In order to understand the current medical practice on gestational diabetes mellitus (GDM) screening and management, an online survey was sent to 250 general practitioners, obstetricians/gynaecologists, diabetologists, and endocrinologists throughout India, working in both public and private health facilities. A varying number of responses were received for different sections of the survey, with the overall distribution of respondents covering sixteen states.
Screening and diagnosis
65% of respondents typically did not screen until after the 16th week of pregnancy. However, almost one in five screened in the first eight weeks. 86% of respondents screened all pregnant women, but the remaining 14% screened only those with risk factors (e.g. family history of diabetes). The criteria used to diagnose GDM varied across all respondents, with four different sets of criteria all used by at least 18% of respondents.
The main problem reported with screening was nausea caused by the concentrated glucose solution consumed during screening, which was reported by just over half of respondents. 15% reported the lack of clear GDM screening and diagnosis criteria as a difficulty. 13% responded that testing takes too long in the opinion of women, and the same proportion noted that women are not able to come in fasting for tests. However, almost 40% did not experience any constraints.
Over 90% of centres provided education to women with positive screening results on the need for tight control of GDM, fetal complications, and the risk of type 2 diabetes. 98% of respondents recommended physical activity for women with GDM. Of those giving further information, 96% recommended walking (average ca. 30 minutes per day), 43% recommend yoga (average ca. 20 minutes per day), and 38% recommended upper body exercises (average ca. 15 minutes per day). Dietary recommendations were similarly widely given, by 98% of respondents. With regard to pharmacological interventions, over 90% of respondents prescribed insulin therapy to some extent. Metformin was used by approximately half of respondents, whilst sulphonylurea drugs were prescribed very rarely, and exclusively in combination with metformin; half of respondents did not use OHAs.
Instances where pregnant women sometimes do not follow advice was the most commonly reported limitation in managing GDM for physicians, and was reported by 35% of respondents. One in five respondents had difficulties in following women, and a similar proportion reported a lack of coordination between hospitals.
The data from this survey provides information on the current state of GDM care in India, and also highlights the lack of consistency and uniformity in screening and management of GDM, and the constraints experienced. Such issues are common around the world, and it is for this reason that IDF initiated the WINGS project. The WINGS Model of Care is currently being piloted in Chennai, India, with the aim of developing a set of guidelines suitable for use in other low and middle income countries. The Model recommends screening of all women at the first antenatal visit using a 2hour-75g OGTT blood glucose level of 140mg/dl. The WINGS Model of Care will help to unify practice in GDM care by offering a feasible and effective set of guidelines which are complementary to the basis of care described by this data and which can be integrated into existing systems for maternal and child health.