Fetal & Maternal Outcome of Diabetes Mellitus at Aljomhoria Hospital, Benghazi-Libya, 2010

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1 Fetal & Maternal Outcome of Diabetes Mellitus at Aljomhoria Hospital, Benghazi-Libya, 2010 Najat Bettamer 1, Asma Salem Elakili 2, Farag Ben Ali 1 & Azza SH Greiw 3 1 Gynecology Department, 3 Family & Community Department - Faculty of Medicine, Benghazi University. Benghazi- Libya. Introduction: 2 Ministry of Health Diabetes Mellitus (DM) is a chronic illness that requires continuing medical care. The classification of diabetes includes four clinical classes; type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency), type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance), other specific types of diabets due to other causes and gestational diabetes (GDM). It is diabetes diagnosed during pregnancy that is not clearly overt diabetes. (1) Diabetes Mellitus is the most common pre-existing medical condition complicating 2-3 % of pregnancies, 90 % of these cases present with Gestational Diabetes Mellitus and 10 % as pregestational diabetes. It does recur in about 60% of subsequent pregnancies. Women with GDM have increased risk for potential morbidity and for impaired glucose tolerance. Furthermore, they are at high risk of developing type 2 diabetes in the years following the pregnancy. Forty percent of these cases will develop non-insulin dependent diabetes within 15 years after delivery. (2) In addition to higher risk of perinatal morbidity, the offspring of mothers with GDM face increased risk of childhood obesity and early onset of type 2 diabetes mellitus. (3) Studies suggest that the prevalence of diabetes mellitus (DM) among women of childbearing age is increasing worldwide. This increase is believed to be attributable to more sedentary lifestyles, changes in diet, and the virtual epidemic of childhood and adolescents' obesity. (4,5&6) If GDM is not properly treated, there is an increased risk of adverse maternal, fetal and neonatal complications. Maternal complications include (preeclampsia, pregnancy induced hypertension, recurrent vulvo-vaginal infections, increased incidence of operative deliveries, obstructed labor and development of diabetes mellitus later in life). Fetal complications such as; macrosomia, polyhydromnios, preterm labour, respiratory distress, unexplained intrauterine fetal death, traumatic 1

2 delivery and neonatal complications e.g. hypoglycemia, jaundice, polycythemia, tetany, hypocalcaemia, hypomagnesaemia (3,7,8&9). Management Women with gestational diabetes can be managed using diet and insulin therapy. Nutritional counseling with individualization based on height and weight and a diet that provides an average of 30 kcal/kg/d based on pre-pregnant body weight for non obese women. Most practitioners initiate insulin therapy in women with gestational diabetes if fasting glucose levels exceeding 105 mg/dl persist despite diet therapy. This is accomplished in a specialized outpatient clinic, but occasionally (10,11 &12) hospitalization is necessary. Obstetrical Management In general, women with gestational diabetes who do not require insulin seldom require early delivery or other interventions. Elective cesarean delivery to avoid brachial plexus injuries in macrosomic infants is an important issue. (13) Postpartum Evaluation The Fifth International Workshop Conference on Gestational Diabetes recommended that women diagnosed with gestational diabetes undergo evaluation with a 75-g oral glucose tolerance test at 6 to 12 weeks postpartum and other intervals thereafter (9). Postpartum follow-up are based on the 50-percent likelihood of women with gestational diabetes developing overt diabetes within 20 years. (14) According to Holmes and colleagues, recurrence of gestational diabetes in subsequent pregnancies was documented in 40 percent of 344 primiparous women. Obese women were more likely to have impaired glucose tolerance in subsequent pregnancies. Thus, lifestyle behavioral changes, including weight control and exercise between pregnancies, would likely prevent recurrence of gestational diabetes as well as modify onset and severity of type 2 diabetes later in life. (15) Objective of study : The objective was to describe the maternal, fetal and neonatal outcome in pregnancies in women with pre-gestational & gestational diabetes during the period of study. Patients and Methods Retrospective review of registry records was conducted on pregnant women with GDM & pre-gestational diabetes mellitus (PGDM) in the Department of Obstetrics and Gynecology, Al jamhoria Hospital, over a the period of one year, from January 1 to December 31, During this period, the total number of records were 317 records. The collected data included; age, gravidity, history of abrtion, gestational 2

3 age at admission, type of diabetes, history of fetal death or still birth,, mode of delivery, birth weight and congenital malformations Statistical Package for Social Sciences (SPSS) version 11.5 was used for statistical analysis. The mean, standard deviation, minimum, maximum values and other descriptive statistics were computed. The presentation of these statistics were in the form of tables & graphics. Results : During the period of the study, diabetic mothers represented 1.4 % of total pregnant women admitted to the hospital. GDM was diagnosed in 0.8 % of pregnant women and 0.6 % of them had pregestational diabetes. Most of the pregnant women (86.7%) aged above 27 years, Figure 1. Their gravidity ranged between 1-13, more than two thirds (67.4 %) of the cases were gravida 3 & more. Figure 2. Table 1 showed that 91.7% of diabetic mothers had previous history of (1-2) abortions and about 1% of mothers had more than 5 abortions. More than quarter of newborn babies of diabetic mothers (28%) were preterm at gestational age less than 36 weeks. Table 2 Table 3 revealed that perinatal mortality was recorded in 2.2 % of the babies. Only 1.2% of babies born to diabetic mothers had congenital anomalies. Table 4. About thirty perecnt of infants born to diabetic women had macrosomia, as shown in table 5 Table 6 presented the mode of delivery of diabetic mothers. Ninty perecnt of diabetic mothers had cesarean sections. 3

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5 Table (1): Abortion categories of the diabetic mothers Abortion categories of the diabetic mothers Number Percent > Total Table (2) Gestational age categories of newborns of diabetic mothers Gestational age categories Number Percent weeks weeks > 40 weeks Total

6 Table (3) newborn outcome of diabetic mothers Newborn outcome of the diabetic mothers Number Percent Alive & full term delivery Alive & preterm delivery Intra uterine death Stillbirth Total Table (4) Congenital anomalies of the newborn babies of the diabetic mothers Congenital anomalies of the newborn babies Number Percent No congenital anomalies Neural tubal defect Hydrocephalus Total

7 Table (5): Birth weight categories of newborn babies of the diabetic mothers Birth weight categories of newborn babies Number Percent <2.5 Kg Kg >4 Kg Total Table (6): Mode of delivery of the diabetic mothers at Aljmhouria hospital Mode of delivery Number Percent Urgent cesarean section Elective cesarean section Normal delivery Total

8 Discussion During the period of the study, women delivered. The total number of women with DM was 317 (1.4%),181; ( 0.8% ) were complicated with gestational diabetes (PGDM) and the rest had pregestational diabetes (PGDM). The present study showed that the gestational period was in the range of weeks. 71% of women with DM were able to carry their fetuses to full term while 28% were preterm at gestational age less than 36 weeks. Perinatal mortality amongst offspring of diabetic mothers has remained high and was previously an indication for termination of pregnancy. The cause of increased perinatal morbidity and mortality is not known but has been attributed to increased insulin levels leading to hyper anabolism. Studies have shown higher mortality amongst infants of diabetic mothers compared to controls. Mortality was recorded in 7 (2.2%) of the babies. The babies who died were five intrauterine fetal death and two still birth (abruption placenta). (8) An excess risk of fetal macrosomia, defined as a birth weight of more than 4 kg, has been observed among diabetic women. Mathew et al found that macrosomia doubled the rate of delivery (16). Macrosomia is a major adverse outcome when evaluating patient with diabetes gestational or non gestational because it is often lead to labour dystocia & increase the risk of cesarean section in this study the rate of macrosomia 29.9 % more than half (61 %)of the newborns birth weight was kg The rate of macrosomia was 29.9% among infants born to diabetic women, Other studies also reported higher rates of macrosomia and/or cases of "large for gestational age" among infants born to women with PGDM and GDM. (16,17&,18 ) In our study, 90% of women had a cesarean section this figure is higher than the figure reported from Saudi Arabia where the rate 48% and fivefold increase when compared to non diabetics (19) The incidence of major congenital malformations has been reported to be 2-5 times greater in IDMs than in other infants with cardiac malformations recorded as the most common (20). In the present study, there were no obvious congenital malformations except 4 infants two with neural tube defect two infant with mylomenigiocele. in the present study the rate of congenital anomalies was 1% a figure that correlate well with other studies reporting 3.3%-4% (21) The unavailability of routine echocardiography in this study may have missed out cases of asymptomatic congenital cardiac malformations. 8

9 In conclusion, it is evident from the abovementioned study findings that the presence of maternal diabetes mellitus during pregnancy has important consequences for both mother and child. Most of the subjects were above 27years and multigravida. Caesarean section was a common mode of delivery In maternal diabetes, macrosomia was most prominent complications among neonates. It is recommended that, further studies to be applied to evaluate the system of care provided to pregnant women and to identify gaps that should be bridged to achieve favorable outcomes of diabetes in women and infants. Establishing maternal-infant centers with standard protocols for prevention, screening and management of diabetes in pregnancy on a national scale will go a long way in reducing the complications of this condition. 9

10 References 1. American Diabetes Association. Standards of medical care in diabetes Diabetes Care 2013; 36 (S1): Ferrara A: Increasing prevalence of gestational diabetes. Diabetes Care 2007; 30:S Farooq MU, Ayaz A, Ali Bahoo L, Ahmad I. Maternal and neonatal outcomes in gestational diabetes mellitus. Int J Endocrinol Metab. 2007;3: Narayon KM, Boyle JP, Thompson TJ, et al: Lifetime risk for diabetes mellitus in the United States. JAMA. 2003; 290: Gale EAM: Is there really an epidemic of type 2 diabetes? Lancet. 2003; 362: Getahun D, Nath C, Ananth CV, et al: Gestational diabetes in the United States: Temporal trends 1989 through Am J Obstet Gynecol. 2008; 198: HAPO Study Cooperative Research Group: Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008; 358: Sheffield JS, Butler-Koster EL, Casey BM, et al: Maternal diabetes mellitus and infant malformations. Obstet Gynecol. 2002; 100: Eriksson UJ: Congenital anomalies in diabetic pregnancy. Semin Fetal Neonatal Med 14(2):85, 10. Metzger BE, Buchanan TA, Coustan DR, et al: Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes. Diabetes Care ; 30(2):S Langer O, Yogev Y, Xenakis EMJ, et al: Insulin and glyburide therapy: Dosage, severity level of gestational diabetes, and pregnancy outcome. Am J Obstet Gynecol. 2005; 192 a: Langer O, Yogev Y, Xenakis EMJ, et al: Overweight and obese in gestational diabetes: The impact on pregnancy outcome. Am J Obstet Gynecol. 2005; 192b:

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