Prevalence of gestational diabetes mellitus in South India (Tamil Nadu)--a community based study.

AIM: Women diagnosed to have Gestational Diabetes Mellitus (GDM) are at increased risk of developing diabetes in future. Thus, diagnosis of GDM is an important public health issue. In a random survey 16.2% of pregnant women were found to have GDM in the Chennai urban population. Hence we undertook a planned community based study to ascertain the prevalence of GDM. MATERIALS AND METHODS: We conducted a prospective screening for GDM in the urban, semi urban and rural areas. All pregnant women irrespective of gestational weeks underwent a 75 g glucose challenge test in the fasting state. Diagnosis of GDM was made if the 2 hr plasma glucose was > or = 140 mg/dl (WHO criteria). RESULTS: A total of 4151, 3960 and 3945 pregnant women were screened in urban, semi urban and rural areas, respectively. GDM was detected in 739 (17.8%) women in urban, 548 (13.8%) in semi urban and 392 (9.9%) in rural areas. Out of 1679 GDM women, 1204 (72%) were detected in first visit and the remaining 28% in subsequent visits. A significant increase (P < 0.0001) in the prevalence of GDM was observed with family history of diabetes, increased maternal age and BMI. A trend for increased prevalence of GDM was observed in women with less physical activity, however, not statistically significant. CONCLUSION: In this community based study, the prevalence of GDM varied in the urban, semi urban and rural areas. Age > or = 25 years, BMI > or = 25 and family history of diabetes were found to be risk factors for GDM.

Scope for prevention of diabetes--'focus intrauterine milieu interieur'.

The prevalence of diabetes is increasing globally and India is no exception. The lifestyle modification and drug intervention are likely to delay or postpone the development of overt diabetes in persons diagnosed to have impaired glucose tolerance. This is a post primary prevention strategy. The primary prevention is more important as this effort is likely to reverse or halt the epidemic of disease. Women with Gestational Diabetes Mellitus (GDM) are an ideal group for the primary prevention of diabetes as they are at increased risk of future diabetes, predominantly type 2 diabetes, as are their children. Pima Indians have the highest prevalence of diabetes. This is attributed to the children exposed in utero to maternal diabetes. Hence as a policy to identify GDM and its consequences on the infant, a 75 gm Oral Glucose Tolerance Test has been recommended to all Pima Indian women during the 3rd trimester of pregnancy. Ethnically Asian Indian women also have high prevalence of diabetes and the relative risk of developing Gestational Diabetes Mellitus in them is 11.3 times compared to White women. This necessitates universal screening for gestational diabetes during pregnancy in India. Probably the undiagnosed gestational diabetes that has been occurring in the past has resulted in the increased prevalence of diabetes in India. The timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition may prevent in all possibility, India becoming the diabetes capital of the world.

Glycemic level at the first visit and prediction of GDM.

OBJECTIVE: To evaluate the glycemic level at the first visit that is likely to predict gestational diabetes mellitus (GDM). METHODS: Consecutive pregnant women underwent a 75g oral glucose tolerance Test (OGTT) recommended by WHO and diagnosed GDM if 2hr post plasma glucose (PG) value > or = 140 mg/dl. Women with normal OGTT results at the first visit were screened again with an OGTT at the subsequent visits. RESULTS: A total of 4151 pregnant women from different trimesters underwent OGTT. Of them 739 women (17.8%) had GDM. Among the GDM women, 528 (71.4%) were detected at the first visit. On screening during subsequent visits, GDM was diagnosed in the remaining 211(28.6%) women who had normal OGTT in the first visit. We performed the analysis taking the glycemic level in the first visit of 211 pregnant women who manifested GDM in the subsequent visit. During normal pregnancy, 2hr PG level is < 120 mg/dl. Taking this value into consideration among the 211 women who turned to have GDM in the subsequent visits 119 women (56.4%) had 2hrPG > or = 120 mg/dl and the remaining 92(43.6%) had 2hrPG < 120 mg/dl. CONCLUSION: Pregnant women irrespective of 2 hr PG > or = or < 120 mg/dl at initial visit progressed to GDM in the subsequent visit. No glycemic level in the early weeks of pregnancy predicts GDM and at the same time at no statistically significant glycemic cut-off level could we say that a woman will not develop GDM. Hence rescreening in the subsequent trimester or visits is essential.

Gestational diabetes mellitus--guidelines.

The Diabetes In Pregnancy Study group India (DIPSI) is reporting practice guidelines for GDM in the Indian environment. Due to high prevalence, screening is essential for all Indian pregnant women. DIPSI recommends that as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oral glucose load and at 2 hrs a venous blood sample is collected for estimating plasma glucose. This one step procedure of challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible. Screening is recommended between 24 and 28 weeks of gestation and the diagnostic criteria of ADA are applicable. A team approach is ideal for managing women with GDM. The team would usually comprise an obstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician. Intensive monitoring, diet and insulin is the corner stone of GDM management. Oral agents or analogues though used are still controversial. Until there is evidence to absolutely prove that ignoring maternal hyperglycemia when the fetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintain normoglycemia in every pregnancy complicated by gestational diabetes. The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists. A short term intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in the offspring, as the preventive medicine starts before birth.

Gestational diabetes mellitus in India.

BACKGROUND: Glucose intolerance during pregnancy predisposes the offspring for increased risk of developing glucose intolerance in the future. This vicious cycle is likely to influence and perpetuate the incidence and prevalence of glucose intolerance in any population. AIM: No data is available about the prevalence of glucose intolerance during pregnancy in our country and hence a study was undertaken on this aspect. METHODS: This study was performed in the antenatal clinic of Government Maternity Hospital, Chennai, India. As a pregnant woman in second or third trimester checks into the antenatal clinic, she was given 50 gm oral glucose load and blood sample was collected after one hour. This test was performed on 1251 pregnant women. They were requested to come after 72 hours for the 75 gm OGTT recommended by WHO. Among the 1251 women, 891 responded. The blood sample was taken in the fasting state and at 2 hours after 75 gm of oral glucose. Diagnosis was based on the WHO criteria for gestational diabetes mellitus (GDM). RESULTS: The mean age of these pregnant women was 23+/-4 years. There was a significant increase in the prevalence of GDM in relation to gravida. The effect of BMI did not quite reach statistical significance (chi2 (df=1) = 3.659, P = 0.055), but a model of linear trend was significant. Of the 1251 women who underwent the 50 gm oral glucose challenge test, 670 (53.55%) had one hour plasma glucose > or = 130 mg/dl. Among the 891 pregnant women who had 75 gms OGTT, 168 (18.9%) were diagnosed as GDM, taking both FPG > or = 126 mg/dl and/or 2 hr PPG > or = 140 mg/dl as cut-off values. Taking only 2 hr plasma glucose for analysis, 144 (16.2%) had a value > or = 140 mg/dl. A similar study was conducted in different parts of the country taking only the 2 hr 75 gm post-glucose value of > or = 140 mg/dl as diagnostic criteria for GDM. Of the total number of pregnant women (n = 3674) screened, 16.55% of them found to have GDM. CONCLUSION: Our study has documented the increased prevalence of GDM in our population necessitating universal screening for glucose intolerance in pregnancy. Using 2 hr plasma glucose > or = 140 mg/dl as a one step procedure is simple and economical, particularly for the countries ethnically more prone to high prevalence of diabetes.

Diagnosis and management of diabetes in pregnancy.

Diabetes and pregnancy encompass not only pregestational diabetes mellitus but also any form of abnormal glucose tolerance during gestation. While screening for glucose intolerance is mandatory for high-risk patients in pregnancy, it is not required in others. There are various methods for screening of gestational diabetes mellitus eg, urine glucose detection, O'Sullivan screening test, WHO criteria, etc. Proper management of diabetes in pregnancy can arrest foetal mortality and morbidity. Practical self management skills are essential for attaining good glycaemic control. Management of gestational diabetes mellitus rests on the idea of medical nutrition therapy and insulin therapy.

Gliclazide in the treatment of obese non-insulin dependent diabetic patients.

The clinical efficacy of gliclazide and its effect on plasma glucose, body weight and serum lipids was assessed in a 3 months open trial of 30 obese, Non-Insulin Dependent diabetes mellitus (NIDDM) patients who failed to respond to diet therapy alone. By day 20, the mean post prandial plasma glucose (PPG), and fasting plasma glucose (FPG) were significantly reduced from 276 +/- 13.5 to 195.8 +/- 13.9 mg % (p < 0.01) and 179 +/- 9.3 to 130.6 +/- 9.6 mg % (p < 0.01) respectively. This early glycaemic control was maintained, and by 3 months a further significant decrease occurred in PPG to 156.46 +/- 7.6 mg % (p < 0.01), and FPG to 106.9 +/- 3.8 mg % (p < 0.01). Mean glycosylated haemoglobin (HbA1c) was reduced from 10.3% to 7.7%. The drug had a favourable effect on serum lipids, significantly increasing high density lipoprotein fraction of cholesterol (HDL-C) (p < 0.034), and decreasing low density lipoprotein fraction of cholesterol (LDL-C) (p < 0.049). Mean body weight showed a significant reduction of 1.5 kg (p < 0.003). We conclude that gliclazide is an effective hypoglycaemic agent that ensures a rapid and sustained blood glucose control with a favourable effect on lipids and body weight in obese NIDDM patients.

Effect of bed time intermediate acting insulin in NIDDM subjects refractory to a combination of sulphonylureas and biguanides.

The effect of a single dose of intermediate acting (Lente) insulin given subcutaneously at 9.00 P.M. in 22 NIDDM subjects refractory to a combination of Sulphonylureas and Biguanides was analysed. Euglycemia was achieved and maintained during the study period of three months with a mean insulin requirement of 14.22 +/- 5.98 units/day. Plasma FFA, Total cholesterol, triglyceride and VLDL-cholesterol also showed significant reduction. The level of FFA modulates hepatic glucose production, which in turn correlates positively with the fasting blood glucose. The therapeutic modality of bed time Lente Insulin based on physiological principles is an effective way of achieving glycemic control in NIDDM subjects who have become non-responsive to oral hypoglycemic agents.

Subcutaneous insulin pulse therapy.

Subcutaneous Insulin Pulse Therapy (SIPT) consists of administration of small doses of regular insulin hourly or two hourly in the subcutaneous tissue of anterior abdominal wall through a scalp vein needle. Fifteen Non-Insulin Dependent Diabetes Mellitus (NIDDM) subjects, 8 males and 7 females with mean ages 58 +/- 8.7 years and mean duration of diabetes 11.7 +/- 9.1 years and mean BMI 25.2 +/- 5.64 were admitted for elective surgery. Glycemic control was attempted preoperatively with multiple pre-meal doses of Actrapid MC with a single injection of Monotard MC at bed time. The mean fasting plasma glucose in the 15 subjects with this insulin regimen was 321.28 +/- 69.32 mgm% and the insulin requirement per day was 106.87 +/- 35.77 units. The subjects were put on SIPT for 48 to 72 hours. During SIPT the mean fasting plasma glucose dropped to 123.2 +/- 74.11 mgm% and this marked decline in fasting plasma glucose value was statistically significant (P < .05). The insulin requirement during SIPT was 96.42 +/- 31.36 units, similar to the previous regimen (NS). The subjects were switched back to conventional insulin therapy after SIPT during which period the mean fasting plasma glucose was 125.82 +/- 34.50 mgm% and this value was again significantly lower than the pre SIPT fasting plasma glucose value (P < .05). Insulin requirement during conventional insulin therapy after SIPT was reduced to 71 +/- 21.89 units/day. This dose was significantly lower than the insulin dose administered during SIPT (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Keloids and diabetes in a family.

An interesting familial association of keloids with diabetes mellitus in three successive generations is reported. Keloids did not develop if the injection site was changed to the anterior abdominal wall.