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Long and short-term outcomes of Gestational Diabetes Mellitus (GDM) among South Asian women – A community-based study

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Abstract

Aims

To quantify short and long-term outcomes of Gestational Diabetes Mellitus (GDM) among South Asians.

Methods

Prospective cohort-study in Gampaha District, Sri Lanka following a community-prevalence study (WHO 1999 criteria). All women with GDM (exposed) and within sample non-GDM (non-exposed) were recruited. Data was gathered at selected intervals until one-year post-partum by interviewer-administered questionnaire, anthropometry, blood pressure, post-partum 75gOGTT and cholesterol.

Two groups were compared for pregnancy outcomes; and age, parity, first-trimester BMI adjusted odds ratios (aOR) calculated.

Results

GDM and non-GDM (n = 194 each) had 169 (87.1%) and 178 (91.8%) responders respectively.

Significant differences in outcomes:

Antenatal/Perinatal – obstetric and/or medical complications (aOR = 1.8; 95% CI = 1.1–2.7), pregnancy induced hypertension (aOR = 3.1; 95% CI = 1.5–6.5), birth-weight ≥ 3.5 kg (aOR = 2.8; 95% CI = 1.4–5.5), special baby-care for prematurity (aOR = 4.1; 95% CI = 1.1–15.1), low mean POA at delivery (p = 0.005), vaginal moniliasis (aOR = 4.9; 95% CI = 1.4–17.4) and breast-engorgement (aOR = 2.6; 95% CI = 1.02–6.4).

Two months postpartum: impaired glucose tolerance (IGT) (aOR = 6.1; 95% CI = 2.7–13.8) and abnormal glucose tolerance [AGT = diabetes, impaired fasting glucose (IFG) and IGT collectively] (aOR = 9.1; 95% CI = 4.3–19.1).

One-year postpartum (participation rate = 39.7%): exclusive breastfeeding for six months (aOR = 0.3; 95% CI = 0.1–0.7), diabetes mellitus (aOR = 4.1; 95% CI = 1.1–15.7), IGT (aOR = 5.8; 95% CI = 1.5–21.8), AGT (aOR = 7.7; 95% CI = 2.9–20.6).

Conclusions

Hyperglycaemia in Pregnancy detected and followed up in a sub-urban community setting in Sri Lanka, had significantly worse pregnancy outcomes with a high risk of maternal pre-diabetes/diabetes in first post-partum year.

Introduction

The original definition of GDM was any degree of glucose intolerance with onset or first recognition during pregnancy [1], [2]. The WHO 2013 classification denotes hyperglycemia first detected at any time during pregnancy into two groups, namely diabetes in pregnancy (DIP) and GDM [3]. It is estimated that 25% of pregnancies in South East Asia are affected by hyperglycemia [4]. The prevalence of GDM reported recently from a sub-urban district of Sri Lanka was 13.9% [5], a 35% increase from a similar study done a decade before [6].

A pregnancy complicated by GDM gives rise to short and long-term complications to the mother, fetus and offspring with potential for trans-generational metabolic risk by fetal programming and epigenetics. Short-term fetal and neonatal complications include fetal macrosomia or intra uterine growth retardation, premature birth, congenital defects, need for neonatal intensive care and perinatal mortality. Even borderline GDM is associated with increased perinatal complications, with maternal glycemia demonstrating a continuum effect on the perinatal outcome [7]. Short-term maternal complications are spontaneous and late miscarriage, pregnancy induced hypertension (PIH) and preeclampsia, a greater need for induction of labor, instrumental delivery and cesarean section, polyhydramnios, diabetic ketoacidosis, birth trauma and postpartum hemorrhage. Babies born to mothers with GDM are at increased risk of developing long term complications as obesity [8], impaired glucose tolerance and type 2 diabetes, high systolic and diastolic blood pressure, dyslipidemia and the metabolic syndrome from their early life [9]. Some studies have demonstrated an increased risk of future GDM in girls born to mothers with GDM affecting their index pregnancies [10]. Women with GDM have a higher risk of developing impaired glucose tolerance and type 2 diabetes, obesity, metabolic syndrome and cardiovascular diseases in the early post-partum period and in the long-term [11]. Thus, GDM increases the cost of health care during and after pregnancy.

We believe the quantification and scientific analysis of the determinants of adverse outcomes of pregnancy complicated by hyperglycemia in a South Asian setting would enable strategic planning of pragmatic preventive and control measures to achieve a trans-generational health gain for the region. Hence, the aim of this study was to assess the short and long-term outcomes of pregnancies complicated by GDM and their determinants.

Section snippets

Study setting and design

A prospective cohort study was carried out from January 2014 to March 2016 in two selected health administrative divisions (Medical Officer of Health – MOH areas) of the Gampaha District of Sri Lanka.

Study population

The study population was selected from a large prevalence study of 1600 pregnant women attending field-based antenatal clinics. The prevalence of GDM as per WHO 1999 criteria (Fasting plasma glucose ≥ 126 mg/dl and/or 2 h value ≥ 140 mg/dl) of 75 g fasting oral glucose tolerance test (75gOGTT) was

Results

Of 194 women with GDM, 169 participated for the cohort study (response rate 87.1%). Of 194 women recruited without GDM, 178 participated for the cohort study (response rate 91.8%) until two months post partum. However, the response rate at twelve months post partum had reduced to ≤40% (Fig. 1).

Discussion

To the best of our knowledge this is the first report of a field-based long-term postpartum follow up of pregnancy outcomes of a large cohort of women detected with and without GDM in a community based South Asian setting. We observed significant adverse pregnancy, maternal and offspring outcomes; chief among the obstetric and/ or medical complications being PIH during the index pregnancy. Meanwhile a greater propensity for birth weight exceeding ≥3.5 kg (exceeding 2SDs of the national average)

Acknowledgement

We thank Medical Officer Maternal and Child Health Gampaha, Medical Officers of Health, Public Health Nursing Sisters, Public Health Midwives Gampaha and Dompe MOH areas for their support. We also thank all the study participants of this study.

Funding

Medical Research Institute (MRI 48/2012) and Nirogi Maatha project supported by World Diabetic Foundation (WDF 12-683).

Author contribution

All authors have contributed to the data collection and analysis, drafting the article, critical review and revision of the manuscript. All authors have approved the final version of the article.

Declaration of interests

There are no conflicts of interest.

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