Prevalence of pregestational diabetes and its pregnancy outcome among mothers attending antenatal care at three teaching hospitals in Addis Ababa

Prevalence of pregestational diabetes and its pregnancy outcome among mothers attending antenatal care at three teaching hospitals in Addis Ababa, Prospective follow up Study

A THESIS SUBMITTED TO SAINT PAUL’S HOSPITAL MILLENNIUM MEDICAL COLLEGE, DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR POSTGRADUATE STUDY IN OB-GYN

INVESTIGATOR:- DR TALEMA AYTENEW
OB-GYN, RESIDENT

February, 17, 2017

Saint Paul’s Hospital Millennium Medical College
Department of Obstetrics and Gynecology

Title:- Prevalence of pregestational diabetes and its pregnancy outcome among mothers attending antenatal care at three teaching hospitals in Addis Ababa, Prospective follow up Study

Name of Candidate:-Dr Talema Aytenew, OB-GYN Resident
Phone:- +251 920 499 143
Email:- [email protected] Or
[email protected]

Name of advisors:-Dr Delayehu Bekele(MD, MPH, MFM Fellow)
Associate professor department of obstetrics and gynecology, SPHMMC
Phone:-+251 922 743 743
Email:- [email protected]

Feb 17, 2017
Acknowledgments
First of all I would like to thank those patients who gave their consent and participated in the study. I would also like to pass my deepest appreciation to Dr Delayehu Bekele for his unlimited support and SPHMMC for funding.
I would like to thank those who aid me in collection of data at the three hospitals, Dr Tedila Kebede for his support and Zewude Aderaw for his comment and feedback beginning from proposal writing till data analysis.

Contents
Acknowledgments I
List of abbreviations IV
List of tables V
Abstract VI
Background 1
Statement of the problem 3
Significance of the study 3
Literature review 4
Objectives 9
General Objective 9
Specific Objectives 9
Methods and Materials 10
Method of study 10
Study Area 10
Study Setting 10
Study Period 11
Source 11
Study Populations 11
Inclusion and exclusion criteria 11
Inclusion Criteria 11
Exclusion criteria 11
Data collection procedures 11
Dependent variables 12
Independent variables 12
Data Analysis 12
Ethical consideration 12
Dissemination of results 13
Operational Definitions 13
Pregestational Diabetes mellitus 13
Macrosomia 13
Adverse pregnancy outcome definitions 13
Results of the Study 14
1. Sociodemorgaphic characterstics of pregnant mothers with pregestational diabetes (Table II) 14
2. Reproductive Performance 14
3. Glycemic control during pregnancy (Table-III) 16
4. Maternal, Fetal and Neonatal Complications (Table-IV) 17
Discussion:- 21
Strength 25
Limitation 25
Conclusion 26
Recommendations 26
References 27
Annex I:- Questionnaire Format 31
Annex II:- Consent Form 33
Declaration 34

List of abbreviations
ANC Antenatal Care
AOR Adjusted odds ratio
APOs Adverse pregnancy outcomes
CI Confidence Interval
COR Crude odds ratio
DM Diabetes Mellitus
DKA Diabetic ketoacidosis
EC Ethiopian Calendar
FBS Fasting Blood Sugar
FMOH Federal Ministry of Health
GDM Gestational Diabetes Mellitus
HgA1C Glycosylated Hemoglobin
IDDM Insulin Dependent Diabetic Mellitus
IDF International Diabetes Federation
NICU Neonatal Intensive Care Unit
NIDDM Noninsulin-dependent diabetes mellitus
OHG Oral hypoglycemic agents
OR Odds ratio
PGDM Pre-gestational Diabetes Mellitus
RBS Random Blood Sugar
RDS Respiratory Distress Syndrome
SAB Spontaneous Abortion
SPHMMC St.Paul’s Millennium Medical College
SPSS Statistical Package for the Social
Sciences
SVD Spontaneous Vertex Delivery
TAH Tikur Anbessa Hospital
TMP Trimester of pregnancy
WHO World Health Organization

List of tables
Table I:- Pregnancy Outcomes of Births in Nova Scotia from 1988 to 2002 in Women with and Without Pregestational Diabetes………………………………………………………………..6
Table II:- Sociodemorgaphic characterstics of pregnant mothers with pregestational diabetes who had follow and delivery at three teaching hospitals in Addis Ababa from 1 January 2016 – 30 December 2016……………………………………………………………………………….15-16
Table III:- The Average maternal Glycemic control of pregnant mothers with pregestational diabetes who had follow and delivery at three teaching hospitals in Addis Ababa from 1 January 2016 – 30 December 2016 ………………………………………………………………………17
Table IV:- Maternal and Fetal and Neonatal Complications of pregnant mothers with pregestational diabetes who had follow and delivery at three teaching hospitals in Addis Ababa from 1 January 2016 – 30 December 2016 …………………………………………………….19
Table V Neonatal complications of pregnant mothers with pregestational diabetes who had follow up and delivery at three teaching hospitals in Addis Ababa from 1 January 2016 – 30 December 2016…………………………………………………………………………………..19
Table VI:- Multivariate analysis of adverse pregnancy outcome in mothers with pregestational diabetes who had follow up and delivery at three teaching hospitals in Addis Ababa from 1 January 2016- 30 December 2016……………………………………………………………….20

Abstract
? Background:-Diabetes mellitus is a metabolic disorder of multiple etiologies characterized by chronic hyperglycaemia resulting from defects in insulin secretion, insulin action, or both. Diabetes affects 3-5% of pregnancies. It is unquestioned that pregestational—or overt—diabetes has a significant impact on pregnancy outcome. The embryo, the fetus, and the mother commonly experience serious complications directly attributable to diabetes.
Objective:- To assess the prevalence of pregestational diabetes mellitus and its pregnancy outcome in relation to the glycemic control at three teaching hospitals in Addis Ababa, Ethiopia from 1 January 2016 – 30 December 2016.
? Methods:- Prospective cohort study conducted at three teaching government hospitals in Addis Ababa, Ethiopia from 1 January 2016 – 30 December 2016.
? Results:- There were a total of 19,797 deliveries among these 80 were women with pregestational diabetes mellitus making prevalence of 0.4%. Out of the study population 39(48.8%) were women with type 1 diabetes mellitus and 41(51.2%) women with type 2 diabetes mellitus. Iatrogenic preterm delivery is high for fetal and maternal indications as 67% of labor is induced. There is statically significant relation between adverse pregnancy outcome and having preconceptional care with p-value=0.033
Conclusion:- There should be management guideline for follow up of patients with pregestational diabetes to have optimal pregnancy outcome. Encourage reproductive age diabetic women to have planned pregnancy and preonceptional care. Prospective cohort study should be conducted to see associations with other determinants like glycemic control.
? Key Words:- Pregestational diabetes mellitus; Pregnancy outcome, Preconceptional care

Background
Diabetes mellitus is a metabolic disorder of multiple etiologies characterized by chronic hyperglycaemia resulting from defects in insulin secretion, insulin action, or both. It is caused by inherited and/or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of the insulin produced.(1)
The prevalence of diagnosed diabetes among American adults has increased by 40 percent in 10 years and rose from 4.9 percent in 1990 to 6.9 percent in 1999 (Narayon and colleagues, 2003). More worryingly, it is estimated that this incidence will increase another 165 percent by 2050. To put this into perspective, the lifetime risk of diabetes in individuals born in 2000 is 33 percent for males and 39 percent for females! This increase primarily is due to type 2 diabetes, which is also referred to as diabesity. (2)
The increasing prevalence of type 2 diabetes in general, and in younger people in particular, has led to an increasing number of pregnancies with this complication (Ferrara and co-workers, 2004). Many women found to have gestational diabetes are likely to have type 2 diabetes that has previously gone undiagnosed (Feig and Palda, 2002). Indeed, the incidence of diabetes complicating pregnancy has increased approximately 40 percent between 1989 and 2004.(3)
Diabetes is now classified based on the pathogenic processes involved (Powers, 2008). Absolute insulin deficiency characterizes type 1 diabetes, whereas defective insulin secretion or insulin resistance characterizes type 2 diabetes. The terms insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) are no longer used. Age is also no longer used in classification, because pancreatic ?-cell destruction can begin at any age. Most commonly, its onset is before age 30, but in 5 to 10 percent of affected individuals, onset is after age 30 years. Type 2 diabetes, although most typical with increasing age, also develops in obese adolescents.(2)
Due to the more severe fetal and maternal complications resulting from such diabetes mellitus antedating pregnancy, in 2013, the WHO has divided hyperglycemia in pregnancy as follows: (1) Diabetes in pregnancy: Pre-gestational diabetes or pregnancy occurring in a women with known diabetes, and Overt diabetes – diabetes first detected during pregnancy; and (2) Gestational diabetes mellitus.(4)

Statement of the problem
Diabetes is one of the medical conditions complicating pregnancy. It is estimated that by the year 2030 more than 360 million people will have diabetes mellitus (5) and as the burden of the disease increases the management of pregnancies complicated by DM will be part of the daily obstetric practice in many regions of the world.
Abnormalities in glucose regulation occur in 3-5% pregnancies. This prevalence may increase with new screening guidelines and obesity. Pregestational diabetes accounts about 10% of diabetes in pregnancy the rest are gestational.
Though the incidence of pregestational diabetes mellitus is lower it is prudent to study adverse pregnancy outcome because it is associated with high rate of miscarriage, preterm delivery, preeclampsia, perinatal mortality, congenital malformations and maternal mortality than gestational diabetes mellitus.
Exact incidence of diabetes is not known in Ethiopia however, more and more mothers are becoming pregnant in the presence of diabetes and are prone to have recurrent pregnancy loss, stillborn, babies with multiple congenital anomalies.
Significance of the study
1. T o have baseline data on pregestational diabetes mellitus in our set-up
2. It can also be used as a reference for studies in this area.
Literature review
Advances in the care of pregnant women who have diabetes have improved, but not eliminated, the risk of morbidity and mortality in their infants. Therefore, the newborn care provider must plan and assess for the specific problems frequently encountered by the infant of a woman with diabetes.
It is unquestioned that pregestational—or overt—diabetes has a significant impact on pregnancy outcome. The embryo, the fetus, and the mother commonly experience serious complications directly attributable to diabetes. The likelihood of successful outcomes with overt diabetes is related somewhat to the degree of glycemic control, but more importantly, to the degree of underlying cardiovascular or renal disease.(2)
An infant of a woman with hyperglycemia has as much as 7.9% higher risk of having congenital malformations than infants born to mothers without diabetes. Complications vary based on the type of maternal diabetes, type 1 or type 2 diabetes versus Gestational Diabetes Mellitus (GDM) as well as the adequacy of maternal blood glucose control. A recent systematic review showed that pregnancies complicated by type 2 diabetes mellitus (T2DM) are associated with worse perinatal mortality and neonatal mortality than those complicated by type 1 diabetes mellitus (T1DM). (6)
In a retrospective cohort study done on Omani women, women with pregestational diabetes mellitus had a significantly higher incidence of pre-eclampsia (p-0.022), preterm deliveries (p