https://doi.org/10.35845/kmuj.2023.23126 ORIGINAL ARTICLE

Management of gestational diabetes mellitus: an insight into evidence-based practice among postgraduate trainees of obstetrics and medicine disciplines

Fouzia Gul¹ $Description: Description: Description: C:\Users\Asghars\Downloads\email corrspondence.gif$ , Razia Bibi¹, Sadia Shamsher², ShandanaBawar³, Rukhsana Karim²

1: Department of Obstetrics and Gynecology (OBG) , Khyber Medical University Institute of Medical Sciencs (KMU-IMS), Kohat, Pakistan

2: Department of OBG, Medical Teaching Institution (MTI), Hayatabad Medical Complex, Khyber Girls Medical College, Peshawar, Pakistan

3: Department of OBG, MTI, Lady Reading Hospital, Peshawar, Pakistan

Email $Description: Description: Description: C:\Users\Asghars\Downloads\email corrspondence.gif$ : fgmeena@gmail.com

Contact #: +92-336-5660201

Date Submitted: September 23, 2022

Date Revised: December 12, 2022

Date Accepted: January 05, 2023

THIS ARTICLE MAY BE CITED AS: Gul F, Bibi R, Shamsher S, Bawar S, Karim R.Management of gestational diabetes mellitus: an insight into evidence-based practice among postgraduate trainees of obstetrics and medicine disciplines. Khyber Med Univ J 2023;15(1):20-25. https://doi.org/10.35845/kmuj.2023.23126

ABSTRACT

OBJECTIVE: To explore the discrepancies regarding screening, diagnosis and management of gestational diabetes mellitus (GDM) among postgraduate trainees of Obstetrics and Gynaecology (OBG) and medicine disciplines.

METHODS: This multicentre cross-sectional study was conducted from 1^stto 31^st August 2022.The questionnaire regarding screening, diagnosis, management of GDM, and postnatal follow-up with neonatal care were distributed among postgraduate trainees of medicine/OBG through google-form/hardcopies. Data was analysed through SPSS-22

RESULTS: Out of 236 trainees, 184 (78%) were following national institute of clinical excellence (NICE) guidelines for management of GDM. Majority of medicine (n=87/120 (72.5%) and OBG (n=76/116; 65.5%) trainees failed to identify the correct cut-off of oral glucose tolerance test for GDM. A big chunk of both OBG (n=93/116; 80.2%) and Medicine (n=96/120; 80%) trainees were unable to differentiate pre-existing diabetes mellitus from GDM. The clinical knowledge about carbohydrate diet (n=119/236; 50.4%), calories intake (103/236; 43.6%) and low glycaemic index (138/236; 58.5%) was poor among trainees of both specialities. Surprisingly, the medicine trainee’s knowledge about insulin types, dose and tocolytic agent was not evidence-based. The practicing knowledge of both specialities was poor about identification of neonatal hypoglycemia (n=30/236; 12.7%) and its management (n=47; 19.9%). Trainees of both specialities had poor knowledge about postnatal follow-up (n=64/236; 27.1%) of GDM patients.

CONCLUSION: GDM is a common domain for OBG and medicine disciplines with no consensus guidelines for its uniform management. This study has identified some basic gaps in the clinical practice of future consultants regarding GDM management, urging the need of combined local guidelines.

KEYWORDS: Pregnancy in Diabetics (MeSH); Guideline (MeSH);Practice Guidelines (MeSH); Evidence-Based Practice (MeSH);Diabetes, Gestational (MeSH); Pakistan (MeSH); Khyber Pakhtunkhwa (Non-MeSH); Postgraduate Trainees (Non-MeSH); Obstetrics and Gynecology Department, Hospital (MeSH).

INTRODUCTION

Diabetes mellitus (DM) is one of the most challenging public health issues of 21^st century, especially for low and middle-income countries.¹Globally the diabetic population increasing at rate of 8.6million/year and 21.3 million live births are affected by some form of hyperglycaemia in pregnancy affected by some form of hyperglycaemia in pregnancy.²With the prevalence rate of 26.3%,³Pakistan has been ranked 10^th among 221 countries across the globe regarding the burden of DM.²The global prevalence of Gestational Diabetes Mellitus (GDM) is almost 15%.⁴With significantly high frequency in the South Asian region, the frequency of GDM reported in Pakistan is 19%.⁵

The GDM is associated with a large number of maternal, fetal and neonatal morbidity as well as mortality and increased risk of developing Type 2 Diabetes Mellitus (T2DM) later in life.⁶The various adverse maternal complications include hypertension, preeclampsia, urinary tract infection, hydramnios, increased operative intervention and future DM. In the fetus and neonates it is associated with macrosomia, congenital anomalies, metabolic abnormalities, respiratory distress syndrome and subsequent childhood and adolescent obesity and its related complications.³

GDM cannot be taken ones a single clinical entity, rather it is a trans-generational disease. Women with GDM is becoming an ideal group for primary prevention of DM, who can be benefited by early non-therapeutic intervention with diet and exercise to delay or even possibly to prevent the onset of T2DM.⁷

GDM is a topic of controversy when it comes to its screening, diagnosis and its management. Precise level of glucose intolerance characterizing GDM remained controversial over decades. Unfortunately, there is no international consensus on the screening and diagnostic criteria for GDM. Various existing diagnostic criteria’s and guidelines are country specific.^8-10There is a lack of agreed screening tests and criteria for diagnosis and management of GDM and health care providers are not abreast with the latest evidence-based national and international recommendations.

This study was planned to explore the discrepancies among obstetrics and gynaecology (OBG) and medicine trainees regarding screening, diagnosis and management of GDM. Undergraduate trainees and residents are the future community healthcare workers. Efforts to understand the gaps in their knowledge and practice and strategies to overcome these gaps may have far-reaching implications in management of GDM.

METHODS

This multi-centred, cross-sectional study was conducted in collaboration with postgraduate Medical Institute (PGMI )Peshawar, Pakistan. The questionnaire regarding screening, diagnosis, management of GDM and postnatal follow-up with neonatal care were shared both with postgraduate (PG) trainees of medicine/OBG and their respective supervisors as google form/ hardcopies through PGMI.

Inclusion Criteria:

· PG trainees who have cleared intermediate module (IMM) of fellowship training of College of Physicians & Surgeons of Pakistan in their respective speciality.

Exclusion criteria

· PG trainees who refused to participate in the study.

The sample size was calculated by taking a population (Medicine + OBG trainee Medical Officers in Khyber Pakhtunkhwa) size (N)=570, and in the absence of published figures, taking the hypothesized frequency of outcome factor (practicing of one out of the three types of guidelines) in the population (p)= 33% ±5, using an absolute precision (d) = 5%, and a design effect (DEFF) = 1, we calculated a sample of 214 participants using the formula:

Sample size n = [DEFF*Np(1-p)]/ [(d²/Z²_1-α/2*(N-1)+p*(1-p)]

accounting for a 10% potential non-response we rounded-off the sample size to 235.

Proforma was based on questions related to screening, diagnosis and management of GDM along with postnatal and neonatal care as per latest guidelines including National Institute for Health and Excellence (NICE) guidelines,¹¹American Diabetes Association(ADA) guidelines,¹²Management of Diabetes in Pregnancy guidelines(IADPSG),¹³ Society of Obstetrics &Gynaecology of Pakistan(SOGP) guidelines,¹⁴and standard text books of OBG/Medicine.

The first portion of questionnaire had five questions about the guidelines currently used in their respective speciality and screening criteria of gestational diabetes. The second portion was about management of diabetes during pregnancy. It has seven questions regarding various management categories like exercise and diet criterial, oral hypoglycaemic criteria, insulin therapy criteria. Monitoring frequency of blood sugar levels and management during labour and postnatal screening. A pre-test of the questionnaires was carried out on twenty trainees who were not study participants and corrections were made accordingly.

Data was analysed using SPSS 23 and frequencies and percentages were calculated.

RESULTS

Out of 236 study participants, 177 (75%) were females and 55(25%) were males. The mean age of study participants was 28.8±1.57 years. Majority of study participants (n=184/236; 78%) were reading NICE guidelines followed by standard textbooks (n=31/236; 13.1%) for management of GDM(Table I).

Table I: BASELINE CHARACTERISTICS OF STUDY PARTICIPANTS

Variables		OBG Trainees (n=116)	Medicine Trainees (n=120)	Total (n=236)	P value
Gender	Male	0	59 (49.2%)	59 (25%)	0.000
Gender	Female	116 (100%)	61 (50.8%)	177(75%)	0.000
Training year	3^rd year	57 (50.8%)	85 (70.8%)	142 (60.2%)	0.001
Training year	4^th year	59 (49.1%)	35 (29.2%)	94 (39.8%)	0.001
Family history of diabetes	Yes	80 (54.2%)	65 (69%)	145 (61.4%)	0.02
Practicing guidelines	NICE guidelines	81 (69.8%)	103 (85.8%)	184 (78%)	0.000
	SOGP Guidelines	10 (8.6%)	0	10(4.2%)
	ADA guidelines	0	7 (5.8%)	7 (3%)
	IADPSG	1(0.9%)	1 (0.9%)	2(0.9%)
	Standard text book of OBG/Medicine	23(19.8%)	8 (6.6%)	31 (13.1%)
	None of the above	1(0.9%)	1 (0.9%)	2 (0.8%)

^{NICE: National institute for Health and
care Excellence; ADA: American Diabetes Association; SOGP: Society of Obstetricians &Gynecologists of
Pakistan; IADPSG: International
Association of the Diabetes and Pregnancy Study Groups; OBG: Obstetrics
&Gynecology}

Overall, fasting blood sugar (FBS) and random blood sugar (RBS) were correctly identified by 226 (95.8%) and 216 (91.5%) trainees respectively. Screening time was correctly identified by OBG trainees (n= 85; 73.3%) as compared to medicine trainees (n=61, 50.8%). Though the correct screening test (OGTT) was identified by 106 (88.3%) medicine trainees and 102 (87.9%) OBG trainees, the cut off for diagnosis of GDM was wrongly answered by 87 (72.5%) medicine trainees and 76 (65.5%) OBG trainees. A big chunk of both OBG (n=93; 80.2%) and medicine (n=96; 80%) trainees were unable to differentiate pre-existing diabetes from GDM (Table II).

Table II: SCREENING AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS

Variable	OBG Trainees (n=116)	Medicine Trainees (n=120)	Total (n=236)	P value
Correctly diagnosed fasting blood glucose	106 (91.4%)	120 (100%)	226 (95.8%)	<.001
Correctly diagnosed random blood glucose	101 (87.1%)	115 (95.8%)	216 (91.5%)	.036
Correctly diagnosed HbA1c	108 (93.1%)	118 (98.3%)	226 (95.8%)	.125
Correct screening group of GDM identified	53 (45.7%)	42 (35%)	95 (40.3%)	.09
Correct screening time of GDM identified	85 (73.3%)	61 (50.8%)	146 (61.9%)	<.001
Correctly identified Best screening test (OGTT) for GDM	102 (88.3%)	106 (87.9%)	208 (88.1%)	.53
Correctly identified OGTT cut-off	39 (33.6%)	30 (25%)	69 (29.2%)	.119
Correct diagnosis of Pre-existing diabetes Mellitus	23 (!9.8%)	24 (20%)	47 (19.9%)	.614

^{HbA1c:Hemoglobin
A1c (Glycosylated Haemoglobin);GDM: Gestational Diabetes Mellitus; OGTT: Oral
Glucose Tolerance Test, OBG:
Obstetrics &Gynecology}

The clinical knowledge about carbohydrate diet (n=119/236; 50.4%), calories intake (103/236; 43.6%) and low glycaemic index (138/236; 58.5%) was poor among both specialities. Surprisingly the medicine trainee’s knowledge about insulin types, dose and tocolytic agent was not evidence-based (Table III).

Table III: MANAGEMENT OF GESTATIONAL DIABETES MELLITUS

Variable	OBG Trainees (n=116)	Medicine Trainees (n=120)	Total (n=236)	P value
Correct diagnosis of blood glucose level for diet &exercise	111(95.7%)	116(96.7%)	227 (96.2%)	.91
Correct diagnosis of exercise time	80(69%)	91(75.8)	171(72.5%)	.238
Correct diagnosis of caloric intake	23(19.8%)	80(66.7%)	123(43.64%)	.000
Correct diagnosis of CHO intake	48(40.8%)	71(59.2%)	119 (59.42%)	.006
Correct diagnosis of low glycemic	58(50%)	80(66.7%)	138(58.47%)	.004
Correct identification of fasting blood glucose level	112(96.6%)	115(95.8%)	227(96.18%)	.773
Correct identification of post prandial blood glucose level	79(68.1%)	63(52.5%)	142(60.17%)	.014
Correct identification of blood glucose levels during labour	101(87.1%)	101(84.2%)	202(85.6%)	.430
Correct identification for GDM group to be management by oral hypoglycaemic agents	110(94.8%)	81(67.5%)	191(81.3%)	.000
Correct identification for GDM group with obstetric complication for management with insulin	99(85.3%)	108(90%)	207(87.7%)	.227
Correct identification for GDM group with raised FBS for management with insulin	59 (50.9%)	84(70%)	143(60.5%)	.003
Correct identification of basal insulin	80(69%)	53(44.2%)	123(56.3%)	.000
Correct identification of insulin not recommended in pregnancy	37(39.1%)	35 (29.2%)	72(30.5%)	.649
Correct identification of parameter for insulin dose calculation	80(69%)	115(95.8%)	195(82.6%)	.000
Correct distribution of calculated insulin dose	113(97.4%)	119(99.2%)	232(98.3%)	.297
Correct selection of insulin combination	78(67.2%)	59(49.2%)	137(58.05%)	.01
Correct selection of tocolytics	110(94.8%)	56(46.7%)	166(70.3%)	.000

^{GDM:
Gestational Diabetes Mellitus; OGTT: Oral Glucose Tolerance Test, FBS: Fasting
blood sugar; RBS: Random blood sugar, OBG: Obstetrics &Gynecology}

The practicing knowledge of both specialities was poor about identification of neonatal hypoglycemia (n=30/236; 12.7%) and its management (n=47; 19.9%). Similarly, the trainees of both specialities had poor knowledge about postnatal follow-up (n=64; 27.1%) of GDM patients (Table IV).

Table IV: KNOWLEDGE ABOUT NEONATAL AND POSTNATAL CARE

		OBG Trainees (n=116)	Medicine Trainees (n=120)	Total (n=236)	P value
Neonatal Care	Correct selection of time for neonatal blood glucose checking	101(87.1%)	101(84.2%)	202(85.5%)	.526
	Correct neonatal blood glucose levels identified	18(15.5%)	12(10%)	39(12.7%)	.20
	Correct neonatal hypoglycaemia blood glucose level identified	29(25%)	18(15%)	47(19.9%)	.05
Postnatal Care	Correct time of postnatal follow-un identified	104(89.7%)	68(56.7%)	172(72.9%)	.000
	Best follow-up blood sugar test is identified	41(35.3%)	26(21.7%	67(28.3%)	.02
	Women with type 2 diabetes were correctly identified	85(73.3%)	107(89.2%)	192(81.3%)	.002
	Annual follow-up test was correctly identified.	39(33.6%)	25(2.8%)	64(27.11%)	.000

^{OBG: Obstetrics &Gynecology}

DISCUSSION

This study identified that the trainees had reasonable knowledge about DM in pregnancy and its management, but were lacking in knowledge about the differentiation of GDM and pre-existing DM. Trainees also had a weak knowledge about postnatal and long term follow up and its importance to women’s health. Identifying correct (FBS) values and timing of screening for GDM was excellent in the OBG group and even to a greater extent in the medicine group. Categorising them for treatment with oral hypoglycaemic agents or insulin and management during labour was also satisfactory. The medicine trainees had better knowledge of FBS values and diabetic diet and caloric intake as compared to OBG trainees.

In our study, only 8.6% of OBG trainees and none of medicine trainee were following comprehensive local guidelines on management of GDM, by Society of Obstetricians and Gynaecologists of Pakistan.¹⁴ Majority of our trainees were following NICE guidelines, which are UK specific. Same discrepancy in using various guidelines on GDM management was observed in an Indian study.¹⁵Similar preferences for international guidelines over local guidelines have been observed in a study conducted in Bangladesh.¹⁶Establishing uniformity in guidelines and reducing knowledge gaps in terms of health care providers is essential for improving GDM detection and management.¹⁷

Inconsistencies in the GDM diagnostic strategy between different guidelines have led to challenges in making clinical diagnosis. The discrepancies in criteria of screening, timing of screening and OGTT cut-off values among various guidelines^14,18 and text books led to inconsistencies in screening and diagnosis of GDM by trainees of both specialities. Similar lack of evidence-based practice has been reported in another study done in Pakistan.¹⁹

The most astonishing finding of our study was that our post-IMM trainees of both specialities were unable to differentiate pre-diabetes from GDM. Though the correct screening test (OGTT) was identified by more than 80 % of the resident of both specialities but they were unable to answer the correct cut-off for GDM. Screening time was correctly identified by 73% of OBG trainees as compared to only 50% of medicine trainees. A study done in India in 2015 showed low standard of screening practices by doctors in the public health centre²¹addressedthis knowledge gap and as a result another study published in 2021 showed almost all resident were aware of the universal testing for GDM and correctly identifying the cut off value of screening test.²¹ Therefore, continuing medical education on GDM is needed to improve the knowledge and skills of health professionals.²²

The knowledge about carbohydrate intake, calorie intake and glycemic index was very poor in OBG trainees and was also low in medicine trainees. Same deficiency in diet knowledge has been reported in a study done in Cairo.²³This shows that post-graduate students are not following evidence-based practice. This highlights the importance of integrated multidisciplinary training modules with summative assessment in postgraduate training rotations.

Regarding management of DM, our trainees were poor in identifying the post-prandial target blood glucose levels. Very surprisingly the post-IMM trainees of medicine were not aware about various types of insulin, insulin contraindications & tocolytics being contraindicated in DM patients. One of the study on pre-diabetes done in Islamabad also identified same knowledge gap of medical students and even practising physicians regarding diabetes management.¹⁹

Neonatal hypoglycemia& respiratory distress syndrome are significantly associated with GDM²⁴ but like GDM, the guidelines on diagnosis and management of neonatal hypoglycemia are also controversial.²⁵ The obstetrician is the first person to welcome neonate to this world, must be aware of the neonatal hypoglycemia and its management as first line emergency service. Unfortunately, our trainees of both specialties were unable to answer correctly about neonatal hypoglycemia diagnosis and management. Those with prior GDM have more than 7-fold increased risk of developing T2DM and are also at risk of developing GDM during their subsequent pregnancies.²⁶For the fetus, there is an increased risk of birth complications and also of future T2DM and GDM in female children.²⁷Majority of our trainees were not clear about postnatal follow-up & diagnosis of Type2 diabetes at postnatal check-up.

These trainees are future diabetologists, endocrinologists, medical specialist and gynaecologists. GDM is common domain for all of them with no consensus guideline for uniform management of GDM. On the other hand, GDM has both short term and long term maternal, fetal and neonatal implications. This study has identified basic gaps in clinical practice of future consultants and raised the need of combined local guidelines addressing needs of our own country.

The strength of this study was being multi centric with large sample size and trainees of two interrelated specialities.

The limitation is that study was restriction to trainees of one province only, so cannot be generalized to whole Pakistan.

The above study highlights the lacunae in the training of our PG trainees in the diagnosis and management of GDM and in turn also highlights the weaknesses of our health care system.

Knowledge of GDM diagnosis at the right time and timely referral to specialized centres is an essential part of any antenatal services even if run by midwives.

For better postgraduate training and good patient care, the following should be ensured.

1. Joint antenatal diabetic clinics by obstetrician and physician in each teaching hospital along with facility of a dietician and a diabetic nurse.

2. Proper protocols for early detection of GDM with separate antenatal booking cards mentioning blood sugar records and free mixed injection dosage and administration protocol.

3. Postnatal counselling regarding life style changes before discharge and follow-up screening at 6 weeks should be made mandatory.

4. Pre pregnancy counselling for next time is to be improved.

REFERENCES

1. Ogurtsova K, da Rocha FJD, Huang Y, Linnenkamp U, Guariguata L, Cho NH, et al. IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract 2017;128:40-50.https://doi.org/10.1016/j.diabres.2017.03.024

2. Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha FJD, Ohlrogge AW, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res ClinPract 2018;138:271-81.https://doi.org/10.1016/j.diabres.2018.02.023

3. World Health Organization. Diabetes country profiles, 2016. [Accessed on: September 02, 2022].Available from URL: https://www.who.int/diabetes/country-profiles/pak_ en.pdf?ua=1

4. American Diabetes Association. Standards of medical care in diabetes—2015 abridged for primary care providers. Clin Diabetes 2015;33(2):97-111.https://doi.org/10.2337/diaclin.33.2.97

5. Sheikh A, Sheikh L. Changing prevalence of gestational diabetes mellitus during pregnancy over more than a decade. J Pak Med Assoc 2020;70(8):1477-8. https://doi.org/10.5455/jpma.65585

6. Cundy T. Diabetes in Pregnancy. In: Holt RIG, Cockram C, Flyvbjerg A, Goldstein BJ. Textbook of Diabetes, 5^thEdition, 2017; Wiley-Blackwell, Oxford

7. Tuomilehto J. A paradigm shift is needed in the primary prevention of Type 2 Diabetes.In: Ganz M. Prevention of Type 2 Diabetes. 2005. John Wiley & Sons. West Sussex. pp. 153-68.https://doi.org/10.1002/0470857358.ch9

8. Chamberlain JJ, Rhinehart AS, ShaeferJrCF, Neuman A. Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med 2016;164(8):542-52.https://doi.org/10.7326/m15-3016

9. Kong JM, Lim K, Thompson DM. Evaluation of the International Association of the Diabetes In Pregnancy Study Group new criteria: gestational diabetes project. Can J Diabetes 2015;39(2):128-32. https://doi.org/10.1016/j.jcjd.2014.09.007

10. Nankervis A, McIntyre H, Moses R, Ross G, Callaway L, Porter C, et al. ADIPS consensus guidelines for the testing and diagnosis of gestational diabetes mellitus in Australia;2014. [Accessed on: September 02, 2022]. Available from URL : http://www.adips.org/downloads/2014ADIPSGDMGuidelinesVJune2014FINALforWEB.pdf

11. National institute for Health and care Excellence (NICE) guidelines [NG3]. Diabetes in pregnancy: management from preconception to the postnatal period;2015.[Accessed on: September 02, 2022].Available from URL:https://www.nice.org.uk/guidance/ng3

12. American Diabetes Association Professional Practice Committee. 15. Management of diabetes in pregnancy: Standards of medical care in diabetes—2022. Diabetes Care 2022;45(Suppl1):S232-S43. https://doi.org/10.2337/dc22-S015

13. Metzger BE, Gabbe SG, Persson BG, Buchahan TA, Catalano PA, Damm P, et al. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33(3):676-82.https://doi.org/10.2337/dc09-1848

14. Masood SN, Baqai S, Naheed F, Masood Y, Sikandar R, Chaudhri R, et al. Guidelines for management of hyperglycemia in pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP). J Diabetol 2021;12(1):83-98.

15. Mahalakshmi MM, Bhavadharini B, Maheswari K, Anjana RM, Jebarani S, Ninov L, et al. Current practices in the diagnosis and management of gestational diabetes mellitus in India (WINGS-5). Indian J EndocrinolMetab 2016;20(3):364-8.https://doi.org/10.4103/2230-8210.180001

16. Afsana F, Bhowmik B, Siddiquee T, Ahmed T, Pathan FM, Ahmed T, et al. Current practices in diagnosis and management of gestational diabetes: A Bangladesh study. J Diabetol 2021;12(5):79-85.https://doi.org/10.4103/jod.jod_14_21

17. Utz B, Kolsteren P, De Brouwere V. A snapshot of current gestational diabetes management practices from 26 low-income and lower-middle-income countries. Int J GynaecolObstet 2016;134(2):145-50. https://doi.org/10.1016/j.ijgo.2016.01.020

18. Nielsen KK, de Courten M, Kapur A. The urgent need for universally applicable simple screening procedures and diagnostic criteria for gestational diabetes mellitus–lessons from projects funded by the World Diabetes Foundation. Glob Health Action 2012;5.https://doi.org/10.3402/gha.v5i0.17277

19. Saeed N, Jaffery T, Ansari FA, Hamid B, Khan BA. Knowledge and perceptions about pre-diabetes amongst doctors, medical students, and patients in a tertiary care hospital of Islamabad. J Pak Med Assoc 2019;69(4):527-32.

20. Babu GR, Tejaswi B, Kalavathi M, Vatsala GM, Murthy GVS, Kinra S, et al. Assessment of screening practices for gestational hyperglycaemia in public health facilities: a descriptive study in Bangalore, India. J Public Health Res 2015;4(1):448. https://doi.org/10.4081/jphr.2015.448

21. Agrawal S, Tripathi V, Srivastava N, Das V, Pandey A, Mishra S. To study the awareness of gestational diabetes mellitus in antenatal women, and medical and paramedical trainees in teaching hospital in North India. Int J Diabetes Dev Ctries2021;42:341-7.https://doi.org/10.1007/s13410-021-00964-2

22. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, et al. Continuing education meetings and workshops: effect of professional practice in health-care outcomes. Cochrane Database Syst Rev 2009;2009(2):CD003030.https://doi.org/10.1002/14651858.cd003030.pub2

23. Abdelaziz S, Elderwi D, Hashima FA, Elshaikh Y. Junior physicians, are they equipped to manage diabetes? Situation analysis at Kasr El-Aini Hospital, Cairo University. J High Inst Public Health 2010;40(4):614-36.https://dx.doi.org/10.21608/jhiph.2010.20624

24. Simeonova-Krstevska S, Velkoska NV, Samardziski I, Atanasova BA, Todorovska I, Sima A, et al. Perinatal outcome in gestational diabetes melitus vs normoglycemic women. Biomed J SciTechnol Res 2020;26(2):19882-8. https://dx.doi.org/10.21608/jhiph.2010.20624

25. Voormolen DN, de Wit L, van Rijn BB, DeVries JH, Heringa MP, Franx A, et al. Neonatal hypoglycemia following diet-controlled and insulin-treated gestational diabetes mellitus. Diabetes Care 2018;41(7):1385-90. https://doi.org/10.2337/dc18-0048

26. Tobias DK, Hu FB, Chavarro J, Rosner B, Mozaffarian D, Zhang C. Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus. Arch Intern Med 2012;172(20):1566-72. https://doi.org/10.1001/archinternmed.2012.3747

27. Damm P. Future risk of diabetes in mother and child after gestational diabetes mellitus. Int J GynaecolObstet 2009;104Suppl 1:S25-6. https://doi.org/10.1016/j.ijgo.2008.11.025

AUTHORS' CONTRIBUTIONS

Following authors have made substantial contributions to the manuscript as under:

FG: Concept and study design, acquisition, analysis and interpretation of data, drafting the manuscript, approval of the final version to be published.

RB: Acquisition of data, drafting the manuscript, approval of the final version to be published.

SS, SB & RK: Acquisition of data, critical review, approval of the final version to be published.

Authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

CONFLICT OF INTEREST

Authors declared no conflict of interest

GRANT SUPPORT AND FINANCIAL DISCLOSURE

Authors declared no specific grant for this research from any funding agency in the public, commercial or non-profit sectors

DATA SHARING STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial 2.0 Generic License.

KMUJ web address: www.kmuj.kmu.edu.pk

Email address: kmuj@kmu.edu.pk