New concerns in the management of the disease with the Covid 19 pandemic have created a state of anxiety amongst expectant mothers.

New Delhi: The rising incidence of gestational diabetes in India and globally is a cause for global concern amongst clinicians and obstetricians. Prevalence of the condition is higher in the urban than the rural population in India. Established risk factors for GDM are a family history of diabetes, obesity, advancing maternal age, reduced physical activity, desk jobs, sedentary lifestyle, unhealthy eating habits, smoking and alcohol consumption, history of PCOD and associated factors such as hypertension.

Due to compromised fetal outcomes in the form of higher incidence of miscarriages, congenital birth defects, higher risk of preterm deliveries, acute respiratory distress and hyaline membrane disease, heart disease, complicated labour due to the large size of the foetus leading to a higher incidence of shoulder dystocia and a higher risk of caesarean sections, hypoglycaemia in the newborn, obesity and a higher incidence of diabetes in the newborn, prevention and active management of altered blood sugars imperative.

How COVID-19 pandemic has changed consultation, diagnosis of gestational diabetes

New concerns in the management of the disease with the COVID-19 pandemic have created a state of anxiety amongst expectant mothers.

The standard glucose tolerance test which was previously held as the gold standard for monitoring women with altered blood sugars has now taken the backseat. Prioritising on social distancing, reducing frequent visits to labs, now monitoring expectant mothers with fasting blood glucose and HbA1c (of 5.7) are now accepted contrary to the glucose tolerance test. Altered routine prenatal visits, lack of personal consultation with the obstetrician and a phobia to visit labs has modified the management criteria. Lifestyle management comprising healthy dietary habits and increased physical activity, regular home monitoring (self) of blood sugars and fortnightly video consultation, routine antenatal tests for maternal well-being with a proper genetic history of any congenital defects or history of consanguinity, an early ultrasound helps rule out the possibility of an extrauterine pregnancy (ectopic) and confirms a healthy heart activity by 5.5 weeks thus ruling out chances of a missed aborption. All expectant mothers are offered the option of prenatal screening for Down’s syndrome (blood tests like the NIPT and dual markers) at 12 weeks, quadruple markers at 14 to 16 weeks, an anomaly scan at 19 weeks and most importantly a fetal cardiac anomaly scan at 23 weeks. Patients prefer to visit stand-alone ultrasound clinics with prior appointments following all the Covid-19 precautions. A repeat ultrasound Doppler at 28 to 30 weeks to check for the interim growth possibility of fetal macrosomia is advisable. At 32 weeks again an HbA1c to monitor blood sugars is advisable with home charting. Known diabetics in pregnancy have to follow up closely with the diabetologist to adjust the dose of insulin. In case of preterm labour, a hospitalization with tocolytics and antenatal betamethasone injection to promote lung maturity is advisable, and should such patients progress to irreversible preterm labour then drugs such as magnesium sulphate are offered as an option after counselling the expectant mother for neuroprotection for the foetus. Delivering such patients is preferred in tertiary care centres where all facilities for neonatal care are available owing to the high incidence of hyaline membrane disease and acute respiratory distress syndrome. COVID-19 evaluation is mandatory for patients prior to admission. Each index case if affected with COVID-19 behaves differently and needs individually tailored treatment for her symptoms. Vertical transmission is not a reason to fear as it is seldom encountered. Commonly encountered heart defects are usually diagnosed early in pregnancy during the anomaly scans. Late-onset issues in infants of diabetic mothers could be macrosomia, fetal cardiomyopathy, cardiomegaly, acute respiratory distress with fetal hypoglycaemia which warrant intensive care.

Maternal issues such as a higher incidence of prolonged labour, obstructed labour, higher incidence of caesarean sections, the associated risk of hypertension, are observed. To avoid these, prevention is better than cure, and hence expectant mothers with a high risk of gestational diabetes with obesity or PCOD are advised monitored weight gain of not more than 7-8 kg. Close monitoring of blood sugars from the first trimester helps reduce the chances of fetal and maternal complications. The TDAP vaccine is offered to all mothers at 32 weeks.

In conclusion, we as physicians have to constantly tailor monitoring techniques, counsel expectant couples with close follow-ups to monitor fetal and maternal well-being. The COVID-19 precautions are here to stay till we see the end of the tunnel in this global pandemic.

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Women who go on to develop type 2 diabetes after having gestational, or pregnancy-related, diabetes are more likely to have particular genetic profiles, suggests an analysis by researchers at the National Institutes of Health and other institutions. The findings provide insight into the genetic factors underlying the risk of type 2 diabetes and may inform strategies for reducing this risk among women who had gestational diabetes.

The study was conducted by Mengying Li, Ph.D., of the Division of Intramural Population Health Research at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and colleagues. It appears in BMJ Open Diabetes Research & Care.

“Our study suggests that a healthful diet may reduce risk among women who have had gestational diabetes and are genetically susceptible to type 2 diabetes,” said the study’s senior author Cuilin Zhang, M.D., Ph.D., of NICHD’s Division of Intramural Population Health Research. “However, larger studies are needed to validate these findings.”

Gestational diabetes (high blood sugar that first occurs during pregnancy) increases the risk of complications for mothers and their infants. In most cases, the condition resolves soon after the baby is born, but nearly half of women with gestational diabetes go on to develop type 2 diabetes later in life. Type 2 diabetes increases the risk of heart disease, kidney disease and other health problems. However, little research has been done on the genetic factors influencing a woman’s risk for progressing to type 2 diabetes after gestational diabetes.

In the current study, researchers analyzed data from 2,434 women with gestational diabetes who participated in the Diabetes & Women’s Health Study. The study followed women before, during and after pregnancy and captured data on their health later in life. Of the original group, 601 women with gestational diabetes went on to develop type 2 diabetes.

Previous research has linked variations in certain genes (called single nucleotide polymorphisms) to a higher risk of type 2 diabetes. In the current study, researchers checked genetic scans of the 2,434 women for the presence of 59 gene variants thought to be more common in people who have type 2 diabetes. The researchers found that women who had the largest proportion of these gene variants were 19% more likely to develop type 2 diabetes, compared to those who had the lowest proportion of these variants.

The researchers also ranked the women’s diets according to the proportion of healthy foods. Among women who adhered to a healthier diet, the risk associated with the gene variants was lower than that of the other women, but the differences between the two groups were not statistically significant.

The authors believe their study is among the largest to date that looks at genetic factors underlying development of type 2 diabetes among women with prior gestational diabetes. However, the number of women participating in the study may not be large enough to find a significant interaction between healthy diet and genetic susceptibility in relation to this risk, explained Dr. Zhang.

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