3 Estimates of DM & IGT in women 20-39 years 19.0 (15.3%)49.7 (32%)68.8 (24.6%)25.0 (13.0%)57.0 (24.4%)82.1 (19.3%)
4 GDM prevalence linked to background IGT rates 2%Agarwal S, Gupta AN. Gestational Diabetes. J Assoc Physicians India 1982;30:203Ramachandran A, et .al., High prevalence of diabetes in an urban population in south India. BMJ 1988;3; 297(6648):587-901980s7.6%Narendra J, Munichoodappa C, et al, Prevalence of glucose intolerance during pregnancy. Int J Diab Dev Countries 1991;11:2-48.2%Ramachandran A, Snehalatha c, Dharmaraj D, Viswanathan M. Prevalence of glucose intolerance in Asian Indians. Diabetes Care 1992; 15:1990s16.6%V Seshiah, V Balaji, Madhuri S Balaji, CB Sanjeevi, A. Green. Gestational Diabetes Mellitus in India. J Assoc Physicians India 2004;52:70714.5%Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V,Das AK, Rao PV, Yajnik CS, Prasanna Kumar KM, Nair JD.For the Diabetes Epidemiology Study Group in India (DESI).Diabetologia 2001;44:2000s4
5 GDM & Pre gestational DM Awareness of diabetes and GDM is lowNo well defined and internationally accepted screening protocols and guidelinesWide variation in estimates of GDM (3 to 15%)Considerable under detectionIncidence of GDM is increasing
6 Diabetes and Pregnancy – Why it is relevant? Hyperglycaemia during pregnancy is associated with high risk of maternal and perinatal morbidity and mortality and poor pregnancy outcomeDiagnosis of GDM identifies women at high risk of future diabetes, offers opportunity of primary preventionMaternal hyperglycaemia is associated with development of metabolic problems including type 2 diabetes in the offspring
7 Diabetes and Pregnancy Maternal hyperglycaemia is associated with high risk of maternal and perinatal morbidity and mortality and poor pregnancy outcomeFoetal RisksSpontaneous abortion, intrauterine death and still birthLethal or handicapping congenital malformationShoulder dystocia and birth injuriesNeonatal hypoglycemia and IRDSMaternal RisksHydroamnios, pre-eclampsia, PIHProgression of retinopathyObstructed labor, assisted delivery & C-sectionInfectionsIt has been shown beyond reasonable doubt that treatment of GDM significantly improves pregnancy outcomes
8 Risk of maternal diabetes after GDM GDM is the best known predictor of type 2 diabetesUp to one third of women with diabetes may have had GDM previously (Cheung NW, Byth K. Population health significance of gestational diabetes. Diabetes Care 2003; 26(7): )Up to 70% of women with GDM may go on to develop diabetes within 10 yearsThe incidence of diabetes after GDM is increasingBy identifying women with GDM and instituting proper care it is possible to prevent or significantly delay the onset of maternal diabetes
9 Glucose tolerance at follow-up J Lauenborg et al, Diab Care 2004
10 Diabetes Begets Diabetes Offspring's of women with GDM, have a 4 to 8 fold increased risk of diabetes.Clausen TD et al., Diabetes Care 2008
11 Foetal ProgrammingRapid increase in IGT, diabetes and other NCDs in the developing world cannot be explained merely on the basis of higher genetic risk factors and rising obesity.Many individuals developing diabetes and other NCDs in low income or emerging economies are not obese by BMI criteria, but are centrally obese (large waist hip ratio) and adipose (higher body fat percent) and fit the criteria of “thin- fat”.Foetal programming may predispose to several chronic non communicable diseases.
12 Foetal Programming Yajnik et al, Diabetes Care 2007 Permanent change in structure or function in response to a defined stimulus during developmentMetabolic, Vascular, etcCritical periods (Windows of opportunity)Stimuli: Nutrients, metabolites, temperature…SpecificityIs it epigenetic?Yajnik et al, Diabetes Care 2007
13 Foetal ProgrammingMaternal malnutrition, particularly protein and micronutrient deficiencies are associated with small babies.These apparently, small-thin babies have significantly higher abdominal fat deposits (thin-fat babies)When over nourished during infancy & early childhood, they develop anthropometric and biochemical markers of metabolic syndrome.These babies have an increased risk of diabetes, impaired glucose tolerance, arterial hypertension, CVD, lipid abnormalities and stroke in adult life, often prematurely.
14 Foetal Programming and Economic Transition Nutrient-mediated TeratogenesisFuel-mediated TeratogenesisAltered fuelsPre gestational and gestational hyperglycemiaObesity and hyperglycemiaMacrosomiaFetal adiposity & islet dysfunctionFetal under nutritionUndernourished (small) motherPostnatal under nutritionInsulin resistanceSmall baby (Thin-fat)Under nutritionOver nutritionPostnatal over nutrition (Urbanization)Yajnik et al, Diabetes Care 2007
15 IUGR vis a vis Macrosomia Predicts development of HTN, Type 2 DM & IGTBarker’s Hypothesis Low birth weightPederson’s hypothesis MacrosomiaSolution Optimal birth weight 3000 – 3500 g.
16 Diabetes and Pregnancy – public health relevance Opportunity to integrate services not only to lower traditional maternal and peri natal morbidity and mortality indicators but also for inter generational prevention of NCDs such as diabetes, hypertension, CVD and strokeHigh risk of maternal and peri natal morbidity and mortality and poor pregnancy outcomeAssociated with development of metabolic problems including type 2 diabetes in the offspringIdentifies women at high risk of future diabetes, offers opportunity of primary prevention