Pregnancy Outcome of Diabetic Mothers Attending a Tertiary Hospital in Rajshahi

Abstract

Background and objectives: Diabetes is often detected in women during their childbearing years and can affect the health of both the mother and her baby. Poor control of diabetes in a pregnant woman increases the chances for birth defects and other problems for the baby. It might also cause serious complications for the woman. Proper health care, before and during pregnancy, will help prevent birth defects and other poor outcomes, such as miscarriage and stillbirth. Though prevalence of diabetes is alarmingly high among Bangladeshi’s there have been very few studies assessing the effect of diabetes on pregnancy outcomes, particularly comparing pre-gestational diabetes mellitus (PDM) and gestational diabetes (GDM). Studies on pregnancy outcomes of Bangladeshi mothers with diabetes mellitus are very limited. To fill this information gap, the present study was undertaken, with the view to determine the prevalence of ante partum and intra partum maternal and perinatal complications of diabetic pregnancy, particularly comparing pregnancy outcomes in pre-gestational diabetes mellitus (PDM) and gestational diabetes (GDM) among pregnant diabetics in a tertiary level Hospital in Rajshahi, Bangladesh. Methods: Pregnant diabetic (both PDM and GDM) women who attended, got admitted, treated and delivered at Rajshahi Medical College Hospital (RMCH), Rajshahi, Bangladesh a tertiary level Government owned public hospital in Rajshahi, a divisional city in the Northern part of Bangladesh from August, 2008 to September, 2011 were selected for this observational retrospective study. Of the total 187 diabetic pregnant women in the study, 113 (60.43%) women were diagnosed as having gestational diabetes (GDM) and the rest 74 (39.57%) women had pre-gestational diabetes (PDM). Research instruments of the study were a structured questionnaire and sources for data were answers from the participants in interview, antenatal checkup cards, diabetic book of the women and hospital files for delivery and birth records. Selection of cases of this study was performed on random (continuous) sampling basis and was based upon some preset inclusion and exclusion criteria. Screening of patients as GDM and PDM was performed on the method adopted by Rajshahi Medical College Hospital following the guideline for diagnosis and screening of DM proposed by the clinical research division BIRDEM, Dhaka, Bangladesh to set a cut off value for screening DM women. GDM and PDM were the only dependent variables of the study. All others were independent Socio demographic variables like, maternal age, level of education of the women, monthly expenditure of the family. Family history of diabetes, first and second degree relatives. Details of pregnancy outcome variables included maternal complications like Pre-eclamsia (PE), Eclamsia, PROM, Caesarean section rate, delivery per vagina, polyhydramnios, the incidence of vulva and vaginal candidiasis and UTI weight were documented. Fetal and Neonetal outcome of diabetes variables were live birth, fetal abortions, congenital malformations, intrauterine death (IUD, and incidence of large babies (macrosomia). Results: Majority (54.54 %) of the diabetic pregnant women were within the 30- 39 years age group. Nearly fifty-eight percent (58.22%) women progressed to term pregnancy where as in 41.78 % diabetic pregnant women it ended before 37 weeks of gestation. Average gestational age was 36.75 ± 0.9 (28-41) weeks. The mean maternal age was 28.9 (18-45) years. Among maternal complications of diabetic pregnancy, pre-eclampsia (PE) developed among 12.9% women; while Eclampsia developed among 2.2% women. Incidence of Pre-eclamsia (PE) was comparatively higher in pre-gestational diabetic (PDM) mothers than in GDM mothers (15 vs 9) and the difference found to be statistically significant (p> 0.014). Similarly, the incidence of Eclampsia was also higher among women having PDM than GDM (3 vs 1) but this differences found to be statistically insignificant (p=0.172). Preterm rupture of membrane (PROM) was higher (15.0%) in pregnant women with GDM as compared to 8.1% women of PDM. but their differences were statistically insignificant (p= 0.158). Ante-partum fetal distress developed in (23.9%) women having GDM and 21.6% women with PDM; but the differences between them was statistically insignificant (p= 0.718). Incidence of polyhydramnios was higher (59.5%) in pregnant women with PDM as compared to 29.2% having GDM and the differences between them found statistically very highly significant (p < 0.001). The rate of delivery by cesarean section (CS) was very high (72.1%) and only 10.7% babies were by vaginal delivery. Nearly seventy eight (77.8%) women of GDM and 47(63.5%) women of PDM delivered babies by cesarean section and the difference is not statistically significant (p>0.634). The results of statistical analyses also revealed that rate of vaginal delivery was significantly higher in GDM mothers than the PDM mothers (p=0.048). The incidence of abortion was higher (18.91%) in the PGDM women as compared to (5.03%) in GDM women and statistical analysis revealed that abortion rate was significantly higher in pregnant women having PDM (p= 0.003). The incidence of vulva and vaginal candidiasis was found to be almost very similar in pregnant women having GDM and PDM. It was 41.6% and 40.5%, respectively and the difference was statistically insignificant (p>0.886). Similarly, the incidence of urinary tract infection (UTI) was found to be almost same in pregnant women having GDM and PDM; 41.6% and 40.5%, respectively and the difference was also found to be statistically insignificant (p>0.771). Regarding Fetal and Neonetal outcome of diabetes; there were 155 (82.88%) normal live birth, 05 (2.67%) live birth with congenital malformations and 12 (6.4 %) intrauterine death (IUD). Among 12 intrauterine deaths, 11 had developed preeclampsia and in one woman the cause was unknown. Regarding congenital malformation, the prevalence was almost the same in pregnant women with PDM and GDM and were 3(4.1%) and 2(1.7%), respectively. The above differences were found to be statistically insignificant (p >0.308). In the present study, the prevalence of ‘large babies’ i.e. Macrosomic babies was much higher (70.3%) in pregnant women having PDM as compared to that of GDM (26.5%) groups. PDM group therefore gave birth to large baby more frequently than the GDM group did. The above difference was found to be statistically highly significant (p <0.001). Regarding socio-economic statuses of the participants, highest numbers of patients (60%) were from the lower middle class group while the lowest number of patients (08%) belonged to the poor class. Educational level of majority (about 44%) of the diabetic patients was less than S.S.C and the least number of patients (only 4.81%) were graduates. Results of study of relation between diabetes incidences in relation to familial history of diabetes showed that 72.92% of PDM patients had first degree relatives, 18.97% second degree relatives and 8.11% had no family history. And of those who had GDM, 76.99% had first degree relatives, 8.85% second degree relatives, and 14.15% had no family history. Results on the frequency of diabetes mellitus (depending upon their type) and their possible relation to location of resident areas demonstrated that 51.35% of those who had PDM had lived in the city, and 36.49% lived in villages, and 12.16% had lived in slums. As gestational diabetes is concerned, 57.52% had lived in the city, 37.18% had lived in villages, and 5.3% had lived in slums. Conclusion: Women with diabetes in our study population have worse pregnancy outcomes as compared to other South Asian countries of the world and even worse than other parts of Bangladesh. And those with pre-gestational diabetes had far worse pregnancy outcome than those with gestational diabetes. The study emphasizes the fact that strict glycemic control is extremely important during diabetic pregnancy for achieving better pregnancy outcome.