Gestational Diabetes Mellitus (GDM) poses numerous problems Diabetes mellitus is a global health problem which cuts across all age groups, of both sexes. …
PREGNANCY OUTCOME OF GESTATIONAL DIABETIC MOTHERS: EXPERIENCE IN A TERTIARY
CENTER
Malak M Al-Hakeem, ABOG
Department of Obstetrics and Gynecology, King Khalid University Hosptial,
Riyadh, Saudi Arabia
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Background: Carbohydrate intolerance is the most common metabolic
complication of pregnancy Gestational Diabetes Mellitus GDM poses
numerous problems for both mother and fetus The objectives of this study
are to find out the incidence of gestational diabetes mellitus in
pregnant women and their pregnancy outcomes It was also to discover the
risk factors for the admission of neonates to the Neonatal
Intensive Care
Unit NICU
Design and Patients: A hospital-based prospective study performed at King
Khalid University hospital KKUH, where 685 pregnant women who were
diagnosed with gestational diabetes mellitus, out of 8000 pregnant women
registered between January 2000 - December 2001, were followed and their
outcomes studied
Results: The incidence of gestational diabetes mellitus was found to be
86 95 CI: 81, 93 There were 511 746 spontaneous vertex
deliveries, and 148 216 were delivered by lower segment cesarean
section Maternal morbidity in these women was 12A total of 697 babies
were delivered by these 685 women, out of whom 675 were singleton
pregnancies, 9 sets of twins and one set of quadruplets Six-hundred-
eighty-seven babies were born alive, 7 babies died in utero and 3 died in
the neonatal period The incidence of neonatal intensive care admission
was 49 The mean length of stay in the NICU was 16 days The commonest
cause of neonatal NICU admission was hyperbilirubinemia 412 The
risk factors for NICU admission were delivery by non SVD procedure RR:
46, 95 CI:28, 77, preterm
deliveries, RR: 46, 95 CI:27, 77,
and induction of labor RR: 25, 95 CI: 14, 45
Conclusion: The observation and quantification of maternal outcomes with
gestational diabetes mellitus are necessary, so that proper measures could
be taken to reduce complications during delivery and the neonatal period
and thereby, minimize particularly NICU admission rate
____________________________________________________________________________
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Correspondence to:
Dr Malak M Al-Hakeem, Department of Obstetrics Gynecology 36, King
Khalid University Hospital, PO Box 7805, Riyadh 11472, Saudi Arabia E-
mail: kmmalak@yahoocom
Key Words: Gestational diabetes mellitus, pregnant women, Neonate
Intensive Care Unit, Saudi Arabia
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INTRODUCTION
Diabetes mellitus is a global health problem which cuts across all age
groups, of both sexes Gestational diabetes mellitus GDM was first
described as diabetes occurring only during pregnancy, being absent at
other times by Duncan in 19821 The frequency of diabetes in pregnancy is
highly variable but generally reflects
the underlying pattern of type 2
diabetes in the particular population1,2 Reported prevalence varies from
06 in China to 15 in Indian-born Australians In the USA, the prevalence
across all ethnic groups is 4 1 Even though, highly improved outcomes
have been reported, reflected by a dramatic decline in maternal and
perinatal morbidity and mortality over the past few years, debate persists
on the care of pregnant women with gestational diabetes mellitus GDM The
complications associated with GDM are macrosomia and stillbirth2 But both
of these complications are preventable as they are related to the degree of
maternal glycaemic control There is also a higher chance of pre-eclampsia
edema, pre-term delivery and polyhydramnios Mothers with GDM are more
likely to have large babies with higher birth weight This increases the
number of deliveries by cesarean section rather than vaginal delivery in
order to reduce the risk of injury to the mother and baby But again the
chances of these complications are lower when women have good glycemic
control Another aspect of the outcome of GDM pregnancy relates to the
babies born to these
women Although not all babies born to these women
will have birth defects, there is a high probability of birth defects, if
there has been no control of glucose level during pregnancy Neonates born
to women with gestational diabetes mellitus have a perinatal mortality rate
similar to that of the control population,3 but with an increased rate of
macrosomia and morbidity in terms of neonatal asphyxia, birth trauma,
hypoglycemia, hypocalcaemia, hyperbilirubinemia and respiratory distress,
among others3,4
For pregnant women with poor diabetic control, the risk for a baby to
be born with birth defects is about 6-10; which is twice the rate when the
mothers diabetes is well controlled Some of the associated birth defects
include spinal cord defects spina bifida, heart defects, skeletal
defects, and defects in the urinary, reproductive, and digestive systems
Also babies born to women with diabetes have an increased chance of having
breathing difficulties, low blood sugar hypoglycemia and jaundice
yellowish skin at birth
Insulin-treated gestational diabetic patients seem to be affected
more frequently than
diet-only-treated patients2 An abnormal glucose
metabolism during pregnancy may lead to various types of adverse outcomes
for both the mother and the fetus As a result screening for diabetes
mellitus during pregnancy is currently being offered to all pregnant women
The approach to gestational diabetes mellitus has altered markedly in the
last decade It is now guided by universal screening and an impetus to
establish 24-hour normoglycaemia in these women through serial measurements
of blood glucose by home monitoring and glycosylated hemoglobin Improved
outcome has been associated with improved levels of glycemia Seventy-five
percent of women with gestational diabetes respond to diet therapy alone
When glycemia is not achieved by diet alone, insulin therapy is
recommended5 With the background of 24 prevalence of diabetes6 in the
Saudi general population, there is a need to quantify the magnitude of GDM
and the pregnancy outcomes Hence the primary objectives of this study are
to quantify the incidence of gestational diabetes in pregnant women and the
outcomes of NICU admission of their neonates
MATERIAL AND METHODS
This is a
hospital-based prospective study carried out between January 2000
and December 2001, where 8000 pregnant women who attended the department of
Obstetrics and Gynecology at KKUH were studied Screening with a 50-g oral
glucose challenge was administered routinely to consecutive pregnant women
at their first antenatal visit Patients with abnormal screening results,
defined as a serum glucose level 78 mmol/l, were later given a 75-g oral
glucose load, glucose tolerance test and the plasma glucose level was
measured in the baseline fasting state, then one, two and three hour
intervals after glucose ingestion Gestational diabetes mellitus was
considered if 2 values exceeded the following cutoff points: fasting, 58
mmol/l; one hour 108 mmol/l; two hours 8 mmol/l; and three hours 6 mmol/l
The tolerance test was repeated at 28 weeks in those patients at high risk
of developing gestational diabetes, particularly those with a positive
family history of diabetes, those who were obese, with a history of fetal
macrosomia or unexplained neonatal death in previous pregnancies, with
repeated urinary tract infections, repeated vaginal
candidiasis or a
history of neonatal hypocalcaemia, and hypoglycemia
After the diagnosis of gestational diabetes mellitus was made,
patients were prescribed a diabetic diet consisting of 1800 kcal/day, and
after a week on the diet admitted to the day care unit DCU for a blood
sugar series BSS The glycemic profile measuring the venous glucose level
was performed in the fasting state, and also two hours after each main
meal If the fasting glucose concentration was 58 mmol/l, and two hours
after each meal 8 mmol/l dietary recommendation was considered enough If
these values were exceeded, provided there was good compliance by the
patient to her diet, insulin treatment was initiated
The women were offered clinic visits of two-week intervals, and
ultrasound examinations were performed at the first antenatal visits, 28
weeks and 36-40 weeks More ultrasound examinations were done as needed by
each case Labor was induced at 40 weeks of gestation using pessaries
prostaglandin E2 pessaries or intra cervical gel if there is no spontaneous
labor Blood glucose was measured in the newborn of diabetic women 30
minutes
after delivery If there was hypoglycemia, measurements were
repeated every second hour until stable values above 25 mmol/l were
obtained Macrosomia was defined as birth weight 4000 g; neonatal
hypoglycemia was defined as a minimum blood glucose value 20 mmol/l
during the first 48 hours of life Apgar scores 7 after 5 minutes were
considered low
STATISTICAL ANALYSIS
The data was entered in MS Excel and analyzed by SPSSpc Version 100
statistical software Univariate analysis was done by using Chi-square
test, and relative risk RR was calculated for categorical variables,
whereas students t-test for independent samples, was used for continuous
variables The 95 confidence intervals were provided for RR and for the
difference in the mean values
RESULTS
Out of 8000 pregnant women admitted, 685 86, 95 confidence interval:
81, 93 were diagnosed with GDM The characteristics of these women and
the distribution of mode of delivery are given in Table 1 The commonest
indication for LSCS whether elective or emergency was having had two or
more previous LSCS Polyhydramnious was found in 15 22 women,
Table 1:
Characteristics of gestational diabetic mothers and their mode of
delivery n685
| | |
|Variables |Mean SD|
| | |
|Age |329 |
| |57 |
|BMI kg/mts2 |333 |
| |42 |
|Gestational age at |290 |
|diagnosis in weeks |59 |
|Gestational age at |399 |
|delivery weeks |18 |
|Apgar score at 1 min |7 |
|Apgar severe at 5 min |8 |
|Parity |44 28|
|Type of delivery |No |
|Spontaneous vertex |511 |
|deliveries SVD |746 |
|Ventonse |17 25 |
|Assisted breech | 9 13|
|Low segment cesarean |148 |
|section LSCS |216 |
|Type of LSCS | |
|Emergency | 81 |
| |5476 |
|Elective |67 453|
| | |
while pre-eclampsia PET was identified in 36 53 women Maternal
morbidity in these women was 12 8 out of 685, while maternal urinary
tract infection UTI due to group-B
streptococcus was detected in two
03 women Manual removal of placenta was performed in three 04
women, one woman needed blood transfusion while one woman had pulmonary
embolism for which Surgical Intensive Care Unit SICU admission was
required
These 685 women delivered 697 babies, 516 of whom were males The
mean weight of these babies was 33899 grams SD 6007 Of these new born
babies, 34 49, 95 CI:33, 65 were admitted to NICU When these 34
cases were compared with a random selection of 68 babies who were not
admitted, it was found that the maternal variables of onset of labor, mode
of delivery, and pregnancy complications were highly statistically
significantly associated with the NICU admission Table 2 Thus, the risk
of NICU admission was 25 times higher for the neonates of women who had
non-spontaneous
Table 2: Risk factors for NICU admission among GDM pregnant women
| | | | | |
|Study variables |New Admission |Relative Risk |95 CI for |
| | |RR |RR |
| |Yes
|No | | |
| | | | | |
|Sex | | | | |
|Male |22 |35 |145 |081, 260|
|Female |12 |33 |10 | |
|Onset of labor | | | | |
|Non-spontaneous |22 |21 |25 |140, 449|
|Spontaneous |12 |47 |10 | |
|Mode of delivery | | | | |
|Other procedures |20 |4 |46 |280, 769|
|SVD |14 |64 |10 | |
|Pregnancy complication| | | | |
|None |13 |52 |10 | |
|Preterm labor |11 |1 |46 |274, 771|
|Others |10 |15 |20 |10, 396 |
| | | | | |
statistically
significant
Table 3: Comparison of mean values of variables of GDM mothers and mean
weight of their babies in relation to the admission of their neonates in
NICU
| | | | | | |
|Study variables |NICU Admission |t-value |p-value |95 CIs for |
| | | | |difference |
| | | | |of mean |
| |Yes |No | | | |
| | | | | | |
|Mothers age |345 |330 |114 |0259 |-112, 412 |
| |168 |59 | | | |
|Mothers weight |855 | 803 |119 |0234 |-34, 136 |
| |222 |162 | | | |
|Gestational age at |272 |287 | |0294 |-44, 136 |
|diagnosis |72 |56 |-106 | | |
|Gestational age at |359 |391 | |0001 |-41, -21 |
|delivery |37 |13 |-62 | | |
|Blood loss ml |3985 |2606 |
|00001|907, 1850 |
| |1649 |820 |58 | | |
|Weight of baby |27317 |34244 | |00001|-10013, |
| | | |-445 | |-3841 |
| | | | | | |
Mean SD statistically significant
labor, 46 times higher for the women who had non SVD procedures Vento
use/forceps, and CS as the mode of delivery, 46 times higher for the
women who had pregnancy complications preterm labor and 20 times higher
for women who had other complications polyhydramnios, oligohydramnios,
IUGR and postdate pregnancy when compared to mothers of those babies who
had not been admitted to NICU A comparison of mean values of variables of
GDM mothers, in relation to the NICU admission by their babies has clearly
demonstrated that, the mothers characteristics such as gestational age at
delivery and blood loss at the time of delivery had a significant effect on
the outcome of the baby Table 3 The new born babys weight also differed
significantly in relation to the NICU admission
The mean length of stay in NICU by these 34
babies was 16 days The
complications which led to the admission of these babies into NICU were
hyperbilirubinemia 14, 412, respiratory complications 11, 323,
hydronephroses 2, 59, congenital anomalies 2, 59, and sepsis 2,
59 Other complications were vomiting, anemia of the new born and
hypoglycemia 3, 88
DISCUSSION
Gestational diabetes mellitus is known as glucose intolerance or diabetes
mellitus which is diagnosed for the first time during pregnancy but
disappears after the pregnancy Pregnancy is a time of increasing insulin
resistance because of great hormonal changes Gestation may unmask a
maternal defect, such as impaired insulin secretion and/or reduced glucose
utilization, in insulin-sensitive tissues eg skeletal muscle
Gestational diabetes ensues when the womans insulin secretory capacity is
inadequate to overcome the progressive insulin resistance It is often
associated with maternal risk factors, such as overweight, advanced age and
a previous complicated obstetric history3,4 It has been claimed that the
higher rate of complications can be ascribed to these risk factors and not
to the
hyperglycemic condition itself7 Our prospective study shows the
magnitude of GDM as 86 in the pregnant mothers, reflecting the underlying
pattern of diabetes in the Kingdom of Saudi Arabia KSA Factors such as
maternal age, BMI and parity were of a higher order in our study sample
The presence of GDM has implications for both the baby and the mother In
our subjects, the mode of delivery by cesarean section was higher 216
which is in agreement with the study which reported a higher rate of
cesarean sections in GDM women in the USA5 This study shows that the
maternal variables: gestational age at the time of delivery, onset of
labor, mode of delivery, pregnancy complications and blood loss during
pregnancy were contributing factors to NICU admission of the newborn This
study also shows that the low birth weight of the new born was
statistically significantly associated with NICU admission Our results
indicate a lower rate of NICU admission when compared with other studies,
but the indications for such admissions are nearly the same8-10 There is
evidence that perinatal morbidity is higher in untreated GDM14
In this
study, the morbidity rate was low probably because all our patients were
treated with insulin or diet As in the Texas study, our study revealed
that the commonest complication in babies of GDM mothers and the leading
cause for NICU admission was hyperbilirubinemia, 412 compared to 64 for
neonates of non-diabetic mothers11 The rate of respiratory complications
in babies of GDM mothers was 323 which could be considered high and in
accord with previous studies8,9 Our results agree with the findings of the
study done by Hod M, et al which showed that, GDM is associated with
increased perinatal morbidity, characterized by macrosomia,
hyperbilirubinaemia, respiratory distress syndrome15 Prematurity and
growth retardation contribute mostly to the development of these
respiratory complications which are also correlated to poor maternal
metabolic control9,10 In our study, there was a high incidence of
hydronephrosis in babies of GDM mothers but we could not find any previous
study that had looked at this complication for comparison Cardiac
malformations were the most common type of
anomaly in these diabetic
pregnancies, which is in agreement with previous results12 Hypoglycemia
was found to be a mild cause for NICU admissions as found in previous
studies13 Other complications like vomiting and anemia of the newborn were
the other important indications for NICU admission
In conclusion, pregnancies complicated by gestational diabetes
mellitus without treatment are associated with a higher frequency of
adverse maternal and fetal outcomes Besides checking on other maternal
factors, diabetes during pregnancy should be controlled, in order to reduce
both the maternal and neonatal complications, and accordingly reduce the
number of NICU admissions
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