Frequency of Uncontrolled Diabetes Mellitus in Late 3rd Trimester and Its Association with Maternal Outcome
DOI:
https://doi.org/10.31580/pjmls.v5i1.2452Keywords:
Gestational Diabetes, Pre-Pregnancy Diabetes, Glycemic Control, Maternal OutcomeAbstract
Diabetes mellitus is a metabolic disorder characterized by elevated blood and tissue glucose levels due to absolute or relative insulin deficiency. In addition to a number of systemic complications, diabetes in pregnant women is associated with poor perinatal outcome. A recent study claimed that not merely the presence of diabetes but also poor glycemic control during pregnancy is associated with adverse maternal outcome. However, the available evidence was limited while there was no such local published material which necessitated the present study.
OBJECTIVE: The objectives of this study were to determine the frequency of uncontrolled diabetes mellitus in late 3rd trimester among diabetic pregnant women presenting at a teaching hospital in Punjab and to compare the maternal outcome among pregnant women with controlled versus uncontrolled diabetes mellitus.
STUDY DESIGN: It was a descriptive case series.
SETTING: Research was conducted at Department of Obstetrics and Gynecology, Sir Ganga Ram Hospital Lahore.
DURATION: Duration of study was 6 months after the approval of synopsis from 01/08/2017 to 31/12/2017 (4 months) and 01/04/2018 to 31/05/2018 (2 months).
MATERIAL AND METHODS: This study involved 217 diabetic pregnant women aged between 18-35 years presenting after 34 weeks of gestation. HbA1c levels were acquired and those with ?6% HbA1c levels were labeled to have uncontrolled diabetes. Frequency of polyhydramnios, cesarean delivery and postpartum hemorrhage was noted and compared between women with controlled and uncontrolled diabetes. A written informed consent was obtained from every patient.
RESULTS: The mean age of the patients was 30.1±3.9 years while the mean gestational age was 39.6±1.6 weeks. Majority (n=190, 87.6%) of the patients were aged between 26-35 years followed by 27 (12.4%) patients aged between 18-25 years. There were 75 (34.6%) primiparas and 142 (65.4%) multiparas. 36 (16.6%) patients had pre-pregnancy diabetes while 181 (83.4%) patients had gestational diabetes. 74 (34.1%) patients were taking oral hypoglycemic while 143 (65.9%) patients were on insulin. HbA1c levels ranged from 5.5% to 7.7% with a mean of 6.5±0.66%. Taking a cut-off value of ?6.0%, 146 (67.3%) patients had uncontrolled diabetes. 46 (21.2%) patients had polyhydramnios, 146 (67.3%) patients required cesarean delivery and 31 (14.3%) patients acquired post-partum hemorrhage. The frequency of polyhydramnios (27.4% vs. 8.5%; p-value=0.001), cesarean delivery (84.9% vs. 31.0%; p-value<0.001) and postpartum hemorrhage (21.2% vs. 0.0%; p-value<0.001) was significantly higher in patients with uncontrolled diabetes.
CONCLUSION: A substantial proportion of diabetic women in late 3rd trimester had poor glycemic control and had significantly higher frequency of polyhydramnios, cesarean delivery and postpartum hemorrhage than women with good glycemic control which advocates routine monitoring and strict glycemic control in diabetic pregnant women to improve the maternal outcome in future practice.
References
2. Karakash SD, Einstein FHL. Diabetes in Pregnancy: glycemic control guidelines and rationale. Curr Opin Endocrinol Diabetes Obes 2011;18(2):99-103.
3. Hjellestad ID, Astor MC, Nilsen RM, Softeland E, Jonung T. HbAlc versus oral glucose tolerance test as a method to diagnose diabetes mellitus in vascular surgery patients. Cardiovasc Diabetol 2013;12:79.
4. Kazmi NHS, Gillani S, Afeal S, Hussain S. Correlation between glycated haemoglobin levels and random blood glucose. J Ayub Med Coll Abbott 2013;25(1):86-8.
5. Rani PR, Begum J. Screening and diagnosis of gestational diabetes mellitus, where do we stand. J Clin Diagn Res 2016;10(4):QE01-4.
6. Khalafallah A, Phuah E, Al-Barazan AM, Nikakis I, Radford A, Clarkson W, et al. Glycosylated haemoglobin for screening and diagnosis of gestational diabetes mellitus. BMJ Open 2016;6(4):e011059.
7. Gupta RS, Shermin S. HbAlC level in late trimester with maternal outcome in diabetic patients. Int J Med Res Prof 2016;2(2):157-60.
8. Ferrara A. Increasing prevalence of gestational diabetes mellitus: a public health perspective. Diabetes Care 2007;30(Suppl-2):S141-6.
9. Jiwani A, Marseille E, Lohse N, Damm P, Hod M, Kahn JG, et al. Gestational diabetes mellitus: results from a survey of country prevalence and practices. J Matern-Fetal Neonatal Med 2012;25(6):600-10.
10. Macaulay S, Dunger DB, Norris SA. Gestational diabetes mellitus in Africa: a systematic review. PLoS ONE 2014;9(6):e97871.
11. HAPO Study Cooperative Research Group. The Hyperglycemia and
Adverse Pregnancy Outcome (HAPO) Study. Int J Gynecol Obstet 2002;78(1):69-77.
12. Yogev Y, Metzger BE, Hod M. Establishing diagnosis of gestational diabetes mellitus: impact of the hyperglycemia and adverse pregnancy outcome study. Semin Fetal Neonatal Med 2009;14(2):94-100.
13. Metzger B, Lowe L, Dyer A, Trimble E, Chaovarindr U, Coustan D, et al. Hyperglycemia and adverse pregnancy outcomes. Obstet Anesth Digest 2009;29(1):39-40.
14. Jensen DM, Korsholm L, Ovesen P, Beck-nielsen H, Mlsted-pedersen L, Damm P, et al. Adverse pregnancy outcome in women with mild glucose intolerance: is there a clinically meaningful threshold value for glucose?. Acta Obstet Gynecol Scand 2008;87(1):59-62.
15. Metzger BE, Gabbe SG, Persson B, Lowe LP, Dyer AR, Oats JJ, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33(7):e98-108.
16. . Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a world health organization guideline. Diabetes Res Clin Pract 2014;103(3):341-63.
17. Barbour LA, Mccurdy CE, Hernandez TL, Kirwan JP, Catalano PM, Friedman JE, et al. Cellular mechanisms for insulin resistance in normal pregnancy and gestational diabetes. Diabetes Care 2007;30(Suppl2):S112-9.
18. Moyer VA. Screening for gestational diabetes mellitus: U.S. preventive services task force recommendation statement. Ann Intern Med 2014;160(6):414-20.
19. Guariguata L, Whiting D, Hambleton I, Beagley J, Linnenkamp U, Shaw J, et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103(2):137-49.
20. Florez JC. The genetics of type 2 diabetes: a realistic appraisal in 2008. J Clin Endocrinol Metabol 2008;93(12):4633-42.
21. Kirwan JP, Hauguel-de mouzon S, Lepercq J, Challier J, Huston-presley L, Friedman JE, et al. TNF-? is a predictor of insulin resistance in human pregnancy. Diabetes 2002;51(7):2207-13.
22. Berkowitz GS, Lapinski RH, Wein R, Lee D. Race/ethnicity and other risk factors for gestational diabetes. Am J Epidemiol 1992;135(9):965-73.
23. Retnakaran R, Hanley AJ, Connelly PW, Sermer M, Zinman B. Ethnicity modifies the effect of obesity on insulin resistance in pregnancy: a comparison of Asian, south Asian, and Caucasian women. J Clin Endocrinol Metabol 2006;91(1):93-7.
24. Cypryk K, Czupryniak L, Wilczynski J, Lewinski A. Diabetes screening after gestational diabetes mellitus: poor performance of fasting plasma glucose. Acta Diabetol 2004;41(1):5-8.
25. Griffin ME, Coffey M, Johnson H, Scanlon P, Foley M, Stronge J, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus:
detection rates, gestation at diagnosis and outcome. Diabet Med 2000;17(1):26-32.
26. Callesen NF, Ringholm L, Stage E, Damm P, Mathiesen ER. Insulin requirements in type 1 diabetic pregnancy: do twin pregnant women require twice as much insulin as singleton pregnant women? Diabetes Care 2012;35(6):1246-8.
27. Hyperglycemia and adverse pregnancy outcome (HAPO) study:
preeclampsia. Am J Obstet Gynecol 2010;202(3):255.e1-7.
28. Gorgal R, Gonalves E, Barros M, Namora G, Magalhes P, Rodrigues T, et al. Gestational diabetes mellitus: a risk factor for non-elective cesarean section. J Obstet Gynaecol Res 2012;38(1):154-9.
29. Nocon JJ, Mckenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol 1993;168(6):1732-9.
30. O'sullivan JB, Charles D, Mahan CM, Dandrow RV. Gestational diabetes and perinatal mortality rate. Am J Obstet Gynecol 1973;116(7):901-4.
31. Crowther CA, Hiller JE, Moss JR, Mcphee AJ, Jeffries WS, Robinson JS, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352(24):2477-86.
32. Jovanovic L, Nakai Y. Successful pregnancy in women with type 1 diabetes: from preconception through postpartum care. Endocrinol Metabol Clin North Am 2006;35(1):79-97.
33. American College of Obstetrics & Gynecology. ACOG practice bulletin #60: pregestational diabetes mellitus. Obstet Gynecol 2005;105(3):675-85.
34. Catalano PM, Thomas A, Huston-presley L, Amini SB. Increased fetal adiposity: a very sensitive marker of abnormal in utero development. Am J Obstet Gynecol 2003;189(6):1698-704.
35. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 1998;179(2):476-80.
36. Turkmen M, Aydogdu A, Uygur O, Odabasi AR, Yuksel H, Tosun A, et al. Neonatal complications in infants born to diabetic mothers. Early Hum Dev 2008;84(12):S16.
37. Cordero L, Treuer SH, Landon MB, Gabbe SG. Management of infants of diabetic mothers. Arch Pediatr Adolesc Med 1998;152(3):11-8.
38. Mace S, Hirschfeld SS, Riggs T, Fanaroff AA, Merkatz IR, Franklin W, et al. Echocardiographic abnormalities in infants of diabetic mothers. J Pediatr 1979;95(6):1013-9.
39. Robert MF, Neff RK, Hubbell JP, Taeusch HW, Avery ME. Association between maternal diabetes and the respiratory-distress syndrome in the newborn. N Engl J Med 1976;294(7):357-60.
40. Bellamy L, Casas J, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009;373(9677):1773-9.
41. Metzger BE, Persson B, Lowe LP, Dyer AR, Cruickshank JK, Deerochanawong C, et al. Hyperglycemia and adverse pregnancy outcome study: neonatal glycemia. Pediatrics 2010;126(6):e1545-52.
42. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25(10):1862-8.
43. Lauenborg J, Hansen T, Jensen DM, Vestergaard H, Molsted-pedersen L, Hornnes P, et al. Increasing incidence of diabetes after gestational diabetes: a long-term follow-up in a Danish population. Diabetes Care 2004;27(5):1194-9.
44. Lacroix M, Kina E, Hivert M. Maternal/fetal determinants of insulin resistance in women during pregnancy and in offspring over life. Curr Diabetes Rep 2013;13(2):238-44.
45. Sullivan SD, Umans JG, Ratner R. Gestational diabetes: implications for cardiovascular health. Curr Diabetes Rep 2012;12(1):43-52.
46. Lauenborg J, Mathiesen E, Hansen T, Glmer C, Jrgensen T, Borch-johnsen K, et al. The prevalence of the metabolic syndrome in a Danish population of women with previous gestational diabetes mellitus is three-fold higher than in the general population. J Clin Endocrinol Metabol 2005;90(7):4004-10.
47. Retnakaran R, Qi Y, Connelly PW, Sermer M, Zinman B, Hanley AJ, et al. Glucose intolerance in pregnancy and postpartum risk of metabolic syndrome in young women. J Clin Endocrinol Metabol 2010;95(2):670-7.
48. Retnakaran R, Shah BR. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: a population-based cohort study. Canad Med
Assoc J 2009;181(6):371-6.
49. Plagemann A. Perinatal programming and functional teratogenesis: impact on body weight regulation and obesity. Physiol Behav 2005;86(5):661-8.
50. Freinkel N. Banting lecture 1980. Of pregnancy and progeny. Diabetes 1980;29(12):1023-35.
51. Ornoy A. Prenatal origin of obesity and their complications: gestational diabetes, maternal overweight and the paradoxical effects of fetal growth restriction and macrosomia. Reprod Toxicol 2011;32(2):205-12.
52. Aerts L, Van assche F. Animal evidence for the transgenerational development of diabetes mellitus. Int J Biochem Cell Biol 2006;38(5):894-903.
53. Dabelea D, Pettitt DJ. Intrauterine diabetic environment confers risks for type 2 diabetes mellitus and obesity in the offspring, in addition to genetic susceptibility. J Pediatr Endocrinol Metabol 2001;14(8):57-64.
54. Dabelea D, Hanson RL, Lindsay RS, Pettitt DJ, Imperatore G, Gabir MM, et al. Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sib-ships. Diabetes 2000;49(12):220811.
55. Clausen TD, Mathiesen ER, Hansen T, Pedersen O, Jensen DM, Lauenborg J, et al. High prevalence of type 2 diabetes and pre-diabetes in adult offspring of women with gestational diabetes mellitus or type 1 diabetes: the role of intrauterine hyperglycemia. Diabetes Care 2008;31(2):340-6.
