Protocol for Diagnosis & Management of

Gestational Diabetes Mellitus for the State of

Goa
 Introduction

• Gestational Diabetes Mellitus (GDM) is defined as any

degree of dysglycemia, not severe enough to be
labeled as DM, with onset or first recognition during
pregnancy.
• ODM – Overt Diabetes Mellitus
• Worldwide, one in 10 pregnancies is associated with
diabetes, 90% of which are GDM.
• Undiagnosed or inadequately treated GDM can lead
to significant maternal & fetal complications.
• Women with GDM and their offspring are at increased
risk of developing type 2 diabetes later in life.
 Introduction (contd…)

• In India, the rates of GDM are estimated to be 10-14.3%.

• In 2010:
– Estimated 22 million women with DM of age of 20 - 39 years
– Additional 54 million women in this age group with pre-diabetes with the
potential to develop GDM if they become pregnant.
• The incidence of GDM is expected to increase to 20%

• In a field study in Tamil Nadu -"Diabetes in Pregnancy" – Awareness

and Prevention project, prevalence of GDM among pregnant
women screened:
– 4151 – urban – prevalence 17.8%
– 3960 - semi-urban – prevalence 13.8%
– 3945 - rural areas – prevalence 9.9%
 Need for formulating State specific guidelines for management
of GDM

• It has been noticed that there is lack of uniformity in the

management of GDM across health care facilities.
• There is delay in referral of uncontrolled GDM cases to higher
centers resulting in increased maternal & fetal morbidity and
mortality too.
• Hence, as for DM, the State Family Welfare Bureau, DHS took the
initiative of formulating State-specific guidelines for management
of GDM in consultation with experts in the State.
• It is envisaged that these protocols will standardize care of GDM
across the State in primary and secondary level health care
facilities; help achieve better glycemic control in antenatal
diabetic population & avert greater proportion of complications
during pregnancy thus reducing out of pocket expenditures and
giving the pregnant women a better quality of life.
 Data on Gestational Diabetes Mellitus (GDM) for the
state of Goa (Source: HMIS)

Indicator 2019-2020 2020-2021

Pregnant Women tested using OGTT 25037 18451

Diagnosed GDM (PW) 1044 940

PW with GDM given insulin 298 158

 Consequences of GDM

• Maternal risks of GDM include abortion, polyhydramnios, pre-

eclampsia, prolonged labour, obstructed labour, cesarean
section, uterine atony, postpartum hemorrhage and infection
which are the leading global causes of maternal morbidity and
mortality.

• Fetal risks include spontaneous abortion, intra-uterine death,

stillbirth, macrosomia, shoulder dystocia, birth injuries, neonatal
hypoglycemia and infant respiratory distress syndrome.

• Long- term clinical effects of GDM are important contributors to

the burden of non-communicable diseases in many countries.
 Operational Definition of Diabetes in Pregnancy

• Diabetes in Pregnancy is defined as any degree of dysglycemia with onset

or first recognition during pregnancy.
• Gestational Diabetes Mellitus (GDM) is defined as any degree of
dysglycemia, not severe enough to be labeled as DM, with onset or first
recognition during pregnancy.
 GDM diagnosis
• Whom to test?
• How to test?
• When to test?
• Whom NOT to test?
• How to interpret the test?
Technical guidelines on testing & management of GDM

• Target population: All pregnant women in the population

• Protocol for investigation is as follows:
Algorithm on Universal testing for GDM
 Methodology: Test for Diagnosis
• Oral Glucose Tolerance Test (OGTT) is the investigation of choice to
diagnose GDM.
• Fasting plasma glucose (venous blood sample) after 8-14 hours of fasting
should be performed using autoanalyser / semi-autoanalyser
× Glucometer recording should not be used for diagnosis of GDM
• 75 gm anhydrous glucose or 82.5 gm glucose monohydrate is to be given
orally after dissolving in approximately 200-300 ml water. The intake of
the solution has to be completed within 5-10 minutes.
– Blood glucose (venous sample) using autoanalyser / semi-autoanalyser should be
measured at 1 hour and 2 hours after ingestion of glucose solution.
• Patient should be resting throughout the test.
• If vomiting occurs within 30 minutes of oral glucose intake, the test has
to be aborted on that day and repeated the next day or else referred to a
higher facility. If vomiting occurs after 30 minutes, the test continues.
• All the above steps of OGTT should be explained by a designated
ANM/counsellor/staff nurse to the patient at the time of scheduling appointment.
Pamphlets explaining the above steps will be given to the patient at the same time.
 Diagnostic Cut-Offs
• The following threshold blood sugar level
is taken as cut off to diagnose GDM:
• 0 hr (FPG) ≥ 92 mg/dl
• 1 hr ≥ 180 mg/dl
• 2 hr ≥ 153 mg/dl
• Any one out of 3 has to be fulfilled for
GDM diagnosis
 Diagnostic tests (contd…)
• Critical to do the second test as many pregnant women develop
glucose intolerance only during 24-28 wks.
– Only 1/3rd of GDM women are detected during the first trimester.
• If OGTT not done during 24-28 weeks, then it can be done any
time after 24 weeks of pregnancy.
• There should be at least 4 weeks gap between the two tests
• Do OGTT at the time of first contact itself if woman comes late
in pregnancy for ANC (beyond 24 weeks).
• If the patient presents beyond 28 weeks of pregnancy, OGTT has
to be done at the first point of contact.
• If the test is positive at any point, protocol of management
should be followed as given in this document.
• If the patient is a known case of DM pre-pregnancy,
then OGTT should not be done
 Diagnostic tests – health care facilities
• At all ANC and labour rooms with facility for collection of sample and interpretation
of result there itself (by training of personnel), following should be available:
– Autoanalyser / semi-autoanalyser,
– Glucometer
– Metformin and insulin

• At all other facilities upto PHC, there should be in-house:

– Autoanalyser / semi-autoanalyser
– 75 gm of anhydrous glucose / 82.5 gm glucose monohydrate for conducting the
test and giving report immediately
• So that necessary advice can be given on the same day by the treating doctor.

• At all other facilities up to SC, there should be an in-house:

– Glucometer
– Insulin and metformin
• To provide appropriate follow up care
Management of GDM: Guiding Principles
• Pregnant women once diagnosed GDM should be started for
2 weeks on:
– Medical Nutrition Therapy (MNT)
– Physical exercise - The woman should walk / exercise for 30 mins a day
(in consultation with an Obstetrician).
– Multiple SMBG to be done at SC / PHC / home using glucometer. Good
control indicated by:
• Pre meal values done 15 min before meals of <95 mg/dl
• Post-meal (2 hr post-meal) value of <130 mg/dl
• If SMBG in target, monitoring to be done every 2 wks till 24
wks/ term. At least 4 SMBG to be done per wk at SC / PHC.
• If GDM is not controlled with MNT, Insulin therapy is added
• If levels are high (beyond above mentioned targets), refer to
obstetrician.
Thus, GDM is managed initially with MNT and physical exercise and if it is not
controlled with MNT (lifestyle changes), Insulin therapy is added to the MNT
Date BBF ABF BL AL BD AD MN/ Remarks

3AM

16
Fig. 1.3: Management of Pregnant Woman
with GDM

Pre meals < 95 &

Post meal > 130
 Medical Nutrition Therapy (MNT)
Principles of MNT

• MNT to be explained by Dietician or Diabetes

Educator (DE). Obstetrician will facilitate the same.
• All pregnant women with GDM should get Medical
Nutrition Therapy (MNT) once diagnosis is made.

• MNT for GDM primarily involves a carbohydrate

controlled balanced meal plan which promotes
– Optimal nutrition for maternal and fetal health
– Adequate energy for appropriate gestational
weight gain
– Achievement and maintenance of
normoglycemia.
 Medical Nutrition Therapy (MNT)
Principles of MNT (contd…)

• Importance of the individualized nutrition assessment in GDM

– To allow an accurate appraisal of the woman’s nutritional status.
– Includes defining her BMI or percentage of desirable pre-
pregnancy body weight
– Optimal pattern of weight gain during pregnancy.
• At diagnosis of GDM, refer to diabetes educator (DE) at nearest
CDC for MNT. Obstetrician will facilitate the advice of DE.
– To determine energy requirement of every patient
– Make adjustments based on weight change patterns
• Energy requirement during pregnancy:
– Normal requirement of adult woman
– Additional requirement for fetal growth
– Ensure optimum increase in the body weight of pregnant
woman.
•
Daily Calorie Requirement (to be calculated by
doctor)
• Calculate pre-pregnancy BMI for woman with
GDM - patient has to know her pre-pregnancy weight
or tell approximate pre-pregnancy weight

• BMI categories for Asian Indians to be used

– Classify as Underweight, Normal weight,
Overweight and Obese

• Calculate Ideal pre-pregnancy Body Weight

(IBW) for the woman with GDM = (Height in cm
– 100) × 0.9
 Daily Calorie Requirement (contd…)

• Sedentary or moderately active woman with GDM in first

trimester
 Normal pre-pregnancy BMI
– Approximately, 30 kcals/kg ideal pre-pregnancy body weight/day.
 Underweight woman/ underweight pre-pregnancy BMI
– Add 200-400 kcal to daily calorie requirement (above formula) OR
– 35 kcal/kg ideal pre-pregnancy body weight/day
 Overweight woman/ overweight pre-pregnancy BMI
– Subtract 200 kcal from daily calorie requirement (above formula) OR
– 25 kcal/kg ideal pre-pregnancy body weight/day
 Obese woman / obese pre-pregnancy BMI
– Subtract 400 kcal from daily calorie requirement (above formula) OR
– 25 kcal/kg ideal pre-pregnancy body weight/day
Daily Calorie Requirement (contd…)
• Sedentary or moderately active woman with GDM in
2nd and 3rd trimester
– Add 350-400 kcal/ day extra to the first trimester calorie
intake for all weight patients.
• Not considered heavy worker/ heavy activity as most
women are advised against heavy exertion in pregnancy
• The actual calories prescribed could be rounded off to
the nearest hundred for convenience of DE & patient.
• More calorie restriction up to 30% below requirement
can be tried in higher classes of Obesity
 Distribution of calories in meals & snacks (to be explained by DE/ dietician)

• Ideal number of daily meals: 3 (breakfast, lunch, dinner)

• Total percentage of calories can be distributed as: 20%, 20% & 20%
respectively.
• The remaining 40% of calories can be provided through 3 snacks:
– mid-morning, evening & bedtime; 15%, 15% and 10% each.
• If snacks are not required, the 15% can be adjusted through meals
• Timings of meals (to be kept fixed for individual patient)
Breakfast: 7 AM - 8.30 AM
Lunch: 12.30 PM - 1.30 PM (portable tiffin if lunch cannot be taken at home)
Dinner: 7.30 PM - 8.30 PM
• Timings of snacks (to be kept fixed for individual patient)
Mid-morning snack: 10.30 AM
Evening snack: 4.30 - 5 PM
Bedtime snack: 10.30 PM
Table 2: Meal timings and calorie distribution
Meal Timing % of total calories

Breakfast 7 AM – 8.30 AM 20%

Mid-morning 10.30 AM 15%

Lunch 12.30 PM – 1.30 PM 20%

Evening 4.30 – 5.00 PM 15%

Dinner 7.30 PM – 8.30 PM 20%

Bedtime 10.30 PM 10%

Macronutrient distribution per day:

•Carbohydrates: Up to 50% (preferably complex carbohydrates)
•Proteins: 20% or greater. Add 0.5g/kg body weight in pregnancy.
•Fats: Up to 20-30%
•Snacks should be ideally complex carbohydrates / protein / fibre
•Fibre should be consumed at the start of the meal
•Fibre: At least 40g/day
 Carbohydrate foods and daily intakes
• Carbohydrate foods - essential for healthy diet of mother & baby.
• Once digested, carbohydrate foods broken down to glucose which
goes into blood stream.
• The type, amount and frequency of carbohydrate intake - major
influence on blood glucose readings
• Foods sources of carbohydrate include
– cereals (wheat, bajra, ragi, corn, rice etc.) and its products (suji,
refined flour, breads, pasta, noodles etc.)
– pulses (green gram, Bengal gram, black gram etc.)
– starchy vegetables (potato, sweet potato, corn, tapioca etc.)
– fruits, sweets, juices etc.
• Large amounts of carbohydrate foods eaten at one time will lead
to high blood glucose level - should be avoided.
• Spread carbohydrate foods over the day to prevent this.
– 3 small meals and 2–3 snacks each day rather than 3 large meals
only daily
 Carbohydrate foods and daily intakes
(contd…)
• Complex carbohydrates
– whole-grain cereals like oats, bajra, jowar, ragi, whole pulses,
vegetables and fruits with skins
• preferred over
• Simple carbohydrates like food with lots of added sugar or honey,
or foods that are made from refined white flour
– sweets, cakes, puddings, sweet biscuits, pastry, juice, soft drinks,
chips, white bread, naan, pizza

• Carbohydrate serves - One serve = approx. 15 gms of carbohydrate

– Count the number of serves that a mother eats daily
– Aim for 2–3 serves at each major meal & 1–2 at each snack
• Exchange list for carbohydrate is given in Annexure 3
 Fat Intake during Pregnancy
• Saturated fat intake (ghee, butter, coconut oil, palm oil, red meat,
organ meat, full cream milk)
– less than 10% of total calories
• Dietary cholesterol should be < 300 mg/dl.
• Obese and overweight patients - lower fat diet overall can help slow
the rate of weight gain
Ways to trim the fat from the diet
• Use less fat in cooking and avoid frying of foods.
• Use low-fat dairy products NOT whole milk or full cream products
• Choose low fat snacks like substituting fresh fruit, salads, baked and
steamed food items NOT high-fat snacks such as cakes, biscuits,
chocolates, pastries, samosas and pakoras
• Using lean meat in place of red meat
 Protein Intake during Pregnancy
• Protein: Protein requirement in pregnancy is
increased to promote fetal growth.
• Add 0.5 g/kg body weight protein (in addition to
the routine 20% of protein intake) in pregnancy.
• At least 3 servings of protein foods are required
everyday to meet the increased demand
• Sources of protein - milk and milk products, egg,
fish, chicken, pulses (dal) nuts
 Fibre intake in pregnancy
• Fiber: High fiber foods especially soluble fibre may
help control blood sugar by
– delaying gastric emptying
– retarding the entry of glucose into the bloodstream
– lessening the postprandial rise in blood glucose
• Soluble fiber in flaxseed, psyllium husk, oat-bran,
legumes (dried beans of all kinds, peas and lentils),
and pectin (from fruit, such as apples) and that in
root vegetables (such as carrots) are helpful
Non-Nutritive sweeteners in pregnancy
• Non-nutritive sweeteners approved for use in
pregnancy:
– Aspartame
– Neotame
– Stevia
– Acesulfame K
• Indiscriminate use should not be encouraged
Fig. 1.3: Management of Pregnant Woman
with GDM

Pre meals < 95 &

Post meal > 130
 3.4 b. Medical Management (Insulin Therapy)

• Insulin - drug of first choice in GDM

• Insulin can be started any trimester during
pregnancy for GDM management
• In pregnant women with GDM once MNT fails,
insulin should be started
• Pregnant women on insulin therapy -
instructed to keep sugar / jaggery/ glucose
powder handy at home to treat hypoglycemia
if it occurs.
 3.4 b. Medical Management (Insulin Therapy)
• Sites of Insulin Injection:
– Preferably Front/Lateral aspect of the thigh
– Anterolateral abdomen.
• Insulin injection given subcutaneously only

• Types of Insulin used in GDM:

• Basal Insulin
– NPH Insulin
• Bolus insulin
– Regular insulin
– Lispro
– Aspart
– Glulisine
 Fig. 1.4: Insulin Therapy in GDM

Targets in pregnancy are defined as pre-meals < 95 and post meals <130
Date BBF ABF BL AL BD AD MN/ Remarks

3AM
BS 108 139 100 147 110 145 135

Insulin R4 R2 R5 N6

BS 110 142 98 150 118 135 128

Insulin
R4 R4 R5 N8

BS 94 123 86 124 98 126 106

36
 Insulin Therapy in GDM
• If the values are before breakfast 86 mg/dl and pre lunch the
sugar level is 102 mg/dl then bolus insulin has to be added
before breakfast to take care of the pre lunch out of target
value.
• Once all targets achieved, patient is advised to monitor at least
one pair (pre and 2 hrs post meal) of reading every alternate
day and 3 AM RBSL once in a week for patient using MSII.
• For patients using only Basal Insulin, monitor only FBS every 2-
3 days and other readings once in a week.
• Insulin doses need to be adjusted based on the above
guidance throughout the pregnancy to achieve and maintain
the targets
 Hypoglycemia Care
Depends on:

A . Degree of hypoglycemia
– > 70 mg/dl: Relative hypoglycemia
– 60-70 mg/dl: mild hypoglycemia especially if symptoms are mild
– 50-60 mg/dl: moderate hypoglycemia
– < 50 mg/dl: severe hypoglycemia (requires emergency care)
B. Time of last medication / insulin injection
C. Time of last meal/next meal
D. Symptoms
• Mild symptoms, asymptomatic patients or those with blood glucose 60-70
mg/dl: preferably avoid direct sugars and use planned meal/ snack with
complex carbohydrate.
• Moderate symptoms with blood glucose 50-60 mg/dl: consider direct sugars.
• If the hypoglycemia is at the time of a meal, reduce the planned insulin dose by
2-4 units and take it soon or just after the meal.
• Treat severe hypoglycemia with intravenous dextrose.
Management of women with PCOD already on metformin

• If metformin is given for inducing ovulation in

a patient with PCOD it has to be continued till
12 -14 weeks of gestation. Then, metformin
needs to be omitted for 2 weeks and conduct
OGTT. Subsequently, refer the Algorithm
Universal Testing of GDM flowchart.
 Special obstetric care for pregnant women with GDM
Antenatal care

• Antenatal care of a pregnant women with GDM should be provided by

gynaecologist / obstetrician.
• In cases diagnosed before 20 weeks of pregnancy, a fetal anatomical
survey by USG should be performed at 18-20 weeks.
• For all pregnancies with GDM, a fetal growth scan should be performed
at 28-30 weeks gestation & repeated at 34-36 weeks gestation. There
should be at least 3 weeks gap between the two ultrasounds and it
should include fetal biometry & amniotic fluid estimation.
• Cardiovascular system evaluation by level II ultrasound /
echocardiogram at 22-24 weeks should be conducted.
• Fetal growth should be assessed on clinical grounds and ultrasound
growth scan at the discretion of gynaecologist / obstetrician.
• Pregnant women with GDM in whom blood sugar level is well
controlled & there are no complications, should continue with
antenatal visits as per high-risk pregnancy protocol or as recommended
by the gynaecologist / obstetrician (as least once monthly).
• Pregnant women with GDM to be diligently monitored for hypertension
in pregnancy, proteinuria and other obstetric complications.
• In pregnant women with GDM between 28-34 weeks of gestation and
requiring early delivery, antenatal steroids should be given as per GOI
guidelines i.e. Inj. Dexamethasone 6 mg four doses IM 12 hours apart or
inj. Betamethasone 12 mg IM two doses 24 hours apart. More vigilant
monitoring of blood sugar levels should be done for next 72 hours
following injection. The steroid dose can be repeated if the pregnancy
continues 4 weeks from the first dose of steroids and before 34 weeks.
• Insulin doses in relation to antenatal steroids: Admit one day prior and
monitor the sugar levels. If controlled the insulin dose should be
increased 25% on day one of steroid, 40% on day two and 25% on day
three. The day four insulin dose may be decided according to the blood
sugar levels.
• Steroids should preferably be given in the morning (8.00 am) and at
night (8.00 pm). In case of emergency cases, after the first dose the
second dose should preferably be in the 8.00 am to 8.00 pm regimen.
 Fetal surveillance in pregnant women with
GDM:
• Pregnant women with GDM are at an increased risk for fetal death
in utero and this risk is increased in pregnant women requiring
medical management. Hence vigilant fetal surveillance is required.
• Fetal heart should be monitored by auscultation on each antenatal
visit.

Pregnant women should be explained about Daily Fetal Activity

Assessment. One simple method is to ask her to lie down on
her side after a meal and note how long it takes for the foetus
to kick 10 times. If the foetus does not kick 10 times within 2
hrs, she should immediately consult a health care worker and if
required should be referred to a higher centre for further
evaluation.
 Labour & Delivery
• Pregnant women with GDM with good control of blood sugar levels (as per
targets mentioned earlier) may be preferably delivered at Sub District
Hospitals/ District Hospitals/ Goa Medical College.
• Timing of delivery: GDM pregnancies are associated with delay in lung
maturity of the fetus; so routine delivery prior to 39 weeks is not
recommended.
• If a pregnant women with GDM with well controlled blood sugar has not
already delivered spontaneously, induction of labour should be scheduled at
or after 39 weeks gestation.
• In pregnant women with GDM with poor blood sugar control, those with
risk factors like hypertensive disorder of pregnancy, previous still birth &
other complications should be delivered earlier. The timing of delivery
should be individualized by the obstetrician accordingly.
• Vaginal delivery should be preferred and LSCS should be done for obstetric
indications only.
• In case of fetal macrosomia (estimated fetal weight >4 kg) consideration
should be given for a primary cesarean section at 39 weeks to avoid
shoulder dystocia.
 Referral to higher Centre
 If one or more of the following conditions are met:
– Nausea & vomiting and not able to take food orally
– Fasting blood sugar >200 mg/dl with or without insulin
– Fasting blood sugar >150 mg/dl or PPBS >250 mg/dl even after giving
insulin - referral is uniformly required
– If PPBS is more than 200 mg/dl at any point of time during
management, then she has to be referred
– Total dose of insulin (combined morning and evening dose) on each day
exceeds 30 units.
– If pregnant women develops low blood sugar (hypoglycemia) more
than once in a day.
– Type 1 DM should be referred
– GDM with multiple co-morbidities should be referred
 Special precaution during labour
• Pregnant women with GDM on medical management (metformin or
insulin) require blood sugar monitoring during labour by a glucometer.
• The morning dose of insulin/metformin is withheld on the day of induction
/ labour and the pregnant women should be started on 2 hourly
monitoring of blood sugar.
• IV infusion with 5% dextrose normal saline (DNS) + 5 cc KCl + 5 U insulin to
be started as per the table below.
Table 3: Details of IV infusion with insulin during labour

Amount of Insulin
Rate of DNS + KCl +
Blood sugar level added in 500 ml
Insulin Infusion
DNS+ KCL

< 100 mg/dl Do not add insulin.

75 to 100 cc/hr
100-150 mg/dl 5U
> 150 mg/dl 6-8U
 Immediate neonatal care for baby of mother with GDM

• All neonates should receive immediately essential

newborn care and should be put immediately to the
breast.
• If required, the sick neonates should be immediately
resuscitated as per GOI guidelines.
• Newborn should be monitored for hypoglycemia.
Monitoring should be done using heel prick sample
tested with glucometer done at
0,1,2,4,6,12,24,36,48,and 72 hours of life after
delivery and continued once a day for term normal
weight babies and twice a day for IUGR/Low birth
weight babies.
• Each test should be performed prior to feed.
 Immediate neonatal care for baby of mother with GDM

• Ensure that the Glucometer device is calibrated and code of

strips is checked before using.
• The cut off capillary blood glucose for hypoglycemia:
– normal birth weight newborn / pre-term is < 45 mg/ dl
– intrauterine growth restriction (IUGR) < 54 mg/dl
• Initiate treatment
• Confirmation done using venous plasma glucose sample for
every episode of hypoglycemia
• However treatment should not be delayed till results of
venous sample are available
• Evaluate for other neonatal complications
– Respiratory distress, convulsions, hyper-bilirubinemia, congenital
heart disease, GI anomalies
 Hypoglycemia in a newborn with GDM mother

• All babies born to mothers with GDM are at

risk for development of hypoglycemia
irrespective of treatment whether they are on
insulin or not and should be observed closely.
• All babies of GDM mother should be checked
for hypoglycemia at or within one hour of
delivery by glucometer and subsequently at
intervals as mentioned
 Symptoms of hypoglycemia
• Usually asymptomatic
• Symptoms - very variable and seen only in a smaller proportion
of patients
• A physician should observe for following signs in a new born
child for hypoglycemia:
o Stupor or Apathy or decreased activity
o Jitteriness or tremors
o Episodes of cyanosis
o Convulsions
o Intermittent apnoeic spells or tachypnea
o Weak and high pitched cry, limpness and lethargy
o Difficulty in feeding or poor feeding
o Eye rolling
o Episodes of sweating
o Any unexplained clinical feature in baby of diabetic mother
 Management of hypoglycemia
All cases of hypoglycemia should be managed in following manner:
Whenever there is suspicion of hypoglycemia, Blood Sugar should be
checked immediately with glucometer.
In all babies born to diabetic mother, Blood Sugar should be checked by
Step 1: heel prick and measured using calibrated glucometer at
0,1,2,4,6,12,24,36,48,72 hours after birth.

If blood sugar values is < 45 mg/dl, this should be considered as

‘hypoglycemia’, collect and send sample for venous plasma glucose in
Step 2:
fluoride bulb. do not wait for the report move to next step

Newborn with hypoglycemia – immediately give a feed without any delay.

Feed can be, expressed breast milk WHICH IS THE BEST OPTION
If mother is not in a position to give breast feed or no breast milk secretion,
baby should be given any infant formula feed with paleda / spoon.
Amount is 5ml/Kg after reconstitution, if hypoglycemia is detected within
birth to 4 hours and at 8ml/Kg if detected after 4 hours.
Step 3: Proper dilution/reconstitution of formula feed has to be ensured (1 scoop of
powder in 30ml of boiled and cooled water).
Use term or preterm infant formula depending upon the gestation.
 Once feed has been given, check blood sugar again after one
hour. If blood sugar is >45 mg/dl, 2 hourly feeding (breast
feeding is the best option but if not available, formula feed can
Step 4: be given) should be ensured by explaining to mother/ relatives
and supervised.
Continue monitoring for blood sugar at intervals mentioned
above
If the blood sugar is between 20-45 mg/dl another feed should be
given and blood sugar repeated after 1 hour.
If third value is <45 mg/dl, then give intravenous bolus injection
Step 5: of 2 ml/Kg 10% dextrose over 5 minutes and transfer the baby to
DHs/GMC with IV drip of dextrose at 5mg/kg/min (80ml/kg/day)
for preterm and 8mg/kg/min (100ml/kg/day) for term on flow
preferably through perfusor if available .
If at any time, blood sugar by glucometer is <20 mg/dl, give
immediate intravenous bolus injection of 10% dextrose 2 ml/kg
body weight of baby over 5 minutes. This should be followed by
Step 6: intravenous infusion of 10% dextrose at a rate of 5mg/kg/min
(80ml/kg/day) for preterm and 8mg/kg/min (100ml/kg/day) for
term on flow preferably through perfusor if available and transfer
the baby to DHs/GMC
Signs of danger: Refer to higher centre
If any of the following sign/reports are observed,
infant should be referred to higher centre with
10% dextrose IV infusion drip (100 ml/kg/day)
– Value of blood sugar < 20 mg/dl in spite of starting
10% dextrose IV infusion
– Occurrence of seizures
– Baby is not able to suck at repeated attempts and
blood sugar is < 20 mg/dl
– Failure to maintain IV line and blood sugar is < 20
mg/dl
Post-delivery follow up of pregnant women with GDM
• Immediate postpartum, do not start insulin but
continue to follow pregnancy diet.
• Use non pregnant targets while monitoring the
blood sugar.
• Maternal glucose levels usually return to normal
after delivery.
• However, these women are at high risk to
develop Type 2 Diabetes Mellitus in future.
• If the patient requires insulin post delivery then
she should be referred to a physician for further
management.
Post-delivery follow up of pregnant women with GDM
• In women not requiring insulin at discharge:
– 75 gm OGTT (fasting and 2 hr post glucose) should be
performed at 6 weeks postpartum to evaluate glycemic status
of woman.
– Cut off for normal and abnormal plasma glucose levels in the
fasting and 75 gms OGTT values are:
o Fasting plasma glucose:
o Normal <100 mg/dl
o Impaired fasting glucose: 100 -125 mg/dl
o Diabetes mellitus ≥126 mg/dl
o 75 gms OGTT 2 hour blood sugar
o Normal: <140 mg/dl
o IGT: 140-199 mg/dl
o Diabetes: ≥ 200 mg/dl
• Test normal: Woman is counselled about
lifestyle modifications, weight monitoring &
exercise. Advise women to get annual
screening for DM in NCD clinic as per their
protocols.
• Test positive/IGT: Woman should be linked with
NCD program for further management.
• Pregnant women with GDM and their offspring
are at increased risk of developing Type 2
Diabetes mellitus in later life. They should be
counselled for healthy lifestyle and behaviour,
particularly role of diet & exercise.
 Pre-conception care & counseling

• Woman with history of GDM to be counseled

about BMI & blood sugar estimation before
next pregnancy
• Desired blood sugar levels:
– FBS - <100 mg/dl
– 2 hr post glucose load - <140 mg/dl
• Counseled to consult Obstetrician as soon as
she misses her period
 Counselling tips:

• Gestational diabetes mellitus (GDM) can be easily controlled by diet (MNT)

and exercise
• Only in few women in whom blood sugar is not controlled by diet and physical
exercise, insulin injections are required
• Insulin injections are required only during pregnancy. Insulin will be stopped in
most of the cases after pregnancy.
• If you are injecting insulin over abdomen, it cannot reach your baby in any
condition. Injecting insulin over abdomen is 100% safe
•Modification of diet is very easy and will not cost more. Sweets should
be avoided at all times during pregnancy
•If blood sugar is controlled, you and your baby both are safe and healthy
•If blood sugar is not properly monitored, it may harm both you and baby
•If you are taking insulin, always keep glucose, sugar with you.
•Pregnant women with GDM should deliver at health facilities. It will
help in management of any complications which can be encountered
during delivery.
 Contraceptive Advice in GDM Patients

• The contraceptive advice should be

individualized from the basket of
contraception which includes spacing
methods like condoms, IUCDs, Injectables,
Oral Pills etc. and terminal methods like
tubectomy.
• Thank You