Medicosnext
Dr. Dina Shrestha
She is an endocrinologist working in diabetes, thyroid disorders, obesity, and endocrine research. She currently serves as a Senior Consultant Endocrinologist at Norvic International Hospital and Siddhi Polyclinic, Kathmandu. Dr. Dina is the President of the South Asian Obesity Forum and has previously led both the Diabetes and Endocrine Association of Nepal (DEAN) and the South Asian Federation of Endocrine Societies (SAFES). She is a founding member of the Diabetes Rehabilitation and Research Centre (DRRC) and chairs the Trial Steering Committee for the Co-Direct Nepal Study. She is actively involved in various national and international organizations, serving as an executive member of the PCOS Society Nepal and the Down’s Syndrome Society of Nepal (DSSHA), and as a member of the Global Endocrine Leadership Coalition (GELC) and the ISE Advocacy Working Group. Dr. Dina also contributes to academic publishing as an international editorial board member of the Asian Journal of Obesity and was the Chief Editor for the National Consensus Statement on Type 2 Diabetes Mellitus and Hypothyroidism. Her research interests include thyroid disorders and diabetes in pregnancy, as well as obesity management. She has authored numerous national and international publications in these fields.
“What if a mother’s blood sugar level during pregnancy could shape her child’s health for life—even before birth? Hyperglycemia in pregnancy does exactly that, silently influencing not just the pregnancy but the long-term health of both mother and child.”
Hyperglycemia in pregnancy is one of the most common endocrine disorders during pregnancy and has a huge impact on both intra and intergeneration. Both the mother and the fetus are at risk of its complications and it has well established the role it plays during fetal life affecting the fetal programming leading to increased morbidity and mortality. Hyperglycemia has a profound impact on the life of the fetus which can start at birth and during adolescence or adulthood with higher incidence of type 2 diabetes despite their normal BMI and risk of early onset.
With the genetic predisposition, environmental triggers are rampant in our daily life which makes healthy life a challenge especially in the urban areas. Access to calorie dense junk food, lack of physical labor or exercise, endocrine disruptors, obesity, stress and lack of sleep, all play a role in this increase in the incidence of hyperglycemia in pregnancy.
Hyperglycemia in pregnancy mirrors the incidence of Type 2 diabetes in the community and we know that unfortunately Type 2 diabetes is a pandemic on the rise despite all our efforts, either in our community, region and globally. Every predicted prevalence for the number of Type 2 diabetes by IDF in the past few decades has been exceeded by millions. Today according to the IDF 589 million people are living with diabetes and interestingly the numbers are worse for pre diabetics which stands at around 635 million. Hence hyperglycemia during pregnancy is quite rampant. As opposed to the statistics of 1 in 6 pregnancies worldwide the estimated incidence in South Asia is even worse with 1 in 4 to 1 in 5 pregnancies that are affected by hyperglycemia and it is hence important that we know how to detect early and manage the disease before we see its dire complications.
Major challenges in our clinical settings are the diagnosis, when to screen, whom to screen and when to treat and how to treat.
GDM Vs DIP Know the difference
Awareness for the correct diagnosis is of utmost importance. Physicians and clinicians need to differentiate the Hyperglycemia in pregnancy and only once established the correct diagnosis can we treat the patient accordingly. It is utmost important to differentiate between Diabetes in pregnancy (DIP) and Gestational Diabetes (GDM). DIP needs aggressive management as the complications are higher while in patients with GDM almost 60-80 percent can be managed with lifestyle and then metformin only, whilst patients with DIP need insulin and usually multiple injections daily.
Very often any kind of hyperglycemia diagnosed during pregnancy is loosely labelled as GDM and this sometimes can have dire consequences as congenital malformations and other serious fetal complications are common in DIP and maternal complications like pre-eclampsia with HELLP syndrome and placental abruption or worsening of their retinopathy and nephropathy can be observed in these individuals with DIP unlike GDM.
Simply put DIP is hyperglycemia in pregnancy when:
1. Preexisting Type 1 Diabetes Mellitus
2. Preexisting Type 2 Diabetes mellitus
3. Diabetes diagnosed during the 1st trimester which reaches the ADA /WHO criteria for Diabetes which is (FBG: 126 mg/dl, Post Prandial 200 mg/dl, Hba1c >_ 6.5% )
4. Diabetes diagnosed during any trimester which reaches the ADA /WHO criteria for Diabetes which is (FBG: 126 mg/dl, Post Prandial 200 mg/dl, Hba1c>- 6.5%)
When to screen & whom to screen
South Asians are at high risk so universal screening at 24-28 weeks is recommended. However, as with have seen with the IDF data a lot of our population is pre diabetic and also are not diagnosed 1 in 2, we can also screen patients pre-natal or as soon as pregnancy is confirmed and each trimester if they have risk factors like family history, being obese or over weight, previous history of any metabolic disorders like dyslipidemia or hypertension, age above 35, PCOS, MASLD or previous pregnancies with macrosomia. This particular set of at-risk population is on the rise and bringing awareness and ameliorating the modifiable risks while managing their hyperglycemia is of utmost importance both peri and pre-natal.
High clinical suspicion of the physician in these otherwise asymptomatic patients with motivation for lifestyle modification still remains to be the primary goal and mode of treatment.
How to screen (OGTT Vs GCT)
Women who are planning for conception and are at risk are advised to do the 75 gms oral glucose tolerance test (OGTT) and further advised for Hba1c tests (interpreted in view of anemia or any other hematology issue). If cost is not an issue, then the metabolic factors like lipid profile, AST, ALT and TSH can be done to assess the risk. Blood pressure measurement with waist circumference should be measured. If OGTT cannot be performed a glucose challenge test (GCT) of 75 gms is also acceptable.
There are studies which indicate that a 1 hour post prandial is more effective in diagnosing and identifying at risk patients and hence can be used judiciously.
To clarify OGTT vs GCT. OGTT is the gold standard test done on an empty stomach, where at least 2 blood samples are taken but up to 4 samples can be drawn. Fasting sample then samples each hour from 1-2-3 hours after 75gms glucose has been ingested preferably within 3 minutes on an empty stomach.
This sometimes can be cumbersome in our part of the world for namely 3 reasons:
1. Patient needs to come back again next day
2. Patient needs to be on an empty stomach which a lot of pregnant patients feel difficult to comply with owing to morning sickness.
3. Patient needs to be at hospital only having consumed glucose for 2-3 hours
Hence GCT is acceptable for screening if the patient is unable to do the OGTT, which is ingesting 75gms glucose any time of the day and checking it after 2 hours or 1 hour of the glucose intake.
How to treat
Once the diagnosis is established, GDM can be treated with lifestyle modification, namely exercise, switching to complex fiber rich carbohydrates, good quality lean proteins, non-starchy vegetables and unsaturated fats rich in PUFA, MUFA and unprocessed food. Despite these lifestyle changes if the blood sugars are not under control, then metformin can be started as an adjuvant treatment to reach target blood glucose levels.
Treatment Targets
At this point one might note that recommended targets for blood glucose during pregnancy are:
1. Fasting < 95 mg/dl
2. 1 hour postprandially <140 mg/dl
3. 2 hours postprandially 120 mg/dl.
4. Hba1c < 6%
Conclusion
DIP treatment needs to be treated with insulin and usually patients need multiple doses. Basal bolus therapy with both long and short acting insulin to mimic the physiologic pattern of insulin secretion. These patients also absolutely need SMBG (self-monitoring blood glucose) as a part of their Diabetes Self-Management Education which helps support and assist the patients to live with their diabetes.
Follow up needs to be encouraged as most patients especially after delivery tend to be lost to follow up. Risk of developing Type 2 Diabetes and obesity needs to be reinstated and a lifetime of healthy living should be encouraged for both mother and baby. Breastfeeding needs to be encouraged in these patients as they have proved to somehow attenuate the risk and help improve health.
“Let’s not miss this window of opportunity. Every pregnancy screened and supported today can prevent a chronic disease tomorrow.”
