Background: Gestational diabetes mellitus (GDM) is a potential risk factor for pregnant women because it leads to various complications during pregnancy and childbirth; thus, GDM directly increases the risk of maternal and neonatal mortality and morbidity. Aim: To estimate the prevalence of GDM and evaluate maternal and fetal outcome in pregnant women with GDM. Materials and Methods: This was a prospective study carried out over a period of 1 year. After informed consent and ethical clearance, a total of 8970 pregnant women were recruited and followed; they underwent universal screening for diabetes as per the Diabetes in Pregnancy Study Group India criteria. Three-hundred and eighty women were diagnosed with diabetes, of this 29 were found to be type 2 diabetes and 351 pregnant women were diagnosed as gestational diabetes. Women with gestational diabetes were followed till 6 weeks of postpartum. After enrollment, 290 women were treated with regular insulin and neutral protamine Hagedorn insulin and only 61 women were kept on medical nutrition therapy. Results: About 76.1% of women underwent cesarean section, whereas 23.9% women delivered vaginally. Elective (LSCS) Lower segment caesarean section was done in 22% of women while emergency cesarean section in 54.1%. Preeclampsia was observed in 13.7%, 45.3% women delivered preterm baby, polyhydramnios was found in 3.41%, and oligohydramnios was found in 2% women. Candida vaginal infection was observed in 2.50% and intrauterine growth restriction present in 11.90% women. 8.3% babies were macrosomic and 3.1% babies were admitted in Neonatal intensive care unit. Stillbirth was noted in 4.3%. Congenital malformation was seen in 1.7% babies of GDM mothers who did not receive any antenatal care. About 26.5% of total GDM cases were unbooked. Conclusion: Gestational diabetes is a rising complication of pregnancy. If women receive proper medical nutritional therapy and insulin therapy during pregnancy, better maternal and fetal outcome could be achieved.
Keywords: Gestational diabetes mellitus, maternal complication, perinatal outcome
|How to cite this article:
Patel ML, Singh M, Sachan P, Sachan R. Outcome in gestational diabetes mellitus after various treatment modality: A tertiary center experience in North India. Ann Trop Med Public Health 2018;11:140-4
|How to cite this URL:
Patel ML, Singh M, Sachan P, Sachan R. Outcome in gestational diabetes mellitus after various treatment modality: A tertiary center experience in North India. Ann Trop Med Public Health [serial online] 2018 [cited 2020 Aug 5];11:140-4. Available from: https://www.atmph.org/text.asp?2018/11/4/140/272557
Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with the onset or first recognition during pregnancy. Worldwide prevalence of gestational diabetes is 1.4%–14%. In India, the prevalence of GDM varies from 3.8% to 21%. GDM is an endocrine disorder. Various studies have been done to evaluate screening methods, diagnosis and management of GDM, but still there are some controversies.,
Various studies have been conducted in different parts of India on GDM,,, and concluded that better outcome can be achieved after proper glycemic control. Maternal complications such as polyhydramnios, preeclampsia, prolonged labor, obstructed labor, increased cesarean section rate, uterine atony, and postpartum hemorrhage have been reported. Various studies have reported intrauterine fetal demise, stillbirth, congenital malformation, shoulder dystocia, and birth injuries associated with gestational diabetes. In neonates, respiratory distress syndrome, polycythemia, hypoglycemia, hypocalcemia, and hypomagnesemia have been observed.
GDM is a strong risk factor for the development of type 2 diabetes. It is also responsible for the development of metabolic syndrome and cardiovascular disease later in life. Around 35%–60% of GDM women developed type 2 diabetes within 10 years. This study was done to assess fetomaternal outcome with various treatment modalities.
The risk factors for GDM are age >25 years, family history of diabetes mellitus, obesity, history of macrosomia, previous unexplained neonatal death, unexplained recurrent abortion, history of previous congenital malformations, and stillbirth.
|Materials and Methods|
This was a prospective study carried out over a period of 1 year from January 2016 to February 2017 in the Department of Obstetrics and Gynaecology in collaboration with the Department of Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India. After informed consent and ethical clearance, a total of 8970 women were recruited and 380 women were diagnosed as a case of diabetes, of which 351 pregnant women were of gestational diabetes and 29 women were of type 2 diabetes mellitus. Pregnant women who came for antenatal checkup underwent universal screening for diabetes as per the Diabetes in Pregnancy Study Group India (DIPSI) criteria. These women were followed till 6 weeks of postpartum. After enrollment of women with gestational diabetes, 290 women were treated with regular insulin and neutral protamine Hagedorn insulin and only 61 women managed on medical nutrition therapy. Ethical clearance was obtained from the institutional ethics committee.
DIPSI guideline was used for screening of women. Here, 75 g oral glucose is given to women irrespective of the last meal and plasma glucose is measured after 2 h – if value is >140 mg/dl, a woman is labeled as a case of GDM. These women were followed till 6 weeks of postpartum.
Pregnant women who developed gestational diabetes in pregnancy were included in this study. Women with chronic medical conditions, hypertension, renal disease, heart disease, epilepsy, and type 1 and 2 diabetes were excluded from the study.
Those women who were diagnosed as a case of GDM initiated lifestyle modification, which included counseling about diabetic diet and exercise. Initially, patients were kept under medical nutrition therapy with glycemic target being <95 mg% in fasting state and up to ≤120 mg/dl in the postprandial state. In those women who had not achieved glycemic target, insulin therapy was initiated. Blood sugar level was measured 6–7 times/day (three preprandial and three 2 h postprandial values) in women on insulin therapy. In women with uncontrolled blood sugar levels despite insulin therapy, a 2 am blood sugar value was done to look for dawn or Somogyi phenomenon. Data were collected in predetermined questionnaire.
Preeclampsia, polyhydramnios, oligohydramnios, preterm premature rupture of membrane (PROM), and preterm delivery were recorded. Perinatal outcome included congenital malformation, stillbirth, macrosomia, and requirement for admission in neonatal intensive care unit. Mode of delivery was recorded including vaginal or cesarean section and either elective or emergency sections.
All statistical evaluations of the data were performed with SPSS, Version 21 (Statistical Program for the Social Sciences software, BM Corporation, Armonk, New York, USA). The continuous variables were stated as mean ± standard deviation.
A total of 8970 women delivered during the study; out of these, during screening, gestational diabetes was detected in 351 pregnant women and type 2 diabetes was found in 29 pregnant women. Thus, the prevalence of GDM complicating pregnancy was 3.91% in our study. Out of them, 69.5% women were more than 25 years of age and 30.8% women belonged to <25 years of age. Mean age of these women was 28.79 ± 4.70 years [Table 1].
|Table 1: Demographic profile
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About 73.5% of women were booked with regular antenatal visit (minimum visit more than 3 times) and the rest 26.5% of women were unbooked, who were referred from either private or government hospital. Nearly 33.6% women were primigravida and whereas 66.38% women were multigravida [Table 2].
|Table 2: Distribution of gestational diabetes mellitus cases according to parity
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Of 351 gestational diabetic women, 54.7% women delivered at term whereas the rest 45.3% women had preterm deliveries [Table 3].
|Table 3: Period of gestational age at the time of delivery
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Nearly 54.1% had emergency cesarean section whereas 22% underwent elective cesarean sections and vaginal deliveries occurred in 23.9% GDM women [Figure 1].
|Figure 1: Distribution according to mode of delivery
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In our study, 13.7% women developed preeclampsia, polyhydramnios was found in 3.4% cases, 2% women had oligohydramnios, vaginal infection was present in 2.50% case, intrauterine growth restriction (IUGR) was found in 11.90%, and antepartum hemorrhage was observed in 4.50% women as complication of gestational diabetes [Figure 2].
|Figure 2: Maternal complications in gestational diabetes
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About 68.7% babies had birth weight between 2.5 and 3.5 kg and 8.3% babies were of >3.5 kg and 23% babies born with birth weight <2.5 kg [Figure 3].
|Figure 3: Distribution according to birth weight of babies
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In our study, macrosomia was present in 8.3%, stillbirth in 4.3%, and congenital malformation in 1.7% neonates. About 3.1% neonates required neonatal intensive care unit admission. Apgar score <7 at 1 min was found in 11.4% babies; Apgar score <7 at 5 min was found in 6.8% babies. 53.8% babies had Apgar score 9 at 5 min [Figure 4].
|Figure 4: Distribution according to neonatal complications
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The prevalence of GDM is rising rapidly across the world and is becoming a public health problem with serious maternal and fetal adverse effects.,,
The prevalence of GDM in Indian women has increased to 11-fold as compared to European women. The prevalence of GDM in our study is 3.9%, which is similarly reported in one study that was done in Kashmiri women; other Indian studies reported GDM prevalence of 4.2%, 6.7%, and 7.7%.,, In a recent study, the prevalence of GDM was found to be 7%. One Indian study reported that overall prevalence from different states was 16.55%.
In our study, 69.5% women were more than 25 years of age with mean age of 28.79 ± 4.70 years. Similarly, one study reported the mean age of women to be 27.1 years. One author found the highest prevalence of GDM in the age group of 30–34 years and another reported that the prevalence of gestational diabetes increases as maternal age increases from 25 to 35 years. One study reported that GDM prevalence increased steadily with increasing age (from 1.7% in women below 25 years to 18% in women 35 years or older).
Cesarean rate was higher as compared to vaginal deliveries because of various complications developed in pregnant women. Although macrosomia is found in only few cases, Although macrosomia is found in only few cases. Higher number of cesarean section might be due to associated problems such as precious pregnancy and bad obstetrics history. Various studies reported cesarean section rate were above 50% and 42%, highest cesarean section were reported 39% and 67% in other studies.,
In the present study, preeclampsia was observed in 13.7% of cases whereas other studies reported preeclampsia prevalence of 26%, 20%, and 40%.,, In our study, polyhydramnios was found in 3.41% and other studies reported polyhydramnios in 20.3% and 16%., Our study showed oligohydramnios in 2%, vaginal infection in 2.5%, and IUGR in 11.90% while another study reported IUGR in 16%, antepartum hemorrhage in 4.50% women as complication of gestational diabetes whereas one author reported gestational hypertension in 36.4% and vaginal candidiasis in 24.2%, PROM in 18.1%, and abruption placentae 12% in their respective studies. One author found that most common maternal complication was gestational hypertension (36.4%), followed by abruption placentae (20%), but in our study, preeclampsia and IUGR were the most common complications. Previous studies reported incidence of macrosomia as 11.4% and 28.7% in GDM patients., Other studies reported large for gestational age babies 14.3% and 16%., A meta-analysis showed that GDM can be an independent factor for increased neonatal birth weight. In our study, 23% babies born with low birth and only 8.3% babies were macrosomic, which might be because of better glycemic control during antenatal period. The Indian consensus is that a newborn weighing >3.5 kg should be considered as macrosomia. Other Indian studies reported macrosomia in 12.5%, 40%, 18.1% of cases., Good glycemic control could be achieved by medical nutrition therapy and insulin therapy both.
In our study, stillbirth was 4.3%, whereas other studies reported 6%., About 1.7% babies were born with congenital malformation in the present study from those women who have not received proper antenatal care and had uncontrolled blood sugar level, whereas other two studies reported congenital malformation in 8% and 10% babies., In comparison to other studies, macrosomia, stillbirth, and congenital malformation were less in the present study, which indicates that if we diagnose GDM in early pregnancy, to treat properly and achieve good glycemic control, we can reduce neonatal complication.
Admission to neonatal intensive care unit is required in 3.1% babies. Apgar score was <7 at 1 min and found in 11.4% babies; one study reported 10 times higher risk of congenital malformations and 4–7 times higher risk of perinatal mortality in GDM patients.
Limitation of the study
There is low prevalence of gestational diabetes in our study as compared to other studies because most of the women in our study belong to urban region and booked cases. These women had received better antenatal care so, maternal and neonatal outcome is good. Women from remote, rural areas of India have a high prevalence of gestational diabetes as reported in different studies, thus larger studies are required to obtain actual facts.
Gestational diabetes is a rising complication of pregnancy. Gestational diabetes is detected in antenatal women by routine standard screening protocol. Diagnosis of GDM at early gestational age can prevent maternal and fetal complication. After the diagnosis of GDM women should be educated about lifestyle modification and sugar monitoring to achieve good glycemic control. Hospital delivery of GDM women is necessary for good fetomaternal outcome.
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Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None
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[Table 1], [Table 2], [Table 3]