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ORIGINAL ARTICLE

Year : 2020  |  Volume : 3 |  Issue : 2 |  Page : 2-6 |  DOI : https://DOI-10.46319/RJMAHS.2020.v03i02.002

 

Comparative study of maternal and fetal outcome in gestational diabetes mellitus with non diabetic pregnancies

B S Dhananjaya1, Samra Sahu 2

1Professor and Head, Department of Obstetrics and Gynaecology, Sri Siddhartha Medical College &
Research Centre, Tumakuru, Sri Siddhartha Academy of Higher Education, Tumakuru.
2Junior Consultant, Motherhood Hospital, Sarjapura, Bangalore

DOI-10.46319/RJMAHS.2020.v03i02.002

Abstract
Background: Diabetes mellitus is a disorder of carbohydrate metabolism characterised by high blood glucose level consequent to defective insulin production or its action or both. According to WHO estimates, highest number of Diabetes cases are recorded in India. An estimated 31.7 million people with diabetes in 2000 in India are projected to increase to 79.4 million in 2030. National Urban Diabetes survey (2001) reported a prevalence of 5.4% in under 30 age group.1 Besides other consequences of this early onset, it also implies that more and more women with diabetes will get pregnant and present a management challenge to the obstetrician. There are effects of pregnancy on glucose metabolism as well as effects of diabetes on the mother and fetus. This study aims to compare maternal &fetal outcome in gestational diabetes with non diabetic pregnancies. Material & Methods: This was a prospective observational study conducted for 12months in Department of OBG, SSMC&RC, Tumakuru.  Pregnant women were screened for gestational diabetes mellitus and divided into GDM and non GDM  group. Results: This study showed that prevalence of GDM in study population was 4.2%. There was higher incidence of complications like Hypertension, Polyhydramnios, Preterm labour, Infection, Shoulder dystocia & PPH in mothers with GDM compared to non diabetic pregnancies. Higher birth weight was encountered too.
Keywords: Gestational Diabetes Mellitus, Pre eclampsia, Preterm labour, Macrosomia

Introduction
1-14% of pregnancies are complicated by gestational diabetes depending on the population and the diagnostic tests used. Pregnancy induces progressive changes in maternal carbohydrate metabolism.[1] As the pregnancy advances insulin resistance and diabetogenic stress due to placental hormones necessitate compensatory increase in insulin secretion. Indian women have high prevalence of diabetes and their relative risk of developing GDM is 11.3 times compared to white women.[2] A universal recommendation for the ideal approach for screening and diagnosis of GDM remains elusive. Significant questions remain regarding the implications of GDM diagnosis on the pregnant woman and her family, the impact of diagnosis on obstetric interventions, and whether the early recognition and treatment of GDM will improve perinatal, neonatal, and maternal outcomes besides overall health care costs.[3] Abnormal glucose tolerance during pregnancy is not only associated with pregnancy morbidity but also increases the likelihood of subsequent diabetes in the mother. As such GDM has implications beyond the index pregnancy, identifying two generations (mother and her offspring) at risk of future diabetes. Better identification and treatment of mothers and foetuses at risk may have far-reaching implications for maternal and child health.[4] This was a small endeavour to compare the maternal and fetal outcome in pregnancies complicated by gestational diabetes mellitus with non- diabetic pregnancies
Material and methods
This is a prospective observational study which was conducted in the Department of Obstetrics and Gynecology at Sri Siddhartha Medical College, Tumakuru for a period of 12 months (November 2017- October 2018).
All antenatally registered patients were screened for Gestational diabetes. Study participants were divided into two groups with gestational diabetics mellitus and with out gestational diabetes.
Study participants  who had documented evidence of diabetes mellitus prior to pregnancy, irrespective whether on treatment or not, were excluded from the study.
A detailed clinical history was recorded and a thorough physical examination was performed at the time of presentation with specific emphasis on the risk factors of GDM. Symptoms of diabetes and its associated complications were noted. Investigations like complete blood count, liver function tests, kidney function tests, serum electrolytes, fundoscopy, Urine routine microscopy, HbA1c, a congenital anomaly scan at 22 weeks and third trimester ultrasound were done in all patients.
All GDM patients were admitted at 37 completed weeks for safe confinement or before if presenting in labour or if they developed complications. The birth weight, APGAR score, admission to NICU and other complications including presence of congenital malformations if any were noted by the neonatologist.
After discharge the patients were called after a period of 6 weeks for follow up and for testing fasting and post prandial blood sugars to look for persistence of raised glucose levels.
Results
Table-1 depicts demographic characteristics of patients which reveals maximum patients were in the age group of 25-30 years, majority were detected to be diabetic at a gestational age of more than 20 weeks. Most of them were multigravidas, literate residing in rural areas and having a BMI between 18.5-24.[9]

Table 1: Demographic characteristics of Patients


Parameter

GDM n=50

Non GDM n=50

Age in years
<25
25-30
>30

 

7 (14%)
28 (56%)
15 (30%)

 

10 (20%)
30 (60%)
10 (20%)

Gestational age at diagnosis in weeks
<20
>20

 

4 (8%)
46 (92%)

Parity
primigravida (%)
multigravida (%)

 

14 (28%)
36 (72%)

 

14 (28%)
36 (72%)

Literacy
literate (%)
illiterate (%)

 

35 (70%)
15 (30%)

 

30 (60%)
20 (40%)

Residence
rural (%)
urban (%)

 

40 (80%)
10 (20%)

 

35 (70%)
15 (30%)

BMI in kg/m2
<18.5
18.5-24.9
25-29.9
>30

 

0
5 (10%)
35 (70%)
10 (20%)

 

0
5 (10%)
35 (70%)
10 (20%)

Table-2 reveals significant past history of patients which might have an adverse impact on present pregnancy. It included previous history of anomalous baby, macrosomia, GDM, IUFD, abortions.
Table 2: Significant past history


PAST HISTORY

GDM

Non GDM

NO.

%

NO.

%

Anomalous baby

2

4

0

0

Macrosomia

9

18

0

0

GDM in previous pregnancy

3

6

0

0

H/O IUFD

4

8

2

4

H/O previous abortions

5

10

5

10

Normal

27

54

43

86

Table-3 shows differences in maternal outcomes between diabetic & non diabetic pregnancies. Outcomes compared were incidence of hypertension, polyhydramnios, preterm labour, vaginal/ urinary tract infection, IUFD, shoulder dystocia, perineal injuries, PPH, puerperal sepsis and the mode of delivery.

Table 3: Maternal outcome between diabetic & non diabetic pregnancies


Outcome

GDM

Non GDM

P value

Number

%

Number

%

Hypertension

9

18

2

4

0.02

Polyhydramnios

8

16

1

2

0.01

Preterm labour

12

24

3

6

0.04

Vaginal/Urinary tract infection

30

60

10

20

0.04

IUFD

2

4

0

0

0.1

Shoulder dystocia

5

10

0

0

<0.01

Perineal injuries

2

4

0

0

0.1

PPH

8

16

1

2

0.01

Puerperal sepsis

2

4

1

2

0.2

Mode of delivery
-VD
-OVD
-CS

 

15
5
30

 

30
10
60

 

30
2
18

 

60
4
36

 

0.009

Table-4 shows differences in neonatal outcomes between diabetic & non diabetic pregnancies in terms of birth weight, APGAR score at 1st & 5th minute, incidence of meconium stained liquor, NICU admissions, RDS, hypoglycaemia, hypocalcemia, hyperbilirubinemia, MAS, polycythemia& neonatal sepsis.
Table 4: Neonatal Outcomesbetween diabetic & non diabetic pregnancies


Outcome

GDM

Non GDM

P value

Birth weight (kgs)
<2.5
2.5-3.5
>3.5

 

10
20
20

 

10
35
5

 

<0.05

APGAR Score at 1 min
(Mean +/- SD)

6.96+/-2.128

6.98+/-1.857

0.96

APGAR Score at 5 min
(Mean +/- SD)

8.84+/-1.167

9.06+/-0.998

0.314

Meconium stained liquor

4

2

0.308

NICU admissions

4

2

0.47

RDS

6

2

 

Hypoglycaemia

4

0

 

Hypocalcemia

1

0

 

Hyperbilirubinemia

5

2

 

MAS

2

0

 

Polycythemia

1

0

 

Neonatal sepsis

2

0

 

Table-5 reveals the differences in fasting and post lunch blood sugar values between diabetic and non diabetic pregnancies during follow up after 6weeks of delivery.
Table 5: Blood sugar level during follow up of GDM subjects

 

Number of patients (37)

%

FBS
-normal
-impaired
-raised

 

25
7
5

 

67.9
18.9
13.5

PLBS
-normal
-impaired
-raised

 

23
10
4

 

62.2
27
10.8

Discussion
The prevalence of GDM varies between different races and ethnic groups and is reported to vary from 1.4 to 14% worldwide.[5]
In the present study, GDM comprised 4.2% of the total patients screened whereas reported prevalence of carbohydrate intolerance was 7.7 percent in a study conducted at a tertiary hospital in Maharashtra.[6]
In this study, maximum patients (56%) were clustered in the age group of 26-30 years and 30% of patients were over 30 years of age. A study in Jammu stated that women with normal OGTT were younger in comparison to women with GDM who were found to be older.[7]
In the present study, 28% patients were primigravida while 72% patients were multigravida. The study by Rajput et al, showed that higher parity would have a higher rate of GDM.[8]
Positive family history as a risk factor was noted in 20% patients in this study. In the study conducted in UK by Nanda et al, positive family history was found in 23.9% patients.[9]
Polyhydramnios was found in 16% of our patients in this study. The study by Bhat et al, cites a 14.7% incidence of polyhydramnios v/s 2.7% in controls.[10]
Pre-eclampsia can complicate the course of pregnancy and has an adverse effect on the feto-maternal outcome. In this study 18% of GDM patients had associated preeclampsia. In the study be Saxena et al, the incidence of pre-eclampsia was 40%.[11] According to Xiong et al, mothers with GDM were at increased risk of presenting with pre-eclampsia.[12]
Diabetes causes delayed wound healing. Post operatively, 4% patients had puerperal sepsis.  Surgical site infection is more common in patients with GDM compared to nondiabetic patients.
In the present study, 78% of babies were born at term and 22% were pre-term. In a study by Mahalakshmi MM et al, in South India, 77.5% of babies were term live births while 19% were preterm live birth.[13] Preterm births in present study were attributed to premature preterm rupture of membranes, preterm labour and early induction in cases of severe preeclampsia.

 

In our study 60% of patients having GDM were delivered by Caesarean section as compared to 36% in control group. 30% of patients with GDM delivered vaginally as compared to 60% in control group. 10% deliveries were assisted vaginal deliveries. According to Kale et al, the incidence of LSCS in patients with GDM was found to be 60%.[14] Mothers with gestational diabetes were two times more likely to have caesarean section because of big babies and obstructed labour than the controls in the study by Emmanuel Odar et al. [15] Macrosomia is considered as adverse pregnancy outcome in patients with GDM. The Indian consensus is that a new born weighing >3.5 kg should be considered as macrosomia. In present study, 40% babies were macrosomic at birth which is high compared to other Indian studies were the incidence was 28%. Incidence of low birth weight (weight <2.5 kg) was 20% in present study.  Complications noted in neonates born to GDM mothers include fetal macrosomia, impaired fetal growth, metabolic and electrolyte abnormalities, cardiovascular and CNS anomalies. In the present study 8% of the babies had hypoglycemia whereas 2% had hypocalcemia. According to Shefali et al, 1.4% babies had congenital anomalies, while according to Saxena et al, 10% babies had congenital anomalies.[4, 10]
In present study 37 patients followed up at 6 weeks with FBS and PLBS. Out of these, 16.2% patients were found to have diabetes on follow-up. 7 patients had impaired fasting glucose levels where as 10 patients had impaired glucose tolerance. According to a study by Mahalakshmi MM et al, half of the patients developed diabetes within 5 years and over 90% within 10 years after delivery. The rates of conversion to type 2 diabetes as high as 50% found in Latina women in southern California and other high-risk ethnic groups.[16]
The proportion of women with previous gestational diabetes mellitus (GDM) receiving postpartum diabetes testing is far less than desired. Even in health care systems with high testing rates, some women remain untested.
Conclusion
GDM is a commonly occurring medical disorder in pregnancy. Women with a history of GDM as well as offspring exposed to maternal diabetes in utero should be a major area of focus for preventive medicine. Preventive measures against type 2 diabetes mellitus should start during intrauterine period and continue throughout life from early childhood.
In conclusion, a short term intensive care gives a long term pay off in the primary prevention of impaired glucose tolerance, diabetes and obesity in the offspring, as preventive medicine starts before birth. The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists.
Acknowledgement : Nil
Financial support and sponsorship: Nil
Conflict of interest: Nil
References
1.     American Diabetes Association Position statement on diagnosis and classification of Diabetes mellitus. Diabetes Care 2011; 34(1): S62-69.
2.     Dornhost A, Paterson CM, Nicholls JS, Wadsworth J, Chiu DC, Elkeles RS, et al. High prevalence of GDM in women from ethnic minority groups. Diabetic Med. 1992;9:820-2.
3.     American college of obstetricians and gynecologists committee on practice bulletins obstetrics. ACOG practice bulletin, authors. clinical management guidelines for obstetrician-gynecologists. Gestational DiabetesObstet Gynecol. 2001;98:525-38.
4.     Barbour LA. Unresolved controversies in gestational diabetes: implications on maternal and infant health. Current Opinion Endocrinology Diabetes Obstet. 2014;21(4):264-70.
5.     Shefali AK. Pregnancy outcomes in pre-gestational and gestational diabetic women in comparison to non-diabetic women-a prospective study in Asian Indian mothers. J Assoc Physicians India. 2006;54:613-8. 
6.     Swami SR, Mehetre R, Shivane V, Bandgar TR, Menon PS, Shah NS. Prevalence of carbohydrate intolerance of varying degrees in pregnant females in western India (Maharashtra) a hospital-based study. J Indian Med Assoc. 2008;106:712-4.
7.     Wahi P, Dogra V, Jandial K, Bhagat R, Gupta R, Gupta S, et al. Prevalence of gestational diabetes mellitus (GDM) and its outcomes in Jammu region. J Assoc Physicians India. 2011;59:227-30.
8.     Rajput R, Yadav Y, Nanda S, Rajput M. Prevalence of GDM In Haryana. Indian J Med Res. 2013;137:728-33.
9.     Nanda S, Savvidou M, Syngelaki A, Akolekar R, Kypros H. Prediction of gestational diabetes mellitus by maternal factors and biomarkers at 11 to 13 weeks. Prenat Diagn. 2011:10.1002/pd.2636.
10.  Bhat M, Sarma SP, Menon S. Determinants of gestational diabetes mellitus: a case control study in a district tertiary care hospital in south India. Int J Diabetes Dev Ctries. 2010;30(2):91-6.
11.  Saxena P, Tyagi S, Prakash A, Nigam A. Pregnancy outcome of women with gestational diabetes in a tertiary level hospital of north India. Indian J Community Med. 2011;36(2):120-3.
12.  Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes. Int J Gynaecol Obstet. 2001;75:221-8.
13.  Mahalakshmi MM. Clinical profile, outcomes, and progression to type 2 diabetes among Indian women with gestational diabetes mellitus seen at a diabetes center in south India. Indian J Endocrinol Metab.  2014; 18(3): 400-6
14.  Yajnik CS, Kale SD, Kulkarni SR, Meenakumari K, Joglekar AA, Khorsand N et al. High risk of diabetes and metabolic syndrome in Indian women with gestational diabetes mellitus. Diabetes Medicine 2004;21:1257-9.
15.  Odar E, Wandabwa J, Kiondo P. Maternal and fetal outcome of gestational diabetes mellitus in Mulago Hospital, Uganda. Afr Health Sci. 2004; 4(1):9-14.
16.  Buchanan TA, Xiang AH, Peters RK. Preservation of pancreatic beta-cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk hispanic women. Diabetes. 2002;51:2796-803.  
Address for Correspondence: Dr. Samra Sahu, Junior Consultant, Motherhood Hospital, Sarjapura, Bangalore, Karnataka. India.  E-mail: samrasahu@gmail.com

 


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