Diabetes in Pregnancy : Maternal Profile and Neonatal Outcome

Background: Diabetes in pregnancy is associated with increased risk to the woman and to the developing fetus. Historically, infants born to mother with diabetes (IDM) have significantly greater risk for spontaneous abortion, stillbirth, congenital malformations and perinatal mortality and morbidity. Objective: To evaluate the complications associated with diabetes in pregnancy in the periconceptional, fetal, neonatal and postnatal period. Materials and method: This observational study was carried out in the department of Obstetrics & Gynaecology of Bangladesh Institute of Research & Rehabilitation in Diabetes, Endocrine & Metabolic Disorders (BIRDEM), Dhaka, Bangladesh, from July 2013 to December 2013. Data of 100 patients with pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM) delivering live baby after 37 completed weeks were evaluated during the period. They were divided into two groups: patients with PGDM in group-A and patients with GDM in group-B. Results: Majority of the PGDM patients were in 31-35 years age group whereas 50% of the GDM patients were from younger group (26-30). A major proportion of the patients of both the groups required Caesarean section with a higher rate in group-A. Diabetic mothers had more macrosomic babies than GDM mothers (14% vs 4%). Most commonly found neonatal complications were hyperbilirubinaemia followed by RDS and hypoglycaemia in both the groups with a higher proportion in PGDM group. Conclusion: Almost similar maternal and neonatal complications were observed in both PGDM and GDM group in our study despite of integrated antenatal, intranatal and perinatal care with a higher proportion in PGDM patients.


Introduction
Diabetes is the most common endocrine disorder complicating pregnancy.Incidence of both type-I and type-II diabetes is increasing throughout the world.As the incidence of diabetes continues to rise and increasingly affects individuals of all age including young adults and children, women of childbearing age are at increased risk of diabetes during pregnancy. 1abetes may manifest itself for the first time in pregnancy i.e. gestational diabetes mellitus (GDM) or a diabetic woman may become pregnant i.e. pregestational diabetes mellitus (PGDM).World Health Organization (WHO) defined gestational diabetes mellitus as 'Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognized during pregnancy '. 2 There has been a marked increase in the prevalence of diabetes in Asia over recent years.Diabetes complicating pregnancy, in particular gestational diabetes, has also increased markedly in the region. 3It is estimated to affect approximately 16.9% of pregnancies globally, with the highest prevalence in South-East Asia, where an estimated 25% of pregnancies are affected. 4abetes in pregnancy is associated with increased risk to the woman and to the developing fetus. 5estational diabetes mellitus also increases the likelihood of subsequent diabetes in the mother in high risk women and the risk of recurrence in future pregnancies has been reported to be as high as 68%. 6storically, Infants of diabetic mothers (IDMs) have significantly greater risk for spontaneous abortion, stillbirth, congenital malformations and perinatal mortality and morbidity. 7Their morbidity and mortality rates have decreased nearly 30-fold since the development of specialized maternal, fetal, and neonatal care for women with diabetes and their offspring over the past three decades.Before then, fetal and neonatal mortality rates were as high as 65%. 8Advances in maternal and fetal care have improved the outlook of the IDM to the point at which most pregnant women with diabetes can expect to deliver a healthy child when they have received appropriate prenatal care. 7rrently 3-10% pregnancies are complicated by abnormal glycaemic control.Of these, 80-88% are caused by gestational diabetes mellitus as opposed to pregestational diabetes mellitusand 65% of these mothers have been found to have type 2 diabetes mellitus. 7,8This number may rise significantly in the next decade as the current significantly overweight paediatric population head into their childbearing years. 7e IDM is at increased risk for periconceptional fetal, neonatal and long-term morbidities.The cause of the fetal and neonatal sequelae of maternal diabetes are likely to be multifactorial, however, many of the perinatal complications can be traced to the effect of maternal glycaemic control on the fetus and can be prevented by appropriate preconceptional and prenatal care. 9 Most of the fetal and neonatal complications of diabetes during pregnancy are due to maternal hyperglycaemia.The concept had its own ontogeny in the Pedersen hypothesis which states that maternal hyperglycaemia results in fetal hyperglycaemia because glucose readily traverses the placenta.Before 20 weeks of gestation, the fetal islet cells are not capable of responsive insulin secretion, and the main pathogenic condition to which the embryo and early fetus are subjected is hyperglycaemia.Thereafter the fetus has a functioning pancreas and is responsible for its own glucose homeostasis.Unchecked fetal hyperglycaemia results in hypertrophy of fetal pancreas and hyperinsulinaemia.The pathogenic conditions in the late gestation fetus and IDM are the result of fetal hyperglycaemia, hyperinsulinaemia or the combined effects of the two. 7is article focuses on the complications associated with diabetes in pregnancy, both PGDM and GDM, as they occur in the periconceptional, fetal, neonatal and postnatal time period.Rehabilitation in Diabetes, Endocrine & Metabolic Disorders (BIRDEM), Dhaka, Bangladesh during the period of July 2013 to December 2013.Purposive sampling was done at the time of delivery and data were collected.The inclusion criteria were live fetus of diabetic mother (both PGDM and GDM) delivered after 37 completed weeks.Data of 100 patients were evaluated during the period.They were divided into two groups: patients with PGDM in group-A and patients with GDM were in group-B.Patients on nutrition therapy, multiple pregnancy and those with other co morbidities (e.g.chronic hypertension, preeclampsia, endocrine disorders affecting fetal outcome, etc.) were excluded.Verbal consent was taken from all the participants.Confidentiality was maintained.

Results
A total of 100 pregnant patients were evaluated.Fifty patients had pregestational diabetes mellitus (group-A) and fifty had GDM (group-B).Majority of the PGDM patients were in 31-35 years age group whereas 50% of the GDM patients were from younger group (26-30).Most of the patients were multipara in both the groups.The patients were mostly on regular antenatal checkup.Majority of the patients of both the groups required termination by Caesarean section with a higher rate in group-A (Table I).

Table I: Maternal profile
Caesarean section was required more in group-A and was influenced by several factors like previous history of C-section, bad obstetric history, fetal macrosomia and others (Table II).

Discussion
Strict maternal glycaemic control during a pregnancy complicated by diabetes mellitus reduces neonatal mortality and morbidity.Fetal hyperinsulinaemia and its associated metabolic abnormalities can be reduced by tight glycaemic control after 28 weeks of gestation.Similarly fetal macrosomia can be prevented by appropriate glycaemic control from 32 weeeks of gestation until term. 7onatal outcome was evaluated just after delivery and is presented in Table III.

Table III: Neonatal profile including complications
Good glycaemic control by medical nutrition therapy and insulin, when required, along with proper antenatal check up can make up diabetic and GDM pregnancies as safe as non diabetic pregnancies.Though several studies showed that good glycaemic control reduces neonatal complications, [10][11][12] still PGDM and GDM are associated with adverse fetal and maternal outcomes even after adequate antenatal care and glycaemic control. 12,13Adverse fetal outcomes include congenital anomalies, trauma during birth, macrosomia, and perinatal morbidity and mortality. 14,15Adverse maternal outcomes include increased rates of caesarean section and increased lifetime risk of developing type 2 diabetes. 15,16garding analysis of the demographic characteristics, in our study group majority (40%) of the PGDM patients were in 31-35 years age group whereas 50% of the GDM patients were from younger group (26-30).This observation is in line with previous studies. 17-21[20][21] Majority of the patients of both our study groups required termination by Caesarean section with a higher rate in PGDM group which was influenced by several factors like previous history of C-section, bad obstetric history, fetal macrosomia and others.In a study by Fong et al. 21 subjects with PGDM were more likely than those with GDM to have a shoulder dystocia, failed induction of labor, or undergo Caesarean delivery.[24] Neonatal outcome in both groups were evaluated.Majority of the neonates were of appropriate birth weight but diabetic mothers had more macrosomic babies than GDM mothers (14% vs 4%).In a study by Wahabi et al. 20 the neonates of the mothers with PGDM were significantly heavier when compared to those of GDM group and the frequency of macrosomia was more than threefold among PGDM group compared to GDM group which is almost similar to the finding of this study.Many factors might have influenced the difference in the outcomes between these two groups such as the prolonged exposure of the fetus to maternal hyperglycemia in the case of PGDM with the resultant prolonged fetal hyperinsulinaemia and increased C-peptide level and thus more severe effect on fetal weight gain, macrosomia and the related complications such as increased number of Caesarean delivery. 13,257][28] The hospital where this study was conducted is a major referral centre for women with GDM and also pregnancy with DM.The management of pregnant diabetic women is part of the routine obstetric practice in this tertiary health care centre, and there is also an established protocol for antenatal, perinatal and postnatal management of diabetic pregnant women and their infants.And these facts might explain the lower rate of macrosomia observed in this study as compared to the published literature.
We found relatively good APGAR score in neonates of GDM group than PGDM.Niliet al. 17 and Rackham et al. 29 also got similar findings.Most commonly found neonatal complications were hyperbilirubinaemia followed by RDS and hypoglycaemia in both the groups with a higher proportion in PGDM group.This is consistent with the findings of Niliet al. 17 though frequency was variable.
Diabetes in pregnancy either in the form of PGDM or GDM impose a number of maternal and neonatal morbidities.Almost similar maternal and neonatal complications were observed in both PGDM and GDM group in our study despite of integrated antenatal, intranatal and perinatal care with a higher proportion in PGDM patients.This message must be kept in mind while managing such pregnancies.