims to provide valuable insights into the national and regional prevalence of GDM among pregnant women in India.

METHODS

We conducted an initial article search on PubMed, Scopus, Google Scholar, and ShodhGanga searches to identify quantitative research papers (database inception till 15th June,2022). This review included prevalence studies that estimated the occurrence of GDM across different states in India.

RESULTS

Two independent reviewers completed the screening of 2393 articles, resulting in the identification of 110 articles that met the inclusion criteria, which collectively provided 117 prevalence estimates. Using a pooled estimate calculation (with an Inverse square heterogeneity model), the pooled prevalence of GDM in pregnant women was estimated to be 13%, with a 95% confidence interval (CI) ranging from 9 to 16%.. In India, Diabetes in Pregnancy Study of India (DIPSI) was the most common diagnostic criteria used, followed by International Association of Diabetes and Pregnancy Study Groups (IADPSG) and World Health Organization (WHO) 1999. It was observed that the rural population has slightly less prevalence of GDM at 10.0% [6.0-13.0%, I2=96%] when compared to the urban population where the prevalence of GDM was 12.0% [9.0-16.0%, I2 = 99%].

CONCLUSIONS

This review emphasizes the lack of consensus in screening and diagnosing gestational diabetes mellitus (GDM), leading to varied prevalence rates across Indian states. It thoroughly examines the controversies regarding GDM screening by analyzing population characteristics, geographic variations, diagnostic criteria agreement, screening timing, fasting vs. non-fasting approaches, cost-effectiveness, and feasibility, offering valuable recommendations for policy makers. By fostering the implementation of state-wise screening programs, it can contribute to improving maternal and neonatal outcomes and promoting healthier pregnancies across the country.

Comparison of Diabetes in Pregnancy Study Group India (DIPSI) and WHO criteria for diagnosis of gestational diabetes by assessment of fetomaternal outcomes

OBJECTIVE

To evaluate fetomaternal outcomes in women who are normoglycemic by Diabetes in Pregnancy Study Group India (DIPSI) but have gestational diabetes mellitus (GDM) by WHO criteria versus those who are normoglycemic by both DIPSI and WHO criteria.

METHODS

This was a prospective, cohort study. A total of 635 women participated. They underwent a 2-h non-fasting oral glucose tolerance test (OGTT) and results were interpreted by DIPSI. Out of 635 women, 52 were lost to follow up and 33 were diagnosed as GDM by DIPSI and excluded from the study. The remaining 550 women, after 72 h from the first test, underwent a 75-g fasting-OGTT and results were interpreted using WHO 2013 criteria. Results of the second test were blinded till delivery. The 550 women were followed for fetomaternal outcomes. Participants with normal DIPSI and normal WHO 2013 OGTT were labeled group 1. Participants with normal DIPSI but abnormal WHO 2013 OGTT were labeled group 2. Fetomaternal outcomes were compared between these groups.

RESULTS

Occurrence of GDM by DIPSI was 5.1%, by WHO 2013 criteria it was 10.5%. Composite fetomaternal outcomes occurred more commonly in women with a normal DIPSI but an abnormal WHO 2013 test. Out of 550 women, 492 had normal DIPSI and normal WHO 2013 test. Out of this 492, 116 (23.6%) women had adverse fetomaternal outcomes. Fifty-eight women out of 550 had a normal DIPSI but an abnormal WHO 2013 test. Thirty-seven (63.8%) women out of 58 had adverse fetomaternal outcomes. We found statistically significant association between adverse fetomaternal outcome and GDM by WHO 2013 test (with normal DIPSI test).

CONCLUSION

WHO 2013 has superior diagnostic value compared with DIPSI criteria for diagnosis of GDM.

A community health worker-led program to improve access to gestational diabetes screening in urban slums of Pune, India: Results from a mixed methods study

The World Health Organization recommends all pregnant women receive screening for gestational diabetes (GDM) with a fasting oral glucose tolerance test (OGTT). However, very few women receive recommended screening in resource-limited countries like India. We implemented a community health worker (CHW)-delivered program to evaluate if home-based, CHW-delivered OGTT would increase GDM screening in a low-resource setting. We conducted a mixed methods study in two urban slum communities in Pune, India. CHWs were trained to deliver home-based, point-of-care fasting OGTT to women in their third trimester of pregnancy. The primary outcome was uptake of CHW-delivered OGTT. Secondary outcomes included GDM prevalence and linkage to GDM care. Individual interviews were conducted with purposively sampled pregnant women, CHWs, and local clinicians to assess barriers and facilitators of this approach. From October 2021-June 2022, 248 eligible pregnant women were identified. Of these, 223 (90%) accepted CHW-delivered OGTT and 31 (14%) were diagnosed with GDM. Thirty (97%) women diagnosed with GDM subsequently sought GDM care; only 10 (33%) received lifestyle counseling or pharmacologic therapy. Qualitative interviews indicated that CHW-delivered testing was considered highly acceptable as home-based testing saved time and was more convenient than clinic-based testing. Inconsistent clinical management of GDM was attributed to providers' lack of time to deliver counseling, and perceptions that low-income populations are not at risk for GDM. Convenience and trust in a CHW-delivered GDM screening program resulted in high access to gold-standard OGTT screening and identification of a high GDM prevalence among pregnant women in two urban slum communities. Appropriate linkage to care was limited by clinician time constraints and misperceptions of GDM risk. CHW-delivered GDM screening and counseling may improve health education and access to preventive healthcare, offloading busy public clinics in high-need, low-resource settings.

A Mobile Clinical Decision Support System for High-Risk Pregnant Women in Rural India (SMARThealth Pregnancy): Pilot Cluster Randomized Controlled Trial

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women in India. Early identification is crucial to reducing deaths. Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) carry independent risks for future CVD, and antenatal care is a window to screen and counsel high-risk women. In rural India, community health workers (CHWs) deliver antenatal and postnatal care. We developed a complex intervention (SMARThealth Pregnancy) involving mobile clinical decision support for CHWs and evaluated it in a pilot cluster randomized controlled trial (cRCT).

OBJECTIVE

The aim of the study is to co-design a theory-informed intervention for CHWs to screen, refer, and counsel pregnant women at high risk of future CVD in rural India and evaluate its feasibility and acceptability.

METHODS

In phase 1, we used qualitative methods to explore community priorities for high-risk pregnant women in rural areas of 2 diverse states in India. In phase 2, informed by behavior change theory and human-centered design, we used these qualitative data to develop the intervention components and implementation strategies for SMARThealth Pregnancy in an iterative process with end users. In phase 3, using mixed methods, we evaluated the intervention in a cRCT with an embedded qualitative substudy across 4 primary health centres: 2 in Jhajjar district, Haryana, and 2 in Guntur district, Andhra Pradesh.

RESULTS

SMARThealth Pregnancy embedded a total of 15 behavior change techniques and included (1) community awareness programs; (2) targeted training, including point-of-care blood pressure and hemoglobin measurement; and (3) mobile clinical decision support for CHWs to screen women in their homes. The intervention focused on 3 priority conditions: anemia, HDP, and GDM. The evaluation involved a total of 200 pregnant women, equally randomized to intervention or enhanced standard care (control). Recruitment was completed within 5 months, with minimal loss to follow-up (4/200, 2%) at 6 weeks postpartum. A total of 4 primary care doctors and 54 CHWs in the intervention clusters took part in the study. Fidelity to intervention practices was 100% prepandemic. Over half the study population was affected by moderate to severe anemia at baseline. The prevalence of HDP (2.5%) and GDM (2%) was low in our study population. Results suggest a possible improvement in mean hemoglobin (anemia) in the intervention group, although an adequately powered trial is needed. The model of home-based care was feasible and acceptable for pregnant or postpartum women and CHWs, who perceived improvements in quality of care, self-efficacy, and professional recognition.

CONCLUSIONS

SMARThealth Pregnancy is an innovative model of home-based care for high-risk pregnant women during the transitions between antenatal and postnatal care and adult health services. The use of theory and co-design during intervention development facilitated acceptability of the intervention and implementation strategies. Our experience has informed the decision to initiate a larger-scale cRCT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03968952; https://clinicaltrials.gov/ct2/show/NCT03968952.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3389/fgwh.2021.620759.

Meta-analysis comparing diabetes in pregnancy study group India (DIPSI) vs the international association of the diabetes and pregnancy study groups (IADPSG) criteria for diagnosis of gestational diabetes among Indian population

Despite consensus on universal screening of women at 24-28 weeks for a diagnosis of gestational diabetes, controversy remains on an appropriate criterion. The study is aimed to find out the sensitivity and specificity of Diabetes in Pregnancy Study Group India (DIPSI) criteria compared to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosis of Gestational Diabetes Mellitus (GDM). A meta-analysis of studies comparing DIPSI as an index test to IADPSG as the reference test for diagnosing GDM was carried out. A total of 8 comparative studies were included. Pooled analysis showed a sensitivity of 0.44 [0.29 to 0.60] and specificity of 0.97 [0.94 to 0.98], which means the index test DIPSI will correctly identify only 44% of the subjects who have the disease (GDM positive) but it will also fail to identify 56% of the GDM positive subjects. Derek's funnel graph revealed fewerchances of publication bias. Though convenient, DIPSI criteria was not found to be sensitive enough for a diagnosis of GDM and missed an opportunity to improve pregnancy and subsequent long-term outcomes for a substantial number of women. Further studies should focus on comparing pregnancy outcomes for the two criteria, so that decision to adopt any criteria is more evidence-based.

Prediction of pre-eclampsia in diabetic pregnant women

Background & objectives

Gestational or preexisting diabetes is one of the risk factors of pre-eclampsia. Both are responsible for higher maternal and fetal complications. The objective was to study clinical risk factors of pre-eclampsia and biochemical markers in early pregnancy of women with diabetes mellitus (DM)/gestational diabetes mellitus (GDM) for the development of pre-eclampsia.

Methods

The study group comprised pregnant women diagnosed with GDM before the 20 wk of gestation and DM before pregnancy and the control group had age-, parity- and period of gestation-matched healthy women. Sex hormone-binding globulin (SHBG), insulin-like growth factor-I (IGF-I) and 25-hydroxy vitamin D [25(OH)D] levels and the polymorphism of these genes was evaluated at recruitment.

Results

Out of 2050 pregnant women, 316 (15.41%) women (296 had GDM and 20 DM before pregnancy) were included in the study group. Of these, 96 women (30.38%) in the study group and 44 (13.92%) controls developed pre-eclampsia. Multivariate logistic regression analysis indicated those who belonged to the upper middle and upper class of socio-economic status (SES) were likely to be at 4.50 and 6.10 times higher risk of developing pre-eclampsia. The risk of getting pre-eclampsia among those who had DM before pregnancy and pre-eclampsia in their previous pregnancy was about 2.34 and 4.56 times higher compared to those who had no such events, respectively. The serum biomarkers [SHBG, IGF-I and 25(OH)D] were not found to be useful in predicting pre-eclampsia in women with GDM. To predict risk of development of pre-eclampsia, the fitted risk model by backward elimination procedure was used to calculate a risk score for each patient. Receiver operating characteristic (ROC) curve for pre-eclampsia showed that area under the curve was 0.68 (95% confidence interval: 0.63-0.73); P<0.001.

Interpretation & conclusions

The findings of this study suggested that pregnant women with diabetes were at a higher risk for pre-eclampsia. SES, history of pre-eclampsia in previous pregnancy and pre-GDM were found to be the risk factors.

Prevalence of Hyperglycemia in Pregnancy and Related Screening Practices in Rural Dehradun: The First Population-Based Study from Uttarakhand (PGDRD-1)

Aims

Phase I of the Prevalence of Gestational Diabetes Mellitus in Rural Dehradun (PGDRD) project estimates hyperglycemia in pregnancy (HIP) prevalence and identifies gaps in the utilization of community-related services in rural areas of the Dehradun district (western Uttarakhand); a state where notably no prior population-based study has ever been conducted despite being an Empowered Action Group state for more than two decades.

Methods

Using a multistage random sampling technique, 1,223 pregnant women locally registered in the rural field practice area of a block were identified. Those requiring HIP screening were subjected to a 2-h 75 g oral glucose tolerance test during the house visit irrespective of their period-of-gestation and last meal timings, diagnosed using the Diabetes in Pregnancy Study Group India (DIPSI) criterion (when indicated). Data were collected by personal interviews using a pretested data collection tool. Statistical Package for Social Sciences version 20.0 was used for analysis.

Results

The overall HIP prevalence recorded was 9.7% (95% CI: 8.1-11.5%); the majority (95.8%) were GDM followed by overt DIP (4.2%). Less than 1% of the subjects (0.7%) self-reported pre-GDM. Despite this burden, more than three-fourths were never screened for HIP in their pregnancy. Of those tested, the majority availed secondary healthcare facilities. Few even had to bear expenses in private with a very handful being tested free-of-cost by ANM in the community; findings that altogether sharply contrast to those recommended by national protocols.

Conclusion

Despite the high HIP burden, beneficiaries are unable to utilize community-related universal screening protocols as desired.

High maternal glucose exacerbates the association between prenatal per- and polyfluoroalkyl substance exposure and reduced birth weight

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) exposure has been associated with reduced birth weight. However, the association may be complicated by glucose status due to PFAS impact on fetal growth and placental transport.

OBJECTIVES

To examine whether maternal glucose status modifies the association between prenatal PFAS exposure and birth weight z-score.

METHODS

We analyzed data of 1405 mother-child pairs from the prospective Shanghai Birth Cohort. Plasma concentrations of six PFAS were quantified in the first trimester. Fasting plasma glucose (FPG) was collected at 24-28 gestation weeks. A range of FPG cutoffs (4.9-5.4 mmol/L) covering current recommendations for gestational diabetes mellitus were used to define high and low FPG groups. Association between PFAS concentration and birth weight z-score was evaluated using multivariate linear regression in two FPG groups respectively, and the dose-response relationship was estimated with cutoffs ranging from low to high. We then used propensity score to counterbalance the effects of different PFAS concentrations between the high and low FPG groups, and run the regression again.

RESULTS

A doubling increase in concentrations of several PFAS was inversely associated with birth weight z-score. The association was more evident in high FPG groups and the magnitudes intensified when FPG cutoff increased. The strongest association was observed for PFOA, with the magnitude increased from -0.34 (95 % CI: -0.66, -0.03) for 5.0 mmol/L cutoff, to -0.41 (95 % CI: -0.77, -0.05) for 5.1 mmol/L cutoff, and further to -0.51 (95 % CI: -0.98, -0.03) for 5.3 mmol/L. Propensity score matching yielded similar results.

CONCLUSIONS

High maternal glucose level may increase the risk of reduced birth weight z-score related to prenatal PFAS exposure. Moreover, exploring the effects with different FPG cutoffs may contribute to providing intervention strategies for pregnant women with high PFAS exposure.

Evolution of Gestational Diabetes Mellitus across Continents in 21st Century

Over the last few decades, several definitions of gestational diabetes mellitus (GDM) have been described. There is currently not enough research to show which way is the best to diagnose GDM. Opinions differ in terms of the optimal screening and diagnostic measures, in part due to the differences in the population risks, the cost-effectiveness considerations, and the lack of an evidence base to support large national screening programs. The basic method for identifying the disease is the measurement of glucose plasma levels which may be determined when fasting, two hours after a meal, or simply at any random time. The currently increasing incidence of diabetes in the whole population, the altering demographics and the presence of lifestyle changes still require better methods of screening for hyperglycemia, especially during pregnancy. The main aim of this review is to focus on the prevalence and modifications to the screening criteria for GDM across all continents in the 21st century. We would like to show the differences in the above issues and correlate them with the geographical situation. Looking at the history of diabetes, we are sure that more than one evolution in GDM diagnosis will occur, due to the development of medicine, appearance of modern technologies, and the dynamic continuation of research.

Screening of GDM during COVID pandemic in an Italian setting: comparison between IADPSG and WHO '99 criteria

BACKGROUND

During pandemic period, a single fast glycemia value (≥ 92 mg/dl) performed within the recommended time window for the risk level defined by the Italian guidelines, was considered an acceptable surrogate for GDM diagnosis following Italian Diabetes Association recomendations.

METHODS

All pregnant women who performed an OGTT following Italian Guidelines from march 2020 to september 2021 and then delivered at our University Hospital were prospectively enrolled in this study. Primary outcome of the study was the number of women diagnosed with GDM with only the FPG value (≥ 92 mg/dl), following Italian Diabetes Societies recommendations for COVID 19 pandemic period. At the same time, the data of women who became diabetic according to the 1999 WHO criteria was collected too. The secondary outcome was the comparison of risk factors of women undergoing OGTT according to IADPSG and WHO'99 criteria for the diagnosis of GDM and associated clinical outcomes.

RESULTS

The number of women with a diagnosis of GDM following Italian guidelines in the 18-month period considered was 161. Only 109 (67.7%) had a fast glucose value ≥ 92 mg/dl. No differences between IADPSG and WHO'99 groups in relation to risk factors, with the exception for overweight and obesity, and clinical outcomes.

CONCLUSION

Recommendations of Italian Diabetes Societis for COVID 19 pandemic failed to recognize one third of GDM diagnosis. Clinical Trial Registration ClinicalTrials.gov, www.

CLINICALTRIALS

gov , NCT05026840, August 30, 2021, 'retrospectively registered'.

Screening for gestational diabetes, Ahmedabad, India

Objective

To implement a community-based screening and awareness-raising project for gestational diabetes in Ahmedabad, India.

Methods

The project took place between April 2016 and August 2019 in Ahmedabad. Medical college faculty members and medical officers trained 3582 paramedical staff on screening for gestational diabetes. These paramedical staff tested all pregnant women 24–28 weeks gestation, who were attending village health and nutrition days – also called mamta days – in urban and rural health centres for routine antenatal care, for gestational diabetes. An oral glucose tolerance test was used and blood sugar ≥ 7.8 mmol/L was the cut-off for gestational diabetes. Women with gestational diabetes were referred for counselling and treatment and all women were followed until 6 weeks after delivery.

Findings

Of 53 522 pregnant women screened, 6786 (12.7%) had gestational diabetes and were referred for nutritional therapy or medication; 836 (12.3%) of these women started medication. There was no significant difference in the prevalence of stillbirths between women with gestational diabetes (0.8%; 54/6786) and women without (0.7%; 338/46 736; P-value: 0.51). Of the women on treatment, 38 had abnormal blood glucose after delivery and continued with the medication. Two women with gestational diabetes died; they had other associated co-morbidities – pre-eclampsia and anaemia.

Conclusion

We found a high prevalence of gestational diabetes, indicating the need for gestational diabetes screening and implementation of this project on a larger scale. Gestational diabetes screening at the community level is operationally feasible using the existing human resources and infrastructure of the reproductive health programmes.

Diagnosing Gestational Diabetes with a Probably Too Simplified Diagnostic Procedure Compared to International Criteria: The Indian Case Study

Diagnostic procedures for the diagnosis of gestational diabetes mellitus (GDM) are not uniformly defined worldwide. We retrospectively applied two diagnostic procedures (i.e., the IADPSG and the Indian) to the same pregnant women in order to compare the clinical characteristics and the prevalence of risk factors for GDM. Overall, 1015 pregnant women were evaluated. GDM was diagnosed in 113 cases (11.1%) by the IADPSG criteria and in 105 cases (10.3%) by the Indian criteria. The women diagnosed with GDM according to the IADPSG criteria had higher pre-gestational BMIs, higher previous macrosomia rates, higher first trimester fasting blood glucose levels, higher fasting and 1 h glucose levels after glucose load at OGTT, and lower 2 h glucose levels at OGTT compared with the women with GDM diagnosed according to the Indian criteria. Only 49.6% of the women who were diagnosed by the IADPSG criteria were also diagnosed with GDM by the Indian diagnostic criteria. For 47.8% of the women who were diagnosed by the IADPSG criteria, a diagnosis of GDM was missed by applying the Indian diagnostic criteria. Interestingly, 49 women were diagnosed with GDM by the Indian criteria but were normal according to the IADPSG criteria. Different diagnostic criteria could lead to different GDM detection rates with different practical approaches.

CGMS profile of women diagnosed as GDM by IADPSG criteria and labelled as normoglycemic by alternate criteria in early pregnancy

AIMS/INTRODUCTION

We aimed to evaluate and compare CGMS-based glycemic parameters in women in early pregnancy (<20 weeks of gestation) who were classified as: a) GDM by IADPSG but normoglycemia by alternate (UK NICE, CDA and DIPSI) criteria, and b) normoglycemia by both (IADPSG and alternate) criteria.

MATERIAL AND METHODS

In this cross-sectional study, eligible women underwent standard 75-g OGTT, followed by the placement of a CGMS. Glycemia-related parameters were calculated using the standard approach for CGMS data in pregnancy.

RESULTS

We enrolled 96 women at 14.0 ± 3.2 weeks of gestation. Of the women diagnosed as GDM by IADPSG criteria, 34.2%, 26.3% and 44.7% were classified as normoglycemic by UK NICE, CDA and DIPSI criteria, respectively. Mean 1-h postprandial glucose and time above range were significantly higher in women who were GDM by IADPSG, but normoglycemia by CDA criteria, compared to women with normoglycemia using both criteria. Similarly, mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, 1-hr postprandial glucose excursion and time above range were significantly higher in women who were not identified as GDM by UK NICE criteria. Finally, women missed by DIPSI criteria had significantly higher mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, postprandial glucose excursion, 24-h glucose, and time above range parameters.

CONCLUSIONS

More than a quarter of women diagnosed as GDM by IADPSG criteria are not identified by alternate criteria. Such women are significantly different from normoglycemic women in terms of several CGMS-based glycemic parameters of clinical significance.

Gestational Diabetes Mellitus Among Pregnant Women Attending Ante-natal Clinic at a Secondary Care Health Facility in Haryana, India

Introduction: Gestational diabetes has serious health effects during pregnancy and childbirth. We estimated the occurrence of gestational diabetes mellitus (GDM) among pregnant women in a secondary care hospital in Haryana.

Methods: It was a hospital-based cross-sectional study, done in an ante-natal clinic (ANC) at a sub-district hospital (SDH), Faridabad district of Haryana, India. Eligible pregnant women attending the ANC clinic were recruited. An oral glucose tolerance test (OGTT) with 75 g of glucose was done with a collection of blood for fasting blood sugar (FBS) and two-hour post-OGTT blood glucose. A pre-tested semi-structured interview schedule was administered. Both the modified International Association of the Diabetes and Pregnancy Study Groups criteria (IADPSGC) and the Diabetes in Pregnancy Study Group of India (DIPSI) criteria were used. Data were presented as percentages, means, standard deviation, and 95% confidence interval (CI). Bi-variable and multi-variable logistic regressions were done. The level of significance was set at 0.05.

Results: Of the 623 eligible participants, 66.1% were within the 20-25 age group. The GDM was found in 14.1% (95%CI: 11.5-17.1) participants as per modified IADPSG criteria and 6.7% (95%CI: 4.9-9.0) participants as per DIPSI criteria, respectively. Increasing age [adjusted odds ratio (AOR): 1.24 (95% CI: 1.05-1.47), p=0.008] and increasing years of schooling [AOR: 1.19 (1.01-1.41), p=0.032] were significantly associated with GDM by DIPSI criteria. Family history of DM was also found to have an increased odds with GDM using modified IADPSG criteria [AOR 2.87 (95% CI: 1.09-7.54), p=0.032]. 

Conclusion: Considerable proportion of pregnant women were found to have GDM in a Sub-district hospital at Ballabgarh in north India. The study highlighted the need and generated evidence about the feasibility of GDM screening utilizing routine staff in a secondary care facility.

Peri-conceptional diet patterns and the risk of Gestational diabetes mellitus in South Indian women

OBJECTIVE

To identify peri-conceptional diet patterns among women in Bangalore, and examine their associations with risk of gestational diabetes mellitus.

DESIGN

BANGLES, started in June 2016, was a prospective observational study, in which women were recruited at 5-16 weeks' gestation. Peri-conceptional diet was recalled at recruitment, using a validated 224-item food frequency questionnaire. GDM was assessed by a 75-gram oral glucose tolerance test at 24-28 weeks' gestation, applying WHO 2013 criteria. Diet patterns were identified using principal component analysis and diet pattern-GDM associations were examined using multivariate logistic regression, adjusting for 'a priori' confounders.

SETTING

Antenatal clinics of two hospitals, Bangalore, South India.

PARTICIPANTS

785 pregnant women of varied socio-economic status.

RESULTS

GDM prevalence was 22%. Three diet patterns were identified: a) High-diversity, urban (HDU) characterised by diverse, home-cooked and processed foods was associated with older, more affluent, better-educated and urban women; b) Rice-fried snacks-chicken-sweets (RFCS), characterised by low diet-diversity, was associated with younger, less-educated, and lower income, rural and joint families; c) Healthy, traditional vegetarian (HTV), characterised by home-cooked-vegetarian and non-processed foods was associated with less-educated, more affluent, and rural and joint families. The HDU pattern was associated with a lower GDM risk (aOR: 0.80 per SD, 95% CI: 0.64, 0.99, p=0.04) after adjusting for confounders. BMI was strongly related to GDM risk and possibly mediated diet-GDM associations.

CONCLUSIONS

The findings support global recommendations to encourage women to attain a healthy pre-pregnancy BMI and increase diet-diversity. Both healthy and unhealthy foods in the patterns indicate low-awareness about healthy foods and a need for public-education.

Role of Serum Irisin During Early Pregnancy to Predict The Development of Gestational Diabetes Mellitus at 24-28 Weeks of Pregnancy in high-risk patients

AIMS

The aim of this prospective study was to investigate the role of serum irisin during early pregnancy to predict the development of GDM at 24-28 weeks in high-risk patients.

METHODOLOGY

This study was conducted among the pregnant women attending the Department of Endocrinology and antenatal clinic of Department of Obstetrics and Gynecology of MKCG Medical College for a period of one year with at least one risk factor for the development of gestational diabetes mellitus (GDM). Blood samples were collected for measurement of fasting plasma glucose, serum insulin, serum irisin, lipids (TC, LDL, HDL, TG), and HbA1c. Oral glucose tolerance test was performed using 75 g of glucose during the first trimester and between 24-28 weeks of pregnancy. Patients were diagnosed as GDM based upon IADPSG criteria at 24-28 weeks. Serum irisin, glycemic parameters, and homeostatic model assessment of insulin resistance during first trimester were analyzed for predicting GDM between 24-28 weeks.

RESULTS

Sixty-five patients were included in the study, out of which 20 (30.8%) patients developed GDM and the rest 45 patients had normal glucose tolerance (NGT). The first trimester mean serum irisin concentration was significantly lower in women who later developed GDM compared with women who had NGT (111.65 ± 25.43 μg/L vs 185.89 ± 28.89 μg/L). Serum irisin concentration was the best predictor with an optimal threshold value of 149 μg/L, which had sensitivity, specificity, positive predictive value, and negative predictive value of 90%, 91.1%, 81.8%, 95.3%, respectively, for predicting GDM at 24-28 weeks of pregnancy.

CONCLUSION

We suggest the utility of serum irisin as an early biomarker to predict the development of GDM later in pregnancy in high-risk patients.

Maternal vitamin D deficiency and GDM risk: evidence for the case of investing more attention in antenatal clinics

Gestational diabetes mellitus (GDM) is a global public health problem, and in India, it affects about 20% of pregnancies. India, despite being a tropical country with abundant sunshine has a high prevalence (80%) of vitamin D deficiency (VDD) among reproductive-aged women. Global and Indian evidence links VDD with a higher risk of hyperglycaemia in pregnancy and GDM. VDD has also been implicated in gestational hypertension, preterm birth and poorer offspring health. Global scientific consensus acknowledges the need for maternal vitamin D screening and supplementation, but knowledge gaps exist about optimal blood levels (50-100 nmol/l), and the required vitamin D dosage (400-4000 IU). Diet can provide <10% of the vitamin D requirements, food fortification can deliver limited amounts, and hence optimal antenatal supplementation is key. Prenatal calcium supplements containing 400 IU of vitamin D may be sufficient for calcium absorption and bone health, but may not provide immunomodulatory benefits, including GDM prevention. Increasing evidence calls for higher maternal vitamin D requirements (2000-4000 IU) for skeletal, metabolic and immune health benefits. Current screening and supplementation for maternal VDD in India is low. We need to invest in future studies to determine optimal maternal vitamin D requirements and formulate policies for vitamin D supplementation to prevent GDM. Improving the maternal vitamin D status is an important nutritional priority for policymakers to reduce the large economic burden of non-communicable diseases (10% of India's gross domestic product), and eventually achieve the 2030 UN sustainable development goals.

Negotiating Gestational Diabetes Mellitus in India: A National Approach

The worldwide epidemic of diabetes mellitus and hyperglycemia in pregnancy (HIP) presents many challenges, some of which are country-specific. To address these specific problems, parochial resolutions are essential. In India, the government, by working in tandem with (a) national groups such as the Diabetes in Pregnancy Study Group of India, and (b) global organizations such as the International Diabetes Federation, has empowered the medical and paramedical staff throughout the country to manage HIP. Additionally, despite their academic university backgrounds, Indian health planners have provided practical guidelines for caregivers at the ground level, who look up to these experts for guidance. This multipronged process has helped to negotiate some of the multiple problems that are indigenous and exclusive to India. This review traces the Indian journey to manage and prevent HIP with simple, constructive, and pragmatic solutions.

Indian Research in Gestational Diabetes Mellitus during the Past Three Decades: A Scientometric Analysis

Background

India plays an important role in global research on gestational diabetes mellitus (GDM), but a bibliometric assessment of this research is lacking.

Objective

To provide a comprehensive analysis of Indian GDM research during the last 30 years using select bibliometric indicators.

Methods

The Scopus international database was used to retrieve publication data, using a defined search strategy. The analysis focused on research output of Indian authors and organizations and their collaborations. The qualitative performance was assessed in terms of relative citation index and citations per paper (CPP).

Results

Overall, 100 countries participated in GDM research producing 13,193 publications during 1990-2019. India ranked ninth in global output (1182 publications, 3.1% share) and CPP of 18.6. Only 21.3% of publications had international collaboration and 9.4% were funded. Of the 235 organizations and 544 authors that participated in India's research on GDM, the top 50 organizations and authors contributed 53.8 and 36.4% to national publication share, respectively. The leading productive organizations were AIIMS, New Delhi, KEMH, Pune and PGIMER, Chandigarh, whereas the most productive authors were S. Kalra, V. Seshiah and C.S. Yajnik. Indian Journal of Endocrinology and Metabolism, Journal of Clinical and Diagnostic Research, Journal of Obstetrics and Gynecology of India and Diabetes Research and Clinical Practice were the most productive journals.

Conclusions

Indian research on GDM is lagging behind other countries which have a similar disease burden. Increasing national and international collaborations, and active support of national and international funding agencies is urgently required to produce quality research on GDM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-021-01444-7.

A Prospective Study to Determine if Management of Cases of Gestational Diabetes Mellitus (GDM) can be Modified

Background

To study maternal-fetal outcomes in patients of GDM diagnosed by International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria but subsequently using a twenty-four-hour seven-value sugar profile to evaluate patients before instituting management.

Methods

This prospective observational study was conducted at a tertiary hospital in New Delhi, India, over a period of one year. During this period, women diagnosed as GDM between 24 and 28 weeks of gestation using IADPSG criteria underwent seven-value sugar profile in twenty-four hours before initiating any therapy. Those with normal profile were kept on observation only, whereas others were managed by Medical Nutrition Therapy (MNT) with or without pharmacotherapy as required to maintain euglycemia. Maternal and fetal outcomes were documented and analysed to detect differences between the groups.

Results

Out of 2279 pregnant women, 201 (8.8%) were diagnosed as GDM. The twenty-four-hour seven-value sugar profile was normal in 78 (38.8%) patients, who were managed only by close observation. Treatment was given to other patients; 93 (46.2%) patients were managed with MNT only, whereas pharmacotherapy by way of metformin was added to 22 (10.9%) patients and 8 (3.9%) patients required insulin. Differences in maternal-fetal outcomes between the treated and untreated groups were not found to be statistically significant.

Conclusions

The policy of evaluating patients with twenty-four-hour seven-value sugar profile after an abnormal Oral Glucose Tolerance Test eliminated over one-third women from receiving treatment and interventions for GDM without compromising maternal-fetal outcomes.

Prevalence of 'Hyperglycemia in pregnancy' remained stable between 2006 and 2015, despite rise in conventional risk factors: A hospital based study in Delhi, North India

AIMS

Between 2006 and 2015, the trends in prevalence of Hyperglycemia in pregnancy (HIP); Gestational diabetes (GDM), Diabetes in Pregnancy (DIP), Pre existing diabetes (PDM) and GDM risk factors were studied in 30,692 pregnancies among Asian Indian women.

METHODS

GDM (n = 4089) and DIP (n = 259) diagnoses were by 75 g OGTT, while PDM (n = 103) was identified by ICD code O24. Women with DIP and PDM were grouped together as pre-gestational diabetes (PGDM n = 362). Crude and age-adjusted prevalence trend analysis by Poisson and Jointpoint regression models respectively, were done in GDM and PGDM groups.

RESULTS

During study years, the GDM prevalence by WHO 1999 and modified IADPSG criteria, showed decreasing and static trends respectively, while PGDM prevalence remained static. In a subgroup of 2560 women, mean BMI increased from 24.12 ± 4.16 in year 2011 to 25.18 ± 4.7 Kg/m² in 2015 (p < 0.014), but this rise had no impact on GDM prevalence. GDM risk factors; maternal age, gravidity ≥3, previous GDM and abortion, high income, diabetes and hypertension in family, were higher in 2011-2015 than in 2006-2010 period. On multivariate analysis, BMI was not an independent GDM risk factor.

CONCLUSION

Despite rise in conventional GDM risk factors, HIP prevalence was static for a decade among pregnant Asian Indian women.

Gestational diabetes in rural central India: low prevalence but absence of typical risk factors

Introduction

The reported prevalence of gestational diabetes mellitus (GDM) varies widely across India. Given the short-term, long-term, and multigenerational health impacts of GDM, understanding its frequency and risk factors is important for population screening strategies. We estimated the prevalence of GDM and determined associated risk factors in rural, central India, where data is sparse.

Methods

We conducted a cross-sectional study of a convenience sample of 575 pregnant women attending antenatal care (ANC) clinics at Jan Swasthya Sahyog's (JSS) outreach clinics in rural Chhattisgarh, India. Study participants underwent a non-fasting 75g oral glucose tolerance test (OGTT) between 24-28 weeks gestation. Using Diabetes in Pregnancy Study Group of India (DIPSI) criteria, a 2-hour post-OGTT glucose ≥140 mg/dL was used to diagnose GDM.

Results

We found 11 patients (1.9%) who met diagnostic criteria for GDM. Median age, systolic blood pressure, and diastolic blood pressure were higher in those with GDM (26 vs 23 years, p = 0.02; 117 vs 106 mmHg, p = 0.04, 77 vs 68 mmHg, p < 0.01, respectively). Pre-hypertension was associated with increased odds of GDM on multivariate analysis (OR 4.0, 95% CI: 1.1, 14.8). BMI was not associated with GDM. With appropriate management there were no differences in fetal complications between GDM and normal glucose tolerance (NGT) groups.

Conclusions

In rural, central India the prevalence of GDM was 1.9% in the absence of traditional risk factors such as increased BMI. Further research is needed to define the applicability of optimal screening strategies in such settings.

Health care professionals' perspectives on screening and management of gestational diabetes mellitus in public hospitals of South India - a qualitative study

BACKGROUND

Women developing Gestational Diabetes Mellitus (GDM) are subsequently at a higher risk of developing Type 2 Diabetes later in life. Screening and effective management of women with GDM are essential in preventing progression to type 2 diabetes mellitus. We aimed to explore the perspectives of healthcare providers regarding the barriers from the health system context that restrict the timely screening and effective management of GDM.

METHODS

We conducted six in-depth interviews of health care providers- four with nurses and two with obstetricians in the public hospitals in India's major city (Bengaluru). The interviews were conducted in the preferred language of the participants (Kannada for nurses, English for the obstetricians) and audio-recorded. All Kannada interviews were transcribed and translated into English for analysis. The primary data were analyzed using the grounded theory approach by NVivo 12 plus. The findings are put into perspective using the socio-ecological model.

RESULTS

Health care providers identified delayed visits to public hospitals and stress on household-level responsibilities as barriers at the individual level for GDM screening. Also, migration of pregnant women to their natal homes during first pregnancy is a cultural barrier in addition to health system barriers such as unmet nurse training needs, long waiting hours, uneven power dynamics, lack of follow-up, resource scarcity, and lack of supportive oversight. The barriers for GDM management included non-reporting women to follow - up visits, irregular self-monitoring of drug and blood sugar, trained staff shortage, ineffective tracking, and lack of standardized protocol.

CONCLUSION

There is a pressing need to develop and improve existing GDM Screening and Management services to tackle the growing burden of GDM in public hospitals of India.

Increasing prevalence of gestational diabetes mellitus when implementing the IADPSG criteria: A systematic review and meta-analysis

AIMS

Quantify the proportional increase in gestational diabetes (GDM) prevalence when implementing the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria compared to prior GDM criteria, and to assess risk factors that might affect the change in prevalence.

METHODS

A systematic review and meta-analysis was performed of cohort and cross-sectional studies between January 1, 2010 to December 31, 2018 among pregnant women with GDM using IADPSG criteria compared to, and stratified by, old GDM criteria. Web of science, PubMed, EMBASE, Cochrane, Open Grey and Grey literature reports were included. The relative risk for each study was calculated. Subgroup analyses were performed by maternal age, body mass index, study design, country of publication, screening method, sampling method and data stratified according to diagnostic criteria.

RESULTS

Thirty-one cohort and cross-sectional studies with 136 705 women were included. Implementing the IADPSG criteria was associated with a 75% (RR 1.75, 95% CI 1.53-2.01) increase in number of women with GDM with evidence of heterogeneity.

CONCLUSIONS

The IADPSG criteria increase the prevalence of GDM, but allow movement towards more homogeneity. More studies are needed of the benefits, harms, psychological effects and health costs of implementing the IADPSG criteria.

Prevalence, risk factors and morbidities of gestational diabetes among pregnant women attending a hospital in an urban area of Bhubaneswar, Odisha

Background

Gestational diabetes mellitus (GDM) causes several maternal and neonatal complications.

Aims

This exploratory study was conducted to estimate the prevalence, determine the risk factors and morbidities among pregnant women.

Methods

In this prospective study, 1557 pregnant women attending the Gyn. & Obs. clinic of a hospital in an urban area of Bhubaneswar were enrolled. Various socio-demographic factors and clinical profiles were assessed. We used a Glucometer for the diagnosis of GDM.

Results

More younger pregnant women residing in slums, sedentary and overweight were having diabetes. A large percentage of pregnant women living in rural areas and slums visit the government hospitals as they are benefitted by the State govt.'s scheme, Mamata. Pregnant women residing in the urban areas prefer to go for ante-natal check-ups in private Nursing homes/Clinics owing to the crowd and prolonged waiting hours. In this study, body mass index (BMI) and family history of the pregnant women appeared to be the significant risk factors for the gestational diabetes. Out of 1557 pregnant women, 154 were having diabetes, the prevalence being 9.89%. This is low when compared to the studies reported from other regions of the country.

Conclusions

Gluco-One is suitable for screening gestational diabetes using the optimal threshold capillary glucose level of 140 mg/dl. As the pregnant women find it difficult to come the next day just to collect the results, this facilitated in getting the test results promptly and appropriate consultation by Doctor the same day. Glucometer can be used for accurate screening of gestational diabetes mellitus. Pregnant women with screening values not normal were identified on the spot and followed up at regular intervals. Screening for diabetes among pregnant women would result in early case detection indirectly resulting in better outcomes of treatment and prevention of complications.

Food habits in pregnancy and its association with gestational diabetes mellitus: results from a prospective cohort study in public hospitals of urban India

Background

Few studies have explored the relationship between food habits and the risk of gestational diabetes mellitus (GDM) in women from India. We aimed to investigate the associations of food habits and the risk of GDM.

Methods

As part of the MAASTHI prospective cohort study in urban Bengaluru, India, pregnant women between 18 and 45 years, less than 36 weeks of gestation were included. During baseline, the participant’s age, education, physical activity levels, and food habits were recorded. Screening of GDM was done by the World Health Organization diagnostic criteria using a 2-h 75-g oral glucose tolerance test between the 24th–36th weeks of gestation.

Results

We included 1777 pregnant women in the study. We show that 17.6% of the women had GDM, of which 76.7% consume red meat. Red meat consumption was associated with an increased risk of GDM (aRR = 2.1, 95% CI 1.5, 2.9) after adjusting for age, family history of diabetes and socioeconomic status.

Conclusion

The high intake of red meat consumption in pregnancy needs further examination. Also, future evaluations should consider evaluating the risk of red meat consumption against the combined effect of inadequate consumption of vegetables, fruits, and dairy products in pregnant women. Interventions to educate women in lower socioeconomic status on inexpensive, seasonal, and healthy food might be helpful.

Prevalence and predictors of gestational diabetes mellitus in rural Assam: a cross-sectional study using mobile medical units

OBJECTIVE

To determine the prevalence and predictors of gestational diabetes mellitus (GDM) in rural Assam, India using a network of Mobile Medical Units.

STUDY DESIGN

A field-based cross-sectional study.

SETTINGS

Rural areas of Assam state, India.

PARTICIPANTS

A total of 1410 pregnant women in gestational age of 24-28 weeks INTERVENTION: Identification of pregnant women in 24-28 weeks of pregnancy from villages and administering them Government of India recommended oral glucose tolerance test for GDM confirmation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Presence of gestational diabetes among pregnant women, risk factors and predictors of GDM.

RESULTS

A total of 1212 pregnant women underwent the oral glucose tolerance test. One hundred and ninety-eight women were ineligible due to existing chronic diseases or very high blood glucose level before the test. The overall GDM prevalence in Assam was 16.67% (95% CI 14.61% to 18.89%). Women aged 26-30 years (adjusted odds ratio, aOR 1.70; CI 1.14 to 2.52), who passed 10th class (aOR 1.58; CI 1.05 to 2.37), belonging to Muslim religion (aOR 1.52; 95% CI 1.05 to 2.21) and above poverty line (aOR 1.38; 95% CI 1.00 to 1.91) had significantly increased likelihood of developing GDM compared with respective baseline groups (p<0.05). Body mass index, gravida and being non-anaemic were non-significant risk factors for GDM. Family history of diabetes (aOR 1.82; 95% CI 1.08 to 3.06) and smoking (aOR 1.61; 95% CI 1.10 to 2.35) were significant and independent predictors of GDM.

CONCLUSION

The prevalence of GDM in rural Assam is high. The mobile medical units may play a significant role in the implementation of GDM screening, diagnosis, treatment to ensure better maternal and foetal health outcomes in rural Assam.

Prevalence of Gestational Diabetes in India by Individual Socioeconomic, Demographic, and Clinical Factors

IMPORTANCE

Gestational diabetes is common in pregnancy and is associated with adverse pregnancy and fetal outcomes. Currently, population-based data on the prevalence of gestational diabetes are limited in India.

OBJECTIVE

To provide a comprehensive national assessment of gestational diabetes in India and its socioeconomic, demographic, and geographic associations, using elevated random blood glucose data as a proxy for a gestational diabetes diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed the fourth National Family Health Survey, conducted in India between January 2015 and December 2016. This nationally representative sample comprised 699 686 women 15 to 49 years of age, of whom 32 428 (4.6%) were pregnant. Data were analyzed between July and December 2019 and between July and August 2020.

EXPOSURES

Age, body mass index, hypertension, wealth, and social caste were factors potentially associated with gestational diabetes.

MAIN OUTCOMES AND MEASURES

Gestational diabetes, defined as elevated random blood glucose according to predetermined thresholds (≥200 mg/dL for nonfasting, ≥92 mg/dL for fasting).

RESULTS

Of the 31 746 pregnant women with complete data in the study, the mean (SD) age was 24.3 (4.7) years, and the mean (SD) gestational age was 5.1 (2.3) months. The weighted age-adjusted prevalence of gestational diabetes was 1.3% (95% CI, 1.1%-1.5%). The prevalence of gestational diabetes increased with age, from 1.0% (95% CI, 0.5%-1.5%) at age 15 to 19 years to 2.4% (95% CI, 1.0%-3.8%) at age 35 years or older. The age-adjusted prevalence of gestational diabetes was higher among women with a body mass index of 27.5 or greater (1.8%; 95% CI, 1.0%-2.5%) compared with women with a body mass index of less than 18.5 (0.8%; 95% CI, 0.5%-1.1%), among women in the highest wealth quartile (1.7%; 95% CI, 1.1%-2.5%) compared with those in the lowest (0.9%; 95% CI, 0.7%-1.2%), and women in the south (eg, Kerala: 4.5%; 95% CI, 2.4%-6.7%; Telangana: 5.4%; 95% CI, 0.0%-11.0%) compared with the northeast (eg, Assam: 0.23%; 95% CI, 0.0%-0.48%; Mizoram: 0.16%; 95% CI, 0.0%-0.49%).

CONCLUSIONS AND RELEVANCE

In this study, considerable variation was found in the prevalence of gestational diabetes by state, socioeconomic status, and demographic factors. This finding has implications for the method of gestational diabetes screening in low-resource settings in India, especially in areas or among demographic groups with lower prevalence.

Comparison of criteria of International Association of Diabetes and Pregnancy Study Groups (IADPSG) with National Institute for Health and Care Excellence (NICE) for diagnosis of gestational diabetes mellitus

BACKGROUND

Different screening procedures and diagnostic criteria are being followed in the same as well as in different countries with no single standard criteria established for diagnosis of GDM. So far, there are no studies in the Indian population comparing IADPSG with NICE criteria.

OBJECTIVE

To compare International Association of Pregnancy and Study Groups (IADPSG) criteria with the National Institute for Health and Care Excellence (NICE) for diagnosis of gestational diabetes mellitus and its influence on maternal and perinatal outcomes.

METHOD

This prospective observational study was conducted in the Department of Obstetrics and Gynaecology of a tertiary care institute in South India from March 2017 to October 2018. Six-hundred and eighty women with or without risk factors for GDM were recruited in the study and screened for GDM based on IADPSG and NICE criteria. Women with preexisting diabetes mellitus or with fasting plasma glucose ≥ 126 mg/dl were excluded.

RESULTS

The overall prevalence of GDM in our study was 27.2% by either IADPSG/NICE criteria. In this study, 25.1% women and 11.6% women were diagnosed as GDM using IADPSG and NICE criteria, respectively. The level of agreement between the two diagnostic criteria was found to be poor in our study and was statistically significant (kappa = 0.429, p < 0.001). Women testing IADPSG-positive NICE-negative had a higher risk of GHTN, abortions, PROM, preterm delivery, caesarean section and congenital anomalies, meconium-stained liquor, and low Apgar scores at 1 min when compared to non GDM group. In addition, except for preterm delivery, women diagnosed as GDM by both IADPSG and NICE criteria had adverse outcomes such as preeclampsia, urinary tract infection, and polyhydramnios. Women diagnosed as GDM in IADPSG-negative NICE-positive had no significant adverse maternal or perinatal outcomes.

CONCLUSIONS

IADPSG criteria appear to be more robust than NICE criteria for diagnosis of GDM. Women with substantial risk of maternal and perinatal outcomes are better identified by IADPSG criteria who would have been missed if NICE criteria was used.

A step towards real-time implementation of GDM guidelines in India: Review of Gaps in RCH Programme

Gestational Diabetes Mellitus (GDM) risks the affected mother-child duos not only with respect to adverse perinatal outcomes but also for chronic diseases later in life. Therefore, in 2014, the Government of India (GoI) mandated universal GDM screening for all pregnant women as a part of essential obstetric care within the Reproductive and Child Health (RCH) programme. Later in 2018, the domain experts from GoI envisaged pan India implementation of GDM screening services within its RCH framework by 2023. As Uttarakhand—a hilly, EAG state of north India—would also be part of this nation-wide drive; prior identification of RCH services coverage in the State assumes paramount importance, as it reflects probable executability of GDM screening services within its delivery platform. Therefore, the present review aims to assess the readiness of Uttarakhand maternal health functionary system in view of GDM national guidelines implementation at both state and district levels. In this regard, freely accessible, full-text GoI documents pertaining to GDM implementation guidelines and maternal health program of India and Uttarakhand available in public domain in English language were reviewed. The present review favors the pilot implementation in district Dehradun prior to implementing in all districts of the state. It may, however, require overall improvement in maternal health programmatic services in all parts of the State for much efficient service delivery. Effective implementation of GDM guidelines requires urgent correction in the background performance of RCH program.

Is there a connection between gestational diabetes mellitus, human immunodeficiency virus infection, and tuberculosis?

Pregnancy is associated with insulin resistance similar to that found in type 2 diabetes mellitus (DM). The prevalence of gestational diabetes mellitus (GDM) in key tuberculosis (TB) endemic countries, such as India and China, has been increasing rapidly in the last decade and may be higher in human immunodeficiency virus (HIV) infected women. Pregnancy is also an independent risk factor for developing active TB; however, little is known about the interaction of GDM, HIV and TB. We review the epidemiology and immunology of GDM, and significant research gaps in understanding the interactions between GDM, pregnancy, and TB in women living with and those without HIV.

Projections of the prevalence of hyperglycaemia in pregnancy in 2019 and beyond: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIM

Hyperglycaemia in pregnancy (HIP) is one of the most common complications of pregnancy. This study aims to examine the projected HIP prevalence in 2030 and 2045 using multiple methods.

METHODS

The International Diabetes Federation Diabetes Atlas 2019 prevalence was projected to 2030 and 2045 by: (1) carrying forward the 2019 age-adjusted prevalence rates; (2) applying a linear regression of the past four editions of the IDF Diabetes Atlas; (3) applying a regression of the previous editions with the most consistent trend, followed by extrapolation from the 9th edition HIP estimate.

RESULTS

Respectively, for 2030 and 2045, Method 1 projected a declining HIP rate with prevalences of 14.0% and 13.3%, Method 2 projected an increasing HIP prevalence at 16.5% and 18.3%, Method 3 predicted stabilisation of the rate from 16.0% to 15.8%.

CONCLUSION

Assuming other factors remain unchanged, our best estimation of age-adjusted HIP will show stabilisation between 2019 and 2045 of 15.8% to 16.0%. However, this estimate is confounded by the heterogeneity of studies and the influence of different gestational diabetes mellitus diagnostic criteria. To provide accurate future comparisons we recommend standardising the diagnostic criteria to the International Association of Diabetes in Pregnancy Study Groups.

Increased risk of non-alcoholic fatty liver disease in women with gestational diabetes mellitus: A population-based cohort study, systematic review and meta-analysis

AIMS

Non-Alcoholic Fatty Liver Disease (NAFLD) is one of the leading causes of liver transplantation in the West. This study seeks to examine whether women with gestational diabetes mellitus (GDM) are at increased risk of developing NAFLD compared to women without GDM.

METHODS

We conducted a population-based retrospective matched-controlled cohort study utilising The Health Improvement Network (THIN), a large primary care database representative of the United Kingdom population, between 01/01/1990 to 31/05/2016 followed by systematic review of available literature. The study population included 9640 women with GDM and 31,296 controls without GDM, matched for age, body mass index (BMI) and time of pregnancy. All study participants were free from NAFLD diagnosis at study entry. Patients with GDM and patients developing NAFLD were identified by clinical codes.

RESULTS

The median (range) follow-up duration was similar in women with and without GDM (2.95 (1.21-6.01) vs 2.85 (1.14-5.75) years respectively). Unadjusted incidence rate ratio (IRR) for NAFLD development in women with vs without GDM was 3.28 (95% CI 2.14-5.02), which remained significant after adjustment for wide range of potential confounders (IRR 2.70; 95% CI 1.744-4.19). The risk of NAFLD in GDM remained high (IRR 2.46: 95% CI 1.51-4.00) despite women being censored after they developed type 2 diabetes. The meta-analysis of 3 studies (including the current study) showed increased NAFLD risk in women with vs without GDM (OR 2.60; 95% CI 1.90-3.57, I₂ = 0%). As our study is based on routine clinical diagnosis of NAFLD, this study could potentially have underestimated the risk of NAFLD development.

CONCLUSIONS

Women with GDM are at increased risk of developing NAFLD in their later life compared to women without GDM regardless of the development of type 2 diabetes. Clinicians should have a low threshold to investigate women with history of GDM for the presence of NAFLD. Further studies to identify screening strategies are needed.

Prevalence of gestational diabetes mellitus in Eastern Mediterranean region: a systematic review and meta-analysis

PURPOSE

Gestational diabetes mellitus (GDM) is one of the costly challenges in the health field. Despite the individual studies in the Eastern Mediterranean, there is no comprehensive study in this regard. The aim of this study was to determine the prevalence of GDM in the Eastern Mediterranean region.

METHODS

In this meta-analysis and systematic review, three international databases (PubMed, Web of science and Scopus) were searched from inception until 30 December 2018. The Hui tool was used to assess the quality of the included studies.

RESULTS

Thirty-three studies performed on 887166 participants were included in the meta-analysis. Based on the results of random effect method, the overall prevalence of GDM was 11.7%. Between six country with have three or more study, pooled prevalence for Saudi Arabi it was 3.6 times more than Israel (17.6 vs. 4.9%), and for Pakistan, Qatar, Bahrain and Iran were 15.3%, 14.7%, 12.2%, and 8.6%, respectively.

CONCLUSION

Despite the high diversity of methods, the results of the present study indicate a high prevalence of GDM in the Eastern Mediterranean region, indicating more policymakers' interest in timely screening and proper management.

Evaluation of guidelines on the screening and diagnosis of gestational diabetes mellitus: systematic review

OBJECTIVE

Guidelines for screening and diagnosis of gestational diabetes mellitus (GDM) have been updated in the past several years, and various inconsistencies exist across these guidelines. Moreover, the quality of these updated guidelines has not been clarified. We thus conducted this systematic review to evaluate the relationship between the quality and detailed recommendations of these guidelines.

DATA SOURCES

The Guidelines International Network Library, the National Institute for Health and Clinical Excellence (NICE) database, the Medline database, the Embase and the National Guidelines Clearinghouse were searched for guidelines containing recommendations on screening and diagnosis strategies for GDM between 2009 and November 2018.

METHODS

Guidelines included a target group of women with GDM, and contained recommendations for screening and diagnostic strategies for GDM were included in the present systematic review. Reviewers summarised recommendations on screening and diagnosis strategies from each guideline and rated the quality of guidelines by using the Appraisal of Guidelines Research and Evaluation (AGREE) criteria.

RESULTS

A total of 459 citations were collected by the preliminary literature selection, and 16 guidelines that met the inclusion criteria were assessed. The inconsistencies of the guidelines mainly focus on the screening process (one step vs two step) and criteria of oral glucose tolerance test (OGTT) (International Association of Diabetes and Pregnancy Study Groups [IADPSG] vs CarpenterandCoustan). Guidelines with higher AGREE scores usually recommend a one-step OGTT strategy with IADPSG criteria between 24 and 28 gestational weeks, and the majority of these guidelines likely to select evidence by Grading of Recommendations Assessment, Development and Evaluation criteria.

CONCLUSIONS

The guidelines of WHO-2013, NICE-2015, American Diabetes Association-2018, Endocrine Society-2013, Society of Obstetricians and Gynaecologists of Canada-2016, International Federation of Gynecology and Obstetrics-2015, American College of Obstetricians and Gynecologists-2018, United States Preventive Services Task Force-2014 and IADPSG-2015 are strongly recommended in the present evaluation, according to the AGREE II criteria. Guidelines with higher quality tend to recommend a one-step 75 g OGTT strategy with IADPSG criteria between 24 and 28 gestational weeks.

The Role of Inflammation in the Development of GDM and the Use of Markers of Inflammation in GDM Screening

Gestational diabetes mellitus is a hyperglycaemic state first recognised in pregnancy. GDM affects both mother and child. Women with GDM and their new-borns are at risk of developing type 2 diabetes in the future. The screening and diagnostic criteria for GDM are inconsistent and thus novel biomarkers of GDM are required to strengthen the screening and diagnostic processes in GDM. Chronic low-grade inflammation is linked to the majority of the well-established risk factors of GDM such as old age, obesity and PCOS. This review provides an overview of the present knowledge on the pathology of GDM, the screening criteria applied, the role of inflammation in the development of GDM and the use of markers of inflammation namely cytokines, oxidative stress markers, lipids, amino acids and iron markers in screening and diagnosis of GDM.