One in four Indian adults is dysglycemic, GLP-1 users are conceiving unexpectedly, and few antenatal patients return fasting. Dr Sunil Gupta, Dr Anuradha Salphale and Dr Parikshit Tank chart a practical path from preconception to postpartum.
The numbers that change preconception care
Citing ICMR data, Dr Gupta counted 10.1 crore diabetic and 13.6 crore prediabetic adults and distilled it into a rule: “Prediabetes in a non-pregnant state is GDM in pregnancy.” Preconception counselling can’t stop at known diabetics. Assess prediabetic women early for cardiovascular risk and lipids, and aim for HbA1c below 5.7 at conception.
GLP-1s: the washout clock and the safety checklist
Metformin prevents neither GDM nor preeclampsia, so PCOS patients can stop it at 12 weeks. GLP-1 analogues look better: a 2026 study of about 4,000 exposed and 4,000 unexposed pregnancies showed less GDM, preterm birth and hypertensive disease. Stop semaglutide two months and tirzepatide one month before conception, and SGLT2 inhibitors two to three weeks. Accidental exposures (900–1,200) show no obvious malformations, yet the drugs stay contraindicated, so document strict contraception. Dr Gupta likened early prescribing to a paan shop; he now screens retina, gallbladder, pancreatic enzymes and medullary thyroid carcinoma history first.
Nobody comes back fasting
Fasting or 75 g? “You have to become first Indian,” Dr Gupta said, backing DIPSI: 75 g at any visit, a two-hour value above 140 mg/dL is GDM, and 120–140 is gestational glucose intolerance. Targets: fasting below 90, post-meal below 120, HbA1c below 6, after a two-week nutrition trial in pure GDM.
Metformin’s blind spots
Insulin does not cross the placenta; metformin reaches about 70% of maternal levels. Citing the MiTy trial, he accepts metformin in type 2 diabetes, but not with placental insufficiency, IUGR, macrosomia, polyhydramnios, poor obstetric history or preeclampsia. Half of GDM patients on it end up on insulin, which is the choice before 20 weeks. He described one patient who monitored glucose at 160–170 for two months without adjusting her insulin; education must include acting on readings.
From steroids to the delivery table
Antenatal steroids lift insulin needs two-and-a-half to threefold for 72 hours, taking seven days to settle. Intrapartum glucose of 70–120 mg/dL prevents neonatal hypoglycaemia, by infusion if labour is long. In pure GDM, use short-acting insulin three times daily instead of premix, starting at 2–4 units, and stop metformin 24–48 hours before caesarean. Most GDM resolves within 72 hours, but 15% persist, so the rule of six (six days, weeks and months, then yearly) matters.
Pregnancy is a stress test for life, and GDM at 30 can mean type 2 diabetes at 45. Treat prediabetes before conception, prescribe with justification, and fix the weakest link: postpartum follow-up.