What are the Indian guidelines for managing gestational diabetes mellitus (GDM) in pregnancy?

Indian Guidelines for Gestational Diabetes Mellitus in Pregnancy

Important Note on Indian-Specific Guidelines

While the evidence provided does not contain official Indian national guidelines (such as from the Ministry of Health and Family Welfare or Indian Council of Medical Research), Indian clinical practice commonly follows the Diabetes in Pregnancy Study Group India (DIPSI) criteria, which differs from international approaches. 1

Screening and Diagnosis

DIPSI Approach (Commonly Used in India)

• The DIPSI protocol recommends a single-step 75g oral glucose tolerance test (OGTT) performed at any time of the day, irrespective of meals, with diagnosis made if the 2-hour plasma glucose is ≥140 mg/dL. 1
• This approach has been validated in Indian populations and shows a GDM prevalence of approximately 6.6-17.9% depending on the region. 1, 2
• Universal screening is recommended for all pregnant women between 24-28 weeks of gestation. 1, 2

Early Screening Considerations

• Women with risk factors should undergo screening at the first prenatal visit using standard diagnostic criteria. 3
• Risk factors include: obesity, family history of diabetes in first-degree relatives, previous GDM, prior macrosomia, advanced maternal age, and previous congenital anomalies. 4
• Indian studies demonstrate that 38.7% of GDM cases manifest before 24 weeks of gestation, suggesting the importance of early screening in high-risk women. 2
• Women with normal glucose tolerance at first visit require repeat OGTT at subsequent visits, as 28.9% of GDM cases are diagnosed on repeat testing. 2

Glycemic Targets

Target glucose values for optimal control are:

• Fasting plasma glucose <95 mg/dL (5.3 mmol/L) 3
• 1-hour postprandial <140 mg/dL (7.8 mmol/L) 3
• 2-hour postprandial <120 mg/dL (6.7 mmol/L) 3

Management Approach

Initial Treatment

• Lifestyle modifications including medical nutrition therapy and physical activity should be the cornerstone of initial management. 5
• An individualized nutrition plan should be developed with a registered dietitian, providing adequate calorie intake with a low glycemic index diet to avoid postprandial hyperglycemia. 5, 6
• Women with GDM should perform fasting and postprandial blood glucose monitoring for optimal glucose control. 3

Pharmacological Management

• Insulin is the preferred medication when lifestyle modifications are insufficient to achieve glycemic targets. 5, 6
• No specific insulin or insulin analog regimen has demonstrated superiority in GDM. 5
• Metformin and glyburide should not be used as first-line agents as both cross the placenta, but glyburide can be considered as an adjunct when insulin is not an option. 5
• Up to 46% of women on metformin may require additional insulin to maintain expected blood glucose levels. 6

Monitoring and Surveillance

Maternal Monitoring

• Self-monitoring of blood glucose (SMBG) is essential for assessing glycemic control. 3, 5
• Blood pressure and urinary protein should be measured at each prenatal visit to detect preeclampsia, as hypertensive disorders are increased in women with GDM. 3
• Telehealth visits have been shown to improve outcomes compared with standard in-person care. 5

Fetal Surveillance

• Ultrasound measurement of fetal abdominal circumference starting in the second and early third trimesters, repeated every 2-4 weeks, can guide management decisions. 5
• Fetal ultrasound screening for congenital anomalies is recommended for women with A1C ≥7.0% or fasting plasma glucose ≥120 mg/dL. 3
• Mothers should be taught to monitor fetal movements during the last 8-10 weeks of pregnancy and report immediately any reduction in perception of fetal movements. 3, 5

Timing of Delivery

• There are no data supporting delivery before 38 weeks' gestation in the absence of objective evidence of maternal or fetal compromise. 3
• Women with diet-controlled GDM can wait for spontaneous labor expectantly in the absence of obstetric indications. 6
• In women with GDM under insulin therapy or with poor glycemic control, elective induction at term is recommended. 6
• It is reasonable to intensify fetal surveillance when pregnancy continues beyond 40 weeks' gestation. 3

Postpartum Management

Immediate Postpartum Testing

• Women with GDM should be tested for persistent diabetes or prediabetes at 4-12 weeks postpartum using a 75g OGTT with non-pregnancy criteria. 3, 5
• All guidelines emphasize that women should undergo glycemic testing at 6-12 weeks after delivery. 7

Long-term Follow-up

• Lifelong screening for diabetes should be performed at least every 1-3 years using standard non-pregnant criteria, as women with GDM have a 50-70% lifetime risk of developing type 2 diabetes. 3, 5
• Women should be counseled about their increased risks of impaired glucose tolerance, type 2 diabetes, hypertensive disorders, cardiovascular diseases, and metabolic syndrome. 6

Prevention Strategies

• Breastfeeding is recommended as it may reduce obesity in children and provide metabolic benefits to both mother and offspring. 5
• Postpartum weight loss should be encouraged for women who were overweight or obese during pregnancy. 5
• Healthy eating patterns and intensive lifestyle intervention can prevent or delay progression to diabetes in women with prediabetes and a history of GDM. 5

Common Pitfalls

• Failure to recognize that GDM manifests in all trimesters: Indian data shows significant early-onset GDM, requiring vigilance beyond the standard 24-28 week screening window. 2
• Inadequate postpartum follow-up: Many women are lost to follow-up after delivery despite their high lifetime diabetes risk. 5
• Overlooking maternal complications: Hypertension, vaginal candidiasis, and abruptio placentae are common maternal complications in Indian populations with GDM. 1
• Insufficient fetal monitoring: Macrosomia and stillbirths are significant fetal complications that require appropriate surveillance. 1