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Absence of Fasting Hyperglycemia in Gestational Diabetics as a Predictor of Good Perinatal
Outcome in High Risk Population – A Study from Northern India

Smita Nanda¹,Umber Agarwal¹,Harbans Lal²,Krishna Sangwan¹,Ritu Aggarwal¹

- Departments of Obstetrics & Gynaecology¹ and Biochemistry²
Pt. B.D. Sharma PGIMS, Rohtak – 124 001, Haryana
Source: Indian Medical Gazette, Vol. CXXXVI, No 3

The mean birth weight of the babies born to gestational diabetic mothers was 3.075 + 0.326 mg versus the babies born to mothers whose mean birth weight was 2.79 + 0.473kg. The difference between mean birth weight in the two groups come out to be statistically significant at 1% level of significance (Z=2.67, p < 0.01) but none of the babies had macrosomia (i.e. birth weight > 4.0 kg). The Apgar score of babies born to gestational diabetic mothers was 8/10 at one and five minutes. All these babies were observed for signs and symptoms of hypoglycemia and hyperbilirubinimia. The plasma glucose and serum bilirubin values remained within normal range of all babies. None required admission to neonatal intensive care unit (NICU) and all were discharged uneventfully.

Discussion

Evidence from observational studies suggests that untreated gestational diabetes mellitus is associated with increased maternal risk of per-eclampsia, hydramnios and operative delivery and an increased fetal risk for macrosomia, birth injury, respiratory distress syndrome and transient biochemical abnormalities. There is also accumulating evidence that in utero metabolic derangement can create a long term predisposition to obesity and diabetes in the infant of mother with gestational diabetes mellitus7.

Whereas pregnancies in women with overt diabetes are at greater risk for fetal death this danger is not apparent for those with post prandial hyperglycemia only, in contrast gestational diabetes with elevated fasting glucose (class A2) has been associated with unexplained still birth8.

Gabbe et al9 reported a higher perinatal mortality rate among infants born to women with gestational diabetes with elevated fasting plasma glucose concentrations, compared with a rate among infants born to mothers with gestational diabetes mellitus and normal fasting plasma glucose concentrations similar to those among mothers without diabetes.

Schrader et al10 reported that fasting plasma glucose on the oral glucose tolerance test significantly correlated with infant birth weight (P < 0.001, r = 0.94). A value greater than 90 mg/dL proved to be 100% sensitive and 64% specific for infant birth weight more than 4000 gm. Skyler and coworkers11 did show that a fasting plasma glucose > 90 mg % increased the risk for macrosomia.

Investigators at The Toronto Tri-Hospital Gestational Diabetes Project5 found that increasing carbohydrate intolerance in women without overt gestational diabetes was associated with significantly increased risk of cesarean sections, pre-eclampsia, macrosomia, need for phototherapy as well as increased length of material and neonatal hospital stay. Univariate analysis revealed that the odds for cesarean section rose with progressively increasing plasma glucose values on all four GTT values. Multivariate analysis for primary outcomes revealed that only the fasting value on the oral GTT was an independent predictor of macrosomia.

In a retrospective analysis of 3764 pregnancies complicated by gestational diabetes Schafer et al12 found that the initial fasting serum glucose values were significantly higher in pregnancies with major (n=143) and minor (n=112) anomalies and genetic syndromes (n=9) compared with pregnancies with no anomalies (n=3895). Pregnancies with major anomalies affecting multiple organ system had significantly higher initial fasting serum glucose level (166+64 mg/dL) compared with pregnancies with one organ system affected (141+55 mg/dL, p<0.04) or no organ system affected (115+38 mg/dL, p <0.0007).

All above studies stress the importance of fasting plasma glucose levels in management of pregnancies complicated by gestational diabetes mellitus. Except for increased cesarean section rate there was no other maternal or neonatal morbidity and mortality in our study. None of the babies had macrosomia though the difference between the mean birth weight between the two groups was statistically significant.

Conclusion

In conclusion this study demonstrated that absence of fasting hyperglycemia an oral GTT in high risk women with gestational diabetes mellitus is associated with overall good perinatal outcome.

Reference

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World Health Organization Expert Committee on Diabetes Mellitus, Diabetes Mellitus: report of a WHO study group. Geneva : WHO 1985.
Magee MS, Walden CE, Beneditti TJ, Knopp RH.- Influence of diagnostic criteria on the oncidence of gestational diabetes and perinatal morbidity. JAMA; 269: 60-615,1993.
Metzger BE, Coustan DR. – Summary and recommendations of the fourth international workshop – conference on gestational diabetes mellitus. Diabetes Care; 21 (supp 2): B161-7, 1988.
Sermer M, Naylor CD, Gave DJ, Kenshole AB, Rithie JW, Farine D, et al. – Impact of increasing carbohdrate intolerance on maternal fetal outcomes in 3637 women without gestational diabetes. The Toronto Tri-Hospital Gestational Diabetes Project. Am J obstet Gynecol 173(1) : 146-56,1995.
Sacks DA, Greenspoon JS, Fotheringham N. – Could the fasting glucose assay be used to screen for gestational diabetes ? J Reprod Med; 37 : 907-909, 1992.
Pettitti DJ, Bennett PH, Kowler WC, et al – Gestational diabetes mellitus and impaired glucose tolerance during pregnancy: long term effects on obesity and glucose tolerance in the off spring. Diabetes, 34 (supp 2): 112-119, 1985.
Johnstone FD, Nasrat A A, Prescott R J. – The effect of established and gestational diabetes on pregnancy outcome. Br J Obstet Gynecol; 97 : 1009-1012, 1990.
Gabbe SG, Mestman JH, Freeman R K. – Management and outcome to class A diabetes mellitus. AM J Obstet Gynecol; 127 : 465-469, 1977.
Schrader HM, Peterson LJ, Bevier WC, Peterson CM. – Fasting plasma glucose and glycosylated plasma protein at 24-28 weeks of gestation predict macrosomia in the general obstetric population. Am J Periat; 12(4) : 247-251, 1995.
Skyler JS, O’Sullivan MJ, Robertson EG.- Blood glucose control during pregnancy. Diabetes Care; 3:69-76, 1980.
Schafer-Graf UM, Buchanen TA, Xiang A, Sangster G, Montoro M, Kjos SL. – Patterns of congenital anomalies and relationship to initial maternal fasting glucose levels in pregnancies complicated by type 2 and gestational diabetes mellitus. Am J Obstet Gynecol; 182(2) : 373-420, Feb 2000.

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