What are the Indian National Guidelines for antenatal care in diabetic patients during pregnancy?

Antenatal Care for Diabetic Patients in Pregnancy: Indian National Guidelines

While specific Indian National Guidelines exist (DIPSI guidelines), the comprehensive management framework aligns with international standards, emphasizing multidisciplinary care, strict glycemic control, and intensive monitoring throughout pregnancy. 1

Preconception Care (Critical Foundation)

All women with diabetes of childbearing age must receive preconception counseling and achieve optimal glycemic control before conception to prevent congenital malformations and pregnancy complications. 2

Glycemic Targets Before Conception

• Target A1C <6.5% (<48 mmol/mol) before attempting pregnancy - this is associated with the lowest risk of congenital anomalies (anencephaly, microcephaly, congenital heart disease, renal anomalies, caudal regression), preeclampsia, and preterm birth 2
• Organogenesis occurs at 5-8 weeks gestation, often before women know they are pregnant, making preconception control essential 2
• Effective contraception (preferably long-acting reversible contraception) must be used until glycemic targets are achieved 2, 3

Preconception Multidisciplinary Team

Ideally includes: 2, 4

• Endocrinologist/diabetologist
• Maternal-fetal medicine specialist
• Registered dietitian nutritionist
• Diabetes care and education specialist

Comprehensive Preconception Assessment

Medical Evaluation: 2

• Diabetes complications screening: comprehensive ophthalmologic exam (dilated), comprehensive foot exam, ECG (if age ≥35 years or cardiac risk factors), serum creatinine, urine protein-to-creatinine ratio, lipid panel, TSH
• Obstetric/gynecologic history: previous cesarean section, congenital malformations, fetal loss, hypertensive disorders, postpartum hemorrhage, preterm delivery, macrosomia, Rh incompatibility, thrombotic events
• Comorbidities assessment: hyperlipidemia, hypertension, NAFLD, PCOS, thyroid dysfunction, nephropathy, neuropathy, retinopathy, macrovascular disease

Medication Review: 2

• Discontinue teratogenic medications: ACE inhibitors, angiotensin receptor blockers, statins
• Review all prescription and over-the-counter medications for pregnancy safety

Supplementation: 2, 4

• Folic acid 400 mg daily (routine dose, start preconception)
• Potassium iodide 150 mg daily 2
• Prenatal vitamins

Infectious Disease Screening: 2

• Neisseria gonorrhoeae/Chlamydia trachomatis, Hepatitis B, Hepatitis C, HIV, syphilis, Pap smear

Immunizations (if not immune): 2, 4

• Rubella, varicella, hepatitis B, influenza

Genetic Carrier Screening (based on history/ethnicity): 2

• Cystic fibrosis, sickle cell anemia, Tay-Sachs disease, thalassemia

Preconception Education and Counseling

Diabetes-Specific Counseling: 2

• Natural history of insulin resistance in pregnancy and postpartum
• Risks to pregnancy: miscarriage, stillbirth, congenital malformations, macrosomia, preterm labor/delivery, hypertensive disorders
• Risk of diabetic retinopathy progression
• Avoidance of DKA/severe hyperglycemia and severe hypoglycemia

Nutrition Assessment: 2, 4

• Weight management (overweight/obesity or underweight)
• Meal planning and carbohydrate counting
• Correction of dietary deficiencies
• Caffeine intake counseling
• Safe food preparation techniques

Lifestyle Recommendations: 2, 4

• Regular moderate exercise
• Adequate sleep
• Avoidance of hyperthermia (hot tubs)
• Complete avoidance of alcohol, tobacco, and recreational drugs (including marijuana) 2

Antenatal Care During Pregnancy

Frequency of Visits

Women with preexisting diabetes should be reviewed every 1-2 weeks throughout pregnancy by the multidisciplinary antenatal team to optimize glucose control and monitor fetal growth 5

Glycemic Monitoring and Targets

Blood Glucose Monitoring: 2

• Fasting and postprandial self-monitoring of blood glucose is mandatory
• Specific targets:
  • Fasting plasma glucose <95 mg/dL (5.3 mmol/L)
  • Either 1-hour postprandial glucose <140 mg/dL (7.8 mmol/L) OR 2-hour postprandial glucose <120 mg/dL (6.7 mmol/L)
• Some patients should also check preprandial glucose 2

A1C Targets During Pregnancy: 2

• Ideally A1C <6% (42 mmol/mol) if achievable without significant hypoglycemia
• May be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia
• A1C is slightly lower in normal pregnancy due to increased red blood cell turnover 2

Continuous Glucose Monitoring (CGM): 2

• When used in addition to pre- and postprandial blood glucose monitoring, CGM can help achieve A1C targets 2
• CGM can reduce macrosomia and neonatal hypoglycemia in type 1 diabetes 2
• CGM metrics are adjunctive only - do NOT substitute for blood glucose monitoring to achieve optimal pre- and postprandial targets 2
• Do NOT use estimated A1C or glucose management indicator calculations in pregnancy 2

Insulin Management

• Glycemic targets are achieved through combination of insulin administration and medical nutrition therapy 2
• Early pregnancy: enhanced insulin sensitivity, lower glucose levels, lower insulin requirements (type 1 diabetes) 2
• Second and early third trimesters: exponential increase in insulin resistance requiring dose adjustments 2
• Consistent carbohydrate intake matched to insulin dosing is essential 2
• Insulin analogues, pen devices, and insulin pumps are part of modern management 1

Ophthalmologic Surveillance

Dilated eye examinations: 2, 4

• Ideally before pregnancy or in first trimester
• Then every trimester during pregnancy
• Continue for 1 year postpartum
• Frequency determined by degree of retinopathy and eye care professional recommendations
• Women with preexisting retinopathy need close monitoring for progression and treatment 2

Preeclampsia Prevention

Low-dose aspirin (81-150 mg daily) is recommended for all pregnant women with diabetes (if no contraindication) starting by 16 weeks gestation to reduce preeclampsia risk 2, 4

Fetal Surveillance

Third Trimester Monitoring: 4

• Ultrasound for fetal growth assessment
• Antepartum fetal surveillance starting at 32-34 weeks for high-risk pregnancies

Delivery Timing: 4

• Women with diabetes and good glycemic control: delivery at 39 0/7 to 39 6/7 weeks
• Women with diabetes and poor glycemic control or vascular complications: delivery at 36 0/7 to 38 6/7 weeks
• Individualized delivery planning based on maternal glucose control, fetal growth, and complications

Nutrition During Pregnancy

• Referral to registered dietitian is essential to establish food plan, insulin-to-carbohydrate ratio, and weight gain goals 2
• Balanced macronutrient intake 2
• Consistent carbohydrate amounts to match insulin dosing and avoid hyperglycemia/hypoglycemia 2

Common Pitfalls to Avoid

Critical Errors: 4

• Failure to provide preconception counseling - especially for women with chronic conditions
• Insufficient postpartum care planning and transition
• Using CGM as substitute rather than adjunct to blood glucose monitoring 2
• Failing to adjust insulin doses as pregnancy progresses 2
• Not screening for retinopathy progression 2

Postpartum Care

Immediate Postpartum: 5

• Insulin requirements drop dramatically after delivery
• Blood glucose management during labor and delivery requires close monitoring

Long-term Follow-up: 5

• Women with gestational diabetes: fasting plasma glucose at 6 weeks OR HbA1c at 13 weeks to confirm resolution
• Annual HbA1c for women with previous gestational diabetes (high risk for future type 2 diabetes)
• Continued contraception counseling until ready for next pregnancy 2, 3

The Indian context emphasizes that these evidence-based guidelines, while aligned with international standards (particularly American Diabetes Association), must be adapted to local healthcare infrastructure and resources, as outlined by DIPSI. 1