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   Table of Contents - Current issue
Coverpage
July 2021
Volume 12 | Issue 5 (Supplement)
Page Nos. 1-109

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EDITORIAL  

Gestational diabetes mellitus: The silent epidemic p. 1
Viswanathan Mohan, Dhanasekaran Bodhini, Balaji Bhavadharini
DOI:10.4103/jod.jod_77_21  
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ORIGINAL ARTICLE - GUIDELINES Top

IDF-MENA region guidelines for management of hyperglycemia in pregnancy Highly accessed article p. 3
Shabeen Naz Masood, Nadima Shegem, Shehla Baqai, Mohamed Suliman, Dalal Alromaihi, Mohamed Sultan, Bashir T Salih, Uma Ram, Zaheer Ahmad, Zainab Aljufairi, Eman F Badran, Omaima A Saeed, Abeer Alsaweer, Asma Basha, Shabnam Saquib, Kinda Alani, Erum Ghafoor, Osman A Mohamed, Lobna Farag Eltoony, Ayesha Fazal, Maham Mohsin, Bachar O Afandi, Mohamed Hassanein, Fatheya Alawadhi, Saadia Khan, Ahmed Bilal
DOI:10.4103/jod.jod_58_21  
Introduction: Hyperglycaemia in pregnancy (HIP) is the most common medical disorder complicating pregnancy. This includes women who have pre-existing Type 1 and Type 2 diabetes mellitus (DM) and those diagnosed to have gestational diabetes mellitus (GDM), with glucose intolerance identified for the first time in pregnancy. In the Middle East and North Africa region, the prevalence of DM in women of reproductive age group is high and it varies widely between different regions due to variation in screening and diagnostic criteria for the identification of GDM. Universal blood glucose screening at first antenatal booking visit helps in identifying women with HIP. Women who are screen negative at first antenatal should subsequently be screened with a fasting oral glucose tolerance test (OGTT) around 24-28 weeks to identify GDM. There is a clear evidence that the identification and management of hyperglycaemia improves pregnancy outcomes. Antenatal care involves more visits as these women are at higher risk of fetal malformations, preterm labour and stillbirth. Timing of delivery is based on glycaemic control, fetal wellbeing, and the presence of co-morbidities. Objective: The objective of this article is to provide guidelines regarding the management of hyperglycemia in pregnancy. Materials and Methods: These recommendations are made after reviewing various existing guidelines including American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynecologists, and American College of Sports Medicine. A literature search was done using PubMed, Cochrane Database, Google Scholar, EMBASE, various systematic reviews, and original articles. Search was done using key words “Hyperglycemia in pregnancy,” “gestational diabetes mellitus,” and “diabetes in pregnancy.” Conclusion: Hyperglycemia in pregnancy can be managed effectively if appropriate measures are taken and potential consequences can be avoided.
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REVIEW ARTICLES Top

Screening, diagnosis, and management of GDM: An update p. 43
Christos Bagias, Aggeliki Xiarchou, Ponnusamy Saravanan
DOI:10.4103/jod.jod_101_20  
Gestational diabetes mellitus (GDM) is characterized by an imbalance between insulin supply and resistance, resulting in maternal hyperglycemia first diagnosed during pregnancy. The increasing incidence of GDM parallels the obesity epidemic. There is no universal consensus on optimal screening and diagnostic criteria but it is widely accepted that pregnancies complicated by GDM are at high risk of short- and long-term adverse outcomes for both mother and offspring. Early intervention with lifestyle changes and medical treatment has been shown to prevent perinatal complications. At the same time, the application of clinical guidelines to real world clinical practice may be challenging as it is affected by socioeconomic diversities.
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Management of gestational diabetes mellitus with medical nutrition therapy: A comprehensive review p. 52
Sheryl Salis, Natasha Vora, Shefa Syed, Uma Ram, Viswanathan Mohan
DOI:10.4103/jod.jod_44_21  
Gestational diabetes mellitus (GDM) also referred to as hyperglycemia during pregnancy is posing to be a big health concern for women and is emerging as a major public health problem in India. Early diagnosis and tight glycemic control during pregnancy play a pivotal role in improving pregnancy outcomes in women with GDM. Once diagnosis is made, lifestyle behavioral changes with medical nutrition therapy (MNT) and physical activity form the first choice of therapy for the management of GDM. Failure to meet glycemic goals with these requires the addition of medication/insulin. Regular blood glucose monitoring and record keeping must be encouraged to improve adherence and review treatment efficacy. MNT for GDM is defined as a “carbohydrate-controlled” meal plan that provides adequate nutrition along with appropriate weight gain and fetal well-being to meet increased requirements of energy, protein, and micronutrients, achieve normoglycemia, and prevent nutritional ketosis. Choosing nutrient-dense carbohydrate sources which are low to moderate in glycemic index and glycemic load with focus on the correct amount and distribution of carbohydrates at meals helps control postprandial glucose excursions which is the biggest challenge in GDM. Blood glucose levels can be difficult to control in the morning due to increased insulin resistance secondary to dawn phenomenon seen in women with GDM. Splitting meals at breakfast has shown to improve post-breakfast blood glucose levels. This article is a comprehensive review of guidelines and scientific literature for the dietary management of GDM aimed at achieving normoglycemia, ensuring fetal and maternal wellbeing, and preventing adverse outcomes in pregnancy. The literature has been retrieved from various databases such as “Google Scholar,” “PubMed,” and “Cochrane Database of Systematic Reviews” using relevant keywords related to the topics discussed in this manuscript.
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ORIGINAL ARTICLES Top

Survey of diabetologists and obstetricians’ practice patterns related to care for gestational diabetes mellitus during the COVID-19 pandemic in India p. 59
Balaji Bhavadharini, Ram Uma, Ranjit M Anjana, Viswanathan Mohan
DOI:10.4103/jod.jod_106_20  
Aim: There are limited data on the management of gestational diabetes mellitus (GDM) during the coronavirus disease 2019 (COVID-19) pandemic. This survey was carried out in India to understand the practice patterns of diabetologists and obstetricians (OBs) during the pandemic. Materials and Methods: An online questionnaire was designed, and the link to the survey was shared with doctors through email. Questions were related to the diagnosis and management of GDM both before and during the COVID-19 pandemic. Results: A total of 117 diabetologists and 90 OBs from different parts of India participated in the survey. During the COVID-19 pandemic, diabetologists carried out higher random glucose and HbA1c tests and lower numbers of oral glucose tolerance tests (OGTTs), but differences compared with before COVID-19 were nonsignificant. The OBs reported doing a significantly lower number of OGTTs (85.6% vs. 95.6%, P = 0.02) and significantly more HbA1c tests (16.7% vs. 5.6%, P = 0.03) and self-monitoring of blood glucose (59.4% vs. 37.1%, P < 0.0001) during the pandemic, than earlier. Although 97% of all the doctors surveyed reported using some form of telemedicine, several challenges were identified. Conclusion: The COVID-19 pandemic has resulted in changes in the management of women with GDM. The use of digital technologies could help improve the care of women with GDM during such pandemics.
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Serum human placental lactogen and prolactin may not be associated with aberrant glucose homeostasis in GDM p. 66
Mohammad Fakhrul Alam, Sharmin Jahan, Mashfiqul Hasan, Nusrat Sultana, Mahmudul Hossain, Mohammad Farid Uddin, Muhammad Abul Hasanat
DOI:10.4103/jod.jod_111_20  
Background: Gestational diabetes mellitus (GDM) shows insufficient β-cell compensation for insulin resistance (IR) during late pregnancy, whereupon derangements of human placental lactogen (hPL) and prolactin (PRL) have a presumed role in its pathogenesis. Aims: To assess the relationship of serum hPL and PRL with IR and β-cell function in GDM and pregnant women with normal glucose tolerance (NGT). Materials and Methods: This cross-sectional study was performed with 40 women with GDM and an equal number of pregnant women with NGT who were diagnosed on the basis of the WHO 2013 criteria during 24–40 weeks of gestation. hPL was measured by an enzyme-linked immunosorbent assay (ELISA); PRL and fasting insulin were measured by a chemiluminescent immunoassay. Equations of homeostatic model assessment (HOMA) were used to calculate the indices of IR (HOMA-IR) and β-cell function (HOMA-B). Results: No statistically significant difference was found between the GDM and NGT groups in circulating concentrations of either hPL (6.01 ± 1.76 vs. 5.92 ± 2.10 mg/L, mean ± SD; P = 0.852) or PR [180.27 (125.95–306.20) vs. 166.87 (134.24–284.70) ng/mL, median (IQR); P = 0.704]. There was no relationship of circulatory levels of hPL and PRL with glucose values at different time points during oral glucose tolerance test as well as with AUCglucose (P = NS for all). On multiple regression analysis, neither hPL nor PRL emerged as a significant predictor for fasting insulin, HOMA-IR, and HOMA-B in GDM (P = NS for all). Conclusions: Circulating concentration of hPL and PRL may not be a potential determinant of IR and β-cell dysfunction in GDM.
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Postpartum abnormal glucose tolerance and predictive factors among women with gestational diabetes mellitus in Gampaha District, Sri Lanka p. 73
Buddhika Hemali Sudasinghe, Chandrika Neelakanthi Wijeyaratne, Samitha P Ginige
DOI:10.4103/jod.jod_9_21  
Context: Gestational diabetes mellitus (GDM) is a recognized risk for abnormal glucose tolerance (AGT) long-term. Aims: The aim of this study is to determine the prevalence of postpartum diabetes and AGT and predictive factors among Sri Lankan women with GDM. Settings and Design: The follow-up study was conducted in Gampaha District, Sri Lanka. Materials and Methods: Pregnant women with GDM were identified by a community-based longitudinal study (n = 1200) by WHO 1999 criteria and followed up till 1 year postpartum. Study instruments were interviewer-administered questionnaire, anthropometric measurements, and fasting 75 gOGTT. Statistical Analysis Used: χ2 tests with P-values and odds ratios (ORs) with 95% confidence interval (CI) were used to assess the statistical significance and strength of the associations. Predictive factors of postpartum AGT were identified by the multivariate analysis. Results: Of those identified with GDM (194), 169 participated in postpartum follow-up at 2 months (87.1%). Of the 169, 59 participated at 1 year. At 2 months, 17/169 (10.1%) had diabetes and 55/169 (32.5%) had AGT (diabetes=17, impaired glucose tolerance= 36, impaired fasting glucose=2). At 1 year, 11/59 (18.6%) had diabetes and 28/59 (47.5%) had AGT. Predictive factors of postpartum AGT at 2 months were 2-h postprandial blood sugar (2-h PPBS) before 12 weeks ≥97.5 mg/dL (adjusted OR (aOR)=2.8; 95% CI=1.3–6.0), GDM diagnosis before 16 weeks (aOR=7.7; 95% CI=1.5–39.7), and 1-h oral glucose tolerance test (OGTT) ≥179 mg/dL (aOR=3.1; 95% CI=1.5–6.4). Predictive factors of postpartum AGT at 1 year were 2-h PPBS before 12 weeks ≥97.5 mg/dL (aOR=8.4; 95% CI=2.3–30.3) and physical activity (aOR= 0.2; 95% CI=0.1–0.8). Conclusion: Postpartum AGT following GDM is high among Sri Lankan women. Long-term follow-up is recommended.
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Current practices in diagnosis and management of gestational diabetes: A Bangladesh study p. 79
Faria Afsana, Bishwajit Bhowmik, Tasnima Siddiquee, Tareen Ahmed, Faruque Md Pathan, Tofail Ahmed, Mohammad Abdus Samad, Mohammad Farid Uddin, Shahjada Selim, Nayla Cristina do Vale Moreira, Purobi Rani Debnath, Kaiser Alam Choudhury, Abdul Alim, Mohammad Robed Amin, Hajera Mahtab, Akhtar Hussain, A K Azad Khan
DOI:10.4103/jod.jod_14_21  
Background: In the absence of international or national guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM), physicians’ current practice varies a great deal. This is particularly true for most developing countries, including Bangladesh. We have conducted a study to register the current practices related to the diagnosis and management of GDM in Bangladesh. Materials and Methods: A cross-sectional survey was conducted to obtain details regarding diagnostic criteria used, screening methods, management strategies, and postpartum follow-up of GDM using a structured questionnaire. A total of 756 physicians from 30 centers of the Diabetic Association of Bangladesh, Government and Private Hospitals located in both the capital Dhaka city and outside Dhaka participated. Results: The study found that diabetologists look after 42.5% of the GDM patients. Among the physicians participated, 44.4% preferred first antenatal care visit for the GDM screening, and 55.2% preferred two samples oral glucose tolerance test (OGTT) for screening. About 47.6% of the physicians followed the American Diabetic Association (ADA) guidelines for diagnosis. Half of the participated physicians preferred short-acting insulin and four-times home monitoring of blood glucose per day. Around 66.3% of the physicians advised OGTT 6 weeks after delivery. Conclusion: The majority of the participating physicians do not follow the recommendations for the diagnosis and management of GDM. This emphasizes the need for developing an evidence-based national guideline for GDM and necessary training to halt the rise of diabetes and safe mother and child health in Bangladesh.
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Pregnancy outcome in women with type 1 and type 2 diabetes mellitus in Dubai hospital: A retrospective observational study p. 86
Shabnam Saquib, Zenab Y Tambawala, Seema Waheed, Nawal M Hubaishi
DOI:10.4103/jod.jod_29_21  
Aim and Objectives: Pregestational diabetes mellitus (PGDM) affects less than 1% of the obstetric population. It has a significant impact on maternal and fetal morbidity and mortality. This study aimed at evaluating antenatal care and pregnancy outcomes in women with PGDM who delivered in Dubai Hospital during 2017–2019. Materials and Methods: A retrospective analysis of all women with diabetes mellitus who delivered in a tertiary care hospital at Dubai from January 1, 2017, to December 31, 2019, was conducted. Maternal characteristics, type of diabetes mellitus, prepregnancy and antenatal glycemic control, mode of delivery, birth weight, and perinatal outcomes were evaluated during the study period. We also compared glycated hemoglobin (HbA1c) levels prepregnancy and during the antenatal period in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), with its impact on maternal and fetal outcomes. Results: There were 7284 women who delivered during the study period at our hospital, out of whom 28 women (18.8%) had T1DM and 121 women (81.2%) had T2DM. A total of 144 (96.6%) patients were booked in the antenatal-diabetes mellitus combined clinic. Seventy-nine (53%) women had measured HbA1c within six months before pregnancy. Only 53% women preconceptionally had HbA1c levels <6.5%; however, by the third trimester, 74% of women achieved HbA1c <6.5%. Antenatally, 26 women were associated with essential hypertension, 10 with nephropathy, and eight with retinopathy and 12 women developed preeclampsia. Forty-six (30%) women had preterm delivery at less than 37 weeks. This was significantly higher in T1DM versus T2DM (50% vs. 27%, P value = 0.01). The cesarean section rate was 62%, and 50% of them were due to repeat elective cesarean section. Twelve babies born were more than 4kg, and one of them weighed more than 5kg (5.270kg). There were five cases with stillbirth, no neonatal death was recorded within seven days, and the perinatal mortality rate was 30/1000. Conclusion: The interval prevalence of PGDM in our cohort was 2%. Achieving HbA1c levels <6.5% in two-third of the women with diabetes mellitus by the third trimester resulted in a prevalence of macrosomia (8%) similar to the general population.
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Guidelines for physical activity and exercise for women with hyperglycemia in pregnancy p. 92
Ahmed Bilal, Zaheer Ahmed, Maham Mohsin, Ayesha Fazal, Saadia Khan, Saira Saeed, Shabeen Naz Masood
DOI:10.4103/jod.jod_33_21  
Introduction: Lifestyle modification is the most important intervention for control of hyperglycemia in pregnancy (HIP). It includes medical nutrition therapy and exercise. Various guidelines have been published to assist physicians and obstetricians in prescribing physical activity and exercise as a part of management of HIP. Pregnancy provides a unique opportunity to motivate women for exercise. Modifications in recommendations regarding physical exercises are needed particularly for those on bed rest for obstetric indications, orthopedic disability, or competitive athletes. Objective: The objective of this article is to provide guidelines regarding exercise for women with HIP. Materials and Methods: These recommendations are made after reviewing various existing guidelines including American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynecologists, and American College of Sports Medicine. A literature search was done using PubMed, Cochrane Database, Google Scholar, EMBASE, various systematic reviews, and original articles. Search was done using key words “Physical Activity,” “Exercise during Pregnancy,” “Life Style in Pregnancy.” The aim was to identify correct and safe physical activity during pregnancy. Results: Exercise and physical activity is completely safe and recommended in pregnancy. Conclusion: Exercise is safe in pregnancy and should be encouraged in women to control hyperglycemia. They should be educated to continue lifestyle changes in postpartum period and later in life.
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Prevalence of thyroid dysfunction and anti–thyroid peroxidase antibody in gestational diabetes mellitus p. 98
Arun Karat, Chandni Radhakrishnan, Nallaveetil K Thulaseedharan, Suneetha Kalam
DOI:10.4103/jod.jod_34_21  
Background: Gestational diabetes mellitus (GDM) and thyroid dysfunction are the two common endocrine disorders affecting pregnancy. Some association was hypothesized between GDM and thyroid dysfunction in the literature. The main aim of this study was to unveil this metabolic interplay as better understanding may facilitate early diagnosis and intervention thereby limiting major fetal and maternal adverse events. Here we estimated the prevalence of abnormal thyroid function and anti–thyroid peroxidase (anti-TPO) antibody and also studied the risk factors for thyroid disorders in patients with GDM. Materials and Methods: This cross-sectional study was conducted between February 2014 and January 2015. A total of 100 consecutive pregnant women diagnosed to have GDM as per the American Diabetes Association 2013 recommendations were recruited and thyroid stimulating hormone, free triiodothyronine (T3), free thyroxine (T4), and anti-TPO antibody assays were done. Details regarding pregnancy outcome and any complications if present were also obtained and analyzed. The prevalence is expressed as proportions, and the statistical significance of risk factors was assessed using the chi-square test and independent t-test. Results: Abnormal thyroid function was detected in 31 (31%) patients, which includes 17 cases of subclinical hypothyroidism (54%), 10 hypothyroidism (32%), 2 (6%) subclinical hyperthyroidism, and one case each of isolated low T3 and isolated low T4. Anti-TPO antibody was positive in 35 patients (35%). History of GDM in previous pregnancy, family history of diabetes mellitus, presence of clinically detectable thyroid gland enlargement, and presence of anti-TPO antibody in serum were found to increase the risk of thyroid dysfunction. Majority of the subjects had uneventful delivery, and no significant increase in maternal or fetal complications was reported. Conclusions: This study showed a high prevalence of thyroid dysfunction and anti-TPO antibody in GDM patients. The significant thyroid abnormalities detected were subclinical hypothyroidism and hypothyroidism. The risk of thyroid dysfunction is elevated in patients with the presence of anti-TPO antibody. This scenario provides a strong ground to recommend meticulous assessment of thyroid function in GDM patients.
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Practice patterns among healthcare professionals for screening, diagnosis, and management of gestational diabetes mellitus (GDM) in selected countries of Asia, Africa, and Middle East p. 104
Shabeen Naz Masood, Balaji Bhavadharini, Viswanathan Mohan
DOI:10.4103/jod.jod_63_21  
Background: Healthcare professionals (HCPs) face several challenges while treating women with gestational diabetes mellitus (GDM) and often get confused by the different diagnostic criteria recommended by different scientific organizations. A survey was carried out to understand the practices of physicians and obstetricians in South Asia, Africa, and the Middle East, to identify the screening methods and diagnostic criteria used by them for managing women with GDM in the respective countries. Materials and Methods: HCPs across three different regions including South Asia, Middle East, and Africa were contacted through professional diabetes organizations. An online survey designed with Google Forms was created. The link to the survey was shared with HCPs, and the responses were collected and stored in the Google Sheets which was later downloaded for analysis. Results: A total of 356 doctors participated in the survey. The survey covered a total of 18 countries: 3 in South Asia, 5 in Africa, and 10 in the Middle East. The vast majority of the HCPs (64.6%) screened all pregnant women for GDM. About 42.4% of them screened for GDM between 24 and 28 weeks, 21.1% screened before 12 weeks, and the rest carried out screening at different time points. With regard to the screening method, 58.5% of the HCPs responded that they followed the two-step process. However, when asked about the criteria used, the responses were inconsistent. The criteria of the International Association of Diabetes in Pregnancy Study Group (IADPSG) were used by 36.5% doctors and the 1999 criteria by the old World Health Organization (WHO) were used by 27.2%, and only 23.9% reported following the American Diabetes Association (ADA) criteria. Conclusion: This large international survey shows that there are still considerable inaccuracies in doctors following the recommended guidelines for GDM diagnosis. This reiterates the fact that more education and training will help HCPs to manage GDM better.
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