ESI Diabetes in Pregnancy Task Force - EARLY GDM May 29 2026

Ajouté : 2026-06-01

[00:00:00]May we can start in 30 seconds sir.

[00:00:02]>> Okay sir. We are live. We can start in 10.

[00:00:18]Yeah.

[00:00:31]A very good evening everyone. So we meet again after a gap of a of a month or so for this very important area. We keep on discussing on a monthly basis that is diabetes in pregnancy because it has not only implications for the mother, it has also implications for the fetus for the baby and also uh probably has future implications for for the whole progeni. So and and we have gone through multiple evolutions uh in in the understanding of gestational diabetes and one such area which has actually emerged as a very very important topic and we still trying to understand how best we can deal with that condition is early gestational diabetes malitis. So we have a very eminent set of faculty to discuss that we have Dr. Koshik Vishwas who is a senior consultant in Manipas hospital em byipas from Kolkata. We also have after that Dr. Jazib Gupta faculty at all India institute of medical sciences New Delhi. So he has been actively researching this aspect of gestational diabetes malitis along with any other uh he has active research on other aspects of gestational diabetes malitis also. We also have with us Dr. Andreasa Jo. She's a consultant in Mars lea medicine in in Kerala and uh I won't take much time. So we have very three important uh topics lined up. So first is a presentation on the stride study a journal club presentation. Then Dr. Jajep will review the literature on early JDM and after that we have a very interesting quiz by Dr. Andreasa Jo. So over to Dr. Koshik for your presentation.

[00:02:39]Dr. Koshik you are muted.

[00:02:46]Good evening everyone. Uh thanks to ESI and Shaptois and Goon madam for having me here. Today I'll be disc uh discuss about prevalence and risk factors of early gestational diabetes malitis or EGDM in Indians. A critical review of the stride study.

[00:03:09]So the we know that nowadays the concept of early GDM that the GDM that that is diagnosed below 20 weeks of gestations in comparison to the conventional or classic GDM diagnosed in between 24 to 28 weeks of gestations is gradually shaping up in southeastern Asian regions. There is a profound risk of development of early and classic GDM.

[00:03:37]The early A1C elevation is strictly linked to the adverse neonatal outcomes.

[00:03:43]However, because of the lack of universal criteria for diagnosis of early GDM, the prevalence of early GDM varies from 0.7% to 36%.

[00:03:55]And as uh we know that after the publication of Tobo GM trial the higher the individuals of early GDM who are especially in the higher band blood glucose levels could be benefited with the early treatment. Now what are the objective of stride study?

[00:04:15]This is to rigorously estimate the prevalence of EGDM and LGDM that is late GDM and to map their distinct risk factors within an Asian Indian cohort.

[00:04:28]In that study it was uh to see women who develop GDM in the earlier gestations whether they are metabolically distinct from those who develop later or second trimester of pregnancy. In that study which is the multic-enter retrospective study involving approx 3,70 pregnant women aging uh 80 to 50 years of age uh recruited less than 60 weeks of gestations. The study participants were from seven antiatal clinics across three south Indian cities.

[00:05:06]The patients with the mother with known diagnosis of type 1 or type two diabetes, severe anemia, cle cell disease or prior metformin uses are excluded from that study. At baseline there are there was measurement of anthropometrics like body weight, BMI, waist circumference. The modified kush shami scale was used to assess the socioeconomic status and medical and family history were taken at the baseline. Three clinical phenotypes were identified in that study. Early GDM uh defined as D screening uh less than 16 weeks of gestations by single criteria fasting plasma glucose above 92 mg per deciliter but less than 125 mg per deciliter and LGDM or late GDM when the there was early screening by fasting plasma glucose was less than 92 and late screening with the oral glucose tolerance test according to IDPHG criter criteria in between 24 to 28 weeks.

[00:06:15]Those who are positive and NGT or normal glucose tolerance were defined by the early screen normal and late screen with the OGT being also normal. So this is the participant flow and the categorization. Among the 3,70 study participants, 2,700 underwent the early fasting plasma glucose. Less than 20 of gestations.

[00:06:43]Those who who are having more than 126 migram per deciliter of fasting plasma glucose are classified as having over diabetes militus and those having fasting plasma glucose above 92 but below 125 were having uh early EGD early GDM group and those who had normal glycemic according to the fasting plasma glucose below 90 mig per deciliter less than 60 weeks of gestation Patients are again subjected to or glucose tolerance test in between 24 to 28 weeks and again classified according to the IDPG criteria to late or classic GDM group and normal normal group tolerance group. So in that study it was found that there was a staggering ex exceptionally high prevalence of dislycemia around 21% of patient had egm and 19.5% had late GDM. So nearly one in five pregnancy affects the early gestational uh period. So if you look at the baseline data at booking women who eventually develop early GDM already exhibit significantly higher adiposity in terms of body mass index waste circumference blood pressure and HBA1C compared to both normal lucos tolerance and late GDM patients or mothers. Now if you look at the uh cartoon that EGDM risk scales aggressively with the adiposity the stratified BMI and weight circumference uh is placed according to the the early or late GDM status and we can see that the the body weight is or circumference and BMI is linearly almost related to the risk of EGDM where there is this association is less less robust to the late GDM. In that study, soio economic stat was also taken into account and there was a soio economic paradox in which especially in low soio economic status in case of early GDM though the mother is less than uh is having lesser 3.3 kg less 3 kg per meter square lesser BMI 3 years younger than The counterpart belonging to high soio economic status and having lesser 6 cm lesser waist circumference than the higher soio economic counterparts are having much risk of having early gestational diabetes mitus. So in that case not obesity was not the risk factor clearly. So some unknown factors is uh playing role in that particular low soioeconomic early GDM cases and it is hypothesized that environmental factors like air pollution or maternal under nutrition in the first thousand days leading to poor beta cell endomment can be responsible for that phenomenon.

[00:10:09]Now a very important divergent predictors uh different uh predictors came out in that study uh showing that the EGDM risk predictors most important one is previous history of GDM the or ratio being 2.48 48. On the other hand, in case of late GDM or classic GDM, the most important risk factor being the family history of diabetes malitas. So the uh ratio being 1.71.

[00:10:39]So this is one of the important differentiator between the risk between early GDM and classic GDM or late GDM in terms of uh having those conditions.

[00:10:53]So early GDM is not simply the early LGDM. Early GDM means the prime mover is maternal adiposity and prior history of gestational diabetes malitis. And in case of late gestational diabetes malitis. Possibly genetic predisposition or family history plays an very important role. In early GDM there is worse early glycemic profile uh including uh raised baseline A1C even that has been shown in that study. In case of late GDM the glycemic status below 69 weeks sorry 16 weeks is normal.

[00:11:37]So these two entities are different that warrants tailored screening strategies, diagnostic threshold and management protocols.

[00:11:50]The critical appraisal of the stride studies involve the the methodological strength of the study is that it is a large robust study which is prospective in nature. Multic-enter uh design was there and comprehensive capture of both early and late phenotypes sequentially within this exact same cohort was done.

[00:12:11]Rigora's definition of normal glucose tolerance verified by both early fasting plasma glucose and late oral glucose tolerance test was done. In that study, the early GDM was compared not only with the late GDM but also those who are having normal glucose tolerance. There are some limitations like the diagnosis of early GDM was based on the single fasting value of more than 92 mig per deciliter.

[00:12:41]So there is some uh risk of missing diagnosis uh if it is done with the po 75 g post glucose tolerance test. Some EGM patients we know are you know uh progress to normoglycemia within 24 to 28 weeks highlighting ongoing global debates about optimum early diagnostic thresholds.

[00:13:08]Thank you.

[00:13:12]Yeah, thank you so much Dr. Koshik. Um that was a wonderful summary of the uh study. Uh just a few quick questions. Uh one when we talk of early GDM like Tobo GM gave us two clusters like the ones who progressed and the ones who did not progress.

[00:13:30]Is there some kind of a data in the stride also that looks at it?

[00:13:35]No madam in the primary study analysis there was no some subgroup analysis is not there >> right and anthropometrically were you able to compare our data versus you know what came in the tobo GM like was the anthropometric parameters somewhere different >> anthrometric uh mam regarding anthrometry uh the body mass index BMI high and US circumference were both higher in case of classic GDM and the early GDM. But in comparison to normal glycemic uh individuals in patients with early GDM the these anthrotic measurements are significantly different both in case of in comparison to EGDM classic GDM or late GDM or in comparison to NGM. That is interesting.

[00:14:34]>> Yeah. Thank you. Thank you so much Dr. Koshik. I'll request you to stay back.

[00:14:38]Maybe after Dr. Yashep's talk we'll have more discussion. Uh so thank you so much for a wonderful session and uh it's my pleasure to now announce uh invite Dr. Yashep Gupta who as we already said has done a lot of extensive work in gestational diabetes melatus. He is professor of endocrinology at all institute of medical sciences at as New Delhi. So a warm welcome to Dr. Yash.

[00:15:05]>> Thank you ma'am.

[00:15:20]So slides are visible ma'am.

[00:15:24]Hello.

[00:15:28]Hello.

[00:15:29]>> Yeah Dr. We can see your slides.

[00:15:31]>> Okay. So uh good evening everyone. Uh it's my pleasure to speak on this topic.

[00:15:38]uh which is one of the hot topic nowadays uh early GDM. So what will be our approach especially keeping the Indian settings in mind.

[00:15:48]So let me uh define their different uh definitions as uh uh in the previous talk Dr. Koshik has highlighted that stride studied actually enrolled women at less than 16 weeks and Tobo GM study like uh enrolled women till 20 weeks. So it's basically a debate whether it should be 16 weeks, 20 weeks, 24 weeks, what should be the cut of foot for defining early GDM. But in general is that when you divide pregnancy into two halves, less than 20 weeks and more than 20 weeks, equal halves. So the first half is basically taken as early uh GDM.

[00:16:23]So when you investigate a women uh early in the pregnancy, basically your intention to investigate is to detect an undiagnosed pre-existing diabetes. So that is how the testing uh came became popular for early uh uh pregnancies. But when uh actually women is not diagnosed to have over diabetes and is also not normal there are intermediate values uh that are high than the normal uh cutoffs. So that category of women are actually labeled as early gestational diabetes. So this is uh basically when I talk about early GDM so I I'm basically talking a woman who has been diagnosed with an intermediate level of hyperglycemia at less than 20 weeks of gestation.

[00:17:06]So I will basically highlight uh and discuss uh the management from two for two different category of cases. One is a high-risisk case as you can see that this woman presents early in the pregnancy is overweight has family history of diabetes also has history of PCOS. So there are multiple risk factors and the women has not been evaluated in the last 6 to 12 uh months. So the question comes that whether we should screen such a women or not and obviously as you know that women with the risk factors definitely has to get an early pregnancy screening. But from Indian perspective since South Asian ethnicity is a risk factor in it in itself. So the Indian guidelines suggest universal screening for any women irrespective of risk factors. So there is no not a much debate in from uh in India whether to screen or not to screen. We have to screen uh for early hypoglycemia with one of the available test. Then the second case as you can see is a women who is like normal BMI and there is no risk factors. So women basically with no risk factors for GDM uh not previously evaluated for glycemia. Again these women need to be screened only we have to see what test will be appropriate for screening. So this is an approach which we use uh in our GDM clinic at as uh New Delhi. So basically if a women has uh risk factors in addition to South Asian ethnicity any Indian women with risk factors then we prefer a 75 gt and A1C because the chances of avoid diabetes in a high-risisk women is much more than in the low-risk women. So the strategy is to employ A1C if it is if she is presenting at less than 15 weeks of gestation. A1C is not utilized for diagnosis of diabetes beyond 15 weeks of gestation. So GT can be done at any period but A1C has to be deployed before 15 weeks of gestation. And if the women is not having any risk factors that has was seen in the case two that is low risk then we don't employ a full-fledged GT we screen with fasting and A1C and depending upon the values if they are perfectly normal so then we usually uh rescreen at 24 to 28 weeks but if there is any doubt then we do a selective 75 gt in case there is some elevation seen in fasting and A1C. So this is what we use a 75 gtd for high risk and fasting and A1C for a low lowrisk women.

[00:19:30]So if we uh screen a case one with a GD and these are the results. So as per IADPS criteria so this women basically uh is meeting thresholds for all the three values. So this is a classical case of early gestational diabetes and the recent or the refined definition of gestational diabetes is basically after exclusion of a word diabetes in pregnancy. So initially it was any hypoglycemia first discovered in pregnancy irrespective of the values but now if the values are more than the uh means more than the uh this GDM uh category means meeting the thresholds of non-pregant diabetic stage then the patient is called a word diabetes and pregnancy and this category is exclusive category so we don't include them any further in the gestational diabetes category so the question comes that whether early GDM is different or not different and has Dr. for Koshik has highlighted with the stride uh study also. So there is a difference between the early GDM and standard GDM but in that study the maternal and invital outcomes were not evaluated. So this is one study from Delhi which has looked into like what could be the degree of differences among women with the early gestational diabetes and late gestational diabetes and especially compared to the normal. So you can clearly see see that uh that standard GDM obviously has a higher risk for adverse neonatal and maternal outcomes and the early GDM even had much worse outcomes compared to the standard GDM.

[00:20:55]So early gestational diabetes has a distinct adverse pregnancy outcomes and it need to be uh taken care of. It's not only the pregnancy outcomes. Even in the postpartum period, we have seen that women uh who are been diagnosed as early gestational diabetes. The risk of type 2 diabetes in the postpartum is nearly 22% within 5 years. Whereas the risk of postpartum diabetes in women with a classical gestational diabetes or late GDM is around 12%. So there is two-fold more risk for uh postpartum diabetes among women with early gestational diabetes. We suggest that observational studies have clearly shown association with uh uh between the early gestational diabetes and adverse outcomes both in the pregnancy and the postpartum period.

[00:21:39]This is a tobagam study which Dr. Gagan Priya was referring to. So this is a landmark study on management of early gestational diabetes. So in this uh uh study uh uh basically uh the women were randomized into two arms uh when uh and they were enrolled at less than 20 weeks. So what they have seen that in the intervention arm uh if uh women is managed has early gestational diabetes. So there is a reduction of 5 to 6% in the adverse neonatal outcomes compared to the standard arm which was just observed uh till late pregnancy.

[00:22:16]So it clearly showed that means uh intervening early gestational diabetes can help in improving the pregnancy uh outcomes.

[00:22:27]The second point which came out from the tobagum study was that the benefit was much more when the women had higher glycemic values than in the lower glycemic range. And the higher glycemic band on the basis of iodph criteria is labeled uh is uh basically categorized as follow like 0 more than 95 95 or more than 95 1 are 191 and more than that and 2 or 162 and more than that whereas 153 to 161 180 to 190 and 92 to 94 are taken as a lower glycemic uh band hypoglycemia. So if the women has higher glycemic band hypoglycemia and these women are treated the benefit is much more uh than the lower glycemic band.

[00:23:10]And the second point that came out that intervention when started at less than 14 weeks is more effective than intervening at a later stage. So this means that any diagnosis in the early antiatal period should be accomplished before 14 weeks of gestation and uh higher glycemic band need to be intervened so that we can improve the pregnancy outcomes.

[00:23:31]Then comes the management. So management obviously we know that diet, exercise, metformin and insulin are more four pillars of management. So in diet what are the things that need to be taken care of. Obviously we have to maintain your glycemia. The diet has to be nutritious and it should also satisfy the needs of a women. We periodically should ask whether the women is satisfied what with whatever the diet is being given or not. And the key parameters which need to be monitored is a gestational weight gain. So if the women is not gaining adequate gestational weight gain as per IM recommendation then means that patient may be compromising diet to maintain uglycemia. So that to avoid initiation of insulin uh therapy. So there are certain women who feel that restricting diet can help them prevent uh hyperinsulinemia. Again the uh sorry insulin therapy which again is not a good factor from a fetal perspective. uh so therefore the gestational weight gain has to be uh taken care of and we need to keep a tab on it. The second parameter fetal growth means we usually can have fetal scans after 28 weeks when they are available and the fetal growth parameters again can give reassurance that the diet uh is going fine. So if it is a fetal growth obviously then we have to look back to the diet and improve it so that the fetal growth can pick up. The third important parameter is that to take care into take care of this points that it should not be less than 1,600 kilo calories especially not less than 1500 kilo calories at any uh time point uh carb should not be less than 45% and at least 175 g carb should be given and diet should not be high glycemic index. So this is uh additional parameters which we need to keep and obviously then we have to split into three meals and three to four snacks and timings and the content of meal again become important and periodic review of diet is important in second and third trimester and the postpartum period so it can adjust to the need of the patient. Physical activity uh it depends upon how much uh women is active before pregnancy. So it can be 20 to 50 minutes per day either 20 minutes morning 20 minutes after evening snacks or 10 minutes in certain cases where is a postprandial peak. So patient can do 10 minutes of walk after 30 minutes of meal. So it can cut down the glycemia by 5 to 10 mig per deciliter in certain cases and can avoid initiation of phicotherapy in borderline cases. But there should not be any obstetrical contraindication and no medical contraindication for physical activity. This is a typical log which we ask patient to come with if we are calling this patient after one week. So we actually need a three pair of glucose values uh at each meal when we review so that we can take a decision appropriate uh for the patient. So staggered paired log uh we follow and uh 95 or 120 mg per deciliter are the cutffs for preandial and two are postprandial but given that we use glucometers for monitoring and there is a 5% bias positive bias in glucometers. So we adjust that positive bias of 5% and use these cut offs for monitoring in our clinic. So if it is uh more than 80% of the values are in control then it's okay. If it is like greater than 20% of the values are out of control then we have to intensify the management plan. Insulin uh these are the points which we need to keep in uh mind. So education uh technique hypoglycemia care how to maintain log how to adjust those I think this these are critical components of education insulin we have a conventional or analog pandal insulins or conventional or analog basil insulin so in GDM per se since they are at low risk of hypoglycemia there's no pressing need for analog uh insulin even conventional insulins can give good results but both are equal in terms of maternal and neonatal outcomes so insulin regimen we usually don't prefer premix insulin though in certain patient it may work.

[00:27:20]But the standard management plan what we follow is a basil uh basil bolers or basil plus uh insulin regimen and obviously then it has to be adjusted on the basis of glucose and current medication rather than weight based uh prescription.

[00:27:36]Metformin uh especially in the case one which is like overweight obese uh and some cases there is high insulin dose it can help in reducing uh some doses like 25 to 33% if the dose is quite high and if the women is gaining excessive gestational weight gain it may help in certain subsection of women but what we have to keep in mind that there should not be GI intolerance mean in case patient is having nausea vomiting physiological nausea vomiting also in the early pregnancy and we give metformin then the patient may not tolerate Well, if the pregnancy is complicated and there is risk of preterm delivery, again metformin is not a good choice. If there are medical contraindication like renal insufficiency, obviously we not have to give the metformin. Then if we see this that is suboptimal fetal growth suboptimal gestational weight gain and especially if there is fetal growth retardation then metformin has to be uh means either reduced or taken out from the uh prescription altogether. In certain cases one if patient is on high dose it can reduce to the uh can be reduced to the lower dose 500 to,000 migram if it works and the uh things are better and split dosing and after meals is another consideration that we should keep in mind while prescribing metformin and regular review of gestational weight and fetal growth and tolerance helps in uh prescription.

[00:28:53]If you see that the fetal uh abdominal uh circumference or the estimated fetal weight is going beyond 75 centile then it is better to tighten the control and insulin may help in such cases though metforming can be continued and conversely if uh the fetus is doing fine then then some relaxation of glycemic targets can be given. Coming to the case two again this is a case which needs a lot of attention a low-risk women who have a borderline hypoglycemia like 92 is a cutff and 94 migram is a value and there's a dilemma whether we should means label these women as early gestational diabetes or not. So what the tobagum study has shown that in the lower glycemic range the benefit was not significant. So practically there was no much benefit when uh treating women in a lower glycemic range compared to the uh means observational arm and uh it's not only uh the benefit but actually they what they have seen that when these women with a lower glycemic band were treated so there were more small for gestational age uh babies. So there were 5% more uh risk for small for gestational age babies which basically compensate the benefit which was seen with the uh when treating women with a higher glycemic band. So we need to be cautious when we treat women with the lower glycemic band with the mild hypoglycemia and it becomes more important because in Indian studying there is a higher risk for small forestrational age than the large forestrational age. So in the lower glycemic band by cut offs you can say that these women this women like in case two has a GDM but by behavior or whatever the evidence is available. So it looks uh it suggest that these women are actually not GDM and it just could be a physiological elevation or there is mild hypoglycemia which is not detrimental to the fetal growth of the women. So what is an evidence? uh what we know is that that there could be a physiological fall of 10 mig per deciliter as we progress uh during the pregnancy. So if women we see at 7 to 8 weeks or 9 to 10 weeks and uh at 24 weeks what they observed that there could be 10 mig per deciliter for fall uh during this early pregnancy. So like uh in our case uh it was fasting 94 means if we don't would do nothing for that women. So there are chances that women can go to the normal glycemia even without intervention. It could reach like 84 85 milligram per deciliter which is then perfect as per definition of normal glycemia and GDM.

[00:31:27]Uh in that similar study what they have observed that especially the women has isolated fasting plasma glucose elevation 92 to 99 mig per deciliter. So only one/ird of the women actually progresses to GDM and 2/3 are actually normal and without any intervention they will behave as normal. Even at 100 to 109 migram per deciliter what they have seen in a Chinese study that 50% are actually progressing to GDM and 50% regress to normal glycemia. So this phenomena is now called regression means you have an elevated uh hypoglycemia early in pregnancy and you do nothing and the women come back at 24 to 28 weeks a normal GT value. what this this phenomena is called the regression. So in tobagum study also what they have seen that the regression was seen in 50% cases in the lower glycemic band though the regression phenomena was seen in the high glycemic band the chances of regression is only 20%. What it suggests that 80% of the women in a higher glycemic band could be true GDM whereas 50% of the women in the lower glycemic band could be true GDM and 50% are just means having physiological elevation or who are mild hypoglycemia which is not detrimental and if even if you don't treat such women means uh who mild hypoglycemia which has chances of regression there's no difference in outcomes when compared to the normal group. So actually this is the controversy that uh leads to means lack of implementation or lack of consensus on what should be the diagnostic cutffs and whether we should treat all women above that particular diagnostic cutff or not.

[00:33:01]So in the low-risk women what we do follow is that these women are very unlikely to progress to means classical GDM or even if they progress to classical GDM they are unlikely to require phicotherapy. So if it is mild hyperglycemia especially isolated fasting of 92 to 99 in a normal uh weight be uh women. So we just advise lifestyle modification and follow these women with a less frequent intensity means every four weeks till 24 weeks when we do a repeat GT. So less frequent monitoring can be done with a fasting or a 1 hour or two hour plasma value every four weeks and if it is abnormal then we can channelize these women into the conventional management pathway. But if it is going normal then PH GT is done at 24 to 28 weeks to recategorize the women whether women actually has GDM or a normal glycemia. And if we treat these women there should be a cautious use of metforming because as we have seen that these women are actually prone to small for gestational age and metforming can just exaggerate that association.

[00:34:00]So three points are important when dealing with a case two keep a tab on gestational weight gain and fetal growth again because these women are prone to develop less gestational weight gain and fetal growth retardation which can result in small for gestational age.

[00:34:16]Second, when using metformin, be cautious because metformin again as is associated with high chances of small for gestational age and low BMI women are actually prone to develop uh means small for gestational age and metformin can just exacerbate. So this uh need to be kept in mind and third if one see that the fetal centiles are less than 25th and especially there are declining centiles then it requires deescalation and especially in the for metformin. So metformin dos has to be reduced or taken out from the prescription patient better manage with some relaxed targets and with insulin therapy in such uh cases.

[00:34:55]So uh glucor obviously we have to keep it tight means 4 to 7 millles is what is required. So around 90 to 110 is the classical goal during labor and in case women is in active labor prolonged labor or is NPO then the choice of fluid is DNS along with the insulin infusion. So this uh and the third one uh is basically when women deliver. So we also need to keep in mind that the dose of insulin can reduce by 60%. Especially if the women is on high dose then there is a reduction of insulin uh of around 30 to 40% but if like dose is less than 20 units per uh day then the most of the women can even do well without any uh medical therapy.

[00:35:42]So if the patient is on insulin this is what we follow means first follow-up is around 7 days then another follow-up after 2 weeks then followup of around 2 months and then every 2 to 3 months uh to see what is a trajectory in how patient behave and these windows also act as a motivating window so that women can be consult for diet and physical activity to reduce the risk of further postpartum uh diabetes and the last slide is uh this uh which we classically say a toj approach in the postpartum period so patient needs a periodic assessment not only for glycemia but also for other cardio metabolic risk factors like lipid fatty liver and blood pressure and overweight obesity and this need to be periodic if it is everything is normal a yearly follow-up is enough but if it is a high-risk case like pre-diabetes with at least two or three values dange on on like fasting 2 GT and A1 say two out of three values are the range then it is better to keep patient under six monthly follow-up so breastfeeding should be encouraged as we know that It reduces the chances of overweight obesity and diabetes both in mother and the uh offspring. Contraception has to be advised D for diet and exercise has to be maintained. Family involvement is very important. So uh some women will not be able to come in the postpartum period. So even spouses can follow up with the reports and it maintains in the continuity of care and then subsequently women when in a position can join back for medical follow-ups. Individualized goals has to be set for a particular women. We need to be have a friendly approach. These women should be free as early as uh possible from the hospital.

[00:37:16]So priority uh attend attendance and uh dealing is required. Individualized attention and concerns need to be addressed and we need to take care of that we don't give any undue stress and can accomplish our work uh with min by giving minimum stress or no stress and regular follow-up is important because some patients may plan another pregnancy in this uh window can also act as a interconception care to improve the outcomes in another pregnancy.

[00:37:45]So thank you so much and this is what uh I have to present in this uh approach.

[00:37:49]We'll be happy to take any questions there.

[00:38:20]I think uh so do we have questions? Uh >> uh just a minute. Just checking.

[00:38:50]Otherwise we can start with the quiz. Uh I think Dr. Gagan has >> uh sir I'm ready with the quiz.

[00:38:57]>> Okay I think we can start with the quiz and then Dr. Gagan can join and we can go for the question answer session.

[00:39:03]Maybe we can have the discussion after the quer.

[00:39:05]>> Yeah. Yeah.

[00:39:07]>> Yeah. Uh yes ma'am. Just allow us 2 minutes for the setup and then uh we'll let you know. We'll give you a queue.

[00:39:13]>> Sure. Thank you so much.

[00:40:27]Uh ma'am uh I am ready now. Can uh can we start now or uh can I show the QR code?

[00:40:34]>> Uh yes please show the QR code right.

[00:40:37]>> Oh okay.

[00:40:38]>> Uh everybody anybody's joining.

[00:40:42]>> Uh ma'am the questions >> menty right. So yeah, >> are we starting the menty quest please?

[00:41:07]>> Uh yes ma'am. We we'll just give you a queue. The participants must be joining.

[00:41:11]>> Right. Right. Please do ma'am. the questions.

[00:41:18]>> Yeah. Yeah. You can start the questions only and uh we'll get it started.

[00:41:26]>> No, the questions who are going to share the screen ma'am the presentation >> uh you can do it or uh Dr. Antrinsa you have the questions with you? Ma'am I have it in the word document because it was said that >> okay will do it.

[00:41:45]>> So Dr. Shan if you have it we can do in the meantime let's start with the discussion till you do the screen share.

[00:41:56]>> Uh Dr. Sham you sorry Sham you have the questions in the back end.

[00:42:02]>> Uh ma'am uh already I uploaded that questions ma'am in the mnty. Uh but normally normally the presentations will be uh will be from your side and I will uh start the quiz from menty.

[00:42:19]>> Okay. So can we sort this out in the next 5 minutes at your end and in the meantime I'll take forward the discussion because I've received some audience questions.

[00:42:29]>> Okay. Okay ma'am. Okay. Allow me at least 10 minutes now.

[00:42:32]>> Yes. 10 minutes we'll have.

[00:42:34]>> Yeah. Okay.

[00:42:35]>> So uh Dr. Thanks for a wonderful talk. Uh are a few questions we have. One how do you place?

[00:43:03]>> Uh Dr. you are with us. Yeah ma'am. Uh I'm not able to uh hear you properly.

[00:43:10]Can you repeat?

[00:43:13]I think I lost in between.

[00:43:20]>> Okay. Can you hear me now?

[00:43:22]>> Yeah. Yeah. Now it's better.

[00:43:26]>> Yeah. So uh when it comes to early GDM uh the diagnostic like what should be we be looking at diagnostic criteria like should we use a fasting glucose A1C where do we stand there?

[00:43:40]>> Okay so uh if we do a GT right if there are multiple values abnormal it lands uh it leads to more credibility. So if it is like fasting range especially one of the postprandial then actually it could be just a true early GDM >> if it is only isolated fasting plasma glucose especially 92 to 99 so these patient can just have a mild hypoglycemia we are not sure whether they are too GDM or not so what a Chinese study suggested that only oneird of these women are actually true GDM so two3 are actually placious and you should to be careful uh in dealing with such mild hypoglycemia so If it is isolated post parental one or two hour value then again the chances of GDMR are more because we don't expect a one or two hour to be drained early in the pregnancy but isolated fasting should not be taken especially in the lower glycemic band >> and uh regarding A1C there is no diagnostic cutff but uh if we see A1C of more than 5.4%.

[00:44:46]So these women actually should be advised lifestyle modification because this tried study has shown that women with more than 5.4% can actually progress to late GDM.

[00:44:57]>> So this is an action point A1C more than 5.4% with a normal GTT should trigger a pathway for prevention. So lifestyle modification and maybe four to six weekly follow-up with the fasting plasma glucose. uh that is what what uh reflects from the uh stride study and 5.4% again is a important cut off because 95 percentiles are for Indian women is 5.4 so only 5% of the women has value more than 5.4% 4% in the pregnancy.

[00:45:29]>> Right. Right. And now let's say we're talking of cut off. So even for fasting glucose and for the GT because see the GT Hapo has done is at 24 28 weeks right but when we talk of GTT in the early pregnancy what cut offs are we using?

[00:45:49]Are we using the cut offs for pre-diabetes that was you know for the general population as such or do we use the hypo cut offs to define it?

[00:45:58]>> Okay so I think uh for fasting we should use the pre-diabetic cut off which is 100. So most of the experts we more than 100 uh fasting should be taken as GD >> right >> for one or two hour uh it is a higher glycemic bands which gives more credibility to the GDT. So higher glycemic band means one R should be more than 191 and two R more than 16uh2.

[00:46:27]So this is where the consensus lies. So 100 uh 191 and 162 where most of the experts agree that these women can actually be taken as >> and there is a uh push from Australia and Belgium. So they are using her glycemic band. So likely they will push and uh mean advocate this higher glycemic band for diagnosis of early GDM.

[00:46:53]>> Okay, that's interesting. Yeah, that's good work. Um Dr. Koshik, I'll call you back. So uh you know earlier there was data that the cut off for the early GDM it was kept at 5.7 then it went to 5.9 and now we Indian data from stride is showing 5.4. Um any comments from your side on that Dr. >> Yes madam as the uh our population is concerned our population is much higher risk of development of uh any kind of diabetes and hyper hypoglycemia in pregnancy. So possibly we should treat more aggressively or I we should be more proponent of a lower HB1C criteria in our population.

[00:47:48]>> Right? So I think these tria is giving us actual values for our population which the risk of progression is high. U also uh Dr. Dr. Koshik, do you think there should be a risk profiling in the early tri pregnancy where we could use some risk scores like there are risk scores that are being used in some countries for early uh screening of GDM?

[00:48:13]Do you think is there any data from India or do you think they are really applicable here?

[00:48:19]Yes madam. Uh in that particular stite study the history of uh previous gestational diabetes malitis was found to be uh very important as far as early GDM is concerned. On the other hand the family history of uh diabetes type 2 diabetes is important uh as far as the classic GDM is concerned. So in addition to that the newer datas are coming especially CGM derived datas are coming uh which could could be of help in better classifying this this uh you know population where still we are in gray zone metabolic profiling through mean like mean blood glucose in several uh CGM derived uh studies. So I think uh a better I think the early GDM is a new type of uh a different type of of diabetes than the classic GDM and different professional body body should come with a new consensus statement with that in terms of the management the diagnostic criteria how to proceed >> right right okay uh Dr. Ash getting back to you um on risk profiling in your experience like what are the factors you think see it may practically not be possible to do a GTT for every patient in early pregnancy also and then the ones who haven't had it to do it again uh so how do we screen early pregnancy that's the main you know the achilles heal question >> yeah so in one of the slide uh I showed our approach means if there are risk factors I means like overweight, obesity, PCS, PR rescue GDM then it is better not to miss ugly GDM for 75 g >> this may be 10% 20% 25 30% of the women but 70 to 75% of the women still are in the lower BMI category when we talk about uh any setting public or private so then the fasting plasma glucose alone can be used for a screening has uh means used by many of the countries for early pregnancy so high risk low-risk fasting, >> right? And also when it comes to fasting glucose, you know, some of the modi women also they can have an elevated fasting glucose and maybe treating them actually might not be that good. So how do you recommend we you know differentiate and categorize these women out?

[00:50:57]>> Yeah. So I think what genetics again is not uh means available and maybe not be feasible because if we take about uh means the proportion of mod patients in the GDM category means overall hypoglycemian pregnancy their fraction will be very very low compared to the GDM award pre-existing type 1 type two diabetes right >> uh so uh I think the what can uh means fit is a classical clinical history so if there is clear-cut young onset at history in multiple generations. So then uh with a patient with isolated fasting elevation especially without any uh means features of type 2 diabetes aanthosis isolated and clear-cut history. So these women need to keep a watch uh so that we don't overag aggressively uh treat because keeping fetal growth will be available only later on.

[00:51:52]>> Very true. So clinical call can I think help >> if available obviously doubtful cases one can do this one >> genetic testing >> right >> and when it comes to target setting you know goal setting we are extrapolating the late pregnancy goals onto early pregnancy again how do you set reasonable goals in early pregnancy >> so uh again we take a 5% relaxation in the glycemic targets. So 95 120 are general. So in general means not to overt treat because we have very low chances of LGA in Indian settings. And >> yeah similarly if LGA chances are low the chances of neonatal hypoglycemia numission hyperbilia per se is lower in Indian settings compared to the western settings. So that sort of side effect profile is very very less compared to uh the western. So uh a little bit relaxed targets actually can help. It's not purely relaxed because there is a 5% bias in even best to the glucometers. So keeping a target of 101 126 can avoid uh over treatment. And the second thing is then we have to see uh whether uh not all values need to be in targets. So if it is like more than 80% of the values are in target then just has to look like what is going on. we just have to rectify the lifestyle modific lifestyle part so that the rest values can come target so not over aggressively targeting keeping a relaxed target and proportional values that need to be target >> yeah I think there is enough data showing that at least yeah there's uh some data that shows that 20 if more than 20% of your values are above target >> that is when you would want to escalate the treatment intensify the treatment So this is a protocol.

[00:53:47]If we have >> true >> Yeah. So if we have more questions, we'll get back to you. In the meantime, uh we are ready with the quiz. So I'll hand over back to uh Andreza for the quiz session. So can we have the slide deck also?

[00:54:12]Yeah.

[00:54:14]So Dr. Andres can take over the place.

[00:54:18]>> Thank you so much Gagan ma'am for the opportunity. Um so thank you Sham for uh uploading it in menty and uh everybody's requested to scan the QR code to join the quiz.

[00:55:08]Bash can we start?

[00:55:32]Um, ma'am, can we wait for one minute because they have to join now?

[00:55:37]>> Sure.

[00:55:38]>> I think we'll just wait for a minute because people might be logging in right now. Sure.

[00:55:43]>> After 1 minute, let's start whatever.

[00:57:08]Let's get started in that case. No.

[00:57:35]Oh man. Start man.

[00:57:45]So uh the first question is according to the American diabetes association how is over diabetes distinguished from early GDM during the first prenatal visit whether it is by the 100 gram O GGT or it is HB1C or whether it is solely based on the plasma fasting glucose or both plasma fasting glucose and HB1C.

[00:58:24]Next.

[00:58:30]Okay. Accord this is according to the topogian study. uh what was the finding regarding early gestational diabetes malitis? So I think the first part is not visible. So as per the tobo gym study what was the finding if we treat early gestational diabetes malitis uh aggressively what was the finding whether it is increased the risk of SDA babies whether differing treatment to for 24 to 28 weeks was a better option or uh whether it actually resulted in a better neonatal outcome.

[00:59:21]Next.

[00:59:23]Okay. This is regarding the use of continuous glucose monitor in pregnancy.

[00:59:28]So among when CGM is used in pregnancy, which among the following is correct?

[00:59:32]whether the time in range should be maintained more than 75%. And the time above range that is more than 140 mig should be less than 20%. Even while on CGM the fasting what are the blood glucose targets it should be less than 92 less than 140 or less than 120 and the time below range that is severe hypoglycemia should should it be kept less than 2%. Which among the following options is correct?

[01:00:24]on next.

[01:00:29]So physiologically uh why is a plasma flu fasting plasma glucose threshold of less than 92 mg per deciliter is controversial when applied to the first trimester compared to the 24 to 28 week window. This question has already been answered by sir. So what is the correct answer?

[01:00:50]Whether it is that the fasting plasma glucose level normally decreases in the early pregnancy or whether it is uh due to the effect of human placental lactogen whether insulin resistance or increased insulin sensitivity has something to do with it and or it is solely because of the high progesterone levels.

[01:01:23]It is less than 92 in early 75 g uh in 75 g ogt performed at early pregnancy that is 12 weeks of gestation using the I A DPSG criteria.

[01:01:37]What is the specific 1 hour post load plasma glucose cutff to diagnose early GDM? What is the 1 hour value where we diagnose early GDM?

[01:02:13]Next. I have ma'am. Next.

[01:02:27]Can we have the next question on the screen please? Or Bashir? Next question please.

[01:02:45]I think the screen is frozen. Can we move it forward?

[01:03:16]So, can we have the screen share back up?

[01:03:38]So, so far I think very interesting discussion till they get the screen back. Um, so Anra uh let's just start discussing the answers also. First question you might be having.

[01:03:50]>> Yes. Okay. Sham is back here.

[01:03:53]>> Uh so the first question was according to the American Diabetes Association, how is over diabetes disting distinguished from early gestational diabetes during the first prenatal whistle?

[01:04:03]>> Yeah.

[01:04:04]>> So uh okay ma'am the screen is back I think.

[01:04:06]>> Yeah. Okay. Let's just finish the questions in that case. Yes. So in early gestational diabetes malitis if unable to maintain a target fasting plasma glucose less than 95 despite strict adherence to medical nutrition therapy what is the preferred firstline pharmacological treatment recommended by ADA whether it is metforming because it is known to cross the placenta significantly only in the third trimester whether it is insulin whether it is glyide or because of newer SDLT2 inhibitors are preferred what is the preferred agent when we choose pharmacotherapy in gestation ational diabetes malitis.

[01:04:51]>> Next, >> when managing a pregnant lady with early gestational diabetes malitis, what is the specific clinical rational for avoiding maternal glycemic over treatment and keeping fasting levels from dipping chronically below 60 to 70 mg per deciliter? So uh among this question the best option has to be chosen because uh the best option there are similar options everywhere but uh best among this answer should be chosen.

[01:05:19]So whether it is due to because it can trigger maternal keto acidosis or whether uh it there is an increased risk of small forestation age infants or whether it actually contributes to fetal macrosomia whether it leads to uh severe polyhydramus. So what happens if we keep very tight targets causing maternal hypoglycemia?

[01:05:44]>> Next one.

[01:05:48]>> If a patient is diagnosed with early gestational diabetes malitis at 12 weeks and manage her blood glucose excellently with lifestyle modification and the baby was born at term and the baby was fine with no macrosomia or neonal hypoglycemia. When should she undergo her postpartum screening for type 2 diabetes malitis and which is a preferred test whether it is 2 weeks postpartum as already Ash has told whether when we call the patient first time or whether it is 4 to 12 weeks postpartum using a 75 g ogt or for convenience sake it is 6 months using HB1C or whether if the glucose values falls back to normal does she require any further evaluation Next one.

[01:06:37]>> Which of the following represents an established clinical risk factor that justifies the universal or targeted early laboratory screening of glucose intolerance at the first prenatal visit?

[01:06:47]So when at the first prenatal visit itself when do we screen somebody for gestational diabetes malitis? If there is a isolated elevated blood pressure, maternal pre-preg BMI is more than 30 kilogram per meter square or history of gestational diabetes in the previous pregnancy. Maternal age less than 25 years with a normal pregnancy BMI. Is it a or whether any previous history of infant more than 3 kg at time?

[01:07:18]>> Next, last question.

[01:07:21]>> This is the last question. A 29year-old second gravida with history of gestational diabetes malitis underos early screening at 11 weeks of gestation. Her hbc is fine to have 6.1.

[01:07:33]This is regarding this is according to the Australian guidelines. What is the most appropriate next step? whether to initiate metformin immediately, diagnose her as over diabetes malitis and start insulin, reassure and schedule a 75 gram OGT later at 24 to 28 weeks or perform a diagnostic oral GTT before 20 weeks of gestation. What would be the ideal next step?

[01:08:07]Done.

[01:08:10]Thank you.

[01:08:14]>> Right. So, uh maybe we can have a discussion of the answers before uh we have the results taled.

[01:08:23]>> Yes, ma'am.

[01:08:24]>> Can we have the questions back on screen starting from the first question so that Dr. Andrea and the others can have a discussion on them?

[01:08:38]Uh can you please screen share the questions back again? Yeah, great. So Andrew, we can have a discussion and Dr. Koshik and Dr. Yash, please feel free to pitch in.

[01:09:03]We are having a little difficulty with the screen share I guess >> like go back for them I think.

[01:09:13]>> Yeah please >> it's it's coming in now let's discuss.

[01:09:21]>> Yes.

[01:09:22]>> So according to the American diabet association how is over diabetes distinguished from early gestational diabetes during the first prenatal visit. So uh fasting plasma glucose tend to fall during the first trimester and uh it is diagnosed usually uh as Ashdips has already told beyond 15 weeks of gestation the HB1C becomes unreliable.

[01:09:43]So two criterias fasting plasma glucose more than 126 mg per deciliter or an HB1C more than 6.5 defines our diabetes malitis.

[01:09:54]Uh so the answer will be D. Uh can we have the next slide please?

[01:09:59]In the landmark Tobogium study, what was the primary finding regarding the treatment of early GDM? Actually my questions apparently seems very similar to yes talk and almost all the questions are from that only and the answer is that uh even though uh slightly aggressive treatment had shown a few increased risk of small for gestational babies. The final outcome only showed that active early treatment significantly reduced a composite adverse perinatal outcomes compared to deferred treatment. So it was always found to bene found beneficial to identify the diabetes malitis risk early and treat it properly. So the answer would be D here. Can I have the next slide please? When CGM is used in pregnancy, which among the following is correct. The time in range 63 to 140 mg per deciliter should be kept for more than 70%. Time in range above more than 100 mg per deciliter should be kept less than 10%. And time below range 54 should be kept less than 1%. And even while on continuous glucose monitoring the targets remains the same that the fasting blood glucose target should be less than 92, 1 hour ppbs less than 140 and 2 hours less than 120 and the answer would be C. Next slide please.

[01:11:19]So physiologically why is the plasma glucose threshold of less than 92 mg per deciliter controversial when applied to the first trimester compared to the 24 to 28 weeks window. So in pregnancy because of hemodilution and accelerated transfer to the child. Normally in the first trimester the fasting plasma glucose levels normally decreased and hereafter the insulin sensitivity comes down and in 24 to 28 weeks the insulin resistance become maximal because of the human plasma lactogen and other hormones. That is why we traditionally screen for gestational diabetes at that point in time. So because there is a normal uh reduction of fasting plasma glucose uh it may overdiagnose transient metabolic adjustments. So the answer would here would be a. And the f next question please. This is an easy question. Everybody knows in the 75 g o gutt during I using the IA DPGST criteria the specific 1 hour post plasma glucose value is more than 180 mg per deciliter. Next slide please.

[01:12:26]In early gestational diabetes malitis, if the target is not able to be maintained, the first line pharmacological therapy uh is always insulin according to the current guidelines because metformin that had been a few controversies even though uh it is found to accelerated this plastal transfer is found only in the third trimester but still the because of the MIT and multiple other studies have shown long-term fetal risks and later in early adolescence and childhood. So preferred currently is insulin therapy even though glyencclamide and glyuride has been given in certain cases. So the answer would be B.

[01:13:05]Uh next slide please. When managing a pregnant woman with early gestational diabetes malitis uh the specific rationale for avoiding maternal glycemic over treatment is that it may increase the risk of infant being uh bone small for gestational age. So there is a chance of maternal uh starvation keto ketosis more than keto acidosis but still uh the baby's risk is more higher than the risk of maternal starvation ketosis. Next slide please.

[01:13:36]A patient diagnosed with early GDM at 12 weeks managed her blood glucose. So she should ideally be screened in 4 to 12 weeks postpartum using a 75 g oral glucose tolerance test. Answer would be B. Uh, which of the following uh represents an established clinical risk factor? This is an easy question and uh as obvious the answer is B. Maternal pre-preg BMI more than 30 kilogram per meter square or history of early gestation diabetes malitis in previous pregnancy.

[01:14:06]Next question please. If a 29year-old uh second gravida with a history of gestational diabetes undergo screening at uh 11 weeks according to the Australian guidelines, what should be the next step? Uh the cutoff is HBMC 6.5. So when in doubt, we have to perform a oral glucose tolerance test before 20 weeks of gestation to identify early gestational diabetes mitis. So the answer would be D.

[01:14:34]Thank you.

[01:14:39]Yeah, thank you Dr. And I think they excessions and been covered by Dr. Yash earlier. So the winner of our quiz >> Yes. Hi. Did you say something?

[01:14:59]>> No, I was telling it's like I copy.

[01:15:01]>> Yes. So we have but without copying it from sir. So that's important. So uh the winner of our quiz is Dr. Bibbouti. Huge congratulation.

[01:15:16]Thanks from Dr. K and Dr. Yash.

[01:15:32]Dr. Koshik, any comments on the quiz?

[01:15:36]We can see you but we can't hear you.

[01:15:38]You are muted Dr. Koshik.

[01:15:40]>> Yeah. Yeah. In this part of the world uh there's a higher risk of development of uh hypoglycemia in pregnancy. So, so we should uh embrace the concept of early GDM more and more in our day-to-day clinical practice and appropriate management from the beginning in especially in higher uh glycemic band will definitely provide benefit to our neonates. So, we should be more proactive. Thank you.

[01:16:10]>> Very well said Dr. Yashid.

[01:16:13]>> Yeah, I enjoyed that quiz. I think it was very similar like So we managed to cover uh things uh uh so overall I think this is important topic and uh thanks to ESI and you and Dr. Sabrishi for taking a lead and uh means resulting in increased awareness regarding this entity which is very important from public health perspective. So maybe we will continue to engage and learn more about this controversially. So I think in the times forward we should take the lead on early GDM and ex you know exploring what exactly is early GDM where are the dilemmas what are the nuances so uh thank you so much to all of you uh to Dr. Satrishi Dr. Yashi Dr. Koshik and Dr. Entrea this is a very very eyeopening session for me as well even though I listened to Dr. quite a few and every time I learning something new. So thanks to ESI team also. Yeah.

[01:17:17]>> Great.

[01:17:20]So yeah. So uh this is a series of you know the journal clubs and these meetings we will be doing every alternate month. So the next session will happen in July and on the other alternate months we have the Facebook live which is an awareness program. So we invite all the SI members to send us their names as volunteers for either of these activities and we really look forward to taking the work of the task force forward. Thank you so much and have a good night.

[01:17:50]>> Thank you ma'am. Thank you everyone.

[01:17:52]Have a great day.