31.4.11 Feto-Maternal Complications in Gestational Diabetes and in Pre-Existing Diabetes Mellitus

 

Original Article

 

Feto-Maternal Complications in Diabetes

Feto-Maternal Complications in Gestational Diabetes and in Pre-Existing
Diabetes Mellitus

Asifa Alia, Riaz Ahmad and Maria Husain

ABSTRACT

Objective: Study aimed to compare the feto-maternal outcomes in pregnancy with gestational diabetes to pregnant women with preexisting diabetes.

Study Design: Descriptive observational clinical study

Place and Duration of Study: This study was conducted at the Doctors Trust Teaching Hospital affiliated with Rai Medical college Sargodha for one year from January 2019 to January 2020.

Materials and Methods: A population of pregnant women (n= 240) with singleton pregnancies were enrolled and divided into two groups based on pre-existing (group A, n=120) and gestational (group B, n=120) diabetes diagnosed by 2-hr-75g-OGTT. Descriptive analysis of categorical data was presented as frequencies and percentages. Pearson chi square test of independence was applied for qualitative variables. Statistically, p-value <0.05 was considered significant.

Results: The most recurrent maternal complication was vaginal candidiasis (46.67% & 43.3%) as seen in both groups A and B respectively. In the groups, 30 % of the pre-gestational diabetic mothers suffered from preterm labor in comparison to the 23.3% of gestational diabetic mothers.  Equal incidence of urinary tract infection (23.3%) and pregnancy induced hypertension (30%), polyhydromnias (16.6%), preterm rupture of membranes (10%), and intra uterine growth retardation (6.67%) were observed in both groups. Though gestational diabetic mothers developed 13.3% and 6.67% hypertension and postpartum hemorrhage respectively as compared to the pre gestational mothers in which only hypertension was observed (13.3%). Fetal complications in “group A” included NICU admission, low birth weight, still births, shoulder dystocia and congenital anomalies whereas group B neonates had higher frequency of macrosomia, and hypoglycemia.

Conclusion: Both GDM and preexisting diabetes have adverse feto-maternal outcomes; however some complications are seen more in pre-gestational as compared to gestational diabetes.

Key Words: Diabetes Mellitus, Gestational Diabetes, Feto-maternal Outcomes

Citation of article: Alia A, Ahmad R, Husain M, Chaudry B. Feto-Maternal Complications in Gestational Diabetes and in Pre-Existing Diabetes Mellitus. Med Forum 2020;31(4):45-49.

 

 

 

 

 

 

INTRODUCTION

It is estimated that more than 360 million people will have diabetes by the year 2030 and women of childbearing age are at increased risk of developing diabetes during pregnancy. The increased prevalence is attributed to the sedentary life style, urbanization and obesity1,2. Pregnancy affects both the maternal and fetal

 

 

Department of Obs and Gynea, Rai Medical College, Sargodha-Islamabad Road, Sargodha.

 

 

Correspondence: Prof.Dr.Riaz Ahmad.Professor of Gynae Rai Medical College Sargodha, 55 Tulip Extension Bahria Town, Lahore.

Contact No: 03004389976, 03454414440

Email: riazmughal111@outlook.com

 

 

Received:  February, 2020

Accepted:  February, 2020

Printed:      April, 2020

 

 

metabolism and even in non-diabetic women exerts a diabetogenic effect.

The overall prevalence of gestational diabetes mellitus is increasing worldwide, with an overall score of 2.8% to 5% globally and is estimated to rise by the year 20303. Incidence of gestational diabetes in Pakistan is about 8%4, Pre-existing diabetes in women can lead to infertility, and during pregnancy it predisposes the fetus to many developmental alterations, and diabetes related complications to the mother5  Normal pregnancy leads to insulin resistance and pancreatic β-cells reserve is stressed aiming to maintain glycemic level within normal ranges. If this reserve fails to maintain glycemic control then the result is development of gestational diabetes6.

A higher risk of obstetrical complications including miscarriage, pre-eclampsia and preterm labor is observed in women7. Fetal exposure to maternal diabetes is associated with birth defects, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems such as hypoglycemia. On the other hand children exposed in utero to maternal diabetes are at higher risk of obesity and diabetes suggesting the effect not exclusively genetic8. Despite major advances in clinical management, a higher incidence of malformations and perinatal morbidity is observed. Therefore this study aimed to compare the feto-maternal outcomes in pregnancy with gestational diabetes to those pregnant women with preexisting diabetes in Pakistani population.

MATERIALS AND METHODS

An observational study recruiting a total of two hundred and forty singleton pregnant females was conducted during a period of 1year. Females with pre pregnancy diabetes or diagnosed as having diabetes before the 24th week of gestation were classified as pre-diabetics (Group A; n=120); whereas a 2 hour-75gm oral glucose tolerance test was administered at 28th week of gestation for screening and recruiting females with gestational diabetes. . The pregnant females were classified as GDM if any of the following plasma glucose value was exceeded; Fasting: ≥92 mg/dL (5.1 mmol/L), 2 h: ≥153 mg/dL (8.5 mmol/L)9. These females were recruited as GDM (Group B; n=120). Females with impaired glucose tolerance, normal glucose tolerance, hypertension, thyroid disorders, and twin pregnancies or with any other life threatening complications for both mother and fetus were excluded from this study.

The maternal outcomes noted were vaginal candidiasis, urinary tract infection (UTI), preterm labor, polyhydromnios, preterm rupture of membranes (PROM) hypertension, intra uterine growth retardation (IUGR) and pregnancy induced hypertension (PIH). The fetal complications observed were weight over 4 kg or below 2.5 kg, hypoglycemia, shoulder dystocia, congenital abnormalities, still birth and neonatal intensive care unit (NICU) admission. 

A statistical analysis of data was performed using SPSS (version 16; SPSS Inc., Chicago, IL, USA). Descriptive analysis of categorical data was presented in terms of frequencies and percentages.  Pearson chi square test of independence was applied for qualitative variables. In all statistical analysis only p-value <0.05 was to be considered significant.

RESULTS

.The detailed results are shown in tables 1 to 4. Briefly, mean age of preexisting DM group was 32.80 ± 5.49 while mean age of GDM was 28.70 ± 3.92. GDM was commonly seen in young women (p=0.002) with multiple pregnancies, while pre gestational DM was associated with a higher rate of caesarian section, and increased maternal mortality [Table 1]. The most frequent maternal complication observed in both groups was vaginal candidiasis (46.67% & 43.3%), while the frequency of preterm labor was more prominent in the pre-gestational diabetic group (30%) as compared to the gestational diabetic mothers (23.3%). Equal incidence of urinary tract infection and pregnancy induced hypertension (23.3% & 30%); polyhydromnias (16.6%), preterm rupture of membranes (10%), and intra uterine growth retardation (6.67%) were observed in both groups. [Table 2] Gestational diabetic mothers had a higher predisposition to develop hypertension and postpartum hemorrhage (13.3% and 6.67% respectively) as compared to the pre gestational mothers. Fetal born to mothers with preexisting diabetes had more NICU admission, low birth weight, still births, shoulder dystocia and congenital anomalies whereas neonates of gestational diabetic mothers had higher frequency of macrosomia, and hypoglycemia. [Table 3]. Most females with pre-existing diabetes and GDM were managed by insulin (85% and 65%) respectively, while few were put on dietary restrictions (15% and 35%) respectively. (Table4).

 

 

 

 

 

 

Table No.1: Age Distribution, Gravidity and Mode of Delivery: A Comparison in Pre-Gestational DM & GDM

GROUP – A (Pre Gestational DM) (n=120)

GROUP – B (GDM) (n=120)

Age (in years)

Number(Percentage)

Number (Percentage)

21 – 30

48(40)

87(73)

31 – 40

72(60)

33(27)

> 40

00(00)

00 (00)

Gravidity

Primi-gravida

16(13.33)

36(30)

2-4

72(60)

72(60)

>4

33(27.5)

12(10)

Mode of delivery

SVD

48(40)

76(63.33)

LSCS

72(60)

44(36.67)

 

         

 

Table No.2. Common Maternal Complications:  A Comparison in Pre-Gestational DM & GDM

Complications

GROUP –A (Pre gestational DM) (n=120)

GROUP – B (GDM) (n=120)

 

No. of patients(Percentage)

No. of patients (Percentage)

p-value

Vaginal Candidiasis

56(46.67)

52(43.33)

0.795

UTI

28(23.33)

36(30)

0.559

PIH

28(23.33)

36(30)

0.559

Preterm Labor

36(30)

28(23.33)

0.623

Poly-hydromnias

20(16.67)

20(16.67)

1.000

PROM

12(10)

20(10)

1.000

PPH

00(00)

08(6.67)

-

IUGR

08(6.67)

08(6.67)

1.000

Hypertension

04(3.33)

16(13.33)

0.161

Table No.3. Common Fetal Complications: A Comparison in Pre-Gestational DM & GDM

Complications

GROUP –A (Pre gestational DM) (n=120)

GROUP – B (GDM) (n=120)

 

No. of patients(Percentage)

No. of patients(Percentage)

P-Value

Weight > 4kg

20(16.67)

24(20)

0.644

NICU admission

64(53.33)

28(23.33)

0.824

Hypoglycemia

12(10)

24(20)

0.375

Weight <2.5kg

08(6.67)

04(3.33)

0.554

Shoulder dystocia

08(6.67)

04(3.33)

0.225

Congenital abnormalities

16(13.33)

04(3.33)

0.375

Stillbirth

04(3.33)

16(13.33)

0.375

Table No.4. Treatment options:  A Comparison in Pre-Gestational DM & GDM

Complications

GROUP –A (Pre gestational DM) (n=120)

GROUP – B (GDM) (n=120)

 

No. of patients (Percentage)

No. of patients(Percentage)

P-Value

Diet

18 (15)

42 (35.5)

0.04

Insulin

102 (85)

78 (65)

0.03

 

 

 

 

 

 

 

DISCUSSION

Diabetes is the most common disorder complicating
3-5% of all pregnancies; our results are consistent with the previous studies
. Iincidence in young primi gravida was found to be <1%10. Another study by Akhter et al.11 showed an overall 3.3% prevalence of GDM among Pakistani women. It is plausible by these reports that multiple pregnancies predispose to hyperglycemic states and lead to the development of GDM. However, risk of hypertension and preeclampsia has been proven to increase with increasing age and BMI, independently of maternal glycemia. Contrary to our results no differences were observed in terms of frequency of complications in patients with and without gestational diabetes by Bodmer-Roy. Perhaps this was due to the difference in population, and screening criteria.
(Table 1)

Moreover among the study groups, the rate of preterm delivery was higher in pre-existing diabetic mothers which is consistent with the results of previous studies12, especially relating with Indian women where the frequency of preterm deliveries reported was about 8.2%13.  

The finding of this study indicated that 20% of neonates born to GDM pregnant females were large sized (macrosomia) and suffered from post-delivery hypoglycemia (Table 3). These findings are in accordance with the studies done by Wahabi and group14 where almost 11% of the new born delivered to the diabetic mothers was macrosomic. Poorly controlled maternal diabetes has undesirable influences on fetal weight and growth, which results in macrosomia and intrauterine growth restriction15. This effect may be due to high availability of insulin, amino-acids, and glucose and lipid levels in the blood. All these factors play a role in organogenesis16. Other factors also influences fetal macrosomia including maternal age over 30 years, prolonged pregnancy, multiparity and maternal obesity17. Overall 60% patients were delivered by caesarean section. Similar results were also observed in a study conducted by Reem Zeki et.al which showed total cesarean section rate of 53.6% for women with pre gestational diabetes and 36.8% for women with gestational diabetes18. One of the likely explanations of this is history of previous cesarean section in multigravidas. Another likely explanation for this finding is macrosomia which in turn is associated with significant maternal and perinatal complications including increased rate of C/S, birth asphyxia and perinatal mortality19. The perinatal mortality was high in established diabetics as compared to GDM, in our study population.20 Similar outcomes were observed by other investigators20,21,22. The fetal complications including shoulder dystocia, small for gestational age, congenital malformations and NICU admissions were higher in diabetic group when compared with GDM group in our study. These findings are in line with the studies done by Vangen
et al23, who observed increased risks for low birth weight, macrosomia, preterm birth, preeclampsia, and cesarean sections in women with predominantly type 2 diabetes.

When the overall outcomes where compared to different study populations (like Caucasians, Moroccan, African American, Hispanic, and Indian) we found somewhat similar results with exception of preterm labor, polyhydromnia, pregnancy induced hypertension, macrosomia, shoulder dystocia and still births being more common in our study population24. The importance of these findings is that it investigated a key public health problem and that it gives preliminary indicators about the impact on pregnancy outcome in the Pakistani population. Such information is imperative for practice and research considering the paucity of data and health care for managing the complications related to diabetic pregnancy in our population. Very few patients in our under resourced country get pre pregnancy care. It should however be emphasized that pre pregnancy care markers, especially HbA1c prior to discontinuation of contraception is associated with lower rates of adverse pregnancy outcome25. Diabetic pregnancy is an important cause of perinatal morbidity and mortality, as more than half of perinatal deaths worldwide are contributed by South East Asia.

CONCLUSION

This study concluded that both gestational and pre-diabetes have adverse feto-maternal outcome. But there are no significant differences or increased association between the two groups. However some complications such as LSCS, NICU admission, shoulder dystocia, congenital malformation are slightly more but statistically non-significantly associated with pre-gestational DM.

Author’s Contribution:

Concept & Design of Study:

Asifa Alia

Drafting:

Riaz Ahmad

Data Analysis:

Maria Husain

Revisiting Critically:

Asifa Alia, Riaz Ahmad

Final Approval of version:

Asifa Alia

Conflict of Interest: The study has no conflict of interest to declare by any author.

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