To help expectant women to enjoy the arrival of their sweet little ones, the Tamil Nadu government has directed that all women be tested for Gestational Diabetes Mellitus (GDM). Thus, the state's Public Health Centres (PHCs) of rural areas and towns and general hospitals in cities will test all pregnant women for blood sugar in order to ensure the early diagnosis of GDM. The move is expected to reduce Infant Mortality Rate (IMR) in the state, as GDM can harm both mother and child and prove fatal if left unchecked.

"This step will go a long way in providing multiple benefits. First, there will be a reduction in the number of stillbirths and second, congenital abnormalities caused by gestational diabetes will come down, as will infant deaths caused by asphyxia during birth. Finally, complications caused during the delivery of large babies will come down as well," says Dr P. Padmanabhan, Tamil Nadu's Director of Public Health.

Diabetes leads to large babies, as the mother does not absorb sugar from food like a normal person would. Instead, the sugar crosses the placenta and enters the growing foetus. The foetus' pancreas produces large amounts of insulin, absorbing the sugar and accumulating fat, which leads to a condition called macrosomia. The more severe complication occurs in the last trimester, when the baby dies suddenly due to placental insufficiency.

The government has issued the necessary orders and has acquired auto analysers (equipment that analyses blood) at the rate of one machine per 100,000 people. Around 385 PHCs and all general and medical college hospitals in the state have been geared to take glucose challenge tests. While 175,000 expectant mothers will be tested at the PHCs, around 425,000 mothers will be covered through hospitals. This comes to roughly 55 per cent of the total 11,00,000 births per annum in the state, Dr Padmanabhan says.

While some other states test urine for sugar, Tamil Nadu has become the first to introduce blood testing. The latter being more reliable, as many patients have a 'high renal threshold' - where the sugar does not show up in the urine.

A couple of years ago, several doctors with interest in the field of diabetes and pregnancy joined hands to set up the Diabetes in Pregnancy Study Group India (DIPSI) and with it, a framework for establishing practice guidelines for the diagnosis and treatment of GDM in the Indian environment was put in place.

Dr V. Seshaiah, who is the Chairman of Diabetes Care and Research Institute as well as president of DIPSI, explains that GDM is a transient abnormality of glucose intolerance during pregnancy. Women with GDM are at increased risk of diabetes in future, as are their children and following generations.

According to Dr Seshaiah, the success of a project for prevention of any disease en masse is dependent on the awareness about the disease among the general population. In India, there is little awareness about the possibility of glucose intolerance during pregnancy, or its consequences. Moreover, even though doctors and healthcare professionals are aware that GDM is one among the various complications that could occur during pregnancy, no statistically significant data was available to further study the problem in the Indian context.

This led Dr Seshaiah to take up a baseline study to assess the knowledge, attitude and practice (KAP) in a sample population in Chennai. The city was divided into 424 health sub-units, with population ranging between 30,000 and 51,000. Multi-purpose health workers monitored the health of each unit. The study revealed that only 13.2 per cent of the population had knowledge and awareness of GDM. After this startling discovery, an intensive awareness campaign was launched and, a year later, another study was conducted to assess the impact: awareness had risen to 23.5 per cent.

Thereafter, the group, with funding from the World Diabetic Foundation, decided to screen a number of antenatal women to determine the prevalence of GDM. When the team informed the government of the proposed study, the then Director of Public Heath, Mr Murugan, and, later, Dr Padmanabhan, showed tremendous interest and recommended that medical personnel team up with statisticians to help validate the data.

As Dr Madhuri, one of the doctors involved, points out, the study would not have been quick and effective but for the cooperation and enthusiasm of the government. It was conducted on 4,300 pregnant women in 2004-2005, involving over 90 PHCs and some private practitioners.

One of the important aspects of the testing methodology was that it used a one- step procedure where only one blood sample would have to be collected. To their dismay, it was found that 17 per cent of 4,300 women tested had Gestational Diabetes. Tests were conducted in all three trimesters of pregnancy. In addition, around 3,000 women were screened in rural areas where the rate of GDM was found to be around 10.4 per cent. The low prevalence could be attributed due to the less mechanised, agriculture-based lifestyle. The study concluded that early screening could go a long way in avoiding the dreaded complications of the disorder.

To begin with, laboratory technicians in PHCs are being trained to operate auto analysers. Pregnant women will be given 75 grams glucose orally and their blood glucose level tested after two hours. All those who record a level of over 120 mg/dl will be deemed as patients with GDM. The primary mode of management will be diet and exercise, as medication may affect the foetus. Doctors attached to the PHCs are being trained in the standard treatment protocol for management of diabetes, says Dr Padmanabhan.

Recently at a conference on Diabetes and Pregnancy in Istanbul, Turkey, the Tamil Nadu governments' order was hailed as the first initiative for universal screening for GDM in the world. To the government's credit, a number of countries - such as Spain - took copies of the state's order to set up a similar system.

From the gynaecological point of view, Dr Gita Arjun, noted gynaecologist and obstetrician, who runs the E.V. Kalyani Nursing Home in Chennai, says, "This is an excellent move to ensure the health and well-being of both mother and child, given the fact that Indians have a predilection for metabolic disorders like diabetes. Studies have shown that high blood glucose levels in the mother can cause decreased oxygen transport to the baby and decreased clearance of toxic products from the baby. While the screening programme was very welcome, the government should make sure that implementation and follow-up are carried out
properly."

Tamil Nadu has an Infant Mortality Rate of 31/1,000 live births. This is well below the national average (34.6/1000 live births, 2006), but any measure that can bring this down further is welcome.      

June 10, 2007

By arrangement with WFS 

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