Patlolla Rajini Reddy^1*, S Nagamani²

¹Associate Professor, ²Professor, Department of Obstetrics and Gynaecology, MGMH Petlaburz Osmania Medical College, Koti, Hyderabad, Telangana, INDIA.

Email: drsujathapasula@gmail.com

RESULTS

This study was undertaken in Modern Government Maternity Hospital, Petlaburz, Hyderabad. Total of cases are 100.

Table 1: Mean comparison of Gestational age of GDM detection among two groups

The Mean Gestational age of GDM detection in GDM alone group was 26.2 weeks compared to GDM with preeclampsia (27.45 weeks). No significant difference was found between these two groups. The mean 1^st hour OGTT value in GDM with PE group was 192.10 mg/dl when compared to GDM alone group (174.46 mg/dl). There was a significant difference found between these two groups. The mean 2^nd hour OGTT value was 172.10 mg/dl in GDM with PE, when compared to GDM alone, it was 153.06 mg/dl. No significant difference was found between these two groups. From the above table, HbA1C levels are higher (7.47%) among with PE compared to GDM without PE(6.42%). Significant difference was found between these two groups The mean weight gain in GDM with PE group was 16.58kg, whereas in GDM alone group it was 11.54kg. Significant difference was seen between these two groups.

Table 2: Pregnancy outcome measurements

NS: Non Significant

From the above table Emergency section rate was more than the Elective section rate among both groups. But Emergency section rate was little higher in GDM with PE group (56.66%) compared to GDM alone group (51.4%), which was statistically non-significant with p value more than 0.05.

NICU Admission rate was 63.33% among GDM with PE group, which was higher than the GDM alone group (28.6%), which was statistically significant with p value 0.02

Table 3: Patient selected characteristic data

Statistically significant (p<0.05)

From the above table, Maternal age is statistically similar among two groups with p value 0.143( non-significant).

The Men Maternal age of GDM with PE group was 24.45 years, compared to GDM alone group, it was 25.99 years.

OBESITY is statistically similar among two groups with p value greater than 0.05.

Table 4: GDM detection according to trimester among two groups

Among GDM with PE group, in most of the cases ((53.3%%) GDM was detected in third trimester.

Among GDM without PE group, In most off the cases (58.6%) GDM was detected in second trimester

Mean birth weight of GDM with PE group is lower (2.94Kg) than that of GDM without PE group ((3.26kg). Significant difference was found between these two groups with p value of 0.0001.

Table 5: Distribution of cases and incidence of preeclampsia in variables

In GDM with PE group most of the cases were PRIMI’S (45.2%), Compared to GDM alone most of the cases were SECOND GRAVIDA’S (35.7%). Most of them were in the age group of 20 to 25 years. Mean age in the study population was 25.22 years. In GDM with PE group Mean Age was 24.45 years, compared to GDM alone it was 25.99 years. Most of the cases in the study population were BOOKED CASES (63%). Among GDM with PE group, most of the cases were UNBOOKED CASES (63.33%). Among GDM without PE group, most of the cases were BOOKED CASES (74.3%). Most of the cases ((41.9%) of GDM with PE had their babies birth weight between 2..5-3kg and more than 33kg. Whereas most of the cases (50%%) of GDM alone had their babies birth weight more than 3 kg.

Table 6: Distribution of cases according to trimester wise (detection of preeclampsia)

Among GDM with PE group most of the cases (90%) were developed preeclampsia in third trimester: 10% developed in second trimester.

DISCUSSION

Pregnancy is a diabetogenic state manifested by insulin resistance and hyperglycemia it is implicated to be associated with significant obestric complications. The incidence of diabetes complicating pregnancy has increased by approximately 40% between 1989 and 2004 (Getahun and colleagues 2008). As incidence of diabetes is right in epidemic proportion more women of childbearing age are at increased risk of diabetes during pregnancy.^4,5 In fact, a high prevalence of gestational diabetes around 18% has been reported in India(46). GDM has been recognized as a clinical entity for 50 years . Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance with recognition in or onset during pregnancy irrespective of the treatment with diet or insulin .⁶ Early studies have strongly indicated untreated carbohydrate intolerance during pregnancy to be associated with higher rates of maternal morbidity and mortality. In the Indian context, screening is essential in all pregnant women as the Indian women have eleven fold increased risk of developing glucose intolerance during pregnancy compared to Caucasian women. Hence, universal screening during pregnancy has become important in our country. The screening for glucose tolerance is usually performed around 24-28 weeks of gestation. But a statistically significant number of GDM mothers deliver big babies despite good glycemic control in the third trimester. This is due to influence of maternal hyperglycemia in the early weeks of gestation on the fetal growth.⁶ Studies have also shown an increases in beta cell mass and insulin secretion in fetus of poorly controlled diabetic women by the 16^th week of gestation. These studies stress the need for screening for GDM during early weeks of gestation. We may not miss any GDM by screening around 24-28 weeks, but a substantial number of pregnancy women who develop GDM in the earlier weeks of pregnancy are likely to have a delayed diagnosis and may not receive appropriate medical care. Evidence shown that early screening for glucose intolerance and care could avoid some diabetes related complications in women with gestational diabetes especially preeclampsia. According to Mudd LM, Owe KM, Mottola MF, Pivarnik JM et al. Schneider S et al.^7,8 concluded that GDM and Preeclampsia share many risk factors, including advanced maternal age, nulliparity multifetal pregnancies, non-white race/ethnicity and prepregnancy obesity. GDM is often listed as a risk factor for the development of Preeclampsia. According to Schneider S et al. ⁸ retrospective investigation of 6,47,392 and Preeclampsia while controlling for common risk factors. The authors found that the odds of Preeclampsia were increased among women with GDM, even after controlling for age, nationally, smoking, parity, multifetal pregnancy, pre-pregnancy weight status and gestational weight gain. In the present study incidence of preeclampsia is in pregnant women with GDM is 30%. Our findings are comparable with some of the studies like Van Hoorn J, Dekker G, Jeffries B et al.,⁹ A study conducted by Jenson DM, Sorensen B et al., ¹⁰ have examined the association between gestational diabetes and preeclampsia, although some have been limited by small sample size or limited descriptive information. We also found that association between gestational diabetes and preeclampsia differed among booked cases and unbooked cases. Percentage of preeclampsia cases among unbooked cases was higher (51%) compared to booked cases (17.4%) while inadequate prenatal care has been describe as increasing the risk of preeclampsia by 30 to 35%, according to the studies conducted have suggested that early detection and aggressive treatment might reduce the risk of preeclampsia.

In our study rate of preeclampsia was assessed in the different severity categories of GDM(by 10 mg/dl increments of fasting value in the OGTT), an ongoing increase in the rate of preeclampsia was identified. GDM patients who developed preeclampsia had significantly higher OGTT values in comparison to GDM patients who did not. According to the present study Mean FBS levels are higher (113.39 mg/dl) among GDM patients who developed preeclampsia, compared to GDM patients who did not (98.36 mg/dl). We found no difference in the age group between GDM patients who developed preeclampsia and patients those who did not. We found Mean Birth Weight of GDM patients who develop preeclampsia is lower (2.94+/-0.65), than that of patients who did not (3.26+/-0.67). We found no difference in Gestational Age at Delivery. The results are comparable with other studies conducted. In our study GDM patients who developed preeclampsia had higher rates of Nulliparity and gained significantly more weight during pregnancy. These findings are consistent with other studies conducted by Oded Langer et al.¹¹ GDM patients who developed preeclampsia had significant weight gain (16.58kg), compared to those who did not (11.54kg). In the present study, among GDM with PE group, most of the cases (90%) were developed preeclampsia in the third trimester, whereas 10% of the patients developed in second trimester. In our study Preterm deliveries were higher (66.6%) in patients with GDM who developed preeclampsia, compared to those who did not (35.7%). It is possibly because of the only definitive treatment for the preeclampsia is delivery. Among 30 cases of preeclampsia one case had Eclampsia during Intrapartum period. No significant difference was found in mode of delivery among two groups. Probably because of small sample size. The study conducted by Yogev et al., M.J.Xenakis et al., Oded anger et al.,⁹ found higher rates of induction of labour and elective casarean delivery were observed in GDM patients who developed preeclampsia. Total IUD’S were 4 out of 100 cases.(4%). Among these two cases were term sudden IUD’S and other two cases were Preterm IUD’S at 36 weeks. NO gross congenital abnormalities were found in these four cases. Uncontrolled sugar levels were there in sudden IUD cases, these patients were not on regular follow-up. NICU admissions were higher (63.33%) among GDM with PE group compared to GDM alone group (28.6%). But according to Yogev, Xenakis, Langer et al.,⁹ there was cleft lip and cleft palate. In the present study HbA1C was done, once the patient was diagnosed as having GDM. The purpose of doing this is to know whether the patient has well controlled sugars in the past 3 months. HbA1C levels were higher among GDM with PE (7.47%), compared to GDM alone group (6.42%). Means GDM with PE patients had uncontrolled sugars in the past 3 months, but these patients goes undetected by the 75 grams OGTT, thereby causing uncontrolled sugars, which is the factor responsible for the development of preeclampsia.

CONCLUSION

Providing patients education for enabling self-care and management: public health system constraints, due to shortage of resources, and providers, can be addressed to great extent by empowering community health workers, midwives, women self-help group and patients and communities with necessary information on GDM and diabetes prevention that they can utilize for self-monitoring and self-care. This can facilitate achievement of improved health outcomes, reduced unnecessary hospital visits, contributing to considerable cost savings for the health system. By doing early detection and giving proper management with strict glycemic control we can decrease the incidence of Preeclampsia. Regular and more frequent Pressure monitoring is required in Gestational Diabetes pregnant women, so there by we can decrease the maternal morbidity and mortality.

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