Gestational Diabetes During and After Pregnancy

6. Burden of GDM in Developing Countries

Chong Shou and Huixia Yang 

(1)

Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, P.R. China

Huixia Yang

Email: yanghuixia688@sina.com

Abstract

This chapter will summarize the growing literature from developing countries regarding gestational diabetes mellitus (GDM), particularly from China. While the rate of GDM is still lower in China than in other developing countries, the number of women annually affected by GDM exceeds 2 million each year. Risk factors for GDM in developing countries appear to be similar to risk factors in developed countries, especially obesity, driven by increasing westernization of traditional lifestyles. Complications of GDM in developing countries are similar to those of more developed countries and emphasize the need for effective interventions for prevention and treatment.

6.1 Epidemiological Studies

Diabetes is rapidly emerging as a global health care problem that threatens to reach pandemic levels by 2030; the number of people with diabetes worldwide is projected to increase from 171 million in 2000 to 366 million by 2030. According to the World Health Organization (WHO), Southeast Asia and the Western Pacific region are at the forefront of the current diabetes epidemic, with India and China facing the greatest challenges.1 These increases are driven by decreased physical activity and over-consumption of cheap, energy-dense food. The subsequent obesity also contributes to greater risk for gestational diabetes mellitus (GDM).

While screening for GDM is common in China, there is significant variation between geographical regions due to differing lifestyle behaviors as well as varying diagnostic criteria. Xu et al2 reported the prevalence of GDM was 2.9%, using American Diabetes Association (ADA) criteria. Yang et al3 reported the total incidence of gestational abnormal glucose metabolism was 7.3%, and had increased gradually between 1995 and 2004 based on National Diabetes Diagnostic Group (NDDG) criteria. Between January 1995 and December 1999, there was a gradual increase in GDM incidence [4.3% (376/8,739)]. Between January 2000 and December 2001, there was a more rapid rise with an average incidence of 10.8% (445/4,133). Between January 2002 and December 2004, GDM incidence was stable at 8.9% (678/7,640). In the largest Chinese GDM surveillance study, Yang et al4 showed that the prevalence of GDM in Tianjing City is 2.3% by WHO criteria, much lower than that of Chinese women in western countries using the same diagnostic criteria. A 75-g-2h oral glucose tolerance tests (OGTT) was performed in 4000 gravidas who were 28–30 weeks pregnant. Women were recruited from Kunming City in southwestern China and were less likely to be Han Chinese and more likely to be of southeast Asian racial/ethnic origin. GDM prevalence was much higher, 11.6% as opposed to the 2.3% prevalence rate found by Yang et al.4

Established risk factors for GDM include advanced maternal age, obesity, and family history of diabetes. The trends for a greater proportion of mothers who are older and obese, along with the adoption of modern lifestyles in developing countries, may all contribute to an increase in the prevalence of GDM. We have evaluated the risk factors for GDM and gestational impaired glucose tolerance (GIGT) at Peking University First Hospital. In 2004, we performed a prospective case–control study in 85 women with GDM, 63 cases with GIGT, and 125 controls. Results showed that1 mean age and body mass index (BMI) before pregnancy and larger maternal weight gains during pregnancy were significantly different between GDM/GIGT and control groups2 (p < 0.05). Greater intake of fruits and carbohydrates per day was associated with increased incidence of GDM and GIGT (p < 0.05),3 and there was a higher proportion of women with a family history of diabetes among the GDM (42.2%) and GIGT groups (36.5%) compared with the control group (19.2%, p < 0.05).5 In the GDM and GIGT groups, irregular menses (16.5, 23.8%) and polycystic ovary syndrome (PCOS) (5.9, 3.2%) were more prevalent compared with controls (6.4%, 0).5 Multivariate logistic regression showed that age, irregular menses, BMI before pregnancy, history of spontaneous abortion, and educational level all were independent factors for GDM or GIGT.5

Data on changes in incidence over time are generally not available from other countries, but cross-sectional data suggest that risk factors are similar to western and Chinese populations. In Iran, Hossein et al6reported that the prevalence of GDM was 4.7%. Women with GDM had significantly higher parity and BMI than did nondiabetic women. Women with GDM were also more likely to have a family history of diabetes and a history of poor obstetric outcome. Keshavarz et al7 reported similar risk factors for GDM in Iran and also included maternal age >30 years, previous macrosomia, and glycosuria. In India, Zargar et al8 reported that the prevalence of GDM among Kashmiri women was 3.8%. 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. Women with obesity, hypertension, osmotic symptoms, proteinuria, or hydramnios also had a higher prevalence of GDM. In South Africa, Mamabolo et al9 reported that the prevalence of GIGT and GDM was 8.8% (7.3% GIGT; 1.5% GDM). The prevalence of GDM in this region is high as compared to other parts of Africa, which could have lower GDM prevalence due to chronic malnutrition precipitated by famine, drought, and war, as well as racial/ethnic differences. In Ethiopia, Seyoum et al10 reported that the prevalence of GDM was as low as 3.7%.

6.2 Screening and Diagnostic Criteria in Developing Countries

As discussed in the chapters on screening, screening for GDM consists of a 1- or 2-step approach. The initial screening test occurs between 24 and 28 weeks and consists of plasma glucose 1-h after 50-g oral glucose load (glucose challenge test or GCT). A 1-h value >140 mg/dL identifies 80% of women with GDM. Lowering the threshold to 130 mg/dL increases the sensitivity to 90% but at the cost of false positivity. The ADA and American College of Obstetricians and Gynecology (ACOG) recognize both thresholds.11 Confirmation of GDM is based on a second step, the subsequent 3-h OGTT. The WHO has proposed different diagnostic criteria, based on a 75-g OGTT with GDM defined as either the fasting plasma glucose (FPG) ≥126 mg/dL or 2-h plasma glucose ≥140 mg/dL. Both algorithms are valid options for the diagnosis of GDM and the prediction of adverse pregnancy outcomes.12

In the last decade, the 50-g GCT and management of gestational impaired glucose metabolism has become standard in most hospitals in China. Between 1995 and 2001, at Peking University First Hospital, we examined GCT values from pregnant women to determine the optimal GDM screening value.13 The 1-h average plasma glucose level of the GCT was 6.8 ± 1.7 mmol/L. The abnormal rate of GCT was 25.2% using 7.8 mmol/L as the cutoff, which missed 5.3% of women (17/321) with GDM by OGTT. When the cutoff was lowered to 7.2 mmol/L, the abnormal GCT rate was increased to 36.5%, and only 2.8% (9/321) of women with GDM by the OGTT were missed. With a value of 8.3 mmol/L as a threshold, 15.9% (51/321) women with GDM by OGTT were missed. When the glucose after the GCT is ≥11.2 mmol/L, the incidence of GDM is 55.8% (92/165).13 Among these women, 62.0% (57/92) GDM could be diagnosed according to the FPG alone. When the GCT glucose level is ≥11.2 mmol/L, FPG could be done first to diagnose GDM, without the OGTT.13

We have also investigated the effects of setting different OGTT thresholds. We examined OGTT data from 647 women with GDM and 233 women with GIGT diagnosed between 1 January 1989 and 31 December 2002.14Among GDM women, 535 cases were diagnosed by the 75-g OGTT and 112 cases of GDM diagnosed by the FPG alone. Of 535 cases of GDM diagnosed by OGTT, 49.2% (263/535) women had an FPG value >5.8 mmol/L; 90.1% (482/535) women had 1-h glucose values >10.6 mmol/L; 64.7% (359/535) had 2-h glucose levels >9.2 mmol/L.

In this particular series, women also had a 3-h glucose level done despite the fact that only a 75-g challenge was given. There were only 114 cases (21.3%) with abnormal 3-h plasma glucose levels among the 535 women with OGTT. Among those with abnormal 3-h level, 49.1% (56/114) had abnormal glucose values at the other three points of OGTT, and 34.2% (39/114) with two other abnormal values of OGTT. Our study showed that omission of the 3-h PG of OGTT only missed 19 cases of GDM and these women would be diagnosed as having GIGT. Among the 233 women with GIGT, only four cases had abnormal 3-h PG. Thus, omission of the 3-h glucose value of OGTT only resulted in failure to diagnose 3.6% (19/535) women with GDM, which means 2.9% (19/647) of all the GDM and 1.7% (4/233) of GIGT in this cohort. A glucose level >11.2 mmol/L following a 50-g GCT was highly associated with GDM necessitating insulin therapy (75.4%). An elevated FPG level was also associated with insulin therapy (59.7%).14

A diagnosis of GDM in China now is based on a fasting glucose level ≥5.8 mmol/L (105 mg/dL) on more than two occasions, or two or more abnormal values on the 3-h OGTT, with cut-off values of 5.8 mmol/L (105 mg/dL), 10.6 mmol/L (190 mg/dL), 9.2 mmol/L (165 mg/dL), and 8.1 mmol/L (145 mg/dL) at fasting, 1-, 2-, and 3-h, respectively. GIGT is diagnosed when there is only one abnormal value during the OGTT.

In Iran, Shirazian et al15 also evaluated the effects of various criteria on GDM prevalence. They reported that among 670 pregnant women, GDM was diagnosed in 41 (6.1%), 81 (12.1%), and 126 (18.8%) on the basis of ADA, WHO, and Australian Diabetes in Pregnancy Society (ADIPS) criteria, respectively. The kappa value was 0.38 (p < 0.0001) for the agreement between ADA and WHO criteria, 0.41 (p < 0.0001) for agreement between ADA and ADIPS criteria, and 0.64 (p < 0.0001) for agreement between WHO and ADIPS criteria.

We also evaluated the effect of gestational age on glucose tolerance. We found no difference in the abnormal GCT rates when GCT was administered between 24 and 36 weeks of gestation.13 Among 4,151 Indian women who underwent sequential OGTTs,16 741 were diagnosed with GDM by WHO criteria. Of these women, 16% were identified within the first 16 weeks of gestation, 22% were identified between 17 and 23 weeks gestation, and 61% were identified after the 24th week of gestation. In summary, glucose intolerance occurred early in gestation, leading the investigators to suggest earlier OGTT testing in their population.

6.3 Adverse Pregnancy Outcomes

6.3.1 Maternal Adverse Outcomes

Adverse maternal short-term outcomes can be categorized as exacerbation of GDM and other complications that impact on maternal morbidity and mortality such as hydramnios, hypertension, preeclampsia, and increased risk of cesarean section.

Yang et al17 reported that the incidence of preeclampsia was 12.6% in 1,202 pregnant women at Peking University First Hospital with abnormal glucose metabolism. The incidence of preeclampsia in diabetic women, women with glucose intolerance preceding pregnancy (IGT), and GIGT pregnant women was 34.9, 11.8 and 6.9%, respectively. Incidence of preeclampsia in women with diabetes and GDM women was higher than glucose tolerant women (8.1%, 3,634/44,899). Yang et al18 also found women with GDM were more likely to develop pregnancy-induced hypertension (14.7 vs. 7.9%) and macrosomia (13.8 vs. 7.54%) than glucose tolerant women. However, there were no significant differences in pregnancy outcomes between GDM women and women with GIGT.

Recently, we investigated risk factors for preeclampsia in pregnant Chinese women with abnormal glucose metabolism (n = 1,499) in a retrospective cohort study.19 Subjects were women who delivered between January 1995 and December 2004. The prevalence of preeclampsia in women diagnosed with diabetes mellitus prior to pregnancy was higher than that in women with GDM or GIGT (29.1 vs. 8.7 vs. 7.8%, p < 0.01). Prepregnancy BMI was significantly higher in women with preeclampsia than in those without. A higher rate of preeclampsia was found in women with chronic hypertension and those with poor glucose control. The independent risk factors for preeclampsia were chronic hypertension and elevated prepregnancy BMI. Our study indicated that the type of diabetes, chronic hypertension, and elevated prepregnancy BMI are risk factors for preeclampsia in pregnant women with abnormal glucose metabolism.

Long-term maternal adverse effects are mainly due to increased risk of developing

diabetes later in life with the magnitude of the risk ranging from 20 to 80%.20 We are still lacking evidence of long-term adverse maternal outcomes of GDM in China, although such studies are ongoing. In other developing countries, the risk of diabetes after delivery is similar to that observed in western countries. Krishnaveni et al21 found that 37% of women with GDM developed type 2 diabetes within 5 years, with greater insulin levels, waist-to-hip ratios, BMIs, and 30 min insulin levels associated with greater incidence of diabetes.

6.3.2 Adverse Fetal Outcomes

The infants of GDM women are at an increased risk of stillbirth and aberrant fetal

growth (macrosomia and growth restriction) as well as metabolic (e.g., hypoglycemia and hypocalcemia), hematological (e.g., hyperbilirubinemia and polycythemia) and respiratory complications that increase neonatal intensive care unit admission rates and birth trauma (e.g., shoulder dystocia).22

In China, the incidence of macrosomia is 2.2–13%.23 We have investigated the impact of GDM and an abnormal GCT on macrosomia.24 We examined the prenatal and delivery records of 8,656 pregnant women who delivered in Peking University First Hospital from January 1995 to March 2001. The incidence of macrosomia was 8.1% (700/8,656). The incidence of infants with macrosomia in GDM or IGT women was 12.5% (69/552), which was significantly higher than that of infants of women with normal glucose levels (7.8% or 631/8,104, p < 0.01). The macrosomia rate in women with GDM Class A2 (13.8%) was significantly higher than that of women with GDM Class A1 (6.0%, p < 0.01). The macrosomia rate among the women under age 25 years (5.9%) was lower than that of the women over 35 years (9.9%, p < 0.01). The macrosomia rate of infants of mothers with GDM or IGT (18.2%) was higher than that of those whose mothers did not have these conditions. The average BMI of the women between 26 and 28 gestational weeks was 24.9 ± 2.9 kg/m2. The women with BMI ≥27.8 kg/m2 had infants with a macrosomia rate of 16.2%, which was higher than that of women with lesser BMIs (6.3%, p < 0.01). The obese women without GDM or IGT had infants with a similar rate of macrosomia (15.9%) to women with GDM (18.3%). Women with GIGT or GDM have a higher rate of infants with macrosomia than do women with normal glucose tolerance, despite good glycemic control, especially in GDM type A2. Among Indian women, optimal glycemic control during a GDM pregnancy, as assessed by hemoglobin A1c, was associated with birthweights similar to birthweights of infants of mothers with normal glucose tolerance.25

We also analyzed fetal lung maturity in 1,198 women with abnormal glucose metabolism and tested amniotic fluid lamellar body counts (LBC) in 42 women with abnormal glucose metabolism and 42 normal pregnant women.26The incidence of respiratory distress among infants of women with abnormal glucose metabolism was 0.67%. LBC from women with abnormal glucose metabolism was 10,013 ± 6,318 × 10/3 μL vs. 84.2 ± 52.2 × 10/μL in the control group, a nonsignificant difference ( p = 0.21). In other words, under strict glucose control, fetal lung maturity is not delayed in mothers with abnormal glucose metabolism, and if the gestational age exceeded 37 weeks, the fetal lung maturity should not be detected before delivery.

In order to understand neonatal outcomes after standard management, we conducted a retrospective study of neonatal outcomes in 1,490 pregnant women who were diagnosed and treated for abnormal glucose metabolism and delivered in the Peking University First Hospital from January 1995 to December 2004.3 The selected cases consisted of 79 women with diabetes mellitus, 777 women with GDM, including 355 cases of Class A1 GDM, 316 with Class A2 GDM, 106 women whose glucose tolerant status was not known, and 634 women with GIGT. Fetal outcomes were analyzed in comparison with 19,013 pregnant women with normal glucose metabolism who delivered during the same period. We found that the perinatal mortality rate of the abnormal glucose metabolism group was 1.2% (18/1,513) which was significantly higher in the diabetes group (4.93%) than the GDM (1.1%) and GIGT groups (0.78%, p < 0.01). The incidence of neonatal asphyxia, hypoglycemia, malformation, and admission to the neonatal intensive care unit in the diabetes group were all higher than in the GDM and GIGT groups (p < 0.01). Neonatal respiratory distress syndrome (NRDS) was found in nine cases among 1,505 neonates (0.6%) and all were delivered preterm. Our results indicated that macrosomia and preterm birth remain the two most common complications, even after standardized glycemic management, but neonatal complications (other than macrosomia) are reduced in the GIGT group. Women in the DM group had a higher rate of neonatal complications than those in GDM and GIGT groups, so management in these patients should be intensified. NRDS is no longer a primary neonatal complication provided proper management is performed.3

Kashavarz et al7 reported that 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 cesarean section (p < 0.001) than women with normal glucose tolerance.

Since Barker’s primary epidemiologic studies in 1989 showing an inverse

relationship between birthweight and mortality due to adult ischemic heart disease,27 it has become increasingly clear that fetal stress may lead to fetal programming and an alteration of normal developmental gene expression. Research indicates that the child of a diabetic mother remains at increased risk for a variety of developmental disturbances including obesity, IGT or diabetes, and diminished neurobehavioral capacities.28 In developing countries such as China, it has not yet been demonstrated that the fetal distress that causes all the short-term neonatal complications in infants of GDM mothers may also be associated with the above long-term risks.

In India, children whose mothers were tested for glucose tolerance during pregnancy had detailed anthropometry performed at birth and annually thereafter.29 While infants of GDM mothers were larger than controls, at 1 year these differences were not significantly large. However, at 5 years, the female offspring of diabetic mothers had a greater percentage of body fat and higher insulin levels at 30 and 120 min than control children, leading the authors to conclude that GDM in utero was associated with greater offspring adiposity and glucose and insulin concentrations.

6.4 Focus of GDM Research in China

Our group at Peking University First Hospital has done some basic research on pathophysiology of GDM. Our results have shown that women with GDM have the highest values of tumor necrosis factor alpha (TNFα) and leptin and the lowest value of adiponectin compared to women with GIGT and healthy controls (p < 0.01) at 14–20 weeks of gestation. These differences persisted at 24–32 weeks gestation. These results indicate that the concentrations of TNFα, leptin, and adiponectin may change before the appearance of the abnormal glucose level during pregnancy.30 In addition, we investigated the relationship between the polymorphism of site rs228648 in the urotensin II gene and the genetic susceptibility to GDM in northern Chinese women. Genotyping was conducted to investigate the polymorphism of site rs228648 (G-A) in urotensin II gene among 70 unrelated GDM subjects and 70 normal controls.31 We found that the distribution of genotype frequencies of site rs228648 was in accord with Hardy–Weinberg’s equation law, being colony representative. The frequency of G allele of site rs228648 was 70.7% in GDM group, significantly higher than that in the control group (57.9%, p < 0.05), and the frequency of A allele of site rs228648 was 29.3% in the GDM group, significantly lower than that of the control group (42.1%, p < 0.05). There was no significant difference in the frequency of G/G genotype between the GDM group and control group (52.9 vs. 41.4%, p > 0.05). Women in the control group were more likely to be homozygous for the allele A of site rs228648 than were women with GDM. The frequency of A/A genotype of rs228648 was negatively correlated with the GDM group. After adjustment for age and gestational weeks, the association was still significant (odds ratio 0.312, p = 0.031).

Literature searches of English-language databases may not capture the extent of GDM research performed in other countries, particularly China. We searched the Chinese full-text literature database for all original and experimental research articles on GDM published in Chinese. We notice that the quantity of publications has increased yearly since 1981: 10 in 1999, 51 in 2003 and 133 in 2006. The focus of these studies were: etiology and pathogenesis (71 articles, 54.2%), the mechanism of influence on pregnancy outcome (21, 16.0%), and laboratory results reports (19, 14.5%). The main themes of the clinical studies were on maternal-fetal outcome (196, 51.0%), analysis of maternal-fetal outcome after clinical treatment (88, 22.9%), screening and diagnosis of GDM (56, 14.6%), risk factors for GDM (25, 6.5%) and long-term follow up after a GDM delivery (9, 2.3%). Five papers in all were multi-centered research reports from Beijing, Tianjin, and Shanghai, respectively. Therefore, while the study of GDM has drawn remarkable attention during the past 30 years, the number of basic mechanism studies lags behind the clinical studies. Moreover, clinical studies are focused on clinical outcome reports and there is a lack of prospective multi-centered reports and clinical trials.32

Type 2 diabetes is presently thought to affect 246 million people, representing 5.9% of the global adult population, with the vast majority of diabetes affected subjects living in developing countries.33 The number is expected to reach some 380 million by 2025, representing 7.1% of the adult population. For developing countries, there will be a projected increase of 170% of cases. Thus, diagnosis and management of GDM are necessary to decrease short-term adverse complications during pregnancy as well as to identify the group of women and offspring at increased risk for the development of later diabetes and possibly atherosclerotic cardiovascular disease. Resource allocation for research on GDM in developing countries, particularly for countries with high annual birth rates such as China, is needed.

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