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ORIGINAL ARTICLE
Year : 2022 | Volume
: 49
| Issue : 3 | Page : 265-271
Prevalence, clinical profile, and maternal and perinatal outcomes of hyperglycemia in pregnancy in a tertiary care hospital in South India
Romana Khursheed1, Jayanth Shivalingappa1, Arif Maldar2, Anita Dalal1
1 Department of Obstetric and Gynecology, Jawahar Lal Nehru Medical College, Belagavi, Karnataka, India
2 Department of Medicine, Jawahar Lal Nehru Medical College, Belagavi, Karnataka, India
Correspondence Address:
Dr. Arif Maldar
Department of Medicine, Jawahar Lal Nehru Medical College, Belagavi, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jss.jss_65_22
Background: Hyperglycemia in pregnancy (HIP) is an umbrella term for any degree of carbohydrate intolerance in pregnancy which carries risk of transgenerational transfer of metabolic disorders. The present observational study was carried out to know the prevalence, clinical profile, and maternal and perinatal outcome in different categories of HIP, in a South Indian setup. Materials and Methods: The study was carried out for 1 year at KAHER's Dr Prabhakar Kore Charitable Hospital, Belagavi in South India. The HIP was diagnosed by Diabetes in Pregnancy Study Group of India criteria and further categorized into gestational diabetes mellitus (GDM), gestational glucose intolerance (GGI), and diabetes in pregnancy (DIP). The prevalence, clinical profile, and maternal and perinatal outcome were analyzed in three groups. Results: The prevalence of HIP among pregnant population was found to be 17.47% in 1 year. 222 women (75.5%) had GDM, followed by 49 (17%) and 23 women (8%) presented with GGI and DIP, respectively. The maternal outcomes among HIP were cesarean delivery 230 (78.2), preterm labor 53 (18.02%), preeclampsia 50 (17.01%), premature rupture of membranes 34 (11.56%), and infections 33 (11.22%). The perinatal outcome recorded were neonatal intensive care unit admissions in 107 neonates (36.39%), hyperbilirubinemia in 44 neonates (15%), hypoglycemia in 79 neonates (26.8%), respiratory distress syndrome in 43 neonates (14.46%), and macrosomia in 44 fetuses (15%). Conclusion: Degree of hyperglycemia affects pregnancy outcomes. Continued surveillance of women in preconceptional, antenatal, and postnatal period ensures early diagnosis and management of glucose intolerance and helps in delaying the onset of overt diabetes.
Keywords: Diabetes in pregnancy, gestational diabetes mellitus, gestational glucose intolerance, hyperglycemia in pregnancy, mild gestational hyperglycemia
Hyperglycemia in pregnancy (HIP) is one of the most common endocrinopathy in pregnancy. The International Diabetes Federation (IDF) estimates that globally 1 in 6 live births (16.8%) happen to women with some form of HIP, whereas 1 in 4 live births are affected in South Asia, accounting for over 40% of global burden of HIP.[1] In the world, over the next two to three decades, there would be 80 million women of reproductive age group with diabetes. It is estimated that India alone will have 27 million of them.[2] Given the Asian Indian ethnicity and obesity epidemic, Indian women have 11 times increased relative risk of suffering from HIP compared to the Caucasians.[3] HIP not only causes adverse pregnancy outcomes but also blamed to be the precursor of “fetal origin of adult disease,” which subsequently increases risk of diabetes, heart disease, hypertension in adult life, escalating high burden on finances, and health of individuals and nations.[4] According to the World Health Organization (WHO) recommendations in 2013, hyperglycemia first detected at any time during pregnancy should be classified either as diabetes mellitus in pregnancy (DIP) or gestational diabetes mellitus (GDM). Pregnant women with hyperglycemia meeting the criteria of diagnosis of diabetes in the nonpregnant state as per the WHO definition are classified as having diabetes in pregnancy (DIP), previously known to be pregestational DIP. The term GDM is restricted to hyperglycemia detected during routine testing in pregnancy (generally between 24 and 28 weeks), which does not meet the criteria of pregestational diabetes.[5],[6] However, increasing maternal carbohydrate intolerance in pregnant women without GDM is also having a graded positive correlation with adverse maternal and fetal outcome.[7] This group forms milder forms of hyperglycemia and is classified as gestational glucose intolerance (GGI)' by Diabetes in Pregnancy Study Group of India (DIPSI) and mild gestational hyperglycemia by few researchers.[8],[9],[10] Prior research has projected treatment of this category of hyperglycemia to improve maternal and perinatal outcomes.[9] Although all categories of HIP are reported to carry adverse maternal and perinatal outcomes such as preeclampsia, infections, macrosomia, and preterm delivery, there is a dearth of scientific literature studying their individual contribution to HIP and comparing the outcome among the different categories of HIP. Hence, we wished to determine the prevalence of hyperglycemia in its different categories, their clinical profile, and maternal and perinatal outcomes, in a cohort of South Indian women attending a single specialized tertiary care facility.
Materials and MethodsStudy setting and design
This prospective observational study was conducted for a duration of 1 year (January 1, 2020, to December 31, 2020) at KAHER's Dr. Prabhakar Kore Charitable Hospital, attached to Jawahar Lal Nehru Medical College, Belagavi in South India.
Study participants
The antenatal women attending the outpatient antenatal clinic and who get diagnosed for hyperglycemia in pregnancy [by 75gm OGCT ,recommended by, IFOG(International Federation Of Obstetrics and Gynecology) and MHFW-GOI(Ministry Of Health And Family Welfare-Government of India),[11] Plasma glucose values were tested 2 h following ingestion of 75 g of glucose, irrespective of fasting status of pregnant woman. The test was interpreted as per the DIPSI recommendations into 2-h plasma glucose value ≥200 mg/dl as DIP, between ≥140 and ≤199 mg/dl as GDM, and between ≥120 and ≤139 mg/dl as GGI. Plasma glucose value was considered to be normal if it was 120 mg/dl or less than it.[9]
The test was subsequently repeated at 24–28-week gestation in women who had normal DIPSI test value at first visit. Written informed consent was taken from all the study participants at the time of enrollment.
Data collection
The demographic and baseline data of the study participants were recorded. The antenatal history, present and past medical history, previous obstetric history, and presence or absence of other disorders such as hypertension, thyroid disorder, and pregestational diabetes were noted. Detailed general examination and obstetric examination were carried out. In addition to all the basic obstetric investigations, glycosylated hemoglobin (HBA1C) test was carried out. Obstetric ultrasound was performed as per the routine recommendations (dating, target ultrasound, and growth scan) and also if indicated at any time during antenatal and intranatal period. The management of hyperglycemia was carried out by a multidisciplinary team of endocrinologist, obstetrician, and neonatologist. Dietary modification through education and motivation was given priority in every clinic visit with one-to-one counselling. When diet failed to achieve the euglycemia, insulin therapy was initiated. The outcome of pregnancy and presence or absence of antenatal, intranatal, and postnatal complications and early neonatal outcomes were recorded. All women were assessed by the specialist obstetrician at 36 weeks of gestation to plan for timing and mode of delivery. Women with good glycemic control and requiring medical nutrition therapy (MNT) alone were planned to await spontaneous onset of labor up to 40 weeks of gestation. For the others, induction of labor/cesarean delivery was planned at 38–39 weeks of gestation depending on glycemic control and individual obstetric factor.
Statistical analysis
The data were analyzed using statistical software R version 4.1.1 (R core team, Vienna, Austria) and Microsoft Excel. Categorical variables were given in the form of frequency tables. Continuous variables were given in mean ± standard deviation/median (min, max). Chi-square test was used to check the association between categorical variables. P ≤ 0.05 was considered statistically significant. One-way ANOVA was used to compare the mean of variables between the groups. Tukey's HSD significant difference was used as post hoc analysis. Kruskal–Wallis test was used to compare the distribution of variables between the groups. Dunn test was used as post hoc analysis.
ResultsIn the 1-year study period, there were 294 (17.47%) women with HIP among 1682 antenatal women attending the health facility, and there were 222 women (75%) had GDM, followed by 49 women (17%) and 23 women (8%) having GGI and DIP, respectively.
[Table 1] demonstrates the sociodemographic characteristics and clinical profile of the study participants. The mean age of women presenting with GDM, GGI, and DIP was 28.08, 26.04, and 28.09 years, respectively, with a mean overall age in HIP being 27.74 years. From one-way ANOVA, we observe that the mean age differs significantly over groups. The proportion of registered women was higher among all the categories of HIP; a total of 178 (60.54%) women were registered. The proportion of multigravida women was 175 (59.52%). The mean gestational age at diagnosis of hyperglycemia was 22.82 ± 4.88 weeks in GDM and 25.12 ± 2.8 weeks in GGI group, whereas it was 15 ± 5.78 weeks in DIP group [Figure 1]. From Kruskal–Wallis test and post hoc analysis (Dunn test), we observed that there was a significant difference in the distribution of gestation age at diagnosis and HBA1C over groups (P < 0.05). The mean HBA1C value was 5.51 ± 0.53 among HIP and 6.73 ± 0.29 in DIP group [Figure 2]. [Table 2] depicts that all women with different degrees of HIP were managed by MNT as a primary mode of management. All women with GGI, achieved euglycemia with MNT alone. Furthermore, all women with DIP required insulin therapy in addition to MNT. 21.62% of women in GDM group required insulin therapy. [Table 3] describes the maternal complications in HIP. It was recorded as follows: preterm labor in 53 (18%), pregnancy induced hypertension in 50 (17.01%), premature rupture of membranes in 34 (11.56%), antenatal infections in 33 (11.22%), polyhydramnios in 28 (9.5%), and antepartum hemorrhage in 6 (2.04%). The distribution of polyhydramnios was statistically significant among groups (P = 0.0014). The perinatal complications in HIP are shown in [Table 4]. There were 107 (36.39%) neonatal intensive care unit (NICU) admissions, 7 (2.38%) fetuses with congenital malformations, 44 (15%) neonates with hyperbilirubinemia, 79 (26.8%) neonates with hypoglycemia, 43 (14.46%) neonates with respiratory distress, 44 (14.9%) macrosomia, and 19 (6.4%) fetuses with growth restriction. From Chi-square test, we observed that there was a significant difference in the distribution of congenital malformations, NICU admission, hyperbilirubinemia, and macrosomia among groups with P value being 0.012, 0.0072, 0.001, and < 0.0001, respectively. [Table 5] highlights the birth characteristics of neonates born to women with HIP. The overall prevalence of cesarean births among HIP was 78.2%. The proportion of babies delivered between 37 and 41 weeks was 238 (81%), whereas 53 (18.03%) women delivered at or below 36 weeks. The mean birth weight among HIP was found to be 2.75 ± 0.57 kg.
Figure 1: Mean gestational age of women at time of diagnosis of Hyperglycemia in different categories
Figure 2: Mean HBA1C (%) among different groups at time of diagnosis of Hyperglycemia. HBA1C = Glycosylated hemoglobin
Table 1: Sociodemographic and clinical characteristics of women in hyperglycemia in pregnancy
Table 3: Maternal complications in women with hyperglycemia in pregnancy
Table 4: Perinatal complications in women with hyperglycemia in pregnancy
Table 5: Birth characteristics of neonates born to women in hyperglycemia in pregnancy Discussion The prevalence of hyperglycemia in this cohort of South Asian Indian ethnicity pregnant population was found to be 294 (17.47%) among a total of 1682 antenatal women in the 1-year study period. GDM accounted for a lion's share of 222 (75.5%) followed by GGI 49 (17%) and DIP 23 (8%) among total HIP.
According to IDF estimates, the prevalence of HIP is 16.2% globally, GDM accounted for 85.1%, while other types of diabetes first detected during pregnancy being 7.4% and pregestational diabetes being 7.5%.[12] A South Indian study shows the prevalence of HIP as 18.9% whereby 16.3% had GDM and 2.6% had DIP.[13] The scientific data about prevalence of GGI, its contribution to HIP, and its outcomes are scarce. We can attribute our comparative higher prevalence of HIP to South Asian ethnicity, which is considered to be a nonmodifiable risk factor for GDM and to universal screening of pregnant women for HIP.[14],[15]
Universal screening of HIP enhances detection of a substantiate number of pregnancies affected by glucose intolerance. A recent study reports that selective screening may miss up to 30% of women with glucose intolerance.[15] The Colombo South Asian Declaration on HIP in 2016 advocated universal testing for hyperglycemia in South Asian population.[16] A total of 186 (63.27%) women among study participants were residing in urban areas. Urbanization is considered as a risk factor for hyperglycemia.[17],[18] The mean age of pregnant women diagnosed as HIP was 27.74 ± 4.76 years. A younger group of women with a mean age of 26.04 ± 4.25 years presented with GGI and an older group with a mean age of 28.08 ± 4.76 years and 28.09 ± 5.13 years had developed GDM and DIP. The difference in maternal age among GGI and DIP was found to be statistically significant (P = 0.02). As glucose intolerance is a continuous process, it gets intensified with increasing age, GGI presents at an early maternal age, and DIP presents at a later age in a woman's life. Maternal age exceeding 35 years had a significantly greater risk for having DIP rather than HIP in early pregnancy.[19]
The mean BMI of the women with HIP was 23.36 ± 2.36 in the study. Asian populations with normal BMI tend to have more visceral fat specially over the abdomen.[20] This is positively associated with insulin resistance and impaired β cell function, resulting into development of various form of glucose intolerance in pregnancy.[21],[22] DIP group among study participants depicted higher mean BMI of 25.53 ± 1.76, confirming that obesity is a risk factor for developing DIP.[23]
Although the mean gestational age of women detected with HIP was 22.59 ± 5.24 weeks, there was a statistically significant difference (P < 0.001) among the groups of DIP, GGI, and GDM, with DIP detected at a mean age of 15 ± 5.78 weeks and GDM at a mean age of 22.82 ± 4.88 weeks of gestation. As all the pregnant women underwent DIPSI test at first antenatal visit, women with DIP were diagnosed early in gestation unless they presented in later trimester. Previous research also recommended screening to be done as early as in first trimester, as the fetal pancreatic beta cells detect and start responding to glycemic level of the mother at 16th week of pregnancy.[24],[25]
A total of 175 women (59.52%) were multigravidas in the study. Jayawardane et al. reported continued metabolic risk among multiparous women affected by varying degrees of HIP.[19] The mean HBA1C in HIP was 5.51 ± 0.53. DIP group depicted a high mean HBA1C value of 6.73 ± 0.29. A study by Antoniou et al. reported that a HbA1c value ≥5.5% at the 1st GDM booking doubles the risk of cesarean section and LGA compared to women with a HbA1c <5.5%. They also suggested the risk adapted care of GDM women who were having HBA1C value >5.5% at first booking.[26] 51 women (17.13%) carried burden of dual endocrinopathy of diabetes and hypothyroid in our study. There is wide variation of women presenting with combined endocrinopathy in pregnancy, and the prevalence ranges from 2.5% to 30%.[27],[28] Further studies should explore the relationship of this dual endocrinopathy with adverse outcomes in HIP. Furthermore, thyroid screening should be universal in antenatal women for early detection and minimizing complications.
Based on the degree of carbohydrate intolerance, the required interventions varied in different groups in our study. All women with GGI (100%) achieved euglycemia with MNT alone, whereas all women with DIP (100%) required insulin therapy in addition to dietary modification. Insulin was required in 21.62% of GDM population. Jayawardane et al. reported that half of the GDM women could be managed with lifestyle modification, whereas 80% of DIP required insulin therapy.[19] Farrar suggested the “step-up” approach in hyperglycemia management ensures that interventions are only offered if required, which reduces the burden for the woman and care providers, considering the increasing prevalence of GDM.[29] Furthermore, we suggest further large-scale RCTs to analyze the roles of different management strategies in different categories of HIP.
The most prevalent maternal complications among HIP were preterm labor 53 (18.02%), pregnancy induced hypertension 50 (17.01%), premature rupture of membrane 34 (11.56%), antenatal infections 33 (11.22%), and polyhydramnio 28 (9.5%). All maternal complications showed an increasing trend of prevalence among different categories, being lowest in GGI, higher in GDM, and highest in DIP group except for infections; the more affected group was GDM (11.7%) and GGI (10.2%) when compared to DIP (8.7%). Furthermore, premature rupture of membrane was found more common in GGI (18.37%). Li et al. also found more risk of preeclampsia, preterm labor, and cesarean section in DIP than in GDM.[30] The most common infections found in HIP were urinary tract infections and vaginal candidiasis. We report a serious infectious morbidity in GGI, where the woman, with no earlier evidence of infection, had developed organ specific SSI following cesarean section and had to undergo hysterectomy. The higher prevalence of infections among GGI warrants further large-scale studies to check this association. Furthermore, this emphasizes more attention to achieve tight glycemic control in this milder form of carbohydrate intolerance. The distribution of polyhydramnios was statistically significant (P = 0.0014) among groups as the proportion of women with polyhydramnios was doubled in DIP when compared to GGI and GDM. Although proportion of pregnancy-induced hypertension in DIP was 26.09%, compared to 17.12% in GDM and 12.24% in GGI group, its distribution was not statistically significant among three groups, showing an equal risk of PIH in all categories of hyperglycemia.
A total of 230 women (78.2%) had cesarean section in the present study and 95.6% of DIP and 76.5% of GDM group women were delivered by CS. A North Indian study also reported the prevalence of cesarean section among GDM to be 75%.[31] Previous research has highlighted that the medical disorders of pregnancy increase the cesarean deliveries.[32]
The difference in distribution of adverse perinatal outcome such as congenital malformations, macrosomia, hyperbilirubunemia, and NICU admissions among different categories of HIP was statistically significant as DIP represented 2–3-fold increase in complications when compared to GDM and GGI, reflecting the severe degree of metabolic disturbance affecting pregnancy in HIP. Our study, in line with other studies, has linked maternal hyperglycemia to increased risks of total adverse maternal and neonatal outcomes.[19],[27]
Strengths of the study
Ours is the first study (to the best of our knowledge) to report the prevalence of mild gestational hyperglycemia or GGI in HIP and to analyze the maternal and perinatal outcomes among different categories of HIP in a cohort of South Asian ethnicity pregnant population.
ConclusionHIP is a significant public health problem impacting maternal and perinatal health. DIP is the severe form of carbohydrate intolerance, which is least prevalent among HIP but carries greatest, significant risk of complications. The mildest form of hyperglycemia or GGI too proves to be a risk factor for adverse outcomes. Our study provides evidence for designing interventions such as testing of blood glucose levels of women in preconceptional counseling and reproductive and child health programs, universal screening of pregnant women for HIP preferably in first antenatal visit, and emphasis on health education of pregnant women regarding lifestyle modifications to improve maternal and neonatal outcome in vulnerable population.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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