Gestational diabetes mellitus (GDM) is defined

Prevalence of Gestational Diabetes Mellitus in a

Medical College in South India: A Pilot Study

aBstract

Background: The prevalence of diabetes is increasing in India with projected rates of 79.4 million in 2030 — a 15.1% increase from 31.7 million in 2000. The increased prevalence is attributed to the aging population structure, urbanization, the obesity

epidemic and physical inactivity. Though prevalence of diabetes is alarmingly high among Indians, there have been very

few studies assessing the effect of diabetes on pregnancy outcomes. Diabetes in pregnancy causes maternal and neonatal

complications like stillbirth, hydramnios, etc. Among ethnic groups in South Asian countries, Indian women especially south Indians have the highest frequency of gestational diabetes mellitus (GDM) necessitating universal screening. The recognition

of glucose intolerance during pregnancy is more relevant as Indian women have 11-fold increased risk of developing GDM

compared to other places. Aims and objectives: To find the prevalence of GDM in Kollam and to find the relation of GDM with

various risk factors like age, obesity, previous large baby, abortion, previous abnormal glucose tolerance test (GTT), complications in previous pregnancy like hydramnios, bleeding, etc. Study design: A retrospective study of prevalence and possible risk

factors associated with gestational diabetes was undertaken on 71 mothers between the age group of 20 and 35 years who

were screened. Setting: Details on the medical history, family history of diabetes and obstetric history were collected using a

performa. All the study subjects underwent a complete physical examination and biochemical assessment was done. Results

and conclusion: This study on prevalence of GDM in Kollam district showed that the prevalence of GDM was 17%. It was

found out that the factors such as increased age of pregnant women, overweight and obesity, lack of exercise and diet control,

GDM in first-degree relatives, previous abnormal GTT predispose to GDM. Also women with previous large weight babies

(macrosomia), previous loss of pregnancy, GDM in previous pregnancy, complications in previous pregnancy like hydramnios,

bleeding, etc. have increased chances of getting GDM.

keywords: Gestational diabetes mellitus, pregnancy, glucose intolerence

G

as any degree of glucose intolerance with

onset or first recognition during pregnancy. The definition applies whether insulin or only diet modification is used for treatment and whether or not the condition persists after pregnancy. It does not exclude the possibility that unrecognized

glucose intolerance may have antedated or began concomitantly with the pregnancy. The prevalence of diabetes is increasing globally and the total

number of people with this condition is projected to rise from 171 million in 2000 to 366 million in 2030. India is no exception, with projected rates of 79.4 million in 2030 — a 15.1% increase from 31.7 million *Professor

†_{Associate Professor, Dept. of Medicine} ‡_{Professor and Head, Dept. of Pediatrics}

Azeezia Institute of Medical Sciences and Research Center Meeyannoor, Kollam, Kerala

Address for correspondence

Azeezia Institute of Medical Sciences and Research Center Meeyannoor, Kollam - 37, Kerala

E-mail: [email protected]

in 2000. The increased prevalence is attributed to the aging population structure, urbanization, the obesity

epidemic and physical inactivity.

Diabetes can complicate pregnancy, but it is not the

major complication of pregnancy. Although prevalence

of diabetes is alarmingly high among Indians there

have been very few studies assessing the effect

of diabetes on pregnancy outcomes. Diabetes in pregnancy causes maternal and neonatal complications like stillbirth, hydramnios, etc.

Maternal complications occurring in GDM are pregnancy-induced hypertension, maternal infection, fasting hyperglycemia, etc. Pregnancy complications include abortion, preterm labor, hydramnios and unexplained fetal deaths. Fetal complications are fetal macrosomia, fetal malnutrition, neural tube defects and cardiac anomalies like ventricular septal defect, atrial septal defect, etc.

Among ethnic groups in South Asian countries, Indian women especially south Indians have the highest frequency of GDM necessitating universal screening. The recognition of glucose intolerance during

pregnancy is more relevant as Indian women have

11-fold increased risk of developing GDM compared to

other places.

aims and oBjectiVes

The objectives of this study was to find the prevalence of GDM in the Kollam district and to find the relation

of GDM with various risk factors like age, obesity, previous large baby, abortion, previous abnormal GTT, complications in previous pregnancy like hydramnios, bleeding, etc.

material and methods

A study on the prevalence and possible risk factors associated with gestational diabetes was undertaken on

71 mothers between the age group of 20 and 35 years;

among pregnant women recruited from Gynecology

and Obstrectics outpatient of Azeezia Medical College, Kollam, Kerala, India from December 2013 to January 22, 2014. Details on the medical history, family history

of diabetes and obstetric history were collected using a

performa. All the study subjects underwent a complete

physical examination and laboratory investigations were done. A self-administrative interview schedule

was prepared and 71 pregnant ladies were selected for study. Data collected was entered in Microsoft Excel and analyzed further using SPSS Software version 20.0. results

According to this study, it was found that prevalence

of GDM in Kollam district was 17% and there was a significant relationship between GDM and its risk

factors. With data collected the statistical and

chi-square value to find out the correlation between the

risk factors and development of GDM were calculated.

Exercise (p = 0.019) and age (p = 0.013) are significant in

relation with diabetes. There was no relation between diabetes and hypertension.

Out of 71 pregnant women 12 (17%) were having diabetes (Fig. 1) 10 (14.1%) were having hypertension 1 (1.4%) person had body mass index (BMI) <18, 34 (47.9%) had BMI between 18-24.9, 30 (42.3%) had BMI between 25-29.9 and 6 (8.5%) had BMI above 30 (Fig. 2).

In those who are having diabetes, a relationship

between BMI and diabetes mellitus (DM) was noted. Eight (66.66%) women had normal BMI and 4 (33.33%)

were overweight. The chi-square value obtained was

13.928 with third-degree of freedom and the p value was 0.003, which is <0.01, which shows that the relationship between BMI and DM was highly significant. Out of

12 diabetic women, eight of the pregnant women had

history of abortion. The chi-square value obtained was

9.537 with first-degree of freedom and the p value was 0.002 which is <0.01, which shows that the relationship

between history of abortion and diabetes was highly

significant (Fig. 4).

Out of 12, 9 (75%) had no control on diet. The chi-square value obtained was 10.187 with first-degree of freedom and the p value was 0.001 which is <0.01,

which shows that the relationship between diet control

and diabetes was highly significant (Fig. 6). While

comparing with complications in present pregnancy 5

(41.66%) diabetics were having. The chi-square value obtained was 13.347 with first-degree of freedom and the p value was 0.000, which is <0.01, which

shows that the relationship between complication

in pregnancy and diabetes was highly significant

(Fig. 7). Four diabetic women reported with diabetes in previous pregnancy. The chi-square

value obtained was 15.248 with first-degree No (83%)

Yes (17%)

Figure 1. Frequency of diabetes mellitus.

Figure 2. Frequency of BMI of pregnant women.

15-20 21-25 42% 48% 9% 1% 26-30 31-35

of difference and the p value was 0.000, which was <0.01, showing that the relationship between

history of diabetes in previous pregnancy and diabetes

0 58 10 1 2 10 20 30 40 50 60 70 No Yes No. of persons No GDM GDM

Figure 5. Relationship between exercise and diabetes mellitus. Exercise 0 5 46 4 13 8 10 15 20 25 30 35 40 45 50 No Yes No. of persons No GDM GDM

Figure 4. Relationship between history of abortion and diabetes. History of abortion 0 5 33 3 2 3 24 6 10 15 20 25 30 35 18-24 25-32 >32 No. of persons No GDM GDM

Figure 3. Relationship between age and diabetes.

Age 0 58 9 1 3 10 20 30 40 50 60 70 No Yes No. of persons No GDM GDM

Figure 6. Relationship between diet control and diabetes mellitus. Diet control 0 56 7 3 5 10 20 30 40 50 60 No Yes No. of persons No GDM GDM

Figure 7. Relationship between complication in pregnancy and diabetes mellitus.

Complication in pregnancy

in present pregnancy was highly significant (Fig. 8). Out of 12, 5 (41.66%) pregnant women had complication in previous pregnancy and 5 (41.66%) had history of diabetes in first-degree relatives. The chi-square value obtained was 9.017 with first-degree of difference, the p value was 0.003, which was <0.01, the relationship

between complication during previous pregnancy and

diabetes was highly significant (Fig. 10).

Three women (25%) which shows that had baby of weight >3.5 kg in their previous delivery and 6 (50%) of them have baby within a range of 2.5 -3 kg and 3 (25%) had baby of weight <2.5.

The chi-square value is 20.468 with third-degree of

difference, the p value is 0.000, which is <0.01, the

relationship between birth weight of baby and diabetes

was highly significant (Fig. 9) Among the 12 diabetic pregnant women 10 (83.33%) were not doing any

exercise; only 2 (16.66%) were doing regular exercise.

The chi-square value obtained was 5.523 with

first-degree of freedom and the p value was 0.019, which was

<0.01, and hence the relationship between exercise and diabetes was significant (Fig. 5). In short the factors that found to be significant were BMI, history of abortion,

diet control, complications in pregnancy, diabetes in previous pregnancy, complications during previous pregnancy, birth weight of baby and exercise.

The study conducted on the basis of GDM and its risk factors showed that prevalence of GDM is

17%. According to the study, major significant risk

factors were obesity, previous large birth weight baby (macrosomia), complications during previous pregnancy, history of abortion, diet control, DM in previous pregnancy and exercise.

There exists a significant relationship between BMI and GDM (p = 0.003). The chance of getting GDM increases with obesity. Now-a-days, obesity is becoming a major

health problems due to the lack of physical activity and diet control.

Maternal health programs can be conducted by healthcare workers, focusing on prevention and control

of modifiable risk factors during pregnancy period

and introducing necessary corrective therapeutic

interventions such as exercise and dietary modifications. It was found out that there exists a highly significant

relationship (p = 0.002) between abortion and GDM. Eighty percent of cases of abortions had history of GDM during previous pregnancy. It occurs mainly due to fetal hyperinsulinemia (when maternal insulin level falls fetal insulin level rises). Abortions occur mainly due to lack of knowledge and awareness that GDM leads to abortions and lack of proper precautions like regular glucose level monitoring.

discussion

This study showed the prevalence of GDM as 17%. GDM prevalence has been reported variably from 0.7% to 31.6% in the previous studies conducted in India.

A similar study in Keralite women gave a prevalence

figure of 31.6%. GDM is an epidemically explosive

problem, which is increasing at an unstoppable pace. The Diabetes in Pregnancy Study Group India (DIPSI) guidelines having suggested one time plasma sugar

level as a measure to detect GDM is an attempt to

pre-empt future possibility and predisposition for GDM. Finding of this study is largely at tandem with those literatures at the national as well as international level. We therefore, infer from the above study that Kerala, despite its varying ethnicity, food habits physical activities, living standards, etc. are very much a part

0 58 8 1 4 10 20 30 40 50 60 70 No Yes No. of persons No GDM GDM

Figure 8. Relationship between history of diabetes in previous pregnancy and diabetes in present pregnancy.

History of diabetes in previous pregnancy

0 5 2 ₀ 4 7 26 3 27 2 10 15 20 25 30 <2.5 2.5-3.5 >3.5 NA No. of persons No GDM GDM

Figure 9. Relationship between birth weight of baby and diabetes. Birth weight 0 53 7 6 ₅ 10 20 30 40 50 60 No Yes No. of persons No GDM GDM

Figure 10. Relationship between history of diabetes in

first-degree relatives and diabetes.

of gestational diabetes spectrum the world over. In a

study, it has seen that there was significant relationship between age of pregnant women and GDM (Fig. 3); 60.7% of women with GDM were above 25 years of age. In our study, 75% of women with GDM were also

above 25 years of age. So, it is clear that there exists

a significant relationship between age and GDM. The

probable reason may be that in both studies considered population was well-educated and were working and most of them were multiparous. Even though, they are

aware of chance of getting GDM with increasing age

they never give it an importance in their busy schedule.

A group of studies reveals that a significant proportion of subjects with GDM were overweight and obese. In a study, it was seen that 31.06% were overweight (BMI 25-30) and 27.2% were obese (BMI >30); according to our study, 45.2% of women with GDM were overweight (BMI 26-30) and 9% of them were obese (BMI 31-35).

Hence, there exists highly significant relationship between overweight/obesity and GDM in both studies.

In our state, there is a misbelief that during gestational period over nourishment is essential and even though they are educated, they follow this custom. They take lots of ayurvedic products for their nourishment and most of them hesitate to do even simple household works during gestational period due to fear of losing baby. In our study, along with these reasons lack of exercise and diet control plays an important role. In group of studies, family history of GDM had

significant role in a large proportion of cases. The prevalence of family history of GDM in first-degree relative was found to be 36.2%, 86%, 11%, 85.7% and 16.6%, respectively. According to our study prevalence was 41.6%. All these studies express the role of family history of gestational diabetes in first-degree relatives was highly significant and this could be because of some genetic factors transmitting from

generation-to-generation among the families.

Some studies showed that 14%, 27.6% and 9% of cases

had a previous macrosomic babies, respectively that is babies of birth weight >4 kg.Based on our study, 58.33% of diabetic pregnant women had a history of

previous large birth weight babies (>3.5 kg). The reason may be that we took rural population and other studies considered urban population. Also, they considered babies of birth weight >4 kg as macrosomic and we considered babies of birth weight >3.5 kg as macrosomic so there is much variation in prevalence rates.

As regards abortions, study showed the prevalence

as 80%, whereas other studies showed prevalence as

68.96%, 34%, 2.7%, 89.96%, 85.71%, respectively. The

high prevalence rate obtained may be due to choosing a population who never considered GDM as an important complication. In a study, the prevalence rate is low when they give proper care and maintain blood sugar levels by proper medication and diet control.

While considering about exercise and diet control in the

study population a prevalence rate of 18% and 17% was seen. But, in our study it was shown to be 16.66% and 25%, respectively. The population we considered is aware

of importance of exercise and diet control but ignorance and lack of proper instructions is the problem here. In study conducted in Trivandrum, the populations were ignoring exercise and diet control even though they too knew the value of both exercise and diet control. Diabetes in previous pregnancy gave prevalence rate of

29.1% in a study and 33.33% in our study. The recurrence

was due to ignoring the condition, which occurred in previous pregnancy and lack of proper follow-up medication and repeated screening for increase in blood sugar level. The study was also conducted in same community set up followed hence they got almost

similar prevalence. In two studies, the prevalence of

previous pregnancy complications was 7% and 1.4%,

respectively. And in our study, the prevalence of

41.66% is much higher because most of the subjects we

considered were multiparous and in above studies most of women were primigravida. A case-control study (300 cases and 300 controls) in SAT Hospital, Trivandrum in

2010 showed that 60.7% cases above 25 years of age and 39.3% were <25 years of age. BMI ≥25 was significantly higher in cases (37.9%). Around 24% cases had a history of irregular menstrual cycle and 36% of them had a family history of diabetes among first-degree relatives, especially in mother. About 68.96% of the women had

previous losses as compared controls.

A study on prevalence of GDM in South Kerala during 2002 showed that the prevalence of GDM was found

to be 11.2%, 7% reported with hydramnios, 34% had history of loss of pregnancy, 14% with macrosomia, 18% were found not exercising and 17% had not taken

proper diet control.

A study was conducted to determine the incidence of GDM in South India in 2005. Among the 980 mothers

studied only 7 (0.7%) were diagnosed with GDM and the

rate of GDM detected in worldwide women population

is 4% every year. Among them, six of them gave history of miscarriages and five of them were above 25 years

of age and had family history of DM. A prospective study on pregnancy outcomes in pre-gestational and

gestational diabetic women in comparison to non-diabetic women in Asian Indian women (2006) showed

the following results, 82.3% of women who reported with GDM had a family history of diabetes in their first-degree relatives, 2.7% of them had history of abortion, 1.4% of their children showed congenital anomalies, 8.2% of them gave birth to low birth weight babies and 27.6% of them gave birth to large babies in their

previous pregnancy.

A prospective case-control study in diabetic women in a district tertiary hospital in South India (2008) showed

that 89.96% cases reported with loss of pregnancy, 11.33% had incidence of diabetes in their first-degree relatives, 24% had irregular menstrual cycles and 21.33% had incidence of GDM in their first-degree relatives. In Apollo Hospital, Chennai; a study on 1,251 pregnant

women who underwent the 50 g oral glucose challenge

test (OGCT) during 2004, 168 (18.9%) were diagnosed

to have GDM. Taking only 2-hour plasma glucose for

analysis, 144 (16.2%) had value ≥140 mg/dL, that they

were diabetic.

A perspective study in GDM all over India (2002) showed the results as follows - the study conducted

in North Chennai showed the prevalence of 16.2%, in South Chennai 15%, 15% in Trivandrum, 17.5% in Ludhiana, 12% in Bangalore, 31.6% in Alwaye, Kerala and 18.8% was in Erode, Tamil Nadu.

conclusion

The prevalence of GDM in this study was 17%. It

was found out that the factors such as increased age of pregnant women, overweight and obesity, lack of

exercise and diet control, GDM in first-degree relatives

and previous abnormal GTT predispose to GDM. Other factors were women with previous large weight babies (macrosomia) and previous loss of pregnancy. GDM in previous pregnancy, complications in previous

pregnancy like hydramnios, bleeding, etc. have increased

chances of getting GDM. Further studies including

larger samples will substantiate our study results. suggested reading

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