Prevalence of Gestational Diabetes Mellitus in a Medical College in South India: A Pilot Study K Sreekanthan*, A Belicita, K Rajendran, Anil Vijayakumar Abstract Background: The prevalence of diabetes is increasing in India with projected rates of 79.4 million in 2 a 1.1% increase from 1.7 million in 2. 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 () necessitating universal screening. The recognition of glucose intolerance during pregnancy is more relevant as Indian women have 11-fold increased risk of developing compared to other places. Aims and objectives: To find the prevalence of in Kollam and to find the relation of 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 2 and 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 in Kollam district showed that the prevalence of 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, in first-degree relatives, previous abnormal GTT predispose to. Also women with previous large weight babies (macrosomia), previous loss of pregnancy, in previous pregnancy, complications in previous pregnancy like hydramnios, bleeding, etc. have increased chances of getting. Keywords: Gestational diabetes mellitus, pregnancy, glucose intolerence Gestational diabetes mellitus () is defined 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 2 to 66 million in 2. India is no exception, with projected rates of 79.4 million in 2 a 1.1% increase from 1.7 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 - 7, Kerala E-mail: medicalcollge@azeezia.com in 2. 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 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 necessitating universal screening. The recognition of glucose intolerance during 42 Indian Journal of Clinical Practice, Vol. 2,. 4, September 214
pregnancy is more relevant as Indian women have 11-fold increased risk of developing compared to other places. Aims and Objectives (17%) The objectives of this study was to find the prevalence of in the Kollam district and to find the relation of with various risk factors like age, obesity, previous large baby, abortion, previous abnormal GTT, complications in previous pregnancy like hydramnios, bleeding, etc. (8%) 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 2 and years; among pregnant women recruited from Gynecology and Obstrectics outpatient of Azeezia Medical College, Kollam, Kerala, India from December 21 to January 22, 214. 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 2.. Results Figure 1. Frequency of diabetes mellitus. 1% 9% 42% 48% 1-2 21-2 Figure 2. Frequency of BMI of pregnant women. 26-1- According to this study, it was found that prevalence of in Kollam district was 17% and there was a significant relationship between and its risk factors. With data collected the statistical and chisquare value to find out the correlation between the risk factors and development of were calculated. Exercise (p =.19) and age (p =.1) 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) 1 (14.1%) were having hypertension 1 (1.4%) person had body mass index (BMI) <18, 4 (47.9%) had BMI between 18-24.9, (42.%) had BMI between 2-29.9 and 6 (8.%) had BMI above (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 (.%) were overweight. The chi-square value obtained was 1.928 with third-degree of freedom and the p value was., which is <.1, 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 9.7 with first-degree of freedom and the p value was.2 which is <.1, which shows that the relationship between history of abortion and diabetes was highly significant (Fig. 4). Out of 12, 9 (7%) had no control on diet. The chisquare value obtained was 1.187 with first-degree of freedom and the p value was.1 which is <.1, which shows that the relationship between diet control and diabetes was highly significant (Fig. 6). While comparing with complications in present pregnancy (41.66%) diabetics were having. The chi-square value obtained was 1.47 with first-degree of freedom and the p value was., which is <.1, 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 1.248 with first-degree Indian Journal of Clinical Practice, Vol. 2,. 4, September 214 4
7 6 8 2 2 1 1 24 18-24 2-2 >2 Age 6 2 4 2 1 9 Diet control 1 Figure. Relationship between age and diabetes. Figure 6. Relationship between diet control and diabetes mellitus. 4 4 2 2 1 1 46 4 History of abortion 1 Figure 4. Relationship between history of abortion and diabetes. 8 6 4 2 1 6 7 Complication in pregnancy Figure 7. Relationship between complication in pregnancy and diabetes mellitus. 7 6 4 2 1 8 1 Exercise 1 2 Figure. Relationship between exercise and diabetes mellitus. of difference and the p value was., which was <.1, showing that the relationship between history of diabetes in previous pregnancy and diabetes in present pregnancy was highly significant (Fig. 8). Out of 12, (41.66%) pregnant women had complication in previous pregnancy and (41.66%) had history of diabetes in first-degree relatives. The chi-square value obtained was 9.17 with first-degree of difference, the p value was., which was <.1, the relationship between complication during previous pregnancy and diabetes was highly significant (Fig. 1). Three women (2%) which shows that had baby of weight >. kg in their previous delivery and 6 (%) of them have baby within a range of 2. - kg and (2%) had baby of weight <2.. The chi-square value is 2.468 with third-degree of difference, the p value is., which is <.1, the relationship between birth weight of baby and diabetes was highly significant (Fig. 9) Among the 12 diabetic pregnant women 1 (8.%) were not doing any 44 Indian Journal of Clinical Practice, Vol. 2,. 4, September 214
7 6 4 2 1 8 8 History of diabetes in previous pregnancy exercise; only 2 (16.66%) were doing regular exercise. The chi-square value obtained was.2 with firstdegree of freedom and the p value was.19, which was 1 Figure 8. Relationship between history of diabetes in previous pregnancy and diabetes in present pregnancy. 2 2 1 1 2 27 2 4 7 4 <2. 2.-. >. NA Birth weight Figure 9. Relationship between birth weight of baby and diabetes. 6 4 2 1 7 6 26 History of diabetes in first-degree relatives Figure 1. Relationship between history of diabetes in firstdegree relatives and diabetes. <.1, and hence the relationship between exercise and diabetes was significant (Fig. ). 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 and its risk factors showed that prevalence of 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 (p =.). The chance of getting increases with obesity. w-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 =.2) between abortion and. Eighty percent of cases of abortions had history of 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 leads to abortions and lack of proper precautions like regular glucose level monitoring. Discussion This study showed the prevalence of as 17%. prevalence has been reported variably from.7% to 1.6% in the previous studies conducted in India. A similar study in Keralite women gave a prevalence figure of 1.6%. 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 is an attempt to preempt future possibility and predisposition for. 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 Indian Journal of Clinical Practice, Vol. 2,. 4, September 214 4
of gestational diabetes spectrum the world over. In a study, it has seen that there was significant relationship between age of pregnant women and (Fig. ); 6.7% of women with were above 2 years of age. In our study, 7% of women with were also above 2 years of age. So, it is clear that there exists a significant relationship between age and. 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 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 were overweight and obese. In a study, it was seen that 1.6% were overweight (BMI 2-) and 27.2% were obese (BMI >); according to our study, 4.2% of women with were overweight (BMI 26-) and 9% of them were obese (BMI 1-). Hence, there exists highly significant relationship between overweight/obesity and 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 had significant role in a large proportion of cases. The prevalence of family history of in first-degree relative was found to be 6.2%, 86%, 11%, 8.7% 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-togeneration 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, 8.% of diabetic pregnant women had a history of previous large birth weight babies (>. 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 >. kg as macrosomic so there is much variation in prevalence rates. As regards abortions, study showed the prevalence as 8%, whereas other studies showed prevalence as 68.96%, 4%, 2.7%, 89.96%, 8.71%, respectively. The high prevalence rate obtained may be due to choosing a population who never considered 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 2%, 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.% 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 ( cases and controls) in SAT Hospital, Trivandrum in 21 showed that 6.7% cases above 2 years of age and 9.% were <2 years of age. BMI 2 was significantly higher in cases (7.9%). Around 24% cases had a history of irregular menstrual cycle and 6% 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 in South Kerala during 22 showed that the prevalence of was found to be 11.2%, 7% reported with hydramnios, 4% 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 in South India in 2. Among the 98 mothers studied only 7 (.7%) were diagnosed with and the rate of detected in worldwide women population is 4% every year. Among them, six of them gave history of miscarriages and five of them were above 2 years of age and had family history of DM. A prospective study on pregnancy outcomes in pre-gestational and 46 Indian Journal of Clinical Practice, Vol. 2,. 4, September 214
gestational diabetic women in comparison to nondiabetic women in Asian Indian women (26) showed the following results, 82.% of women who reported with had a family history of diabetes in their firstdegree 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 (28) showed that 89.96% cases reported with loss of pregnancy, 11.% had incidence of diabetes in their first-degree relatives, 24% had irregular menstrual cycles and 21.% had incidence of in their first-degree relatives. In Apollo Hospital, Chennai; a study on 1,21 pregnant women who underwent the g oral glucose challenge test (OGCT) during 24, 168 (18.9%) were diagnosed to have. Taking only 2-hour plasma glucose for analysis, 144 (16.2%) had value 14 mg/dl, that they were diabetic. A perspective study in all over India (22) showed the results as follows - the study conducted in rth Chennai showed the prevalence of 16.2%, in South Chennai 1%, 1% in Trivandrum, 17.% in Ludhiana, 12% in Bangalore, 1.6% in Alwaye, Kerala and 18.8% was in Erode, Tamil Nadu. Conclusion The prevalence of 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, in first-degree relatives and previous abnormal GTT predispose to. Other factors were women with previous large weight babies (macrosomia) and previous loss of pregnancy. in previous pregnancy, complications in previous pregnancy like hydramnios, bleeding, etc. have increased chances of getting. Further studies including larger samples will substantiate our study results. SUGGESTED READING 1. Bhat M, K N R, Sarma SP, Menon S, C V S, S GK. Determinants of gestational diabetes mellitus: A case control study in a district tertiary care hospital in south India. Int J Diabetes Dev Ctries 21;(2):91-6. 2. Paulose KP. Prevalence of gestational diabetes in south Kerala. Kerala Med J 28;():14-6.. Shefali AK, Kavitha M, Deepa R, Mohan V. Pregnancy outcomes in pre-gestational and gestational diabetic women in comparison to non-diabetic women--a prospective study in Asian Indian mothers (CURES-). J Assoc Physicians India 26;4:61-8. 4. Bose T. Incidence of gestational diabetes mellitus in general population. J Hum Ecol 2;17(4): 21-4.. Wahi P, Dogra V, Jandial K, Bhagat R, Gupta R, Gupta S, et al. Prevalence of gestational diabetes mellitus () and its outcomes in Jammu region. J Assoc Physicians India 211;9:227-. 6. Seshiah V, Balaji V, Balaji MS, Sanjeevi CB, Green A. Gestational diabetes mellitus in India. J Assoc Physicians India 24;2:77-11. 7. Seshiah V, Balaji V, Balaji MS, Paneerselvam A, Arthi T, Thamizharasi M, et al. Prevalence of gestational diabetes mellitus in South India (Tamil Nadu) - a community based study. J Assoc Physicians India 28;6:29-. 8. Seshiah VS, Balaji V,Balaji M. Gestational diabetes mellitus - A prospective. Gestational Diabetes Mellitus 211 vember; p.21-4. 9. Ferrara A. Increasing prevalence of gestational diabetes mellitus: a public health perspective. Diabetes Care 27; Suppl 2:S141-6. 1. Soheilykhah S, Mogibian M, Rahimi-Saghand S, Rashidi M, Soheilykhah S, Piroz M. Incidence of gestational diabetes mellitus in pregnant Women. Iranian J Reprod Med 21;8(1): 24-8. Indian Journal of Clinical Practice, Vol. 2,. 4, September 214 47