Gestational diabetes in Iran: incidence, risk factors and pregnancy outcomes

The objective of this study was to determine the incidence of gestational diabetes mellitus (GDM) and compare fetal, maternal and neonatal complications amongst women with GDM and pregnant women with normal glucose tolerance in an urban Iranian population. In a prospective cohort study, universal screening for gestational diabetes mellitus was performed for 1310 pregnant women who were referred from private clinics and community health care centers to Fatemiyeh Hospital in Shahrood City. Screening was performed with a 50 g oral Glucose Challenge Test (GCT) with 130 mg/dl cut-off point, then a diagnostic 100 g Oral Glucose Tolerance Test (OGTT) was done according to Carpenter and Coustan criteria. The incidence of GDM was 4.8%. There were differences in risk factors: age >30 years, family history of diabetes, obesity, previous macrosomia, glycosuria between the two groups (P<0.001). Women with GDM had a higher rate of stillbirth (P<0.001; odds ratio 17.1, 95% CI=4.5-65.5), hydramnios (P<0.001; odds ratio 15.5, 95% CI=4.8-50.5), gestational hypertension (P<0.001; odds ratio 6, 95% CI=2.3-15.3), macrosomia (P<0.05; odds ratio 3.2, 95% CI=1.2-8.6) and caesarean section (P<0.001). We have found that the incidence of GDM in an urban Iranian population is similar to developed countries. Complications were more common in the GDM group than in the normal group and outcomes for women with persistent diabetes post-partum were particularly poor. We recommend screening for GDM in Iran, but further evaluation of selective screening and cost effectiveness will need to be performed. Measures to improve the outcome of GDM pregnancy will also need to be addressed in the future.     

Impact of gestational diabetes on the risk of diabetes following pregnancy among Chinese and South Asian women

Aims/hypothesis

Ethnicity and gestational diabetes mellitus (GDM) are both risk factors for the development of type 2 diabetes. However, it is uncertain whether ethnicity modifies the effect of GDM on diabetes risk. We aimed to determine the risk of diabetes following pregnancy with and without GDM for Chinese and South Asian women compared with white women.

Methods

Using healthcare databases, all 1,050,108 women aged 20–49 with live births between January 1995 and June 2008 in Ontario were identified. They were followed for up to 15?years for the diagnosis of diabetes.

Results

The age-standardised prevalences of GDM were 4.1%, 7.1% and 2.9% for Chinese, South Asian and white women, respectively. The cumulative incidence of diagnosed diabetes at the median follow-up time of 7.6?years was 16.5% and 1.8% for Chinese women with and without GDM, 31.8% and 3.6% for South Asian women with and without GDM, and 25.7% and 1.8% for white women with and without GDM. The presence of GDM conferred an increase in the risk for diabetes after pregnancy of more than 13-fold in white women, but only a nine- to tenfold increase among Chinese and South Asian women.

Conclusions/interpretation

Although one-third of South Asian women with GDM were diagnosed with diabetes within 8?years postpartum, the incremental impact of GDM on diabetes risk was not as strong among Chinese and South Asian women as it was among white women.     

Changing environment of hyperglycemia in pregnancy: Gestational diabetes and diabetes mellitus in pregnancy

The diagnosis and treatment of gestational diabetes mellitus (GDM) have been in a state of flux since the World Health Organization accepted and endorsed the International Diabetes and Pregnancy Study Group's diagnostic pathway and criteria in 2013. These new diagnostic criteria identify an increasing number of women at risk of hyperglycemia in pregnancy (HGiP). Maternal hyperglycemia represents a significant risk to the mother and fetus, in both the short and long term. Controversially, metformin use for the treatment of GDM is increasing in Australia. This article identifies the multiple and varied presentations of HGiP, of which GDM is the most commonly encountered. The degree of maternal hyperglycemia experienced affects the outcomes for both the mother and neonate, and specific diagnosis determines the appropriate treatment for the pregnancy. Given the increasing incidence of women with dysglycemia and those developing HGiP, this is an important area for research and clinical attention for all health professionals.     

Seven years experience of home management in pregnancy in women with insulin-dependent diabetes

Fifty-eight of a consecutive series of 75 pregnancies in women with insulin-dependent diabetes went into the third trimester. Diabetes was managed by home blood glucose monitoring and women were not routinely admitted at any stage before delivery. The mean number of in-patient days before delivery was 15 for the whole series but has been reduced to 9 during the past four years. Each woman performed an average of 171 blood glucose measurements during her pregnancy. Mean blood glucose (including post-prandial levels) fell significantly from 7.9 mmol/l in the first trimester to 7.3 in the second and 6.4 in the third. Mean percentage of haemoglobin A1 was within the normal range in the second and third trimesters. The cesarean section rate was high at 66% but there were no perinatal deaths. Three infants had congenital abnormalities. We conclude that home blood glucose monitoring is a safe and effective way of managing pregnant diabetic women as out-patients. The cost of meters and sticks is repaid many times over in the saving of hospital costs. In addition, home blood glucose monitoring is popular with the patients and many choose to continue it after delivery.     

Gestational diabetes mellitus manifests in all trimesters of pregnancy

Screening for GDM is usually performed around 24-28 weeks of gestational age. We undertook a study to estimate the prevalence of glucose intolerance during different trimesters, as data in this aspect is sparse. A total of 4151 consecutive pregnant women irrespective of gestational weeks attending antenatal health posts across Chennai city underwent a 75 g OGTT recommended by WHO and diagnosed GDM if 2 hr PG value > or =140 mg/dl. Women who had normal OGTT at the first visit were screened with a repeat OGTT at the subsequent visits. Among the screened, 741 women (17.9%) had 2 hr PG> or =140 mg/dl and were identified to have gestational diabetes. Analysis based on gestational weeks revealed that out of the 741 GDM women, 121 (16.3%) were within 16 weeks, 166 (22.4%) were between 17 and 23 weeks and 454 (61.3%) were more than 24 weeks of gestation. Observation in this study was that 38.7% developed gestational diabetes even prior to 24th week of gestation. Out of the total 741 GDM women, 214 (28.9%) were diagnosed on repeat testing at subsequent visits. Glucose intolerance occurs in the early weeks of gestation. Women who had normal glucose tolerance in the first visit require repeat OGTT in the subsequent visits.     

Metabolic syndrome at follow-up in women with and without gestational diabetes mellitus in index pregnancy

We prospectively studied 262 women with prior gestational diabetes mellitus (GDM) and 66 control women to compare their prevalence of metabolic syndrome and its relationship with insulin secretion and sensitivity. A 75-g oral glucose tolerance test was scheduled 5 years after delivery along with lipid profile, anthropometrics, and blood pressure measurement. Metabolic syndrome was defined according to the National Cholesterol Education Program 2001, and insulin sensitivity and secretion were estimated with the homeostasis model assessment. Women with prior GDM had similar insulin sensitivity and lower insulin secretion than control women. In comparison with control women, women with prior GDM had higher blood pressure, waist circumference, very low-density lipoprotein cholesterol, and oral glucose tolerance test blood glucose values but, with the exception of fasting hyperglycemia, did not have an increased prevalence of metabolic syndrome or its components. The multivariate prediction of metabolic syndrome and its components was similar with age and current homeostasis model assessment-insulin secretion and resistance indexes or with age, obesity, and GDM. The main predictor was current insulin resistance in the first case and obesity in the second, obesity being the best predictor overall. We conclude that in our population and at midterm follow-up, women with prior GDM have a decreased insulin secretion and display a higher prevalence of fasting hyperglycemia but not the full-blown picture of metabolic syndrome. Obesity, a surrogate index of insulin resistance, is the best predictor of metabolic syndrome at follow-up.     

Gestational diabetes mellitus in teenage pregnancy: a case-control study

In a retrospective study, teenage Asian pregnancies with gestational diabetes managed over a 4-year period were compared with a group of age and parity matched controls (2 for each study case) to determine the incidence of gestational diabetes and its impact on the pregnancy outcome. The incidence of gestational diabetes in teenage pregnancy was 5.4 % (33/611), and accounted for 1.4 % of all the cases of gestational diabetes. There was no difference in the maternal anthropometric parameters or antenatal complications, but the study group had a higher incidence of postpartum haemorrhage (p = 0.010), greater amount of estimated blood loss at delivery (p = 0.016), a trend towards a higher incidence of large-for-gestational age infants, a higher incidence of admission to the neonatal unit (p = 0.024), mostly due to meconium-stained liquor for observation (p = 0.014), and a lower first minute Apgar score (p = 0.012). Our findings support the recommendation that in ethnic groups with a high prevalence of diabetes, universal as opposed to age-limited screening for gestational diabetes should be undertaken. Copyright © 1998 John Wiley & Sons, Ltd.     

Gestational diabetes mellitus in a cohort of HIV-1 infected women

Objectives

We undertook a prospective study to estimate the prevalence of gestational diabetes mellitus (GDM) and associated risk factors in a cohort of 669 HIV‐1 infected women.

Methods

The O'Sullivan and glucose tolerance tests were performed during regular visits of 609 mothers.

Results

The median age of the cohort was 30.7 years (range 16–44), with most women having had heterosexual contact (67%). The majority were in Centers for Disease Control (CDC) category A (71%) and 53% exhibited hepatitis C co‐infection. Median viral load and CD4 count at third trimester were 545 cells/μL (range 139–1690 cells/μL) and 1.9 log (range 1.7–5.4), respectively. Seventy‐four per cent of the patients were treated with highly active antiretroviral therapy (HAART), of whom 41% received a protease inhibitor (PI). An above‐average prevalence of 7% [95% confidence interval (CI) 5.2–9.5] for positive GDM diagnosis was found. Risk factors associated with GDM in univariate analysis included older age, hepatitis C co‐infection, stavudine and PI exposure. However, only older age [adjusted odds ratio (AOR) 1.09, 95% CI 1–1.1] and PI exposure (AOR 2.4, 95% CI 1–5.3) remained as independent risk factors for GDM development in multivariate analysis.

Conclusions

In our cohort, the prevalence of GDM appears to be increased, with older age and PI exposure contributing as significant independent risk factors.

     

Adverse pregnancy outcomes in women with diabetes

ABSTRACT: Pregnancy affects both the maternal and fetal metabolism and even in nondiabetic women exerts a diabetogenic effect. Among pregnant women, 2 to 17.8% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, that can predispose the fetus to many alterations in organogenesis, growth restriction and the mother to some diabetes-related complications like retinopathy and nephropathy or accelerate the course of these complications if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle modification; when these changes fail in keeping an optimal glycemic control, then insulin therapy must be considered. Women with type 2 diabetes in use of oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes must start an intensive glycemic control, preferably before conception. All these procedures are performed aiming to keep glycemic levels normal or near-normal as possible to avoid the occurrence of adverse perinatal outcomes to the mother and to the fetus. The aim of this review is to reinforce the need to improve the knowledge on reproductive health of women with diabetes during gestation and to understand what are the reasons for them failing to attend for prepregnancy care programs, and to understand the underlying mechanisms of adverse fetal and maternal outcomes, which in turn may lead to strategies for its prevention.     

Incidence of diabetes mellitus in women following impaired glucose tolerance in pregnancy is lower than following impaired glucose tolerance in the non-pregnant state

Summary Impaired glucose tolerance (IGT), which is asymptomatic and requires a glucose tolerance test for detection, is a well-known risk factor for diabetes mellitus. Outside the research setting it is rarely identified in people who lack specific risk factors for diabetes except during pregnancy, at which time screening with an oral glucose challenge is a routine procedure. A 75-g oral glucose tolerance test was performed during the latter part of pregnancy or during a routine epidemiology survey in 15–39-year-old Pima Indian women with no history of abnormal glucose tolerance. Those with IGT by World Health Organization criteria were included in this study. Diabetes incidence in women was compared between those whose IGT was first detected during pregnancy and those who were not pregnant when IGT was first recognized. Seventeen of 73 pregnant women and 114 of 244 non-pregnant women developed diabetes within 10 years. When controlled for plasma glucose concentration, age, body mass index, parity and duration of follow-up, those who were not pregnant were at higher risk of developing diabetes than those who were pregnant (hazard rate ratio = 1.71, 95 % confidence interval = 1.01–2.91). Previous studies had reported that women with IGT during pregnancy are at higher risk of diabetes than women with normal glucose tolerance. This study suggests that women with IGT during pregnancy are at lower risk than non-pregnant women with a similar plasma glucose concentration who, in the clinical setting, are likely to remain unrecognized. [Diabetologia (1996) 39: 1334–1337] Received: 15 February 1996 and in revised form: 8 May 1996     

Prevalence of gestational diabetes mellitus in Kashmiri women from the Indian subcontinent

This prospective study was carried out to determine the prevalence of gestational diabetes mellitus (GDM) in Kashmiri women and to assess the effect of various demographic factors. Two thousand pregnant women (divided into groups A and B, being the first and last 1000 consecutive women) attending various antenatal clinics in six districts of Kashmir valley were screened for GDM by 1 h 50 g oral glucose challenge test. Four hundred and fourteen (20.8%) women (216 from group A and 198 from group B) had an abnormal screening test and proceeded to oral glucose tolerance testing. Women from group A had a 3 h 100 gram oral glucose tolerance test (OGTT) and GDM was as classified by Carpenter and Coustan. A 2 h 75 g OGTT was performed on group B subjects and WHO criteria applied for diagnosis of GDM. The overall prevalence of GDM was 3.8% (3.1% in group A versus 4.4% in group B-P-value 0.071). GDM prevalence steadily increased with age (from 1.7% in women below 25 years to 18% in women 35 years or older). GDM occurred more frequently in women who were residing in urban areas, had borne three or more children, had history of abortion(s) or GDM during previous pregnancies, had given birth to a macrosomic baby, or had a family history of diabetes mellitus. Women with obesity, hypertension, osmotic symptoms, proteinuria or hydramnios had a higher prevalence of GDM.     

Short communication decreased incidence of dual infections in South african subtype C-infected women compared to a cohort ten years earlier

Previously, we determined the incidence of dual infections in a South African cohort and its association with higher viral setpoint. Ten years later, we compare the incidence and impact of dual infections at transmission on viral setpoint in a geographically similar cohort (n = 46) making use of both the heteroduplex mobility assay (HMA) and the more recent single genome amplification (SGA) approach. HIV incidence was lower in this cohort (7% compared to 18%), and we find a similar reduction in the number of dual infections (9% compared to 19%). Unlike the previous study, there was no association between either dual infection (n = 4) or multivariant transmission (n = 7) and disease progression. This study emphasized the importance of monitoring changes in the HIV epidemic as it may have important ramifications on our understanding of the natural history of disease.